Abstract
Dear Editors,
We have read the letter by Professor Ghanem and appreciate the interest shown in the article entitled: “Varus-producing osteotomy for patients with lateral pillar type B and C Legg-Calvé-Perthes disease followed to skeletal maturity”; we are grateful for the insight provided.
It is true that there are numerous preoperative variables that must be taken into account when deciding on a particular treatment, and in the case of patients with Legg-Calvé-Perthes disease the range of motion, presence of hinge abduction, extrusion or subluxation are very important factors to be considered. We reviewed a large series of patients who were very similar both demographically and clinically; range of motion was similar preoperatively in both groups with abduction averaging 43.3° for the patients undergoing a varus osteotomy and 41.4° for the group undergoing physical therapy; the percentage of patients with extrusion or subluxation was similar in both groups, and none of our patients had documented hinge abduction.
In our review, we only included the lateral pillar involvement as this system carries the best interobserver reliability of all current classification methods.
In the question of deciding not to operate on patients with type C lateral pillar involvement, it was deemed that surgery would have an insignificant or negative influence on the outcome in these patients; however, this does represent the changing philosophy at our institutions.
We do no attempt to be pragmatic in stating that no patients should undergo surgical treatment; in fact, our conclusion is that no statistical difference could be found between the two groups, but it may well be the case that the patients who underwent a varus osteotomy would have presented a worse outcome had they only undergone physical therapy. Our current stance is to perform containment treatment in patients over 6 years of age with type-B lateral pillar involvement.
We believe that our position may not differ significantly from that of Professor Ghanem as we do believe that when faced with a patient of these characteristics, one must individualise the treatment based on the best available evidence.
We would like to congratulate Professor Ghanem on his interest and having analysed our results in depth. We hope that this kind of discussion on such a controversial topic will enhance our understanding and ultimately improve the care of patients with the disease.
Sincerely,
Pablo Castañeda, MD; Richard Haynes, MD; Jorge Mijares, MD; Héctor Quevedo, MD, and Nelson Cassis, MD.