THE

NATURAL

HISTORY

A.
From

Assessment

the

of the

the final outcome,
occurs
when
these
factors
outcome

series
form

indications
of

disease

of Perthes’

for

treatment,

treatment

are

good

a concept

that

the

Street,

disease

London

is confused

Frequently
paper
is the

so

its form

and

variable

that

connection

prognosis,

originally

final

Ormond

by an

incomplete

its natural
history.
The age of the patient,
and the sex are generally
accepted
as factors

In this

with

confirming

suggested

Great

in which

was

influence

(1959)

only

the

to
part

by Waldenstr#{246}m

(1922).

to

the

the

amount

of the
remain

final

be

published

anterior

proportional

outcome
for other

prediction
us we will

upon

it is difficult

O’Garra

introduced

prognosis

its

the stage
influencing

an unfavourable
result
of a search

of diagnosis
we may develop
a sounder
disease.
So long as this knowledge
eludes

comparable.

Perthes’

involved,

of treatment

the time
Perthes’

results

strictly

of

also

the

reported

are

Children,

DISEASE

ENGLAND

especially
if the child
is treated.
criteria
promise
otherwise.
This

about

The

PERTHES’

LONDON,

Sick

that govern
of diagnosis,

upon
which
at
in a child with

undecided

CATTERALL,

Hospitalfor

results

knowledge
of the factors
of the disease
at the time

OF

sure

result.
that

the

evidence
of the

on

head

Ponseti
of

the

a

was

(1961)
epiphysis

involved.
The

object

determined
an effective

of

this

paper

is to

suggest

by a study
of the early
prognosis
and treatment

that

THE

This
studied
matched

degree

of

epiphysial

PRESENT

and

involvement

that

such

be

can

diagnosis

allows

STUDY

study was stimulated
by the findings
in a series of untreated
cases of Perthes’
disease
in this department
by Murley
and Lloyd-Roberts
(1960).
These
cases were carefully
with treated
controls
but there
was little difference
in the overall
results.
A more

detailed

analysis

mild

the

radiological
appearances,
to be advised.

showed

(half-head

that

problems

Clinical

disease,

the

disease

in

most

cases

was

of

two

types.

First

there

were

Group
1 below)
in whom
the prognosis
was very good,
and
secondly,
severe
cases
(see Group
4 below)
in which
the prognosis
was bad.
In each
of
these types it was evident
that some cases,
both treated
and untreated,
did not behave
in the
manner
which the age, stage at diagnosis,
and sex would
suggest.
It was decided
to investigate
the

cases

posed

by

these

cases.

material-Between

seen

at the

Hospital

were

in girls.

the years
for

Of the

see

total

Sick

1950

Children.

of 133 hips,

and 1967, 121 patients
with Perthes’
disease
were
Of these cases twelve
were bilateral
and twenty-five

ninety-seven

have

been

followed

Of the
definitive
not adhered

ninety-seven
treatment.
to, the child

a follow-up
of four years or more,
forty-six
had received
either
by design
or because
treatment
once instituted
was
out-patients
not wearing
the prescribed
apparatus
within

three

shape

of the

dysplasia

was

taken

in which

Assessment-In
shape

to exclude
a Perthes’-like

the
was

review

then

an

compared

those

conditions

change
assessment
with

such

as

myxoedema,

and

multiple

epiphysial

occurs.
was
the

initial

made

of

the

radiographic

final

radiological
changes

state.
and

the

The

53 B, NO.

1, FEBRUARY

1971

final

radiological

course
of the disease.
When
weight-relieving
apparatus
had been used arthrographs
been performed
during
the disease.
It was therefore
possible
to evaluate
arthrography
aid in understanding
the natural
history
of the process.
VOL.

head.

months.
Care

head

final

or more

by most
authors
to these ninety-seven

hips with
This was
attending

the

four

is the time recognised
study will be confined

no

to assess
hips.

