What is the initial treatment for a child diagnosed with Legg Calve Perthes (LCP) disease?

Initial Treatment for Legg-Calvé-Perthes Disease

Children diagnosed with Legg-Calvé-Perthes disease should be referred to a pediatric orthopedic surgeon for specialized management, as this is the recommended standard of care. 1

Understanding Legg-Calvé-Perthes Disease

Legg-Calvé-Perthes disease (LCPD) is an avascular osteonecrosis of the proximal femur that typically affects children between 5-10 years of age. The condition involves ischemia leading to necrosis of the femoral head, though the exact cause remains unknown.

Treatment Approach

Initial Management

1. Referral to Specialist

   • Immediate referral to a pediatric orthopedic surgeon is essential as these specialists have completed orthopedic residency plus additional fellowship training in pediatric orthopedics 1
   • During the COVID-19 pandemic, some centers have postponed non-urgent reviews for conditions like LCPD to minimize exposure risk, especially for younger children who may be more vulnerable to infection 1

2. Physical Therapy and Activity Modifications

   • Stretching exercises are recommended for all disease stages to maintain range of motion 2
   • Strengthening exercises may be recommended depending on the disease stage 2
   • No complete non-weightbearing treatment is typically recommended 2
   • Activity restrictions typically include:
     • Allowed: Swimming, short walks, cycling, and horseback riding
     • Restricted: Trampolining, running, ball sports, and gymnastics (especially in early stages) 2

3. Containment Treatment

   • The primary goal is to maintain or restore containment of the femoral head within the acetabulum
   • An A-frame orthosis combined with daily hip range-of-motion exercises has shown excellent results in maintaining hip abduction and achieving spherically congruent hips 3
   • Adductor tenotomy and abduction casting may be used initially to restore hip abduction 3

Surgical Options

Surgical intervention is determined based on:

• Patient's age at onset
• Stage of the disease
• Severity of involvement
• Range of motion
• Extent of necrosis (according to Herring and Catterall classifications) 4

Surgical options include:

1. Early Stage Containment Procedures

   • Femoral varus osteotomy (FVO)
   • Salter's innominate osteotomy (SIO)
   • Triple pelvic osteotomy (TPO) 5

2. Treatment Based on Severity

   • Moderate cases: Either FVO or SIO
   • Severe cases: FVO combined with either SIO or TPO 5

3. Later Stage Procedures

   • For increased femoral head damage: Non-containment procedures such as femoral valgus extension osteotomy or trochanter apophyseodesis 5

Monitoring and Follow-up

• Regular follow-up is essential until skeletal maturity
• Monitoring should include:
  • Hip range of motion
  • Pain levels
  • Femoral head sphericity and congruence
  • Presence of femoral neck deformity
  • Limb-length inequality 3

Key Prognostic Factors

• Patient age at onset of LCPD
• Range of motion
• Extent of necrotic process according to Herring and Catterall classifications 4

Treatment Outcomes

With appropriate treatment, especially when focused on maintaining hip range of motion and using containment devices like the A-frame orthosis, studies have shown that up to 93% of hips can achieve congruence at maturity, with 78% of more severe cases (lateral pillar B and C) achieving spherically congruent hips 3.

Pitfalls to Avoid

• Delaying referral to a pediatric orthopedic surgeon
• Failing to maintain hip range of motion through appropriate exercises
• Recommending complete non-weightbearing, which is not supported by current evidence 2
• Waiting too long for surgical intervention if indicated, as early intervention in appropriate cases yields better outcomes 6