Conservative Treatment of Legg-Calvé-Perthes Disease

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Conservative Treatment of Legg-Calvé-Perthes Disease
J Bone Joint Surg Am. 1967;49:1043-1051.

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Publisher Information         The Journal of Bone and Joint Surgery
                              20 Pickering Street, Needham, MA 02492-3157
               Conservative                                                       Treatment                                                of Legg-Calve-Perthes
                                                         BY          JACOB                 F.      KATZ,                  M.D.*,              YORK,
                                                                                                                                            NEW                     N.Y.

          Front         The Ml.                  Sinai             Hospital,             New         York             City,           and    Blythedale                Children’s             Hospital,            Valhalla

              The         aim                 of treatment                          in          Legg-Calv#{233}-Perthes                                disease              (coxa          plana)           is the         reduc-
tion           of deformity                              during                  healing             of        the         necrosis               of     the         capital            femoral             epiphysis.               The
efficacy                of any form                           of      treatment                     is judged                         by     how          near             to     normal            the      involved               hip
becomes.                      The              object                 of        this     paper                 is to                compare              the          epiphyseal-quotient            and          con-
centric-circle                                methods                      of      evaluation                    with                 reference         283    to    patients     treated                   by       bed
rest           either              in          an    abduction                        splint              or         in        traction.


                                                                           SPHERICAL                                                        HEAD

                                                                                                           FIG.            1
    Lateral            and            anteroposterior          tracings                           in a patient       whom
                                                                                                                     in         the epiphyseal                                     quotient           was      80 per
cent.          When the               head      is spherical,           that                        is, the  outline    is circular     in both                                      anteroposteriorand      lateral
views            and    the          radii     of the      circles       are                      equal,    the result     is graded      good.                                    Good       results         have   an        epiphy-
seal          quotient              above        60 per        cent.

              Since           the              femoral                 head           corresponds                              to      a sphere,               its                as
                                                                                                                                                                         distortion,       a result           of the
disease                and              its      treatment,                is    a measure                     of the                end     result.             Historically,                  there           has been
a continuing                              search        for                a simple      method       of measurement             and     thus    of coding        the                                                               dis-
tortion.     The                            irregularity                        of the      femoral      head     following          coxa
                                                                                                                                  plana       may     lead     to
secondary                     osteo-arthritis                              with    varying       degrees      of joint      limitation         and    discomfort.
The            need  for assessment                                              of treatment                          therefore        is most                             important.
              In the early    literature                                           descriptive                       terms,      such mushroom
                                                                                                                                          as                                and      cap      deformities,
were            used          to         classify                  types of structural                          alteration.                    They              were           criticized            for        being        too
          *    1 East              100th            Street,                New       \ork,N.Y.            10029.

VOL.          49-A,     NO.        6.         SEPTEMBER                1967                                                                                                                                      1043
1044                                                                                                    J.       F. KATZ


                                                                      SPHERICAL                                                                   HEAD

                                                                                                               FIG.       2

       Lateral              and         anteroposterior                    tracings               in         a patient               in   whom              the         epiphyseal                quotient      49 was
cent       and            the     result          was            graded         fair.        The             shape        of the          surface            of the            femoral          head         was spherical                         but
the       epiphysis               was           crescent-shaped.                      Fair             results           by       the         Mose          method                have         epiphyseal                       quotients
below            60   per       cent.

