Feng, X.Y. Reviewed by Fu, C.H. Reviewed by
Ischemic necrosis of the femoral head in children, also known as Perthes disease, was discovered almost simultaneously by Legg and Waldenstrom in 1909 and by Perthes in 1910 and remains a difficult disease after more than 100 years [[i]], and over the years the disease has had many different names, including not only those containing the name of the discoverer (Legg- Calve-Perthes disease, Legg-Perthes disease, Calve-Legg-Perthes disease), but also nomenclature with specialized terms such as: flat hip, hip osteochondritis, juvenile-type deformational arthritis, juvenile-type deformational hip osteochondritis, etc. Fu Zhihou, Department of Orthopedics, General Hospital of Jinan Military Region
The incidence of Perthes disease varies greatly with geographic distribution and ethnicity, and varies greatly between 0.5‰ to 11‰[[ii]], easily occurring in the hip joints of children between 2 and 12 years of age, with typical cases of this disease almost always occurring in children between 3 and 7 years of age, more common in boys than in girls, with a ratio of about 4:1 and unilateral accounting for 90%. The disease is one of the more common and important hip diseases in pediatric orthopedics. During the active phase of the disease, partial or total necrosis of the femoral head gradually progresses to deformity, followed by the formation of new bone structures in the epiphysis and thus self-healing. If the disease continues to progress, eventually the femoral neck widens and acetabular dysplasia leads to early osteoarthritis to the point where total hip replacement is necessary.
1. Etiology of Perthes’ disease
The etiology of Perthes disease is still unknown, but a number of possible causes have been mentioned, including repeated minor trauma, delayed skeletal development, and inadequate function of the vascular system. Repeated minor trauma to the femoral head causes microfractures of the cancellous skeleton of the immature femoral head, and this hypothesis is supported by the observation that overactive children are prone to this disease during their service hours [[iii]]. The blood supply to the femoral head comes from the blood flow within the femoral neck joint, which is more susceptible to damage during childhood, supporting the vascular hypothesis that blood clotting or abnormalities in blood viscosity can lead to epiphyseal necrosis as can alterations in the vascular system [[iv],[v]]. The urinary deoxypyridinoline/creatinine coefficient is lower than normal during the duration of this disease, which also suggests that abnormal decreases in bone metabolism are a cause of Perthes disease [[vi]]. Recent genetic studies have identified variants of type II collagen as a possible cause of Perthes disease in children [[vii],[viii]]. The etiology of childhood Perthes disease remains unknown, but clinical and experimental studies have demonstrated that disruption of blood flow to the femoral head is an important causative factor in childhood Perthes disease, and several histopathological studies have confirmed that articular cartilage, epiphysis, growing epiphyseal plates, and epiphysis are affected during the pathology of childhood Perthes disease [[ix]].
2. Classical x-ray typing of Perthes’ disease
Catterall’s staging: type I: anterior femoral head is involved without collapse; type II: partial femoral head necrosis with elevated density of the necrotic portion visible on ortho-x-ray; type III: necrosis of about 3/4 of the femoral head; type IV: necrosis of the entire femoral head [[x],[xi]].
The lateral column of the femoral head was typed by Herring in 1992: the femoral epiphysis was divided into three columnar regions: medial, middle and lateral on a standard orthopantomograph; the lateral region accounted for about 15%-30% of the width of the femoral head, and the medial region was 20%-35%; the disease was then typed according to the degree of involvement of the lateral column: type A: the lateral column was not involved; type B: the lateral column was involved, and it was compressed and collapsed Type C: involvement of the lateral column with a height of >50% [[xii],[xiii]].
