Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Michael Leunig, MD*,
Schulthess Clinic, Zürich, Switzerland
Posted July 2007
Residual Legg-Calvé-Perthes disease and Perthes-like
deformities in adulthood, as described in the paper by Clohisy et al., present
a therapeutic challenge to the orthopaedic surgeon. In their paper, the authors
describe midterm follow-up of treatment of twenty-four hips in nine male and eleven
female patients with a mean age of 22.7 years with a diagnosis of acetabular
dysplasia associated with Perthes-like femoral head configuration.
Hip morphologies in Legg-Calvé-Perthes disease and Perthes-like
deformities can be quite complex, spanning a wide range of acetabular and
femoral alterations. In addition to the insufficient femoral head coverage that
is found in hips with acetabular dysplasia secondary to Legg-Calvé-Perthes
disease, acetabular retroversion has recently been identified in 42% of hips in
patients with Legg-Calvé-Perthes disease1. Another issue increasing
the complexity of care is that, in these hips, good femoral cartilage is present
only in the peripheral "nonspherical" zone, while the central cartilage is
frequently affected by the femoral head necrosis.
In addition to these intra-articular problems of incongruity
that lead to instability or impingement, a short femoral neck is associated
with a reduced limb length and a high-riding greater trochanter, potentially
leading to extra-articular impingement and/or abductor dysfunction. It is
becoming evident that these isolated or combined deformities can result in a
complex morphology, meaning that the cause of symptoms frequently cannot be
attributed to one deformity. As a consequence, the treatment of one problem
alone may be insufficient and may even aggravate coexisting pathologies.
Clohisy et al. present a rational treatment strategy for
these complex situations. Clinically, the qualifications for surgical treatment
were hip flexion of ≥95°
and an absence of advanced osteoarthritis. Pelvic anteroposterior, false
profile, and lateral radiographs were made. Although its use was not proposed
in this paper, magnetic resonance arthrography has been shown to be of value in
assessing the coexistence of dysplasia and impingement2. Acetabular and femoral
morphologies in Legg-Calvé-Perthes disease and Perthes-like deformities can
lead not only to a lateral labral overload due to dysplasia but also to
anterior labral destruction by femoroacetabular impingement3. Because
the two conditions require different treatment, optimum preoperative workup of
these hips is most helpful.
Periacetabular osteotomy was performed in twenty-four hips
and was combined with twenty-one concurrent femoral osseous or soft-tissue
procedures in fifteen hips (63%). The potential overlap of coexisting
acetabular undercoverage (dysplasia) and femoroacetabular impingement,
potentially aggravated after periacetabular reorientation, is clearly
discussed. At a mean follow-up of 4.5 years, clinical outcome as measured with
use of the modified Harris Hip Score was significantly improved (p < 0.0001)
and reported as excellent in the majority of patients. The Tönnis osteoarthritis
grade remained stable in the majority of hips.
Despite the promising data, enthusiasm should be tempered
slightly. One issue is that these hips may improve but frequently may not
attain excellent function, even though the result on the modified Harris Hip
Score (which was designed for patients who have undergone hip replacement) is
excellent. Periacetabular osteotomy in hips with Legg-Calvé-Perthes disease or
Perthes-like deformities is technically demanding, which can be evidenced from
the high number of required combined procedures. It is not the osteotomy
itself, but rather the correction, that can become quite challenging. The
acetabular fragment is not positioned on top of a round sphere as it is in hips
with classic dysplasia; instead, it is on top of a mushroom-like deformed
femoral head, which frequently limits desired maneuvers. It would have been interesting
to know the percentage of preoperative and postoperative retroverted acetabuli that
were seen in this study, as this malalignment, if unaddressed, can contribute
to impingement. Not mentioned was the need to first address the femoral side in
hips that have an appreciable pelvic-trochanteric impingement, as that
condition does not permit acetabular reorientation prior to femoral treatment.
Taken together, residual Legg-Calvé-Perthes disease and
Perthes-like deformities remain a therapeutic challenge. Careful preoperative
clinical and radiographic workup is key to the
planning of successful management. If a periacetabular osteotomy is considered,
substantial experience with this osteotomy technique will help in coping with the
potential difficulties that may be encountered during reorientation of the
acetabular fragment. As implemented by the authors in the management of their
most recent patients, intraoperative capsulotomy must be performed along with
the periacetabular osteotomy4 because improved coverage
after reorientation enhances the risk of secondary femoroacetabular impingement.
Quite frequently, correction-induced intra-articular and extra-articular
impingement may be aggravated after reorientation, thus requiring subsequent
femoral treatment. Only the adherence to these principles and the individualization
of acetabular and eventual femoral treatment will provide the basis for a
successful outcome. The authors should be congratulated for their original
presentation of this complex topic.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
References
1. Ezoe M, Naito M, Inoue T. The prevalence of acetabular retroversion among various disorders of the hip. J Bone Joint Surg Am. 2006;88:372-9.
2. Eijer H, Podeszwa DA, Ganz R, Leunig M. Evaluation and treatment of young adults with femoro-acetabular impingement secondary to Perthes' disease. Hip International. 2006;16:273-80.
3. Leunig M, Werlen S, Ungersböck A, Ito K, Ganz R. Evaluation of the acetabular labrum by MR arthrography. J Bone Joint Surg Br. 1997;79:230-4.
4. Myers SR, Eijer H, Ganz R. Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop Relat Res. 1999;363:93-9.
|
