The Epidemiology and Prognosis of Bilateral Legg-Calve-Perthes Disease :A comparative study with...
-
Upload
johnny-dynes -
Category
Documents
-
view
222 -
download
0
Transcript of The Epidemiology and Prognosis of Bilateral Legg-Calve-Perthes Disease :A comparative study with...
The Epidemiology and Prognosis of Bilateral Legg-Calve-Perthes Disease
:A comparative study with unilateral LCPD
Sung-Taek Jung, Ju-Kwon Park, Nam-Young Cho, Sung-Man RoweSung-Taek Jung, Ju-Kwon Park, Nam-Young Cho, Sung-Man Rowe
Department of Orthopaedic Surgery Chonnam National University Hospital
Introduction Legg-Calve-Perthes disease
Most have unilateral involvement Prevalance of bilateral involvement : 8-24%
Salter et al, J Bone Joint Surg Am, 1984
Guille JT et al, J Pediatr Orthop, 2002
There was few study on bilateral LCPD Clinical course of bilateral disease has not been evaluated
exactly
Purpose
To know the epidemiologic difference of unilateral and
bilateral Legg-Calve-Perthes disease
To evaluate the outcome and prognosis of unilateral and
bilateral LCPD
MaterialsMaterials From 1973 to 2009
1099 patients were diagnosed as LCPD at our hospital 82 patients presented bilateral LCPD
Bilateral group : 82 patients, 69 male, 13 female Inclusion criteria
Waldenstrom stage was initial, fragmentation and reossification state
They were followed up periodically 69 patients were included
58 male, 11 female 69 patients presented unilateral LCPD
Unilateral group : 58 male, 11 female They were randomly selected
MethodsMethods Three groups
Group A : First affected bilateral LCPD Sex
58 male, 11 female Treatment method
Op 9 case, Conservative 60 case Group B : Second affected bilateral LCPD
Sex 58 male, 11 female
Treatment method Op 5 case, Conservative 64 case
Group C : Unilateral LCPD Sex
58 male, 11 female Treatment method
Op 18 case, Conservative 51 case
MethodsMethods Design
Retrospective study Plain radiograph review
Hip anteroposterior & frog leg view Reviewed by 2 orthopaedic surgeons
Statistic ANOVA test was used to evaluate differences in group
A, B and C
MethodsMethods Epidemiologic assessment
Distribution of sex & age Radiographic assessment
Initial Waldenstrom stage
Severity Catterall classification Lateral pillar classification
Outcome Radiologic
Stulberg classification 40 patients(bilateral) and 46 patients(unilateral) were evaluated
because of short follow up duration Clinical
Pain (VAS), limping, ROM limitation Limb shortening
Result - IResult - I Three group
Group A : First affected bilateral LCPD Onset age : 6.0 years (2.0-12.3) Follow up duration : 11.1 years (5.8-24.3)
Group B : Second affected bilateral LCPD Onset age : 6.8 years (2.4-13.1) Follow up duration : 11.1 years (5.8-24.3)
Group C : Unilateral LCPD Onset age : 6.1 years (2.1-11.6) Follow up duration : 11.9 years (6.3-24.5)
Result - II
58(84.1%)
11(15.9%)
58(84.1%)
11(15.9%)
0
10
20
30
40
50
60
Unilateral Bilateral
Male
Female
Distribution of Sex & Age
No statistically difference between these group
28(40.6%)
33(47.8%)
8(11.6%)
23(33.3%)
36(52.2%)
10(14.5%)12(17.4%)
51(73.9%)
6(8.7%)
0
10
20
30
40
50
60
1st(A) 2nd(B) Uni(C)
<5 years old
5-9 years old
>9 years old
Result - III
23(33.3%)
32(47.8%)
13(18.8%)
55(79.7%)
8(11.6%)
6(8.7%)
38(55.1%)
21(30.4%)
10(14.5%)
0
10
20
30
40
50
60
1st(A) 2nd(B) Uni(C)
InitialFragmentationReossification
Waldenstrom Classification – Initial
Group p-value
A & B
A & C
B & C
0.002
0.054
0.000
Significant statistically difference between group A & B, B & C No statistically difference between group A & C 2nd hip present more initial finding than other group
Result - IV
34(49.3%)
22(31.9%)
13(18.8%)
0
5
10
15
20
25
30
35
Metachronous Synchronous N.A.
