The modified Stulberg classification is a strong predictor of the radiological outcome 20 years after the diagnosis of Perthes' disease.

AIMS: The aim of this study was to assess the prognostic value of the modified three-group Stulberg classification, which is based on the sphericity of the femoral head, in patients with Perthes' disease. METHODS: A total of 88 patients were followed from the time of diagnosis until a mean follow-up of 21 years. Anteroposterior pelvic and frog-leg lateral radiographs were obtained at diagnosis and at follow-up of one, five, and 21 years. At the five- and 21-year follow-up, the femoral heads were classified using a modified three-group Stulberg classification (round, ovoid, or flat femoral head). Further radiological endpoints at long-term follow-up were osteoarthritis (OA) of the hip and the requirement for total hip arthroplasty (THA). RESULTS: There were 71 males (81%) and 17 females. A total of 13 patients had bilateral Perthes' disease; thus 101 hips were analyzed. At five-year follow-up, 37 hips were round, 38 ovoid, and 26 flat. At that time, 66 hips (65%) were healed and 91 (90%) were skeletally immature. At long-term follow-up, when the mean age of the patients was 28 years (24 to 34), 20 hips had an unsatisfactory outcome (seven had OA and 13 had required THA). There was a strongly significant association between the modified Stulberg classification applied atfive-year follow-up and an unsatisfactory outcome at long-term follow-up (p < 0.001). Between the five- and 21-year follow-up, 67 hips (76%) stayed in their respective modified Stulberg group, indicating a strongly significant association between the Stulberg classifications at these follow-ups (p < 0.001). CONCLUSION: The modified Stulberg classification is a strong predictor of long-term radiological outcome in patients with Perthes' disease. It can be applied at the healing stage, which is usually reached five years after the diagnosis is made and before skeletal maturity. Cite this article: Bone Joint J 2021;103-B(12):1815-1820.

Intra- and inter-observer reliability of Laredo classification system in Legg-Calvé-Perthes Disease.

The purpose of the current study was to investigate intra- and inter-observer reliability of arthrographic Laredo classification system in Perthes disease. Forty-seven patients were included in this cross-sectional descriptive study. Patients' age, gender, physical findings and hip arthrographs were collected from hospital medical records. Two different sets of power point slides were prepared in which the order of cases was randomized and blinded. Observers were divided into three groups according to their surgical experience (9 residents, 10 seniors, 10 pediatric orthopedists), and they assessed two times 1 month's intervals. Statistical analysis was performed by using the SPSS v21. Inter- and intra-observer reliabilities were calculated using intra-class correlation coefficient, weighted kappa and percentage agreement. Percentage agreement of Laredo classification was about 50% for all groups (residents, seniors and pediatric orthopedists); intra-observer reliabilities were excellent, excellent and fair, respectively. Inter-observer reliability of Laredo classification for each set was found to be excellent for all groups. Length of experience did not correlated significantly with the level of intra-observer agreement. As a conclusion, our results showed that Laredo's arthrographic classification system's intra-observer reliability is at least at a fair level and inter-observer reliability is at an excellent level. We believe that this classification system is valuable for an orthopedic surgeon who deals with the treatment of Perthes disease.

Height-Width Ratio of Proximal Femoral Epiphysis: Estimation of Lateral Pillar Involvement in Bilateral Perthes Disease.