subjective,         so                      that                the   results                  of different                        observers                  could                 not be                compared.                         Eyre-
Brook       suggested                                 the         use of an                   epiphyseal                        index     to            express                  the degree                 of flattening                              of
the         epiphysis.                      This                 index          was            the            height             of       the         epiphysis                    from           the        growth                   plate              to
the         highest                     point              of       the       epiphyseal                             surface              contour                  divided                by        the         breadth                     of        the
epiphysis.           Sjovall        converted                                                the            epiphyseal         index      to an epiphyseal           quotient        by
dividing         the     epiphyseal           index                                           of          the    affected      head     by that     of the    uninvolved         side.
This       produced          a direct       measure                                                      of the      deviation       from    normal    caused      by flattening
and widening                               of the epiphysis,            which                                      he expressed           in percentage.             Heyman        and Hem-
don      amplified                          this     measurement            by                                    analyzing         collateral         deformities:          the   epiphyseal
quotient,          the                       acetabular          quotient,                                        the     head-neck            quotient,          and    the     acetabulum-
head             quotient.                       By             averaging                    these                four          quotients,                    a composite                          called                 the        compre-
hensive                    quotient                    was          obtained.                     This                considerable                     arithmetical                          computation                              fails            to
add              anything                        of         value              to        the              information          contained                      in         the          epiphyseal                      quotient
alone;                I     have            shown                   that          a linear                   relation                exists          between                    the       comprehensiveand                  the
epiphyseal                          quotients                6

             Investigators                                  continued                    to             be        dissatisfied                       with           the          epiphyseal                      quotient                        as         a
total          statement                              of the              deformity                       of      the         femoral                head.               The          sphericity                     of     the         normal
hip          joint     makes                     it        impossible                        to          describe                 the           potential                      deformities                      in         one         plane.
Several                     groups                    of         investigators,                including                        Sundt,                Goff,               and            Hauge,                 returned                      to
descriptive                         techniques.                            Spherical,                        ovoid,            cylindrical,                       and          quadrangular-shaped                heads
were             catalogued                           by         Sundt.               Goff             used            a similar                technique,                       classifying                    the         end         results
                                                                                                                               THE        JOURNAL                  OF       BONE          AND           JOINT             SURGERY
                                                   TREATMENT                           OF     LEGG-CALVI%-PERTHES                                         DISEASE                                                 1045

                                                                                            SUBJECT-                                   O.M.

                                                                                                        FIG.         3
       Lateral             and       anteroposterior             in a  tracings                          patient                 in      whom             the        epiphyseal               quotient               was         42       per
cent.            The result          by the Mose      method pooris                                     because              the         radii         of the          circles        most            nearly         approxi-
mating                the surface       of the femoral      head the
                                                              in                                        two         views              differ       by      more       than            two        millimeters.                   The
head             also    is irregular,      which    also   makes                                       the        grading                 of    poor       mandatory.

as        spherical,                  mushroom-shaped,                                 or     malum                       coxae             juvenilis.                    Hauge               equated                 a ball-
shaped                    epiphysis        as              equivalent                     to a good     result,                                       a flattened                  but        still      rounded      epiph-
ysis   to                 a fair    result,                  and      an               angular    epiphysis                                          to a poor                   result.              Mose     argued      that
since               the       main               element        in       osteo-arthritis                                 predilection                       was           incongruity                        of      the         joint
surfaces,      a spherical                                 concentricity                        between                        the femoral                             head   and  acetabulum                                    was              a
prime     requisite     for                             a good      result.                   A precise                       measurement                               of the femomal      head                             spheric-
ity         was            obtained                 by         using               a    transparent                               template                      on       which              was          ruled             a series               of
twenty-eight          concentric      circles      two      millimeters                                                                          apart.          By this                    overlay,      it                was            pos-
sible    to determine         in both    anterior-posterior       and                                                                 lateral             roentgenograms                          whether                   the
outline                   of the          head           was         truly             circular.                The              deviation                      from        circularity                     could           be        meas-
ured    in each                      projection.                   When                   there       was                  no      deviation        and     the                            radii   were                equal, the
surface    was                     spherical.                   In this                classification                            a good      result     is that                              in which                the head    is
spherical                and     the               epiphyseal                     quotient                      is above      60                        per cent                (Fig.    1).                A fair result  in-
cludes               a spherical                   head    but                crescent-shaped                          femoral                           capital               epiphysis                    and an epiphy-
seal         quotient                  below               60 percent                       (a deviation                               of less            than            two         millimeters                     separating
adjacent        circles      of the template                                               between                         the  radii   of the respective        circular                                                 heads                  in
the anteroposterior               and   lateral                                           projections                        is permitted        in this  category)                                                   (Fig.     2).               A
poor     result       includes      all cases                                           in which                         the   femoral     heads     are non-spherical                                                       and                  in
which                the         radius            of the              circle           making                  up           the            outline                  of the          head             is different                    in the
lateral               and          frontal               views,             whatever                      the             index             quotient                   (Fig.         3).

