Clinical Orthopaedics and Related Research®

, Volume 470, Issue 9, pp 2421–2430 | Cite as

What Is the Evidence Supporting the Prevention of Osteoarthritis and Improved Femoral Coverage After Shelf Procedure for Legg-Calvé-Perthes Disease?

  • Jason E. Hsu
  • Keith D. Baldwin
  • Moritz Tannast
  • Harish Hosalkar
Symposium: Legg-Calvé-Perthes Disease: Where Do We Stand After 100 Years?



The evidence supporting continued use of shelf acetabuloplasty in Legg-Calvé-Perthes disease (LCPD) is not well-defined, and there is controversy regarding the long-term benefits related to clinical and functional improvement.


Our goals were to determine whether shelf arthroplasty for LCPD (1) prevents the onset of early osteoarthritis; (2) improves pain, ROM, activity, and functional outcomes; (3) maintains or improves femoral head containment, sphericity, and congruency; (4) changes the acetabular index; and (5) is associated with a low rate of complications.


We performed a systematic review of the medical literature from 1966 to 2009 using the search terms Perthes, shelf procedure, and acetabuloplasty. We excluded reports using multiple/combined treatment methods and those not clearly stratifying outcomes. Thirteen studies met the criteria. There were no Level I studies, one Level II prognostic study, five Level III therapeutic studies, and seven Level IV studies. Mean followup ranged from 2.6 to 17.9 years.


Only one study reported progression to early osteoarthritis in one patient. We found no evidence for improvement in ROM and continued pain relief at long-term followup. Mean decrease in lateral subluxation ratio was 13% to 30%, demonstrating an improvement in femoral head containment. Mean acetabular cover percentage improved 16% to 38%, and mean acetabular and center-edge angles improved 4° to 14° and 8° to 33°, respectively. There were no reports of any major complications after the procedure.


While radiographic measurements indicate improved coverage of the femoral head after shelf acetabuloplasty for LCPD, available evidence does not document the procedure prevents early onset of osteoarthritis or improves long-term function.