In children with Perthes’ disease, the femoral head growth plasticization does not end until the cessation of growth and development. Stulberg et al. [[xiv]] proposed in 1981 to classify the long-term outcome assessment of Perthes disease into 5 grades: grade I for a normal spherical hip with a normal femoral head, femoral neck and acetabulum; grade II for a normal spherical femoral head with an enlarged hip, shortened femoral neck or shallow acetabulum; grade III for a femoral head that becomes In grade III, the femoral head becomes oval (not oval), and the deviation of the femoral head contour from the Mose concentric circle in the orthopantomogram and frog lateral radiograph is within 2 mm; in grade IV, the femoral head and acetabulum still match, but the femoral head shape has become oval, at least 1/3 of the femoral head contour is flattened, or at least 1 cm of the femoral head contour is flattened; in grade V, the femoral head is flattened and the acetabulum shape is normal, but the femoral head and acetabulum do not match.
3. Differential diagnosis of Perthes’ disease
Perthes’ disease should be differentiated from several diseases [[xv]]: temporary hip arthritis, juvenile idiopathic arthritis, osteomyelitis, Meyer’s dysplasia, spondyloepiphyseal dysplasia, chondroblastoma, hip dysplasia due to so-called “Perthes’ disease”, hormonal necrosis of the femoral head, and others Other diseases similar to Perthes disease that can cause osteonecrosis: thalassemia, trisomy 21, hair-nose-toe syndrome, chondrodysplasia, Gaucher disease, hemophilia, hypothyroidism, congenital testicular hypoplasia. 4.
4. Treatment of Perthes’ disease
The treatment of Perthes disease still lacks a basis because its etiology is still not understood, the pathological changes are unclear, and the healing of the disease varies widely, so the various complicated treatments used in the clinic so far are not etiologic treatments. The aim of treatment is to create a treatment that can eliminate the unfavorable factors affecting the development and shaping of the epiphysis, prevent or reduce the secondary deformity of the femoral head and osteoarthritis of the hip joint, and enable the necrotic femoral head to successfully complete its self-limiting process. The choice of treatment is based on the radiological staging of the disease, the presence or absence of the “femoral head risk sign”, the degree of hip mobility restriction and the age of the patient, but there is still no consensus on the treatment for the different stages of the disease. Wiig O et al [[xvi]] found that patients with >50% femoral head invasion were treated with physiotherapy, Scottish Rite orthosis, and femoral osteotomy, respectively, and there was no significant difference in the efficacy of these treatments after 5 years of follow-up, and Wiig O et al’s study provided the most reliable evidence for non-surgical treatment in patients younger than 6 years of age. However, with further understanding of the etiology, pathological changes, and course of the disease, the treatment of Perthes’ disease tends to favor aggressive interventions at an early stage, with surgery being the most important one. better results.
4.1 Non-surgical treatment
Non-surgical treatment includes avoidance of weight bearing on the affected limb, various orthopedic braces, fixation in a traditional cast and hyperbaric oxygen therapy for Catterall’s type I and II lesions. Kim HK [[xviii]] et al. concluded from an extensive review of the literature that for patients younger than 6 years of age it has been proven that surgical treatment does not provide additional benefit and therefore non-surgical treatment is preferable for patients at this age. Sharma S et al [[xix]] used the pairing principle for patients younger than 8 years of age with Perthes disease. Perthes disease in children younger than 8 years of age were studied by strictly matching gender, body mass index, age of onset, stage of disease at initial diagnosis, area of necrosis of the femoral head and radiological frequent risk markers, 14 pairs (28 hips) were selected and the results of the study showed that surgical treatment of children younger than 8 years of age with Perthes disease did not achieve better results than conservative treatment.
4.1.1 Bed rest and traction
Traction or bed rest alone for 3-4 weeks is generally used to significantly relieve pain and increase hip mobility, reduce weight bearing on the femoral head, and prevent collapse of the femoral head, which is both a good method of observation and treatment, as well as a method of identification for children with transient synovitis of the hip joint.
