Hindawi Publishing Corporation
Advances in Orthopedics
Volume 2012, Article ID 490806, 7 pages
AComparisonof the Effectivenessof Surgicaland
NonsurgicalTreatment of Legg-Calve-Perthes Disease:
Mohammad Taghi Karimi1and Tony McGarry2
1Musculoskeletal Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran
2National Centre for Prosthetics and Orthotics, University of Strathclyde, Glasgow G1 1XQ, UK
Correspondence should be addressed to Mohammad Taghi Karimi, firstname.lastname@example.org
Received 17 April 2012; Accepted 24 June 2012
Academic Editor: Masato Takao
Copyright © 2012 M. T. Karimi and T. McGarry. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
Legg-Calve-Perthes disease (LCPD) is a degenerative condition of the hip joint characterised by idiopathic avascular necrosis of
the femoral head. Loss of bone mass causes a degree of collapse of the joint and may result in deformity of the ball of the femur
and the surface of the hip socket. A reduction in hip joint range of motion, alternation in growth of femoral head, and associated
pain are most important problems associated with this disease. Various treatment methods are currently in use and aim to increase
containment of the femoral head within the acetabulum, redistribute loading patterns applied to the femoral head, and to decrease
the final deformities associated with this condition. These treatments depend on a variety of underlying factors and the aim of
this paper was to determine appropriate pathways for treatment and the evidence of treatment method success. A review of the
relevant literature was carried out in a variety of data bases including PubMed and ISI Web of Knowledge, and Gale between
1950 and 2011. Research results were categorised depending on the identified treatment method. The success of each treatment
outcome. Evidence relating to the effectiveness of the treatment method used was conflicting. Different methods of screening and
follow-up periods were employed in each study which used subjects of varying ages. Minimal evidence of sufficient quality exists
in the literature to determine the most appropriate treatment of Legg-Calve-Perthes disease. Research provides some evidence
to suggest that nontreatment may be as effective as orthotic or surgical intervention. More research is required to determine the
effectiveness of orthotic and surgical treatment.
Legg-Calve-Perthes disease (LCPD) is a condition in which
the blood supply of femoral head is interrupted and the bone
temporarily dies. This may lead to irritability of the hip joint
and, depending on the severity, deformation of the head of
be multifactorial and may be of genetic or deprivation influ-
ence [1, 2]. The disease occurs in children between 5 and 12
years of age and is more prevalent in males. Incidence differs
in different countries and is also dependant on race (10.8 per
100,000 Caucasian, 0.45 Negroid children) [3, 4]. Higher
incidence is recorded in the areas of lower population com-
pared to more densely populated areas [3, 5, 6].
Problems associated with LCPD include decreased hip
joint range of motion, especially abduction, and alternation
in the growth of femoral bone which may lead to pain while
walking. Long term outcomes include instability or reduced
range of motion of the hip joint and increased incidence of
osteoarthritis [3, 5, 6].
A variety of treatment methods are used in LCPD to
maintain hip joint range of motion and aim to relieve
Treatments may be classified as operative and nonoperative
methods (Figure 1).
Although the original description of LCPD was made
over one hundred years ago , there is still a lack of agree-
ment as to the most appropriate form of treatment of the
2 Advances in Orthopedics
Bed rest with bucks traction
Ischial weight bearing brace
Scottish rite brace
Figure 1: Operative and nonoperative treatment of LCPD.
Table 1: Reported assessment methods used to categorise severity
of LCPD disease.
Score Mose method 
Wiberg centre edge
angle (Stulberg et al.)
(1981)  degree
condition and the patient groups to whom it should be
applied. There is no general agreement regarding whether
operative or nonoperative treatment is beneficial . As
the disease is relatively uncommon, most reports are based
on a limited number of patients. The availability of different
treatment modalities in various countries also adds uncer-
tainty and increases difficulty in facilitating comparison of
the outcome of different treatment methods [11, 12].
Most surgical corrections for LCPD are carried out
to increase the containment of femoral head within the
acetabulum by femoral or innominate osteotomy . A
combination of femoral and innominate osteotomy is also
suggested by some researchers [11, 13].