  1. 1.
    Atsumi T, Yoshihara S, Hiranuma Y. Revascularization of the artery of the ligamentum teres in Perthes disease. Clin Orthop Relat Res. 2001;386:210–217.PubMedCrossRefGoogle Scholar
  2. 2.
    Bowen JR, Foster BK, Hartzell CR. Legg-Calvé-Perthes disease. Clin Orthop Relat Res. 1984;185:97–108.PubMedGoogle Scholar
  3. 3.
    Broder H. The late results in Legg-Perthes’ disease and factors influencing them: a study of one hundred and two cases. Bull Hosp Joint Dis. 1953;14:194–216.PubMedGoogle Scholar
  4. 4.
    Bursal A, Erkula G. Lateral shelf acetabuloplasty in the treatment of Legg-Calvé-Perthes disease. J Pediatr Orthop B. 2004;13:150–152.PubMedCrossRefGoogle Scholar
  5. 5.
    Calvé J. Sur une forme particuliere de coxalgie greffe sur des deformations caracteristiques de 1′extremite superieure de femur. Rev Chir. 1910;42:54.Google Scholar
  6. 6.
    Catterall A. The natural history of Perthes’ disease. J Bone Joint Surg Br. 1971;53:37–53.PubMedGoogle Scholar
  7. 7.
    Catterall A. Legg-Calvé-Perthes syndrome. Clin Orthop Relat Res. 1981;158:41–52.PubMedGoogle Scholar
  8. 8.
    Crutcher JP, Staheli LT. Combined osteotomy as a salvage procedure for severe Legg-Calvé-Perthes disease. J Pediatr Orthop. 1992;12:151–156.PubMedCrossRefGoogle Scholar
  9. 9.
    Daly K, Bruce C, Catterall A. Lateral shelf acetabuloplasty in Perthes’ disease: a review of the end of growth. J Bone Joint Surg Br. 1999;81:380–384.PubMedCrossRefGoogle Scholar
  10. 10.
    Domzalski ME, Glutting J, Bowen JR, Littleton AG. Lateral acetabular growth stimulation following a labral support procedure in Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 2006;88:1458–1466.PubMedCrossRefGoogle Scholar
  11. 11.
    Domzalski ME, Inan M, Guille JT, Glutting J, Kumar SJ. The proximal femoral growth plate in Perthes disease. Clin Orthop Relat Res. 2007;458:150–158.PubMedGoogle Scholar
  12. 12.
    Ezoe M, Naito M, Inoue T. The prevalence of acetabular retroversion among various disorders of the hip. J Bone Joint Surg Am. 2006;88:372–379.PubMedCrossRefGoogle Scholar
  13. 13.
    Freeman RT, Wainwright AM, Theologis TN, Benson MK. The outcome of patients with hinge abduction in severe Perthes disease treated by shelf acetabuloplasty. J Pediatr Orthop. 2008;28:619–625.PubMedCrossRefGoogle Scholar
  14. 14.
    Ghanem I, Haddad E, Haidar R, Haddad-Zebouni S, Aoun N, Dagher F, Kharrat K. Lateral shelf acetabuloplasty in the treatment of Legg-Calvé-Perthes disease: improving mid-term outcome in severely deformed hips. J Child Orthop. 2009 November 13 [Epub ahead of print].Google Scholar
  15. 15.
    Grzegorzewski A, Bowen JR, Guille JT, Glutting J. Treatment of the collapsed femoral head by containment in Legg-Calvé-Perthes disease. J Pediatr Orthop. 2003;23:15–19.PubMedCrossRefGoogle Scholar
  16. 16.
    Herring JA. Legg-Calvé-Perthes disease. In: Herring JA, ed. Tachdjian’s Pediatric Orthopaedics. 3rd ed. Philadelphia, PA: WB Saunders; 2001:655–704.Google Scholar
  17. 17.
    Herring JA, Neustadt JB, Williams JJ, Early JS, Browne RH. The lateral pillar classification of Legg-Calvé-Perthes disease. J Pediatr Orthop. 1992;12:143–150.PubMedCrossRefGoogle Scholar
  18. 18.
    Herring JA, Williams JJ, Neustadt JN, Early JS. Evolution of femoral head deformity during the healing phase of Legg-Calvé-Perthes disease. J Pediatr Orthop. 1993;13:41–45.PubMedCrossRefGoogle Scholar
  19. 19.
    Hoikka V, Poussa M, Yrjonen T, Osterman K. Intertrochanteric varus osteotomy for Perthes’ disease: radiographic changes after 2–16-year follow-up of 126 hips. Acta Orthop Scand. 1991;62:549–553.PubMedCrossRefGoogle Scholar
  20. 20.
    Huang MJ, Huang SC. Surgical treatment of severe Perthes disease: comparison of triple osteotomy and shelf augmentation. J Formos Med Assoc. 1999;98:183–189.PubMedGoogle Scholar
  21. 21.
    Ippolito E, Tudisco C, Farsetti P. The long-term prognosis of unilateral Perthes’ disease. J Bone Joint Surg Br. 1987;69:243–250.PubMedGoogle Scholar
  22. 22.
    Jacobs BW. Early recognition of osteochondrosis of capital epiphysis of femur. J Am Med Assoc. 1960;172:527–531.PubMedCrossRefGoogle Scholar
  23. 23.
