Nonsurgical treatment to regain hip abduction motion in Perthes disease: a retrospective review.

Abstract: The purpose of this study was to document the ability of a nonsurgical program to improve restricted passive hip abduction in children with Perthes disease. Containment as a form of treatment was recommended if passive hip abduction of 30 degrees or more could be achieved. Medical records and radiographs were retrospectively reviewed for 74 children. Age at admission and onset, side, length of stay, and measurement of passive hip abduction at admission/discharge were recorded. The average increase in abduction with the hip extended was 13 degrees. Forty-two children achieved 30 degrees or more of abduction with the hip extended. Average length of stay was 13 days. Management of restricted abduction in an inpatient setting can allow consideration of containment in 61% of children previously not thought to have the required motion.

Key Words: femur head necrosis, Legg-Perthes disease, therapy

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Perthes disease is an osteochondrosis of the proximal femoral epiphysis. There may be genetic, (1-4) environmental, (5-7) and traumatic influences. (8) There may be abnormal coagulation. (9-17) Smoking may have an effect. (18,19) The onset is usually between 6 and 9 years of age. There is a male predominance. Symptoms are at least partly attributable to synovitis. The pathologic findings suggests infarction. (20-22)

Prognosis appears related to femoral head deformity. (23-25) Gower and Johnston (23) reported 36 of 112 patients with average follow-up of 36.3 years. Only three patients had surgery for hip problems. McAndrew and Weinstein (24) re-evaluated 35 of these patients. The average follow-up was 47.7 years. Half of the hips had been treated with arthroplasty for degenerative disease. Factors associated with a poor outcome included coxa magna. Spherical heads did well without degenerative changes. (24) Stulberg et al (25) described five possible femoral head shapes at the end of the healing phase and correlated these with long-term follow-up. When the femoral head was spherical, arthritis did not develop. Mose (26) proposed matching the shape of the healed femoral head to a template of concentric circles.

Containment is an accepted form of treatment. (27) The goal is to improve outcome by maintaining the healing femoral head within the acetabulum. (28) Salter (29) reviewed the status of surgical treatment for Perthes disease. He outlined the indications (the lack of which means the child does not need containment) as involvement of more than half of the femoral head, age at onset of more than 6 years (possibly more than 5 years in girls), and loss of containment (subluxation of the femoral head in the position of weight bearing). He outlined the prerequisites (the lack of which means the child cannot be helped by containment) as full or almost full range of motion and a round or almost round femoral head (congruency of the hip joint in abduction). Containment can be achieved with casting, (30-32) bracing, (33) or surgery. (29,34,35) Motion should be restored before containment. (27,29-31,33,36-38)

Materials and Methods

From April 1990 to February 1999, 335 children were initially evaluated with Perthes disease. During the same period, 118 children with a diagnosis of Perthes disease were admitted for nonsurgical treatment to regain abduction motion. Forty-four patients were excluded for the following reasons: bilateral disease (22 patients), previous treatment (11 patients), admission hip abduction in extension of 30 degrees or more (7 patients), no radiographs within 30 days of admission (2 patients), radiographic reossification (1 patient), or incorrect diagnosis (1 patient).

Seventy-four children were included in the study. The design of the study was a retrospective review of medical records and radiographs. Age at admission, age at onset of symptoms, duration of symptoms, side involved, sex, and length of hospital stay were recorded. Hip abduction in extension at admission and discharge was recorded. An anteroposterior pelvis radiograph documented lateral epiphyseal involvement in all cases. (39) Treatment for each patient included bedrest, skin traction with progressive bilateral abduction, and physiotherapy to include pool and bike. This was a retrospective chart review study that qualified for and was granted exemption certification by the University of Kentucky Institutional Review Board.

Results

There were 52 male patients (70%) and 22 female patients (30%) evaluated in this study. Forty children (54%) were affected on the right side and 34 children (46%) were affected on the left side (Table 1).

Improvement in hip abduction from admission to discharge was recorded. The data were divided into three groups for statistical analysis: those children improving by 10 degrees or more of abduction (Table 2), those children improving to 30 degrees or more of abduction (Table 3), and those children improving to 45 degrees or more of abduction (Table 4). For each group, unpaired t tests performed with StatView software (Abacus Concepts, Inc., Berkeley, CA) were used to measure age at admission, age at onset of symptoms, duration of symptoms, sex, side, and hip abduction at admission.