4.1.2 Application of orthopedic brace
Orthopedic brace is best applied under normal acetabular condition, so that the femoral head is completely placed in the acetabulum without lesions, which can not only relieve the pain but also release the soft tissue spasm, so that the femoral head can be biologically shaped in the acetabulum to prevent the deformation and collapse of the femoral head and further improve the function of the hip joint. The basic principle of all types of braces is the same, they are all designed to increase the inclusion of the femoral head. The Milgram hip abduction brace is applied under ambulatory conditions; the Bobechko-Toronto brace, the New-ington A-type abduction brace, the Robert-abduction flexion internal rotation brace, the Scoltish-Rite brace, the Harrison brace and the three-tray single-limb brace are applied under non-weight-bearing walking conditions of the affected limb. In general, abduction of the lower extremity to the extent that the lateral aspect of the epiphysis is close to the upper edge of the acetabulum is considered, and the installation of the brace is confirmed by taking an upright x-ray. Most scholars believe that 350 to 550 degrees of abduction and 50 to 100 degrees of internal rotation are preferable because at 350 to 450 degrees of abduction, the abductor muscle basically fails and the adverse stress on the joint is reduced. When applying brace treatment, it is also necessary to take X-ray films regularly to observe the morphological changes of the femoral head epiphysis, and only when the femoral head epiphysis necrosis is completely recovered, it is possible to release the brace and start weight-bearing walking. There are many treatment methods for femoral head necrosis in children, and the current trend of treatment has developed from weight-bearing restriction to weight-bearing treatment to improve inclusion down to the ground [[xx],[xxi]]. Professor Yuan Hao started to use hip abduction weight-bearing stent to treat ischemic necrosis of the femoral head in children in 1993, and was the first to propose the concept of “abduction weight-bearing shaping” for the treatment of femoral head necrosis in children in China.
4.1.3 Plaster fixation
Plaster fixation has the advantages of being simple, easy and economical. It can be used for short-term fixation to facilitate further observation, estimate the extent of femoral epiphyseal necrosis, and lay the foundation for further treatment. A duration of 2 to 3 months is appropriate for each fixation. If long-term fixation is required, removal of the cast for a few days of rest followed by re-plaster fixation can prevent knee stiffness and articular cartilage degeneration. There are reports in the literature that using a double lower limb tubular cast with 300-500 abduction and no fixation of the hip joint, which can be sat up, and changing the cast once in 3-6 months and fixing it for 15-18 months, has good results, but the treatment period is long and it is difficult for the child to adhere to it.
4.1.4 Hyperbaric oxygen therapy
Hyperbaric oxygen can increase blood oxygen content, improve blood oxygen tension, promote capillary neovascularization, oxygen diffusion along the capillaries to the ischemic necrotic area, increase the oxygen supply to the necrotic area, promote new bone formation, and enhance the vitality of phagocytes to accelerate the resorption of necrotic bone [[xxii]]. The principles of hyperbaric oxygen application [[xxiii]]: (1) even if the aseptic necrosis of the femoral head of the child causes fragmentation and deformation, good results can be achieved as long as hyperbaric oxygen therapy is adhered to; (2) it generally takes 2 to 3 months from the start of hyperbaric oxygen therapy to the time when the bone tissue is clearly reflected on the X-ray film in repair and growth; (3) after 3 months of continuous treatment with hyperbaric oxygen therapy, the radiographs confirm that the aseptic necrosis of the femoral head (3) After 3 months of continuous hyperbaric oxygen therapy, the radiographs confirm that the aseptic necrosis of the femoral head has significantly improved, indicating that neovascularization has formed and the bone is being repaired, after which the treatment can be changed to intermittent treatment; (4) The most important factor in the success or failure of the treatment is to strictly limit the weight bearing of the affected limb. Xia Ronggang et al [[xxiv]] reported in 2005 that 35 patients with Perthes disease were treated with non-weight-bearing hyperbaric oxygen continuous mask oxygenation, 21 males and 14 females, including 12 cases of Catterall stage II, 18 cases of stage III and 5 cases of stage IV, with an average of 169 treatments and an average follow-up of 6.4 a. The results: clinical symptoms disappeared after 2 months, and X-ray films after 6 months showed that the femoral head There is no significant difference between the density of femoral head and normal side after 1a, good development of femoral head and normal hip joint gap after 1a, Mckay’s assessment standard, excellent rate of 85.7%, concluding that non-weight bearing hyperbaric oxygen treatment of Perthes disease is simple, convenient, non-invasive, non-side effects, satisfactory efficacy and a good treatment method.
