Intertrochanteric varus osteotomy for Perthes' disease. Radiographic changes after 2-16-year follow-up of 126 hips.

We analyzed various prognostic factors in 112 children operated on for Perthes' disease (Catterall's groups II-IV); special attention was paid to acetabular changes and postoperative containment. The radiographic results of 126 intertrochanteric femoral varus osteotomies were analyzed 2-16 years postoperatively. Catterall's grouping or head-at-risk phenomenon, bicompartmentalization of the acetabulum, and preoperative subluxation of the femoral head did not correlate with the result. The result was worse in cases operated on in the healing phase of the disease and in patients operated on at the age of 9 years or older. The strongest prognostic factor was containment of the femoral head after osteotomy.     

Prognosis in Perthes' disease after noncontainment treatment. 106 hips followed for 28-47 years.

The results in 96 patients (106 hips) with Perthes' disease who had had conservative noncontainment treatment were studied after 35 (28-47) years. At skeletal maturity, the radiographic result was poor in 65 hips. At the average age of 43 years, radiographic signs of arthrosis were found in 48 patients (51 hips); 5 patients had had hip replacement and 13 patients had symptoms justifying that procedure. At early phases of the disease, radiographs showed biocompartmentalization of the acetabulum in 24 percent of the hips, but the acetabulum normalized in the majority. There was no difference in long-term prognosis between Catterall's Groups III and IV; two or more signs of head-at-risk were not of prognostic value. The patients' age at diagnosis and the shape of the femoral head at skeletal maturity were the most reliable prognostic factors.     

Intertrochanteric varus osteotomy for Perthes' disease: Radiographic changes after 2-16-year follow-up of 126 hips

We analyzed various prognostic factors in 112 children operated on for Perthes' disease (Catterall's groups II-IV); special attention was paid to acetabular changes and postoperative containment. The radio-graphic results of 126 intertrochanteric femoral varus osteotomies were analyzed 2-16 years postoperatively. Catterall's grouping or head-at-risk phenomenon, bicompartmentalization of the acetabulum, and preoperative subluxation of the femoral head did not correlate with the result. The result was worse in cases operated on in the healing phase of the disease and in patients operated on at the age of 9 years or older. The strongest prognostic factor was containment of the femoral head after osteotomy.     

Modified Chiari osteotomy for arthrosis after Perthes' disease: 14 hips followed for 2-12 years

Between 1983 and 1995, a modified Chiari pelvic osteotomy was performed for coxarthrosis after Perthes' disease in 13 patients (14 hips). The median age at operation was 33 (16-56) years. The median duration of follow-up was 6 (2-12) years.

The center-edge angle, Sharp's angle, acetabulum head index and acetabular edge angle improved substantially. The median hip score substantially improved from 76 (46-90) points to 91 (71-100) points at the most recent follow-up examination. We recommend this procedure for patients who have early arthrosis, acetabular dysplasia, pain and good range of motion.     

Perthes' disease: prognosis in children under six years of age

Children presenting with Perthes' disease before their sixth birthday are considered to have a good prognosis. We describe 166 hips in children in this age group. The mean age at onset of the disease was 44 months (22 to 72). Mild forms (Catterall I and II) were treated conservatively and severe forms (Catterall III and IV) either conservatively or operatively. The aim of the former treatment was to restrict weight-bearing. Operative treatment consisted of innominate osteotomy and was indicated by a Conway type-B appearance on the bone scan. All the patients were followed to skeletal maturity with a mean follow-up of 11 years (8 to 15). The end results were evaluated radiologically using the classifications of Stulberg and Mose. A total of 50 hips were Catterall grade-I or grade-II, 65 Catterall grade-III and 51 Catterall grade-IV. All hips with mild disease had a good result at skeletal maturity. Of the hips with severe disease 78 (67.3%) had good (Stulberg I and II), 26 (22.4%) fair (Stulberg III) and 12 (10.3%) poor results (Stulberg IV and V). Of the Catterall grade-III hips 38 were treated conservatively of which 31 (81.6%) had a good result, six (15.8%) a fair and one (2.6%) a poor result. Operative treatment was carried out on 27 Catterall grade-III hips, of which 21 (77.8%) had a good, four (14.8%) a fair and two (7.4%) a poor result. By comparison conservative treatment of 19 Catterall grade-IV hips led to ten (52.7%) good, seven (36.8%) fair and two (10.5%) poor results. Operative treatment was carried out on 32 Catterall grade-IV hips, of which 16 (50.0%) had a good, nine (28.1%) a fair and seven (21.9%) a poor result. We confirm that the prognosis in Perthes' disease is generally good when the age at onset is less than six years. In severe disease there is no significant difference in outcome after conservative or operative treatment (p > 0.05). Catterall grade-III hips had a better outcome according to the Stulberg and Mose criteria than Catterall grade-IV hips, regardless of the method of treatment.     

