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

Treatment of severe late-onset Perthes’ disease with soft tissue release and articulated hip distraction: Revisited at skeletal maturityORIGINAL CLINICAL ARTICLE
Treatment of severe late-onset Perthes’ disease with soft tissue release and articulated hip distraction: revisited at skeletal maturity
Eitan Segev Æ Eli Ezra Æ Shlomo Wientroub Æ Moshe Yaniv Æ Shlomo Hayek Æ Yoram Hemo
Received: 30 July 2007 / Accepted: 25 August 2007 / Published online: 27 September 2007
EPOS 2007
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.
the Oxford hip questionnaire for pain and function.
Radiographic assessment included: Sharp transverse ace-
tabular 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.
Results 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 (range
36–54) compared to 39 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.
parameters did not change significantly. This should be
regarded as a salvage procedure.
Keywords Late-onset Perthes’ disease Soft tissue release Hip distraction Skeletal maturity
Introduction
Perthes’ disease is defined as being of late onset when it is
first diagnosed in patients older than 9 years of age. Older
age at initial presentation carries a less favorable progno-
sis—rapid deterioration of the joint and early arthritic
changes are common [1]. These patients may develop a
saddle-shaped subluxating femoral head that cannot be
contained in the acetabulum. Since conservative treatment
does not change the shape of the femoral head or affect
joint congruency [2–10], different surgical treatment
options have been proposed, including varus osteotomy
(which may increase the incongruency) and valgus oste-
otomy (which may succeed in unloading the deformed part
but may increase the subluxation without influencing the
basic avascular process) [11–13].
E. Segev (&) E. Ezra S. Wientroub M. Yaniv S. Hayek Y. Hemo
Department of Pediatric Orthopaedics,
The Sackler Faculty of Medicine, Tel-Aviv University,
6 Weizmann Street, Tel-Aviv 64239, Israel
e-mail: [email protected]
DOI 10.1007/s11832-007-0046-0
Acetabular lateral shelf, Salter, Chiari, and triple oste-
otomies are considered salvage procedures at this age
group that aim to reorient or increase the size of the ace-
tabulum and produce more support to the femoral head
[14–18]. A newer approach to the disease involves intra-
epiphyseal femoral head osteotomies, but no long-term
results are available to date [19].
For the last several years, we have been using a com-
bination of soft tissue release and joint distraction with a
hinged mono-lateral external fixator to salvage the hip in
severe late-onset Perthes’ disease. The combined procedure
had a positive effect on the regeneration of bone and car-
tilage on both sides of the joint [20–23].
Our early results with 16 patients have been reported
elsewhere [24]. Ten of these patients have since reached
skeletal maturity. Their functional clinical and radio-
graphic assessments are described below.
Patients and methods
[24]. We used gradual distraction over a period of time
rather than acute distraction on the operating table during
surgery [23]. Of 16 patients who had undergone a com-
bined surgical procedure of soft tissue release and joint
distraction with a hinged mono-lateral external fixator in
our department between 1999–2004 [24], 10 had reached
skeletal maturity and comprise our current study group.
They included eight boys and two girls whose mean age at
surgery was 12.3 years (range 9.4–15.1). Their mean age at
last follow-up was 18.1 years (range 15.2–22.8), and the
mean follow-up was of 5.7 years (range 4.3–7.8). The
study was approved by our institutional review board and
registered with the ministry of health regulation with
application no 920060515.
last outpatient visit. We calculated the Harris hip score for
pain, function, daily activities, hip range of motion (ROM),
and limb length discrepancy [25], and all patients com-
pleted the Oxford hip questionnaire for pain and function
[26] (Table 1).
Orthocrat (OrthoCad Version 1.6) digital planning
software. We measured the following parameters; the
results are shown in Table 2.
1. Sharp transverse acetabular inclination for comparison
of the ten affected hips to the eight unaffected hips. This
is defined as the angle between a transverse pelvic line
at the tip of the tear drop and the oblique line from this
point to the superolateral corner of the acetabulum [27].
