Medical Therapy
Consultation with an orthopedist is recommended. Goals in the treatment of Legg-Calvé-Perthes disease (LCPD) include the following:
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Eliminating hip irritability
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Restoring and maintaining good range of motion in the hip
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Preventing femoral epiphyseal collapse
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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.
Surgical Therapy
Results of surgical containment appear to be better than those of nonsurgical containment (orthosis). Surgery does not speed healing of the femoral head, but it does cause the head to reossify in a more spherical fashion.
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. [8, 9, 10, 11, 12, 13, 14] A systematic review and meta-analysis by Adulkasem et al found that for severe LCPD, combined osteotomy was the most effective procedure. [15]
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. [8] 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. [16]
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. [17] 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. [18] The mean follow-up period of the study was 15.2 years. The investigators concluded that triple osteotomy provides satisfactory, reproducible long-term results.
Complications
Because LCPD is a local self-healing disorder, treatment consists of protection of the joint by allowing new bone formation to occur and restore a spherical femoral head. The aim is to prevent the development of any of the following:
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Irregular contouring, flattening, or mushrooming of the head
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Shortening and broadening of the neck
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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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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.
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Anteroposterior radiograph from 9-year-old boy with Legg-Calvé-Perthes disease. Image courtesy of Dennis P Grogan, MD.
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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.