The assessment of prognosis in Perthes' disease

Seventy children who had suffered from Perthes' disease were reviewed clinically and radiologically three to eight years from the onset of the condition in order to determine retrospectively the most satisfactory method of assessing the prognosis and the correlation between the clinical and radiological result. In younger children the femoral head was more likely to be spherical at the conclusion of the pathological process but not necessarily of normal proportions nor normally covered by the acetabulum. The prognosis was significantly poorer for girls than for boys. Clinical factors were not an aid to prognosis in the individual cases, but overall there was a close correlation between the clinical and the radiological end-results. The most reliable radiological factors indicating the prognosis were the extent of uncovering of the femoral head, the Catterall grouping, the presence of calcification lateral to the outer limit of the acetabulum and lateral displacement of the femoral head, as measured by comparing the head to tear-drop distances on each side.     

Perthes' disease after the age of twelve years. Role of the remaining growth.

In order to define the prognostic factors in Perthes' disease in children older than 12 years, we reviewed 15 patients at the end of growth who were aged 12.1 to 14 years at presentation. The patients with the worst long-term prognosis (Stulberg class V) were compared with the others for age, skeletal maturity and remaining growth (Oxford method), as well as Catterall and Waldenstr?m classifications at presentation. A significant difference (p = 0.001) was found for remaining growth (25% in Stulberg class V and 35% in the others) and also for the results at the end of growth when the remaining growth was over 30%, since this allowed sufficient time for reformation and remodelling of the femoral head.     

The long-term prognosis of unilateral Perthes' disease

We have attempted to identify the most important long-term prognostic factors in Perthes' disease by studying 61 patients affected unilaterally. The average age at diagnosis was 7 years 5 months and at follow-up it was 32 years, an average interval of 25 years. The age at diagnosis, age at follow-up, Catterall group, acetabular coverage, femoral head subluxation and the other head-at-risk signs were statistically correlated with Stulberg, Cooperman and Wallensten (1981) radiographic classes and the Iowa hip score. Statistically significant correlations were found between Stulberg class and Iowa hip score; age at diagnosis and Stulberg class; age at follow-up and Iowa hip score; and between lateral subluxation of the femoral head and Iowa hip score. Three age-groups of patients were found to carry different long-term prognoses. Those below five years of age at diagnosis showed a statistically significant correlation between Catterall group and Stulberg Classes I and II. Patients between five and nine years of age at diagnosis showed a significant correlation between Catterall group and Stulberg Classes I, II, III and IV while in patients diagnosed after nine years of age there was no statistical correlation between Catterall group and Stulberg class, all having a poor prognosis and ending up in Stulberg Classes III, IV and V.     

The acetabular opening angle in Perthes' disease. Radiographic study of 62 unilateral cases.

Pelvis AP radiographs in 62 patients with unilateral Perthes' disease were studied in search of changes of the acetabulum throughout the active stages of this disease. The length of the acetabular roof, the diameter of the acetabulum, and the opening angle of the acetabulum, were compared with the contralateral hip. The length of the acetabular roof did not change, but the opening angle and the diameter of the acetabulum increased. This increase began in the earliest stage of the disease in half of the cases; it reached a maximum during the resorptive and the reconstructive stages, then it decreased to reach normal values at skeletal maturity. These changes were related to the extent of the epiphyseal necrosis. Probable causes were local hyperemia and a mechanical adaptation of the acetabulum to a cartilaginous coxa magna. The opening angle has a prognostic value and influences our choice of therapy.     

The ScanHip ® total hip arthroplasty: Radiographic assessment of 72 hips after 10 years

We analyzed the radiographic and clinical outcome of the ScanHip total hip arthroplasty in 70 patients after 10 years. The Swedish National Hip Register, in which the end-point of the survival analysis is defined as revisions, reported a 10-year survival rate of 94% with the ScanHip, but in the present series 13% of the femoral stems and 29% of the sockets met the criteria for aseptic loosening. Focal osteolysis was found around 8 sockets (11%) and 23 stems (32%) and had occurred significantly oftener around loose sockets, but not around femoral stems. Linear polyethylene wear was significantly increased in loose sockets, but no relationship was noted between polyethylene wear and stem loosening or was there a correlation between clinical symptoms or patients' satisfaction and component loosening. Therefore precise serial long-term radiographic follow-up is the only satisfactory method for detecting aseptic loosening of total hip arthroplasty. It gives the surgeon more detailed information about each case than survival analysis alone.     

Acetabular remodelling in Perthes' disease after primary healing.

We conducted a study to assess the remodelling potential of the acetabulum of 29 children with Perthes' disease. In all but four, the acetabular head index (AHI) increased in the time between primary healing of the femoral head and follow-up at skeletal maturity. We classified 13 cases (44.8%) in which the increase in AHI was more than 10% as group I. In this group, the outcome at follow-up was predictable when subluxation during the active phase of the disease decreased until primary healing. Our observations suggest that the position of the femoral head, rather than sphericity, is the most important factor in acetabular growth and remodelling.     

