Comparison of surgical and nonsurgical containment methods for patients with Legg-Calvé-Perthes disease of the onset ages between 6.0 and 8.0 years: Salter osteotomy versus a non-weight-bearing hip flexion-abduction brace

Abstract

Since bone healing potential decreases with age, patients with Legg-Calvé-Perthes disease should receive treatment appropriate to their age group. Nonsurgical treatment is commonly applied to patients under 6.0 years of age at the onset and surgical treatment is recommended for those over 8.0 years of age, but it remains unclear which is better for those between 6.0 and 8.0 years. The aim of this retrospective study was to compare outcomes of Salter osteotomy and a non-weight-bearing brace in this age group. Inclusion criteria were unilateral Legg-Calvé-Perthes disease patients who were 6.0–8.0 years of age at the onset, who had more than 50% femoral head involvement without hinge abduction, and who underwent either Salter osteotomy (n = 35) or a non-weight-bearing hip flexion-abduction brace (n = 18). Radiological and clinical outcomes at skeletal maturity were compared between the two groups. The mean follow-up durations were 9.4 years in the Salter osteotomy group and 10.0 years in the brace group. There was no significant difference in the modified Waldenström classification at the beginning of treatment and the Catterall and modified lateral pillar classifications evaluated at the fragmentation stage between the groups. At skeletal maturity, the Stulberg classification, the sphericity deviation score, femoral head overgrowth, and the articulo-trochanteric distance were similar between the groups, but the Salter osteotomy group showed significantly smaller lateralization of the femoral head and better acetabular shape and coverage than the brace group: femoral head lateralization (P < 0.001), acetabular depth-to-width ratio (P = 0.002), Sharp angle (P < 0.001), lateral acetabular shape (P = 0.027), acetabular head index (P < 0.001). There was no significant difference in hip pain and motion between the groups. In this age group, Salter osteotomy provides better femoral head position and acetabular shape and coverage than a non-weight-bearing brace.

Range of abduction in patients with Legg-Calvé-Perthes disease – a nationwide register-based cohort study

“…The effectiveness of surgical treatment options to maintain the hip's morphology has been investigated and proven in two prospective multicenter studies [5,18]. But, controversies exist as to whether surgery is needed in younger children between 6 and 8 years of age at diagnosis [5,8,18]. Nevertheless, there is a consensus that a good range of abduction before surgery is vital [3].…”

“…Nonsurgical treatment of Perthes' disease mainly aims to maintain abduction either by physiotherapy (PT) or with orthoses or Petriecasting. An alternative approach to nonsurgical treatment is to change the hip and its bony anatomy by performing Varus osteotomy of the proximal femur, Salter osteotomy or Triple osteotomy of the pelvis [8,16,17]. All these surgical techniques reduce the range of hip abduction temporarily.…”

Bypass of Epiphyseal Fragmentation Following Early Salter Innominate Osteotomy and Its Clinical Relevance in Legg-Calvé-Perthes Disease

“…Pelvic osteotomy was done as described previously after restoring 30 degrees or more of hip abduction with preoperative skin traction. 14 We have not adopted a "wait-to-classify" approach in fear of the collapse of brittle capital epiphysis during the waiting period. Post-operatively hips were immobilized in one and one-half hip spica cast for 3 weeks, followed by an aggressive range-ofmotion exercise.…”

“…We had performed 2 retrospective studies on clinical and radiographic outcomes of 3 containment therapies for LCPD. One is a comparative study between FVO and SIO,12 and the other is one between SIO and a nonweight-bearing brace 14. A total of 28 patients from the latter study were included in this study, with 20 patients operated on in stage I and 8 in stage IIa, whereas the exact number of patients included both in the former study and this study is uncertain because we could not find documented personal information of the patients included in that study.…”

“…Pelvic osteotomy was done as described previously after restoring 30 degrees or more of hip abduction with preoperative skin traction 14. We have not adopted a “wait-to-classify” approach in fear of the collapse of brittle capital epiphysis during the waiting period.…”