2. The uncoverage percentage (using Reimer’s subluxa-
tion index) for comparison of the ten affected hips to the
eight unaffected hips. This is defined as the percentage
of the femoral head at the widest transverse diameter that
protrudes laterally to Perkin’s vertical line [27].
3. The epiphyseal index (Eyre–Brook modified by Ton-
nis) as assessed on arthrograms before surgery, at
frame removal and on plain X-rays at last follow-up.
This is defined as the ratio between the epiphyseal
height at the midline point divided by the epiphyseal
width at its widest points [27]. The value was
multiplied by two for convenience of presentation;
normal range for our age group is 0.8–0.9.
4. The epiphyseal quotient (of Sjovall) on the last follow-
up X-rays, defined as the epiphyseal index of the
affected hip divided by the epiphyseal index of the
unaffected hip. This is a measure of epiphyseal flatness
compared to the unaffected side; normal range for our
age group is 0.8–0.9.
5. The Stulberg classification [28] (Table 2).
Statistical methods
to compare the affected and the unaffected hips for dif-
ferences in the acetabular inclination angle and subluxation
index. Two cases were excluded from this analysis since
both hip joints were involved. The non-parametric Wilco-
xon signed ranks test was used to compare the epiphyseal
index before surgery, at frame removal, and at last follow-
up. Significance was set at P \ 0.05.
Results
The mean Harris hip score was 86.3/100 (range 48.5–
96), with one patient scoring below 85 points. Six of the
ten patients reported slight pain (40/44 points) after
walking for more than an hour, but none was limited in
walking distance. Most patients had some limitation of
hip extension: the mean fixed flexion contracture was
230 J Child Orthop (2007) 1:229–235
123
6 (range 0–20), with 5 of extension on the unaffected
side (range –10 to 10). The abduction was limited, with
a mean of 28 (range 0–50) compared to 45 for the
unaffected side (range 30–50). The mean internal rota-
tion was 9 (range 0–15) compared to 40 for the
unaffected side (range 35–45). Three of the ten patients
had a limp due to limb shortening, and one of them had
a positive Trendelenburg sign.
There was no limb length discrepancy in three patients;
it was 1 cm in four patients and 2.5, 3.5, and 4 cm each in
the remaining three patients. The latter three patients used
shoe lifts (Table 1).
17.4/60 (range 12–31). Six of the ten patients reported
slight pain related to strenuous activity during the month
preceding the last follow-up.
No/gender Hip
30
15
No/no/0
Range 15.2–22.2 years 9.4–15.1 years 4.3–7.8 48.5–96 12–31 FFD: 0–20
AB: 0–50
IR: 0–15
Mean 18.1 years 12.3 years 5.7 86.1 17.2 FFD: 6
AB: 28
IR: 9
DOB, date of birth; FU, follow-up; ROM, range of motion; FFD, fixed flexion deformity; AB, abduction; IR, internal rotation; LLD, limb length
discrepancy
123
The mean Sharp transverse acetabular inclination for the
ten affected hips was 42 (range 36–54) compared to a
mean of 39 (range 36–46) for the eight unaffected hips
(P \ 0.045). The mean uncoverage percentage (using
Reimer’s subluxation index) for the ten affected hips was
37% (range 27–47) compared to a mean of 20% (range 0–
41) for the eight unaffected hips (P \ 0.017). The mean
epiphyseal index (Eyre–Brook modified by Tonnis) before
surgery was 0.71 (range 0.31–0.92), and it improved to a
mean of 0.79 (range 0.50–0.93) at frame removal
(P = 0.012). The results for the epiphyseal index at the last
follow-up showed similar values to those before surgery
(mean 0.72, range 0.51–0.89; P = 0.646). The epiphyseal
quotient (Sjovall) for the eight unilateral cases was 0.72
(range 0.49–0.91). Three of the affected hips had a type III
Stulberg classification and seven had a type IV (Figs. 1, 2;
Table 2).
