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

OGarra

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

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

A. (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.
height.

1 -Good
Figure

result.
2-Fair

no

showed

There

is loss

completely

contained

within

of

height.

epiphysial

the acetabulum,

space

was

round.

was

not

A fair

increased.
result

adaptive

Some
was

one

loss
in

of

which

fair

or poor

the hip caused

was round
and
1).

(Fig.

changes

The

no
well

medial

FIG. 3
There is some
completely

Figure

3-Poor

result.

shows

adaptive

changes.

which

good,

in which
the head

is well contained
within the acetabulum.
The
head
remains
round
but
is not

remains

joint

one

The head
result.

acetabulum.

graded

result
was
Radiologically

Fio.

Figure

was

follow-up

criteria.
A good
range
of movement.

acetabulum,

RAIL.

loss of epiphysial

contained

The

head

The

within

is flattened

infero-medial

the

and
joint

not
space

wide.

epipilySial

the

hip

height

caused

was

accepted

no symptoms

provided

but

the

movements

head

were

a little restricted,
especially
medial
rotation
(Fig. 2). Radiologically
the head was round
but
a little broadened
and may not have been fully contained
within
the acetabulum,
up to one-fifth
being
uncovered.
Some
adaptive
changes
in the acetabulum
were accepted
provided
the head
was
round.
There
was
always
loss
of epiphysial
height.
A poor result
was defined
as one in
which
the hip might
not be completely
free from symptoms
and always
showed
restriction
of
movement,

especially

rotation.

Radiologically

the

head

was
THE.

flattened,

JOURNAL

broad,
OF

BONE

AND

irregular
JOINT

and
SURGERY

THE NATURAL
at

least

one-fifth

widening
This

the

uncovered

of tile

medial

grading

probable

(Fig.

joint

two

months

Figure
months

that

suggested

1-Child

of limping.

6
aged 8

Figure

years.

by

Treatment

4-Antero-posterior

5-Lateral
radiograph:
anterior
later healing
well established.

forms
they

and

of

from

group

VOL.

53 B,

NO.

sex and

another

describing

quality

during

the

details

radiographs

1,

changes

(1949).

Sundt

in the

It is useful

FEBRUARY

in
1971

by weight-relieving
radiograph.

OF

acetabulum

and

because

it reflects

were

FIG.

FIG.

caliper.

Figures

cystic

appearance

the

4 and

5-After

of epiphysis.

No sequestrum.
Figure 6-Nine
months.
Healed.
Good
result.

CASES

that

there

a different
hips

Note

only involved.
another
fifteen

impression

running

Individual

age,
to

the

each

indistinguishable.

one

high

disease,

end-results,

Before
of

I gained

study

Perthes

were

the

this

in

adaptive

part of epiphysis
Figure
7-After

GROUPING

Early

were

FIG.

I. Case

There

39

DISEASE

of osteoarthritis.

FIG.

Group

3).

OF PERTHES

space.

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.
In no case was there a change
the course
of the disease.
of each group,
I would
emphasise
the extreme
importance
distinguishing

between

the

forms

of

Perthes

disease.

The

40

A.

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.

appearance,

but

the
In

its

epiphysis

and

occurs

height

with the
position.

feet

pointing

is involved

(Figs.

complete
absorption
tile
alltero-posterior
is maintained.

forwards.
4 to

11).

of the involved
radiograph
the

Tile

lateral

radiograph

10
at onset 4l years.
No
treatment.
Figures
8 and 9-After
six months
of intermittent
limping.
Figure 8-Antero-posterior
radiograph.
Note the cystic appearance
of epiphysis.
No sequestrum.
Diffuse metaphysial
reaction.
Figure 9-Lateral
radiograph.
Anterior
involvement
only. No sequestrum,
but absorption
has involved
the adjacent
anterior
metaphysis.
Figure
10-Seven
months
later healing
established.
Figure
lI-After
another
FIG.

Group

1. Case

2-Age

twelve

shows

that

the

anterior

part

of

months.

the

Healed.

epiphysis

Good

only

result.

is abnormal.