    Jacobs R, Moens P, Fabry G. Lateral shelf acetabuloplasty in the early stage of Legg-Calvé-Perthes disease with special emphasis on the remaining growth of the acetabulum: a preliminary report. J Pediatr Orthop B. 2004;13:21–28.PubMedCrossRefGoogle Scholar
  24. 24.
    Kallio P, Ryoppy S, Kunnamo I. Transient synovitis and Perthes’ disease: is there an aetiological connection? J Bone Joint Surg Br. 1986;68:808–811.PubMedGoogle Scholar
  25. 25.
    King EW, Fisher RL, Gage JR, Gossling HR. Ambulation-abduction treatment in Legg-Calvé-Perthes disease (LCPD). Clin Orthop Relat Res. 1980;150:43–48.PubMedGoogle Scholar
  26. 26.
    Kleinman RG, Bleck EE. Increased blood viscosity in patients with Legg-Perthes disease: a preliminary report. J Pediatr Orthop. 1981;1:131–136.PubMedCrossRefGoogle Scholar
  27. 27.
    Kruse RW, Guille JT, Bowen JR. Shelf arthroplasty in patients who have Legg-Calvé-Perthes disease: a study of long-term results. J Bone Joint Surg Am. 1991;73:1338–1347.PubMedGoogle Scholar
  28. 28.
    Kumar D, Bache CE, O’Hara JN. Interlocking triple pelvic osteotomy in severe Legg-Calvé-Perthes disease. J Pediatr Orthop. 2002;22:464–470.PubMedCrossRefGoogle Scholar
  29. 29.
    Kuwajima SS, Crawford AH, Ishida A, Roy DR, Filho JL, Milani C. Comparison between Salter’s innominate osteotomy and augmented acetabuloplasty in the treatment of patients with severe Legg-Calvé-Perthes disease: analysis of 90 hips with special reference to roentgenographic sphericity and coverage of the femoral head. J Pediatr Orthop B. 2002;11:15–28.PubMedCrossRefGoogle Scholar
  30. 30.
    Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res. 1963;31:85–93.PubMedCrossRefGoogle Scholar
  31. 31.
    Lee MC, Eberson CP. Growth and development of the child’s hip. Orthop Clin North Am. 2006;37:119–132, v.PubMedCrossRefGoogle Scholar
  32. 32.
    Legg AT. An obscure affection of the hip joint. Boston Med Surg. 1910;162:202.CrossRefGoogle Scholar
  33. 33.
    Lloyd-Roberts GC, Catterall A, Salamon PB. A controlled study of the indications for and the results of femoral osteotomy in Perthes’ disease. J Bone Joint Surg Br. 1976;58:31–36.PubMedGoogle Scholar
  34. 34.
    Love BR, Stevens PM, Williams PF. A long-term review of shelf arthroplasty. J Bone Joint Surg Br. 1980;62:321–325.PubMedGoogle Scholar
  35. 35.
    McAndrew MP, Weinstein SL. A long-term follow-up of Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 1984;66:860–869.PubMedGoogle Scholar
  36. 36.
    Mose K. Methods of measuring in Legg-Calvé-Perthes disease with special regard to the prognosis. Clin Orthop Relat Res. 1980;150:103–109.PubMedGoogle Scholar
  37. 37.
    Noonan KJ, Price CT, Kupiszewski SJ, Pyevich M. Results of femoral varus osteotomy in children older than 9 years of age with Perthes disease. J Pediatr Orthop. 2001;21:198–204.PubMedCrossRefGoogle Scholar
  38. 38.
    O’Connor PA, Mulhall KJ, Kearns SR, Sheehan E, McCormack D. Triple pelvic osteotomy in Legg-Calvé-Perthes disease using a single anterolateral incision. J Pediatr Orthop B. 2003;12:387–389.PubMedGoogle Scholar
  39. 39.
    Paterson DC, Leitch JM, Foster BK. Results of innominate osteotomy in the treatment of Legg-Calvé-Perthes disease. Clin Orthop Relat Res. 1991;266:96–103.PubMedGoogle Scholar
  40. 40.
    Perthes G. Uber Arthritis Deformans Juvenilis. Dtsch Z Chir. 1910;10:111.CrossRefGoogle Scholar
  41. 41.
    Petrie JG, Bitenc I. The abduction weight-bearing treatment in Legg-Perthes’ disease. J Bone Joint Surg Br. 1971;53:54–62.PubMedGoogle Scholar
  42. 42.
    Purvis JM, Dimon JH 3rd, Meehan PL, Lovell WW. Preliminary experience with the Scottish Rite Hospital abduction orthosis for Legg-Perthes disease. Clin Orthop Relat Res. 1980;150:49–53.PubMedGoogle Scholar
  43. 43.
    Quain S, Catterall A. Hinge abduction of the hip: diagnosis and treatment. J Bone Joint Surg Br. 1986;68:61–64.PubMedGoogle Scholar
  44. 44.
    Reinker KA. Early diagnosis and treatment of hinge abduction in Legg-Perthes disease. J Pediatr Orthop. 1996;16:3–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Richards BS, Coleman SS. Subluxation of the femoral head in coxa plana. J Bone Joint Surg Am. 1987;69:1312–1318.PubMedGoogle Scholar
  46. 46.
    Salter RB. The present status of surgical treatment for Legg-Perthes disease. J Bone Joint Surg Am. 1984;66:961–966.PubMedGoogle Scholar
