Ischemic necrosis of the femoral head in children is a self-healing, self-limiting, non-systemic disease that occurs locally in the femoral head in children. The disease has been reported for more than 100 years, but the true etiology of the disease has remained unclear since then, with numerous theories and diverse treatment approaches. Most current views advocate improving blood circulation to the femoral head, reducing intraosseous and intra-articular pressure, reducing mechanical compression of the femoral head, and increasing inclusion of the femoral head. The aim of various current treatments is to stop and delay the onset of femoral head deformity and degenerative osteoarthritis, and to restore and maintain the function of the hip joint. The treatment methods include surgical treatment and non-surgical treatment. Proximal femoral osteotomy has been proven to be a proven treatment method for severe perthes disease. Fu Zhihou, Department of Orthopedics, General Hospital of Jinan Military Region
1 Principle of surgery and its indications.
1.1 Principle of surgery
Proximal femoral osteotomy for the treatment of perthes disease, although there are different surgical methods but the basic principle is the same. The main purpose is to increase the inclusion of the femoral head in the acetabulum through osteotomy, change the weight-bearing point of the femoral head and reduce the intraosseous pressure, with the aim of completely placing the femoral head epiphysis with shaping potential into the acetabulum, restoring the “concentric circle” relationship between the femoral head and the acetabulum, and using the acetabulum to biomodel the femoral head to shape a normal or near-normal The acetabulum can be used to biomodel the femoral head to create a normal or nearly normal head. It is also possible to correct the excessive stem angle and anteversion of the femoral neck as needed. Internal rotation can increase the tolerance of the acetabulum to the femoral head, which can provide the best bioplasty of the femoral head and increase the mobility of the affected hip; at the same time, internal rotation can relax the iliopsoas muscle, hip abductor muscle, adductor muscle group and rectus femoris muscle and reduce the pressure on the head socket; after internal rotation, the distance between the center of the femoral head and the abductor muscle increases, the lever arm lengthens and the muscle tension decreases, which can also reduce the load on the femoral head.
1.2 Surgical indications
The indications for surgery in Perthes’ disease are not standardized, but it is now accepted that the treatment plan is based on Herring’s lateral column typology, age, and the presence of femoral head crisis, etc. Herring et al. concluded that children aged 6-8 years with femoral head involvement up to Herring type B or Catterall type II or III should be closely followed up, and if their condition changes, they should be treated conservatively or surgically. If the disease changes, conservative or surgical treatment should be performed. More studies have shown that age 6-9 years is usually considered to have an uncertain prognosis, but they usually benefit from inclusive surgery [36,37,38,39].The results of a multicenter study by Herring et al [33] in 2004 showed that surgery was superior to conservative treatment in patients aged >8 years with Herring B, B/C types, but there are different views, Pablo Castaneda et al [28] showed no significant difference between the results of surgery and conservative treatment in patients aged >8 years, Herring B, type C, in a follow-up study of Herring B and C patients, who underwent superior femoral internal osteotomy, but the number of their Herring B patients cases was low. The study now shows that children >8 years of age have a progressive loss of bioplastic capacity of the acetabulum and femoral head, so surgery is still recommended for children with Herring B and B/C types with more severe femoral head necrosis at age >8 years of age. In conclusion, for Herring type B/C and C at any age of onset, Herring B at >6 years of age should be treated surgically, while Herring B at less than 6 years of age should be followed up closely. The current study showed no significant difference in the outcome of various inclusive surgeries, so the above surgical indications are also applicable to proximal femoral medial osteotomy. Although most studies have found a poor outcome for patients with Herring C at any age of onset with or without surgery [33,28], surgery is still advocated.
2 Current status of treatment of proximal femoral inversion osteotomy
Proximal femoral osteotomy is a commonly used method for the inclusion of Perthes disease in children. Several methods and fixation devices have been used for proximal femoral osteotomy [1,4-10,17], and long-term practice has confirmed that proximal femoral osteotomy is a practical and effective treatment. With the advancement of treatment technology, some new minimally invasive techniques have been applied in the treatment of Perthes disease.
The rotational osteotomy under the rotor is the most commonly used osteotomy for internal rotation, and the corresponding rotational osteotomy can be performed according to the need, which is mainly divided into two categories: closed wedge osteotomy and open wedge osteotomy. According to the different ways of osteotomy and fixation, there are several different procedures. Deng Xiaobo [15] treated 28 patients with Catterall’s stage III and IV Perthes disease by using subtrochanteric internal rotation and internal rotation osteotomy, and achieved satisfactory results with an overall excellent rate of 97.1%. Guo Limin [31] and others treated 108 cases ( 123 hips) with subtrochanteric internal rotation osteotomy, all aged between 5 and 12 years old, with 36 hips in stage II, 48 hips in stage III and 39 hips in stage IV of Catterall’s disease. The majority of foreign scholars [3, 5, 10, 11, 33] also considered that subrotor medial osteotomy has good results. However, pablo et al [2] showed no significant difference between patients with proximal femoral osteotomy and those treated conservatively in a study on patients with lateral column fraction B and C. Fu Qizhen et al [23] reported that a group of 137 hip patients treated with four different methods had the best outcome with an excellent rate of 98.87%. Herceg et al [34] and Than et al [35] also achieved good results using internal rotation osteotomy of the upper end of the femur.
