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Patients with Perthes disease show good hip range of motion at 25 years
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At 25-year follow-up for pediatric patients with Legg-Calvé-Perthes disease using with an A-frame orthosis, 93% of hips were congruent among patients with pillar A, B and C hips, according to this study.
“Treatment that restored and maintained hip range of motion along with the use of an A-frame orthosis resulted in a high proportion of spherically congruent hips for patients of all ages irrespective of the extent of disease,” Margaret M. Rich, MD, PhD, and colleagues wrote in the study abstract.
The researchers followed 213 patients with 240 hips that were either necrotic or fragmented treated using adductor tenotomy and an abduction cast in addition to daily hip range of motion exercises or using an A-frame orthosis, according to the abstract. All hips were analyzed at follow-up using a modified Stulberg grade at maturity.
Rich and colleagues found that all pillar A hips were spherically congruent; among patients with pillar B classified hips, 101 hips were spherically congruent, 8 hips were spherical but congruent and 4 hips were aspherical and incongruent, according to the abstract. With hips that were classified as pillar C, 77 hips were spherically congruent, there were 26 aspherical but congruent hips and 12 hips were aspherical and incongruent.
The researchers noted that patient age did not impact outcome and that hip outcome was improved in all groups, regardless of pillar classification, according to the abstract.
Disclosure: One of the authors (Schoenecker) is on the editorial board of the Journal of Pediatric Orthopaedics.
Perspective
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Alvin H. Crawford, MD, FACS
First, let me congratulate the team on their tenacity and willingness to treat Legg-Calvé-Perthes disease (LCPD) with AF-ROM when most centers have had less than satisfactory results with this method. The success is possibly in the details. They aggressively pursued obtaining and maintaining their requisite range of motion with emphasis on adequate abduction in hip extension.
There are several nuggets: greater than 25° of abduction in extension or adductor tenotomy was performed to achieve 35° to 40° of hip abduction; adequacy of femoral head coverage confirmed by plain film or arthrography; cast applied to abduct hips sufficiently for femoral epiphysis to be covered by acetabular dome; adequate coverage of the epiphysis confirmed on standing AP pelvis radiograph; and daily hip range of motion exercises.
However, when faced with the need for consistent daily exercises and orthotic wear, compliance is often a problem. They mention the need to occasionally repeat soft tissue releases or return to cast if necessary. While their patient mix was acceptable to performing the rehabilitation and wearing an orthosis (AF-ROM) for an average duration of 36 months during the past 25 years, the study may not be as reproducible today.
I personally prefer the clinical assessment of stiffness to examination under anesthesia because often when examining under anesthesia most of the synovitis is gone and the range of motion appears satisfactory. A number of centers agree completely that achieving sufficient containment and range of motion, especially abduction is the key to success when treating LCPD to the extent of recommending adductor, iliopsoas tenotomy, capsulotomy and transverse acetabular ligament release followed by abduction casting for early subluxation and decreased range of motion. Again, maintenance of containment and motion then becomes the issues regardless of the modality, i.e., boney or orthotic.
These well-respected authors have presented a 25-year history of a successful method of treating the majority of their patients with LCPD. It is not unusual to see cycles of treatment modalities in the management of pediatric musculoskeletal diseases.
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