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    Hip Preservation vs. THA for Legg-Calve-Perthes Disease

    A 22 year-old woman with history of left hip Legg-Calvé-Perthes disease treated with a femoral osteotomy during childhood presents with severe groin pain that is compromising her quality of life. Should she undergo a hip preservation procedure, or would total hip arthroplasty be the better option?

    Authors

    Claudio Diaz-Ledezma, MD, and Javad Parvizi, MD FRCS

    Disclosures

    The authors have no disclosures relevant to this article.

    Background

    Legg-Calvé-Perthes disease (LCPD) treated during childhood has reasonable clinical and radiographic results. A recently published series with mean follow-up of 20 years demonstrated that only 5% of cases required a total hip arthroplasty (THA). [1]

    However, 44% of patients in the study presented with severe radiographic osteoarthritis, [1] which can result in a future need of THA. [2] Further, these patients may complain of lateral hip pain during ambulation as a result of abductor weakness.

    Case Presentation

    A 22-year-old otherwise healthy woman with history of LCPD presented with hip pain. At age 7, she had been diagnosed with LCPD that was treated with a femoral osteotomy.

    Over the years, she had some minor problems with her hip, which were better characterized as groin and lateral hip pain after long walks. For the past 2 years, the groin pain has become progressively worse.

    At the time of presentation, she described her pain as intolerable. Weight-bearing and rotation and flexion of the hip exacerbated the hip pain.

    She also complained of pain in the lateral aspect of her hip that occurred after long walks. Her ability to walk has been reduced to a few blocks. She described occasional night pain as well.

    The patient walked with a limp, but did not use any assistive devices. She stated that the symptoms had considerable impact on her quality of life.

    Physical Examination

    • Height 5 feet, 6 inches; weight 175 pounds
    • Severe limp
    • Left lower extremity 15 mm shorter than right lower extremity
    • Right hip range of motion: full and painless
    • Left hip range of motion: flexion to 90°, internal rotation 0°
    • Strongly positive impingement test
    • Positive FABER test, Stinchfield’s test, and all other provocative maneuvers
    • Abduction and flexion strength 5/5
    • Neurovascular examination otherwise normal

    Imaging

    • Evidence of dysplasia and acetabular retroversion in radiographs of the hip and pelvis (Figure 1)
    • Shenton’s line not interrupted [3]
    • Tönnis angle 20°
    • Wiberg angle 17°Positive cross-over sign [4]
    • Positive ischial spine sign [5]
    • Typical appearance of coxa magna on the femoral side; diameter of the femoral head more than 10% greater than the contralateral unaffected side [6]
    • Neck shaft angle 122°; compatible with coxa vara
    • High-riding greater trochanter [7]
    • Joint space 3 mm at the sourcil and at the inferior portion
    • Subchondral cysts on the acetabular and femoral side
    • Femoral ostephyte on the posteromedial aspect



    Figure 1. Standing AP pelvis (top) and abduction view of the left hip (bottom).

    Diagnosis

    • Sequelae of LCPD on the left hip with secondary osteoarthritis (OA) of Tönnis grade II [8]

    Surgical Treatment Options

    When a young active adult with sequalae of LCPD presents with hip pain, non-operative treatment is usually the first option to be offered, including:

    • Modification of physical activities
    • Non-steroidal anti-inflammatory drugs (NSAIDs)
    • Physical therapy
    • Intraarticular steroid injections

    In some patients, however, non-operative measures fail. We are not aware of any studies reporting on the success of non-operative management of LCPD. Surgical treatment may, therefore, be offered to patients with failed non-operative measures. The surgical option in young, symptomatic LCPD include joint preservation and total hip arthroplasty.

    The goal of hip preservation surgery in LCPD patients is to prolong the survival of the native hip by addressing the labral tear, the chondral damage, and the morphologic alterations in the proximal femur and the acetabulum.

    The most important study in this field, which is helpful for decision-making, was presented by Albers et al. [9] They describe an algorithm based on 53 patients (mean age 21 years) who presented with chondral damage of the femoral head. Forty-seven percent presented with acetabular dysplasia, and 55% had radiographic signs of acetabular retroversion. Eighty-nine percent of patients required relative lengthening of the greater trochanter.