up for

years,
which
The present

had

often
as an

37

epiphysial the acetabulum. 2). loss of epiphysial contained The head The within is flattened infero-medial the and joint not space wide. Radiologically the head was THE. space was round. 1 -Good Figure result. 2-Fair no showed There is loss completely contained within of height. graded result was Radiologically Fio.A. A poor result was defined as one in which the hip might not be completely free from symptoms and always showed restriction of movement. changes The no well medial I FIG. 3 There is some completely Figure 3-Poor result. was not A fair increased. (‘ATTI 38 Tile according IlIlal state of’ patients symptoms to the following and had a full contained within the at tile end of which FIG. flattened. in which the head is well contained within the acetabulum. A good range of movement. acetabulum. There was always loss of epiphysial height. JOURNAL broad. RAIL. Some adaptive changes in the acetabulum were accepted provided the head was round. acetabulum. which “good”. up to one-fifth being uncovered. Radiologically the head was round but a little broadened and may not have been fully contained within the acetabulum. OF BONE AND irregular JOINT and SURGERY . especially medial rotation (Fig. (Fig. The head remains round but is not remains joint one 2 The head result. especially rotation. Figure was follow-up criteria. height. shows adaptive changes. result adaptive Some was one loss in of which “fair” or “poor” the hip caused was round and 1). epipilySial the hip height caused was accepted no symptoms provided but the movements head were a little restricted.

Healed. NO. I. Sundt in the It is useful FEBRUARY in 1971 by weight-relieving radiograph. Group 3). CASES that there a different hips Note only involved. 7 caliper. Figure 6-Nine months. forms they and of from group VOL. OF acetabulum and because it reflects were FIG. to the each indistinguishable. another fifteen impression running Individual age. In no case was there a change the course of the disease. 5 FIG. is essentially incidence HISTORY might be as many radiological therefore course allocated as four although to one of different clinically these groups other factors were analysed. Good result. The . I would emphasise the extreme importance distinguishing between the forms of Perthes’ disease. Figures cystic appearance the 4 and 5-After of epiphysis. 6 aged 8 Figure years. end-results. FIG. one high disease. joint two months Figure months that suggested 1-Child of limping. No sequestrum. OF PERTHES’ space. by Treatment 4-Antero-posterior 5-Lateral radiograph: anterior later healing well established. 53 B.THE NATURAL at least one-fifth widening This the uncovered of tile medial grading probable (Fig. sex and another describing quality during the details radiographs 1. changes (1949). Case There 39 DISEASE of osteoarthritis. of each group. Before of I gained study Perthes’ were the this in adaptive part of epiphysis Figure 7-After GROUPING Early were 4 FIG.

Figure lI-After another FIG. antero-posterior The radiographs lateral Group projection I-in this It differs segment from epiphysis has variety other occurs of is taken ill without a rather the the oniy groups both ill hips “frog” should be taken or Loewenstein part anterior tilat 110 collapse sequestrum cystic CATTERALL of I ormatioll. or a phase sequestrum. of the involved radiograph the Tile lateral radiograph 10 at onset 4l years. from the periphery. but absorption has involved the adjacent anterior metaphysis. feet pointing is involved (Figs. Figure 10-Seven months later healing established. appearance. but the In its epiphysis and occurs height with the position. Anterior involvement only. complete absorption tile alltero-posterior is maintained. epiphysis Good only result. Figure 9-Lateral radiograph. 12 involved collapsed antero-posterior AND JOINT SURGERY . Radiologically the course of the disease appears to be absorption of the involved segment followed by regeneration which occurs initially Group to 2-In this variety 19). rather more of the the major difference of absorption This anterior in the undergoes is absorbed part of the epiphysis course of the disease collapse before healing with the formation JOURNAL of a dense In the commences. the Healed. Case 2-Age twelve shows that the anterior part of months. Metaphysial changes are unusual in the early phases but later a large circumscribed reaction may appear. Radiologically segment after segment. 4 to 11). is abnormal. No treatment. Figures 8 and 9-After six months of intermittent limping. Note the cystic appearance of epiphysis. These metaphysial changes lie beneath the involved epiphysial segment.40 A. forwards. Diffuse metaphysial reaction. No sequestrum. No sequestrum. Figure 8-Antero-posterior radiograph. Group 1. THE is involved is that the OF BONE (Figs.