BACKGROUND: The standard evaluation of epiphyseal involvement in Perthes disease is lateral pillar classification. However, it needs to be compared with contralateral normal hip leading to limited use in bilateral disease. We, therefore, develop a ratio between epiphyseal height and metaphyseal width of affected hips to estimate lateral pillar involvement. This study aimed to assess the height-width ratio of the proximal femoral epiphysis in non-Perthes children, and to find the relationship between the height-width ratio and lateral pillar classification in Perthes disease. METHODS: A cross-sectional study was conducted between 2009 and 2015. Phase I included children aged 2 to 15 years who did not have Perthes disease. Phase II included children aged 2 to 15 years who had Perthes disease. Other abnormal proximal femoral epiphysis was excluded. Lateral pillar height and metaphyseal width were independently measured twice by 2 assessors in each phase. Intraobserver and interobserver levels of agreement, height-width ratio and cut-off points to differentiate lateral pillar types were determined. RESULTS: There were 69 children (87 hip radiographs) who had non-Perthes hips, and 18 boys with Perthes disease (20 hip radiographs). Height-width ratio in the non-Perthes group increased from 0.38 to 0.48 at 2 to 10 years of age and remained constant until maturity. Average height-width ratio in lateral pillar A/non-Perthes hip was 0.47±0.05, lateral pillar B or B/C 0.32±0.05, and lateral pillar C 0.18±0.05. Intraobserver and interobserver level of agreements of height-width ratio in Perthes disease were 0.007 (95% confidence interval, -0.030 to 0.043) and 0.006 (95% confidence interval, -0.119 to 0.107), respectively. Cut-off values to differentiate lateral pillar A and B or B/C was 0.40, and to differentiate lateral pillar B or B/C, and C was 0.25 with 90% accuracy and area under receiver operating characteristic curve of 0.9. CONCLUSIONS: Height-width ratio is useful for grading severity in unilateral and bilateral Perthes disease. It has excellent reliability and validity with exact cutoff values to estimate lateral pillar classification. LEVEL OF EVIDENCE: Level II-diagnostic study.

A simple, precocious, and reliable way to assess future clinical outcome in children with Perthes disease and mild femoral head involvement: correlation between MRI with diffusion-weighted and dynamic gadolinium-enhanced subtraction and Catterall and Herring classifications.

BACKGROUND: In children older than 5 years with a mild form of Legg-Calvé-Perthes disease, the outcome is difficult to predict. In this study, we retrospectively correlated gadolinium-enhanced subtracted (DGS) and diffusion (DWI) MRI findings to the radiographic assessment according to the Catterall and Herring et al. classifications and to the final score according to Stulberg et al.: the aim was to identify a precocious, simple, and objective criterion to differentiate between forms evolving favourably and forms requiring an early surgical treatment in order to avoid femoral head deformity and subsequent osteoarthritis. METHODS: Twelve boys with unilateral mild femoral head involvement (Catterall grade 2 or grade 3) underwent DSG and DWI MR during the early phase of the disease. The absence of enhancement of the external pillar on DSG MRI and the presence of metaphyseal hyperintensity on DWI were considered to be the signs of poor outcome. These findings were correlated with the Catterall and Herring et al. classifications at the initial sclerotic stage and early fragmentation phase and with the Stulberg et al. classifications at least 5 years after the onset of the disease. RESULTS: DSG MRI findings correctly discriminated three out of four patients with a good outcome but underestimated two out of eight patients with a poor outcome. DWI findings correlated with the Catterall and Herring et al. classifications in 12 out of 12 cases. In only one case, DWI findings did not correlate with the Stulberg et al. classification. CONCLUSION: DWI MR provides an objective and accurate prognostic criterion that is relatively easy to recognise. DGS MR findings are less accurate, thus underestimating the gravity of the disease in one-fourth of the patients with a poor outcome.

MRI appearance in the early stage of Legg-Calvé-Perthes disease to predict lateral pillar classification: A retrospective analysis of the labral horizontalization.

