A combined treatment strategy of Legg-Calve-Perthes disease with BEST quartet

Abstract

Purpose: The main pathology of Legg-Calvé-Perthes Disease (LCPD) is the disruption of blood flow of the femoral head resulting ischemic necrosis which leads hip joint incongruency. The most frequent methods in the treatment are the methods improving the containment of the femoral head. There are limited studies in the literature addressing the treatment of necrosis using methods such as epiphyseal drilling or distraction osteogenesis. Our study aimed to investigate the mid-long-term outcomes of LCPD patients treated with the BEST method, which aims to improve congruency and containment simultaneously. Materials and methods: LCPD patients (23 male, 1 female) who were treated with (B)leeding the epiphysis by drilling, (E)vacuation of the joint synovitis, contained with (S)alter’s Osteotomy, and distracted with skin (T)raction investigated retrospectively. Only patients who reached skeletal maturity at latest follow-up were included in the study. Patients’ final radiographs were classified according to the Stulberg classification, Mose classification, and Tönnis osteoarthritis classification. Results: The mean follow-up of the patients was 10.44±1.35 (8.5-13) years, and the mean age at the last followup was 17.71±1.73 (15.25-20.83) years. According to the Stulberg classification, 11 (45.8%) of the patients had a Class-I hip; 6 (25%) a Class-II hips; 3 (12.5%) a class-III hips, 4 (16.7%) a class-IV hips. According to the Mose classification, 12 (50%) of the patients had good results; 5 (20.8%) had fair results; 7 (29.1%) had poor results. Conclusion: BEST treatment method for LCPD is a combined procedure which addresses to all pathologies of disease at the same time. This combined treatment protocol may be preferred for severely affected LCPD cases who with subluxation especially in higher lateral pillar class that are prone to nonspherical incongruency

Keywords

• Legg-Calve-Perthes disease
• Salter’s osteotomy
• femoral head osteonecrosis

Legg-Calve-Perthes hastalığının BEST dörtlüsü ile bir kombine tedavi stratejisi

Öz

Amaç: Legg-Calvé-Perthes hastalığının (LCPH) temel patolojisi, femur başındaki kan akışının bozulması sonucunda kalça ekleminde uyumsuzluğa yol açan iskemik doku nekrozudur. Tedavide sık uygulanan yöntemler femur başının kapsamasını artıran yöntemlerdir. Epifizin delinmesi veya distraksiyon osteogenezi gibi nekroz tedavisine değinen nadir yayın vardır. Çalışmamızın amacı, uyum ve kapsamayı aynı anda geliştirmeyi amaçlayan BEST yöntemiyle tedavi ettiğimiz LCPH hastalarının orta-uzun dönem sonuçlarını araştırmaktı. Gereç ve yöntem: LCPH tanısı ile 24 (23 erkek, 1 kadın) hastaya uygulanan epifizi delme yoluyla kanlandırma (B), eklem ponksiyonu ile fazla eklem sıvısının boşaltılması (E), Salter Osteotomisi (S) ile femur başı kapsamasının artırılması ve cilt (T)raksiyonu ile eklemdeki basıncın azaltılması yöntemlerinin birlikte kullanıldığı kombine yöntem araştırıldı. Çalışmaya sadece iskelet olgunluğuna ulaşan hastalar dahil edildi. Hastaların son radyografileri Stulberg sınıflaması, Mose sınıflaması ve Tönnis osteoartrit sınıflamasına göre sınıflandırıldı. Bulgular: Hastaların ortalama takip süresi 10,44±1,35 (8,5-13) yıl, son takip yaş ortalaması ise 17,71±1,73 (15,25-20,83) yıldı. Stulberg sınıflamasına göre hastaların 11'inde (%45,8) sınıf I kalça, 6 hastada (%25) sınıf II kalça, 3 hastada (%12,5) sınıf III kalça, 4 hastada (%16,7) sınıf IV kalça görüldü. Mose sınıflamasına göre hastaların 12'sinde (%50) iyi sonuç, 5'inde (%20,8) orta sonuç, 7'sinde (%29,1) kötü sonuç elde edildi. Sonuç: LCPH için BEST tedavi yöntemi, hastalığın tüm patolojilerine aynı anda hitap eden kombine bir prosedürdür. Bu kombine tedavi protokolü, özellikle asferik uyumsuzluğa eğilimli, yüksek lateral pillar sınıfında, subluksasyonlu ve ciddi şekilde etkilenmiş LCPH vakalarında tercih edilebilir.

