What is the treatment for Perthes disease?

Management of Legg-Calvé-Perthes Disease

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

Diagnosis and Assessment

• Legg-Calvé-Perthes disease (LCPD) is a self-limiting idiopathic avascular necrosis of the capital femoral epiphysis in children 2
• Key prognostic factors that determine treatment approach:
  • Age at disease onset (older children have worse prognosis)
  • Degree of limitation of range of motion
  • Extent of femoral head involvement
  • Presence of "head-at-risk" signs on radiographs 3

Treatment Principles

The primary goal of treatment is to prevent femoral head deformity and premature coxarthrosis (hip arthritis) by maintaining or restoring joint congruence while biological plasticity is still present - known as the "containment principle" 3.

Treatment Algorithm:

1. Initial Assessment Phase

   • Determine disease stage (Waldenstrom Stage I, II, or III)
   • Assess lateral pillar classification (Herring classification)
   • Evaluate range of motion and pain level
   • Determine extent of femoral head involvement

2. Treatment Selection Based on Severity:

   Mild Cases:

   • Observation with frequent follow-up
   • Regular radiographic monitoring
   • Maintenance of range of motion through physical therapy

   Moderate to Severe Cases:

   • Non-surgical containment methods:
     • Activity modification
     • Bracing
     • Physical therapy to maintain hip mobility

   Severe Cases with Poor Prognosis:

   • Surgical containment methods:
     • Femoral osteotomy
     • Pelvic osteotomy
     • In some cases, soft tissue release with joint distraction using external fixation 4

Specific Treatment Approaches

Non-surgical Management:

• Weightbearing and activity restrictions are commonly prescribed during active disease stages
• Restrictions range from non-weightbearing with cast/brace to full weightbearing with activity limitations
• Important consideration: While mobility scores are lower with more severe restrictions, mental health measures (depression, anxiety) and social health (peer relationships) are not significantly affected by these restrictions 5

Surgical Management:

• Surgical intervention aims to achieve containment when non-surgical methods are insufficient
• Options include:
  • Femoral varus osteotomy
  • Pelvic osteotomy (Salter or triple)
  • Soft tissue release with joint distraction using external fixation
  • The latter has shown good results even in older children with typically poor prognosis 4

For Older Patients with Painful Sequelae:

• Palliative operations can be effective for adults with painful old Perthes' disease:
  • Subcutaneous adductor tenotomy
  • Cheilectomy of femoral head
  • Multiple drilling for femoral head decompression
  • Muscle-pedicle bone grafting
  • These approaches have shown good to excellent results in most cases 6

Follow-up and Monitoring

• All children with LCPD require individualized treatment and continued follow-up into adulthood 3
• Regular monitoring of:
  • Hip range of motion
  • Pain levels
  • Radiographic changes in femoral head shape
  • Development of limb length discrepancy

Important Considerations and Pitfalls

• Early diagnosis and management are crucial to prevent femoral head collapse, progressive deformity, and impingement 2
• The variable course of LCPD means treatment must be determined individually in each case 3
• Age at onset is a critical prognostic factor - children diagnosed after age 8 typically have worse outcomes
• Avoid delaying referral to pediatric orthopedic specialists as early intervention may improve outcomes
• Consider the impact of restrictive treatments on quality of life, particularly physical mobility 5