BACKGROUND: The Herring lateral pillar classification is widely used for the classification of Legg-Calvé-Perthes disease, but is not applied at the early stage of Legg-Calvé-Perthes disease because it is typically applied at the late fragmentation stage. The purpose of this study was to investigate the correlation between the early appearance on magnetic resonance imaging of the acetabular labrum and lateral pillar involvement in Legg-Calvé-Perthes disease. METHODS: Non-contrast magnetic resonance images of 26 hips in 25 children with early-stage Legg-Calvé-Perthes disease were retrospectively reviewed. The extent of labral horizontalization was quantitatively evaluated with a new method, the labral angle, on T2*-weighted magnetic resonance images. A small labral angle indicates strong labral horizontalization. Calculation of the teardrop distance and acetabular head index on radiographs was modified for application to magnetic resonance imaging, and the extent of cartilaginous lateral subluxation (cartilaginous tear drop distance) and cartilaginous lateral extrusion (cartilaginous acetabular head index) were evaluated. The outcome measure was the lateral pillar classification. RESULTS: There were statistically significant correlations between the labral angle and the cartilaginous tear drop distance (p = 0.002, ɤ = -0.58) and the cartilaginous acetabular head index (p < 0.001, ɤ = 0.65) on magnetic resonance images. The labral angle was small in order of groups C, B, and A, and there were significant differences between groups A and C (p < 0.001) and B and C (p = 0.006). CONCLUSION: Greater labral horizontalization observed on magnetic resonance imaging at the early stage of Legg-Calvé-Perthes disease correlated with strong cartilaginous lateral subluxation and extrusion, and with increased lateral pillar collapse at the maximum fragmentation stage. Our finding suggests that a quantitative evaluation of labral horizontalization using magnetic resonance imaging in the early-stage of Legg-Calvé-Perthes disease can predict the later lateral pillar classification.

Effect of greater trochanteric epiphysiodesis after femoral varus osteotomy for lateral pillar classification B and B/C border Legg-Calvé-Perthes disease: A retrospective observational study.

This is a retrospective observational study. Greater trochanteric epiphysiodesis (GTE) has been recommended to prevent Trendelenburg gait and limitation of the hip joint motion due to trochanteric overgrowth after femoral varus osteotomy (FVO) in Legg-Calvé-Perthes disease (LCPD). However, capital femoral physeal arrest frequently occurs in patients with severe disease (lateral pillar C), so GTE might not be as effective in these patients. The aim of this study was to compare trochanteric growth inhibition due to GTE after FVO between 2 age groups (<8 or >8 years) in patients with lateral pillar B and B/C border LCPD and evaluate the effectiveness of GTE compared with the normal, unaffected hip.This study included 19 children with lateral pillar B and B/C border LCPD in 1 leg who underwent FVO followed by GTE. Of the 19 children, 9 underwent GTE before the age of 8 years and 10 underwent GTE after 8 years of age. On radiographs taken at the immediate postoperative period and at skeletal maturity, the articulo-trochanteric distance (ATD), center-trochanteric distance (CTD), and neck-shaft angle (NSA) were compared between the 2 age groups. The amount of correction was compared between groups. The contralateral, unaffected hip was used as a control for trochanteric growth. The patients were clinically evaluated with Iowa hip score at the final follow-up.There was no significant difference between the 2 age groups in terms of time to GTE, length of follow-up, or lateral pillar classification. In the affected hip, the amount of correction of the ATD, CTD, and NSA was significantly greater in patients < 8 years than in patients > 8 years. However, in the unaffected hip, the change in the ATD, CTD, and NSA did not differ significantly between the 2 groups.We suggest that FVO followed by GTE for lateral pillar B and B/C border LCPD in patients under the age of 8 years can affect growth of the greater trochanter. However, effective growth inhibition due to GTE was not achieved after 8 years of age.

Radiographic classifications in Perthes disease.

Background and purpose - Different radiographic classifications have been proposed for prediction of outcome in Perthes disease. We assessed whether the modified lateral pillar classification would provide more reliable interobserver agreement and prognostic value compared with the original lateral pillar classification and the Catterall classification. Patients and methods - 42 patients (38 boys) with Perthes disease were included in the interobserver study. Their mean age at diagnosis was 6.5 (3-11) years. 5 observers classified the radiographs in 2 separate sessions according to the Catterall classification, the original and the modified lateral pillar classifications. Interobserver agreement was analysed using weighted kappa statistics. We assessed the associations between the classifications and femoral head sphericity at 5-year follow-up in 37 non-operatively treated patients in a crosstable analysis (Gamma statistics for ordinal variables, γ). Results - The original lateral pillar and Catterall classifications showed moderate interobserver agreement (kappa 0.49 and 0.43, respectively) while the modified lateral pillar classification had fair agreement (kappa 0.40). The original lateral pillar classification was strongly associated with the 5-year radiographic outcome, with a mean γ correlation coefficient of 0.75 (95% CI: 0.61-0.95) among the 5 observers. The modified lateral pillar and Catterall classifications showed moderate associations (mean γ correlation coefficient 0.55 [95% CI: 0.38-0.66] and 0.64 [95% CI: 0.57-0.72], respectively). Interpretation - The Catterall classification and the original lateral pillar classification had sufficient interobserver agreement and association to late radiographic outcome to be suitable for clinical use. Adding the borderline B/C group did not increase the interobserver agreement or prognostic value of the original lateral pillar classification.

