The management of Legg-Calvé-Perthes’ disease: Is there a consensus?

Abstract

Purpose The aim of the study was to find out whether or not there is consensus among experienced pediatric orthopaedists about the management of certain clinical scenarios in Legg-Calvé-Perthes' disease. Methods A questionnaire was sent to all 297 members of the European Paediatric Orthopaedic Society (EPOS) describing four cases of Legg-Calvé-Perthes' disease (LCPD) with two X-rays each and a short description of the clinical scenario. Two of the patients were younger and two were older than six years of age. From both age groups there was one with a good range of motion and an X-ray classified as Herring A or B, while the other patient had a poor range of motion and an X-ray classified as Herring C. EPO members were asked to choose from various treatment options or to describe any other therapy that they would advise in the clinical scenarios. Results One-hundred and fifty members answered the questionnaire. The participants had an average of 20 years of experience in pediatric orthopaedics. There was a consensus that no surgery should be performed in a young patient with a good range of motion and that there should be no weight relief when older with a good range of motion. Conservative containment treatment (abduction splint, Petrie cast) and arthrodiastasis was suggested in only very few centres. There was a tendency to perform• an operation when the patient is older with a poor range of motion and to perform operative treatment only when there were subluxation or head at risk signs.• pelvic osteotomies or a combination of pelvic and femoral osteotomies rather than femoral osteotomies alone. Age did not determine the indication for treatment and there was no agreement on the indications for physiotherapy. There was also no consensus on the type of pelvic osteotomy to be used. ConclusionsThe study showed that indications for the treatment of LCPD is based more on the personal experience of the surgeon rather than on scientific data.

Triple pelvic osteotomy in the treatment of Legg-Calve-Perthes disease

“…Some authors [7,[11][12][13][14]18] have reported that if such treatment is initiated in the phase of fragmentation, there is a possibility to correct or eliminate some risk signs (primarily femoral head subluxation and limited hip abduction), which then additionally improve later results.…”

“…Radiographic assessment in preoperative, immediate postoperative and final evaluation periods, and classifications according to CE angle [1], phase of the disease by Hirohashi-Menelaus [11,12], containment by Klisić-Menelaus [24], Catterall group grading and presence of risk signs [2,24], as well as on the basis of Herring's classification [12,13] were performed. Functional findings were evaluated according to the Harris hip score [10].…”

“…The best illustration of this is presented in the study of Hefti and Clarke from 2007 [11], which involved 151 members of the European Paediatric Orthopaedic Society (EPOS) who were offered four cases of LCP and asked to give their therapeutic propositions. The replies were diverse, from non-treatment to various modes of surgical treatment.…”

“…Patients aged less than four years have a very good prognosis even without treatment, while those aged above ten years have a poor prognosis. In addition, treatment results depend on the degree of involvement of the disease; hip involvement up to 50% (Catterall types I and II) have better prognosis, while higher grade hip involvement (Catterall types III and IV) have considerably poorer prognosis [2,11,21,24]. Naturally, treatment results are also influenced by the type of treatment; containment is best achieved by pelvic osteotomy (Salter or triple), which mostly results in spherical congruence of the hip, without leg shortening and gait disorders [2,20,24].…”

<p>Role of Arthrodiastasis Using Hinged Monolateral External Fixator Without Soft Tissue Release in Advanced Stage of Legg–Calve–Perthes Disease</p>

“…In this classification Several publications have demonstrated better clinical outcomes with surgical intervention for groups B and B/C after the age of 8 years. 9,10 Several surgical procedures have addressed patients with the advanced stage of the disease; these include femoral and pelvic osteotomies. 11 Both procedures change the anatomy of the hip joint, which may hinder future joint arthroplasty.…”