Does Early Proximal Femoral Varus Osteotomy Shorten the

Does Early Proximal Femoral Varus Osteotomy Shorten the Length of Fragmentation in LCPD? Lessons from a Prospective Multi-Center Cohort Study Wudbhav N. Sankar, MD The Children’s Hospital of Philadelphia

Prognosis of Perthes Disease • Multifactorial • • • Age at disease onset Extent of epiphyseal involvement Amount of extrusion Lateral pillar height (Herring classification) Duration of Fragmentation • Joseph et al (JPO 2005): Early PFO may alter natural disease course (34% bypassed fragmentation, shorter overall disease duration)

Joseph et al, JPO B

Study Design • Prospective, multi-center cohort • Serial q 3 month xrays • Subcohort used for reliability analyses at last year’s meeting (min 2 yr FU) • Waldenstrom stage (22 -26 reviewers) -- mode • Worst lateral pillar (22 -26 reviewers) -- mode • % Hypoperfusion on p. MR (Kim) • 28 early PFO vs. 7 non-surgical

Demographics and Follow-Up Overall Weighted Kappa Statistics for Waldenström Staging and Lateral Pillar Classification.

Results—Duration of Fragmentation All hips (in both cohorts) went through fragmentation!

Results—”Severity” of Fragmentation P=0. 563 “Worst” Lateral pillar during fragmentation

Results—% Hypoperfusion

226 263

Case 1: Shortest Duration of Fragmentation (147 days) - Surgical Cohort Pre-Op: Stage Ib

Case 1: Shortest Duration of Fragmentation (147 days) – Surgical Cohort 3 months: Stage Ib

Case 1: Shortest Duration of Fragmentation (147 days) – Surgical Cohort 8 months: Stage IIb

Case 1: Shortest Duration of Fragmentation (147 days) – Surgical Cohort 11 months: Stage IIb

Case 1: Shortest Duration of Fragmentation (147 days) – Surgical Cohort 13 months: Stage IIIa

Case 1: Shortest Duration of Fragmentation (147 days) – Surgical Cohort 16 months: Stage IIIb

Case 2: Longest Duration of Fragmentation (525 days) – Surgical Cohort Pre-Op: Stage Ib

Case 2: Longest Duration of Fragmentation (525 Days) – Surgical Cohort 3 months: Stage IIa

Case 2: Longest Duration of Fragmentation (525 days) – Surgical Cohort 7 months: Stage IIb

Case 2: Longest Duration of Fragmentation (525 days) – Surgical Cohort 12 months: Stage IIb

Case 2: Longest Duration of Fragmentation (525 days) – Surgical Cohort 20 months: Stage IIIa

Case 2: Longest Duration of Fragmentation (525 days) – Surgical Cohort 25 months: Stage IIIb

Case 3: Shortest Duration of Fragmentation (91 days) – Non-Surgical Cohort Pre-op: Stage Ib

Case 3: Shortest Duration of Fragmentation (91 days) – Non-Surgical Cohort 3 months: Stage Ib

Case 3: Shortest Duration of Fragmentation (91 days) – Non-Surgical Cohort 6 months: Stage IIa

Case 3: Shortest Duration of Fragmentation (91 days) – Non-Surgical Cohort 9 months: Stage IIIa

Case 3: Shortest Duration of Fragmentation (91 days) – Non-Surgical Cohort 13 months: Stage IIIa

Case 3: Shortest Duration of Fragmentation (91 days) – Non-Surgical Cohort 16 months: Stage IIIb

Case 3: Shortest Duration of Fragmentation (91 days) – Non-Surgical Cohort 16 months: Stage IIIb

Case 4: Longest Duration of Fragmentation (373 days) – Non-Surgical Cohort Pre-op: Stage Ib

Case 4: Longest Duration of Fragmentation (373 days) – Non-Surgical Cohort 3 months: Stage IIa

Case 4: Longest Duration of Fragmentation (373 days) – Non-Surgical Cohort 4 months: Stage IIa

Case 4: Longest Duration of Fragmentation (373 days) – Non-Surgical Cohort 8 months: Stage IIb

Case 4: Longest Duration of Fragmentation (373 days) – Non-Surgical Cohort 15 months: Stage IIIa

Case 4: Longest Duration of Fragmentation (373 days) – Non-Surgical Cohort 24 months: Stage IIIb

Take home points • 100% hips experienced fragmentation (No bypass? ? ? ) • No significant difference in duration of fragmentation • Trend toward shorter duration in non-surgical group • Trend toward better perfusion in non-surgical group • No significant difference in severity of fragmentation • With available numbers, cannot confirm findings of Joseph et al.

Discussion points • Definition of bypass • Underpowered

Thank You!