Advanced Containment With Triple Innominate Osteotomy in Legg-Calve-Perthes Disease: A Viable Option Even in Severe Cases.

BACKGROUND: Legg-Calve-Perthes disease (LCPD), in its severe form, remains a challenge. More recent classifications, particularly the modified Elizabethtown classification, have highlighted the chronologic stage of LCPD and its effect on surgical outcome. Hip severity and age of disease onset have also been shown to be powerful determinants of outcome. This study was performed to determine whether disease stage, disease severity, or patient age, are absolute indicators of whether a patient can benefit from surgical containment with triple innominate osteotomy (TIO). METHODS: All patients with LCPD treated with TIO between 1995 and 2011 were collected. Only those patients with a minimum of 2-year radiographic follow-up and no previous or concomitant femoral realignment surgery were included. Fifty-four patients (56 hips) met our inclusion criteria. The modified Elizabethtown classification was used to classify disease stage as early (

Short follow-up evaluation of proximal femoral varus osteotomy for treatment of Legg-Calvé-Perthes disease.

BACKGROUND: There are many methods of treating Legg-Calvé-Perthes disease, including operative and nonoperative methods. Femoral varus osteotomy is one of the surgical methods used to treat this disease, and it involves changing the alignment of the proximal femur to improve containment of the femoral epiphysis in the acetabulum. The aims of this study were to evaluate the results of femoral varus osteotomy for the treatment of Perthes disease according to various classification and grading schemes, as well as to compare the results to those obtained using other methods of treatment reported in the literature. MATERIALS AND METHODS: Twenty-three patients with Legg-Calvé-Perthes disease were treated using a proximal femoral varus osteotomy procedure. The mean age of the patients was 7.8 years (range: 6-11.5 years). The average follow-up was 36.2 months (range: 29-48 months). RESULTS: The patients were classified and graded according to the Catterall and Herring classifications. The preoperative and postoperative mean epiphyseal extrusion indices were as follows: group III (B), 10.88 % and 7.22 %, P = 0.027; group III (BC), 15.81 and 8.93 %, P = 0.005; group IV (C), 72.64 and 39.44 %, P = 0.018. The preoperative and the postoperative mean Wiberg's CE angle were as follows: group III (B), 26.88° and 37.81°, P = 0.028; group III (BC), 24.4° and 32.2°, P = 0.005; group IV (C), 20.89° and 28.41°, P = 0.018. Changes in Iowa clinical hip scores were as follows: group III (B), 54.8 to 92.33, P = 0.027; group III (BC), 47.3 to 87.8, P = 0.005; group IV (C) 34.43 to 68.29, P = 0.017. In the last follow-up, the mean limb length discrepancy after plate removal was 0.9 cm (range: 0.0-2 cm) of shortening on the operated side. The author of the present study did not see any progressive change in this parameter during the follow-up period, especially after hardware removal and in the younger boys. All of the osteotomies united within 3 months without loss of fixation. CONCLUSION: According to the results of the present study, proximal femoral varus osteotomy gives good results in children between the ages of 6 and 10 years without any femoral head deformity and flattening, especially with good containment in abduction. LEVEL OF EVIDENCE: Level IV.

Interobserver and intraobserver reliability of the modified Waldenström classification system for staging of Legg-Calvé-Perthes disease.

