Prevention of Legg-Calvé-Perthes disease.

Transphyseal Neck-Head Drilling.

Nuno Craveiro Lopes; Carolina Escalda and Carlo Villacreses.
Orthopedic and Traumatologic Department, Pediatric Orthopedic Unit,
Garcia de Orta Hospital, Almada, Portugal

It is known that multiple factors are involved in the pathogenesis of the disease and that a specific
sequence of chained events is necessary to trigger LCPD in a susceptible child. By the other hand, the
existence of several fractional and sequential ischemic episodes on the onset of Legg-Calvé-Perthes
(LCPD) is well documented.

Within this context, the reinforcement of the arterial blood flow and of the venous drainage of the
epiphyseal femoral head, independent from the reticular network, could constitute a way of avoiding the
repetition of ischemic episodes thus preventing the onset of LCPD. The idea of supplementing the unstable
epiphyseal blood flow trough the growth plate was attractive but controversial.

To determine the effects of neck-head drilling across the physeal growth plate, namely the possible
reinforcement of the epiphyseal blood flow and the repercussion on the growth of the proximal femur, we
have developed a experimental study. Forty-four, White New Zealand rabbits, aged between 6 and 12
weeks, were used. Drills from 2 to 3.5mm in diameter were used along with a specially made guide, in order
to minimize trauma.
There were 4 study groups:
Group I – 44 left hips. Not operated on, used as a control.
Group II – 30 right hips. Drilling of <10%. Single drilling with 2 and 2.5mm drills, using as an entry
point the trochanter crossing the neck-head growth plate thru the epiphysis. The perforated area ranged in
size from 6% to 10% of the total growth plate area, depending on the rabbit’s age.
Group III - 7 right hips. Drilling of >10%. Single drilling with 3 and 3.5mm drills, using the same
technique. The perforated area ranged in size from 12% to 20% of the total growth plate area.
Group IV – 7 right hips. Metaphyseal drilling. Single drilling with 2.5mm drills on the metaphyseal area
of the trochanter and neck of the femur, without reaching the growth plate.

We found that transphyseal neck-head drilling (TNHD) with the perforation of less than 10% of the
growth plate area didn’t interfere with the growth of the proximal femur and induces a marked increase of
epiphyseal micro-vascularisation, due to the formation of anastomosis between metaphyseal and
epiphyseal circulation.

We have been using TNHD for 30 years. We reviewed 205 TNHD procedures done in 96 cases of
ischemic disease of the growing hip (IDGH) and 117 cases of Legg-Calvé-Perthes disease (LCPD).

We consider indication for TNHD, a child over 5 years old presenting an ischemic episode on the MRI
or a Perthes lesion on the necrotic or early fragmentation stage.

TNHD is performed with image intensifier control, with a 5mm trephine (perforated area correspond
to less than 5% of the growth plate), over a wire guide centred on the ischemic or necrotic area. It is a low
risk, 10-minute procedure.
 From the 96 IDGH patients treated with TNHD, 55 have already reached the end of growth. None
have progressed to LCPD and no growth disturbances of the affected femur where observed.

Studies done with Gadolinium enhanced MRI, showed patent anastomosis between the metaphyseal
and epiphyseal circulations.

From a group of 20 IDGH patients not subjected to TNHD, 5 on stage III, all developed LCPD, and
from 15 on stage II, 3 developed LCPD.

10/1989

10/1989 – 6 years old 11/1989 – 6 years old 09/1993 – 10 years old 04/2002 – 19 years old
IDGH stage III One month after TNHD 4 years after TNHD 13 years after TNHD

Epidemiological data from the area of influence of our unit, comparing the incidence of LCPD before
and after the implementation of the IDGH detection protocol and LCPD prevention with TNHD, have
shown a decrease of LCPD cases from 8.5/100.000 to 1.8/100.000 per year, on the population less than 16
years of age.

IDGH Stage III Gadolinium enhanced MRI

7 months after TNHT Vascular anastomosis
metaphysis-epiphysis

We confirmed clinically what we have found experimentally: TNHD induces anastomosis of small
blood vessels between metaphysis and epiphysis, thus supplementing the epiphyseal unstable supply,
preventing new ischemic episodes on a IDGH patient and aborting the evolution to LCPD.