Treatment

Consult expert advice.

The main aim of treatment in Perthes disease is to relieve clinical symptoms (especially pain) to improve mobility, reduction of mechanical stress and to contain the femoral head in the acetabulum ("motion and containment") (1,2).

Treatment type in perthes disease is determined by the following factors:

• radiological severity of the disease
• presence or absence of "head-at-risk signs,"
• extent of limitation of mobility of the hip joint
• age of the patient (2)

Although the disease has been known for a long period there is still an uncertainty as to the most appropriate form of treatment and the patient groups to whom it should be applied (1)

Treatment methods can be divided into surgical and non surgical methods (1).

• non surgical methods
  • used in less severe disease, for example where less than half the femoral head is affected and the joint space is well preserved. Measures include:
    • minimal weight bearing and protection of the joint (1,2)
    • analgesia
      • important mainly in the initial phase
      • not useful in long term treatment
    • non containment approaches
      • bed rest with bucks traction
      • ischial weight bearing brace
      • Snyder sling
    • containment approaches
      • newington brace, Toronto orthosis, Scottish rite orthosis, (2)
    • regular program of physiotherapy
    • treatment with botulinum toxin, together with intensive physiotherapy - useful in the presence of adductor musculature contactures to increase the range of motion in abduction and thereby improve containment (2)
• surgical methods
  • used when the disease takes an unfavorable course, or in cases where the conservative therapy fails (2)
  • measures include:
    • osteotomy -
      • are done to increase the containment of femoral head within the acetabulum (1)
      • approaches include femoral or innominate osteotomy (or combination as suggested by some researchers) (2)
      • can be used instead of bracing to improve head/acetabular congruity - ie the femoral head is itself realigned into the acetabulum, or more rarely the acetabulum realigned onto the femoral head. Although more radical than bracing, it requires only about six weeks of disability
  • if surgical treatment or immobilisation in plaster is indicated then some clinicians may recommend surgical management rather than immobilization - treatment generally being delayed until the condition requires surgery. This minimizes the amount of time a child is disabled by the condition and its treatment, and thus reduces what can be a considerable psychological impact

In addition to the time required for proper treatment the other major problem is that the child is often asymptomatic, or coping very well with symptoms, and the treatment can seem worse than the disease.

Note that "at least half of involved hips do well with no treatment, and many others have good hip function well into middle age " (2)

Reference:

• (1) Taghi Karimi, McGarry T.  A Comparison of the Effectiveness of Surgical and Nonsurgical Treatment of Legg-Calve-Perthes Disease: A Review of the Literature. Adv Orthop. 2012; 2012: 490806.
• (2) Nelitz M, Lippacher S, Krauspe R, Reichel H. Perthes Disease Current Principles of Diagnosis and Treatment Dtsch Arztebl Int. 2009 July; 106(31-32): 517–523.