Aims

To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

Purpose of the study: Special care is warranted only for severe forms of Legg-Perthes-Calvé disease (LPCd) (Catterall 4, Herring B and C, Salter B, involvement > 50%). Should we propose specific treatment or simply monitor the inevitable disease course?

Material and method: Among a series of 485 hips with LPCd, 148 (30.5%) with massive involvement were identified. Ninety-six (64.9%)severe forms were analyzed at the end of growth. Magnetic resonance imaging, scintigraphy and arteriography were used to better assess the femoral head and identify hips at risk. These hips were treated surgically: Salter osteotomy (SA), triple pelvis osteotomy (TO), or varus osteotomy (VA). Three groups of infants were identified according to age at diagnosis of LPCd: less than 6 years, 6–9 years, more than 9 years. Outcome was considered good (Stulberg 1 and 2, Mose good), fair (Stulberg 3, Mose fair), or poor (Stulberg 4 and 5, Mose poor).

Results: There were 54 hips (56.3%) in the less than 6 years group, 26 (27.1%) in the 6–9 years groups, and 16 (16.6%) in the greater than 9 years group. Outcome was good for 45 hips (46.9%), fair for 22 (22.9%) and poor for 29 (31.2%) hips and was independent of age at onset of treatment. In the less than 6 years group, 54 hips (56.3%) were Catterall 4, Herring B or C, Salter B. Among the 24 Catterall 4 hips (44.4%) treated orthopedically, outcome was good for 15 (62.5%), fair for 7 (29.2%) and poor for 2 (8.3%). Among the 30 Cartell 4 hips treated surgically, outcome was good for 16 (53.3%), fair for 9 (30%) and poor for 5 (16.7%). In the 6–9 year group, 26 hips (27.1%) were Catterall 4, Herring B or C, Salter B. Among the 10 Catteral 4 hips treated orthopedically (38.5%), outcome was good for 3 (30%), fair for 2 (20%) and poor for 5 (50%). For the 16 Catterall 4 hips treated surgically, outcome was good for 8 (50%), fair for 2 (12.5%) and poor for 6 (37.5%). In the greater than 9 years group, there were 16 (16.6%) Catterall 4, Herring B or C, Salter B hips. Among the 10 Catterall 4 hips treated orthopedically, outcome was good for 1 (10%), fair for 2 (20%) and poor for 7 (70%). Among the 6 Catterall hips treated surgically, outcome was good for 2 (33.3%), fair for 0 and poor for 4 (66.7%).

Conclusion: Good outcome decreases with age. Surgery increases the rate of good outcome in all age groups, but before the age of six years, there is no significant difference between orthopedic and surgical treatment. Before six years, spherical heads (Stulberg 1 and 2) were achieved in six out of ten hips in the 6–9 year group and in only two of ten in the group aged over 9 years.

Purpose of the study: The appropriate treatment for Legg-Perthes-Calvé disease (LPCd) remains a subject of debate. Certain teams consider orthopedic treatment adequate. Others advocate surgery to improve prognosis. Is surgery necessary? When is the proper time? We reviewed retrospectively 91 surgically treated hips (Salter osteotomy or triple pelvis osteotomy) at the end of growth.

Material and methods: Among 485 hips with LPCd, 349 (71.9%) presented massive involvement (Catterall 3 and 4, Herring B and C, Salter B). Ninety-one patients with severe disease were reviewed at the end of growth. Complementary explorations included magnetic resonance imaging, scintigraphy and arteriography using the Dias protocol which enables an assessment of the excentration and the femoral head deformation and identifies hips at risk. Surgical treatments were Salter osteotomy (SA) or triple osteotomy (TO). Three groups were identified depending on the age at disease diagnosis: less than 5 years, 5–9 years, more than 9 years. Using the Stulberg and Mose classifications, outcome was considered good (Stulberg 1 and 2, Mose good), fair (Stulberg 3, Mose fair), or poor (Stulberg 4 and 5, Mose poor).

Results: There were 50 Carttell 3, Herring B, Salter B hips and 41 Catterall 4, Herring B and C, Salter B hips (80% boys). Distribution by group of age at diagnosis was: 34 (37.4%) less than 5 years, 48 (52.7%) 6–9 years, 9 (9.9%) more than 9 years. Salter osteotomy was performed on 32 hips (35.2%) and triple pelvic osteotomy on 59 (94.8%). Outcome at end of growth was: less than 5 years Catterall 3: 77% good, 15.4% fair, 7.6% poor; Catterall 4: 52.4% good, 33.3% fair, 14.3% poor; 6–9 years: Catterall 3: 70% good, 20% fair, 10% poor; Catterall 4: 55.5% good, 22.2% fair, 22.2% poor; more than 9 years: Catterall 3: 42.9% good, 42.9% fair, 14.2% poor; Catterall 4: 50% good, 50% poor.

Conclusion: Outcome worsens with increasing age at diagnosis. Despite surgery, a spherical femoral head (Stulberg 1 or 2) is achieved in only one hip Catterall 4 hip out of two. This result is observed in Catterall 3 hips only in children whose diagnosis is established after the age of nine years. Prognosis is better in Catterall 3 hips.

Poor results increase in older patients. After Orthopaedic treatment 60% of hips in children with LPC Disease appearing before the age of 6 find again its sphericity (Stulberg 1 or 2). About 30 % of hips in children with LCP Disease appearing between 6 and 9 years of age became “normal” (Stulberg 1 or 2) at the end of growth/Only 1 hip out of 10, in the oldest group of children (over 9 years), became spherical at the end of growth. Surgery increases the percentage of good results in all groups of patients.