LCPD SUPPLEMENT
The Role of Valgus Osteotomy in LCPD
In Ho Choi, MD, Won Joon Yoo, MD, Tae-Joon Cho, MD, and Hyuk Ju Moon, MD
Abstract: When the hip is noncontainable due to established
hinge abduction, restoration of joint congruity and/or acet-
abular volume should be the primary goal of treatment. Various
salvage procedures have been attempted for the management of
noncontainable hips, but no long-term follow-up data have been
reported. A valgus osteotomy, which permits realignment of the
leg with the hip in the “best fit” position in neutral weight-
bearing position, has been most commonly applied to restore
joint congruity and to reduce femoroacetabular impingement.
Evidence continues to accumulate, indicating that valgus
osteotomy, when combined with or without other salvage
procedures, can result in sustained improvement of symptoms
and function, and beneficially influences remodeling of the hip in
a subgroup of children with hinge abduction.
Key Words: Perthes’ disease, valgus osteotomy, hinge abduction
(J Pediatr Orthop 2011;31:S217–S222)
I n children with severely involved Legg-Calvé-Perthes
disease (LCPD), abnormal painful hinge movement, so-
called “hinge abduction,” may occur during both the
early and late stages of the disease.1 This phenomenon is
thought to be due to impingement of the protruded
epiphyseal segment of the deformed femoral head,
abutting against and hinging on the superior lip of the
acetabulum.1,2–6 Hinge abduction seems to be a complex
manifestation of the hinge movement occurring in the
continuum between lateral and anterior impingement.6 If
hinge abduction is fixed, abnormal hinge movement
results in progressive subluxation, collapse of the lateral
pillar, and widening of the femoral head.1,3–6 When the
patient presents late with established hinge abduction,
pain, restricted hip motion, gait disturbance, and an
unpleasant clunking sensation are frequent on examina-
tion.3 Patients may present with abnormal gait in the
transverse plane, that is, out-toeing and in-toeing gaits.7
From the Seoul National University Children’s Hospital, Seoul, Korea.
No benefits in any form have been received or will be received from any
commercial party related directly or indirectly to the subject of this
article.
This investigation was conducted in the Department of Orthopedic
Surgery, Seoul National University Children’s Hospital.
This article is exclusively for LCPD supplement (“Centennial of Legg-
Calvé-Perthes disease”).
The authors declare no conflict of interest.
Reprints: In Ho Choi, MD, Division of Pediatric Orthopaedics, Seoul
National University Children’s Hospital, 101 Daekak-ro,
Jongno-gu, Seoul 110-744, Korea. E-mail: inhoc@snu.ac.kr.
Copyright r 2011 by Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 31, Number 2 Supplement, September 2011
It is the intention of this study to provide the treatment
guidelines for noncontainable LCPD hips, focusing on
valgus osteotomy for the treatment of hinge abduction.
TREATMENT GUIDELINES FOR
NONCONTAINABLE LCPD HIP
Figure 1 illustrates the investigator’s algorithmic
treatment approach to hinge abduction. The first step
is to determine whether the subluxated hip showing
abnormal hinge movement is “reducible” or “irreducible”
using dynamic arthrography under general anesthesia.
The degree of reducibility can be determined by the
position of the femoral head within the acetabulum in
abduction without imposing undue pressure on the lateral
edge of the acetabulum.8,9 Aggressive soft tissue release
(adductor tenotomy, psoas tenotomy, and medial joint
capsular release, if necessary), followed by traction and/or
abduction casting is indicated for the hip with “reducible”
hinge abduction, which is usually found in the transi-
tional stage. If follow-up arthrograms demonstrate stable
movement of the femoral head within the acetabulum,
continued hip motion exercises and a bracing program
may be implemented. However, we had little experience
of such instance. In contrast, when the hip remains
unstable due to previously extruded epiphyseal segment
of the femoral head, that is, containable in abduction, but
subluxatable in adduction, containment surgery (eg, a
femoral varus osteotomy,1,10 double-level osteotomy,11,12
triple innominate osteotomy,13,14 and shelf acetabulo-
plasty8,9,15) should be contemplated, taking into con-
sideration the age, the neck-shaft angle, and the extent of
uncoverage of the femoral head.