  47. 47.
    Salter RB, Thompson GH. Legg-Calvé-Perthes disease: the prognostic significance of the subchondral fracture and a two-group classification of the femoral head involvement. J Bone Joint Surg Am. 1984;66:479–489.PubMedGoogle Scholar
  48. 48.
    Singh S, Hee HT, Low YP. Significance of the lateral epiphysis of the acetabulum to hip joint stability. J Pediatr Orthop. 2000;20:344–348.PubMedCrossRefGoogle Scholar
  49. 49.
    Sponseller PD, Desai SS, Millis MB. Comparison of femoral and innominate osteotomies for the treatment of Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 1988;70:1131–1139.PubMedGoogle Scholar
  50. 50.
    Staheli LT, Chew DE. Slotted acetabular augmentation in childhood and adolescence. J Pediatr Orthop. 1992;12:569–580.PubMedGoogle Scholar
  51. 51.
    Stulberg SD, Cooperman DR, Wallensten R. The natural history of Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 1981;63:1095–1108.PubMedGoogle Scholar
  52. 52.
    Sundt H. Further investigation respecting malum coxae Calvé-Legg-Perthes’ disease with special regard to the prognosis and treatment. Acta Chir Scand. 1949;suppl 148:1–101.Google Scholar
  53. 53.
    Tachdjian MO. Tachdjian Pediatric Orthopedics. Philadelphia, PA: WB Saunders; 1990.Google Scholar
  54. 54.
    Theron J. Angiography in Legg-Calvé-Perthes disease. Radiology. 1980;135:81–92.PubMedGoogle Scholar
  55. 55.
    Thompson GH, Salter RB. Legg-Calvé-Perthes disease: current concepts and controversies. Orthop Clin North Am. 1987;18:617–635.PubMedGoogle Scholar
  56. 56.
    van der Geest IC, Kooijman MA, Spruit M, Anderson PG, De Smet PM. Shelf acetabuloplasty for Perthes’ disease: 12-year follow-up. Acta Orthop Belg. 2001;67:126–131.Google Scholar
  57. 57.
    van der Haven I, Kooijman MA, Havinga ME, van der Geest IC, Jacobs W, Anderson PG. Teardrop-femoral head distance after shelf acetabuloplasty for Perthes’ disease. Acta Orthop Belg. 2003;69:157–161.PubMedGoogle Scholar
  58. 58.
    Vukasinovic Z, Slavkovic S, Milickovic S, Siqeca A. Combined Salter innominate osteotomy with femoral shortening versus other methods of treatment for Legg-Calvé-Perthes disease. J Pediatr Orthop B. 2000;9:28–33.PubMedGoogle Scholar
  59. 59.
    Waldenstrom H. Der obere Tuberkulose collumnerd. Z Orthop Chir. 1909;24:487.Google Scholar
  60. 60.
    Wiberg G. Shelf operation in congenital dysplasia of the acetabulum and in subluxation and dislocation of the hip. J Bone Joint Surg Am. 1953;35:65–80.PubMedGoogle Scholar
  61. 61.
    Willett K, Hudson I, Catterall A. Lateral shelf acetabuloplasty: an operation for older children with Perthes’ disease. J Pediatr Orthop. 1992;12:563–568.PubMedGoogle Scholar
  62. 62.
    Wynne-Davies R, Gormley J. The aetiology of Perthes’ disease: genetic, epidemiological and growth factors in 310 Edinburgh and Glasgow patients. J Bone Joint Surg Br. 1978;60:6–14.PubMedGoogle Scholar
  63. 63.
    Yoo WJ, Choi IH, Cho TJ, Chung CY, Shin YW, Shin SJ. Shelf acetabuloplasty for children with Perthes’ disease and reducible subluxation of the hip: prognostic factors related to hip remodelling. J Bone Joint Surg Br. 2009;91:1383–1387.PubMedCrossRefGoogle Scholar
  64. 64.
    Yrjonen T. Prognosis in Perthes’ disease after noncontainment treatment: 106 hips followed for 28–47 years. Acta Orthop Scand. 1992;63:523–526.PubMedCrossRefGoogle Scholar
  65. 65.
    Zaza S, Wright-De Aguero LK, Briss PA, Truman BI, Hopkins DP, Hennessy MH, Sosin DM, Anderson L, Carande-Kulis VG, Teutsch SM, Pappaioanou M. Data collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services. Task Force on Community Preventive Services. Am J Prev Med. 2000;18:44–74.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Jason E. Hsu
    • 1
  • Keith D. Baldwin
    • 2
  • Moritz Tannast
    • 3
  • Harish Hosalkar
    • 4
  1. 1.Department of Orthopaedic SurgeryHospital of the University of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of Orthopaedic SurgeryChildren’s Hospital of PhiladelphiaPhiladelphiaUSA
  3. 3.Department of Orthopaedic Surgery, InselspitalUniversity of BernBernSwitzerland
  4. 4.Department of Orthopedic SurgeryRady Children’s Hospital, UCSD San DiegoSan DiegoUSA

Personalised recommendations