Metaphysial

changes

are

unusual
in the early
phases
but later
a large
circumscribed
reaction
may appear.
These
metaphysial
changes
lie beneath
the involved
epiphysial
segment.
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).
Radiologically

segment

after

segment,

or

a phase
sequestrum.

from

the

periphery.

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

is involved
is that the

OF

BONE

(Figs.
12
involved
collapsed

antero-posterior
AND

JOINT

SURGERY

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.
When
collapse
occurs
the viable
fragments
maintain
epiphysial
height.
On
tue lateral
radiograph
the sequestrum
is separated
posteriorly
from
the viable
fragments
by
a V
which,
when present,
is characteristic
of this group
(Fig.
1 7). If there
is a metaphysial
change,

is usually

this

witil

a veil

defined

cyst

situated

anteriorly,

which

is transitory

aIld

disappears

ilealing.

FIG.
14
FIG.
15
Group
2. Case 3-Age
at onset 41 years.
No treatment.
Figure
12-First
radiograph:
six months
history
of pain and limping.
There is a large central
sequestrum
with small viable fragments.
The head
is contained
within the acetabulum.
Figures
13 and 14-Eleven
months
later. The sequestrum
is partly
absorbed.
The epiphysial
height is maintained.
The lateral radiograph
shows that only half the head
is involved.
Figure
15-Six
years later.
Healed.
Good result.

Group
The

3-In

within
very

this

occurs

while

normal
is small

this

in the
and

direction
NO.

a small

1, FEBRUARY

part

later

phases

segments

on the

osteoporotic,
segment
producing

1971

of the

epiphysis

is not

the early
phases
there is a collapsed

during

textured

osteoporotic

antero-lateral
53 B,

only
radiograph

a head
small

fragment

VOL.

variety

antero-posterior

medial

appearing
with
with

its

associated
growth

and

as

lateral

specks
growth

broadening

sequestrated

reveals
the
sequestrum
of

sides.

of

becomes
the

20 to 23).
of a head
placed,
with

Frequently

calcification.
plate

(Figs.

appearance
centrally

neck.

the
When

displaced
On

lateral
collapse

the

in an
lateral

42

A.

CATTERALL

radiograph
it will be seen that only a very small
portion
of the posterior
part
uninvolved.
The junction
of the sequestrum
and
tile
viable
segment
is often
the two blending
in an area of sclerosis.
The course
of the disease
is essentially
in Group

of the
not

head

is

definable,

the

same

as

when

2, in that the sequestrum

once formed
is gradually
from
the periphery.
The osteoporotic
segment
may
it regenerates
in its displaced
position.
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.

I
FIG.

18

FIG.

19

Group

2. Case 4-Age
at onset 41 years.
Treatment
by weight-relieving
caliper.
Figures
16
and 17-After
six months
of limping.
Cystic
appearance
of epiphysis
and small central
sequestrum.
Gage sign present.
The lateral
radiograph
shows that the anterior
part of the
epiphysis
is involved.
There
is a small
sequestrum
embraced
by a V of viable epiphysis.
Figure
18-Eight
months
later.
Sequestrum
reabsorbed.
Healing
commenced.
Figure
19Five and a half years later good result, with remodelling.

Group

4-In

this

antero-posterior
an early
flattening

variety

whole

total

loss of the height

between
of the head.
Displacement

posteriorly

producing

there

posterior

is no

epiphysis.

the

radiographs

As in Group

epiphysis

portion,

3 metaphysial

of the

the growth
plate and the roof
of the epiphyses
can occur

a mushroom-like
viable

sequestrated
(Figs.
24 to 31).
epiphysis
produces
a dense
line.

appearance
there

On the
There
is

is now

collapse

being

changes

of the
only
may

an

of the acetabulum
not only anteriorly

head.

irregular

On
linear

the

lateral

opacity

indicating
but also
radiograph

replacing

the

be extensive.
THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

NATURAL

TI-Il

HISTORY

OF PERTHES

43

I)ISEASE

RESULTS

General-Before
several

the

general

patients

of the

observations.

seen

at diagnosis
ten years.
The average

results

between

was four
The ratio
follow-up

individual

1950

and

1964,

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.
This
was ten and a half years with a scatter

FIG.