When the child presents in more advanced stages,
that is, in late reossification or healed stages with
established hinge abduction, the enlarged, crushed
femoral head may remain “irreducible.” In this situation,
the surgical treatment modality should be changed from
one that depends on remodeling by “containment” of the
femoral head to one that improves joint “congruity” and/
or acetabular volume. A variety of surgical techniques
have been addressed for the management of noncontain-
able LCPD hips, including a proximal femoral valgus
osteotomy,2,3,6,16 shelf acetabuloplasty,8,15,17 Chiari
osteotomy,18–20 hip joint distraction,21,22 osteochondro-
plasty,23 femoral head reshaping procedure,24 and com-
binations of these procedures, although no long-term
follow-up data have been published. Moreover, the
optimum indications of each surgical technique are
controversial. Our position on articulated hip joint
distraction is that this treatment should be used very
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Choi et al
Hinge abduction
check stage & reducibility
STR
‘Reducible’ ‘Irreducible’
Petrie cast check congruity in adduction
check stability
‘Improve’ ‘No improve’
check coverage check irregularity
‘stable’ ‘unstable’
& stability & maturity
PT & Containment by
Stiff (+)
Bracing • FVO Hip distraction
• TIO
• Shelf • Valgus osteot. • Chiari osteotomy
• Double-level +/- TIO, Shelf, • Osteochondroplasty
osteotomy Chiari osteot.(?) +/- Valgus osteotomy
• Head reshaping(?)
FIGURE 1. The author’s algorithm of treatment for noncontain-
able Legg-Calvé-Perthes disease hips (see text). STR indicates
soft tissue release; FVO, proximal femoral varus osteotomy; PT,
physiotherapy; TIO, triple innominate osteotomy.
selectively for noncontainable, severely subluxated hips in
adolescents or young adults in whom other conventional
methods have proven to be insufficient and the hip
remains stiff after adductor and psoas tenotomy (Fig. 2).
Shelf acetabuloplasty is known to be effective for
remodeling of hips with “reducible subluxation” during
the early stage of LCPD in older children, usually over 7
years.8,9,15 For this reason, there is a view that shelf
acetabuloplasty is a primary method of containment.
However, shelf acetabuloplasty, if performed in the
noncontainable hips with “irreducible” hinge abduction,
should be considered as a salvage procedure to cover
enlarged femoral head. In this situation, shelf acetabulo-
plasty would not reduce lateral impingement of the
femoral head in abduction. “Coxa irregularis” is fre-
quently found in adolescent Perthes’ disease, in which
segmental collapse or destructive patterns are often
observed without radiologic evidence of revasularization
and remodeling.25 It is generally agreed that Chiari
osteotomy is effective for the treatment of a painful,
subluxated hip with “coxa irregularis”.18–20 We, however,
think that a Chiari osteotomy should be considered as
one of the last resort salvage procedures. It is because a
Chiari osteotomy does not necessarily improve lateral
impingement in abduction and may exacerbate any
existing abductor weakness, although there is theoretical
advantage of Chiari osteotomy over shelf acetabulolasty;
Chiari osteotomy enables medialization of the hip with a
resultant reduction of the load. When “coxa irregularis”
is associated with a saddle-shaped epiphysis, it is our
experience that a Ganz osteochondroplasty of the femoral
head and a valgus osteotomy by surgical dislocation
seem to be effective for pain relief and restoration of hip
motion in adolescents or young adults with hinge
abduction.25 We have no experience of the femoral
head-reshaping procedure.
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J Pediatr Orthop  Volume 31, Number 2 Supplement, September 2011
PROXIMAL FEMORAL VALGUS OSTEOTOMY
If the femoral head and acetabulum become
congruent when the joint is adducted, but remain
incongruent in a neutral or abducted position, a valgus
osteotomy is preferred for restoration of joint congruity
and alleviation of femoroacetabular impingement by
reducing nonphysiologic forces through the hip
joint.2,3,6,16 The concept of realignment of the leg with
the hip in the position of the “best fit” by redirecting the
more congruent, round, posteromedial aspect of the
femoral head to the neutral position of weight bearing
has been popularized by Bombelli26 and Quain and
Catterall.3 This procedure is contraindicated if the
“irreducible” hip is very stiff.