4.2 Surgical treatment
As with non-surgical treatment, the aim is to increase the inclusion of the femoral head and maintain the morphology of the femoral head. Although non-surgical treatment can also increase the inclusion of the femoral head, prevent early collapse of the femoral head and reduce the degree of deformity in the late stage, the treatment period is long and difficult for children to adhere to, whereas surgical treatment can significantly shorten the course of treatment and has a more definite effect. However, because the etiology of Perthes disease is unknown, there are various surgical methods, and many non-inclusive surgeries such as synovectomy, reconstructive hemorrhage surgery, bone flap grafting with myotomy and vascular tissues have emerged.
4.2.1 Non-inclusive surgery
4.2.1.1 Synovectomy
This procedure was first created and reported by Qiu Jiande [[xxv]] in 1981, who believed that synovectomy of the hip joint could increase the blood flow of the femoral head, use its natural phenomenon of growth and development, correct the deformed femoral head by itself, and restore the function of the hip joint. In 1991, Xu Hao et al [[xxvi]] used puppies born between 2 and 4 months of age as test subjects and performed synovectomy in the hip joint of dogs, and performed microangiography and nuclear bone visualization of the femoral head at different stages after surgery. In 1997, Fu Qizhen [xxvii] of the First Affiliated Hospital of Zhongshan Medical University reported that the treatment of Perthes disease in children with 137 hips had the best outcome: the intertrochanteric osteotomy group had the best outcome, the hip osteotomy group had the second best outcome, and the synovectomy group had the worst outcome. Most scholars now believe that the treatment of Perthes disease does not advocate opening the hip capsule or entering the hip joint, so simple synovectomy is rarely used.
4.2.1.2 Reconstructive surgery
Reconstructive hemorrhage surgery is performed by drilling a hole in the inferior head of the femur and implanting an ascending branch of the external rotating femoral artery or a multi-bundle vessel to increase the blood supply to the femoral epiphysis and achieve intra-femoral decompression through the drilling. Wang Xixun et al [[xxviii]] studied 27 patients with Perthes disease in children, and the treatment groups were divided into two groups: 12 patients in group I were treated with multiple vessel bundle implantation and modified Chiari osteotomy lengthening, and 15 patients in group II were treated with modified Chiari osteotomy lengthening alone. self-limiting disease, the use of vascular bundle implantation cannot shorten its course and has many complications, for patients with poor inclusion, surgical inclusion is the key to treatment. In recent years, with the changing understanding of the etiology, this procedure has been gradually diluted and even replaced [20,[xxix]].
4.2.1.3 Bone flap grafting with myotome and vascular tip
This procedure is mainly used for the treatment of aseptic necrosis of the femoral head in adults, but it has also been attempted for the treatment of Perthes disease in children, mainly in patients with Catterall II-IV with significant necrotic collapse of the femoral epiphysis. In general, the collapsed cartilage is removed, the necrotic tissue of the femoral head is scraped, and the femoral head is drilled and decompressed, and a myotubular bone flap with the femoral square, suture, and gluteus medius muscles or a bone flap with vascular tissues such as branches of the external rotator femoral artery is placed into the bottom of the scraped capsule to repair the collapsed area of the femoral head necrosis and improve the blood flow of the femoral head epiphysis. Lv Honghai et al [[xxx]] reported in 1999 that between 1990 and 1997, 83 hips of Perthes disease were treated with double bone flap implantation of sutured muscle flap and rotary deep iliac artery bone flap, and after 1-5 years of follow-up, 58 of the 83 hips were excellent, accounting for 70.0%, 22 were good, accounting for 26.5%, 2 were acceptable, accounting for 2.4%, and 1 was poor, accounting for 1.1%, and the efficacy was positive The efficacy is positive. However, some scholars believe that the use of adult surgical methods to treat Perthes disease in children is not very scientific, and there are many controversies, and such surgeries are rarely used now.
