Date Published: August 16, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Mohammad Taghi Karimi, Tony McGarry.
Legg-Calve-Perthes disease (LCPD) is a degenerative condition of the hip joint characterised by idiopathic avascular necrosis of the femoral head. Loss of bone mass causes a degree of collapse of the joint and may result in deformity of the ball of the femur and the surface of the hip socket. A reduction in hip joint range of motion, alternation in growth of femoral head, and associated pain are most important problems associated with this disease. Various treatment methods are currently in use and aim to increase containment of the femoral head within the acetabulum, redistribute loading patterns applied to the femoral head, and to decrease the final deformities associated with this condition. These treatments depend on a variety of underlying factors and the aim of this paper was to determine appropriate pathways for treatment and the evidence of treatment method success. A review of the relevant literature was carried out in a variety of data bases including PubMed and ISI Web of Knowledge, and Gale between 1950 and 2011. Research results were categorised depending on the identified treatment method. The success of each treatment pathway was assessed and reasons for the pathway selected were grouped by the age of disease onset, follow-up period, and the final outcome. Evidence relating to the effectiveness of the treatment method used was conflicting. Different methods of screening and follow-up periods were employed in each study which used subjects of varying ages. Minimal evidence of sufficient quality exists in the literature to determine the most appropriate treatment of Legg-Calve-Perthes disease. Research provides some evidence to suggest that nontreatment may be as effective as orthotic or surgical intervention. More research is required to determine the effectiveness of orthotic and surgical treatment.
Legg-Calve-Perthes disease (LCPD) is a condition in which the blood supply of femoral head is interrupted and the bone temporarily dies. This may lead to irritability of the hip joint and, depending on the severity, deformation of the head of the femur. The aetiology of LCPD is idiopathic but is likely to be multifactorial and may be of genetic or deprivation influence [1, 2]. The disease occurs in children between 5 and 12 years of age and is more prevalent in males. Incidence differs in different countries and is also dependant on race (10.8 per 100,000 Caucasian, 0.45 Negroid children) [3, 4]. Higher incidence is recorded in the areas of lower population compared to more densely populated areas [3, 5, 6].
An electronic search was completed via the Pubmed, Embase, and ISI Web of Knowledge data bases from 1950 to 2010. The key words used for the search were Perthes disease treatment, avascular necrosis of the hip, and included specific topics, such as gait analysis, orthosis, and containment and noncontainment approach, which were identified by a multidisciplinary team of expert scientists and clinicians. The abstract and title of each individual study was assessed by reviewers. A first selection of the relevant articles was completed based on whether or not the title/abstract addressed the key words. Selection stages are illustrated in Figure 2. The second selection of the articles was completed according to the following criteria:articles addressing the Perthes disease and its treatment methods,experimental studies published in English.
Initial application of the key search words generated a total of 100 articles from reviewed databases. Following application of inclusion criteria 50 papers were selected for final analysis. Analysis of papers determined four main themes which were dependant on the treatment method: containment; noncontainment; surgery, non-treatment. Based on the search strategy, 50 articles were found, most of which were prospective cohort study, case series, and case control (only one research study was randomized-control trial). The results of quality assessment of the research are summarised (Table 2), and the results of heterogeneity test summarised in Table 3.
Most studies examining treatment options in LCPD are of high quality and were of appropriate sample size (Table 2). In most studies, subjects were followed up by investigators for a long period of time ( from 4.5 to 22 years). Assessment methods used to evaluate the condition were the same in the most of the research studies. Heterogeneity tests also showed that the final results of different noncontainment treatment approaches did not illustrate important heterogeneity (Table 3). In contrast, the heterogeneity between the results of other methods of treatment was high which causes difficulty when establishing the effect of different treatment methods.
The aim of this paper was to examine the evidence of success of treatment methods used in Legg-Calve-Perthes disease (LCPD) to assist in determining appropriate pathways for treatment.