The advantages of valgus osteotomy2,3,6,16 are as
follows: (a) correction of abnormal hinge movement by
repositioning the hinge segment away from the acetabular
margin, and thereby pain is relieved by unloading the
lateral parts of the femoral head; (b) increasing the
effective weight-bearing contact surface area with a
resultant decrease in peak contact pressure and a decrease
in the potential for degenerative arthritis; (c) correction of
the shortening by increasing the femoral neck-shaft angle;
(d) improvement in the abductor mechanism by increasing
the abductor muscle length and redirecting the abductor
muscle pull; and (e) producing favorable remodeling of the
hip with a resultant improvement in lateral acetabular
coverage, particularly in younger children. Remodeling
may be further enhanced if a valgus osteotomy is
combined with a shelf acetabuloplasty, which provides
additional molding effect.16 Moreover, a valgus osteotomy
can safely and effectively be repeated if the deformity
recurs. The reported positive results after valgus osteo-
tomy include improvement in gait and hip motion, reduced
pain, and improved superior joint space, overall shape of
the femoral head, bicompartmentalized acetabulum, and
leg length inequality. Other reported positive results
include a decrease in lateral femoral subluxation, and
healing of a central osteochondral defect of the femoral
head.3,4 However, these positive clinical and radiologic
observations do not preclude the possibility of the future
development of degenerative arthritis in adulthood. The
theoretical disadvantage of a valgus osteotomy is that by
making the femoral neck more vertical, increased contact
pressures on the femoral head may occur, and it will alter
forces passing vertically through the knee, unless the shaft
is laterally displaced on the proximal fragment.17
Technical Considerations and Pitfalls
of Valgus Osteotomy
In cases of advanced osteoarthritis, Bombelli26,27
reported that a valgus osteotomy at an angle of 30 degrees
or more made the capital drop a fulcrum, redirecting the
axis of abnormal hinge movement toward the medial side
of the femoral head along with a decreased compression
force at the lateral margin of the joint. This concept may
not apply to children with hinge abduction, because most
children with hinge abduction do not present with capital
drop osteophyte. Therefore, the degree of valgization
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J Pediatr Orthop  Volume 31, Number 2 Supplement, September 2011 The Role of Valgus Osteotomy in LCPD

FIGURE 2. A case treated by a combination of salvage procedures including articulated hip distraction. A, Preoperative
radiograph taken 7 months after shelf acetabuloplasty, which was performed at an age of 11 years and 5 months elsewhere,
shows a flattened femoral head with epiphyseal extrusion suggestive of Catterall group III, Salter-Thompson group B, and Herring
pillar type C. She had undergone soft tissue release (tenotomy of the adductor and psoas) and Petrie cast (5 wk) before shelf
acetabuloplasty. She presented with an antalgic gait with stiff hip. B, Arthrogram shows incongruent hip in neutral position. C,
The femoral and acetabulum remain incongruent with medial dye pooling in abduction, suggestive of hinge abduction. D, The
femoral head and acetabulum become congruent in adduction. E, Femoral valgus osteotomy coupled with articulated hip
distraction using an external fixator (4 wk) was performed to restore joint congruity and to reduce subluxation. Two proximal
Shanz pins, which were inserted for hip distraction, are seen in the supra-acetabular area. Subsequently, Chiari osteotomy was
performed as an acetabular enlarging procedure. F, A radiograph obtained at 16 years and 1 month of age suggests Stulberg class
IV. She has reasonably good hip motion with minimal limp.

should be better determined by the “best fit” joint
congruity position in adduction using intraoperative
dynamic arthrograms.
Although Bombelli26 and Quain and Catterall3
recommended a valgus-extension osteotomy, we believe
that the decision-making as to whether or not the
rotational/sagittal components would be combined with
valgization should be based on careful determination of
the spatial features of the hump of the femoral head.6
Valgus-extension osteotomy is an effective procedure,
particularly when hinge abduction is combined with
flexion deformity of the hip in association with a small,
soft anterior hinge segment that can be contained within
the acetabular socket. However, when the “hump” on the
femoral head is formed relatively anteriorly and is large
enough not to be able to be contained within the
acetabulum, a valgus-extension osteotomy may not be
indicated because with the extension component of the
osteotomy, the anterior hump can cause further impinge-
ment against the anterior acetabular rim during an
attempted full flexion. In the same context, those hips
that show optimal congruity in adduction and internal
rotation position of the extended lower limb on dynamic
arthrograms can be treated by a valgus-external rotation
osteotomy. Similarly, those hips that had the most
congruent relationship in the adduction-external rotation

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Choi et al J Pediatr Orthop
position of the extended lower limb can be treated by a
valgus-flexion-internal rotation osteotomy. When the
flexion component is combined with a valgus-internal
rotation osteotomy, anterior capsulotomy of the hip may
be combined to prevent possible residual flexion defor-
mity of the hip.28 Preoperative planning and selection of a
suitable fixation of the osteotomy is essential. We have
used AO 130 degrees-angled blade plate for the fixation of
the osteotomy. The ideal position of the blade plate can
be determined by adjusting the angle between the
direction of chisel and the shaft of femur. Recently,
locking compression plates (Synthes, West Chester, PA)
are available with a screw angle of 150 degrees.
