Clinical Orthopaedics and Related Research®

, Volume 471, Issue 3, pp 1021–1027 | Cite as

Does Valgus Femoral Osteotomy Improve Femoral Head Roundness in Severe Legg-Calvé-Perthes Disease?

  • Hui Taek Kim
  • Ja Kyung Gu
  • Sung Ho Bae
  • Jae Hoon Jang
  • Jong Seo Lee
Clinical Research

Abstract

Background

Many surgeons perform a varus femoral or Salter pelvic osteotomy in patients with Legg-Calvé-Perthes (LCP) disease. However, more severely deformed femoral heads show greater congruency in adduction rather than in abduction. Therefore, a valgus-(flexion) femoral osteotomy (VFO) seems preferable rather than a varus femoral or Salter pelvic osteotomy.

Questions/purposes

We evaluated whether the VFO improves (1) femoral head roundness, (2) radiographic parameters reflecting hip subluxation, and (3) function.

Methods

We treated 25 patients (25 hips; 18 lateral pillar C and seven B) in the late fragmentation stage by VFO. Seven patients had additional pelvic procedures. VFO was performed at a mean age of 9.8 years. Three hips were Stulberg Class II, 20 were Class III, and two were Class IV. The following components of femoral head roundness were calculated from preoperative MRI and final radiographs: lateral and medial head roundness (LHR and MHR); anterior and posterior head roundness (AHR and PHR); central head height; and the ratios MHR/LHR and PHR/AHR. Continuity of Shenton’s line, medial gap ratio were evaluated. Function was determined with the Iowa hip score. Minimum followup was 3.1 years (mean, 6.3 years; range, 3.1–11.2 years).

Results

All femoral head roundness measurements improved, with greatest improvement in the lateral and anterior head. Pillar C hips showed greater relative improvement than pillar B hips. The continuity of Shenton’s line improved and the mean medial gap ratio decreased. Mean Iowa hip score improved from 71 before surgery to 90 at the last followup.

Conclusions

VFO appears to help the deformed femoral head in the fragmentation stage to remodel to fit the acetabulum.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

