Relative neck lengthening and intracapital osteotomy for severe Perthes and Perthes-like deformities

Intra-articular and extra-articular femoral Perthes deformities, or either, can result in severe alterations of the proximal femur and secondarily even involve the acetabulum, which can lead to premature osteoarthritis (OA) of the hip. In affected hips, joint damage due to impingement and instability may coexist. Classically, extra-articular impingement and associated abductor insufficiency in Perthes disease or similar pathologies are treated by trochanteric advancement. However, this leaves intra-articular impingement and instability unaddressed. The technique of surgical dislocation of the hip, in combination with a retinacular fap, allows for the relative lengthening of the femoral neck and even femoral head reduction osteotomy in such cases. This can be combined with an acetabular procedure to treat the secondary dysplasia. Since 2001, 14 patients with a minimum follow-up of 3 years have been treated by this technique without complications, such as femoral head osteonecrosis or trochanteric failures. All patients had markedly improved pain levels, hip mobility, and gait.     

Hip abductor function in adults treated for Perthes disease

This study investigated hip abductor function by isokinetic dynamometry and gait analysis in adults treated for Perthes disease and its relationship with clinical results. Eighteen patients were divided into two groups on the basis of good versus poor clinical results (IOWA hip-rating scale above or below 90 points). We found that patients with poor clinical results had a lower peak abduction moment (P=0.01) when tested on a dynamometer, and a higher hip abductor moment during gait, as percentage of peak abduction, at the affected hip than at the unaffected hip (P=0.047). Inefficient hip abductor function at the affected hip seems to be associated with poor clinical results.     

Algorithm for Femoral and Periacetabular Osteotomies in Complex Hip Deformities

Background  

Residual acetabular dysplasia of the hip in most patients can be corrected by periacetabular osteotomy. However, some patients have intraarticular abnormalities causing insufficient coverage, containment or congruency after periacetabular osteotomy, or extraarticular abnormalities that limit either acetabular correction or hip motion. For these patients, we believe an additional proximal femoral osteotomy can improve coverage, containment, congruency and/or motion.     

The Need for Total Hip Arthroplasty in Perthes Disease: A Long-term Study

Background  

Legg-Calvé-Perthes disease (LCPD) was described a century ago. In previous long-term reports of patients with LCPD, nonoperative treatment varied considerably. The likelihood of hip osteoarthritis (OA) developing in patients with LCPD and possible need for THA are not well defined.     

Perthes-like disease in Alagille syndrome

We describe a unique case of a bilateral osteochondrosis of the femoral heads, similar to Perthes disease, in a boy affected by Alagille syndrome. This is a rare genetic syndrome, caused by vascular anomalies, and characterized by five main features: hepatic, cardiovascular, ophthalmological, skeletal malformations, and characteristic facial appearance. The most frequent skeletal finding is the 'butterfly vertebra'. We have followed the patient from the age of 5 years to the age of 20 years. We performed two bilateral valgus osteotomies when he was 10 years old to limit the progression of the deformity. We believe that the association of a bilateral osteochondrosis of the femoral heads with Alagille syndrome, a disease characterized by a vascular etiology, supports the hypothesis of angiogenic pathogenesis of Perthes disease.     

Residual Acetabular Dysplasia in the Reduced Hip

BackgroundResidual acetabular dysplasia occurs in up to a third of patients treated successfully for developmental dysplasia of the hip (DDH) and has been found to be a significant risk factor for early hip osteoarthritis (OA).DiscussionAge at the time of initial reduction and the initial severity of DDH have been linked to residual acetabular dysplasia. An anteroposterior pelvic radiograph is the main diagnostic modality, but MRI also provides valuable information, particularly in equivocal cases. The literature supports intervening when significant residual acetabular dysplasia persists at 4–5 years of age, and common surgical indications include acetabular index (AI) > 25°–30°, lateral center–edge angle (LCEA) < 8°–10°, and a broken Shenton’s line on radiographs; and a cartilaginous acetabular angle (CAI) > 18°, cartilaginous center–edge angle (CCE) < 13°, and/or the presence of high-signal intensity areas on MRI. Surgical options include redirectional pelvic osteotomies and reshaping acetabuloplasties, which provide comparable radiographic and clinical results.ConclusionRAD is common after treatment of DDH and requires regular follow-up for diagnosis and appropriate management to decrease the long-term risk of OA. Long-term outcomes of patients treated with pelvic osteotomies are generally favorable, and the risk of OA can be decreased, although the risk of total hip replacement in the long-term remains.     

