title: Advanced Containment With Triple Innominate Osteotomy in Legg-Calve-Perthes Disease: A Viable Option Even in Severe Cases.
abstract: BACKGROUND
  Legg-Calve-Perthes disease (LCPD), in its severe form, remains a challenge. More recent classifications, particularly the modified Elizabethtown classification, have highlighted the chronologic stage of LCPD and its effect on surgical outcome. Hip severity and age of disease onset have also been shown to be powerful determinants of outcome. This study was performed to determine whether disease stage, disease severity, or patient age, are absolute indicators of whether a patient can benefit from surgical containment with triple innominate osteotomy (TIO).
  
  
  METHODS
  All patients with LCPD treated with TIO between 1995 and 2011 were collected. Only those patients with a minimum of 2-year radiographic follow-up and no previous or concomitant femoral realignment surgery were included. Fifty-four patients (56 hips) met our inclusion criteria. The modified Elizabethtown classification was used to classify disease stage as early (<IIb) or late (≥IIb). Catterall and lateral pillar classifications were used to classify disease severity, and the Stulberg classification was utilized for radiographic outcome, defined as good (I/II) or poor (III/IV/V).
  
  
  RESULTS
  Fifty-one males and 3 females with a mean chronological age at surgery of 8.2±1.8 years were included (2 bilateral cases). Mean follow-up was 72.8±30.2 months. There was no significant difference in the proportion of Stulberg good versus poor outcomes when comparing hips that were graded as early or late stage (P=0.842), or Catterall I and II versus III and IV (P=0.304). Although not statistically significant, patients with lateral pillars B and BC (P=0.076) and patients who were aged 8.0 and younger trended toward doing better compared with lateral pillar C and over age 8.0 (P=0.085), respectively.
  
  
  CONCLUSIONS
  Radiographic results demonstrate that good outcomes are not entirely dependent on the stage of disease in LCPD when containment is performed with TIO. As expected, TIO appears to be more effective in younger patients with less severe disease. We conclude that even severely involved LCPD hips, independent of age, should be offered surgical containment. The failure rate in this group is higher, as expected, but many achieve good results and there are treatment methods available to those who fail containment.
  
  
  METHODS
  Level IV.
authors.affiliation: *Division of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA †Naval Medical Center Portsmouth, Portsmouth, VA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Stepanovich
authors.forename: Vidyadhar V
authors.initials: VV
authors.lastname: Upasani
authors.forename: James D
authors.initials: JD
authors.lastname: Bomar
authors.forename: Dennis R
authors.initials: DR
authors.lastname: Wenger
mesh_terms: D000367:Age Factors; D002648:Child; D005260:Female; D006621:Hip Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007873:Legg-Calve-Perthes Disease / Q000145:classification / Q000601:surgery*; D008297:Male; D010027:Osteotomy / Q000379:methods*; D011859:Radiography; D012720:Severity of Illness Index; D016896:Treatment Outcome