BACKGROUND: The absence of a reliable classification system for Legg-Calvé-Perthes disease has contributed to difficulty in establishing consistent management strategies and in interpreting outcome studies. The purpose of this study was to assess interobserver and intraobserver reliability of the modified Waldenström classification system among a large and diverse group of pediatric orthopaedic surgeons. METHODS: Twenty surgeons independently completed the first two rounds of staging: two assessments of forty deidentified radiographs of patients with Legg-Calvé-Perthes disease in various stages. Ten of the twenty surgeons completed another two rounds of staging after the addition of a second pair of radiographs in sequence. Kappa values were calculated within and between each of the rounds. RESULTS: Interobserver kappa values for the classification for surveys 1, 2, 3, and 4 were 0.81, 0.82, 0.76, and 0.80, respectively (with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.0, nearly perfect agreement). Intraobserver agreement for the classification was an average of 0.88 (range, 0.77 to 0.96) between surveys 1 and 2 and an average of 0.87 (range, 0.81 to 0.94) between surveys 3 and 4. CONCLUSIONS: The modified Waldenström classification system for staging of Legg-Calvé-Perthes disease demonstrated substantial to almost perfect agreement between and within observers across multiple rounds of study. In doing so, the results of this study provide a foundation for future validation studies, in which the classification stage will be associated with clinical outcomes.

Comparison of the results from simple radiography, from before to after Salter osteotomy, in patients with Legg-Calvé-Perthes disease,

Objectives: To determine whether the clinical variables and preoperative classification of patients with Legg-Calvé-Perthes disease (LCPD) who undergo Salter osteotomy correlate with the radiographic result at the time of skeletal maturity. Methods: In this retrospective cohort study, 47 individuals with LCPD who were treated using Salter osteotomy (1984-2004) were evaluated. The patients were evaluated according to sex, skin color, side affected and age at which osteotomy was performed. The preoperative radiographs were analyzed in accordance with the classifications of Waldenstrom, Catter-all, Laredo and Herring. The radiographs obtained at the time of skeletal maturity were classified using the Stulberg method. Results: The mean age at the time of surgical treatment was 82.87 months (6.9 years). The age presented a statistically significant correlation with the Stulberg grades at skeletal maturity (p < 0.001). Patients over the age of 6.12 years tended to present less favorable results. The variables of sex, skin color and side affected did not present any statistically significant correlation with the prognosis (p = 0.425; p = 0.467; p = 0.551, respectively). Only the Laredo classification presented a statistically significant correlation with the final result given by the Stulberg classification (p = 0.001). The other classifications used (Waldenstrom, Catterall and Herring) did not present any correlation between the time at which surgery was indicated and the postoperative result. Conclusions: The age at which the patients underwent surgical treatment and the Laredo classification groups were the only variables that presented significant correlations with the Stulberg classification...

Objetivos: Determinar em pacientes com doenca de Legg-Calvé-Perthes (DLCP) submetidos à osteotomia de Salter se as variáveis clínicas e as classificacões pré-operatórias se correlacionam com o resultado radiográfico na maturidade esquelética. Métodos: Neste estudo de coorte retrospectivo foram avaliados 47 indivíduos portadores da DLCP tratados com osteotomia de Salter (1984-2004). Os pacientes foram avaliados de acordo com sexo, cor, lado acometido e idade em que foi feita a osteotomia. As radiografias pré-operatórias foram analisadas de acordo com as classificacões de Waldenstrõm, Catterall, Laredo e Herring. As radiografias obtidas na maturidade esquelética foram classificadas segundo o método de Stulberg. Resultados: A média da idade no momento do tratamento cirúrgico foi de 82,87 meses (6,9 anos). A idade apresentou correlacão estatisticamente significativa com os graus de Stulberg na maturidade esquelética (p <0,001). Pacientes acima de 6,12 anos tendem a apresentar resultados menos favoráveis. As variáveis sexo, cor e lado acometido não apresentaram correlacão estatisticamente significativa com o prognóstico (p = 0,425; p = 0,467; p = 0,551, respectivamente). Apenas a classificacão de Laredo apresentou correlacão estatisticamente significante com o resultado final dado pela classificacão de Stulberg (p = 0,001). As demais classificacões usadas, Waldenstrõm, Caterall e Herring, não apresentaram correlacão entre o momento em que foi indicada a cirurgia e o resultado pós-operatório. Conclusões: A idade em que os pacientes foram submetidos ao tratamento cirúrgico e os grupos da classificacão de Laredo foram as únicas variáveis que apresentaram correlacão significativa com a classificacão de Stulberg...