Hip range of motion in Perthes’ disease: comparison of pre-operative and intra-operative values

Background  Children with early Perthes’ disease and clinical loss of motion are commonly noted to have normal or almost normal hip range of motion (ROM) when examined under anesthesia (EUA). Despite anecdotal comments about this observation, no series has documented these findings. The lack of such data led to this study. Methods  Consecutive patients with unilateral Herring class B or C Perthes’ disease in mid to late Waldenstrom’s fragmentation stages who failed a non-operative course of hip motion restoration had hip range of motion (ROM) documented pre-operatively and intra-operatively by a single, experienced pediatric orthopedic surgeon. The opposite normal hip’s ROM was used as the control. Joint congruity was assessed arthrographically. Results  Twenty-seven patients, 6–10 years old (average 7.9 years) with early Perthes’ disease were reviewed. Twenty-one of 27 patients (77.7%) had full or almost full hip ROM of the involved side when examined under anesthesia (EUA). Six patients (22.3%) had limited abduction (<50 degrees) and underwent an adductor tenotomy that normalized hip ROM. Five of these six patients were older than 8 years. Intra-operative arthrography did not demonstrate lack of containment, hinge abduction or joint incongruity. Conclusions  Loss of hip ROM in this series of patients with early Perthes’ disease without intra-articular incongruity was due to pain and muscle spasm which were obviated by anesthesia, demonstrating essentially normal hip ROM in the majority of patients. Pre-operative bed rest and traction was not required to restore ROM in this group of patients. The author has received no financial support for this study.     

Coracoid Abnormalities and Their Relationship with Glenohumeral Deformities in Children with Obstetric Brachial Plexus Injury

Background  

Patients with incomplete recovery from obstetric brachial plexus injury (OBPI) usually develop secondary muscle imbalances and bone deformities at the shoulder joint. Considerable efforts have been made to characterize and correct the glenohumeral deformities, and relatively less emphasis has been placed on the more subtle ones, such as those of the coracoid process. The purpose of this retrospective study is to determine the relationship between coracoid abnormalities and glenohumeral deformities in OBPI patients. We hypothesize that coracoscapular angles and distances, as well as coracohumeral distances, diminish with increasing glenohumeral deformity, whereas coracoid overlap will increase.     

Perthes-like changes in geleophysic dysplasia

Geleophysic dysplasia is a rare skeletal dysplasia characterised by 'happy natured' facies, short stature with short limbs, brachydactyly, and joint contractures. This report describes a case of a patient with unilateral Legg-Calvé-Perthes-like changes associated with dysplastic proximal capital femoral epiphysis, typical to geleophysic dysplasia.     

外展承重支架治疗Perthes病的临床观察和有限元分析

目的总结髋部外展支架治疗Perthes病的效果,分析其生物力学原理。方法用髋外展支架治疗214例、222髋儿童股骨头缺血性坏死,参照廖前德法按优、良、可、差4个等级评价治疗效果。建立股骨上段三维有限元模型,测定髋外展时股骨头内部和股骨颈的应力。结果所有病例经过2年以上的随访,优202髋,良18髋,可2髋。力学分析髋外展时,股骨头内部的应力逐渐缩小;股骨颈的内、外侧方的应力值则逐渐增大。结论用髋部外展支架治疗Perthes病是一种较好的方法,髋外展可改变应力由股骨头经股骨颈的传导。     