Inter-rotor internal rotation osteotomy is divided into several procedures depending on whether it is rotated or internally displaced, etc. The specific surgical approach is similar. Inter-rotor internal rotation and internal displacement osteotomy for Perthes’ disease has a simple procedure, little injury, and satisfactory results. Yang Yong et al [27] reported that 38 children with Perthes’ disease were treated with inter-rotor inversion osteotomy, aged 4-13 years at the time of surgery, with an average age of 8 years and 10 months; 19 cases were stage II, 14 cases were stage III, and 5 cases were stage IV. The mean follow-up was 7 years (3-15 years), with an overall excellent rate of 84.2%; 94.7% in children with stage II, 85.7% in stage III, and 40.0% in stage IV.Noonan et al [12] treated 17 patients with Perthes disease by this procedure, with 3 hips in Stulberg grade I, 3 hips in Stulberg grade II, and 4 hips in Stulberg grade IV according to the Stulberg grading scale. Stulberg grade IV 4 hips, and Stulberg grade IV or V 8 hips, and after a mean follow-up of 10 years, 7 of them were evaluated as excellent according to the Mose standard ring. The postoperative outcome in older children was not very satisfactory. In addition, Noonan et al. concluded that there is an age limit to the effect of intertrochanteric rotational osteotomy on femoral head inclusion: patients under 9 years of age have better outcomes than children older than 9 years of age. 9.5 years of age is less effective.
A study by Harry Kim et al [18] showed that (i) the postoperative neck stem angle at skeletal maturity did not correlate significantly with the Stulberg score; and (ii) the lateral intertrochanteric rotational osteotomy was performed by logistic regression analysis. (ii) Logistic regression analysis was applied to show that having a larger neck stem angle in patients with lateral column type B was significantly correlated with obtaining Stulberg score I and II results, while no significant correlation was seen for type B/C and C. (iii) A larger neck stem angle in proximal femoral inversion osteotomy does not provide better protection of the femoral head. A 10°-15° internal rotation is recommended for proximal femoral osteotomy in the early stages of perthes disease. Herring et al [33] analyzed the results of a prospective study and suggested that a neck stem angle of 110°-115° would be appropriate. Although a higher inversion angle improves acetabular inclusion of the femoral head, it can exacerbate bilateral lower extremity inequalities, especially in children over 10 years of age with poor plasticity.Hitesh Shah et al [10] showed that flat femoral heads and irregular femoral heads are more often seen in patients with below normal ATD values and less often in patients with normal or above normal ATD values.Trendelenburg The neck stem angle is usually larger in patients with negative Trendelenburg’s disease. It can be seen that inversion osteotomies should not be over-inverted.
Less invasive treatment of Perthes’ disease to obtain an inclusive result has become popular. A new inter-rotor inversion osteotomy was reported by Yoshiteru et al [1] in 2009: percutaneous open inter-rotor wedge inversion osteotomy guided by a multiport guide. This percutaneous technique has several advantages over the current surgical treatment of Perthes’ disease: small incision, good soft tissue protection, short fixation time, avoidance of secondary incision, minimal trauma, and less bleeding. This technique has been applied for a short period of time and no adverse complications have been reported.Ito H et al [22] have widely used unilateral external fixation devices in Perthes disease, proximal femoral osteotomy for slipped femoral epiphysis, with satisfactory results. The infection rate of hemi-pin implantation through the incision is about 2% and the average fixation time is 12 weeks. Yoshiteru et al [1] reported a percutaneous open inter-rotor internal osteotomy with an average operative time of 96.5 minutes, an average intraoperative bleeding of about 15 ml and an average fixation time of 51.5 days, and no infection was seen to be caused by the implanted hemi-pin. The advantages of this procedure include avoidance of fixation instability due to bone splitting, maximum protection of the soft tissues surrounding the osteotomy, which creates a favorable biological environment for new bone production, and percutaneous inter-rotor osteotomy with a porous guide that allows easy osteotomy very close to the half nail without damaging the growing bone plate.