Nonoperative pathways are divided into either contain-
ment or noncontainment of the femoral head within the
The containment method was first described by Craig
(1957) and later revised by Bobechko et al. (1968) .
This method assumes that the most important factor in
the treatment of LCPD is to prevent deformity of the
femoral head. By containing the femoral head within the
acetabulum, the femoral head is protected from compression
by the acetabular margin. Containment position is defined
as abduction and internal rotation of the extremity until the
femoral epiphysis is well inside Perkins line [11, 12].
Additionally, orthotic devices may be used in nonopera-
tive treatment of the condition and are used in both contain-
ment and noncontainment treatment methods [7, 11–14].
Different designs are available and include the Newington
brace; the Toronto orthosis; the Scottish rite orthosis; the
broomstick plaster, the Birmingham orthosis.
Previous review papers exist relating to the nonsurgical
treatment of LCPD. Previous reviews are limited by the
attempt to grade the quality and study design of literature
according to a recognised scale has been undertaken. Fur-
thermore, no assessment of treatment success has been
examined and no comparison of the effectiveness the inter-
vention recorded. The aim of this paper is to determine the
most effective treatment method based on the outcome
achieved by examining results of each category of treatment.
keywordsused forthesearchwerePerthesdisease treatment,
avascular necrosis of the hip, and included specific topics,
such as gait analysis, orthosis, and containment and noncon-
tainment approach, which were identified by a multidisci-
plinary team of expert scientists and clinicians. The abstract
first selection of the relevant articles was completed based on
whether or not the title/abstract addressed the key words.
Selection stages are illustrated in Figure 2. The second
selection of the articles was completed according to the
(1) articles addressing the Perthes disease and its treat-
(2) experimental studies published in English.
the disease; treatment methods used; gender, reported treat-
ment outcome were selected for final analysis. Results were
categorised based on containment and noncontainment
hip joint, treatment, orthosis, containment method, surgery,
biomechanics, and gait analysis were selected for the final
2.1. Quality Assessment Tools and Data Extraction. First, the
research design of the studies was determined. Then, the
Advances in Orthopedics3
Table 2: The results of quality assessment of methodology of various research studies (total number of studies was 50).
Treatment approachesReporting (total score 10)
(total score 3)
Internal validity, bias
(total score 7)
confounding (total score 7)
Table 3: Heterogeneity of research studies.
P value of λ2
Degree of heterogeneity
Substantial to considerable
Not important to substantial
Not important to considerable
and Black tool. Two expert reviewers were asked to evaluate
the quality score of the methodology of each research study.
The correlation between the reviewer’s results was 0.87 for
the Downs and Black test. It has been shown that the relia-
bility and validity of this test is acceptable to be used in order
to evaluate the quality of the methodology [15, 16].
2.2. Evaluating the Heterogeneity of the Results of Research
Studies. Heterogeneity describes the difference between the
results of various studies as a result of sampling error or due
to present of a significant diversity of results. The hetero-
geneity of the results of the research studies was evaluated
by use of Q test and by use of I2. The Q test evaluates the
heterogeneity that has a λ2distribution (with n degree of
freedom, where n denotes the number of studies). P values
less than 0.05 indicate the presence of significant heterogene-
ity. The I2was calculated based on the following equation:
where Q is λ2and df is the degree of freedom based on the
number of studies. A rough guide used for heterogeneity in
this study was as follows [15, 16]:
(i) 0–40: not important,
(ii) 30–40: moderate heterogeneity,
(iii) 50–70: substantial heterogeneity,
(iv) 70–100: considerable heterogeneity.
2.3. Method of Assessment Used to Evaluate the Results of Var-
ious Treatment Approaches. A variety of different assessment
methods have been used to evaluate the success of LCPD
treatment. The most commonly used classification system in
research studies is the classification system developed by the
of Stulberg et al. [9, 17, 18], Evans , and Kelly et al. 