Anahtar Kelimeler

• Legg-Calve-Perthes hastalığı
• Salter osteotomisi
• femur başı osteonekrozu

Kaynakça

1. 1. Kim HK, Herring JA. Pathophysiology, classifications, and natural history of Perthes disease. Orthop Clin North Am 2011;42:285-295. https://doi.org/10.1016/j.ocl.2011.04.007
2. 2. Catterall A. Legg-Calvé-Perthes syndrome. Clin Orthop Relat Res 1981;158:41-52.
3. 3. Conroy E, Sheehan E, O' Connor P, Connolly P, McCormack D. Triple pelvic osteotomy in Legg-Calve-Perthes disease using a single anterolateral incision: a 4-year review. J Pediatr Orthop B 2010;19:323-326. https://doi.org/10.1097/BPB.0b013e32833822a4
4. 4. Thompson GH. Salter osteotomy in Legg-Calvé-Perthes disease. J Pediatr Orthop 2011;31:192-197. https://doi.org/10.1097/BPO.0b013e318223b59d
5. 5. Shim SS, Day B, Leung G. Circulatory and vascular changes in the hip following innominate osteotomy: an experimental study. Clin Orthop Relat Res 1981;160:258-267.
6. 6. Yavuz U, Demir B, Yildirim T, Beng K, Karakas ES. Salter innominate osteotomy in the treatment of late presentation Perthes disease. Hip Int 2014;24:39-43. https://doi.org/10.5301/hipint.5000086
7. 7. Park KS, Cho KJ, Yang HY, Eshnazarov KE, Yoon TR. Long-term results of modified salter innominate osteotomy for Legg-Calvé-Perthes disease. Clin Orthop Surg 2017;9:397-404. https://doi.org/10.4055/cios.2017.9.4.397
8. 8. Volpon JB. Comparison between innominate osteotomy and arthrodistraction as a primary treatment for Legg-Calvé-Perthes disease: a prospective controlled trial. Int Orthop 2012;36:1899-1905. https://doi.org/10.1007/s00264-012-1598-2

