Rationale

The aim of treatment of children with Legg–Calvé–Perthes disease is to prevent the femoral head from getting deformed.³ Extrusion of the femoral head predisposes to femoral head deformation and, consequently, prevention or reversal of extrusion (i.e. by containment) should, potentially, minimize the risk of femoral head deformation.¹

Clinical comment

There are two strategies for achieving containment (ensuring that the anterolateral part of the femoral capital epiphysis is well within the acetabular margin). The first involves keeping the hip abducted and internally rotated or abducted and flexed by bracing or a proximal femoral varus de‐rotation (or varus extension) osteotomy. The second entails improving acetabular coverage of the anterolateral part of the femoral epiphysis by an innominate osteotomy (e.g. Salter osteotomy) or a shelf acetabuloplasty.

Available literature and quality of the evidence

• Level II: 3 prospective studies.⁴–⁶
  
• Level III: 1 meta‐analysis⁷ and 3 retrospective cohort studies.⁸–¹⁰
  
• Level IV: 1 retrospective cohort study.¹¹

Findings

Saran and colleagues analyzed 14 level II and III studies and reported a pooled odds ratio (OR) of 1.29 (95% confidence interval [CI]: 1.05–1.60; p = 0.02) for a spherical head at skeletal maturity in children who had surgical containment either with a femoral varus osteotomy or a Salter innominate osteotomy when compared with children who were not operated on. Surgical containment did not influence femoral head sphericity in children under six years at onset of the disease (OR = 1.02; 95% CI: 0.45–2.36).⁷ Children older than six years at the onset of disease were more likely to have spherical femoral heads at skeletal maturity if they had surgical containment rather than nonoperative treatment (OR = 2.05; 95% CI: 1.28–3.26).

Wiig and colleagues undertook a prospective study of 152 children with Legg–Calvé–Perthes disease.⁴ The children were treated by physiotherapy (n = 55), Scottish Rite abduction orthosis (n = 26), or femoral varus osteotomy (n = 71). Sphericity of the femoral head was preserved more frequently following femoral varus osteotomy than following physiotherapy (p <0.001).

Terjesen et al. treated 70 children who were between 6 and 10 years of age at onset of the disease with a femoral varus osteotomy and compared their outcomes with 61 children who received physiotherapy only.⁵ Femoral head sphericity was retained in 86% of children who underwent an osteotomy compared to 25% who were treated with physiotherapy.

Herring et al. in a multicenter prospective study evaluated the shape of the femoral heads at skeletal maturity of 345 hips in 337 children and noted that 61% of hips treated by surgical containment had spherical femoral heads as opposed to 46% of hips that were not surgically contained (p = 0.02).⁶

Joseph et al. analyzed the outcome, after femoral varus osteotomy, of 48 children between 7 and 12 years of age at onset of symptoms in Stage I or II of the disease and compared them with the outcome in 30 historical controls treated symptomatically.⁸ At the time of healing, 62.5% of the operated group had spherical femoral heads compared with 20% of those treated nonoperatively (p <0.001).

Nguyen et al. did a meta‐analysis of 23 reports of treatment of Legg–Calvé–Perthes disease which included 1232 children.¹¹ They observed that among children younger than six years the outcomes of operative and nonoperative treatments were comparable (OR = 1.071; 95% CI: 0.58–1.968; p: 0.828). In children older than six years, operative treatment was almost twice as likely to result in a spherical femoral head (OR = 1.754; 95% CI: 1.299–2.370; p <0.0001).

Carsi et al., in a retrospective cohort study, noted that the shape of the femoral head at healing was spherical or ovoid in 84% of 44 children who had been treated with a shelf acetabuloplasty performed either during Modified Waldenström Stage I or Stage IIb of the disease.⁹

Rich and Schoenecker in a retrospective cohort study of 213 children, treated by a protocol of restoring and maintaining satisfactory hip abduction with an adductor tenotomy and abduction cast, followed by daily range of motion (ROM) exercises and an A‐frame orthosis to facilitate femoral head containment, reported that 79% of hips were spherical at skeletal maturity.¹⁰

Resolution of clinical scenario

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