                                                                  Results                   of Present                           Investigation
            Children                   with              coxa             plana              at         the              Blythedale                        Children’s                       Hospital          have                        been
treated            b         bed          rest     in     an    abduction                    brace              or       by bed                 rest       in bilateral                     shoe     traction;                        a
report               was         published                 of the                 results              evaluated                       by       the       epiphyseal                       quotient               technique
In        the         present                study             evaluation                         of     the             results                in     patients                  treated               in      the       abduction

VOL.        49-A.          NO.      SEPTEMBER
                                    6.                          1967
1046                                                                                            J.      F.     KATZ


                                                                                                     FIG.            5
                                                                                  Bilateral                   shoe         traction.

brace            (Fig.           4)     and           a re-evaluation                                of the               results             in     patients             treated           in bilateral                    shoe
traction                 (Fig.           5) were                carried        out                   by the Mose                            method.
           The            two          treatment                    categories                        represented                          consecutive                    cases        without                  selection
by      age,           severity                of disease,                  or duration                          of disease.                     Abduction                 brace        therapy                  was      used
consistently                          for      the       past             ten       years;                   traction                  therapy               was the
                                                                                                                                                               previous              routine.                 The
group   on which     the       analysis                                                 was             made     consisted                            of      283 patients-233 were                       boys
(82 per   cent)  and     fifty      were                                                girls           (18  per     cent).                          The        right   side    was                       involved              116
times            (41      per          cent)            and         the          left      side              121
                                                                                                             times           (43        per        cent);          forty-six            patients                 had
bilateral                disease                (16      per         cent).              The            sex          predominance                            and     age       group            patterns                in the
patients                 with               bilateral               disease               resembled                          those            in     patients              with        unilateral                    disease.
In      the        breakdown                          of age           groups                   (Fig.           6),        the
                                                                                                                         greatest                incidence              occurred                in        children
five        to     six       years               old;         the         next           greatest                    frequency                     occurred childrenin              seven            to       nine
years            old.
                                                     T1(EAI’M                EXT         OF LEGG-CALVE-PE1(Tl-IES                                       l)ISEASE                                                  1047

                1csults              were          first      atialyzed                  by        the       epiphyseal-(1uotietlt                             method                (Fig.              7, column
               By this                method,              204          of         the      Patients                     with unilateral                  (lisease             (7        jer       cent)            had
 sat          is! :tctory            resUlts               (good               and fair            results           combined),                          and           thirty-one              patients               (13
pel           (‘(lit ) litd             tiiis:tt       isfactorv                    restilts      (poor                and     bad).
                Analyzed                    according                   to         the       method                  of reatment,
                                                                                                                      t                            94       per         (cut        of         the           patients
 treate(l               lii   tile        abdtictioii                   brace             had            satisfactory                         results             (good             and              fair)         compared







                                                                          NUMBER                                               OF                CASES
                                                                                                            FIG.         6
                                                                                              Iiicideiice                by      age.

                                               ALL            CASES                              ABDUCTION                                 BRACE                   TRACTION                              AND
                                                                                                                   BED           REST                                BED    REST

                   I 20

        (I)       I00


        0              60h
        QD             40

        z              20

                                                                                                         FIG.        7
                                                   Ilesults        of        treatment             :tiialvzed                 La epiphvseal                quotient.