20

FIG. 22
3. Case 5--Age
at
and 21-After
two months
small osteoporotic.
Small
shows that the sequestrum
Figure 22-Fifteen
months
re-forming,
but outside
the

Group

it is necessary
hips

ninety-seven

were

bilateral.

The

to

make

in eighty-nine

average

age

from one year nine months

to
did not alter with age (Fig. 33).
of from eighteen
to four years.

FIG.

21

FIG. 23
years.
Treatment
by weight-relieving
caliper.
Figures
20
of pain in groin.
Large sequestrum.
Lateral
segment.
Segmentum
speck of calcification
just lateral to epiphysis.
Lateral
radiograph
involves
almost
the whole epiphysis.
Small posterior
portion
is viable.
later.
Head very flattened
but starting
to heal.
The calcified
area is
acetabulum.
Figure 23-Four
and a half years later.
Healed.
Poor
result.

onset

Of the forty-six
untreated
hips twenty-seven
were graded
good,
eleven
fair and eight
poor,
whereas
of the fifty-one
treated
hips thirty
were good,
thirteen
fair and eight
poor.
The prognosis
varied
with age (Fig. 32).
Fair and poor results
were present
at all ages, but
over the age of five years there was a considerable
reduction
in the proportion
of good results.
As previously
VOL.

53 B,

reported,
NO.

I,

FEBRUARY

the

prognosis

1971

was

worse

in girls

than

boys.

Twelve

cases

had

a clear

44

A.

FIG.

24

CATTERALL

FIG.

FIG.

25

27

Group
4. Case 6-Age
at onset
Figures
24 and 25-The
epiphysis
in lateral
part of epiphysis.
Head

28

FIG.

of limping.
lying
shows
that the whole epiphysis
is
involved.
Figure
26-Eight
months
later.
Epiphysis
almost
completely
absorbed.
Figure 27After
another
fifteen
months.
Healing
well established.
The area of calcification
is re-forming
as part of epiphysis.
No lateral subluxation
of the head.
Figure 28-Seven
years later.
Healed.
Result fair.

29
4. Case 7-Age
30-Antero-posterior
to epiphysis.
FIG.

Group
29 and
lateral

2 years.

Treatment

26

FIG.

by Snyder

is small
and flattened.
There
at risk.
Lateral
radiograph

FIG.

sling.

Two

months

is a large area of calcification

30

FIG.

31

at onset 31 years.
Treatment
by Snyder sling.
With one year history
of limp.
Figures
radiograph
shows that the whole epiphysis
is involved.
Small area of calcification
Head
at risk.
The lateral
radiograph
shows
that the whole epiphysis
is involved.
Figure 31-Ten
years on. Healed.
Result poor.
THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

THE

llistory

of injury

patients,

preceding

necessitating

NATURAL

the

onset

admission

HISTORY

of

OF

symptoms.

to hospital

The

as an

GROUP

General-The
that

the incidence

the epiphysis
Conventional
did

general
results
of a good

is involved.
weight-relieving

appear

to influence

those

FIG.

Figure

reasons

for

treatment
did
the age of four
assumed
that
Thus,
although
be good (Figs.
The ratio
also confirms
most of the

the
the

groups.

shown
in Tables
in direct
proportion

2 and

group,

age and

different.

33-Sex

sex are both

Although

the

seem to influence
the outcome
years
(Table
111). Above
this
younger
children
have a greater
the initial
result
at the time of
16 to 19).
of boys to girls in this series was

The

same

as that

for boys

prognosis
prognosis,

(Fig.

girls
however,

(YEARS)

distribution

shown

average

33).

33

according

to influence

age

to age.

the overall

at onset

is similar

4:1,

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.

the

cases

on

the

contralateral
53 B,

NO.

with

regard

to

both heads
belonged
the two heads
differed
side

developing
hip.

