Severe bilateral Legg-Calvé-Perthes resolved with pamidronate in combination with casts, physiotherapy and adductor tenotomy: a pictorial essay over 11 years.

We describe an 11-year prospective clinical and radiologic course of a 6-year-old boy with bilateral Legg-Calvé-Perthes disease, who was treated with intravenous pamidronate (IV-PAM). His baseline radiographs showed grade IV avascular necrosis/Catterall stage IV, and at worst he progressed to lateral pillar/Herring stage C bilaterally. His disease initially was extremely functionally limiting with expected poor outcome with eventual joint replacement. Because IV-PAM stops bone breakdown and allows for ongoing bone formation while revascularisation of bone occurs, we hypothesised that IV-PAM could act as an adjunct to traditional treatment to help heal the femoral heads. Our patient received nine once monthly doses of IV-PAM (1 mg/kg/dose) over 13 months, along with Petrie/broomstick casts and physiotherapy. Remarkably, over time, his femoral heads healed. Now, at 11-year follow-up, he has excellent functional and radiologic outcome with congruence between femoral head and acetabulum, no residual osteonecrosis and minimal loss of femoral head sphericity.

Beneficio de la rehabilitación y toxina botulínica en la enfermedad de Legg-Calvé-Perthes. A propósito de un caso / Benefits of botulinum toxin rehabilitation in Legg-Calvé-Perthes disease. A case report

El tratamiento de elección en la enfermedad de Perthes continúa actualmente en controversia. Si bien la literatura no muestra evidencia de que la Rehabilitación modifique la evolución natural de la enfermedad, los estudios publicados orientan a un beneficio del recorrido articular, reeducación de la marcha y de la fuerza muscular. Presentamos el caso de un niño de 8 años con enfermedad de Perthes, que se incluyó en el programa de Rehabilitación (fisioterapia más infiltración de toxina botulínica), presentando una evolución muy favorable, eludiendo la intervención quirúrgica. Dados los resultados hallados en nuestro estudio y la bibliografía revisada, postulamos que un programa de Rehabilitación en la enfermedad de Perthes puede proporcionar ganancia del recorrido articular y aumento de la fuerza muscular; proponiendo el tratamiento rehabilitador (infiltración de toxina botulínica más fisioterapia) como una posible opción terapéutica para aquellos pacientes con pronóstico más incierto (grupo B/C y edad menor de 8 años), donde el tratamiento quirúrgico no ofrece total garantía de éxito (AU)

The treatment of choice in Perthes disease is still controversial. Although there is no evidence in the literature that Rehabilitation modifies the natural history of disease, published studies have oriented towards benefits in terms of improvement in joint range, muscle strength and gait training. We report a case of an 8-year male patient with Perthes disease. He was included in the rehabilitation program (physiotherapy and botulinum toxin infiltration), showing very favorable evolution, and could avoid surgery. Given the results found in our study and the review of the literature, we have postulated that a Rehabilitation program in Perthes disease can provide gain in joint range and increased muscle strength, proposing rehabilitation treatment (botulinum toxin infiltration and physiotherapy) as a possible therapeutic option for patients with uncertain prognosis (group B/C and those under 8 years of age) in whom surgical treatment does not offer total guarantee of success (AU)

Evaluation of gait performance of a participant with Perthes disease while walking with and without a Scottish-Rite orthosis.

BACKGROUND: Scottish-Rite orthosis is one of the conservative methods used to treat Legg-Calvé-Perthes disease. As there was not enough evidence to show the effects of using this orthosis on reducing the loads applied on the limb, this research aimed to find the influence of this orthosis. CASE DESCRIPTION AND METHODS: A participant with Perthes disease on the left hip joint was recruited into this study to walk with and without the orthosis. The kinetic and kinematic parameters were collected by a motion analysis system and a Kistler force platform. FINDINGS AND OUTCOMES: No significant differences were noted between the hip joint flexion/extension range of motion and the moments between the sound side and the side affected by Legg-Calvé-Perthes disease. It may be concluded that use of orthosis may not have any positive effects to decrease the loads or to improve the alignment of the hip joint in participants with Perthes disease, as expected. CONCLUSIONS: The use of Scottish-Rite orthosis not only does not improve the containment of the hip joint, but also does not have any significant influence on loads applied on the joint during walking of the subject with Perthes disease. CLINICAL RELEVANCE: The results of this research can be used by clinicians involved in treatment of patients with Legg-Calvé-Perthes disease.

