Late Onset Perthes Research Articles

Calcium sulphate pellets (Osteoset®) improve bone graft incorporation, but not femoral head sphericity after shelf acetabuloplasty for Perthes’ disease

Introduction: Outcome of shelf acetabuloplasty in management of late onset Perthes’ disease can be affected by shelf resorption and inadequate femoral head containment. Various agents have been tried to enhance bone graft incorporation and reduce its resorption. The aim of this study was to assess whether Osteoset® (calcium sulphate pellets) can stimulate autogenous bone graft incorporation and prevent bone resorption after shelf acetabuloplasty for Perthes’ disease and whether its use can improve femoral head remodelling. Methods: Thirty-two children with Perthes’ disease who underwent shelf acetabuloplasty were divided into two groups. In 15 patients (study group) Osteoset (10 ml) mixed with autogenous bone grafts to create extra ‘shelf’ over deficient acetabulum was used. Seventeen patients who served as a control group were managed by shelf acetabuloplasty using autogenous bone graft without Osteoset. Both groups were similar with regards to age and severity of the condition. The mean age at operation was 9 years and 4 months. The mean follow-up was 53.3 and 61.5 months for Osteoset and control groups, respectively, when all patients reached skeletal maturity. On serial radiographs shelf area, extra-osseous shelf length, acetabular coverage and graft incorporation and femoral head sphericity were assessed. Results: Immediately post-operatively the shelf area and shelf length were similar in both groups. From 6 weeks post-operatively and thereafter shelf area and shelf length were significantly better in patients from the study (Osteoset) group. Patients from the control group showed a steady decline in graft area throughout the follow-up period. Graft incorporation was also faster in the Osteoset group. However, femoral head sphericity assessed by Stulberg classification was similar in both groups. Conclusion: Osteoset pellets improve graft volume, encourage earlier graft incorporation and inhibit later shelf resorption. Adding Osteoset does not improve femoral head remodelling following shelf acetabuloplasty for Perthes’ disease.

Hinged versus fixed arthrodiastasis in late-onset Perthes’ disease

Background Late-onset Perthes’ disease occurs in patients older than 8 years and constitutes approximately 20% of cases and is known for its aggressive course and poor outcome with chronic hip pain and stiffness. The best treatment is still unknown, and various surgical treatment options have been proposed, but they have some inherent drawbacks. Arthrodiastasis had been introduced as a treatment method for late-onset Perthes’ disease. Patients and methods This is a prospective study performed in Suez Canal University hospitals during the period from October 2010 to December 2014. Twenty hips were divided into two groups. Group I consisted of 10 hips treated by hinged arthrodiastasis. Group II consisted of 10 hips treated by fixed arthrodiastasis. Arthrodiastasis was done by external ring fixator. At the end of the follow-up period, patients were evaluated clinically and radiologically. Results At the end of the follow-up period, which ranged from 24 to 30 months, with a mean of 27.6 months for group I, and a mean of 26.2 months for group II, preoperative and postoperative clinical features and outcome scoring systems in both groups showed improvement and statistically significant relationship in values of limb length discrepancy, total hip range of motion, modified Harris hip score, and epiphyseal index. Comparing postoperative clinical features and outcome scoring systems between both groups at final follow-up showed values in group I better than group II, but there is no statistically significant relationship. Conclusion Arthrodiastasis either hinged or fixed using ring external fixator combined with adductor tenotomy is an excellent and reliable method for treatment of late-onset Perthes’ disease, where prognosis is usually poor and conventional methods of treatment are not reliable.

Short Term Outcome of Varus Derotation Osteotomy in Late Presenting Perthes Disease.

Background:Untreated Perthes disease can lead to osteoarthritis by the fourth decade. The treatment is conservative for children <6 years, operative within the age group of 6–9 years. Late onset Perthes, older than 9 years or more, are notorious with the aggressive course with poor outcome. However, literature do not come to a consensus between conservative and operative management. This study evaluates the clinical and radiological outcome of varus derotation osteotomy (VDRO) in Perthes disease presenting late with age 8 years or more.Materials and Methods:15 children (13 males and 2 females) with the mean age of 9.4 years belonging to modified Elizabethtown classification Stage IB, IIA, IIB treated with open wedge VDRO between 2008 and 2014 were included in this study. Seven patients (46.67%) were of >10 years of age at presentation. All patients had limitation of abduction and internal rotation. Eight patients (53.33%) had pain at the hip and 12 patients (80%) had limp. Mean time between diagnosis and corrective surgery was 3 weeks.Results:The evaluation was done using caput index (CI) and epiphyseal quotient (EQ) and articulotrochanteric distance radiologically, range of motion and Harris Hip Score for clinical outcome. All the measurements were carried out on pre- and postoperative X-rays after 3 years followup and compared with the contralateral normal hip. After a mean followup period of 3.4 years, we noted the statistically significant difference between pre- and postoperative values. We noted that all (100%) children in Stage IB, IIA and 50% children in Stage IIB achieved satisfactory results. There was a significant change (P = 0.000) in CI among all the patients after surgery. The final EQ after 3 years of VDRO was 0.606 and was significant (P = 0.0000).Conclusion:In our opinion, based on the encouraging short term radiological and clinical outcomes, VDRO may be regarded as a treatment procedure for late presenting Perthes disease in stage IB, IIA, IIB.

