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Legg-Calve-Perthes Disease Treatment & Management

  • Author: George D Harris, MD, MS; Chief Editor: William L Jaffe, MD  more...
 
Updated: Mar 04, 2015
 

Medical Therapy

Consultation with an orthopedist is recommended. Goals in the treatment of Legg-Calvé-Perthes disease (LCPD) include the following:

  • Eliminating hip irritability
  • Restoring and maintaining good range of motion in the hip
  • Preventing femoral epiphyseal collapse
  • Attaining a spherical femoral head when the hip heals

Initial therapy includes minimal weightbearing and protection of the joint, which is accomplished by maintaining the femur abducted and internally rotated so that the femoral head is held well inside the rounded portion of the acetabulum. Abduction and rotation of the femur are accomplished by means of either the use of orthotic devices (bracing) or surgery (osteotomy). The Scottish Rite brace achieves containment by abduction while allowing free knee motion.

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Surgical Therapy

Results of surgical containment appear to be better than those of nonsurgical containment (orthosis). Surgical management typically involves either femoral osteotomy to redirect the involved portion within the acetabulum or innominate osteotomy. The two procedures yield equivalent results, but femoral osteotomy may cause shortening of the limb, leading to a chronic limp.[4, 5, 6, 7, 8, 9, 10]

Surgery does not speed healing of the femoral head, but it does cause the head to reossify in a more spherical fashion.

In a Norwegian study of Perthes disease (ie, LCPD), Wiig et al followed 358 patients for 5 years and determined that proximal femoral varus osteotomy provided the best results in children 6 years and older with hips having more than 50% femoral head necrosis at the time of diagnosis.[4] They found no significant difference between physiotherapy and abduction orthosis and therefore suggested abandoning abduction orthosis for Perthes' disease. For children younger than 6 years, no difference in outcome was determined for any of the three treatments.

A study by Kim et al suggested that contrary to conventional belief, a greater varus angulation may not produce better preservation of the femoral head following proximal femoral varus osteotomy.[11]

A meta-analysis of the medical literature addressing the effectiveness of surgical and nonsurgical treatment of LCPD suggested that there is minimal evidence to determine the most appropriate treatment.[12] This research also provides some evidence that nontreatment may be as effective as orthotic or surgical intervention.

Pailhé et al conducted a prospective study of 45 patients who underwent triple osteotomy of the pelvis for the treatment of LCPD.[13] The mean follow-up period of the study was 15.2 years. The investigators concluded that triple osteotomy provides satisfactory, reproducible long-term results.

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Complications

Because LCPD is a local self-healing disorder, treatment consists of protection of the joint by allowing new bone formation to occur and regain a spherical femoral head. The aim is to prevent the development of any of the following:

  • Irregular contouring, flattening, or mushrooming of the head
  • Shortening and broadening of the neck
  • Flattening of the vertical wall of the acetabulum

The development of any of these conditions can result in osteoarthritis at an early age.

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Outcome and Prognosis

The prognosis for patients with LCPD can be good; it depends on the completeness of involvement of the epiphyseal center. The severity of involvement of the femoral head, its subsequent healing, and proper joint space preservation all help determine when and to what degree an athlete will be able to participate in sports. The functional result depends on the amount of deformity that develops when the structure is softened. Overall, the prognosis for recovery and sports participation after treatment is very good for most individuals.

The short-term prognosis is related to femoral head deformity at the completion of the healing stage. Risk factors include the following:

  • Clinical onset at an older age
  • Extensive femoral epiphyseal involvement
  • Femoral head containment
  • Reduced range of motion in the hip
  • Premature closure of the growth plate

The long-term prognosis is related to the potential for osteoarthritis of the hip as an adult.[14] It is worse for patients with metaphyseal defects, those in whom the disease develops late in childhood (age ≥ 10 years), and those who have more complex involvement of the femoral head with residual deformity; degenerative arthritis occurs in nearly 100% of these patients. This rate is in comparison to patients who are younger than 5 years when the problem develops; the incidence of degenerative arthritis is negligible in this younger population.

The results of one small retrospective study found that total hip replacement can be considered a possible option for patients who had LCPD in childhood. Alhough a high rate of neurologic complications was noted, these were possibly related to inadequate soft-tissue release or excessive limb-lengthening.[15]

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Contributor Information and Disclosures
Author

George D Harris, MD, MS Professor and Chair, Department of Family Medicine, West Virginia University Eastern Division School of Medicine; Attending Physician, Jefferson Medical Center; Medical Director, University Healthcare Physicians Primary Care Division

George D Harris, MD, MS is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, American Medical Society for Sports Medicine, Society of Teachers of Family Medicine, American Society for Colposcopy and Cervical Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Orthopaedic Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Pennsylvania Orthopaedic Society, Pediatric Orthopaedic Society of North America, Orthopaedics Overseas, Limb Lengthening and Reconstruction Society, Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopediatrics, Phillips Healthcare, POSNA<br/>Serve(d) as a speaker or a member of a speakers bureau for: Synthes<br/>Received research grant from: University of Cincinnati<br/>Received royalty from Lippincott Williams and WIcins for editing textbook; Received none from POSNA for board membership; Received none from LLRS for board membership; Received consulting fee from Synthes for none.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American College of Surgeons, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

B Sonny Bal, MD, JD, MBA Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

B Sonny Bal, MD, JD, MBA is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Received none from Bonesmart.org for online orthopaedic marketing and information portal; Received none from OrthoMind for social networking for orthopaedic surgeons; Received stock options and compensation from Amedica Corporation for manufacturer of orthopaedic implants; Received ownership interest from BalBrenner LLC for employment; Received none from ConforMIS for consulting; Received none from Microport for consulting.