References

  1. 1.
    Axer A, Gershuni DH, Hendel D, Mirovski Y. Indications for femoral osteotomy in Legg-Calvé-Perthes disease. Clin Orthop Relat Res. 1980;150:78–87.PubMedGoogle Scholar
  2. 2.
    Bankes MJ, Catterall A, Hashemi-Nejad A. Valgus extension osteotomy for “hinge abduction” in Perthes’ disease: results at maturity and factors influencing the radiological outcome. J Bone Joint Surg Br. 2000;82:548–554.PubMedCrossRefGoogle Scholar
  3. 3.
    Bennett JT, Mazurek RT, Cash JD. Chiari’s osteotomy in the treatment of Perthes’ disease. J Bone Joint Surg Br. 1991;73:225–228.PubMedGoogle Scholar
  4. 4.
    Catterall A. The natural history of Perthes’ disease. J Bone Joint Surg Br. 1971;53:37–53.PubMedGoogle Scholar
  5. 5.
    Catterall A. Adolescent hip pain after Perthes’ disease. Clin Orthop Relat Res. 1986;209:65–69.PubMedGoogle Scholar
  6. 6.
    Clohisy JC, Schoenecker PL. Proximal femoral osteotomy. In: Callaghan JJ, Rosenberg AG, Rubash HE, eds. The Adult Hip. Philadelphia, PA, USA: Lippincott Williams & Wilkins; 2007:781–794.Google Scholar
  7. 7.
    Choi IH, Yoo WJ, Cho TJ, Moon HJ. The role of valgus osteotomy in LCPD. J Pediatr Orthop. 2011;31(2 suppl):S217–S222.PubMedCrossRefGoogle Scholar
  8. 8.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.PubMedCrossRefGoogle Scholar
  9. 9.
    Friedlander JK, Weiner DS. Radiographic results of proximal femoral varus osteotomy in Legg-Calvé-Perthes disease. J Pediatr Orthop. 2000;20:566–571.PubMedCrossRefGoogle Scholar
  10. 10.
    Heikkinen E, Puranen J. Evaluation of femoral osteotomy in the treatment of Legg-Calvé-Perthes disease. Clin Orthop Relat Res. 1980;150:60–68.PubMedGoogle Scholar
  11. 11.
    Herceg MB, Cutright MT, Weiner DS. Remodeling of the proximal femur after upper femoral varus osteotomy for the treatment of Legg-Calvé-Perthes disease. J Pediatr Orthop. 2004;24:654–657.PubMedCrossRefGoogle Scholar
  12. 12.
    Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part I: classification of radiographs with use of the modified lateral pillar and Stulberg classifications. J Bone Joint Surg Am. 2004;86:2103–2120.Google Scholar
  13. 13.
    Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part II: prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am. 2004;86:2121–2134.PubMedGoogle Scholar
  14. 14.
    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
  15. 15.
    Hoikka V, Poussa M, Yrjönen 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
  16. 16.
    Joseph B, Nair NS, Narasimha Rao KL, Mulpuri K, Varghese G. Optimal timing for containment surgery for Perthes disease. J Pediatr Orthop. 2003;23:601–606.PubMedCrossRefGoogle Scholar
  17. 17.
    Joseph B, Varghese G, Mulpuri K, Narasimha Rao KL, Nair NS. Natural evolution of Perthes disease: a study of 610 children under 12 years of age at disease onset. J Pediatr Orthop. 2003;23:590–600.PubMedCrossRefGoogle Scholar
  18. 18.
    Kim HT, Oh MH, Lee JS. MR imaging as a supplement to traditional decision-making in the treatment of LCP disease. J Pediatr Orthop. 2011;31:246–253.PubMedCrossRefGoogle Scholar
  19. 19.
    Kim HT, Wenger DR. “Functional retroversion” of the femoral head in Legg-Calvé-Perthes disease and epiphyseal dysplasia: analysis of head-neck deformity and its effect on limb position using three-dimensional computed tomography. J Pediatr Orthop. 1997;17:240–246.PubMedGoogle Scholar
  20. 20.
    Kim HT, Wenger DR. Surgical correction of “functional retroversion” and “functional coxa vara” in late Legg-Calvé-Perthes disease and epiphyseal dysplasia: correction of deformity defined by new imaging modalities. J Pediatr Orthop. 1997;17:247–254.PubMedGoogle Scholar
  21. 21.
    Kitakoji T, Hattori T, Kitoh H, Katoh M, Ishiguro N. Which is a better method for Perthes’ disease: femoral varus or Salter osteotomy? Clin Orthop Relat Res. 2005;430:163–170.PubMedCrossRefGoogle Scholar
  22. 22.
    Kumar D, Bache CE, O’Hara JN. Interlocking triple pelvic osteotomy in severe Legg-Calvé-Perthes disease. J Pediatr Orthop. 2002;22:464–470.PubMedGoogle Scholar
  23. 23.
    Lack W, Feldner-Busztin H, Ritschl P, Ramach W. The results of surgical treatment for Perthes’ disease. J Pediatr Orthop. 1989;9:197–204.PubMedCrossRefGoogle Scholar
  24. 24.
    Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res. 1963;31:85–93.PubMedCrossRefGoogle Scholar
  25. 25.
    Moberg A, Hansson G, Kaniklides C. Results after femoral and innominate osteotomy in Legg-Calvé-Perthes disease. Clin Orthop Relat Res. 1997;334:257–264.PubMedCrossRefGoogle Scholar
  26. 26.
    Müller ME. Intertrochanteric osteotomy: indication, preoperative planning, technique. In: Schatzker J, ed. The Intertrochanteric Osteotomy. Berlin, Germany: Springer-Verlag; 1984:25–66.Google Scholar
  27. 27.
    Myers GJ, Mathur K, O’Hara J. Valgus osteotomy: a solution for late presentation of hinge abduction in Legg-Calvé-Perthes disease. J Pediatr Orthop. 2008;28:169–172.PubMedCrossRefGoogle Scholar
  28. 28.
    Nakamura S, Ninomiya S, Morimoto S, Moro T, Takatori Y. Combined intertrochanteric valgus and rotational acetabular osteotomy. Clin Orthop Relat Res. 2001;384:176–188.PubMedCrossRefGoogle Scholar
  29. 29.
    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.PubMedGoogle Scholar
  30. 30.
    Patil S, Sherlock D. Valgus osteotomy for hinge abduction in avascular necrosis. J Pediatr Orthop B. 2006;15:262–266.PubMedCrossRefGoogle Scholar
  31. 31.
    Quain S, Catterall A. Hinge abduction of the hip: diagnosis and treatment. J Bone Joint Surg Br. 1986;68:61–64.PubMedGoogle Scholar
  32. 32.
    Raney EM, Grogan DP, Hurley ME, Ogden MJ. The role of proximal femoral valgus osteotomy in Legg-Calvé-Perthes disease. Orthopedics. 2002;25:513–517.PubMedGoogle Scholar
  33. 33.
    Schneider R. Intertrochanteric osteotomy in osteoarthritis of the hip joint. In: Schatzker J, ed. The Intertrochanteric Osteotomy. Berlin, Germany: Springer-Verlag; 1984:135–168.CrossRefGoogle Scholar
  34. 34.
    Song HR, Lee SH, Na JB, Tymowsi GI, Cho SH, Koo KH. Relationship between lateral subluxation and widening of medial joint space in Legg-Calvé-Perthes disease. J Pediatr Orthop. 1998;18:637–642.PubMedGoogle Scholar
  35. 35.
    Than P, Halmai V, Shaikh S, Kranicz J, Bellyei A. Long-term results of derotational femoral varus osteotomy in Legg-Calvé-Perthes disease: 26-year follow-up. Orthopedics. 2003;26:487–491.PubMedGoogle Scholar
  36. 36.
    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.PubMedCrossRefGoogle Scholar
  37. 37.
    Wenger DR, Pring ME, Hosalkar HS, Caltoum CB, Lalonde FD, Bastrom TP. Advanced containment methods for Legg-Calvé-Perthes disease: results of triple pelvic osteotomy. J Pediatr Orthop. 2010;30:749–757.PubMedCrossRefGoogle Scholar
  38. 38.
    Yoo WJ, Choi IH, Chung CY, Cho TJ, Kim HY. Valgus femoral osteotomy for hinge abduction in Perthes’ disease: decision-making and outcomes. J Bone Joint Surg Br. 2004;86:726–730.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Hui Taek Kim
    • 1
  • Ja Kyung Gu
    • 2
  • Sung Ho Bae
    • 1
  • Jae Hoon Jang
    • 1
  • Jong Seo Lee
    • 1
  1. 1.Department of Orthopaedic SurgeryPusan National University HospitalPusanKorea
  2. 2.Department of Medicine, Graduate SchoolPusan National UniversityPusanKorea

Personalised recommendations