INITIAL CONCEPT FOR NONSURGICAL TREATMENT
The treatment of Legg-Calvé-Perthes disease has been variable since 1910, when Legg, Calvé, and Perthes first published their studies describing the disease. The initial concept for nonsurgical treatment involved nonweight bearing and prolonged immobilization. Several investigators stressed its importance. Danforth1 published the results of 5 satisfactory cases, which had nonweight bearing and immobilization for long periods until complete bone regeneration appeared. Eyre-Brook2 wrote that traction in recumbency provided the most satisfactory treatment for children under 7 years of age, or older than 7 years if in the very early stage of the disease. Sundt3 also supported those concepts with his extensive study. In this way, patients were necessarily bound to hospital beds for extensive inpatient treatment.
ADOPTION OF JOINT MOBILIZATION
In contrast, Platt4 stated that there was no definite reason for adopting a prolonged period of immobilization. Howorth5 recommended that traction for immobilization should be applied only for 2 or 3 weeks in incipient or acute and rapidly progressive phases of the disease; he considered use of an outpatient treatment with an ambulatory treatment. Since then, some investigators, therefore, preferred outpatient to inpatient treatment with a weight-relieving orthosis during the entire course of the disease. Evans and Lloyd-Roberts6 concluded that there was no significant difference in the radiologic results between inpatient treatment with traction in bed and outpatient treatment with a Snyder sling.7 This sling and the Thomas splint represented this concept.
THE CONCEPT OF CONTAINMENT
Harrison et al8 emphasized the efficacy of the containment concept, which completely placed the epiphysis within the acetabulum using an abduction plaster cast known as the broomstick plaster. The concept was first introduced by A.O. Paker, in 1929.9 Afterward, Katz10 and Brotherton and Mckibbin11 also reported good results with abduction plaster cast and nonweight bearing. However, a broomstick plaster cast alone sacrificed the active motion of the affected hip by restricting the patients to the hospital. The containment concept is that a deformed epiphysis is completely placed within the acetabulum and a round acetabulum makes it more spherical.
Experimentally, we confirmed the influence of joint incongruity to the necrotic femoral head in young rabbits.12 In the results, we concluded that sphericity of the femoral head could be preserved, if joint congruity was established for the necrotic femoral head. The containment could produce a certain joint congruity, thus being beneficial for keeping the sphericity of the necrotic femoral head.
AMBULATORY ORTHOSES WITH CONTAINMENT
Harrison et al8 produced a new ambulatory splint, which had a containment effect. Hip joint mobilization is important for the following advantages: (1) stimulating new bone formation; (2) preventing disused muscle atrophy; (3) supplying nutrition to the cartilage; and (4) having a molding effect, which might shape the femoral head in the template of the acetabulum. This improved the treatment substantially.
Using this principle, Tachdjian and Jovett13 produced the Trilateral Socket Hip Abduction Orthosis (Tachdjian type orthosis), which allowed the patients to have active hip motion and containment with nonweight bearing. Petrie and Bitenc14 and Curtis et al15 also published on an original type of ambulatory orthoses, the abduction weight-bearing cast and Newington ambulation-abduction brace, respectively. Nishio16 produced the same type of ambulatory orthosis with 25-degree hip abduction and nonweight bearing. The positive results from these studies prompted a prevalent usage of the orthoses and supported the importance of 2 concepts of the conservative treatment: the containment method with hip abduction and the restoration of the range of motion.17,18
The comparison between poor results of noncontainment and containment treatments using ambulatory orthoses was shown in Table 1. The former half showed poor results of noncontainment orthoses,6,19–22 and the latter one showed those of containment with weight-bearing orthoses in past reports.14,15,23–25 Average poor rate was less in containment orthoses (12%) than in noncontainment ones (30%). In our experience, we found the same tendency. The Tachdjian type orthosis (Trilateral socket hip abduction orthosis) produced better results (32% poor rate) than the Thomas splint (48% poor rate).26 Both Catterall27 and Stulberg et al28 reported on the natural history of Legg-Calvé-Perthes disease, in which a poor result was 47% and 43%, respectively. Since then, the purpose of orthotic treatment was that the final result should be better than those of the natural history. Containment treatment, in fact, produced a better result than those in natural history.