9. 9. Saran N, Varghese R, Mulpuri K. Do femoral or salter innominate osteotomies improve femoral head sphericity in Legg-Calvé-Perthes disease? A meta-analysis. Clin Orthop Relat Res 2012;470:2383-2393. https://doi.org/10.1007/s11999-012-2326-3
10. 10. Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.
11. 11. Cıtlak A, Kerimoğlu S, Baki C, Aydın H. Comparison between conservative and surgical treatment in Perthes disease. Arch Orthop Trauma Surg 2012;132:87-92. https://doi.org/10.1007/s00402-011-1382-6
12. 12. Kaneko H, Kitoh H, Mishima K, et al. 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. J Pediatr Orthop B 2020;29:542-549. https://doi.org/10.1097/BPB.0000000000000710
13. 13. Wenger DR, Pring ME, Hosalkar HS, Caltoum CB, Lalonde FD, Bastrom TP. Advanced containment methods for Legg-Calvé-Perthes disease: results of triple pelvic osteotomy. J Pediatr Orthop 2010;30:749-757. https://doi.org/10.1097/BPO.0b013e3181f5a0de
14. 14. Leitch JM, Paterson DC, Foster BK. Growth disturbance in Legg-Calvé-Perthes disease and the consequences of surgical treatment. Clin Orthop Relat Res 1991;262:178-184.
15. 15. Kong SY, Kim HW, Park HW, Lee SY, Lee KS. Effects of multiple drilling on the ischemic capital femoral epiphysis of immature piglets. Yonsei Med J 2011;52:809-817. https://doi.org/10.3349/ymj.2011.52.5.809
16. 16. Herrera Soto JA, Price CT. Core decompression and labral support for the treatment of juvenile osteonecrosis. J Pediatr Orthop 2011;31:212-216. https://doi.org/10.1097/BPO.0b013e318223b4d4
17. 17. Wang ZL, He RZ, Tu B, et al. Drilling combined with adipose-derived stem cells and bone morphogenetic protein-2 to treat femoral head epiphyseal necrosis in juvenile rabbits. Curr Med Sci 2018;38:277-288. https://doi.org/10.1007/s11596-018-1876-3
18. 18. Novais EN, Sankar WN, Wells L, Carry PM, Kim YJ. Preliminary results of multiple epiphyseal drilling and autologous bone marrow implantation for osteonecrosis of the femoral head secondary to sickle cell disease in children. J Pediatr Orthop 2015;35:810-815. https://doi.org/10.1097/BPO.0000000000000381
19. 19. Park KW, Rejuso CA, Cho WT, Song HR. Timing of premature physeal closure in Legg-Calve-Perthes disease. Int Orthop 2014;38:2137-2142. https://doi.org/10.1007/s00264-014-2394-y
20. 20. Waldenström H. The definite form of the coxa plana. Acta Radiol 2016;57:79-94. https://doi.org/10.1177/0284185116642923
21. 21. Wiberg G. Studies on dysplastic acetabula and congenital subluxation of the hip joint: with special reference to the complication of osteoarthritis. Acta Chir Scand 1939;83:58.
22. 22. Stulberg SD, Cooperman DR, Wallensten R. The natural history of Legg-Calvé-Perthes disease. J Bone Joint Surg Am 1981;63:1095-1108.
23. 23. Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am 2008;90:47-66. https://doi.org/10.2106/JBJS.H.00756
24. 24. Mose K. Methods of measuring in Legg-Calvé-Perthes disease with special regard to the prognosis. Clin Orthop Relat Res 1980;150:103-109. 25. Risser JC. The Iliac apophysis; an invaluable sign in the management of scoliosis. Clin Orthop 1958;11:111-119.
25. 26. Joseph B, Varghese G, Mulpuri K, Narasimha Rao K, Nair NS. Natural evolution of Perthes disease: a study of 610 children under 12 years of age at disease onset. J Pediatr Orthop 2003;23:590-600. https://doi.org/10.1097/00004694-200309000-00005
26. 27. Rich MM, Schoenecker PL. Management of Legg-Calvé-Perthes disease using an A-frame orthosis and hip range of motion: a 25-year experience. J Pediatr Orthop 2013;33:112-119. https://doi.org/10.1097/BPO.0b013e318281ab44
27. 28. Wiig O, Terjesen T, Svenningsen S. Prognostic factors and outcome of treatment in Perthes' disease: a prospective study of 368 patients with five-year follow-up. J Bone Joint Surg Br 2008;90:1364-1371. https://doi.org/10.1302/0301-620X.90B10.20649
28. 29. Terjesen T, Wiig O, Svenningsen S. The natural history of Perthes' disease. Acta Orthop 2010;81:708-714. https://doi.org/10.3109/17453674.2010.533935
29. 30. Rosello O, Solla F, Oborocianu I, et al. Advanced containment methods for Legg-Calvé-Perthes disease: triple pelvic osteotomy versus Chiari osteotomy. Hip Int 2018;28:297-301. https://doi.org/10.5301/hipint.5000569
30. 31. Oh HS, Sung MJ, Lee YM, Kim S, Jung ST. Does the duration of each waldenström stage affect the final outcome of Legg-Calvé-Perthes disease onset before 6 years of age? Children 2021;8:118(e1-6). https://doi.org/10.3390/children8020118
31. 32. Bowen JR, Schreiber FC, Foster BK, Wein BK. Premature femoral neck physeal closure in Perthes' disease. Clin Orthop Relat Res 1982;171:24-29.
32. 33. Wagenaar FB, Maathuis CG, van Erve RH. Treatment outcome in the most severely affected Legg-Perthes patients, comparing prolonged traction in abduction with femoral varus derotation treatment. J Child Orthop 2011;5:89-95. https://doi.org/10.1007/s11832-010-0309-z
33. 34. Kamiya N, Yamaguchi R, Adapala NS, et al. Legg-Calvé-Perthes disease produces chronic hip synovitis and elevation of interleukin-6 in the synovial fluid. J Bone Miner Res 2015;30:1009-1013. https://doi.org/10.1002/jbmr.2435
34. 35. Upasani VV, Badrinath R, Farnsworth CL, et al. Increased hip intracapsular pressure decreases perfusion of the capital femoral epiphysis in a skeletally immature porcine model. J Pediatr Orthop 2020;40:176-182. https://doi.org/10.1097/BPO.0000000000001284