is usually this witil a veil defined cyst situated anteriorly. only radiograph a head” small fragment VOL.THE radiograph the sequestrum NATURAL appears HISTORY as a dense OF PERTHES’ oval mass 41 DISEASE with viable fragments on both medial and lateral sides. Case 3-Age at onset 41 years. variety antero-posterior medial appearing with with its associated growth and as lateral specks growth broadening sequestrated reveals the sequestrum of sides. appearance centrally neck. Good result. The head is contained within the acetabulum. On tue lateral radiograph the sequestrum is separated posteriorly from the viable fragments by a “V” which. segment producing 1971 of the epiphysis is not the early phases there is a collapsed during textured osteoporotic antero-lateral 53 B. 14 FIG. is characteristic of this group (Fig. If there is a metaphysial change. The lateral radiograph shows that only half the head is involved. plate (Figs. Figure 15-Six years later. Healed. 1 7). when present. 15 Group 2. with Frequently calcification. of a “head placed. the When displaced On lateral collapse the in an lateral . Group The 3-In within very this occurs while normal is small this in the and direction NO. I FIG. No treatment. The epiphysial height is maintained. of becomes the 20 to 23). a small 1. which is transitory aIld disappears ilealing. Figure 12-First radiograph: six months’ history of pain and limping. FEBRUARY part later phases segments on the osteoporotic. Figures 13 and 14-Eleven months later. The sequestrum is partly absorbed. When collapse occurs the viable fragments maintain epiphysial height. There is a large central sequestrum with small viable fragments.

THE JOURNAL OF BONE AND JOINT SURGERY . 3 metaphysial of the the growth plate and the roof of the epiphyses can occur a mushroom-like viable sequestrated (Figs. the radiographs As in Group epiphysis portion. Gage sign present. The junction of the sequestrum and tile viable segment is often the two blending in an area of sclerosis. 24 to 31). with remodelling. The osteoporotic segment may it regenerates in its displaced position. Sequestrum reabsorbed. Case 4-Age at onset 41 years. Figures 16 and 17-After six months of limping.42 A. 19 Group 2. Displacement posteriorly producing there posterior is no epiphysis. There is a small sequestrum embraced by a ‘V’ of viable epiphysis. CATTERALL radiograph it will be seen that only a very small portion of the posterior part uninvolved. epiphysis produces a dense line. irregular On linear the lateral opacity indicating but also radiograph replacing the be extensive. Metaphysial absorbed before the regeneration become apparent only at this stage changes are more generalised and when extensive of the begins are frequently associated with broadening neck. 18 FIG. I FIG. Group 4-In this antero-posterior an early flattening variety whole total loss of the height between of the head. The lateral radiograph shows that the anterior part of the epiphysis is involved. Treatment by weight-relieving caliper. in that the sequestrum once formed is gradually from the periphery. Figure 19Five and a half years later good result. the same as when 2. Figure 18-Eight months later. The course of the disease is essentially in Group of the not head is definable. Healing commenced. Cystic appearance of epiphysis and small central sequestrum. appearance there On the There is is now collapse being changes of the only may an of the acetabulum not only anteriorly head.

The prognosis varied with age (Fig. Lateral radiograph involves almost the whole epiphysis. Healed. As previously VOL. I. eleven fair and eight poor. onset 5 Of the forty-six untreated hips twenty-seven were graded good. 32). but over the age of five years there was a considerable reduction in the proportion of good results. Small shows that the sequestrum Figure 22-Fifteen months re-forming. Figures 20 of pain in groin. Case 5--Age at and 21-After two months small osteoporotic.NATURAL TI-Il HISTORY OF PERTHES’ 43 I)ISEASE RESULTS General-Before several the general patients of the observations. 21 FIG. This was ten and a half years with a scatter FIG. The calcified area is acetabulum. FIG. Lateral segment. Figure 23-Four and a half years later. The to make in eighty-nine average age from one year nine months to did not alter with age (Fig. of from eighteen to four years. Segmentum speck of calcification just lateral to epiphysis. 23 years. thirteen fair and eight poor. Poor result. Large sequestrum. Head very flattened but starting to heal. 53 B. NO. 20 FIG. Small posterior portion is viable. seen at diagnosis ten years. Twelve cases had a clear . 33). FEBRUARY the prognosis 1971 was worse in girls than boys. reported. Treatment by weight-relieving caliper. 22 3. groups all Considering cases of which are there eight compared were cases and a half years and the age distribution of boys to girls was four to one. later. whereas of the fifty-one treated hips thirty were good. The average results between was four The ratio follow-up individual 1950 and 1964. Fair and poor results were present at all ages. but outside the Group it is necessary hips ninety-seven were bilateral.