References
  1. Hailer YD, Montgomery S, Ekbom A, Nilsson O, Bahmanyar S. Legg-Calvé-Perthes disease and the risk of injuries requiring hospitalization: a register study involving 2579 patients. Acta Orthop. 2012 Dec. 83(6):572-6. [Medline]. [Full Text].

  2. Poul J. Diagnosis of Legg-Calvé-Perthes disease. Ortop Traumatol Rehabil. 2004 Oct 30. 6(5):604-6. [Medline].

  3. Sales de Gauzy J, Briot J, Swider P. Coxa magna quantification using MRI in Legg-Calve-Perthes disease. Clin Biomech (Bristol, Avon). 2009 Jan. 24(1):43-6. [Medline].

  4. Wiig O, Terjesen T, Svenningsen S. Prognostic factors and outcome of treatment in Perthes' disease: a prospective study of 368 patients with five-year follow-up. J Bone Joint Surg Br. 2008 Oct. 90(10):1364-71. [Medline].

  5. Beer Y, Smorgick Y, Oron A, Mirovsky Y, Weigl D, Agar G, et al. Long-term results of proximal femoral osteotomy in Legg-Calvé-Perthes disease. J Pediatr Orthop. 2008 Dec. 28(8):819-24. [Medline].

  6. Canavese F, Dimeglio A. Perthes' disease: prognosis in children under six years of age. J Bone Joint Surg Br. 2008 Jul. 90(7):940-5. [Medline].

  7. Myers GJ, Mathur K, O'Hara J. Valgus osteotomy: a solution for late presentation of hinge abduction in Legg-Calvé-Perthes disease. J Pediatr Orthop. 2008 Mar. 28(2):169-72. [Medline].

  8. Rosenfeld SB, Herring JA, Chao JC. Legg-calve-perthes disease: a review of cases with onset before six years of age. J Bone Joint Surg Am. 2007 Dec. 89(12):2712-22. [Medline].

  9. Zarzycka M, Zarzycki D, Kacki W, Jasiewicz B, Ridan T. Long-term results of conservative treatment in Perthes' disease. Ortop Traumatol Rehabil. 2004 Oct 30. 6(5):595-603. [Medline].

  10. Nowacki W, Szymkowiak E, Futyma J, Stencel P. A comparative analysis of conservative and surgical treatment of Perthes' disease. Ortop Traumatol Rehabil. 2004. 6(6):748-50. [Medline].

  11. Kim HK, da Cunha AM, Browne R, Kim HT, Herring JA. How much varus is optimal with proximal femoral osteotomy to preserve the femoral head in legg-calve-perthes disease?. J Bone Joint Surg Am. 2011 Feb. 93(4):341-7. [Medline].

  12. Karimi MT, 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. [Medline].

  13. Pailhé R, Cavaignac E, Murgier J, Cahuzac JP, de Gauzy JS, Accadbled F. Triple osteotomy of the pelvis for Legg-Calve-Perthes disease: a mean fifteen year follow-up. Int Orthop. 2015 Feb 3. [Medline].

  14. Heesakkers N, van Kempen R, Feith R, Hendriks J, Schreurs W. The long-term prognosis of Legg-Calvé-Perthes disease: a historical prospective study with a median follow-up of forty one years. Int Orthop. 2014 Nov 19. [Medline].

  15. Traina F, De Fine M, Sudanese A, Calderoni PP, Tassinari E, Toni A. Long-term results of total hip replacement in patients with legg-calve-perthes disease. J Bone Joint Surg Am. 2011 Apr. 93(7):e25. [Medline].

  16. Barkin RM, Rosen P. Emergency Pediatrics, A Guide to Ambulatory Care. 5th ed. St Louis: Mosby-Year Book. 1999: 216, 278, 546-7.

  17. Hay WW, Hayward AR, Levin MJ. Current Pediatric Diagnosis and Treatment. 14th ed. Stamford; Appleton and Lange. 1999: 710-1.

  18. Lauren M. Simon. Chapter 35. Thigh, Hip, and Pelvis Injuries. Richard B. Birrer. Pediatric Sports Medicine for Primary Care. philadelphia, PA.: Lippincott Williams and Wilkins; 2002. pages 393-394.

  19. McMillan JA, DeAngelis CD, Feigin RD. Oski's Pediatrics Principles and Practice. 3rd ed. Philadelphia: Lippincott-Raven. 1999: 2105-6.

 
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Image from 8-year-old boy with Herring type C Legg-Calvé-Perthes disease shows evidence of lateral extrusion. Symptoms began 18 months before this view was obtained. Image courtesy of Dennis P Grogan, MD.
Anteroposterior radiograph from 9-year-old boy with Legg-Calvé-Perthes disease. Image courtesy of Dennis P Grogan, MD.
Frog-leg lateral radiograph of same 9-year-old boy with Legg-Calvé-Perthes disease as in previous radiograph. Image courtesy of Dennis P Grogan, MD.
 
 
 
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