CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 465, pp. 80–85
Resurfacing for Perthes Disease
An Alternative to Standard Hip Arthroplasty
Harold S. Boyd, MD*; Slif D. Ulrich, MD†; Thorsten M. Seyler, MD†;
German A. Marulanda, MD†; and Michael A. Mont, MD†
Metal-on-metal total hip resurfacing is an alternative to con-
ventional total hip arthroplasty with several reports describ-
ing the benefits of this procedure in young patients. We ret-
rospectively compared the clinical (including range-of-
motion and leg length restoration) and radiographic outcome
of resurfacing in young patients with Legg-Calvé-Perthes to
those of patients of a similar age treated with a standard total
hip arthroplasty. Eighteen patients (19 hip resurfacings) who
had a mean age of 33 years (range, 18–34 years) were fol-
lowed for a minimum of 26 months (mean, 51 months; range,
26–72 months). We used an anterolateral approach in four
hips and a posterior approach with a trochanteric advance-
ment in 15 hips. Eighteen of the 19 hips had Harris hip scores
greater than 80 points at final followup. All patients im-
proved range of motion while avoiding any clinically appar-
ent impingement. Leg length was gained in 16 hips where
preoperative measurements were available. The short-term
results of hip resurfacing for the treatment of Perthes disease
compare similarly to those found in the literature for stan-
dard total hip arthroplasty in young patients. The trochan-
teric advancement technique described may aid in treating
the deformed femoral anatomy.
Level of Evidence: Level IV, case series study. See the Guide-
lines for authors for a complete description of levels of evi-
dence.
Metal-on-metal total hip resurfacing has been offered as an
alternative to conventional total hip arthroplasty, espe-
cially in young patients. Although the procedure is similar
From *Willamette Orthopedic Group, Salem, OR; and †The Center for Joint
Preservation and Reconstruction, Rubin Institute for Advanced Orthopae-
dics, Sinai Hospital of Baltimore, Baltimore, MD.
One or more of the authors (MAM, HSB) have received funding from Wright
Medical Technology, Inc, Arlington, TN.
Each author certifies that his or her institution has approved the human
protocol for this investigation and that all investigations were conducted in
conformity with ethical principles of research.
Correspondence to: Michael A. Mont, MD, Rubin Institute for Advanced
Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue,
Baltimore, MD 21215. Phone: 410-601-8500; Fax: 410-601-8501; E-mail:
mmont@lifebridgehealth.org or rhondamont@aol.com.
DOI: 10.1097/BLO.0b013e318156bf76
80
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
© 2007 Lippincott Williams & Wilkins
on the acetabular side to a standard hip replacement, it is
bone-preserving on the femoral side, where the femoral
head is mostly preserved and reshaped to allow capping by
the resurfacing component. Multiple reports demonstrate
the short- and midterm benefits of this procedure in young
patients (mean age of < 50 years).1,4,15
Legg-Calvé-Perthes disease affects young patients
(typically between 4 and 8 years of age) and is character-
ized by the premature collapse of the femoral head due to
interruption of the blood supply.9 These patients are often
treated by various soft tissue and bony procedures to try to
gain containment of the femoral head. Some of these pa-
tients may be left with residual arthritis from the disease
itself, as well as from the treatment. The disease can lead
to various deformities of the proximal femur, including
coxa magna, where the head is abnormally enlarged; coxa
plana, where the head is truncated and there may be a short
neck; and various other deformities, such as coxa vara or
valga. Surgical treatment of this disease may include vari-
ous types of osteotomies involving both the acetabulum
and the proximal femur.22 Because of the deformities of
the proximal femur caused by the disease, the surgical
treatments or both, standard total hip replacements can be
difficult to perform.5,11 Standard total hip replacements
may require an ancillary osteotomy, which involves more
surgical time, blood loss, and resulting increased morbid-
ity.
With deformity of the proximal femur, performing a
resurfacing arthroplasty can be easier than a standard total
hip replacement because the deformity does not have to be
addressed. However, in other situations, such as coxa
plana, a standard resurfacing arthroplasty may be untenable
because the short neck would lead to impingement and
dislocation of the resurfacing femoral component. In these
cases, we have used resurfacing in combination with a
trochanteric advancement approach.
We asked whether total hip resurfacing would provide
equally satisfactory clinical scores, range of motion, and
limb length restoration compared to patients who had a
Number 465
December 2007
similar mean age (33 years) and followup (51 months)
treated with standard total hip replacements.
MATERIALS AND METHODS
We retrospectively reviewed 18 patients (19 hips) in whom
metal-on-metal total hip resurfacings were performed for arthri-
tis secondary to Legg-Calvé-Perthes disease from June 2001 to
April 2004. The patients were all part of the FDA multicenter