4.2.2 Inclusive surgery
4.2.2.1 Internal femoral osteotomy
The purpose is to completely place the femoral epiphysis with shaping potential into the acetabulum, restore the “concentric circle” relationship between the femoral head and the acetabulum, increase the inclusion of the femoral head, and enable the child to get out of bed as soon as possible, so that the intra-articular weight-bearing stress is more reasonable and the acetabulum is used to shape the femoral head. The acetabulum can be used to suppress and shape a normal or near-normal relationship. It also corrects the excessive femoral neck stem angle and anteversion. The disadvantages of this procedure are that the limb will be temporarily shortened after surgery, producing an excessive superior femoral valgus angle, and the neck stem angle will decrease with growth. If combined with epiphyseal plate damage, the patient may develop permanent shortening of the affected limb and may also develop temporary or permanent gluteus medius weakness. The main surgical indications [[xxxi]] are: (1) Catterall’s types II, III, and IV but not combined with severe flat hip; (2) type II lesions in children 8 to 10 years old who cannot achieve femoral head inclusion by brace or cast fixation due to psychosomatic or other factors; (3) hip arthrography in neutral lower extremity radiographs showing poor femoral head inclusion, but the femoral head in abduction and internal rotation position of the hip Wiig O et al [16] and Herring JA et al [[xxxii]] conducted a multicenter prospective study in which patients aged 6 years or older had a significantly better long-term outcome with internal femoral osteotomy than with physiotherapy or brace treatment groups. Guo Limin et al [[xxxiii]] performed subtrochanteric osteotomy in 108 patients (123 hips) with Perthes disease. The average age of the patients was between 5 and 12 years, and the lesions were classified as Catterall’s type II, III and IV, with an excellent rate of 93.49%. Herceg MB et al [[xxxiv]] reported 119 cases (124 hips), divided into two groups aged >8 years and <8 years, followed for 2-7 years (mean 5.3 years), with preoperative, postoperative and annual follow-up radiographic observation of osteotomy point and cervical trunk angle remodeling, and found that remodeling of the osteotomy point at 6 years postoperatively in 63% of cases, and at 2 years postoperatively in 40% of them. Similar results were obtained for the cervical stem angle, and there was no statistical difference between the two groups, suggesting that proximal femoral osteotomy allows early remodeling of the osteotomy point and cervical stem angle.
Percutaneous open subtrochanteric wedge inversion osteotomy with multiport navigation. This procedure is a new subtrochanteric inversion osteotomy of the femur recently reported by Kawasaki Y et al [[xxxv]]. They selected the type of half-pin according to the patient’s size, the diameter of the femur and the bone quality. Usually, a 5-mm half-pin is selected and drilled below the greater trochanter in the direction of the femoral neck under the guidance of an X-ray fluoroscopy system, which should avoid penetrating the epiphyseal plate of the femoral epiphysis, and the half-pin is inserted along this hole, and another 5-mm half-pin is drilled obliquely in the same plane at a skin distance of 3 cm from this hole, and two 5-mm half-pins are drilled vertically at the distal end of the femoral stem, which should ensure that the half-pin is in the medullary cavity of the femur and does not penetrate the femoral medial cortex. A short coupling plate is used to connect the proximal and distal half-pins; a longitudinal incision of approximately 1 cm in length is made in the intertrochanteric region, where the first hole is drilled with a common guide, and the second, third, fourth, and fifth holes are drilled in the plane of the first hole with a multi-hole guide, and the five holes are connected with a small bone chisel, but the continuity of the medial cortex is ensured; the proximal femur is tilted under X-ray fluoroscopy to reach The proximal femur was tilted to internal rotation under X-ray fluoroscopy, and after observing that the femoral head was repositioned to the acetabulum to accommodate satisfactorily, the proximal and distal femurs were fixed with the Llizarov joint device; the external fixation device and all the half pins were removed after the formation of the bone joint for 12 months postoperatively with an abducted limb without weight-bearing, avoiding the need for a second incision to remove the internal fixation; the authors have achieved preliminary results through the treatment of two children; the average operation The average operative time was 96.5 minutes and the duration of external fixation 51.5 days, with low intraoperative bleeding, neither exceeding 20 ml, and no significant complications were found; this percutaneous technique has several advantages over the current surgical treatment of Perthes’ disease: small incision, good protection of soft tissues, short fixation time, avoidance of secondary incision, low trauma, and low bleeding. Disadvantages: too few cases of this procedure have been performed, the long-term results cannot be evaluated yet, and the technique is immature.