Hip arthrodiastasis in Legg-Calvé-Perthes disease

Introduction and objectiveArthrodiastasis consists of the mobilisation of the hip while distracted by a hinged distractor. The aim of our study is to show the results of the treatment of late-onset Perthes disease with this technique in our institution. Material and methodsAmbispective review of all the cases that underwent this surgery in our Department of Paediatric Orthopaedics between 2010 and 2014 with the following inclusion criteria: patients over 8 years old, with minimal deformity, and poor prognosis. Mobility, pain, Trendelenburg sign, radiographic sphericity, and complications were assessed. ResultsA total of 13 patients (9 male, 4 female) were included. The mean age was 11.93 years. Radiographic risk signs were present in 7 cases. The mean decrease in pain measured with a visual analogue scale (VAS) after the surgery was 3.83 points (P<.05). Cephalic sphericity was maintained in 11 cases during follow up (1.75 years). Complications were observed complications in 84.6% of the patients, with infection of the screw tract being the most frequent. All of them were easy to treat. ConclusionsArthrodiastasis is a minimally invasive technique, useful in the treatment of late onset Perthes disease. It improves clinical results and maintains cephalic shape when applied in early stages. However, it is not free of complications, which can involve as many as 8 out of 10 patients treated with the technique.

Artrodiastasis de cadera en la enfermedad de Legg-Calvé-Perthes

Introduction and objectiveArthrodiastasis consists of the mobilisation of the hip while distracted by a hinged distractor. The aim of our study is to show the results of the treatment of late-onset Perthes disease with this technique in our institution. Material and methodsAmbispective review of all the cases that underwent this surgery in our Department of Paediatric Orthopaedics between 2010 and 2014 with the following inclusion criteria: patients over 8 years old, with minimal deformity, and poor prognosis. Mobility, pain, Trendelenburg sign, radiographic sphericity, and complications were assessed. ResultsA total of 13 patients (9 male, 4 female) were included. The mean age was 11.93 years. Radiographic risk signs were present in 7 cases. The mean decrease in pain measured with a visual analogue scale (VAS) after the surgery was 3.83 points (P<.05). Cephalic sphericity was maintained in 11 cases during follow up (1.75 years). Complications were observed complications in 84.6% of the patients, with infection of the screw tract being the most frequent. All of them were easy to treat. ConclusionsArthrodiastasis is a minimally invasive technique, useful in the treatment of late onset Perthes disease. It improves clinical results and maintains cephalic shape when applied in early stages. However, it is not free of complications, which can involve as many as 8 out of 10 patients treated with the technique.

Management of late onset perthes: evaluation of distraction by external fixator-5-year follow-up.

Background. Hip distraction in Perthes' disease unloads the joint, which negates the harmful effect of the stresses on the articular surfaces, which may promote the sound healing of the area of necrosis. We have examined the effect of arthrodiastasis on the preservation of the femoral head in older children with Perthes' disease. Methods and Materials. Twelve children with age more than 8 years with Perthes' disease of less than one year were treated with hip distraction by a hinged monolateral external fixator. Observation and Results. Mean duration of distraction was 13.9 days. These children were evaluated by clinicoradiological parameters for a mean period of 32.4 months. There was a significant improvement in the range of movements and mean epiphyseal index, but the change in the percentage of uncovered head femur was insignificant. There was significant improvement in Harris Hip score. Conclusions. Hip distraction by hinged monolateral external fixator seems to be a valid treatment option in cases with Perthes' disease in the selected group of patients, where poor results are expected from conventional treatment.

