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      Therapeutics and Clinical Risk Management (submit here)

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      Role of Arthrodiastasis Using Hinged Monolateral External Fixator Without Soft Tissue Release in Advanced Stage of Legg–Calve–Perthes Disease


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          Presentation with the advanced stage of Legg–Calve–Perthes disease (LCPD) carries a poor prognosis, regardless of the treatment that the patient receives. The aims of this study are to assess the clinical and radiological outcomes of arthrodiastasis in advanced cases of LCPD using a hinged monolateral external fixator without soft tissue release and to raise safety issues regarding its low rate of complications.

          Patients and Methods

          Six patients with LCPD who were classified as lateral pillar types B and C and were operated on in our department were included in this retrospective study. Data collected from medical files and X-ray measurements were retrospectively reviewed.


          A total of six male patients were included in this analysis. The mean age at onset of symptoms was 8.5 years (range 7–10 years). The mean follow-up period was 46 months (range 40–50 months). Five cases were Herring C and one case was Herring B at presentation. The average distraction time was 8 days (range 7–9) and the average duration of external fixator application was 3.1 months (range 2.5–3.5 months). The range of motion of the hip in flexion, abduction and internal rotation were improved postoperatively. Pain score and limping were also improved. At the final follow-up, the mean sphericity deviation score was 10.6. The mean epiphyseal index was improved from 19.3% to 23.8%. In addition, the mean cervical index improved from 99.7% to 89.7% at the last follow-up. Femoral fractures, pin loosening, mechanical failure of the fixator, chondrodiastasis, and hip subluxation were not seen in this group of patients.


          Arthrodiastasis with a hinged monolateral external fixator without soft tissue release improved both the clinical and radiological outcomes in this group of patients.

          Most cited references30

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          The natural history of Legg-Calvé-Perthes disease.

          Two groups of patients who had Legg-Calvé-Perthes disease were studied. The first group of patients consisted of eighty-eight patients (ninety-nine affected hips) followed in three hospitals for an average of forty years. The second group consisted of sixty-eight patients (seventy-two affected hips), all of whose radiographs from the onset of disease to maturity were available and all of whom had been treated in one hospital. The patients in this second group were followed for an average of thirty years. Each hip in both study groups could be placed into one of five classes of deformity based on its radiographic appearance at maturity. Each class showed a characteristic pattern of involvement during the active stages of the disease and had a specific long-term clinical and radiographic course. The clinical and radiographic course of an involved hip subsequent to childhood was related to the type of congruency that existed between the femoral head and acetabulum. Three types of congruency were recognized: (1) spherical congruency (Class-I and II hips) - in hips in this category arthritis does not develop; (2) aspherical congruency (Class-III and IV hips) - mild to moderate arthritis develops in late adulthood in these hips; and (3) aspherical incongruency (Class-V hips) - severe arthritis develops before the age of fifty years in these hips.
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            Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome.

            The treatment of Legg-Calve-Perthes disease has been based on uncontrolled retrospective studies with relatively small numbers of patients. This large, controlled, prospective, multicenter study was designed to determine the effect of treatment and other risk factors on the outcome in patients with this disorder. We enrolled 438 patients with 451 affected hips in a prospective multicenter study in which each investigator applied the same treatment method to each of his or her patients. The five treatment groups consisted of no treatment, brace treatment, range-of-motion exercises, femoral osteotomy, and innominate osteotomy. All patients were between 6.0 and 12.0 years of age at the onset of the disease, and none had had prior treatment. Three hundred and forty-five hips in 337 patients were available for follow-up at skeletal maturity. All hips were classified with the modified lateral pillar classification and the system of Stulberg et al. There were no differences in outcome among the hips with no treatment, those treated with bracing, and those treated with range-of-motion therapy. There were also no differences between the hips treated with a femoral varus osteotomy and those treated with an innominate osteotomy. Treatment did not have a significant effect on children who had a chronologic age of 8.0 years or less or a skeletal age of 6.0 years or less at the onset of the disease. In the lateral pillar B group and B/C border group, the outcomes of surgical treatment were significantly better than those of nonoperative treatment in children over the age of 8.0 years at the onset of the disease (p < or = 0.05). Patients who were 8.0 years old or less at the onset of the disease in lateral pillar group B did equally well with nonoperative and operative treatment. Hips in lateral pillar group C had the least favorable outcomes, with no differences between the operative and nonoperative groups. The lateral pillar classification (p < 0.0001) and the age at the onset of the disease (p = 0.0001) were both strong prognostic factors. Female patients did significantly worse than male patients if they were over the age of 8.0 years at the onset of the disease (p = 0.004). The lateral pillar classification and age at the time of onset of the disease strongly correlate with outcome in patients with Legg-Calve-Perthes disease. Patients who are over the age of 8.0 years at the time of onset and have a hip in the lateral pillar B group or B/C border group have a better outcome with surgical treatment than they do with nonoperative treatment. Group-B hips in children who are less than 8.0 years of age at the time of onset have very favorable outcomes unrelated to treatment, whereas group-C hips in children of all ages frequently have poor outcomes, which also appear to be unrelated to treatment.
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              Validation of the numerical rating scale for pain intensity and unpleasantness in pediatric acute postoperative pain: sensitivity to change over time.

              This study evaluates the construct validity (including sensitivity to change) of the numerical rating scale (NRS) for pain intensity (I) and unpleasantness (U) and participant pain scale preferences in children/adolescents with acute postoperative pain. Eighty-three children aged 8 to 18 years (mean = 13.8, SD = 2.4) completed 3 pain scales including NRS, Verbal Rating Scale (VRS), and faces scales (Faces Pain Scale-Revised [FPS-R] and Facial Affective Scale [FAS], respectively) for pain intensity (I) and unpleasantness (U) 48 to 72 hours after major surgery, and the NRS, VRS and Functional Disability Index (FDI) 2 weeks after surgery. As predicted, the NRSI correlated highly with the VRSI and FPS-R and the NRSU correlated highly with the VRSU and FAS 48 to 72 hours after surgery. The FDI correlated moderately with the NRS at both time points. Scores on the NRSI and NRSU at 48 to 72 hours were significantly higher than at 2 weeks after surgery. Children found the faces scales the easiest to use while the VRS was liked the least and was the hardest to use. The NRS has adequate evidence of construct validity including sensitivity for both pain intensity and unpleasantness. This study further supports the validity of the NRS as a tool to measure both intensity and unpleasantness of acute pain in children. This article evaluates the construct validity including sensitivity of the Numerical Rating Scale for pain intensity and pain unpleasantness over time in children after major surgery. The NRS could be used by clinicians to assess these 2 different dimensions of children's pain experience in acute pain settings. Copyright © 2012 American Pain Society. Published by Elsevier Inc. All rights reserved.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                16 November 2020
                : 16
                : 1117-1124
                [1 ]Department of Special Surgery, School of Medicine, University of Jordan , Amman, Jordan
                [2 ]School of Medicine, University of Jordan , Amman, Jordan
                [3 ]Department of Health and Recreation, School of Physical Studies, University of Jordan , Amman, Jordan
                Author notes
                Correspondence: Omar Q Samarah School of Medicine, University of Jordan , Amman11942, JordanTel +962 6 5353 444/2451Fax +962 6 5353 338 Email o.samarah@ju.edu.jo
                Author information
                © 2020 Samarah et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                : 16 September 2020
                : 25 October 2020
                Page count
                Figures: 2, Tables: 6, References: 30, Pages: 8
                Original Research

                perthes disease,hip arthrodiastasis,external fixator,distraction,safety
                perthes disease, hip arthrodiastasis, external fixator, distraction, safety


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