4.2.2.2 Pelvic osteotomy
Salter[[xxxvi]] first applied Salter pelvic osteotomy to treat congenital hip dislocation in children, and this procedure was applied by many scholars in the treatment of Perthes disease in children because it could increase the acetabular accommodation of the femoral head. The principle is to change the direction of the acetabulum so that the acetabulum is displaced anteriorly and inferiorly to better accommodate the femoral head; Salter’s osteotomy is feasible in children over 6 years of age with the entire femoral epiphysis involved or in patients with hip subluxation; the advantages of Salter’s osteotomy include increased coverage of the acetabulum in the anterolateral direction of the femoral head, increased limb length, and no secondary surgery to remove the internal fixation. However, this procedure also has its disadvantages such as not allowing the femoral head to be adequately accommodated by the acetabulum, increasing the local stress of the acetabulum on the femoral head due to the inferior displacement of the acetabulum, accelerating the pathological process of ischemic necrosis of the femoral epiphysis, and possibly leading to the relative lengthening of the affected limb. Hrongguo et al [[xxxvii]] performed long-term follow-up of 16 patients with Perthes’ disease given Salter’s pelvic osteotomy, of which 10 cases were followed up for an average of 10 years and 3 months, and their proximal femoral epiphyseal plates and acetabular Y-shaped cartilage were completely closed, according to the Stulberg rating method, resulting in 4 cases (33%) of Stulberg grade I, Stulberg grade II in 6 cases (50%), Stulberg grade III in 1 case (8%), Stulberg grade IV in 1 case (8%), and no Stulberg grade V cases. In recent years, the commonly used surgical inclusion therapy modified Salter pelvic osteotomy, improved by Yoon TR et al [[xxxviii]] on the basis of Salter pelvic osteotomy, the iliac wing intercepted in the same way as before, the anterior iliac osteotomy direction is oblique and coronal plane into 450, and the posterior inferior osteotomy with the sagittal plane into 300-400, the results show that changing the osteotomy direction can make the osteotomy more The mean CE angle increased from 190 to 29.40 before surgery. (38 hips), good 10 cases (12 hips), with an excellent rate of 86.2%. It was concluded that triple osteotomy for Perthes disease in children improves the acetabular accommodation of the femoral head, enables the necrotic femoral head to be well shaped in the acetabulum, gradually restores the epiphyseal height, improves the function of the hip joint, and prevents or reduces the premature occurrence of osteoarthritis.
The basic principle of the Chiari procedure [[xl]] is to cut the internal and external plates of the ilium from below the anterior inferior iliac spine to the greater sciatic notch by cutting off the internal and external plates between the hip capsule and the head of the rectus femoris muscle at a low internal height, so that the lower iliac bone moves inward and the upper iliac bone surface completely covers the ischemic and necrotic femoral head, thus facilitating the grinding and shaping of the femoral head within the artificially created acetabulum; this procedure is mainly used to treat congenital This procedure is mainly used to treat congenital hip dislocation, but it can also be used to treat hip enlargement caused by Perthes disease or epiphyseal necrosis after treatment of congenital hip dislocation. Zhang Zhiqun et al[[xli]] used Chiari pelvic osteotomy to treat 68 patients with Perthes disease, with a follow-up of 3 years and 2 months to 10 years and 1 month, with an average of 6 years and 7 months. Wang Xixun et al[[xlii]] used modified Chiari osteotomy, active abduction shaping therapy of both lower extremities and passive rotation and compression shaping therapy of the affected hip to treat 19 cases (19 hips) of advanced Perthes disease in children, with an excellent rate of 89% and normalization of the acetabular-femoral head index (AHI), concluding that modified Chiari osteotomy and lengthening could effectively increase the femoral head inclusion in the acetabulum, resulting in improved hip function. This procedure can only be used as a palliative treatment procedure that can cause permanent deformation of the patient’s pelvis.