1, FEBRUARY

1971

the

the

prognosis

for

to the same
accordingly.

group,
This

disease

while

group,

the

child

an

individual

others
explains
in

is already

hip.

bed

It

groups
for girls
who

(1958),

each

rest

group

differently

Although

they were different

why in some cases
on

series.
into

in the older
age
the most
part in

Groups
3 and 4, the outlook
for which
is worse
than the other
groups.
Within
the prognosis
for girls is approximately
the same as for boys (Table
IV).
Bilateral
cases-Within
the groups
bilateral
cases (Figs.
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. It may be
growth
potential
after healing
of the disease.
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.

Figure

not

poor
poor

in

increase
in the incidence
of poor results.
the results
in Groups
1 and 4 cases, but

FIG.
to age.

acute

I and II.
It will be seen
to the extent
to wllich

AGE

according

was

hip.

the overall
poor prognosis
in girls.
When the results
girls are to be found
in Groups
3 and 4 (Table
I).

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

46

A.

CATTERALL
TABLE

GENERAL

Group

Number
Hips

of bilateral

age

Average
Sex

of hips.
part

ratio

History

Treated

31

31

22

13

,
,

Untreatedcases.

cases

OF

THE

4S

1
4.5

45

1:8

1:6

1:3

1:2

1:8

1:10

1:8

1:4

16

15

10

15

16

12

RESULTS

TABLE
COMPARISON

GROUPS

disease

of injury

OF

(rears)

COMPARISON

11
TREATED

OF

AND

UNTREATED

CASES

Results
Fair

Poor

15

14

Good

,
,

Untreated
Group

Treated
Untreated

10

Group2
Treated

______________

12

Untreated

Treated

Untreated

Group

Group4

Treated

VARIATION

______- _______

-_________________

IN

RESULTS

TABLE

III

AND

BELOW

ABOVE

THE

AGE

OF

FOUR

YEARS

Results

Under

Untreated.

Group

Over

4 years

Good

Fair

Poor

Good

Fair

Poor

10

I
Treated

Untreated.
Group2

5
-

--

Treated

Untreated.
Group3

3
1

-----

Treated

Untreated.
Group

4 years

____
____

_____________
_____________

4
Treated

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

THE

Evaluation

NATURAL

HISTORY

of arthrography-Satisfactory

in fifty-nine
measurements

cases.
were

its widest
point
the arthrographic

arthrographs

During
the routine
made
of the distance

(EA)
and the
appearances

OF PERTHES

width
(Fig.

had

examination
between

of the
40).

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

27

Females

Males

20

Females

10

,,
,

Males

Group

Females
Males
Group4

Females

noted

was

that

in many

cases

the

arthrograph

others
the head
was round
but not spherical.
occurred.
The head is termed
spherical
when
of a sphere.
(Figs.

41

When
to

44).

it is flattened

Nearly

presence
of flattening
3 and 4. 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.
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.

the
some
in

only

whereas

flattening
of the head
head forms
the greater

spherical.

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.
If the epiphysial

compensated
severe

all

Poor

Group

it

Fair

need

for

treatment

importance.
contrast

be established

is

Treatment
to

those

being

considered,

in

presence

the

maintaining

a round

the
of

or

shape

severe

of

the

flattening

spherical

is

appearance.

by arthrography.

DISCUSSION

The treatment
natural
history

the
to

be made

paper
must
differ
VOL.

of any

may
show

form

of treatment.

controversial.
manifestations

It is hoped

act as the basis for such a comparison.

that the prognosis
for untreated
disease,

between
53 B,

of Perthes
disease
remains
of the disease
in its various

NO.

the

groups.

1, 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,

definable.

48

A.

(ATTERALL

FIG.

Bilateral
affection.
radiographs.
The

Case 8-Age
left hip shows
Figure

36

at onset 3 years.
No treatment.
Group
3 affection.
The right hip
36-Three
years later.
Good result.

THE

Figures

shows

JOURNAL

OF

34 and

Group

BONE

35-First
I affection.

AND

JOINT

SURGERY

THE

NATURAL

HISTORY

FIG.
Bilateral
caliper:
Group

VOl..