Vol..         49-A.     NO.      6. SEl’TEMIIER                    1967
1048                                                                                          J.     F. KATZ

                                                                                              ABDUCTION                                 BRACE                    TRACTION                              AND
                                            ALL              CASES
                                                                                                           BED                  REST                                      BED           REST

            HEADS-                            REG.                 IRREG.                                  REG.                         IRREG.                          REG.                   IRREG.






    EPIPHYSEAL                        ABOVE             BELOW                                      ABOVE             BELOW                                       ABOVE BELOW
       QUOTIENT                         60                 60                                        60                 60                                         60     60
                                                                                                    FIG.         8
                                    Results             of    treatment                   analyzed                   by        mean.s          of   the         Mose       template.

                    AGES                          0-2                          3-4                         5-6                          7-9                           10-12                            13+

               90-100                                                    2           I               2                             3           I
                  80-90                                                  2           I         I 7               2                 2          6                                                          I
       7O-8O                                  I                          52                          54                               14
       6O-7O                                  12                          14                         342                          5101                                         I                         I
       5O-6O                                                              II                         42                                    4                                   3

       4O-5O                                                                                                                                  II                               2                         I
       w                0-40                                                                                               2
                                              G         F          P G               F        P            G           F          P
                                                                                                                                  G           F       P            G       F          P
                                                                                                                                                                                      G            F         P

                  TOTAL                       2         2          0           II         9          I
                                                                                                     21        12           4 II           26         2           0        0          60           0         3
                                                                                                    FIG.       9
                                         Results              of       treatment                   with        abduction                   brace          and rest.

with         80     per cent                   of the patients                                treated                  in traction        (Fig.                        7, columns                     2 and   3).
            The      results                  in these     patients                                were                 then     analyzed                             using    the                 i\Iose   template
(Fig.      8). By this                         method                  of evaluation     80 per cent     of the     total     number         of patients
had      satisfactory                         results               (regular      heads)  and   20 per    cent   had      unsatisfactory             results
(irregular          heads).                      This              represents        a 7 per  cent  higher     incidence           of unsatisfactory
results           with         this           method                of analysis                      than            that             obtained                 with        the        epiphyseal-quotient
method.                 By      the           Mose            measurement                             86         per           cent        of the              patients              treated             in abduction
braces            had         satisfactory                         results               compared                      with             72 per            cent          of the          patients                 treated   in
traction.               The          epiphyseal                        quotient                permits     some      patients                                      with     obvious                     femoral-head
irregularity                   to      be         erroneously            classified              as having      satisfactory                                        results      .The                  advantage

                                                                                                                     THE          JOURNAL                 OF     BONE          AND         JOINT          SURGERY
                                                 TREATMENT                             OF        LEGG-CALVE-PERTHES                                    DISEASE                                                1049

                             AGES                          0-2                       3-4                            5-6                    7-9                       10-12                         13+

             9O-IOO                                                              I                             22                     2                         I            I

                       80-90                     I                             6            I                  7              2       4            I            I

             7O-8O                                          I                    511                           66                     222                                                                     I

             6O-7O                                                               1                             44                     13                                     22                               I

             5O-6O                                          I                    1                                       21                      24                                 2

             4O-5O                                                                                                        12          124                                    14

                             0-40                                                                    I                    13                                I                        I

                                                 GFP                           GFP                             GFP                    GFP                           GFP                        GFP

                        TOTAL                        I           2         0           14            2             2          19 18         6          10           10      13          0 0 4 09                  2

                                                                                                           FIG.         10
                                       Results             of        treatment                   with             bilateral        shoe          traction                and rest.bed



       z             60

       Li            40


                                                         INITIAL                                                  FRAGMEN-                                                REPARA-
                                                                                                                  TATION                                                 TIVE
                                                                                                          FIG.          11
                               Stage        of       the         disease             when                the       patient          was
                                                                                                                                  first    seen          related              to    results.