investigational device exemption IRB-approved study of the
Conserve威 Plus prosthesis (Wright Medical Technology, Inc,
Arlington, TN). The patients represented a cohort of 18 patients
taken from 656 resurfacings (3%) performed at two centers. In
this same period of time, 2404 standard total hip replacements
were performed with 65 of those hips (3%) in patients with
Perthes disease. The hospital records for all patients were re-
viewed, including data from preoperative studies, operative re-
ports, and postoperative visits. The patients included 10 men and
eight women with a mean age of 33 years (range, 18–54 years)
and a mean body mass index of 26.3 (range, 23–35). These
patients had undergone a mean of 2.7 procedures (range, 0–7) on
their hip for the earlier treatment of Perthes disease. Five patients
had a prior proximal femoral osteotomy, which presumably
would have made a standard hip replacement more difficult.
Four of these patients would have required an ancillary oste-
otomy to perform a standard THA. The patients were followed
clinically and radiographically for a minimum of 26 months
(mean, 51 months; range, 26–72 months). Each center had spe-
cific Institutional Review Board approval for the study.
The surgeries were performed by two of the authors (MAM,
HSB) through an anterolateral or posterior approach. Standard
instruments for the Conserve威 Plus hybrid metal-on-metal total
hip surface replacement prosthesis were used for all patients in
this study. The acetabular component is nearly hemispherical
with a sintered porous coating for cementless press-fit fixation.
The femoral component has a short metaphyseal stem to facili-
tate accurate component alignment. The stem comes in 10 sizes
and is cemented.
An anterolateral approach was used in four cases (Fig 1). In
these cases, there was no evidence of coxa plana and the patients
had a normal head-neck relationship. Because we anticipated no
problem in retaining length or with impingement, we did not
believe it necessary to do an ancillary osteotomy in these cases.
Fig 1A–B. (A) This preoperative an-
teroposterior radiograph of the left
hip of an 18-year-old man shows os-
teoarthritis secondary to Perthes
disease. (B) The patient’s postop-
erative radiograph shows the hip af-
ter metal-on-metal resurfacing using
the anterolateral approach. In this
case, there was no coxa brevis, and
no ancillary osteotomy was neces-
sary.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Total Hip Resurfacing in Perthes Disease 81
This approach included splitting of the tensor fascia latae muscle
and peeling the anterior 40% of the gluteus medius and minimus
muscles (modified Hardinge approach17). We observed no case
of intraoperative impingement after the components were placed
with range of motion assessed before wound closure.
A posterior approach and trochanteric slide were used in 15
cases,2 where there was coxa plana and a standard resurfacing
procedure would not have allowed enough length to avoid im-
pingement. The incision started 6 to 8 cm distal to the top of the
greater trochanter, continued along the center of the shaft, and
then angled posteriorly from the tip of the trochanter for about 4
to 6 cm. The tensor fascia latae muscle was divided, and then the
gluteus maximus muscle fibers were separated. The short exter-
nal rotator muscle fibers were divided and tagged for later reat-
tachment. The capsule was then incised posteriorly.
With Perthes disease, there is often overgrown bone around
the head and neck that grows out from the original cortex (coxa
magna).8,18 The trochanteric cut was performed in the substance
of the trochanter and then advanced underneath the vastus lat-
eralis. Fixation was achieved with two cables, one over the
greater trochanter and one through two drill holes through the
cortex for compression (Fig 2). In addition, for the first eight
hips, Dall-Miles™ clamps (Stryker, Mahwah, NJ) were used
around the trochanter for additional fixation (Fig 3). In all pro-
cedures, attention was directed to remove any excess tissue,
including redundant capsule that could produce impingement.
The technique ensured that the stem of the prosthesis did not exit
the femur and would be supported by the advanced greater tro-
chanteric bone. In two cases of severe coxa brevis, the stem did
exit the femur 2 to 4 mm. This was covered by the advanced
trochanteric bone and did not lead to further problems. In other
cases, the prosthesis was tilted 140° to 145° so it was directed
away from the lateral cortex. We observed no case of impinge-
ment found intraoperatively after placement of the components.
In both approaches, the capsule was fully excised and the hip
was dislocated. The acetabulum was reamed to accommodate the
acetabular component, and the cup was implanted in a press-fit
manner with undersizing by 1 mm without adjunctive fixation.
The pin shaft angle was measured with a goniometer to achieve
a target of 140° (± 5°). All femoral components were cemented.
The same postoperative management and rehabilitation meth-
ods were used for both approaches. Thromboembolic prophy-
laxis with subcutaneous heparin or enoxaparin was started on the
day of the operation and was continued for 14 consecutive days.
 Clinical Orthopaedics
82 Boyd et al and Related Research