There is controversy as to whether or not the
acetabular procedure, including an innominate osteotomy,
shelf acetabuloplasty, or Chiari osteotomy, should be
performed to cover the extruded femoral head as a
combined procedure at the time of a valgus osteotomy or
as a second-stage procedure. We have a strong view that
acetabular procedures should be delayed in the younger
patient after a valgus osteotomy, because lateral acetabular
growth often improves once the hinging pressure is
relieved. Bankes et al16 also reported favorable remodeling
of the femoral head with disappearance of the prominent
lateral ridge of the femoral head 10 years after a valgus-
extension osteotomy without a simultaneous acetabular
procedure in hinge abduction. We also observed that the
impinging hump can regress in size with time after
operation in accordance with remodeling of the hip
(Fig. 3). The other benefit of a selective, secondary
acetabular procedure is that a “hyaline cartilage-to-hyaline
cartilage” redirectional acetabular osteotomy (eg, triple
innominate osteotomy or periacetabular osteotomy)
becomes possible instead of a “hyaline cartilage-to-
fibrocartilage” covering salvage procedure (eg, shelf
acetabuloplasty or Chiari osteotomy), depending on the
degree of roundness of the femoral head. However, we
agree with others that if there is a substantial increase in
subluxation and the hip remains unstable after a valgus
osteotomy, a concomitant acetabular procedure is neces-
sary to obtain adequate acetabular coverage, and thus
decrease the unit load on the articular cartilage and
prevent the “potential incongruity” that might develop.
There are some technical pitfalls associated with a
valgus osteotomy. First, a valgus osteotomy makes the
position of the femoral neck more vertical. As a result,
abduction contracture with or without pelvic obliquity
may occur after a valgus osteotomy in the case of greater
valgization, which contributes to a substantial increase in
the length of the abductor muscles. If the abduction
contracture does not resolve with physiotherapy, an
abductor faciotomy may be helpful. Little study has
systematically examined how much valgization is too
much. It has been known that severe valgus deformation
or the lateral displacement of the head or both provides
less favorable milieu contributory to earlier degeneration
in the hips. From the biomechanical viewpoint, optimum
degree of valgus correction can be determined by the
degree of adduction to lower the tip of greater trochanter
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 Volume 31, Number 2 Supplement, September 2011
to the level of the center of the femoral head while
restoring the joint congruity in neutral position of weight
bearing.29 However, practical limits of valgization can be
confounded by a variety of anatomic factors before
surgery, including the configuration of the femoral head,
the neck-shaft angle, uncoverage of the head, position of
the greater trochanter relative to the head, and the
steepness of acetabular roof. It has been our empiric
observation that valgization >160 degrees to 165 degrees
tends to cause abduction contracture or lateralization of
the femoral head. Thus, we feel that the maximum
magnitude of valgus correction in LCPD may be around
35 degrees to 40 degrees.
Second, a significant amount of femoral anteversion
can ensue after a “pure” valgus osteotomy. Liu et al30
insisted that femoral version and neck-shaft angle alone
are not sufficient for a complete understanding of the
version of the neck, as the version is dependent on the
neck-shaft angle and does not represent the true anatomic
inclination of the femoral neck. Third, it is necessary to
understand that ground mechanical axis can pass through
the lateral compartment of the knee, unless lateral
translational of the shaft is not conducted at the time of
valgus angulation. Therefore, we advocate preoperative
simulating surgery to calculate the amount of lateral
displacement of the shaft on the proximal fragment, and
thereby unacceptable mechanical axis deviation of the
lower extremity can be prevented. This is particularly
important for skeletally mature or skeletally maturing
patients in whom a valgus osteotomy is contemplated for
treatment of hinge abduction. However, in younger
children, the subsequent remodeling will usually correct
this malalignment spontaneously. If there is any preexist-
ing associated knee deformity, that is, a genu valgum, it
should be simultaneously corrected at the time of valgus
osteotomy. Guided-growth control by medial hemiepi-
physiodesis of the distal femur or supracondylar osteo-
tomy is effective to treat a genu valgum.