What is the usefulness of the fragmentation pattern of the femoral head in managing Legg-Calvé-Perthes disease?

BACKGROUND: Within the lateral pillar classification of the Legg-Calvé-Perthes (LCP) disease, hips seem quite variable in the pattern of fragmentation as seen in radiographs. The purpose of this study was to determine: if it is possible to reliably subdivide the lateral pillar groups into femoral head fragmentation patterns, and if such a subdivision of the lateral pillar groupings is clinically useful in managing LCP disease. METHODS: Two hundred and ninety-three anteroposterior radiographs taken at the maximal fragmentation stage (189 lateral pillar B, 57 B/C border, and 47 C hips; mean bone/chronologic age at the time of first visit, 6.2/7.9 years) and at skeletal maturity (mean age, 16.6 years) were analyzed. We distinguished 3 fragmentation patterns in each pillar group based on the region of major involvement. We tested the inter- and intraobserver reliability of our classification system and analyzed the relationships between the fragmentation patterns and the Stulberg outcomes as well as other factors such as surgical treatment and age. RESULTS: Inter- and intraobserver consistency in fragmentation pattern assignments was found to be substantial to excellent. A statistically significant trend (p = 0.001) in the proportion of Stulberg III or IV outcomes in comparison with Stulberg I and II was only found for the different fragmentation patterns in our lateral pillar B patients: fragmentation patterns having mainly lateral-central necrosis led to poor outcomes. No significant association was found between fragmentation patterns and Stulberg outcomes in pillar groups B/C border and C. CONCLUSIONS: Our results are consistent with the lateral pillar classification itself. Therefore, fragmentation patterns in each lateral pillar classification did not provide clinical usefulness in the management of LCP disease.

What Is the Usefulness of the Fragmentation Pattern of the Femoral Head in Managing Legg-Calve-Perthes Disease?

BACKGROUND: Within the lateral pillar classification of the Legg-Calve-Perthes (LCP) disease, hips seem quite variable in the pattern of fragmentation as seen in radiographs. The purpose of this study was to determine: if it is possible to reliably subdivide the lateral pillar groups into femoral head fragmentation patterns, and if such a subdivision of the lateral pillar groupings is clinically useful in managing LCP disease. METHODS: Two hundred and ninety-three anteroposterior radiographs taken at the maximal fragmentation stage (189 lateral pillar B, 57 B/C border, and 47 C hips; mean bone/chronologic age at the time of first visit, 6.2/7.9 years) and at skeletal maturity (mean age, 16.6 years) were analyzed. We distinguished 3 fragmentation patterns in each pillar group based on the region of major involvement. We tested the inter- and intraobserver reliability of our classification system and analyzed the relationships between the fragmentation patterns and the Stulberg outcomes as well as other factors such as surgical treatment and age. RESULTS: Inter- and intraobserver consistency in fragmentation pattern assignments was found to be substantial to excellent. A statistically significant trend (p = 0.001) in the proportion of Stulberg III or IV outcomes in comparison with Stulberg I and II was only found for the different fragmentation patterns in our lateral pillar B patients: fragmentation patterns having mainly lateral-central necrosis led to poor outcomes. No significant association was found between fragmentation patterns and Stulberg outcomes in pillar groups B/C border and C. CONCLUSIONS: Our results are consistent with the lateral pillar classification itself. Therefore, fragmentation patterns in each lateral pillar classification did not provide clinical usefulness in the management of LCP disease.