of         the       abduction-brace                                  method                    of        treatment                 over           traction                  is reflected                better             by    the
i\Iose               method.              Better                 coverage                   of the                     femoral            head          during                treatment                  in       the       abduc-
tion     brace                  probably    assists      the remodeling        process      and   may                                                                              be        the     basis            for    better
sphericity                     of the joint     surface.
        In the                 compilation       of data    shown     in Figures       9 and    10 the                                                                             results           of treatment                     in
VOL.         49-A,     NO.      6,     SEPTEMBER                 1967
1050                                                                                              J. F.       KATZ

the           two         groups                   of      treatment                       cases             were             regrouped                      according                     to           age           distribution,
epiphyseal                         quotient,                   and        shapes                of the             femoral                heads.                 Good          spherical                       femoral                   heads
were            more               frequent                in the             younger                  age      groups                and            diminished                     beyond                     seven               years           of
age. At this      age the poor                                             results            began                 to         increase                in     frequency,         reaching      a peak                                                 in
the group    over    ten years                                           of age.             A definite                       trend,           with           some     exceptions, noted wasin
correlation                         between                    good        femoral-head                        regularity                            and     high      epiphyseal                                   quotients.
             i\Iost            patients                   both
                                                         in              treatment                      categories        with                         onset      over     ten years                                  had      poor
end           results.                Generally                      satisfactory                      ratings                 were           evident                 at   the             younger                     ages.
     In                the     patients                  treated                 in         traction                (Fig.          10) there                      was an              increase                     in incidence
in poor                 results       in              the fifth               and           seventh-year                         age groups                       compared                 with                  those    treated
ill        abduction                      braces.
      Correlation                                 was        sought      between                             the       end  result      and     the                                 stage               of the     disease       at
onset   of treatment                                      (Fig.     11). Symptoms                                    at onset      were     found                                   to be               unreliable        guides
to   the   duration         of                            the    disease                process    since       different       changes     in the    femoral                                                                             head,
indicating         various                                stages      of             healing    and      repair,       were     noted    at the    time      the                                                                         initial
diagnosis      was      made                               and     they               did not    correlate          with    the duration        of symptoms.                                                                                   In
171           patients,                    the          initial      appearances                              of      the  femoral                          heads     at the    time                                  of     diagnosis
were            reviewed.                        In       eighty-six          patients                             (50 per     cent)                        the   disease    process                                       was    in the
initial               stage           (increased                      density               and        little            crushing,                   indicating                     approximately                                   zero           to
six months’                           duration)                   ; in         twenty-one                        instances                     (12 per                cent)     the    disease                                 had            pro-
gressed     to                     fragmentation                              of the      upper                    femoral                    epiphysis                 (approximately                                       twelve              to
eighteen                      months’        duration)                            ; in sixty-four        cases                                 (38       per cent)      the    reparative          stage
had      set             in     (approximately                                 eighteen       to twenty-four                                           months)     with     bone      regeneration
identifiable                         in     various               amounts.                       Thirty             per          cent          of the               patients                    first          seen           in        the        re-
parative                      stage           ended              with           poor            results             in        comparison                         with       23            per           cent          first
                                                                                                                                                                                                                        iii         seen
the          initial stage                       and           9 per cent first   seen    in the fragmentation                                                                              It
                                                                                                                                                                               stage. disappoint-
ing          to find   that                       only          a 7 per cent    advantage       accrued       from                                                         starting         treatment                                      while
the           disease               was          in      its     early             stages           compared                        with          those              showing                    advanced                      repair               at
time           of onset                     of treatment.
              Metaphyseal                        rarefactions                             and       defects                have            been             considered                      possibly                    to         be      seri-
ous           prognostic                         indicators                   by          some          authors.                    In        this          study,             it     was               found                that             large
metaphyseal                          defects     were                         associated                     with       longer                  periods               required                     for reconstitution
and    with                    greater       degrees                          of residual                      alteration                      in the               epiphysis.                      However,          no                        sig-
nificant       relationship                                     could     be               demonstrated                             in      the         distribution                            of satisfactory                                and
unsatisfactory              results                               between                   this   group                      and         that          of the entire                            series.

