Operative Versus Nonoperative Treatments for Legg-Calvé-Perthes Disease

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) is an idiopathic avascular necrosis of the femoral head primarily affecting children of ages 4 to 12 years. There is no clear consensus on nonoperative or operative treatment protocols for pediatric patients presenting with LCPD. This study uses meta-analysis and a binary logistic regression model to analyze the radiographic outcomes of these treatment modalities in pediatric patients. METHODS: Clinical studies describing patients undergoing either nonoperative or operative treatment of LCPD published from 1960 through 2010 were searched electronically and manually. Eligible studies consisted of (1) a minimum of 10 patients; (2) listed age at the time of diagnosis or treatment; (3) performed an initial severity assessment using the Herring or Catterall classification; (4) detailed the type of intervention; and (5) reassessment of radiographic outcome after a minimum of 1 year after treatment using the Mose or Stulberg classification. RESULTS: Twenty-three studies, 1232 patients, and 1266 hips met the inclusion criteria. Among patients younger than 6 years, operative and nonoperative treatments are equally as likely to results in a successful radiographic outcome odds ratio (OR)=1.071; P=0.828; 95% confidence interval (CI), 7.377-32.937. In patients older than 6 years, operative treatment is nearly twice as likely to result in a successful radiographic outcome (OR=1.754; P<0.0001; 95% CI, 1.299-2.370). For age at treatment less than 6 years, a patient treated with a pelvic rather than femoral procedure was approximately 5 times as likely to have a good radiographic outcome (χ=4.488; P=0.034; unadjusted OR=5.20; 95% CI, 1.021-26.471). Among patients ages 6 or older, pelvic procedures were equally as likely as femoral procedures to yield a successful radiographic outcome (χ=1.845; P=0.174; unadjusted OR=1.329; 95% CI, 0.881-2.004). Sex had no significant influence on radiographic outcome (OR=1.248; P=0.486; 95% CI, 0.670-2.325). CONCLUSIONS: This meta-analysis suggests that operative treatment is more likely to yield a spherical congruent femoral head than nonoperative methods among patients 6 years or older. Among patients younger than 6 years, operative and nonoperative methods have the same likelihood to yield a good outcome. Patients who were 6 years or older were treated operatively, and had the same likelihood of a good radiographic outcome regardless of treatment with femoral or pelvic procedures. Among patients younger than 6 years, pelvic procedures were more likely to result in a good radiographic outcome than femoral procedures. LEVEL OF EVIDENCE: Level IV meta-analysis.