Proximal femoral osteotomy has been developed for half a century, and although this procedure is widely accepted, it still has some disadvantages, such as temporary postoperative limb shortening, excessive superior femoral valgus angle, and a decrease in the cervical stem angle with growth, and if combined with epiphyseal plate damage, patients may develop permanent limb shortening and temporary or permanent gluteus medius weakness. Studies now show no significant difference between proximal femoral osteotomies and pelvic osteotomies in terms of causing shortening of the affected limb. Hitesh Shah et al [10] showed that rotor epiphyseal fixation was effective in reducing the overgrowth of the greater trochanter and the development of Trendelenburg’s disease in a study of patients who underwent open rotor osteotomy with rotor epiphyseal fixation. The results of this study also showed that open inversion osteotomy had a small effect on the length of the affected limb, with a mean shortening of approximately 0.44 cm (SD 0.68 cm). There are a variety of treatments for proximal femoral inversion osteotomy in children with perthes disease, and the reported excellent rates vary widely, yet there is no way to compare which treatment is better. Because there is no standard method for evaluating the efficacy, the evaluation criteria used vary from family to family. In order to facilitate the study of the comparative treatment effects of various procedures, an internationally recognized efficacy evaluation system needs to be established.
3 Prognostic factors of Perthes’ disease.
The main prognostic factors in Perthes disease are age at diagnosis, degree of bone involvement, lateral column typing, gender, in addition to the inclusion of the femoral head.A prospective study of a group of 368 patients with Perthes disease, followed for 5 years and treated with physiotherapy, abduction orthoses, and proximal femoral internal osteotomy, reported by Wiig et al [29], showed that: i) the strongest prognostic factor was the involvement of the femoral head (1) the strongest prognostic factor was whether the affected femoral head was >50%, followed by age at diagnosis and lateral column staging; (2) proximal inversion osteotomy was associated with better outcomes than other modalities when age >6 years was determined and the femoral head was more than 50% involved; (3) there was no significant difference between the physiotherapy and abduction orthosis groups; and (4) they also found no significant difference in any treatment for patients older than 6 years. The authors recommended that abduction orthosis should be abandoned in patients aged ≥6 years with >50% involvement of the femoral head. Other studies [28, 33] also support that age at diagnosis and lateral column typing are significantly correlated with disease prognosis, and that patient gender is also correlated with prognosis.Herring JA et al [33] showed in a prospective multicenter study of 438 patients with 451 hips that: (i) surgery was better than conservative treatment in patients older than 8 years of age with lateral column typing B and B/C; (ii) surgery was better than conservative treatment in patients ≤8 years of age with lateral B typing; and (iii) surgery was better than conservative treatment in patients ≤8 years of age with lateral B typing. The results of the prospective multicenter study showed that: (1) patients diagnosed at age >8 years with lateral column typing B and B/C had a better outcome than conservative treatment; (2) patients diagnosed at age ≤8 years with lateral B had a satisfactory outcome with or without surgery; and (3) patients with lateral C at any age had a poorer prognosis with or without surgery. Although the incidence is higher in men than in women, a multicenter study from Japan showed that the prognosis of female patients was 1.5 times worse than that of men [30].
4 Outlook
Proximal femoral inversion osteotomy is now a widely recognized and long-standing effective treatment, but it does not completely stop the process of aseptic necrosis of the femoral head in children. To some extent this is normal, the etiology of perthes disease is still unclear, and the increased intraosseous pressure and impaired venous return in the femoral head are only key factors, so that the progress of the disease is not completely stopped by a single surviving internal osteotomy. According to herring et al [33], 62% of patients diagnosed at an age greater than 8 years had a better outcome after internal femoral osteotomy, while 30% of patients who underwent hip mobility exercises only also had a better outcome. Thus only 32% of patients benefited from a proximal femoral internal rotation osteotomy. In a study by Wiig et al [29] 43% of patients diagnosed at age >8 years who underwent proximal femoral internal osteotomy had good results, while 33% of patients treated with physiotherapy also had good results. Thus, only 10% of patients benefited from a proximal femoral osteotomy. Overall, however, the proximal femoral internal rotation osteotomy is still effective. Some biological studies have shown that internal rotation osteotomy by itself does not seem to change the healing rate of the femoral head in patients with perthes disease [13, 14]. Harry KM et al [18] suggested that the mechanism of action of internal rotation osteotomy may lie in a combination of factors, including altered hip biomechanics, increased blood flow, forced rest and reduced activity due to surgery. Even so, until we find the true cause of perthes disease and a reliable treatment for the cause, proximal femoral osteotomy is still a wise choice. As people’s standard of living increases, so does their demand for medical care. It is believed that minimally invasive techniques such as percutaneous open intertrochanteric osteotomy will be widely used in the treatment of perthes disease in the near future.
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