    These characteristics illustrate the multidimensional approach of hip preservation surgery in patients with late LCPD, as it is necessary to solve proximal femur and acetabular alterations. In some instances, this effort will require more than 1 operation. [10]

    Despite good overall initial results in the latter cohort, 14% of patients required THA after 5 years, and 39% required THA after 8 years. [10] Interestingly, all the patients included in this study had OA Tönnis grade 0 or 1.

    Hip preservation is not a viable option for patients with degenerative changes of the hip that correspond to Tönnis 2 or 3 OA. [11] THA is the best option for patients with arthritic changes. The outcome of THA for patients with late LCPD are excellent in terms of survival, without an increased risk of revision when compared with a group of OA hips. [12] A case series from the Mayo Clinic demonstrated that uncemented components had 90% survival at 8 years, while hybrid THA (cemented femoral stem and uncemented acetabulum) had 86% survivorship. [13] The authors reported that femoral and acetabular fractures are complications that may occur during surgery.

    Treatment Decision

    The pros and cons of hip preservation and THA were discussed with the patient. Because of the severity of her symptoms – including pain in the groin indicative of intraarticular pathology plus Tonnis II arthritis – the decision was made to proceed with THA. The patients did not wish to undergo joint preservation and also was insistent on gaining leg length equality.

    The patient was also against surgical dislocation of the hip, which would have been needed to advance the greater trochanter, reshape the femoral head, and address the intraarticular pathology. [14,15] She would have also needed reverse periacetabular osteotomy. The outcome of combined pelvic osteotomy, trochanteric advancement, and femoral reshaping is clearly less predictable than THA and is affected by numerous factors, most important of which is the degree of arthritis in the hip.

    A THA was performed through the direct lateral approach to allow for possible greater trochanter advancement, if needed. The chosen components were a trabecular metal hemispherical cup (50 mm), a 32-mm highly cross-linked polyethylene, a 32-mm Delta ceramic head, and a single wedge taper stem (Type I in the Khanuja Classification of stems. [16]

    At the latest follow-up of 2 months (Figure 2), the patient is happy with the outcome of surgery and delighted about her equal limb lengths.


    Figure 2. Postoperative AP pelvis (left) and postoperative left lateral hip view (right).

    Surgical Pearls

    In performing THA for patients with arthritis of the hip as a result of LCPD, the surgeon needs to take into consideration the following issues.

    • These patients often have a considerable limb length inequality, thus lengthening during surgery is required. They should be warned about the possibility of sciatic nerve palsy. Lengthening in excess of 4 cm is not recommended.
    • LCPD patients are often young, and therefore a bearing surface with the potential for the longest survivorship needs to be chosen.
    • The morphology of the acetabulum is grossly abnormal in these patients, and care needs to be taken to avoid over-reaming of the acetabulum in an effort to obtain a hemispherical socket.
    • As with patients with severe dysplasia, the anteroposterior diameter of the acetabulum determines the size of the acetabular component.
    • In some patients with anterolateral deficiency, autograft reconstruction using the femoral head may be needed.
    • In some patients with severely affected proximal femur, the bone in the metaphysis is poor, which poses a challenge with the use of a tapered uncemented stem, as torsional stability may be compromised. We recommend the use of an anatomical fit and fill stem in these patients.
    • It is important to avoid the use of cemented or extensively coated femoral stems in these young patients.

    Author Information

    Claudio Diaz-Ledezma, MD, is from the Clinical Las Condes, Santiago, Chile. Javad Parvizi, MD, FRCS, is from The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

    Adult Reconstruction Section Editor, Rothman Institute Grand Rounds

    Antonia F. Chen, MD, MBA

    References

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    2. Clohisy, JC, Dobson, MA, Robison, JF, Warth, LC, Zheng, J, Liu, SS, Yehyawi, TM, Callaghan, JJ: Radiographic structural abnormalities associated with premature, natural hip-joint failure. J Bone Joint Surg Am 2011;93 Suppl 2:3–9.
    3. Rhee, PC, Woodcock, JA, Clohisy, JC, Millis, M, Sucato, DJ, Beaulé, PE, Trousdale, RT, Sierra, RJ, Academic Network for Conservational Hip Outcomes Research Group: The Shenton line in the diagnosis of acetabular dysplasia in the skeletally mature patient. J Bone Joint Surg Am 2011;93 Suppl 2:35–39.
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