Legg-Calvé-Perthes: interobserver and intraobserver reliability of the modified Herring lateral pillar classification.

BACKGROUND: The purpose of our study was to independently assess the reliability of the modified Herring lateral pillar classification. METHODS: Thirty-five standardized true anteroposterior radiographs of children in the fragmentation phase were independently assessed by 6 senior observers on 2 separate occasions (6 wk apart). The κ analysis was used to assess the interobserver and intraobserver agreement. RESULTS: Intraobserver analysis revealed at best only moderate agreement for 2 observers. Three observers showed fair consistency, whereas 1 remaining observer showed poor consistency between repeated observations (P < 0.01). The highest scores for interobserver agreement varying between moderate to good could only be established between 2 observers. For the remaining observers results were just fair (P < 0.01). CONCLUSIONS: This study highlights the lack of agreement between senior clinicians when applying the modified lateral pillar classification. The results from the Herring group were significantly better than ours, but utilized a weighted κ for analysis, which may have given artificially high scores. To our knowledge, this is the first time the modified lateral pillar classification has been independently tested for its reproducibility by a specialist pediatric orthopaedic unit.

Hinged distraction of the hip joint in the treatment of Perthes disease: evaluation at skeletal maturity.

The aim of this work is to determine the effect of this type of treatment on the shape of the femoral head, the range of motion (ROM), radiological changes in the femoral head, and the prognosis of Perthes disease at skeletal maturity. From 1998 to 2007, 53 patients with Perthes disease were treated with a combination of soft tissue release and joint distraction with a hinged monolateral external fixator in 32 patients and by Ilizarov external fixator in 21 patients. Nineteen of our 53 patients attained skeletal maturity and were evaluated in our study. This study included 15 boys and four girls, mean age at surgery 9.3 years (range 7.2-13.1), and mean age at the last follow-up 17.4 years (range 14.9-21.3). The duration of symptoms varied from a period of 6 to 60 months before the operation. Radiographs taken during the fragmentation stage of the disease were classified by the lateral pillar classification of Herring; 19 of our patients attained skeletal maturity and were evaluated. Clinical assessment included the Harris hip score, hip ROM, and limb length discrepancy. Radiographic assessment included sharp transverse acetabular inclination, the uncoverage percentage, the epiphyseal index before surgery (modified Eyre-Brook), at frame removal, and at the last follow-up, the epiphyseal quotient (of Sjovall), and the Stulberg classification. The mean follow-up was 7.2 years (range 4.1-11.3). The mean Harris hip score was 87.1/100 (range 49.2-94.8). An improvement in hip (ROM) of 83.3% of the normal range was restored. There was a marked improvement in the degree of pain and limp postoperatively. The hip ROM was slightly limited in most patients, and seven patients had limb shortening of between 1 and 3 cm. The mean sharp transverse acetabular inclination of the affected side was 44° (range 35-51) compared with 37° for the unaffected side (P=0.042). The mean uncoverage percentage was 36% (range 24-45) compared with 21% for the unaffected side (P=0.027). The mean epiphyseal index was 0.74 (range 0.36-0.94) before surgery, 0.78 (range 0.49-0.89) at frame removal (P=0.017), and 0.80 (range 0.54-0.91) at the last follow-up (P=0.701). The epiphyseal quotient was 0.74 (range 0.51-0.94) and the Stulberg classifications were type II in eight patients, type III in seven patients, type IV in three patients, and type V in one patient. Arthrodiastasis of the hip joint with soft tissue release may represent a good contribution toward the treatment of Legg-Calvé-Perthes disease. This method of treatment has many advantages such as easy technique, minimal rate of complications, a short hospitalization period, correction of shortening because it adds to the length of the limb, and a higher rate of acceptable results than would be expected compared with other methods. It also improves the ROM, reduces superior and lateral subluxation, and provides better radiographic sphericity of the femoral head. In addition, it does not distort the anatomy of the pelvis or the proximal femur; it can be used with equal success in older children who are typically expected to have a poor prognosis. Distraction treatment is not limited by hip stiffness, degree of femoral head deformity, or subluxation, and can be used when other methods of treatment are contraindicated.