1)

53 B,

NO.

affection.
left hip
3 affection

I,

Case
by

FEBRUARY

Snyder
in healing

1971

9-Age

at onset

OF PERTHES

49

DISEASE

2...

3 years.

sling.
Figures
37 and
phase.
Left hip shows
months
later.
Final

Treatment:

38-Initial

right

radiographs.
4 affection.

Group
result
fair.

hip

by

weight-relieving

Right
hip shows
Figure
39-Fourteen

50
The

A. 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.
for Perthes
disease

I to Group

4 although

These
results
confirm
is not uniform
but

41

FIG.

appearances.
FIG.

Principles
of age.

The

in children
reducing

two

In patients

In

(Table
age

shaded
forming

on this classification-The
in Group

results
age

1 cases,

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.

history

results

in children

restrict

are portion

of

part

made

years.

caliper,

so

face.

weight-relieving

treatment

improve
the final results,
which
are still good without
treatment.
Half
over this age proceed
to a fair or poor result,
while non-operative
treatment
tilis
50 that
three-quarters
now have a good result
(Table
III).

the untreated
considerably

Group

a good

II).
of four
In

does

fair
this

those

did not
children
improves

based

be improved
over

The

40

of treatment
cannot

overall

involved.

Figure 40-Drawing
to show
measurements
radiographs.
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).

and

non-operative

treatment

not

improve
this in children
above
or below
the critical
age of four years (Table
IV).
The head at risk-AIthough
the results
within
the groups
follow
a general
trend
there are
some
cases
in Group
2 (Figs.
45 and 46) which
have
a poor
result
and cases
in Groups
3 and 4
which
have an unexpectedly
good
result.
In considering
these
cases
it is important
to try
to diagnose
It is possible

in advance
to

those

recognise

cases

those

in which

hips,

considerable

which

were

collapse

considered

at

of
risk,

the

head

may

occur.

in which

there

was

on the
and was

high incidence
of poor results.
Gages
sign-This
is the small
lateral
side of the epiphysis.
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.
16).

Calc(flcation
lateral
to the epiphysis-If
collapse
is occurring
a small
area of calcification
is
often
seen just lateral
to the epiphysis.
It may be large (Fig. 24) or small (Figs.
20 and 29).
It is in fact the anterior
part of the viable
lateral
fragment.
This will be apparent
when
the
head starts
to re-form.
At this stage this fragment
is on the edge of the acetabulum
and may
not be subject
to its remodelling
influence,
causing
the end-result
to be fair or more usually
poor.
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.
space

(Fig.

or both of the first two

This may be measured

45).
TIlE

JOURNAL

OF BONE

AND

JOINT

SURGERY

TIlE

NATURAL

HISTORY

FIG.

Figure

Case

I 0-Showing

onset

5. years.

lateral

VOL.

53 B, NO.

42-Arthrograph

I,

segment.
is horizontal.

FEBRUARY

of spherical
head.
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.

of round

head.

plate.

Age at

head.

plane

of growth
Large

sequestrum.

of head.
Head
at risk.
The growth
radiograph:
Group
2 V sign present.

Small

plate

52

A. 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.
viable
antero-lateral

clinically
rotation
first to

Groups

3 and

4 there

are

some

cases

in which,

on

the

radiograph,
the line of the growth
plate is transverse
(Figs.
45 and 46), while
line is inclined
to the horizontal
plane
(Figs.
8 and 24).
Forces
passing
across
would
apply
a shearing
force to the horizontal
plane,
encouraging
displacement
part of the epiphysis.
This shearing
force would
be much less if the growth
plate
to the horizontal
plane.
It is pertinent
to mention
that one of the effects
of
is to produce
this.

