title: Conservative versus surgical treatment of late-onset Legg-Calve-Perthes disease: a radiographic comparison at skeletal maturity.
abstract: BACKGROUND
  Late-onset Legg-Calve-Perthes disease (LCPD; i.e., disease onset after 8 years) has been associated with a more aggressive course and poorer long-term outcomes. The optimal treatment method of LCPD is still controversial, especially in this late-onset patient population. The purpose of this study was to evaluate the radiographic outcomes at the end of skeletal maturity in a cohort of patients with late-onset LCPD, comparing the results between conservative and surgical treatment.
  
  
  METHODS
  We performed a retrospective comparative study of all 371 patients with LCPD seen at a single institution during a 30-year period. Children younger than 9 years of age at disease onset, bilateral cases, and children that had not reached skeletal maturity at last follow-up were excluded. Clinical data was collected from chart review and radiographs were staged according to the Waldenstrom and Catterall classifications. Patients treated conservatively (adductor tenotomy, bracing and physical therapy, or physical therapy alone) were compared to those treated with more extensive surgery (varus femoral osteotomy or Chiari pelvic osteotomy [CPO]). Final radiographic outcomes were based on a modified Stulberg criteria.
  
  
  RESULTS
  Forty-three patients with an average age of 10.8 years and a mean follow-up of 10 years were identified. Twenty-one children received conservative treatment (15 underwent adductor tenotomy, followed by abduction cast or brace and physical therapy; six had only physical therapy) and 22 underwent surgery (16 underwent femoral varus osteotomy and six had CPO). Based on the modified Stulberg criteria, there was no significant difference in radiographic outcome between the surgical and the conservative treatment groups, but there were twice as many patients with a poor result in the conservative group.
  
  
  CONCLUSIONS
  Late-onset LCPD presents with an extensive head involvement and shorter disease course. While there was no statistical difference between surgical and conservative treatment, there was a trend toward better radiographic outcomes when varus derotational osteotomy was performed early in the disease process.
authors.affiliation: Children's Orthopaedic Center, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 W. Sunset Boulevard, Mailstop #69, Los Angeles, CA, 90027, USA, aarkader@chla.usc.edu.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Arkader
authors.forename: Wudbhav N
authors.initials: WN
authors.lastname: Sankar
authors.forename: Romildo Merçon
authors.initials: RM
authors.lastname: Amorim