Reliability and stability of three common classifications for Legg-Calvé-Perthes disease.

BACKGROUND: To predict the course of Legg-Calvé-Perthes disease (LCPD) and select between treatment options in the early stages, it is critical to have a reliable predictive classification. QUESTIONS/PURPOSES: We examined the reliability and stability of three common classification systems for LCPD. METHODS: We identified 69 patients with LCPD, who had hip radiographs taken more than twice after the initial presentation with at least a 3-month interval. The Herring lateral pillar, Catterall, and Salter-Thompson classifications were evaluated in terms of reliability and stability. The inter- and intrarater reliability of the classification systems was determined by three orthopaedic surgeons using intraclass correlation coefficients (ICCs). To evaluate the stability of the classification systems, the percentage agreement and ICCs among the initial rating, rating when entering fragmentation, and final rating were used. RESULTS: The interrater reliability was highest in Herring lateral pillar classification (ICC, 0.885) followed by the Catterall and Salter-Thompson classifications (ICC, 0.802 and 0.702, respectively). The percentage agreement and ICC between the initial and final rating were, respectively, 55% and 0.491 for the Herring classification and 48% and 0.378 for the Catterall classification. CONCLUSIONS: Our data show the highest reliability of the classification of Herring et al. However, more than 40% of the hip radiographs at the initial presentation, and in particular, most of Herring Group A patients, were upgraded. Therefore, for patients older than 8 years old and graded as Herring Group A initially, surgeons should keep the possibility of surgical treatment in mind.

Legg-Calvé-Perthes disease at 100: a review of evidence-based treatment.

BACKGROUND: The year 2010 is the 100th anniversary of the publication of the first 3 reports describing Legg- Calve-Perthes disease (LCPD). This paper summarizes available evidence previously published and discussed at the several world conferences honoring the occasion. METHODS: Relevant articles with evidence-based data regarding the efficacy of treatment methods for LCPD were reviewed by the author. RESULTS: The reviewed studies noted 3 factors related to outcome in patients treated for LCPD as follows: the age at onset, the classification of severity of femoral head involvement, and the type of treatment. In patients over age 8 at onset, surgical treatment with femoral varus osteotomy or Salter innominate osteotomy was associated with improved Stulberg outcomes compared with nonoperative treatment, in those who had lateral pillar B or B/C border class involvement. In the Wiig et al study, patients over age 6 with Catterall 3, 4 classification had better outcomes with these surgical treatment methods compared with nonoperative methods. Children under age 6 at onset had a good prognosis except for a small number of patients between age 4 and 6 years with lateral pillar C involvement. CONCLUSIONS: There is valid evidence of an association between surgical treatment of certain patients with LCPD and improved radiographic outcome.

Prognosis and prognostic factors of Legg-Calve-Perthes disease.

This is an overall review of the published literature in the past 100 years on the prognosis and prognostic factors of Legg-Calve-Perthes disease (LCPD). There were considerable limitations and inadequacies of the reported series. LCPD is not a common disease, and thus most reports were based on relatively small series collected retrospectively over a long period of time without clearly defined case selection, assessment, treatment, follow-up period, and outcome measures. Few studies, if any, would satisfy the strict definition of prognosis, which should only mean those prognostic factors derived from observation of the natural history of the disease-that is the uninterrupted progressive development of a disease that runs its course from onset-inception to resolution without any intervention or treatment. This review attempted to summarize from the mixed series of studies the generally described demographic, clinical, and radiologic prognostic factors of LCPD. The most important radiologic prognostic signs include the extent of femoral capital epiphysis involvement, the degree of metaphyseal changes, and lateral subluxation of femoral head and depend significantly on the time of assessment after the onset of the disease. More detailed discussions on prognostication based on the structured classification systems that have evolved in the past few decades would be described.