From the Guidelines
Legg-Calve-Perthes disease is a childhood hip disorder characterized by avascular necrosis of the femoral head, requiring prompt referral to a pediatric orthopedic surgeon for proper diagnosis and treatment. The diagnosis of Legg-Calve-Perthes disease involves clinical evaluation, imaging studies (X-rays, MRI), and sometimes bone scans, revealing avascular necrosis of the femoral head in children typically aged 4-10 years 1. Treatment aims to maintain femoral head containment within the acetabulum while revascularization occurs. For mild cases, observation with activity modification and anti-inflammatory medications may be sufficient. Physical therapy to maintain hip range of motion is essential. More severe cases require containment methods, including bracing for younger children with early-stage disease.
Key Considerations
- Referral to a pediatric orthopedic surgeon is recommended for children with Perthes disease, as they have completed a residency in orthopedics and an additional Accreditation Council for Graduate Medical Education–approved 1-year fellowship in pediatric orthopedics 1
- Treatment duration typically spans 2-4 years until complete healing occurs
- Prognosis depends on the child's age at onset, extent of femoral head involvement, and treatment adherence
- Regular follow-up with orthopedic specialists is crucial to monitor healing progress and adjust treatment as needed
Treatment Options
- Observation with activity modification and anti-inflammatory medications for mild cases
- Containment methods, including bracing, for younger children with early-stage disease
- Surgical interventions, including femoral or pelvic osteotomies, for older children or advanced cases The disease results from temporary blood supply interruption to the femoral head, causing bone death and subsequent fragmentation before eventual revascularization and remodeling.
From the Research
Definition and Overview of Legg-Calve-Perthes Disease
- Legg-Calve-Perthes disease (LCPD) is a childhood hip disorder characterized by avascular necrosis of the femoral head 2, 3.
- The disease encompasses a wide spectrum of pathology, from mild with no long-term sequelae to severe with permanent degenerative change of the hip joint 2.
- The incidence of LCPD is variable, ranging from 0.4/100,000 to 29.0/100,000 children 3.
Diagnosis of Legg-Calve-Perthes Disease
- A pediatric patient with hip pathology may initially only present with knee or thigh pain, thus obligating the clinician to maintain awareness about the hip during examination 2.
- Common physical examination findings include deficits in hip abduction and internal rotation, along with Trendelenburg gait in late stages 2.
- Plain radiographs demonstrate changes in the anterolateral aspect of the femoral head, sometimes only seen on the frog lateral X-ray in early stages 2.
Treatment of Legg-Calve-Perthes Disease
- Treatment options aim to restore range of motion and maintain adequate coverage of the femoral head 2.
- When appropriate, surgery is used to reorient the femoral head or pelvis to maintain coverage 2.
- The use of bisphosphonate therapy has been explored as a potential treatment for LCPD, with some studies suggesting it may prevent substantial femoral head deformity during the fragmentation phase 4.
- However, clinical evidence lacks consistent patient groups and drug protocols to draw definitive conclusions that bisphosphonate therapy can decrease femoral head deformity in juvenile osteonecrotic conditions 4.
- Factors that are believed to correlate with a poor prognosis include onset of symptoms after age 8 years, lateral head subluxation, involvement of over 50% of the femoral head with collapse of the lateral pillar, and the combination of an aspherical femoral head and an incongruent joint 5.
- Treatment should be guided by age at disease onset, current best evidence, and prognostic factors, with patients aged <6 years at onset often managed nonsurgically and older patients potentially benefiting from surgical treatment 6.