Unpaired t tests yielded no significant difference in age at admission, age at onset of symptoms, or duration of symptoms (Tables 2-4). There was also no difference in sex or side affected between the three levels of abduction improvement (Tables 5 and 6).

An unpaired t test revealed no statistical difference in hip abduction at admission between those children improving by 10 degrees or more versus those children not improving by 10 degrees or more (Table 2). There was no statistical difference in hip abduction at admission between the group of children improving to 45 degrees or more abduction versus the group of children not improving to 45 degrees or more (Table 4). An unpaired t test yielded a significant difference in hip abduction at admission for the group of children improving to 30 degrees or more abduction versus the group of children not improving to 30 degrees or more abduction (P = 0.0452) (Table 3).

When abduction improved by 10 degrees or more, motion was achieved in 50% of these children by 12 days, in 75% of these children by 16 days, and in 95% of these children by 25 days. When abduction of 30 degrees or more was achieved, motion was achieved in 50% of these children by 11 days, in 75% of these children by 15 days, and in 95% of these children by 25 days. Finally, when abduction to 45 degrees or more was achieved, motion was achieved in all these children by 11 days.

Discussion

Nonoperative means can be used to improve motion. Petrie and Bitenc (31) used bedrest, and traction or adductor tenotomy, if necessary, before long leg walking plasters. Brotherton and McKibbin (40) used initial abduction traction and prolonged recumbency until reossification with better results than reported controls or osteotomy in the most involved hips. Purvis et al (33) frequently had to use bedrest with skin traction in the line of deformity to regain range of motion. (33) Salter (29) notes that traction or slings and springs may be required to overcome irritability of the hip to restore range of motion before innominate osteotomy. Killian and Niemann (36) used skeletal traction after split Russel traction failed to produce complete containment before varus femoral osteotomy. Menelaus (37) noted that slings and springs, broomstick casts, soft tissue releases, and bracing can all be used in obtaining and retaining a good range of abduction. Richards and Coleman (32) used traction early in their study, but because of the lack of any substantial improvement in the range of motion, the patients who were treated later did not have any traction before closed reduction and casting. Serlo et al (38) increased the hip motion a mean of 34 degrees after 7 to 14 days of Russel traction before femoral osteotomy. Fulford et al (30) used bedrest and skin traction before a weight-relieving caliper or a proximal femoral varus osteotomy. Joseph et al (34) used an initial period of traction for 1 to 2 weeks to improve the range of hip motion before femoral osteotomy.

The reliability of motion measurements has a range of 10 degrees. Boone et al (41) stated that changes in lower extremity motions should exceed 6 degrees to state that improvement had occurred. Bovens et al (42) noted that it is difficult to show either an improvement or worsening of a joint motion of less than 10 degrees. In our study, 52 children (70%) achieved an improvement of 10 degrees or more of abduction. Over half of these children did so by hospital day 12.

The literature suggests full abduction to 45 degrees is needed for containment. (29,33) Only five children (7%) achieved abduction to 45 degrees or more. These children all did so by hospital day 11.

For this study, abduction to 30 degrees or more was considered necessary for containment. Forty-five children (61%) achieved abduction to 30 degrees or more. Over half of these children did so by hospital day 11.

Thompson and Salter (43) noted that the results of containment suggest improvement over the natural history of the disease process. Canario et al (44) found that 51% of 63 severe Perthes disease hips contained by femoral osteotomy were congruous and spherical, in contrast to 14% of 85 untreated hips. Joseph et al (34) reported 63% of a group of children at risk for deformity treated with surgical containment had a spherical head when healed compared with 20% of those treated nonoperatively.

Containment is considered successful if femoral head deformity is avoided. Herring (27) has reviewed the outcome in relation to the age at the onset of disease. Outcome of femoral head deformity was determined by the Mose rating. (26) Children younger than 6 years of age usually have a good result regardless of the treatment, so containment may not be necessary. Children who are 6, 7, or 8 years old in whom the lateral pillar is at least half the height of the contralateral lateral pillar or who have a bone age less than 6 years did not have an outcome altered by treatment. Children who are 6, 7, or 8 years old and in whom the height of the lateral pillar is less than one half the contralateral lateral pillar and who have a bone age more than 6 years have a better outcome when managed with containment. Children who are 9 years old or more do not seem to benefit from treatment aimed at containment.