(Table 1). In Stulberg et al. method several radiographic
magna are evaluated. Based on this method, the hip joint is
classified into one to five categorizes, which include spherical
congruency (class I and II) and aspherical congruency (class
III, IV, and V) .
The method employed by Mose (1980) determines the
spherical measurement of the femoral head by means of
the resulting bone outline is circular or deviates from a
lateral roentgenograms, the result is considered good. Devi-
ation of 2mm on either X-ray is considered fair, and a poor
result determined to be a deviation of more than 2mm .
The Wiberg centre edge angle is determined as the angle
between the line connecting the lateral rim of acetabulum,
thecentreoffemoralhead,anda verticalline.This method is
also commonly used to determine severity of LCPD.
Analysed studies were categorised by the following
parameters: the number of subjects; the selected treatment
methods; the final outcome of the treatment; follow-up
duration; age at onset of the disease, gender.
100 articles from reviewed databases. Following application
of inclusion criteria 50 papers were selected for final analysis.
Analysis of papers determined four main themes which were
dependant on the treatment method: containment; noncon-
tainment; surgery, non-treatment. Based on the search strat-
egy, 50 articles were found, most of which were prospective
cohort study, case series, and case control (only one research
study was randomized-control trial). The results of quality
assessment of the research are summarised (Table 2), and the
results of heterogeneity test summarised in Table 3.
One of the approaches used for treatment of LCPD is
containment based method. In this treatment, various types
of orthoses such as abduction brace, Scottish rite, and
4 Advances in Orthopedics
Table 4: Results of containment research studies.
Martinez et al.
Herndon et al.
49 male, 11
5–111.5 Abduction orthosis 60.3 good, 30.9 fair, 8.8 poor
17No information7 No information Brace64.7 good, 17.6 fair, 17.6 poor
Meehan et al. 34 No information86.7
9 good, 26 fair, 65 poor
Stulberg et al.
Harrison et al.
88 76 male,12 female7.5 47.3 Bed rest with sling26 good, 25 fair, 49 poor
160 male, 53
No information5.8 Birmingham splint 57 good, 38 fair, 5 poor
Table 5: Results of noncontainment studies.
Gender Age (year)
Method Results (%)
Evans et al. 
Evans et al. 
Kelly et al. 
Sling with crutches
by Ischial weight
62.5 good, 20.8 fair, 16.7 poor
58.4 good, 16.6 fair, 25 poor
80 good, 11.25 fair, 8.75 poor
Herndon et al. 37 No information3.5–11 7.4
32.4 normal, 47.6 good, 10 fair,
studies describing this type of treatment showed that be-
tween 9 and 64.7% of subjects had a good outcome, based
on Paediatric Orthopaedic Society classification system
Conventional callipers, Snyder slings, slings with
crutches, and traction are other methods used as noncon-
tainment approach. Although the number of subjects and
follow-up duration of the selected research studies vary
between the research studies, the final results were nearly the
Three different methods of surgical intervention have
been described in LCPD. These include innominate osteoto-
my, femoral osteotomy, and a combination of both methods.
Results indicate that between 44.4 and 92% of subjects with
LCPD had a good score of treatment and did not show
significant difference when compared to containment and
Researched results of conservative treatment of LCPD,
where no intervention is applied are shown in Table 7. Be-
tween 11 and 59% of the subjects in studies, shown in
Table 7, had good final results. In contrast, form 16.7 to 75%
of the subjects did not have a satisfactory outcome (poor
Most studies examining treatment options in LCPD are of
most studies, subjects were followed up by investigators for a
long period of time ( from 4.5 to 22 years). Assessment
methods used to evaluate the condition were the same in
the most of the research studies. Heterogeneity tests also
showed that the final results of different noncontainment
treatment approaches did not illustrate important hetero-
geneity (Table 3). In contrast, the heterogeneity between the
results of other methods of treatment was high which causes
difficulty when establishing the effect of different treatment
The main aims of treatment of LCPD are to prevent the
further deformity of the femoral head, relief of symptoms,
containment of the femoral head, and restoration of range of
motion of the hip joint . There are two main methods
which have been used to reach to this goal: surgical and non-
surgical approaches. Evidence to determine the best mode
of treatment of the treatment of LCPD is inconclusive. Cur-
rently, most treatment approaches are based on preference,
experience, and training of clinicians. Variability of factors
which may affect disease process and the lack of knowledge
regarding pathophysiology may also contribute to difficulties
in establishing treatment guidelines.
