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Osteochondritis Dissecans of the Femoral Head in Perthes Disease : a Cause for Concern ?

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Osteochondritis Dissecans of the Femoral Head in Perthes Disease : a Cause for Concern ? OSTEOCHONDRITIS DISSECANS OF THE FEMORAL HEAD IN PERTHES DISEASE : A CAUSE FOR CONCERN ? F. STEENBRUGGE, M. F. MACNICOL1 Osteochondritis dissecans (OCD) and loose body for- Legg-Calvé-Perthes disease (LCPD) is the most mation are rare following Perthes’ disease. We have common predisposing disorder (2, 3, 4, 14, 17, 19). reviewed the literature about clinical presentation, The condition may also be familial (19) or follow treatment and outcome and added a further three treatment of a congenital dislocation of the cases of the condition. Cases mentioned in the litera- hip (21). ture were poorly documented. We feel that a Abnormal ossification and constitutional or thorough documentation should be carried out as soon as the diagnosis is made. genetic predisposition have been suggested, but not Conservative treatment should be given when the proved, to be possible etiologic factors. Trauma has disability is moderate. The loose body should only be been implicated, yet in most cases there is no removed surgically when it is mobile, when it bulges underlying or associated abnormality (2, 5, 8, 12). into the joint space or when there are signs of early Treatment may either be conservative or opera- arthritis. tive, with resection of the sequestrum. Arthroscopy of the hip may allow a selective and atraumatic Keywords : osteochondritis dissecans ; loose body ; Perthes’ disease. removal of loose bodies, but the outcome has not Mots-clés : ostéochondrite disséquante ; corps étranger ; been well documented (18). maladie de Perthes. MATERIAL AND METHODS We reviewed 10 papers (7, 9, 10, 12, 13, 15, 17, 18, INTRODUCTION 21, 22), published over the past 30 years, comparing the findings and results with our small series of three Osteochondritis dissecans (OCD), a process that patients. A total of 50 patients with OCD of the femoral leads to separation of a portion of subchondral head following Perthes’ disease included four patients bone and overlying cartilage, most commonly with bilateral Perthes’ disease and one patient with bila- involves the distal femur, distal humerus, and talus teral OCD. The age of the patient at the onset of symp- (2). When the hip is involved, the lesion usually toms, evolution, investigations and imaging, treatment affects the femoral head. A review of the literature confirms that OCD of ———————— the hip in children and adolescents is uncommon. Department of Orthopedic Surgery, Algemeen Stedelijk Reports consist of a few cases (12, 17, 21, 22), Ziekenhuis, Campus Aalst, B-9300 Aalst, Belgium. single cases (3, 5, 8, 14, 19), or examples of out- 1 Department of Pediatric Orthopedics, Royal Hospital for come after a variety of conditions. Sick Children, Sciennes Road, Edinburgh, EH9 1LF, Edinburgh, Scotland, UK. A number of disorders can precede OCD of the Correspondence and reprints : F. Steenbrugge, Department hip. All seem to disrupt the normal vascularity of of Orthopedic Surgery and Trauma, ASZ-Aalst, Merestraat 80, the weight-bearing portion of the femoral head. B-9300 Aalst, Belgium. E-mail : [email protected]. Acta Orthopædica Belgica, Vol. 68 - 5 - 2002 486 F. STEENBRUGGE, M. F. MACNICOL and outcome were analysed for the whole group. Our described as useful. Radiographic presentation revealed aim was to see if there was any difference in the out- all lesions to be well-localized to the superolateral or come in those cases diagnosed at an early age or late in superior central regions of the femoral head, which are childhood, and to see if there was any difference the sites of known maximal contact force. between those cases treated conservatively or operative- Only one paper used the Salter and Stulberg classifi- ly. We added a further three cases of the condition. We cation to categorize the patient when the diagnosis of then matched these findings with the results of our OCD was made. The patient was classified as a Salter series. Group A and Stulberg Type 2. Only three papers mentioned the gender of the No other paper used these or the Herring classifica- patient : 29 boys and 6 girls were affected by loose body tion to categorize the patients at the time of diagnosis or formation (18, 20, 22). at any time at follow-up. The average age of the patients when the diagnosis of LCPD was made was 8 years, ranging from 4 to RESULTS 11 years. No paper mentioned the time interval between the diagnosis of LCPD and the onset of symptoms Thirty seven out of 50 patients in the literature secondary to OCD. One paper described the frequency were treated conservatively, but most papers report- of the combination of LCPD and OCD to be as high as ed only a very short or incomplete follow-up. 6%, but did not mention its source (15). Conservative treatment consisted of bed rest, The most common presenting complaints were limp, crutches and analgesia. One paper mentioned the aching pain, catching, episodic symptoms and instabili- ty (22). Intermittent symptoms were frequently well use of a Thomas splint for an average of two years. documented : asymptomatic periods of several months The average follow-up in this paper was 24 years alternating with frequent spells of painful “catching” in and three out of 17 patients remained relatively free the hip lasting weeks to months. Over time, the episodes of symptoms despite loose body formation and became either more frequent leading to surgical inter- osteoarthritis (15). vention or less frequent. Instability was also expe- None of the other papers described the long-term rienced, the patient describing sudden pain and giving outcome. way of the hip. This was regarded as a pain inhibition Surgical treatment was carried out in 13 patients : response, similar to pseudolocking of the knee seen with arthrotomy in 6 cases (22) and arthroscopy in chondromalacia patellae or OCD of the distal femur, 7 cases (18). rather than true subluxation or dislocation. The most The time from the onset of symptoms to surgery common presenting signs were leg length discrepancy averaged 6 years in the first paper and the age at (with the involved femur always shorter), limited inter- nal rotation, painful flexion-adduction of the hip and surgical exploration averaged 20 years (22). An limp (22). No paper mentioned a history of nocturnal arthrotomy with dislocation of the femoral head in pain. five patients allowed excision of the fragment and In all patients (N = 50), anteroposterior and frog- drilling of the crater. In one case the fragment was lateral radiographs confirmed the diagnosis. elevated, the crater bone grafted and the fragment Since the radiographic diagnosis of OCD is not fixed with a Herbert screw. The average follow-up always easy, computed tomography or arthrography after surgery was 10 years. No patients appeared to may be used to confirm the condition (18) and to assess suffer from the temporary femoral head dislocation the possible formation of a loose body. One paper sug- and excision of the OCD fragment. All cases func- gested that the best method to visualize and diagnose tioned normally during the time of follow-up. The OCD of the femoral head is with an anteroposterior patient with the Herbert screw experienced mild tomogram of the hip in the neutral position (22). Two pain. papers mentioned the use of magnetic resonance imag- ing (MRI) to make the diagnosis (10, 11, 22). T2- The average age of the patients that underwent weighted images showed a band of increased signal arthroscopy was 16 years (18). intensity around the fragment, probably indicating a Nothing is mentioned about the time delay loose fragment although the hip joint might well be between onset of symptoms and arthroscopy asymptomatic. Radioisotope bone scan was not although the authors state that is was recorded Acta Orthopædica Belgica, Vol. 68 - 5 - 2002 OSTEOCHONDRITIS DISSECANS OF THE FEMORAL HEAD IN PERTHES DISEASE 487 preoperatively. All arthroscopies were therapeutic. catching. Xrays showed OCD of the femoral head. In 5 cases a loose body was removed, although the She has been treated conservatively for 5 years as procedure was repeated in one case because of the the OCD fragment has remained in place (Stulberg lack of uniquely curved instruments. The two type 4) and the symptoms have settled down over remaining cases showed the presence of a loose the last 3 years. body on xray but the articular surface was intact The third case is a boy diagnosed with Perthes’ when visualized with the arthroscope. There were disease of the left hip at the age of 5 years. He went no postoperative complications. The average fol- on to a Catterall stage II or a Herring stage B. At low-up was 2 years 10 months, and in six out of the 15 years, 5 years after the end of the evolution of seven patients the symptoms were reduced. The his Perthes’ disease, he developed symptoms of long-term outcome compared to open surgery is catching, limping and pain . Xrays and arthrogra- unknown. phy confirmed the diagnosis of OCD. He was treat- Our series consisted of three cases. The first case ed conservatively for 4 years and the Perthes’ dis- is a boy diagnosed with Perthes’ disease of the left ease has healed with the loose body still in place. hip at the age of 8 years. He went on to a Catterall At that stage, the xrays showed a Stulberg Type 3 stage III and a Herring stage C. At 18 years he hip. At the age of 24 years he still has a limp and developed symptoms of pain and catching. Xray his left hip aches occasionally. and MRI confirmed the diagnosis of osteochondri- The mean age at which Perthes was diagnosed tis dissecans (fig. 1). Three years had elapsed was 6 years 6 months (range 5 years to 8 yrs.).
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