A Comparison of the Effectiveness of Surgical and Nonsurgical Treatment of Legg-Calve-Perthes Disease: A Review of the Literature

Musculoskeletal Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran.
Advances in orthopedics 08/2012; 2012:490806. DOI: 10.1155/2012/490806
Source: PubMed

ABSTRACT 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 pathway was assessed and reasons for the pathway selected were grouped by the age of disease onset, follow-up period, and the final 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.

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    ABSTRACT: The treatment of LCPD employs to an increasing degree the containment principle, in the form of femoral osteotomy, based on the hypothesis that the factor decisive for the prognosis is centralization of the femoral head, and not relief of weight-bearing by the hip. A follow-up of 48 unilateral LCPD hips treated by strict bed-rest showed a poor correlation (best value r=-0.385) between the degree of lateralization of the femoral head (the migration percentage) during the course of the disease and the spherical quotient at follow-up 12.6 years after the onset of the disease. The results reported, such as shortening of the fragmentation phase and a not unequivocally good outcome of intertrochanteric femoral osteotomy in hips "at risk", may therefore not be due to the containment principle, but perhaps to an improved venous drainage from the femoral head.
    Acta Orthopaedica Scandinavica 05/1979; 50(2):191-5. DOI:10.3109/17453677908989756
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    ABSTRACT: A retrospective study was performed in 27 patients who underwent innominate osteotomy for the treatment of severe Perthes disease. Time intervals between surgery and final follow-up ranged from 5 years to 16 years 4 months. Preoperative and postoperative periods of treatment were often more prolonged than those reported by Salter. One-half of the patients were less than 6 years of age at onset of the disease. A number of patients had significant deformity of the femoral head. Nevertheless, clinically good or fair results were obtained in 88% of the patients and poor results were found in 12%.
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    ABSTRACT: Researchers and clinicians commonly use the classification system of Stulberg et al. as a basis for treatment decisions during the active phase of Legg-Calvé-Perthes disease because of its putative utility as a predictor of long-term outcome. It is generally assumed that this system has an acceptable degree of reliability. This assumption, however, is not convincingly supported by the literature. The purpose of the present study was to assess the inter-rater and intra-rater reliability of the classification system of Stulberg et al. with use of a pre-test, post-test design. During the pre-test phase, nine raters independently used the system to evaluate the radiographs of skeletally mature patients who had been managed for Legg-Calvé-Perthes disease. The intervention between the pre-test and post-test phases consisted of a consensus-building session during which all raters jointly arrived at standardized definitions of the various joint structures that are assessed with use of the classification system. The effect of these definitions on reliability then was assessed by reevaluating the radiographs during the post-test phase. The pre-test intra-rater reliability coefficients ranged from 0.709 to 0.915, and the post-test coefficients ranged from 0.568 to 0.874. The pre-test inter-rater reliability coefficients ranged from 0.603 to 0.732, and the post-test coefficients ranged from 0.648 to 0.744. Contributing to the variance was a lack of agreement concerning the assessment of joint structures and the way in which the raters translated these evaluations into a classification according to the system of Stulberg et al. Although intra-rater reliability was marginally acceptable, the degree of variability between the classifications assigned by different raters even after the intervention - calls into question the reliability of the system of Stulberg et al.; consequently, the validity of any treatment decisions, outcome evaluations, or epidemiological studies based on this system is also in question.
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