lead to pain, arthritic changes, and stiffness. In Perthes’
disease the collapse of the femoral head during the
avascular stage creates a deformed incongruent situation
with increased stresses across the joint; this may even-
tually result in early degenerative changes. In order to
prevent degeneration of the joint, different treatment
strategies have been offered. Reports on the value of hip
distraction appeared in the early nineties and again
recently when it was applied to stiff hips with Perthes’
disease and to other conditions with joint surface irregu-
larity [20, 23].
provide nourishment to the joint cartilage and improve
regeneration. Joseph et al. [1] recommended that treatment
should be started before epiphyseal collapse had occurred,
Table 2 Radiographic measurements of 10 Perthes’ patients
No/gender Involved
lt 38 41
lt 38 27
Lt 41 27 0.76 0.93 0.88 3
4/M rt 37 0 0.6
Lt 36 47 0.92 0.92 0.625 4
5/M rt 40 20 0.49
Lt 40 38 0.7 0.75 0.53 4
6/F rt 36 15 0.69
Lt 36 31 0.8 0.93 0.77 4
7/F Rt 54 45 0.7 0.84 0.74 0.86 4
lt 46 19
9/M lt 43 23 0.91
lt 47 27 0.76 0.86 0.89 3
10/M Rt 37 26 0.7 0.74 0.84 3
Lt 43 40
Range Affected hip 36–54 27–47 0.31–0.92 0.50–0.93 0.51–0.89 0.49–0.91
Unaffected hip 36–46 0–41
Mean Affected hip 42 37 0.71 0.79 0.72 0.72
Unaffected hip 39 20
a Rt, right; Lt, left. Italics indicate affected hip; bold indicates old disease; neither italics nor bold indicates unaffected hip
preop, before surgery; postop, at frame removal
232 J Child Orthop (2007) 1:229–235
123
since the potential to remodel in the older age group
children is limited. Maxwell et al. [30] applied the articu-
lated distractor to hips with minimal collapse in order to
maintain epiphyseal height. They reported early results
with preservation of epiphyseal height and arrest of
epiphyseal collapse.
patients with osteonecrosis and joint space narrowing. All
their patients had constant pain and limited ROM, both of
which improved after a mean duration of 4.4 months with
the fixator. Although joint space widened from a mean of
2.6 mm to a mean of 4.8 mm, there was significant dete-
rioration compared to the immediate postoperative period
at latest follow-up [23].
skeletal maturity. Improvement in pain could be attributed
to the late stage of the disease with accompanying
reduction of the inflammatory changes and may not reflect
a better outcome compared to other treatments. Our early
results [24] had shown improvement of head sphericity at
frame removal, but the values we now measured at skeletal
maturity were similar to the preoperative ones. This dete-
rioration may reflect the possibility that the regenerated
femoral head is less resistant to normal stresses across the
joint. Although the overall clinical satisfaction from this
treatment was high, the radiographic results for head un-
coverage and epiphyseal index did not improve
significantly.
We did not perform any additional surgery on the ace-
tabulum after the distraction procedure. Theoretically, such
surgery can still be performed and we will consider addi-
tional surgery should there be any indication for it.
Our results are comparable to those of the established
method of valgus extension osteotomy as a salvage pro-
cedure for hinge abduction. Two recent papers reported
significant clinical improvement following osteotomy, i.e.,
Fig. 2 a Patient no. 3:
radiograph immediately after
follow-up at skeletal maturity,
radiograph before surgery with
follow-up at skeletal maturity,
123
an average Iowa hip score of 86 for 51 operated hips [31]
and an average score of 92 for 21 operated hips [32]. The
radiographic results were, however, again less favorable,
i.e., Stulberg class IV and V in 53% [31] and III and IV in
85.7% [32], results that are similar to the outcome for our
patients.
compared and used as a reference for conservative or
surgical treatment outcome in children with late-onset
Perthes’ disease as they reach the important stage of
skeletal maturity.
protocol to:
– late onset disease, that is a skeletal age of 9 years or
older;
lished deformity; and
obliquity.
procedure without compromising the possibility for future
surgery.
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Treatment of severe late-onset Perthes’ disease with soft tissue release and articulated hip distraction: revisited at skeletal maturity
Abstract
Purpose
Methods
Results
Conclusion
Introduction