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Legg-Calvé-Perthes Disease

Part II: Prospective Multicenter Study of the Effect of Treatment on Outcome

¹ Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75129. E-mail address for J.A. Herring: tony.herring{at}tsrh.org
² Department of Orthopaedic Surgery, Pusan National University Hospital, 1Ga-10, Ami-Dong, Seo-Gu, Pusan 602-739, Korea

Investigation performed at Texas Scottish Rite Hospital for Children, Dallas, Texas

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Texas Scottish Rite Hospital Research Fund and the Pediatric Orthopaedic Society of North America Huene Award. None of the authors 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, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

^* The Legg-Perthes Study Group includes Peter F. Armstrong, John G. Birch, William H. Browning, Alvin H. Crawford, Peter A. DeLuca, Frederick R. Dietz, Anne K. Dzus, Keith Gabriel, Neil E. Green, Richard H. Gross, Curtis R. Gruel, William A. Herndon, John A. Herring, Brian L. Hotchkiss, James G. Jarvis, Charles E. Johnston II, Vicki Kalen, John D. King, Dayle L. Maples, John B. McIvor, Peter L. Meehan, Marc J. Moreau, Raymond T. Morrissy, Colin F. Moseley, Scott J. Mubarak, Richard Nicol, George T. Rab, B. Stephens Richards, Lawrence A. Rinsky, James W. Roach, J. Andy Sullivan, Elizabeth A. Szalay, George H. Thompson, O. Timothy Ward, Hugh G. Watts, Stuart L. Weinstein, Dennis R. Wenger, David A. Yngve, Seymour Zimbler. Diane Ramey was the study coordinator. The eight pediatric orthopaedists in the Pediatric Orthopaedic Study Group included Hugh H. Watts, George H. Thompson, George T. Rab, John A. Herring, W. Timothy Ward, Stuart L. Weinstein, J. Andy Sullivan, and Neil E. Green.

Methods: We enrolled 438 patients with 451 affected hips in a prospective multicenter study in which each investigator applied the same treatment method to each of his or her patients^*. The five treatment groups consisted of no treatment, brace treatment, range-of-motion exercises, femoral osteotomy, and innominate osteotomy. All patients were between 6.0 and 12.0 years of age at the onset of the disease, and none had had prior treatment. Three hundred and forty-five hips in 337 patients were available for follow-up at skeletal maturity. All hips were classified with the modified lateral pillar classification and the system of Stulberg et al.

Results: There were no differences in outcome among the hips with no treatment, those treated with bracing, and those treated with range-of-motion therapy. There were also no differences between the hips treated with a femoral varus osteotomy and those treated with an innominate osteotomy. Treatment did not have a significant effect on children who had a chronologic age of 8.0 years or less or a skeletal age of 6.0 years or less at the onset of the disease. In the lateral pillar B group and B/C border group, the outcomes of surgical treatment were significantly better than those of nonoperative treatment in children over the age of 8.0 years at the onset of the disease (p 0.05). Patients who were 8.0 years old or less at the onset of the disease in lateral pillar group B did equally well with nonoperative and operative treatment. Hips in lateral pillar group C had the least favorable outcomes, with no differences between the operative and nonoperative groups. The lateral pillar classification (p < 0.0001) and the age at the onset of the disease (p = 0.0001) were both strong prognostic factors. Female patients did significantly worse than male patients if they were over the age of 8.0 years at the onset of the disease (p = 0.004).

Conclusions: The lateral pillar classification and age at the time of onset of the disease strongly correlate with outcome in patients with Legg-Calvé-Perthes disease. Patients who are over the age of 8.0 years at the time of onset and have a hip in the lateral pillar B group or B/C border group have a better outcome with surgical treatment than they do with nonoperative treatment. Group-B hips in children who are less than 8.0 years of age at the time of onset have very favorable outcomes unrelated to treatment, whereas group-C hips in children of all ages frequently have poor outcomes, which also appear to be unrelated to treatment.

Level of Evidence: Therapeutic study, Level II-1 (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

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