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Randomized Controlled Trial
. 2022 Apr;104-B(4):510-518.
doi: 10.1302/0301-620X.104B4.BJJ-2021-1708.R1.

The British Orthopaedic Surgery Surveillance study: Perthes' disease: the epidemiology and two-year outcomes from a prospective cohort in Great Britain

Daniel C Perry  1   2   3 , Barbara Arch  1 , Duncan Appelbe  3 , Priya Francis  1 , Joanna Craven  4 , Fergal P Monsell  5 , Paula Williamson  1 , Marian Knight  6 ; BOSS collaborators
Collaborators, Affiliations
Randomized Controlled Trial

The British Orthopaedic Surgery Surveillance study: Perthes' disease: the epidemiology and two-year outcomes from a prospective cohort in Great Britain

Daniel C Perry et al. Bone Joint J. 2022 Apr.

Abstract

Aims: The aim of this study was to evaluate the epidemiology and treatment of Perthes' disease of the hip.

Methods: This was an anonymized comprehensive cohort study of Perthes' disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children's hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.

Results: Overall, 371 children (396 hips) were newly affected by Perthes' disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years.

Conclusion: Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: Bone Joint J 2022;104-B(4):510-518.

Keywords: Avascular necrosis; BOSS; Cohort; Epidemiology; Incidence; Legg-Calvé-Perthes; Legg-calve-perthes disease; Osteonecrosis; Patient-reported outcome measures (PROMs); Perthes; clinicians; cohort studies; epidemiology; hip disease; hips; orthopaedic surgery; radiological outcomes; randomized controlled trials.

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Figures

Fig. 1
Fig. 1
Likelihood of a surgical versus non-surgical strategy according to an a) a priori constructed decision tree and b) optimized decision tree using recursive partitioning to best fit the data, which included optimizing the cut-off for age, based on the 249 hips with a treatment strategy in place at baseline. AP, anteroposterior.
Fig. 2
Fig. 2
Anteroposterior (AP) roundness error stratified by two-year Stulberg grade. This was restricted to hips that reached modified Waldenström stage 3B or 4.
Fig. 3
Fig. 3
Distribution of Paediatric Quality of Life Inventory scores in Perthes’ disease patients at a) baseline (n = 70) and b) two years (n = 99), based on established categorizations.
See this image and copyright information in PMC

References

    1. Perry DC, Skellorn PJ, Bruce CE. The lognormal age of onset distribution in Perthes’ disease: an analysis from a large well-defined cohort. Bone Joint J. 2016;98-B(5):710–714. 10.1302/0301-620X.98B5.36453 - DOI - PubMed
    1. Perry DC, Bruce CE, Pope D, Dangerfield P, Platt MJ, Hall AJ. Perthes’ disease: deprivation and decline. Arch Dis Child. 2011;96(12):1124–1128. 10.1136/archdischild-2011-300413 - DOI - PubMed
    1. Metcalfe D, Peterson N, Wilkinson JM, Perry DC. Temporal trends and survivorship of total hip arthroplasty in very young patients: a study using the National Joint Registry data set. Bone Joint J. 2018;100-B(10):1320–1329. 10.1302/0301-620X.100B10.BJJ-2017-1441.R2 - DOI - PubMed
    1. Perry DC, Machin DMG, Pope D, et al. . Racial and geographic factors in the incidence of Legg-Calvé-Perthes’ disease: a systematic review. Am J Epidemiol. 2012;175(3):159–166. 10.1093/aje/kwr293 - DOI - PubMed
    1. Perry DC, Bruce CE, Pope D, Dangerfield P, Platt MJ, Hall AJ. Legg-Calvé-Perthes disease in the UK: geographic and temporal trends in incidence reflecting differences in degree of deprivation in childhood. Arthritis Rheum. 2012;64(5):1673–1679. 10.1002/art.34316 - DOI - PubMed

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