A number of differing methods of treatment are also
employed in the treatment of this disease including differing
orthoses, the containment and noncontainment methods,
and surgical and non-surgical intervention.
4.1. Orthotic Intervention. A variety of different orthoses are
used in the treatment of LCPD (Tables 4 and 5). Orthoses
may be categorized as ambulatory (e.g., the abduction
orthosis, the Scottish rite orthosis, the Birmingham orthosis,
Advances in Orthopedics5
Table 6: The results of various research studies based on surgical operations.
Gender Age (year)
Robinson et al.
Bellyei and Mike
Bellyei and Mike
27Not reported 6.335–16
92 good, 0 fair, 8 poor
30 Not reported Not reportedNot reported Femoral osteotomy57 good, 23 fair, 20 poor
19Not reported 6.9Not reported Femoral osteotomy63.15 good, 10.5 fair, 26.3 poor
Paterson et al.  27Not reported 5.9 9.3
56 good, 41 fair, 4 poor
Lloyd et al. 
Lloyd et al. 
4–962.5 good, 25 fair, 12.5 poor
44.4 good, 22.2 fair, 33.4 poorNot reported
Table 7: The results of conservative treatment.
Lloyd et al. 
37 male, 9 female
6 male, 2 female
4.5459 good, 20.8 fair, 16.7 poor
58.4 good, 16.6 fair, 25 poor
11 good, 31 fair, 58 poor
25 fair, 75 poor
traditional calipers, and the Snyder sling) or nonambulatory
orthoses (such as traction and bed rest with sling).
Only one research paper was found that compared the
results ambulatory versus nonambulatory treatment. Results
of this paper indicated no outcome differences in the success
of treatment  (Tables 4 and 5). The main aim of weight
relief to protect the necrotic femoral head against body
weight however, is not biomechanically valid as the muscle
forces acting to support the joint in the specific location
applied greater intra-articular pressure than forces produced
during weight bearing . Weight relieving methods may
also produce additional adverse effects, such as muscular
atrophy, osteoporosis, asymmetric reduction in thoracic
kyphosis, urolithiasis, social-emotional problem, increasing
health budget, and high cost of hospitalisation .
4.2. Comparison between the Containment and NonContain-
used by different research studies, it is not possible to con-
clude whether containment or noncontainment is the most
effective method of treatment (Tables 4 and 5). Outcomes of
treatment with containment and noncontainment methods
were similar, although too much variation existed between
age of onset, gender, and follow-up period. Kelly et al. (1980)
have shown that the results not containing the femoral head
(using either a harness or sling with crutches) were good or
vast majority of patients with this disease can be successfully
treated without any attempt to force the femoral head within
the acetabulum. However, more evidence is required to allow
data to be compared.
ods of surgical intervention were inconclusive [23, 25, 26]
(Table 7). However, following innominate osteotomy, the
center edge and neck shaft angles, length of the limbs;
range of abduction, and total range of motion have been
angular positioning between the ball and the shaft of the
femur due to reduced femoral growth plate involvement.
This is also advantageous as scarring is minimised and less
possibility of introducing limb shortening exists .
4.4. Comparison between Surgery and Using an Orthosis.
Although treatment outcomes recorded are similar, the lack
of consistency of methodologies used by different research
studies makes it difficult to conclude whether surgical or
non-surgical treatment is the most effective in management
of this condition (Tables 4 and 7). The percentage of
acetabular coverage, extent of lateral femoral subluxation,
and age of the patients at onset of injury will influence
the final results and must be taken into account during
study design. One study compared orthotic treatment and
surgical intervention in two groups of patients with LCPD
by employing the same procedure . The results of this
research indicated similar outcomes following both methods
of treatment. [21, 22, 29].