sling. Figure 31-Ten years on. by Snyder is small and flattened. Case 7-Age 30-Antero-posterior to epiphysis. 24 CATTERALL FIG. Two months is a large area of calcification I 30 FIG. Group 29 and lateral 2 years. Figure 26-Eight months later. FIG. Epiphysis almost completely absorbed. of limping.” The lateral radiograph shows that the whole epiphysis is involved. lying shows that the whole epiphysis is involved. Treatment by Snyder sling. 25 27 Group 4. Figures radiograph shows that the whole epiphysis is involved. The area of calcification is re-forming as part of epiphysis. There at risk. Result fair. With one year history of limp. THE JOURNAL OF BONE AND JOINT SURGERY . FIG. Case 6-Age at onset Figures 24 and 25-The epiphysis in lateral part of epiphysis. Figure 28-Seven years later. Healed. Healing well established.” Lateral radiograph FIG. Figure 27After another fifteen months. “Head 28 FIG. Result poor. No lateral subluxation of the head.44 A. 31 at onset 31 years. Healed. FIG. 29 4. Small area of calcification “Head at risk. Treatment 26 FIG.

1. bed It groups for girls who (1958). Within the prognosis for girls is approximately the same as for boys (Table IV). which corresponds This to previous are broken down The age distribution is in disagreement with Evans unilateral bilateral prognosis cases for is worse of VOL. This disease while group. the overall poor prognosis in girls. each rest group differently Although they were different why in some cases on series. of boys to girls in this series was The same as that for boys prognosis prognosis. 33 according to influence age to age. acute I and II.THE llistory of’ injury patients. the child an individual others explains in is already hip. Figure not poor poor in increase in the incidence of poor results. healing may be only fair the end-result may on the fact that most of them were is due to the fact that they are for in tell 3. age and different. the cases on the contralateral 53 B. (YEARS) distribution shown average 33). but FIG. the overall at onset is similar 4:1. It may be growth potential after healing of the disease. with regard to both heads belonged the two heads differed side developing hip. 33-Sex sex are both Although the seem to influence the outcome years (Table 111). NO. girls however. to hospital The as an GROUP General-The that the incidence the epiphysis Conventional did general results of a good is involved. to age. Figure reasons for treatment did the age of four assumed that Thus. preceding necessitating NATURAL the onset admission HISTORY of OF symptoms. When the results girls are to be found in Groups 3 and 4 (Table I). 34 to 39) did not behave from prognosis. in each in those cases whose symptoms began below age it does so in Groups 2 and 3. group. into in the older age the most part in Groups 3 and 4. the outlook for which is worse than the other groups. the results in Groups 1 and 4 cases. shown in Tables in direct proportion 2 and group. (Fig. Above this younger children have a greater the initial result at the time of 16 to 19). It will be seen to the extent to wllich AGE according was hip”. is however explained are symptoms 32 each this of (YEARS) 32-Results Age and sex-Within The onset RESULTS was a corresponding treatment did not alter of Groups 45 DISEASE “observation within the group are result steadily declines There AGE PERTHES’ for in some the and the result treatment . Bilateral cases-Within the groups bilateral cases (Figs. The ratio also confirms most of the the the groups. although be good (Figs. FEBRUARY 1971 the the prognosis for to the same accordingly. weight-relieving appear to influence those FIG.