4.2.2.3 Staheli procedure
This procedure emerged gradually after the 1960s and was first summarily named [[xliii],[xliv]] by Staheli in 1981. Previously, Staheli’s slot acetabular extension was mainly used for the surgical treatment of developmental hip dislocation [[xlv],[xlvi]]. The indications for surgery in the treatment of Perthes disease [[xlvii]] are: (1) Perthes disease in children with Catterall’s grade II or higher; (2) age 6 years or older; (3) the presence of critical signs of the femoral head (Gage’s sign; extension and increase in the extent of epiphyseal involvement; lateral acetabular rim, epiphysis (2) the femoral head is in a critical condition (Gage’s sign; the epiphysis is extended and enlarged; there is speckled sclerosis or calcification on the lateral side of the acetabulum; the femoral head is dislocated laterally; part of the deformed femoral head is protruding outside the acetabulum: the epiphyseal plate is horizontal, generating shear forces and causing subluxation of the femoral head). Zhang Zhiqun et al [47] retrospectively analyzed 26 cases of Perthes disease in children treated with Staheli’s groove acetabular extension surgery and found that the epiphyseal height ratio, acetabular coverage, and CE angle increased significantly, the Sharp angle decreased significantly, and the Shenton line continuity and femoral head morphology improved significantly.
4.2.2.4 Hip shelf-capping
In the fragmentation stage of the disease, where the patient is often older than 7 years, hip shelf-cap surgery can better accommodate the subluxated hip [[xlviii],[xlix]]. The indication for hip caps was described as “reducible subluxation” by Daly et al [43], who used dynamic arthrography to confirm the repositioning of the femoral head and demonstrated that an unstable hip with strangulated abduction was a contraindication to hip caps. patients with severe Perthes disease, 16 hips were given an internal femoral osteotomy and hip shelf cap and 14 hips were given a hip shelf cap with a mean follow-up of 9.5 years (5.2 to 12 years), resulting in no pain in the hip in all patients, normal or slightly restricted hip motion, 27 patients could walk normally or with a slight limp, Stulberg grade I or II (18 hips) and Mose grade I or II (18 hips) with a mean neck stem angle of 1270, concluding that hip shelf-capping improves hip function in patients with advanced Perthes disease and that this procedure allows the femoral head to be better accommodated and shaped while preserving acetabular roof growth.Yoo WJ et al [[li]], by performing a hip dislocation on 25 patients with the femoral head in the fragmentation phase and reducible Perthes disease patients with hip shelf caps, the mean age of the patients was 8.9 years (7.0 to 12.3 years), the mean follow-up was 6.7 years (3.2 to 9.0 years), and 18 hips (72%) were satisfactorily contoured. Being a palliative procedure in the late stage of the disease, hip shelf-capping should also be a very good choice.