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.
This may

segment

of

segment
and
be confirmed

fact that medial

rotation
is the first movement
to be limited
while
lateral
full.
If this is accepted,
it follows
that the principle
of treatment
must
be
a concentric
and congruous
hip by containing
this
segment
within
the

acetabulum
and, second,
to relieve
the hip of undue
pressure.
The former
may be achieved
by abduction
and
medial
rotation,
and
the
latter
by bed
rest
or a weight-relieving
apparatus.
Weight-relieving
apparatus
can
only
partially
relieve
stress
from
the
hip.
Trumble
(1935)
has
shown
that
every
time
the
patient
takes
a step
the
abductors
contract,
relief

transmitting
than

produces

a force

a patten-ended
marked

through

the

caliper

shortening.

but

The

hip.

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, quoted
by Harrison
and Menon
1966)
or by an osteotomy
of the varus-derotation
type (Axer
1965).
In summary,
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.
imposed

It does improve
by a caliper

tumble

life.

In the

hips
seems

in Group
protective

remaining

2 in children
to the older

groups

over
boy

non-operative

this age.
accustomed

treatment

In Group
1 the restriction
to leading
a rough
and

is only

of doubtful

value.

CONCLUSIONS

1.

Eighty-nine

2.

The

cases

prognosis

of Perthes

varies

with

disease
the

are

amount

reviewed.

of the

epiphysis

involved.

3. It is possible
to assess
the amount
of epiphysial
involvement
radiographs.
Cases
were allocated
to four groups
on this basis.
4. It is confirmed
The reasons
for
The concept
such cases.
6. It is hoped
of treatment.
5.

this

that both sex and

are discussed.

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.
to diagnose

for

comparisons

I am grateful to Mr G. C. Lloyd-Roberts
for permission
to study his cases and for his encouragement
to do so;
to Mrs M. Glen Haig of the Royal National
Orthopaedic
Hospital
for the typing of the manuscript, and to
Mr R. J. Whitley
of the Institute
of Orthopaedics
for the preparation
of the photographs
and figures.

REFERENCES
AXER,

A. (1965):

Subtrochanteric

Osteotomy

EVANS,

47-B, 489.
D. L. (1958):
Legg-Calvd-Perthes

EVANS,

D.

in

the Treatment

of Perthes

Disease.

Journal

of Bone

and

Joint

Surgery,

L.,

and Joint

and

LLOYD-ROBERTS,

Surgery,

40-B,

Disease.
G. C. (1958):

Journal

Treatment

of

Bone

and Joint

Surgery,

in Legg-Calv#{235}-Perthes

40-B,

168.
Journal

Disease.

of Boiie

182.
THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

THE
GAGE,
HARRISON,

NATURAL

HISTORY

OF

PERTHES

H. C. (1933):
A Possible
Early
Sign of Perthes
Disease.
British
Journal
M. H. M., and MENON,
M. P. A. (1966): Legg-Calv#{233}-Perthes
Disease:

Measurement
Bone

in Clinical

and Joint

Surgery,

Practice
48-A,

with Special

Reference

53

DISEASE

to the Broomstick

of Radiology,

the

Value

Plaster

6, 295.
of Roentgenographic

Method.

Journal

of

1301.

A. M. G. (1960):
Personal
communication.
J. A. (1959):
The Radiographic
Changes
in Perthes
Disease.
Journal
of Bone and Joint
Surgery,
41-B, 465.
PONSETI,
I. V. (1956):
Legg-Perthes
Disease. Journal of Bone and Joint Surgery,
38-A, 739.
PONSETI,
I. V. (1961):
Legg-Calv#{233}-Perthes
Disease-Pathogenesis
and Evolution.
Journal
of Bone and Joint
Surgery,
43-A, 261.
SUNDT,
H. (1949): Further
Investigations
Respecting
Malum Coxae Calv#{233}-Legg-Perthes with Special
Regard
to the Prognosis
and Treatment.
Ada Chfrurgica
Scandinavica.
Supplement
148.
TRUMBLE,
H. C. (1935):
Weight-bearing
Instruments
for Walking.
British
Medical
Journal,
i, 1070.
WALDENSTROM,
H. (1922): The Definite
Form of the Coxa Plana. Acta Radiologica,
1, 384.
MURLEY,

OGARRA,

VOL.

53 B,

NO.

1,

FEBRUARY

1971