Two main aims for the treatment of LCPD are to
decrease loads applied on the hip joint and increase the
congruency of articular surface. The results of selected
research studies focused in this paper show that there is
little difference between the outputs of treatment methods.
A further approach which has not been examined in detail
6 Advances in Orthopedics
ISI Web of Knowledge
100 abstracts selected
Evaluation in terms
of quality criteria
50 articles did not fullfill
one or more criteria
Fullfill the selected
Figure 2: Results of review process.
wouldquantifythemagnitude ofthe forceapplied onthe hip
joint over a period of time (force time integral of the vertical
force applied on the hip joint during walking).
The aim of this paper was to examine the evidence of success
of treatment methods used in Legg-Calve-Perthes disease
(LCPD) to assist in determining appropriate pathways for
Evidence relating to the effectiveness of the treatment
method used was found to be conflicting. Most treatments
were based on preference, experience, and training of
surgeons and clinical staff. Research using different methods
of treatment were difficult to compare as different methods
of screening and follow-up periods were employed in each
study which used subjects of varying ages.
Greater research of appropriate design is required to
facilitate comparison of outcome measurements recorded as
a result of different treatment options.
The results of this paper can be used by clinicians involved in
treatment of patients with LCPD.
 D. L. Evans, “Legg-Calv´ e-Perthes’ disease; a study of late
results,” The Journal of Bone and Joint Surgery, vol. 40, no. 2,
pp. 168–181, 1958.
 H. Eijer, R. P. Berg, D. Haverkamp, and G. A. B. M. Pecasse,
“Hip deformity in symptomatic adult Perthes’ disease,” Acta
Orthopaedica Belgica, vol. 72, no. 6, pp. 683–692, 2006.
 N. A. Purry, “The incidence of Perthes’ disease in three
Journal of Bone and Joint Surgery B, vol. 64, no. 3, pp. 286–288,
 S. M. Rowe, S. T. Jung, K. B. Lee, B. H. Bae, S. Y. Cheon, and K.
D. Kang, “The incidence of Perthes’ disease in Korea. A focus
on differences among races,” Journal of Bone and Joint Surgery
B, vol. 87, no. 12, pp. 1666–1668, 2005.
 D. J. P. Barker, E. Dixon, and J. F. Taylor, “Perthes’ disease of
the hip in three regions of England,” Journal of Bone and Joint
Surgery B, vol. 60, no. 4, pp. 478–480, 1978.
disease in Southwest Scotland,” Journal of Bone and Joint
Surgery B, vol. 87, no. 11, pp. 1531–1535, 2005.
 A. Catteral, Legg-Calv´ e-Perthes’ Disease, Churchill Living-
stone, New York, NY, USA, 1982.
 K. Mose, “Methods of measuring in Legg-Calv´ e-Perthes’
disease with special regard to the prognosis,” Clinical
Orthopaedics and Related Research, vol. 150, pp. 103–109,
 S. D. Stulberg, D. R. Cooperman, and R. Wallenstein, “The
and Joint Surgery A, vol. 63, no. 7, pp. 1095–8304, 1981.
 M. H. M. Harrison, M. H. Turner, and D. N. Smith, “Perthes’
disease. Treatment with the birmingham splint,” Journal of
Bone and Joint Surgery B, vol. 64, no. 1, pp. 3–11, 1982.
 W. Muirhead-Allwood and A. Catterall, “The treatment of
Perthes’ disease. The results of a trial of management,” Journal
of Bone and Joint Surgery B, vol. 64, no. 3, pp. 282–285, 1982.
 B. H. Curtis, S. F. Gunther, H. R. Gossling, and S. W. Paul,
“Treatment for Legg Perthes’ disease with the newington
ambulation abduction brace,” Journal of Bone and Joint
Surgery A, vol. 56, no. 6, pp. 1135–1146, 1974.