Fig 2A–B. (A) This preoperative an-

teroposterior radiograph of a 37-
year-old man reveals coxa magna
on a short neck of the right hip sec-
ondary to Perthes disease. (B) His
postoperative radiograph shows the
hip after metal-on-metal resurfacing
using the posterior approach in com-
bination with a trochanteric ad-
vancement with fixation with two
cables necessary for the coxa
brevis.

On the first postoperative day, all patients were allowed to stand
and physical therapy, including strengthening exercises, was ini-
tiated. Patients were restricted to 50% weight bearing (with the
aid of a cane, crutch, or walker) until the sixth postoperative
week, at which time they were allowed to fully weightbear as
tolerated. Patients were encouraged to continue hip-strength-
ening exercises three times per week for life.
We (MAM, SDU, HB) clinically assessed patients preopera-
tively and postoperatively at 6 weeks, 6 months, 1 year, and
annually thereafter. Pain, function, and deformity were evaluated
using Harris hip scores.10 We clinically assessed range of mo-
tion. If patients complained of any lack of motion, further in-
vestigation was performed under fluoroscopic evaluation to as-
sess for impingement on range of motion. Both the mental com-
ponent summary and the physical summary of the Short Form-12
Health Survey21 (SF-12) was used before surgery and at each
postoperative clinical visit. Patients were assessed for any intra-
operative, postoperative, and final followup complications.
Radiographic evaluation was performed using standard an-
teroposterior and cross-table lateral radiographs. Preoperative
and postoperative limb length measurements were made using
anteroposterior radiographs including full-length views that in-
cluded the pelvis to the ankles with the patient standing on
blocks. Patients were asked to stand on blocks until they believed
that their limbs were of equal length. We then clinically assessed
pelvic tilt by determining if the anterior superior iliac spine and
posterior superior iliac spine lined up. Blocks were then adjusted
until these bony landmarks were aligned and then the full-length
radiographs were used to assess leg length differences. Differ-
ences related only to the hip were determined by the relationship
of a line marked underneath both inferior pubic rami to the lesser
trochanters. If the intersection was higher than the lesser tro-
chanter on the proximal femur, then that hip was judged shorter;
if lower on the proximal femur, then that hip was judged longer.
We (MAM, SDU, DM, HB) evaluated and classified acetabular
radiolucencies according to the zones of DeLee and Charnley.7
To assess radiolucencies at the bone interface of the femoral
component, six zones around the short stem were delineated. All
radiolucencies greater than 1 mm were recorded. In addition, the
stem-shaft angle, cup inclination angle, femoral neck-shaft
angle, and cup migration were recorded during each radiographic
evaluation. Changes in any of these parameters were made by
blinded review of sequential radiographs by three of us (TMS,
SDU, MAM). An assessment was made for progressive radio-
lucencies, cup inclination, and stem and neck shaft angles at final
followup using anteroposterior, lateral, and frog lateral views.
To assess how the results of these procedures compared to
standard total hip replacements performed in similarly aged pa-
tients (mean, 33 years) at a similar length of followup (mean, 51
months), the authors carried out a literature search of the data-
bases of the National Library of Medicine and EMBASE. Ar-
ticles published between 1980 and March 2007 concerning total
hip arthroplasty in young patients were identified and the out-
comes compared to the results of the present study (Table 1). The

Fig 3A–B. (A) This preoperative an-

teroposterior radiograph of a 46-
year-old man shows a flattened
femoral head on a short neck of his
right hip secondary to Perthes dis-
ease. (B) This postoperative radio-
graph shows the hip after metal-on-
metal resurfacing using the posterior
approach in combination with the
trochanteric advancement and with
Dall-Miles ™ clamps used for the
coxa brevis.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Number 465
December 2007 Total Hip Resurfacing in Perthes Disease 83