Legg-Calvé-Perthes disease in children with Down syndrome

The aim of this study was to describe the features of Perthes disease in patients with Down syndrome. The data of this retrospective case series were collected between 2000 and 2011. Patients were assessed according to demographic, clinical and radiographic classifications. The study included 7 hips of 6 patients (5 males, 1 female). Mean age at first visit was 6.1 (range: 3.5 to 12.7) years and mean follow-up period was 52.3 (range: 30.2 to 90.8) months. Initial complaints were pain and limping with limited range of motion at the first visit. Range of motion tended toward early improvement despite continuous radiographic changes. One patient had late onset Perthes disease and developed rapid femoral head collapse managed with total hip arthroplasty. Perthes disease in children with Down syndrome must be followed despite clinical improvement. Radiographic characteristics of Perthes disease in patients with Down syndrome do not differ from those without it.

Shelf acetabuloplasty for Perthes disease in patients older than eight years of age

This is a retrospective review of 24 patients with late-onset Perthes disease treated with shelf acetabuloplasty. The mean age of the patients was 9.8 years. The medial joint space ratio improved from 1.66 to 1.47 (P<0.05) and the acetabular cover ratio improved from 0.87 to 1.18 (P<0.001). At maturity, five hips were Stulberg II, 13 were Stulberg III and six were Stulberg IV. The study suggests that shelf acetabuloplasty favourably affects long-term Stulberg grading and therefore outcome compared with historic nonoperative treatment regimens. We believe that the procedure deserves further evaluation in any future randomized-controlled trial of the management of late-onset Perthes disease.

Outcome of late-onset Perthes’ disease using four different treatment modalities

The outcome of Perthes' disease in children over 8 years tends to be poor. It is unclear whether any treatment modality alters the natural history. This study compares the results of four treatment modalities for this group of patients. A retrospective review was performed of prospectively collected data for 44 children (48 hips) with Catterall grade 2, 3 or 4 Perthes' disease with onset age 8 years or older followed to maturity. Patients were divided into four groups (a no-treatment group and three interventional groups). The interventional groups were demographically similar but the untreated patients were older and had poorer indices for most modalities. Overall for all treatment modalities only 19% had a satisfactory Stulberg grade II outcome. Poorer outcomes (as assessed by center-edge angle and percentage femoral head coverage) were associated with increasing age, greater initial head deformity, and more head involvement. Initial head deformity did not remodel for any group and progressed despite plaster treatment or varus osteotomy but not after acetabular augmentation. Acetabular augmentation gave better outcomes for C/B ratio and center-edge angle. Whatever the treatment, the outcome is poorer with increasing age. No treatment guarantees a good result for significant head involvement or initial deformity but acetabular augmentation improves C/B ratio and center-edge angle and prevents progressive femoral head deformity compared with no treatment, varus osteotomy, and plaster treatment.

To What Extent Does Remodeling of the Proximal Femur and the Acetabulum Occur Between Disease Healing and Skeletal Maturity in Perthes Disease?

Radiographs of 75 children with unilateral disease were studied to quantify the extent of remodeling of the proximal femur and the acetabulum between healing and skeletal maturity in children with Perthes disease. The mean ages at disease onset, healing, and skeletal maturity were 8.3, 11.9, and 15.5 years, respectively. Fifty-seven children were treated surgically by subtrochanteric varus osteotomy with trochanteric epiphyseodesis; the remaining 18 children were treated nonoperatively. Assessment of the Mose's index and Stulberg grading and measurements of the proximal femur and the acetabulum were made at healing and at skeletal maturity. The Stulberg grade and the Mose's index did not change between healing and skeletal maturity in 88% and 95% of children, respectively. In operated children, there was significant improvement of the articulotrochanteric distance, acetabular depth, neck-shaft angle, and Sharp's angle between disease healing and skeletal maturity, but no such changes occurred in children who were not operated on. We conclude that because little change occurs in the shape of the femoral head and congruity of the hip between healing and skeletal maturity, the outcome of treatment based on these 2 variables can be assessed once the disease heals in children with late-onset Perthes disease.