Conclusion

Management of restricted abduction in an inpatient setting can allow consideration of containment in 61% of children previously not felt to have the required motion.

Table 1. Descriptive Statistics (n = 74)

                                      Mean  Range

Age at admission (mo)                 90    47-160
Duration of symptoms (mo)              9     0-41
Age at onset of symptoms (mo)         81    40-149
Length of hospitalization (d)         13     4-31
Hip abduction at admission (degrees)  16     0-25
Hip abduction at discharge (degrees)  29     5-50
Improvement in abduction (degrees)    13     0-45

Table 2. Comparison of children improving by 10 degrees or more of
abduction versus children not improving by 10 degrees or more of
abduction (a,b)

                                  Not     Unpaired
                      Improved  improved   t test
Variable              (n = 52)  (n = 22)  (P [less than or equal to]
                                          0.05)

Age at admission       88       95        NS
  (mo)
Age at symptom onset   80       84        NS
  (mo)
Duration of symptoms    8       11        NS
  (mo)
Hip abduction at       16       17        NS
  admission (degrees)

(a) NS, not statistically significant.
(b) All values are means.

Table 3. Mean comparison of children improving to 30 degrees or more of
abduction versus children not improving to 30 degrees or more of
abduction (a,b)

                                  Not     Unpaired
                      Improved  improved   t test
Variable              (n = 45)  (n = 29)  (P [less than or equal to]
                                          0.05)

Age at admission       86       95        NS
  (mo)
Age at symptom onset   78       86        NS
  (mo)
Duration of symptoms    8        9        NS
  (mo)
Hip abduction at       17       14         0.0452
  admission (degrees)

(a) NS, not statistically significant.
(b) All values are means.

Table 4. Mean comparison of children improving to 45 degrees or more of
abduction versus children not improving to 45 degrees or more of
abduction (a,b)

                                  Not     Unpaired
                      Improved  improved   t test
Variable              (n = 5)   (n = 69)  (P [less than or equal to]
                                          0.05)

Age at admission       76       91        NS
  (mo)
Age at symptom onset   70       82        NS
  (mo)
Duration of symptoms    6        9        NS
  (mo)
Hip abduction at       16       16        NS
  admission (degrees)

(a) NS, not statistically significant.
(b) All values are means.

Table 5. Comparison of boys versus girls on each level of improvement in
abduction (a)

                                            Unpaired
                                    Not      t test
Group                   Improved  improved  (P [less than or equal to]
                                            0.05)

Improved by 10 degrees  52        22        NS
  or more
Improved to 30 degrees  45        29        NS
  or more
Improved to 45 degrees   5        69        NS
  or more

(a) NS, not statistically significant.

Table 6. Comparison of right versus left side on each level of
improvement in abduction (a)

                                            Unpaired
                                  Not        t test
Group                   Improved  improved  (P [less than or equal to]
                                            0.05)

Improved by 10 degrees  52        22        No
  or more
Improved to 30 degrees  45        29        No
  or more
Improved to 45 degrees   5        69        No
  or more

(a) NS, not statistically significant.

Acknowledgments

We thank Jackson Maddux, MD, Carmela Osborne, MD, Susan Wagers, Kelly Ash, and Jennifer Jenkins, PT, for their help with this study.

Accepted February 28, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9705-0485

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RELATED ARTICLE: Key Points

* Seventy percent of children achieved an improvement of 10 degrees or more of abduction. Over half of these children did so by hospital day 12.

* Only 7% of children achieved abduction to 45 degrees or more. These children all did so by hospital day 11.

* Sixty-one percent of children achieved abduction to 30 degrees or more. Over half of these children did so by hospital day 11.

Brian T. Carney, MD, and Christin L. Minter, MA

From the Shriners Hospital for Children, Lexington, KY.

Reprint requests to Christin L. Minter, MA, 1900 Richmond Road, Lexington, KY 40502-1298. Email: [e-mail]