 J. P. Crutcher and L. T. Staheli, “Combined osteotomy as
a salvage procedure for severe Legg-Calv´ e-Perthes’ disease,”
Journal of Pediatric Orthopaedics, vol. 12, no. 2, pp. 151–156,
 W. P. Bobechko, C. A. McLaurin, and W. M. Motloch,
“Toronto orthosis for Legg-perthes’ disease,” Artificial Limbs,
vol. 12, no. 2, pp. 36–41, 1968.
Advances in Orthopedics7 Download full-text
 P. Julian and S. Green, Cohrance Handbook of Systematic
Reviews of Interventions, Edited by P. Julian, S. Green, John
Wiley and Sons, 2008.
 H. L. Julia, C. Jacquelineline, and P. Vijayan, Systematic
Reviews and Meta-Analysis, Edited by T. Tony, Oxford Univer-
sity Press, Oxford, UK, 2008.
 J. A. Herring, H. T. Hui, and R. Browne, “Legg-Calv´ e-Perthes’
disease. Part I: classification of radiographs with use of the
modified lateral pillar and stulberg classifications,” Journal of
Bone and Joint Surgery A, vol. 86, no. 10, pp. 2103–2120, 2004.
 J. G. Neyt, S. L. Weinstein, K. F. Spratt et al., “Stulberg
classification system for evaluation of Legg-Calv´ e-Perthes’
disease: intra-rater and inter-rater reliability,” Journal of Bone
and Joint Surgery A, vol. 81, no. 9, pp. 1209–1216, 1999.
 F. B. Kelly, T. Canale, and R. R. Jones, “Legg-Calv´ e-Perthes’
disease. Long-term evaluation of non-containment treat-
ment,” Journal of Bone and Joint Surgery A, vol. 62, no. 3, pp.
 P. D. Sponseller, S. S. Desai, and M. B. Millis, “Comparison
of femoral and innominate osteotomies for the treatment of
Legg-Calv´ e-Perthes’ disease,” Journal of Bone and Joint Surgery
A, vol. 70, no. 8, pp. 1131–1139, 1988.
 I. K. Evans, P. A. Deluca, and J. R. Gage, “A comparative
study of ambulation-abduction bracing and varus derotation
osteotomy in the treatment of severe legg-calve-perthes dis-
ease in children over 6 years of age,” Journal of Pediatric
Orthopaedics, vol. 8, no. 6, pp. 676–682, 1988.
 H. K. W. Kim, “Legg-Calv´ e-Perthes’ disease,” Journal of the
 H. J. Robinson, H. Putter, M. B. Sigmond, S. O’Connor, and
K. R. Murray, “Innominate osteotomy in Perthes’ disease,”
Journal of Pediatric Orthopaedics, vol. 8, no. 4, pp. 426–435,
 M. Poussa, T. Yrjonen, V. Hoikka, and K. Osterman, “Prog-
nosis after conservative and operative treatment in Perthes’
disease,” Clinical Orthopaedics and Related Research, no. 297,
pp. 82–86, 1993.
 D. C. Paterson, J. M. Leitch, and B. K. Foster, “Results
of innominate osteotomy in the treatment of Legg-Calv´ e-
Perthes’ disease,” Clinical Orthopaedics and Related Research,
no. 266, pp. 96–103, 1991.
 G. C. Lloyd Roberts, A. Catterall, and P. B. Salamon, “A
controlled study of the indications for and the results of
femoral osteotomy in Perthes’ disease,” Journal of Bone and
Joint Surgery B, vol. 58, no. 1, pp. 31–36, 1976.
 R. Sinigaglia, A. Bundy, T. Okoro, C. Gigante, and S. Turra,
“Is conservative treatment really effective for Legg-Calv´ e-
Perthes’ disease? A critical review of the literature,” Chirurgia
Narzadow Ruchu i Ortopedia Polska, vol. 72, no. 6, pp. 439–
significance,” Acta Orthopaedica Scandinavica, vol. 50, no. 2,
pp. 191–195, 1979.
 T. Terjesen, O. Wiig, and S. Svenningsen, “The natural history
of Perthes’ disease: risk factors in 212 patients followed for 5
years,” Acta Orthopaedica, vol. 81, no. 6, pp. 708–714, 2010.