Legg-Calve-Perthes Disease Treatment & Management

Consultation with an orthopedist is recommended.

Treatment goals include eliminating hip irritability, restoring and maintaining good range of motion in the hip, preventing femoral epiphyseal collapse, and attaining a spherical femoral head when the hip heals.

Initial therapy includes minimal weight bearing 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 is accomplished either by the use of orthotic devices (bracing) or surgery (osteotomy). The Scottish Rite brace achieves containment by abduction while allowing free knee motion.

Results of surgical containment appear to be better than those of nonsurgical containment (orthosis). Surgical approaches include either femoral osteotomy to redirect the involved portion within the acetabulum or innominate osteotomy. Both procedures produce equal results, but femoral osteotomy may cause shortening of the limb, leading to a chronic limp.^{[3, 4, 5, 6, 7, 8, 9]}

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 (Legg-Calve-Perthes' disease), 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. 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 3 treatments.^[3] One study by Kim et al suggest that, contrary to conventional belief, a greater varus angulation may not produce better preservation of the femoral head following proximal femoral varus osteotomy.^[10]

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sports Injury Center. Also, see eMedicine's patient education article Repetitive Motion Injuries.

Because Legg-Calvé-Perthes disease 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 goal is to prevent (1) irregular contouring, flattening, or mushrooming of the head; (2) shortening and broadening of the neck; and (3) flattening of the vertical wall of the acetabulum. The development of any of these conditions can result in osteoarthritis at an early age.

The prognosis for patients with Legg-Calvé-Perthes disease can be good and 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 determine the degree and timing for an athlete 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 patient's short-term prognosis is related to femoral head deformity at the completion of the healing stage. Risk factors include a clinical onset at an older age, extensive femoral epiphyseal involvement, femoral head containment, reduced range of motion in the hip, and premature closure of the growth plate.

The long-term prognosis is related to the potential for osteoarthritis of the hip as an adult. In patients with metaphyseal defects, in those in whom the disease develops late in childhood (age 10 y or older), and in those who have more complex involvement of the femoral head with residual deformity, the prognosis is worse, and degenerative arthritis occurs in nearly 100% of these patients. This rate is in comparison to those 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 Legg-Calvé-Perthes disease in childhood. Though a high rate of neurologic complications was noted, these were possibly related to inadequate soft-tissue release or excessive limb lengthening.^[11]