INFLUENCE OF WEIGHT BEARING
As mentioned before, it was obvious that containment was the most important factor in nonsurgical treatment. In contrast, what about weight bearing? This is controversial. Petrie and Bitenc14 and Curtis et al15 reported excellent results using an abduction weight-bearing cast and brace. These orthoses allowed patients to walk with weight bearing while sustaining the desired containment of the femoral head in the acetabulum. According to these facts, weight bearing proved favorable if under containment. However, this type of orthosis was so restrictive that patients could not move smoothly.
To compensate for that disadvantage, the Scottish Rite Orthosis (called the Atlanta brace) was designed in 1971. It was more mobile and lighter, and moreover enabled patients to easily walk with full weight bearing. Purvis et al29 reported their preliminary results with a 22% poor result using the Scottish Rite Orthosis, which kept both hips in 45-degree abduction with weight bearing. He expected more hip mobility than the conventional ambulatory abduction orthoses. However, in 1992, 2 reports were summarized by Meehan et al30 and Martinez et al31 showing that the Atlanta brace produced worse results (65% poor) than other types of orthoses.
Table 2 shows the correlation of poor results and characteristics of the ambulatory orthoses in different series reported in the literature. They were divided into 4 categories according to the following 3 characteristics: weight bearing, containment, and active hip motion. The poor rates were quite varied in each type of orthosis. That was because the evaluation methods and patients' age distribution were quite different among them. Therefore, it might be somewhat unreliable to simply compare those.
Although containment is the most important factor in nonsurgical treatment, weight bearing is controversial. There was a remarkable difference between the third and fourth category groups in Table 2. The difference reflects the quality of the containment. Meehan et al30 observed that the evaluation of orthotic containment while standing might not reflect the ability of the Atlanta brace to contain the femoral head during normal daily activities. The more active hip motion was likely to decrease the effectiveness of containment.
The most reliable orthosis for nonsurgical treatment would be the Petrie abduction weight-bearing cast, because of the best reported results. However, the result was not always better. Furthermore, present-day families dislike their children being kept in a restricted condition for a long time, and sometimes, they want surgical treatment for them, even if conservative treatment would still be effective. The indication of nonsurgical treatment has changed recently. Some investigators have found that there is a benefit of nonsurgical treatment for severe conditions in which a favorable result could not be expected even with surgical treatment. They recommended containment treatment plus physiotherapy, especially for severe patients. On the contrary, such nonsurgical treatment requires prolonged treatment and might cause physical and psychological stresses to patients and their families.
The surgical treatment also aims at the containment effect. The choice of either nonsurgical or surgical treatment is still difficult. Herring et al32 concluded that surgical treatment was recommended for patients who were over the age of 8 years and were in the lateral pillar B or B/C border groups. However, approximately 70% of the patients in the nonsurgical treatment group were treated with no treatment and the Atlanta brace. It was not a true representation of the result in nonsurgical treatment. Therefore, it should be considered after comprehensively examining the patient in terms of the severity of disease, patient's and family's psychological outlook and doctor's skill.
The acceptable radiologic result usually included the Stulberg class I, II, and III, dependent upon the shape of the femoral head. The class I and II needed a spherical head, but the class III indicated an ovoid femoral head with more than a 2 mm difference on the Mose concentric circle.33 Therefore, an acceptable result did not always require a spherical femoral head. However, Lecuire34 stated that a spherical head was a definite element for good long-term results. Some investigators reported that surgical treatment can produce a more spherical femoral head than nonsurgical treatment.35–39 Given this information, the choice of surgical treatment for a Stulberg III patient (acceptable radiologic result) is a difficult call. Therefore, we pediatric orthopaedic surgeons have to deliberate over a balance between advantages and disadvantages in nonsurgical treatment method (Fig. 1). The ideal selection would be when the advantages outweigh the disadvantages in either treatment. Nevertheless, nonsurgical treatment will still be the choice for selected patients, because of its effectiveness, noninvasiveness, and relatively low cost.
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