Case
Waldenstrom Classification – Synchronous vs Metachronous
Synchronous and metachronous was classified According to Waldenstrom classification at first visit
Onset interval in bilateral LCPD Average interval was 7.4 months (4.2-12.4)
Result - V
6(8.7%)
15(21.7%)
30(43.5%)
18(26.1%)
20(29.0%)
33(47.8%)
13(18.8%)
3(4.3%)3(4.3%)
16(23.2%)
29(42.0%)
21(30.4%)
0
5
10
15
20
25
30
35
1st(A) 2nd(B) Uni(C)
IIIIIIIV
Catterall Classification - Severity
Group p-value
A & B
A & C
B & C
0.000
0.697
0.000
Significant statistically difference between group A & B, B & C No statistically difference between group A & C 2nd hip presented milder finding than other group
Result - VI
10(14.5%)
39(56.5%)
20(29.0%)
41(59.4%)
19(27.5%)
9(13.0%)7(10.1%)
50(72.5%)
12(17.4%)
0
5
10
15
20
25
30
35
40
45
50
1st(A) 2nd(B) Uni(C)
ABC
Lateral pillar Classification - Severity
Group p-value
A & B
A & C
B & C
0.000
0.781
0.000
Significant statistically difference between group A & B, B & C No statistically difference between group A & C Class C was few in 2nd affected hip
Result - VII
11(27.5%)
8(20%)9(22.5%)
9(22.5%)
3(7.5%)
22(55%)
5(12.5%)5(12.5%)5(12.5%)
3(7.5%)
5(10.9%)
18(39.1%)
9(19.6%)
13(28.3%)
1(2.2%)
0
5
10
15
20
25
1st(A=40) 2nd(B=40) Uni(C=46)
IIIIIIIVV
Stulberg Classification - Outcome
Group p-value
A & B
A & C
B & C
0.001
0.454
0.031
Significant statistically difference between group A & B, B & C No statistically difference between A & C Class I was much more in 2nd hip
Result - VIII
Limping 2nd hip presented less limping than other group
Pain 2nd hip presented less pain than other group
ROM limitation 2nd hip presented less ROM limitation than other
group
Result - IX
38(55.1%)
6(8.7%)
12(17.4%)13(18.8%)
48(69.6%)
3(4.3%)
11(15.9%)
7(10.1%)
29(42.0%)
6(8.7%)
20(29.0%)
14(20.3%)
0
5
10
15
20
25
30
35
40
45
50
1st(A) 2nd(B) Uni(C)
0mm2-9mm
10-19mm
> 20mm
Limb shortening
Group p-value
A & B
A & C
B & C
0.220
0.354
0.007
Statistically difference between group B & C 2nd hip presented less limb shortening
DiscussionDiscussion Prevalance of bilateral involvement
In our study
1099 patients were diagnosed by LCPD from 1973 to 2009
Among them bilateral LCPD : 82 patient (7.5%)
Author Journal Published year
Total patient
Bilateral(%)
Katz
Kemp HS et al
Wynne-davies R et al
Harrison MHM et al
Salter et al
Guille JT et al
J Mt Sinai Hosp NY
Br J Radiol
J Bone Joint Surg Br
J Bone Joint Surg Br
J Bone Joint Surg Am
J Pediatr Orthop
1965
1973
1978
1980
1984
2002
209
220
310
222
936
637
9.0
10.0
11.3
10.4
23.9
13.0
DiscussionDiscussion
Onset interval between 1st and 2nd hip Bilateral involvement usually developed within two years
of unilateral onset
Sakai R et al, J Jpn Paed Orthop Assoc, 1993
In our study, average interval to bilateral involvement
was 7.4 months (4.2-12.4) It wound be due to follow up interval
Our follow up interval was shorter than Sakai R
et al
DiscussionDiscussion Severity & Outcome
More severe course than unilateral one of Ippolito Higher percentage of severe form
Van den Bogaert G et al, J Pediatr Orthop B, 1999 Ippolito E et al, J Bone Joint Surg Br, 1987
Lateral pillar A hips: statistically more in the 2nd side Milder in patients with bilateral involvement
Treatment of the first side Protective effect on the second side unclear
Guille JT et al, J Pediatr Orthopt Br, 2002
In our study, second affected hip shows better results in outcome and prognosis
ConclusionConclusion
Prevalance of bilateral LCPD was 7.5% in our study Prevalance of bilateral LCPD was 7.5% in our study First affected hip First affected hip
Similar outcome and prognosis of unilateral Second affected hip Second affected hip
Stage : Present more initial stage by Waldenstrom Severity : Present milder finding by Catterall & Lateral
pillar Outcome : Present better state by Stulberg Limb shortening : Present less shortening
Thank you for your kind attention