Number Hips of bilateral age Average Sex . CATTERALL TABLE GENERAL Group .5 45 1:8 1:6 1:3 1:2 . . disease of injury OF . Group 4 years ____ ____ _____________ _____________ 4 Treated . (rears) . 31 31 22 13 8 4 . . 4 Untreated . . Group Over 4 years Good Fair Poor Good Fair Poor 5 0 0 9 1 0 4 0 0 10 1 0 1 0 5 3 1 1 0 9 2 1 4 1 0 2 2 1 3 1 3 2 1 1 0 0 0 0 4 0 1 3 0 2 2 I Treated . . 1 2 3 4 . 1 Treated Untreated 10 . of hips. RESULTS 3 . . Treated . Group2 5 - -- Treated .46 A._______ -_________________ IN RESULTS TABLE III AND BELOW ABOVE THE AGE OF FOUR YEARS Results Under Untreated. 0 3 Group Group4 Treated VARIATION ______. 1:8 1:10 1:8 1:4 16 15 10 5 15 16 12 8 . Group3 3 1 ----- Treated . 5 OF THE 4’S 1 4. . Untreated. THE JOURNAL OF BONE AND JOINT SURGERY . cases . . Untreated. Untreatedcases. I COMPARISON 11 TREATED OF AND UNTREATED CASES Results Fair Poor 15 1 0 14 1 0 Good . part ratio History Treated . TABLE COMPARISON GROUPS . Untreated. . Group2 Treated 4 ______________ - 12 3 1 1 6 3 6 2 0 4 3 5 Untreated . Untreated Group . 1 .

of any may show form of treatment. 41 When to 44). (Figs. definable. . . between 53 B. 2 1 1 4 10 3 1 2 2 0 2 5 I 1 1 2 . by arthrography. result cannot in epiphysial A hip while be height a round with but anticipated this by is frequently an arthrograph or spherical which head proceeds result. proceeds or good late had arthrograph by adaptive head to was an for When head stage shows either the cases revealed In the remainder the surface of the at this stage carried a poor prognosis and was only noticed to the measurements it was found that provided the vertical arthrograph showed the head to be round. controversial. it is “flattened” Nearly presence of flattening 3 and 4. 2 1 0 Males . contrast be established is Treatment to those being considered. the groups. Males . manifestations It is hoped act as the basis for such a comparison. DISCUSSION The treatment natural history the to be made paper must differ VOL. occurred. of Perthes’ disease remains of the disease in its various NO. FEBRUARY Although 1971 the total that Only allows the To justify correlated numbers are a clear understanding an accurate comparison classification such with small suggested a classification the sex incidence the trends are of in this the results and age. ACCORDING been performed during of the plain radiographs the growth plate and the epiphysis TABLE RESULTS 47 DISEASE (EW) and the treatment of the acetabulum findings cases at correlated with IV TO SEX WITHIN THE GROUPS Results Good Group Males . The head is termed “spherical” when of a sphere.THE Evaluation NATURAL HISTORY of arthrography-Satisfactory in fifty-nine measurements cases.. in presence the maintaining a round the of or shape severe of the flattening spherical is appearance. 27 1 0 Females . In relation was maintained the was not increased At a later measurement. the There is nearly flattening to a fair in cartilaginous unlikely This be cases is of rewarding distinction can a spherical articular surface a spherical or no round longer head head is of always value some changes forms in the part early in had part of a sphere phases and the in Groups height (EA) width (EW) but its reduction in the to a poor appearance acetabulum. were its widest point the arthrographic arthrographs During the routine made of the distance (EA) and the appearances OF PERTHES’ width (Fig. the some in only whereas flattening of the head head forms the greater spherical. 1. If the epiphysial compensated severe all Poor 1 Group it Fair need for treatment importance. 20 6 1 Females . had examination between of the 40). that the prognosis for untreated disease. 3 Group Females Males Group4 Females noted was that in many cases the arthrograph others the head was round but not spherical.

48 A. The right hip 36-Three years later. radiographs. Bilateral affection. Group 3 affection. The Case 8-Age left hip shows Figure 36 at onset 3 years. No treatment. THE Figures shows JOURNAL OF 34 and Group BONE 35-First I affection. (‘ATTERALL FIG. Good result. AND JOINT SURGERY .

hip by weight-relieving Right hip shows Figure 39-Fourteen . affection.. NO. Figures 37 and phase. left hip 3 affection I.. Left hip shows months later. Group result fair. 4 affection. 1) 53 B.THE NATURAL HISTORY FIG. sling. 3 years. Case by FEBRUARY Snyder in healing 1971 9-Age at onset OF PERTHES’ 49 DISEASE 2.. Final Treatment: 38-Initial right radiographs. Bilateral caliper: Group VOl.