Dysostotic changes and the prognosis of Perthes' disease after operation (author's transl)]

Goff and Mau for the first time demonstrated dysostotic changes in children with Perthes' disease. Their effect on the course of the disease has not so far been determined. It was examined on 41 patients following varus-osteotomy. Follow-up after 2--6 years showed late radiologic results, measured against the total quotient (Heyman and Herndon) depended essentially on this dysostotic component. The worst results are seen in children with high-grade skeletal retardation. Final results are further influenced by age, stage of the disease at the time of surgery and pre-operative status. Age plays a part in that results are better the younger the child. There are obvious parallels between results of radiologic and histologic examination at the time of operation and the weightbearing capacity. Dysostotic changes prolong the course of Perthers's disease and cause long-term lack of firmness of the femoral head. The influence of these facts on the still controversial indication for surgery is discussed. Our findings suggest that protection against weightbearing should be prolonged after operation according to the dysostotic changes.     

Femoral anteversion in Perthes' disease with observations on irritable hips. Application of a new method using ultrasound

A new ultrasound method was used to measure femoral anteversion (torsion) of both hips in children with unilateral Perthes' disease, children with previous irritable hips, and healthy children of a similar age. In children with Perthes' disease, the mean femoral anteversion of affected hips is significantly higher compared with normal controls. In the opposite hips, femoral anteversion for right and left hips separately is not significantly different from that of controls. The affected hips show a significantly greater scatter of anteversion than do normal hips, which could be secondary to the disease; but the opposite hips also show a significantly wider scatter of anteversion than do normal hips, which suggests a developmental abnormality of femoral torsion in the femur of the unaffected limb. In children with Perthes' disease, femoral anteversion asymmetry is characteristic, marked, and significantly different from that of normal hips, with the affected hips usually being the more anteverted (with two exceptions). Irritable hips show significantly greater femoral anteversion asymmetry than do normal hips, with the affected femur usually being less anteverted than the opposite femur. These observations may have relevance in Perthes' disease with respect to both etiology, femoral osteotomy, and prognosis.     

Skeletal immaturity in Perthes' disease.

Skeletal age was estimated by examination of radiographs of the carpus in 182 children suffering from Perthes' disease after the reliability of the Greulich and Pyle Atlas had been checked for a control group of British children. A striking tendency to delayed skeletal maturation was shown in the children with Perthes' disease. This trait was also found in ninety-three unaffected siblings of the patients. The velocity of skeletal ageing as the disease progressed was estimated. In some patients the carpal skeleton failed to mature at all for periods of up to three years and the term "skeletal standstill" is applied to this phenomenon. The significance of these findings is discussed and it is suggested that the maturation defect may have aetiological significance.     

Serum immunoglobulin in Perthes' disease.

Serum immunoglobulin concentrations in 41 children with Perthes' disease and 82 age and sex matched controls were measured by radial immunodiffusion. Significant increases in IgG and IgM were seen in children with Perthes' disease.     

The pathogenesis of Perthes' disease.

It has been shown that in the puppy, two infarcts separated by an interval of four weeks produce a disorder of long duration which results in flattening and broadening of the femoral head and which reproduces the radiological changes seen in Perthes' disease in man. The histological appearances produced by two infarcts are characteristic. In this study the histological appearance of fifty-seven femoral head biopsy specimens in Perthes' disease in man have been studied. In 51 per cent of hips histopathological changes characteristic of double infarction were present, and there were grounds for postulating that double infarction might eventually occur in all cases. The findings support the concept that the deformation of the femoral head and the chronicity of Perthes' disease in man may be due at least as much or even more to repeated episodes of infarction and the ensuing abnormalities of growth as to mechanical factors related to weight-bearing.     

Arthrodiastasis in Perthes' disease. Preliminary results

We have examined the effect of arthrodiastasis on the preservation of the femoral head in older children with Perthes' disease. We carried out a prospective trial in boys over the age of eight years and girls over seven years at the time of the onset of symptoms. The patients had minimal epiphyseal collapse and were compared with a conventionally treated, consecutive, historical control group. Arthrodiastasis was applied for approximately four months. The primary outcome measure was the extent of epiphyseal collapse at the end of the fragmentation phase. One of the 15 treated hips and nine of the 30 control hips showed a loss of height of 50% or more of the lateral epiphyseal column on the anteroposterior radiographs (Herring grade-C classification). On a Lauenstein view, one of the treated hips and 19 of the control hips showed at least a loss of height of 50% of the anterior epiphyseal column. The complications of arthrodiastasis included pin-site infection in most hips, transient joint stiffness in two, and breakage of a pin in two. The final outcome will be known when all the patients and the control group reach skeletal maturity.     

The Harris-Galante cementless femoral component:Poor results in 57 hips followed for 3 years

Between 1986 and 1991, 68 Harris-Galante femoral prostheses were implanted in 63 patients. 53 patients (57 hips) attended for follow-up after a mean of 3.4 (2-6) years. The average Harris Hip Score (HHS) was 39 preoperatively and 81 postoperatively. Only 34 hips were excellent (27) or good (7). Mid-thigh pain occurred in 30 cases. 10 femoral components were radiographically loose because of osteolysis.

Although 7 cups seemed to be radiographically loose, they probably played only a minor role in the poor overall early clinical results.