Outcomes of Eight‐Plate Epiphysiodesis for Residual Clubfoot Deformities

ObjectiveThe outcome of congenital clubfoot treatment is still challenging if the feet deformities are not completely corrected. Here we explore a minimal invasive procedure with an eight‐plate implant to correct the residual forefoot adduction deformity after treatment of neglected or relapsed clubfoot.MethodsWe retrospectively reviewed patients with residual forefoot adduction deformity after clubfoot treatment between January 2013 and June 2016. The patients underwent temporary epiphysiodesis of the lateral column of the mid‐foot, which in detail, an eight‐plate was placed on each side of the calcaneocuboid joint. The foot deformities were recorded according to the weight‐bearing radiographic measurements including talo‐first metatarsal angle, calcaneo‐fifth metatarsal angle and medial‐to‐lateral column length.ResultsA total of 13 patients (20 feet) with an average age of 7.8 years old were located with an average duration of 40.8 months follow‐up (range, 28 to 54 months). The average talo‐first metatarsal angle improved from 28.3° (range, 19° to 47°) preoperatively to 8.3° (range, 3° to 18°) and the calcaneo‐fifth metatarsal angle improved from 29.1° (range, 19° to 40°) preoperatively to 8.4° (range, 0° to 21°) at final follow‐up. The mean ratio of the medial‐to‐lateral column length improved from 1.14 ± 0.06 to 1.55 ± 0.09 with statistical significance (t = 3.566; P < 0.001).ConclusionsEight‐plate epiphysiodesis is an easy and effective method for the correction of residual forefoot adduction deformity after clubfoot treatment in growing children without the need of osteotomy.     

Relative Femoral Neck Lengthening Improves Pain and Hip Function in Proximal Femoral Deformities With a High-riding Trochanter

BackgroundComplex proximal femoral deformities, including an elevated greater trochanter, short femoral neck, and aspherical head-neck junction, often result in pain and impaired hip function resulting from intra-/extraarticular impingement. Relative femoral neck lengthening may address these deformities, but mid-term results of this approach have not been widely reported.Questions/purposesDo patients who have undergone relative femoral neck lengthening show (1) less hip pain and greater function; (2) improved radiographic parameters; (3) significant complications requiring subsequent surgery; and (4) progression of osteoarthrosis (OA) or conversion to total hip arthroplasty (THA) at mid-term followup?MethodsWe retrospectively reviewed 40 patients (41 hips) with isolated relative femoral neck lengthening between 1998 and 2006 with sequelae of Legg-Calvé-Perthes disease (38 hips [93%]), slipped capital femoral epiphysis (two hips [5%]), and postseptic arthritis (one hip [2%]). During this time, the general indications for this procedure included a high-riding greater trochanter with a short femoral neck with abductor weakness and symptomatic intra-/extraarticular impingement. Mean patient followup was 8 years (range, 5–13 years), and complete followup was available in 38 patients (39 hips [95%]). We evaluated pain and function with the impingement test, limp, abductor force, Merle d’Aubigné-Postel score, and range of motion. Radiographic parameters included trochanteric height, alpha angle, and progression of OA. Subsequent surgeries, complications, and conversion to THA were summarized.ResultsThe proportion of positive anterior impingement tests decreased from 93% (38 of 41 hips) preoperatively to 49% (17 of 35 hips) at latest followup (p = 0.002); the proportion of limp decreased from 76% (31 of 41 hips) to 9% (three of 35 hips; p < 0.001); the proportion of normal abductor strength increased from 17% (seven of 41 hips) to 91% (32 of 35 hips; p < 0.001); mean Merle d’Aubigné-Postel score increased from 14 ± 1.7 (range, 9–17) to 17 ± 1.5 (range, 13–18; p < 0.001); mean internal rotation increased to 25° ± 15° (range, 0°–60°; p = 0.045), external rotation to 32° ± 14° (range, 5°–70°; p = 0.013), and abduction to 37° ± 13° (range, 10°–50°; p = 0.004). Eighty percent of hips (33 of 41 hips) showed normal trochanteric height; alpha angle improved to 42° ± 10° (range, 27°–90°). Two hips (5%) had subsequent surgeries as a result of lack of containment; four of 41 hips (10%) had complications resulting in reoperation. Fourteen of 35 hips (40%) showed progression of OA; four of 40 hips (10%) converted to THA.ConclusionsRelative femoral neck lengthening in hips with combined intra- and extraarticular impingement results in reduced pain, improved function, and improved radiographic parameters of the proximal femur. Although lack of long-term complications is gratifying, progression of OA was not prevented and remains an area for future research.

Level of Evidence

Level IV, therapeutic study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-4032-9) contains supplementary material, which is available to authorized users.