Figure 41-Drawing to show disease the the suggestion depends on the 3 the results are Non-operative years Group in general treatment and only possibly 4 three-quarters fair. does over patients than one-third improve in children of less not have this a poor achieving this prognosis age (Table result. in children result below the III). 20 and 29). 16). and non-operative treatment not improve this in children above or below the critical age of four years (Table IV). 45 and 46) which have a poor result and cases in Groups 3 and 4 which have an unexpectedly good result. Principles of age. so face.50 The A. or both of the first two This may be measured 45). Gage’s sign-This is the small lateral side of the epiphysis. history results in children restrict are portion of part made years. appearances. caliper. in this group prudent inevitable hazards which an ofGroup 2 under the to offour age Ilatural where were it seems areas the both activity are unrestricted almost the age must conventional Perthes’ irrespective of eight a weight-relieving schoolboy years of untreated good over by on plain arthrographic of a sphere not the head. while non-operative treatment tilis 50 that three-quarters now have a good result (Table III). space (Fig. In considering these cases it is important to try to diagnose It is possible in advance to those recognise cases those in which hips. in which there was “V” on the and was high incidence of poor results. of four In does fair this those did not children improves based be improved over The 40 of treatment cannot overall involved. This will be apparent when the head starts to re-form. The in children reducing two In patients In (Table age shaded forming on this classification-The in Group results age 1 cases. considerable which were collapse considered “at of risk”. FIG. for Perthes’ disease I to Group 4 although These results confirm is not uniform but 41 FIG. weight-relieving treatment improve the final results. 24) or small (Figs. causing the end-result to be fair or more usually poor. Half over this age proceed to a fair or poor result. The “head at risk”-AIthough the results within the groups follow a general trend there are some cases in Group 2 (Figs. It may be large (Fig. CATTERALL chances of’ a good results are of Ponseti amount similar (1956) of the result steadily to those that the head decrease reported prognosis from Group by other authors. which are still good without treatment. the head may occur. Figure 40-Drawing to show measurements radiographs. the untreated considerably Group a good II). first described by Courtney There are four radiological signs of value:osteoporotic segment which forms a transradiant This sign is seen on the antero-posterior radiograph Gage (1933) (Fig. TIlE JOURNAL OF BONE AND JOINT SURGERY . At this stage this fragment is on the edge of the acetabulum and may not be subject to its remodelling influence. Lateral subluxation-The signs may be made as an increase in the worse overall prognosis if there is lateral infero-medial joint for an epiphysis with one subluxation of the head. It is in fact the anterior part of the viable lateral fragment. a Calc(flcation lateral to the epiphysis-If collapse is occurring a small area of calcification is often seen just lateral to the epiphysis.

years.TIlE NATURAL HISTORY FIG. plane of growth Large sequestrum. plate. 53 B. NO. Figure 44-A rtllrograph lateral Figure subluxation 45---Antero-posterior Lateral subluxation Figure 46-Lateral 1971 OF PERTIIES’ SI DISEASE 44 Figure 43-Arthrograph of flattened and horizontal radiograph. FEBRUARY of spherical head. “Head at risk. Age at head. lateral VOL.” The growth radiograph: Group 2 ‘V’ sign present. 42-Arthrograph I. is horizontal. segment. Figure Case I 0-Showing onset 5. Small plate . of head. of round head.