Amplitude de movimento articular do quadril em pacientes com a doença de Legg-Calvé Perthes / Evaluation of the hip range of motion in patients with the Legg-Clavé-Perthes disease

Objetivo: Quantificar e comparar os valores da amplitude de movimento articular (ADM) dos quadris acometidos e dos quadris não acometidos em pacientes com doença de Legg-Calvé-Perthes (DLCP), com envolvimento unilateral e que apresentavam indicação para tratamento conservador. Métodos: Estudo prospectivo incluindo 20 pacientes com DLCP unilateral. Nos pacientes, foram avaliados os parãmetros da ADM dos quadris acometidos e não acometidos pela doença, pelo mesmo avaliador antes do início do tratamento conservador. Resultados: Observou-se uma diminuição dos valores de todos os movimentos articulares nos quadris acometidos quando comparados com os quadris não acometidos, conforme a análise estatística realizada para: flexão (p=0,002); extensão (p=0,020); abdução (p menor que 0,0001); adução (p=0,004); rotação medial (p=0,003) e rotação lateral (p=0,004). Conclusão: Verificou-se que os pacientes com DLCP unilateral que com indicação para o tratamento conservador apresentam uma restrição da ADM do quadril acometido em todos os movimentos desta articulação quando comparados com o lado não acometido.

Tratamento fisioterapêutico da doença de Legg-Calvé-Perthes: relato de caso / Physical therapy for Legg-Calvé-Perthes disease: case report

Um paciente com a doença de Legg-CalvéPerthes (DLCP), submetido a tratamento fisioterapêutico, foi estudado prospectivamente objetivando verificar os benefícios da modalidade terapêutica, por meio de avaliações físicas e radiográficas...

A patient with Legg-Calvé-Perthes disease (LCPD), submitted to physical therapy, was studied prospectively in order to assess the benefits of the treatment proposed, by means of physical and radiographic evaluation...

Evaluation of physiotherapy in the treatment of Legg-Calvé-Perthes disease.

INTRODUCTION: Physiotherapy using muscle strengthening and stretching exercises is claimed to have beneficial effects in the treatment of Legg-Calvé-Perthes disease; however, no scientific evidence is available concerning effectiveness of treatment. PURPOSE: The purpose of the present study was to clinically evaluate possible effects of the proposed physiotherapeutic effects compared to observational follow-up in patients with Legg-Calvé-Perthes disease. METHOD: A prospective follow-up study was conducted in 17 patients with unilateral Legg-Calvé-Perthes disease, divided into 2 groups: Group A (observational follow-up) and Group B (physiotherapeutic follow-up). In order to evaluate the outcome of the adopted treatments, the following parameters were assessed: articular range of motion, level of muscular strength, level of articular dysfunction, and radiographic status, both before and after the treatment. RESULTS: Group B exhibited significant improvement in articular range of motion concerning hip flexion, extension, abduction, adduction, medial rotation, and lateral rotation, while in Group A an equally significant worsening occurred concerning abduction, adduction, and medial rotation. Muscular strength also improved in Group B, mainly in the set of hip flexor muscles, while Group A showed no changes. Articular dysfunction after therapy compared to pretherapy was significantly reduced in Group B and increased in Group A. Patients undergoing physiotherapy exercises showed no changes in their radiographic features. CONCLUSION: Physiotherapy produced significant improvement in articular range of motion, muscular strength, and articular dysfunction in patients with Legg-Calvé-Perthes disease, but these improvements were not evident on radiographs.

Abordagem fisioterapêutica em crianças com doença de Legg-Calvé-Perthes submetidas à instalação do artrodistrator: estudo de caso / A physical therapy approach to legg-Calvé Perthes disease in children submitted to artrodistractor

Este trabalho visou avaliar a proposta de um protocolo de tratamento fisioterapêutico em uma criança de 8 anos com doença de Legg-Calvé-Perthes, submetida à instalação do artrodistrator. O protocolo de tratamento foi realizado duas vezes por semana durante os sete meses de acompanhamento do paciente, que permaneceu cinco meses com o equipamento. O tratamento fisioterapêutico constituiu-se de exercícios para ganho de amplitude de movimento (ADM) e função muscular / This study was designed to evaluate a physical therapy treatmnet (PTT) in a eight-year old male child Legg-Calvé-Perthes disease submitted to artrodistractor equipment, used to perform head femur distraction. PTT consisted of range of motion (ROM)exercises and hip and knee strength muscle training...

Classificação e tratamento fisioterapêutico da doença de Legg-Calvé-Perthes: uma revisão / Classification and physical therapy of the Legg-Calvé-Perthes disease: a review

Embora a doença de Legg-Calvé-Perthes (DLCP) seja estudada desde o início do século XX, ainda hoje se discute sua etiologia. Basicamente, consiste em uma interrupção do suprimento sanguíneo que leva a isquemia na cabeça do fêmur. Em geral afeta crianças entre 2 e 12 anos, numa proporção de 4 meninos para uma menina, ocorrendo bilateralmente em 10 por cento a 20 por cento dos casos. O quadro clínico é bem definido, com dor referida no joelho ou na coxa, claudicação e perda do movimento articular do quadril. Não há consenso sobre a melhor forma de tratamento.