Correspondence: Treatment of severe late onset Perthes disease with soft tissue release and articulated hip distraction (Reply)

Correspondence: Treatment of severe late onset Perthes disease with soft tissue release and articulated hip distraction (Reply)

Treatment of severe late-onset Perthes’ disease with soft tissue release and articulated hip distraction: Revisited at skeletal maturity

Late-onset Perthes' disease is diagnosed after 9 years of age. Conservative treatment and conventional surgical techniques have limited ability to reduce the pressure in the joint or change the shape of the femoral head. We used a combination of soft tissue release and joint distraction with a hinged mono-lateral external fixator for these patients. Ten of our patients reached skeletal maturity and were evaluated. Clinical assessment included: Harris hip score, hip range-of-motion (ROM), limb length discrepancy, and the Oxford hip questionnaire for pain and function. Radiographic assessment included: Sharp transverse acetabular inclination, the uncoverage percentage, the epiphyseal index before surgery (modified Eyre-Brook), at frame removal, and, at last follow-up, the epiphyseal quotient (of Sjovall) and the Stulberg classification. Our study included eight boys and two girls (mean age at surgery 12.3 years, range 9.4-15.1, mean age at last follow-up 18.1 years, range 15.2-22.8). The mean follow-up was 5.7 years (range 4.3-7.8). The mean Harris hip score was 86.3/100 (range 48.5-96); one patient had <85 points. The hip ROM was slightly limited in most patients, and seven patients had limb shortening between 1-4 cm. The mean Oxford hip questionnaire score was 17.4/60 (range 12-31). The mean Sharp transverse acetabular inclination of the affected side was 42 degrees (range 36-54) compared to 39 degrees for the unaffected side (P = 0.045). The mean uncoverage percentage was 37% (range 27-47) compared to 20% for the unaffected side (P = 0.017). The mean epiphyseal index was 0.71 (range 0.31-0.92) before surgery, 0.79 (range 0.50-0.93) at frame removal (P = 0.012), and 0.72 (range 0.51-0.89) at last follow-up (P = 0.646). The epiphyseal quotient for the eight unilateral cases was 0.72 (range 0.49-0.91), and the Stulberg classification was type III for three cases and type IV for seven. Patient satisfaction for function and pain following the combined procedure was good. Radiographic parameters did not change significantly. This should be regarded as a salvage procedure.

Pediatric hip disorders

Purpose of review: To critique the literature over the past year and emphasize advances made that may influence the management of pediatric hip disorders in the future. Recent findings: The Plastizote abduction orthosis is a reasonable alternative to the more traditional Pavlik harness in the management of dislocatable or dislocated but reducible hips in neonates. The success of this device is attributed to moderate abduction and ease of use and acceptance by the parents. The importance of an ossific nucleus before reduction of developmental dysplasia of the hip continues to be debated. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage, designed to specifically examine glycosaminoglycan changes in articular cartilage, could provide a valuable means of monitoring the status of articular cartilage and predict the progression of hip arthrosis. A review found that the optimal time for containment surgery for Perthes disease is during the stage of sclerosis or early fragmentation. Soft tissue release combined with unloading of the femoral head with distraction may improve function in patients with late-onset Perthes disease. The morbidity of pelvic osteomyelitis has increased over the past decade, perhaps because of the increased virulence of offending organisms. The development of clinical practice guidelines has been a major emphasis of the movement toward evidence-based medicine. A standardized management process for specific clinical conditions such as septic arthritis may improve the process of care and clinical outcomes. The use of a trochanteric starting point has proved to be a safe alternative for the management of femoral shaft fractures in skeletally immature adolescents. Summary: The articles in this review were selected for clinical relevance, quality, and controversy. This review looks specifically at studies that address the prevention, diagnosis, and treatment of the most common pediatric hip disorders.

Treatment of severe late onset Perthes?? disease with soft tissue release and articulated hip distraction: early results

Sixteen children with late onset Perthes' disease were surgically treated at an average age of 12 years 1 month (9 years 4 months to 15 years) by soft tissue release and articulated hip distraction. Two patients had additional diagnosis of Down syndrome and one suffered from geleophysic epiphyseal dysplasia. Fifteen hips were graded Catterall IV and Herring C and one hip was graded Catterall III Herring B. On preoperative arthrograms, 14 patients had a saddle-shape subluxating femoral head with hinge abduction. The distraction discontinued when Shenton line was corrected. The fixation lasted 4-5 months. At a mean follow-up of 2 years 7 months (1-5 years), an improvement of hip range of motion was found in all patients. Hip joint arthrograms upon removal of the fixator showed disappearance of the saddle-shape femoral head in 10 of the 14 patients with this deformation. Shenton line breakage improved from 7.6 mm to 2.1 mm at last follow-up. The epiphyseal index improved by 14%. The average pain score on an analog scale dropped from a preoperative 7.0 to 1.6 at last follow-up (filled in by patients or parents in case of Down syndrome). Separate analysis of data from the group having only Perthes disease (13 children) showed better results. These preliminary data suggest that soft tissue release combined with unloading of the femoral head and restoration of joint space can improve the function and epiphyseal height.