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New Surgical Technique to Treat Severe Perthes Hip Disease

In this study, treatment of Legg-Calvé-Perthes Disease (also known as Perthes disease) with triple pelvic osteotomy is evaluated for its effectiveness. That statement will make a lot more sense once we describe Legg-Calvé-Perthes Disease and describe what is a triple pelvic osteotomy.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition three names to honor the three physicians who each separately described the disease.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die.

The blood supply eventually returns, and the bone heals. In the process, the joint cartilage softens, the round head of the femur flattens, and subluxation (head of the femur shifts out from inside the hip socket) occurs.

How the bone heals determines how much problem the condition will cause in later life. This condition can lead to premature hip arthritis. That's why every effort is made to contain (hold) the hip in the socket during the necrosis and revascularization phases. Necrosis refers to the period when loss of blood to the bone results in the death of bone cells. Revascularization is the restoration of normal blood supply.

There are different ways to contain the femoral head. Two of the better known (and most often used) methods are called femoral varus osteotomy and Salter innominate osteotomy. In this study, the triple pelvic osteotomy used the bones on three sides of the femoral head (pubic bone, iliac bone, ischium) to hold the head of the humerus firmly in place.

The surgeon uses tools and instruments to cut the bone in the pelvis, shift the pieces of bone, and reshape the bones to form a holding container around the femoral head. The authors provide drawings and photos of X-rays to show how this is done.

This triple technique is really designed for the more severe cases of Perthes disease. These patients need long periods of time with the hip held in place in order to reshape and stabilize the femoral head. Wearing a cast for months on end has many problems. The hope with this triple osteotomy is to avoid a limp or leg length difference from one side to the other that often occur when only one of the other techniques (varus osteotomy, Salter osteotomy) are used.

Of course, the question remains: how effective is this triple pelvic osteotomy in the treatment of Perthes disease and especially in preventing degenerative arthritis? To find out, results were measured using X-rays, presence of a limp, and leg length differences. Joint motion and activity levels were also compared between those patients who had the triple pelvic osteotomy and those who had one of the other more traditional approaches.

The results were considered fair to good and satisfactory. Remodeling was more successful in younger children (under the age of eight). There were only a few cases where additional surgery was required. The majority of patients went from having a painful hip and limp to a pain free normal gait (walking) pattern. And there were no "poor" results.

The authors conclude that surgical containment of the femoral head in the hip socket is safe and effective in the treatment of severe Legg-Calvé-Perthes disease. Using the triple pelvic osteotomy surgery can reshape the head of the femur into a round sphere that stays in the hip socket.

The final result is a pain free, functional hip that can eliminate differences in leg length, and restore a normal walking pattern without a limp. Surgeons must be careful not to overdo it -- too much containment can cause a painful impingement (pinching) problem. But even with this problem, the surgeon can go back in and trim the rim around the hip socket to take care of the impingement.

Reference: Dennis R. Wenger, MD, et al. Advanced Containment Methods for Legg-Calvé-Perthes Disease: Results of Triple Pelvic Osteotomy. In Journal of Pediatric Orthopaedics. December 2010. Vol. 30. No. 8. Pp. 749-757.