What is the recommended management approach for a 4-year-old boy with Legg-Calve-Perthes (LCP) disease, Catterall Stage C on the left and Catterall Stage A on the right?

From the Guidelines

The recommended management for a 4-year-old boy with bilateral Legg-Calvé-Perthes disease (LCP) should focus on containment of the femoral head, with different approaches based on the severity of each hip. For the left hip with Catterall Stage C (more advanced disease), active intervention is warranted, typically with a containment orthosis such as a Petrie cast or Scottish Rite brace worn 23 hours daily for 12-18 months 1. Physical therapy 2-3 times weekly should be implemented to maintain hip range of motion, focusing on abduction and internal rotation exercises. Non-weight bearing or partial weight bearing with crutches may be necessary initially, with gradual return to activities as symptoms improve. For the right hip with Catterall Stage A (mild disease), observation with regular radiographic follow-up every 3-4 months is appropriate, along with activity modification to avoid high-impact activities. Pain management should include scheduled ibuprofen (10mg/kg every 6-8 hours) during painful episodes. The goal of treatment is to maintain the femoral head within the acetabulum during the healing phase to prevent deformity, as the immature femoral head in LCP undergoes avascular necrosis followed by revascularization and remodeling. This containment strategy allows the acetabulum to serve as a mold for the healing femoral head, particularly important during this age when remodeling potential is still good but the disease may have a prolonged course. Given the complexity of the condition, referral to a pediatric orthopedic surgeon is recommended for optimal management, as they have the specialized training and expertise to handle such cases 1.

Some key considerations in managing LCP include:

• Containment of the femoral head to prevent deformity
• Maintenance of hip range of motion through physical therapy
• Activity modification to avoid high-impact activities
• Pain management with scheduled ibuprofen
• Regular radiographic follow-up to monitor disease progression
• Referral to a pediatric orthopedic surgeon for specialized care 1.

It's worth noting that the provided evidence regarding congenital pseudarthrosis of the tibia 1 is not directly relevant to the management of Legg-Calvé-Perthes disease, and therefore should not influence the treatment approach for this specific condition. The most relevant guidance comes from the recommendation to refer patients with Perthes disease to a pediatric orthopedic surgeon 1, emphasizing the importance of specialized care in managing this condition.

From the Research

Management Approach for Legg-Calve-Perthes Disease

The management approach for a 4-year-old boy with Legg-Calve-Perthes (LCP) disease, Catterall Stage C on the left and Catterall Stage A on the right, involves a combination of conservative and operative treatments.

• For Catterall Stage A, which is considered a mild form of the disease, conservative treatment is often recommended, including restriction of weight-bearing activities 2.
• For Catterall Stage C, which is a more severe form of the disease, the treatment approach may involve a combination of conservative and operative methods, such as innominate osteotomy, to improve the prognosis 2.

Treatment Options

Some treatment options for LCP disease include:

• Relieving weight-bearing up to the fragmentation stage, whether the diagnosis has been made by the use of MRI or without it 3.
• Using intravenous pamidronate (IV-PAM) in combination with casts, physiotherapy, and adductor tenotomy to help heal the femoral heads 4.
• Conservative treatment, such as restriction of weight-bearing activities, for mild forms of the disease (Catterall I and II) 2.
• Operative treatment, such as innominate osteotomy, for severe forms of the disease (Catterall III and IV) 2.

Prognosis

The prognosis for LCP disease is generally good when the age at onset is less than six years 2.

• Catterall grade-I and grade-II hips tend to have a good result at skeletal maturity 2.
• Catterall grade-III and grade-IV hips may have a poorer prognosis, with a higher risk of complications such as fracture, collapse, and extrusion 2, 5.

Diagnostic Tools

Diagnostic tools, such as bone scintigraphy, can be useful in detecting LCP disease in its initial stages and providing prognostic information that may affect therapy 5.

• The Catterall classification can be used to determine the severity of the disease, but it may change over time, especially before the fragmentation stage of Waldenström 6.