Journal of Bone and Joint Surgery. quoted by Harrison and Menon 1966) or by an osteotomy of the varus-derotation type (Axer 1965). Weight-relieving apparatus can only partially relieve stress from the hip. relief transmitting than produces a force a patten-ended marked through the caliper shortening. If this is accepted. imposed It does improve by a caliper tumble life. but The hip. 45 and 46). 4. L. this that both sex and are discussed. to relieve the hip of undue pressure. 8 and 24). Journal Disease. of “the that the head at risk” classification age at the time is suggested suggested by of diagnosis and may radiological in future act a study influence the signs described of final as a basis the early prognosis. THE JOURNAL OF BONE AND JOINT SURGERY . of Boiie 182. 47-B. REFERENCES AXER. Disease. has The the Snyder serious containment sling produces disadvantage of the head much better its prolonged that in abduction may weight use be achieved by either an abduction broomstick plaster (Parker 1929. The cases prognosis of Perthes’ varies with disease the are amount reviewed. C. (1958): Journal Treatment of Bone and Joint Surgery. It is pertinent to mention that one of the effects of is to produce this. A.52 A. The former may be achieved by abduction and medial rotation. by the remains produce radiological When fragment grounds it is apparent that the involved flattening of the head occurs it is this anterior that are extruded from the joint. 489. on the radiograph. CONCLUSIONS 1. Lloyd-Roberts for permission to study his cases and for his encouragement to do so. G. the line of the growth plate is transverse (Figs. J. Forces passing across would apply a shearing force to the horizontal plane. in the Treatment of Perthes’ Disease. C. (1958): Legg-Calvd-Perthes’ EVANS. CATTERALL The angle of the epiphysial antero-posterior in others this the hip joint of the lateral were inclined varus osteotomy Problems the the line-In in management-On epiphysis is anterior. D. to Mrs M. 168. Cases were allocated to four groups on this basis. and Joint and LLOYD-ROBERTS. (1965): Subtrochanteric Osteotomy EVANS. Trumble (1935) has shown that every time the patient takes a step the abductors contract. In summary. It is possible to assess the amount of epiphysial involvement radiographs. 3.. accustomed treatment In Group 1 the restriction to leading a rough and is only of doubtful value. second. and to Mr R. This shearing force would be much less if the growth plate to the horizontal plane. It is hoped of treatment. It is confirmed The reasons for The concept such cases. and the latter by bed rest or a weight-relieving apparatus. In the hips seems in Group protective remaining 2 in children to the older groups over boy non-operative this age. L. 40-B. This may segment of segment and be confirmed fact that medial rotation is the first movement to be limited while lateral full. Surgery. to diagnose for comparisons I am grateful to Mr G. in Legg-Calv#{235}-Perthes’ 40-B. my impression is that conventional non-operative treatment does not improve the natural history of Group I and Group 2 cases occurring in children below the age of four years. Eighty-nine 2. 5. of the epiphysis involved. while line is inclined to the horizontal plane (Figs. viable antero-lateral clinically rotation first to Groups 3 and 4 there are some cases in which. D. Whitley of the Institute of Orthopaedics for the preparation of the photographs and figures. encouraging displacement part of the epiphysis. Glen Haig of the Royal National Orthopaedic Hospital for the typing of the manuscript. it follows that the principle of treatment must be a concentric and congruous hip by containing this segment within the acetabulum and. 6.

V. (1935): Weight-bearing Instruments for Walking. O’GARRA. Journal of 1301. I. 1. P. 41-B. M. M. NATURAL HISTORY OF PERTHES’ H. Journal of Bone and Joint Surgery. PONSETI. 295. A. 739. (1956): Legg-Perthes Disease. SUNDT. (1959): The Radiographic Changes in Perthes’ Disease. J. Supplement 148. A. the Value Plaster 6. MURLEY. 384. H. G. I. C. V. 53 B. 38-A. 465. C. (1933): A Possible Early Sign of Perthes’ Disease. H. (1922): The Definite Form of the Coxa Plana. 1070. 261. H. M. Practice 48-A. of Roentgenographic Method. (1949): Further Investigations Respecting Malum Coxae Calv#{233}-Legg-Perthes with Special Regard to the Prognosis and Treatment. 43-A. British Journal M. TRUMBLE. and MENON. British Medical Journal. 1. with Special Reference 53 DISEASE to the Broomstick of Radiology. Ada Chfrurgica Scandinavica.THE GAGE. Journal of Bone and Joint Surgery. i. PONSETI. A. FEBRUARY 1971 . (1961): Legg-Calv#{233}-Perthes Disease-Pathogenesis and Evolution.. VOL. HARRISON. Journal of Bone and Joint Surgery. Acta Radiologica. (1966): Legg-Calv#{233}-Perthes’ Disease: Measurement Bone in Clinical and Joint Surgery. (1960): Personal communication. H. WALDENSTROM. NO.