Results of Valgus Osteotomy
Raney et al2 reviewed 31 hips, with an average of 5.2
years after valgus osteotomy for hinge abduction. They
reported that the Iowa hip scores at follow-up averaged
93 points. Combined clinical and radiographic review for
21 patients yielded 6 (29%) excellent (Stulberg I or II and
Iowa hips scores >95), 7 (33%) good (Stulberg III or less
and hips scores >90), 5 (24%) fair (Stulberg IV and
score >85), and 3 (14%) poor (Stulberg V and hip score
<85) results. Bankes at al16 reported similar results with
valgus-extension osteotomy for hinge abduction in 48
children (51 hips) with a 10-year follow-up. They reported
that the average Iowa hip score of the 46 hips, excluding 5
patients who underwent total hip arthroplasty or hip
fusion, was 86. They found that favorable remodeling of
the hip was associated with the following 3 factors at
surgery: younger age, the phase of reossification, and an
open triradiate cartilage.
We also studied the growth and remodeling of 35
hips after valgus osteotomy combined with rotational
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J Pediatr Orthop  Volume 31, Number 2 Supplement, September 2011 The Role of Valgus Osteotomy in LCPD

FIGURE 3. A case with a satisfactory outcome after femoral valgus osteotomy for “irreducible” hinge abduction. A, A preoperative
anteroposterior radiograph of the hip obtained at 7 years of age showing Catterall group IV, Salter-Thompson group B, and
Herring pillar type C in late fragmentation stage. B, An intraoperative arthrogram shows medial dye pooling and hinge abduction
in hip abduction. C, An intraoperative arthrogram shows good joint congruity in hip adduction. D, A radiograph obtained after
femoral valgus osteotomy showing good joint congruity, especially in the weight-bearing portion. E, A radiograph obtained at 13
years and 7 months of age (postoperative 3 y and 5 mo) suggests Stulberg class III. She has near-normal hip motion without
limping.

and/or sagittal correction for hinge abduction in 35
consecutive patients (27 boys and 8 girls) with Perthes’
disease between 1984 and 2007. The mean age at surgery
was 9.4 years (range, 3.5 to 15 y), and the mean follow-up
after surgery was 9.4 years (range, 3.0 to 18.0 y). Of the 35
patients, 31 were skeletally mature and 4 were near
skeletal maturity at the latest follow-up. All hips were
classified as Catterall group III (15 hips) or IV (20 hips).
Surgery was carried out during the stage of fragmentation
in 14.3% (5 hips), at healing in 71.4% (25 hips), and for
residual deformity of the femoral head in healed disease
in 14.3% (5 hips). A valgus osteotomy resulted in
postoperative improvement of function and symptoms,
and radiographic parameters, particularly in younger age

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Choi et al J Pediatr Orthop
groups. Postoperatively, pain relief, improvement in
limping, and an increase in range of hip motion
(abduction, internal rotation, and external rotation) were
conspicuous findings. Although all patients complained
of pain or discomfort before surgery, at the latest follow-
up, pain disappeared in all except 9 patients, who
nevertheless reported decreased pain severity. Limping
also disappeared in all except 11 patients. Overall, the
Iowa hip score significantly increased from 71.2 (range, 30
to 91) before surgery to 95.2 (range, 76 to 100) at the
latest follow-up. Radiologic observations also revealed
sustained remodeling of the femoral head and acetabulum
with time after the osteotomy. The neck-shaft angle
decreased gradually with remodeling; specifically, the
mean neck-shaft angle was 127.7 degrees before surgery,
142.8 degrees immediately after surgery, and 132.9
degrees at the latest follow-up. There was no increase in
lateral subluxation after surgery, whereas increased
superior joint space and decreased medial joint space
were maintained. The mean Mose sphericity index was
3.97 mm (range, 1 to 13 mm) at the latest follow-up. The
final Stulberg classification of the radiographs was class II
in 4 (11.4%), class III in 22 (62.9%), and class IV in 9 hips
(25.7%).
OVERVIEW
When the patient presents late with established
hinge abduction, the hip may remain “noncontainable.”
In this situation, valgus osteotomy should first be
contemplated if the femoral head and acetabulum become
congruent when the joint is adducted but remain
incongruent in a neutral or abducted position. Favorable
remodeling can be anticipated after a valgus osteotomy,
especially when it is performed before late reossification/
healed stage and in younger age (<8 to 10 y). A
concomitant acetabular procedure is necessary to obtain
adequate acetabular coverage, if there is a substantial
increase in subluxation and the hip remains unstable after
surgery.
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