TABLE 1. Comparison Studies of Total Hip Arthroplasties in Young Patients

Number Age (years) Followup (months) Success
Author Year of Hips Mean (range) Mean (range) Rate (%)
Bizot et al4 2000 27 31 (18–44) 59 (24–156) 100
D’Antonio et al6 2002 349 53 36 98.8
Nich et al16 2003 50 41 (22–79) 51 98
Kawasaki et al12 2005 31 45 (21–57) 60 (3–817) 75
Kim et al13 2005 200 47 (26–55) 51 (26–72) 98
Mont et al15 2006 104 40 (18–64) 36 (24–60) 98
McCullough et al14 2006 42 21 (11–35) 51 94
Seyler at al19 2006 210 45 (21–75) 56 97
Current Study 2007 19 33 (18–34) 51 95

key words used in the search were “hip,” “arthritis,” “Perthes,”
“osteonecrosis,” “degenerative disease,” and “young patient.”
The initial search was refined with the addition of the keywords
“surgery,” “replacement,” and “arthroplasty.”
RESULTS
Eighteen of the 19 hips had a Harris hip score of a mini-
mum of 80 points. The mean preoperative Harris hip score
was 40 points (range, 16–68 points) compared to a mean
postoperative score of 84 points (range, 53–98 points). The
patient that had an unfavorable outcome (Harris hip score
of 53 points) occurred early in the learning curve for the
procedure and had loosening of the femoral component.
The patient is doing well with a Harris hip score greater
than 90 points after conversion to a standard hip arthro-
plasty. The mean SF-12 mental component summary score
was 45 points (range, 21–63 points) preoperatively, com-
pared to 47 points (range, 34–57 points) at final followup.
The physical component summary score had a mean of 24
points (range, 15–40 points) preoperatively compared to
42 points (range, 36–59 points) at final followup (Table 2).
The mean range of motion improved for all motions
measured. The mean flexion improved from an average of
103° (range, 70°–140°) to 124° (range, 115°–140°) at final
followup. Similarly, the ranges of motion of internal rota-
tion, external rotation, abduction, and adduction improved
from initial means of 4° (range, 0°–20°), 14° (range, −10°–
40°), 31° (range, 0°–50°), and 17° (range, 0°–35°), respec-
tively, to means at final followup of 14° (range, 5°–20°),
30° (range, 10°–45°), 50° (range, 30°–60°), and 26°
(range, 15°–35°), respectively. The flexion contracture im-
proved from an average of 14° (range, 0°–50°) preopera-
tively to an average of 1° (range, 0°–10°) postoperatively
(Table 3). No patient had clinically obvious bony or pros-
thetic impingement postoperatively. Four cases in which
there were complaints of decreased range of motion were
assessed by fluoroscopic evaluation but had no bony im-
pingement.
Patients had a short limb by a mean of 11.3 mm before
the procedure (range, 4–26 mm) for the 16 patients for
which we had these measurements. Postoperatively, the
mean shortening was 6.7 mm (range, 0–17 mm) for all
patients. All 16 of the patients for which preoperative mea-
surements were available had increases in length after the
procedure.
The mean postoperative neck-shaft angle was 133°
(range, 132°–165°) in the anteroposterior projection and
19° (range, 7°–35°) on lateral films. The stem-shaft angle
was similar, with a mean of 147° (range, 132°–164°) in the
anteroposterior view and 22° (range, 5°–34°) in the lateral
view. The mean cup inclination was 40° (range, 31°–53°).
There were no progressive radiolucencies around the stem
or around the acetabular component. In addition, there was
no cup or stem migration.

TABLE 3. Summary of Hip Range of Motion

TABLE 2. Summary of Harris Hip and Short
Form-12 Scores Preoperative Latest Followup
Mean Mean
Preoperative Latest Followup Motion (range) (range)
Rating Score Mean Score Mean
System (range) (range) Flexion 103° (70°–140°) 124° (115°–140°)
Abduction 31° (10°–55°) 50° (30°–60°)
Harris Hip Score 40 (16–68) 82 (53–98) Adduction 17° (15°–35°) 26° (25°–35°)
Short Form-12 Internal rotation 5° (−10°–20°) 14° (5°–20°)
Physical 24 (15–40) 42 (26–59) External rotation 15° (0°–40°) 31° (10°–45°)
Mental 45 (21–64) 48 (34–61) Flexion contracture 14° (0°–50°) 1° (0°–10°)

