From the Guidelines
Management of Perthes disease should focus on containing the femoral head within the acetabulum to prevent deformity while the bone heals, with treatment depending on the child's age, disease stage, and extent of femoral head involvement. According to the American College of Radiology Appropriateness Criteria for osteonecrosis 1, early diagnosis and intervention are crucial to prevent articular collapse and the need for joint replacements. For mild cases in younger children (under 6 years), observation with regular follow-up and activity modification is often sufficient, as seen in other forms of osteonecrosis where early intervention can prevent long-term sequelae 1. These children should avoid high-impact activities but maintain range of motion through swimming and gentle cycling.
Key Considerations
- For moderate to severe cases, especially in children over 6 years old, more aggressive intervention is needed, including bracing with devices like the Scottish Rite orthosis or Atlanta Scottish Rite orthosis, worn for 18-23 hours daily until radiographic healing is evident, usually 12-24 months.
- Physical therapy is essential throughout treatment to maintain hip range of motion and strength, similar to the approach for other osteonecrotic conditions where maintaining joint mobility is key 1.
- For severe cases or those not responding to conservative measures, surgical containment may be necessary, including femoral osteotomy (to redirect the femoral head) or pelvic osteotomy (to reposition the acetabulum), as is sometimes required in adult osteonecrosis cases 1.
Pain Management
- Pain management includes NSAIDs like ibuprofen (10mg/kg/dose three times daily) or naproxen (5-7mg/kg twice daily), which is consistent with the management of pain in other osteonecrotic conditions 1. The goal of all interventions is to maintain femoral head sphericity and prevent osteoarthritis later in life, as the natural healing process takes 2-4 years during which proper containment is crucial, highlighting the importance of early and appropriate management based on the latest evidence 1.
From the Research
Perthes Hip Management
- The management of Perthes hip disease aims to relieve pain and disability, with various treatment options available depending on the stage and severity of the disease 2, 3, 4, 5, 6.
- Surgical treatment may be necessary to address loose bodies, hinging abduction of the hip, or lateral displacement of the great trochanter, with procedures such as arthrotomy, valgus osteotomy, or extensive muscle release 2.
- In patients with symptomatic residual Perthes-like deformities and acetabular dysplasia, combined surgical hip dislocation and periacetabular osteotomy (PAO) may be effective in improving pain and functional outcomes 3.
- Containment ameliorating surgery, such as greater trochanteric apophyseodesis, may be indicated in children with loss of containment, particularly those under 8.5 years old 4.
- Total hip arthroplasty (THA) may be necessary in patients with severe osteoarthritis associated with Legg-Calve-Perthes disease, with studies showing acceptable complication rates and excellent patient-reported outcomes at mid-term follow-up 5.
- The prime aim of treatment is to maintain the sphericity of the femoral head and the congruency of the femur-acetabulum relationship to prevent secondary degenerative arthritis, with early diagnosis and management crucial in preventing collapse of the femoral head and progressive deformity 6.