4.3 Others
In late stage patients with hip inversion or giant hip, thickening and shortening of the femoral neck and high upward displacement of the greater trochanter, shortening of the limb can be corrected by optimizing the anatomy of the proximal femur and improving muscle insufficiency through femoral neck lengthening or valgus osteotomy [[lii],[liii]]. In addition Yoo WJ et al [[liv]] treated 21 patients with Perthes’ disease (21 hips) using a rotational osteotomy of the external femur, with a mean age at surgery of 9.7 years (6.1-15.3 years) and a mean follow-up of 7.1 years (3.0-15.0 years), concluding that the external femoral osteotomy allows for rotational correction and sagittal correction, improving the patient’s symptoms and improving Wenger DR et al [[lv]] analyzed 39 children (40 hips, age 5-13 years) with Perthes’ disease who underwent triple pelvic osteotomy (1995-2005) with a mean follow-up of 3 years and concluded that triple pelvic osteotomy for all ages with a lateral column grade B and a lateral column grade C was a good way to improve the hip function in patients with Perthes’ disease. patients and younger patients with lateral column grade C could maintain the femoral head morphology well, but the results were poor in patients with lateral column grade C who were older than 8 years. Qu Jing et al [[lvi]] used periacetabular plus proximal femoral decompression osteotomy to treat 21 children with mid- to late-stage hip subluxation and flattened hip deformity, and achieved good results. Ren Desheng, Wu Xinle et al [[lvii]] used a combination of modified Chiari iliac osteotomy, partial synovectomy of the hip joint, decompression of the femoral neck drill, lengthening of the iliopsoas muscle and release of the internal femoral retraction to treat Perthes disease, and the excellent rate was 75.6% after a follow-up of 82 cases for more than 3 years. In recent years, many scholars in China have studied the use of traditional Chinese medicine in the treatment of Perthes disease, and many scholars have published articles reporting good therapeutic results. group was 90%, and 58.82% in the active calcium group, and there was no significant difference in efficacy between the herbal group and the surgical group, and the herbal treatment played an efficacy similar to that of the surgical treatment. Yuan Puwei et al [[lix]] used Chinese herbal medicine bone resuscitation capsule combined with suture muscle bone flap transplantation to treat 20 cases of Perthes disease, using Mckay bone and joint function assessment criteria, the total effective rate was 85% and the overall excellent rate was 75%, concluding that Chinese herbal medicine bone resuscitation capsule combined with suture muscle muscle bone flap transplantation has a better effect on Cattrall type I and II and some Cattrall type III Perthes disease has better efficacy. Sun Jie et al[[lx]] studied 48 children with Perthes disease (52 hips), including 18 hips in Cattrall I, 13 hips in Cattrall II, and 21 hips in Cattrall III, who were treated with oral bone revitalization capsules and combined with active abduction shaping therapy of both lower extremities and passive rotation pushing and compression shaping therapy of the affected hip. Anderson et al [[lxi]] reported the use of hip surgical dislocation osteochondral grafting (SDO) with rotor advancement in 14 patients with Perthes disease, and through follow-up, this procedure can effectively improve the biomechanics of the hip joint and delay the femoral head This procedure successfully transplanted cartilage around the femoral neck to the cartilage denudation of the femoral head, and the procedure was safe and effective, providing a new idea and a new method for the treatment of Perthes disease. Chen Xiaogang et al [[lxii]] treated 14 patients (16 hips) with Perthes disease using autologous bone marrow transplantation, with an average follow-up of 8.3 years (4-13 years) and an excellent rate of 87.5%, concluding that autologous bone marrow transplantation is an effective method for the treatment of Perthes disease. Ning Jinlong et al [[lxiii]] used femoral head surface reconstruction to treat 5 patients with Ficat stage IV Perthes disease over 12 years old, with a follow-up of 6 months to 36 months, walking without pain, living on their own and going to school, and the average score of 46 points before surgery improved to 92 points after surgery according to the Harris hip function assessment criteria, with 4 cases being excellent and 1 case being good, concluding that femoral head surface It is concluded that reconstruction of the femoral head surface is an effective method for the treatment of Ficat stage IV Perthes disease, and the recent effect is satisfactory.
5. Outlook
In conclusion, since the etiology of Perthes disease is unknown and the course of the disease is highly variable among individuals, individualized treatment should be given to all patients. The age of the patient, the stage of the disease at the time of the first visit, the radiological manifestations of the hip joint, and the clinical symptoms of the patient should be considered in order to select the most scientific, most effective, and least invasive treatment for the patient. Treatment methods range from conservative treatment such as observation and follow-up throughout the disease to more complex surgical treatment for hip function reconstruction, all aimed at preventing deformation of the femoral head with the ultimate goal of preventing secondary deformities and hip arthrosis. The treatment of Perthes’ disease should be based on evidence-based medicine and should be carried out by surgeons who are experienced in pediatric orthopedics and are skilled in performing various surgical procedures. Comprehensive evaluation and treatment.
References: omitted