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

84 Boyd et al
One patient in the anterolateral approach group had a
loosening of the femoral component and was converted to
a standard total hip arthroplasty. In this patient the com-
ponent had been cemented proud (10 mm of cement
mantle) in an effort to increase limb length. At final fol-
lowup, this patient had a Harris hip score of 81 points,
mental SF-12 score of 58 points, physical SF-12 score of
52 points, and full range of motion. Two patients experi-
enced pain over an advanced greater trochanter associated
with the use of the Dall-Miles™ clamps. There was one
complication directly associated with the trochanteric ad-
vancement. The fixation of the trochanter failed and it was
necessary to surgically refix it. This patient subsequently
did well with a Harris hip score of 92 points at 4-year final
followup. There were no other perioperative complica-
tions.
The early clinical success rate of 95% (18 of 19) for this
procedure compared similarly to standard total hip re-
placements at similar followup of 51 months in young
patients with a similar mean age of 33 years (Table 1). In
eight studies compromising 1031 contemporarily per-
formed hips there was a combined success rate of 97%
(range by individual studies of 75–100%).
DISCUSSION
Treatment options for late stage Perthes hip disease in
adults remain controversial.20 In some cases, the only ap-
propriate treatment would be a standard total hip arthro-
plasty. This is usually viewed as the last choice because
patients with Perthes disease are generally young. In ad-
dition, the anatomy of the proximal femur and pelvis may
make a total hip arthroplasty procedure more difficult. We
asked whether total hip resurfacing would be a reasonable
option for Perthes disease patients with end-stage arthritis.
The study was limited by the relatively small patient
population of 19 hips and the short-term followup (mean,
51 months; range, 26–72 months). In addition, we did not
use a concurrent matching or control group of standard
total hip replacements. However, this is a relatively un-
common indication for hip replacement surgery (3%) in
our series, and there have been no studies specifically of
standard total hip replacement in this population. In most
studies of young patients, only a small percentage of the
patient population is represented by Perthes disease as was
found in the present series (approximately 3%).3,4 Never-
theless, the results we found (18 of 19 clinically and ra-
diographically successful) compare similarly to the results
of standard total hip replacements in young patient popu-
lations that were analyzed from a literature review (Table
1).4,6,12–16,19
Despite the anatomic abnormalities, resurfacing pro-
vided uniformly high functional ratings. Only one patient
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics
and Related Research
was converted to standard total hip arthroplasty after loos-
ening of the femoral component. In that patient the com-
ponent had been cemented proud in an effort to restore
limb length. The authors no longer use this technique as it
can lead to loosening and/or fracture.2 At present, no more
than a 2-mm cement mantle is used from the cup to the top
of the femur. We also stopped using Dall-Miles™ clamps
after two of the patients experienced pain over the ad-
vanced greater trochanter. Surface arthroplasty improved
Harris hip score, SF-12 physical and mental scores, and
range of motion in all patients. Radiographs revealed no
radiolucencies and no migration of the cup.
In some patients, the sequelae of Perthes disease or the
treatment leading to coxa plana can make a routine hip
resurfacing difficult or inappropriate. This is because of
the short neck, which in resurfacing would lead to im-
pingement, subluxation, or dislocation of the prosthesis.
Therefore, in these cases, a trochanteric advancement tech-
nique was utilized. In this technique, the greater trochanter
is advanced with the intention of restoring the femoral
neck head length and allowing the avoidance of femoral
head impingement. All 15 patients treated with this tech-
nique did well. The authors believe that when treating
Perthes disease, or any disorder with coxa plana or brevis,
surgeons who would like to perform resurfacing should
carefully evaluate if there is impingement after placement
of the resurfacing device. If this occurs, they should con-
sider the trochanteric advancement technique described
here or consider changing to a standard total hip replace-
ment.
The short-term clinical and radiographic results for
metal-on-metal hip resurfacing for the treatment of Perthes
disease were recently described by Amstutz et al.3 The
authors reviewed the clinical and radiographic results of
12 patients with a history of Perthes disease at a mean
followup of 4.7 years. Their results were similar to the
present study, with improvement in the physical SF-12
score from 32 points to 52.9 points and in flexion from
98.5° to 117.5° at final followup.
We found short-term success in this challenging young
patient population. At a mean followup of 51 months, 18
of 19 hips did well with this protocol. Although hip resur-
facing in combination with the trochanter advancement is
a technically difficult operation in these patients because
of a flattened head and short neck, the results to date are
encouraging. The trochanteric advancement described in
our study provided additional support for the deformed
anatomy of the hip. We believe this is a valid indication
for total hip resurfacing. In four of these patients, the
resurfacing was much less difficult than a standard total
hip arthroplasty, which would have required an ancillary
osteotomy. It remains to be seen whether this is a compa-
rable option in the other cases. The ongoing study of
Number 465
December 2007
metal-on-metal total hip resurfacing will eventually de-
scribe the long-term results, safety, and complications of
this procedure in this difficult-to-treat patient population.
However, based on these initial findings, we can recom-
mend metal-on-metal resurfacing and the trochanter ad-
vancement as reasonable options for patients with ad-
vanced stages of Perthes disease.
Acknowledgments
The authors thank Colleen Kazmarek and David Marker for their
assistance in the preparation of this manuscript.
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