              Emphasis                      again    is directed                             to the                variability                       of coxa      plana.                      Unsatisfactory                                    re-
sults          continue                     to occur    despite                             a uniform                   program                      of disciplined                         non-weight-bearing
therapy.                      Abduction-brace                          support                  with          non-weight-bearing                                 appears              to    have               an       ad-
vantage                   over    treatment                           in bilateral                      shoe   traction.                             Prognosis    is most   favorable                                                   in the
younger                   age group     and                      does    not seem                         to be related                              to the duration      of symptoms                                                      at
the           time            of      diagnosis                  or      to        the       duration                    of      therapy.

      1.    EDGREN,                  WALTER:             Coxa      Plana.                  A Clinical      and                  Radiological          Investigation              with       Particular
            Reference                 to the            Importance         of              the Metaphyseal                       Changes          for the Final          Shape      of the       Proximal
            Part        of the        Femur.              Acta     Orthop.                   Scandinavica,                   Supplementum        84,  1965.
      2.    EYRE-BROOK,                      A. L.: Osteochondritis                               Deformans                Coxae       Juvenilis       or Perthes             Disease.          The
            Results         of Treatment     by Traction                                   in Recumbency.                    British      J. Surg.,     24:     166-182,         1936.
      3.    GOFF,        C. W.: Legg-Calv#{233}-Perthes                                      Syndrome   and               Related Osteochondroses                 of Youth.           Spring-
            field,      Illinois,            Charles             C. Thomas,               1954.
      4.    HAUGE,         M. F.: The Treatment                                          of Coxa       Plana.                   A        Follow-up                  Examination.                Acta           Orthop.
            Scandinavica,           26: 53-65,   1957.
      5.    HEYMAN,          C. H., and HERNDON,                                   C. H.: Legg-Perthes                              Disease.         A I\Iethod        for                the       Measurement
            of the        Roentgenographic     Result.                               J.     Bone          and        Joint           Surg.,          32-A:      767-778,                        Oct.

                                                                                                                         THE        JOURNAL                 OF      BONE            AND           JOINT             SURGERY
                                     TREATMENT               OF      LEGG-CALV-PERTHES                                DISEASE                                               1051

 6.    KATZ,      J.     F.:    Legg-Calv#{233}-Perthes           Disease-Results                  of      Treatment.               Cliii.        Orthop.,                10:      61-78,
 7.                    A. T.:    An Obscure            Affectionof the           Hip-Joint.              Boston         Med.        and            J.,
                                                                                                                                                 Surg. 162:           202-204,
 8.    MEYER,         JOHANNES:        Treatment                  of Legg-Calv#{233}Perthes                Disease.          Acta            Orthop.               Scandinavica,
       Supplementuin           86,    1966.
 9.     Moss,     Kxun:      Legg-Calv#{233}-Perthes                 l)isease.          Aarhu.s,           Universitetsforlaget,          1964.
10.    SJ0VALL,      lIELGE:       Zur     Frage     der           Behandlung              der      coxa       plana.         Mit     besonderer                     Ber#{252}cksichtigung
       der Primarerfolge                bei    knosequenter                  Ruhigstellung.        Acta       Orthop.            Scandinavica,               13:       324-353,
11.     ScNIrr,          IIALFDAN:        Further         Investigations        Respecting                Malum           Coxae         Calv#{233}-Legg-Perthes                        with
       Special          Regard     to   the     Prognosis           and       Treatment.                Chir.
                                                                                                         Acta     Scandinavica,            Supplementum                         148,

VOL.    49-A.     NO.      6.   SEPTEMBER       1967