Although the Legg-Calvé Perthes disease (LCDP) has been studied since 1909, its obscure etiology is still under discussion. It is known that an interruption of blood supply causes ischemia of the femoral head. Typically it affects children aged 2 to 12 years old, with a male-to-female ratio of 4:1, occurring bilaterally in 10 per cent to 20 per cent of the cases. The clinical report is well defined: pain at the knee or thigh, limp, and loss of articular hip motion...

[Nonoperative treatment in Legg-Calvé-Perthes disease]. / Die nichtoperative Therapie des Morbus Perthes.

There is still discussion about the indication for and modalities about treatment of Perthes'disease. The main objective of treatment in Perthes'disease is prevention of deformation and malalignment of the hip joint. Most important for the evaluation of any therapy is the long term outcome, therefore we present this retrospective study on nonoperative treatment of perthes disease with orthoses compared to the natural history. 54 Patients with 59 involved hips, treated between 1945-1975 were clinically and radiologically evaluated. We divided the patients into two subgroups: Group 1 with nonoperative therapy. Group 2 with no therapy. The outcome shows correlation of the results with the degree of malalignment and necrosis. There was no statistically significant correlation between the two groups, but a slightly better outcome in the non-operative group compared to the natural history. The use of orthosis may be justified if there is improvement of the containment and reduction of the femoral head, otherwise surgical treatment like pelvic- and hip osteotomies to realign the hip joint should be considered.

Perthes-like changes in geleophysic dysplasia.

Geleophysic dysplasia is a rare skeletal dysplasia characterised by 'happy natured' facies, short stature with short limbs, brachydactyly, and joint contractures. This report describes a case of a patient with unilateral Legg-Calvé-Perthes-like changes associated with dysplastic proximal capital femoral epiphysis, typical to geleophysic dysplasia.

Preliminary report on usefulness of magnetic resonance imaging for outcome prediction in early-stage Legg-Calvé-Perthes disease.

The usefulness of magnetic resonance imaging (MRI) for predicting prognosis was evaluated in 11 patients with unilateral early-stage Legg-Calvé-Perthes disease who were treated with a non-weight-bearing abduction brace. Six to 10 months after disease onset, severity of cartilage hypertrophy and physeal curvature of the femoral head were scored on MRI. Femoral head deformity was radiographically evaluated. Among five patients whose MRI score was 8 or greater, radiographic evaluation after the treatment was "poor" or "fair," whereas evaluation for the other six patients whose MRI score was 7 or less was "good." The MRI scores indicated possible occurrence of femoral head deformation. Treatment method should be considered carefully when the MRI score is high.

Different methods of treatment related to the bilateral occurrence of Perthes' disease.

We treated 98 consecutive patients with Perthes' disease by a unilateral brace in external rotation, flexion and abduction and a further consecutive 110 by a bilateral cast with the hips in internal rotation and abduction. During treatment in the unilateral brace, six (6.1%) hips on the opposite side developed evidence of Perthes' disease and one developed this after the brace had been removed. In children managed in bilateral casts, no contralateral Perthes' disease was seen. Adequate containment of the femoral head may prevent subsequent changes in the opposite hip.

[Perthes disease--results of a containment-oriented therapy concept]. / Morbus Perthes--Ergebnisse eines am Containment orientierten Therapiekonzepts.

INTRODUCTION: In a retrospective study a treatment concept for Perthes' disease dependent on the containment was applied. PATIENTS/METHODS: 49 hips of 41 children (9 female, 32 male) were treated between 01. 01. 1990 and 31. 12. 1995. In our concept of treatment a varus femoral osteotomy was performed in 28 cases with not contained hips or less than 4/5 coverage of the femoral head (X-ray/MRI). The other 21 well contained hips with 4/5 coverage or more were treated conservatively with physiotherapy and in case of joint effusion and pain additionally with the use of crutches (partial weight bearing) and anti-inflammatory medication. The average age in the non-operative group at the time of first investigation was 4 years and 9 months (3 y./1 m. to 7 y./1 m.) and 6 years and 3 months (4 y/2 m. to 10 y/0 m.) at our last examination (mean follow up 17.7 months, range of 6 to 72 months). At the time of indication for a varus femoral osteotomy the patients had an average age 6 years and 1 month (3 y./6 m. to 10 y./2 m.), the mean age at the last postoperative examination was 7 years and 11 months (4 y./8 m. to 12 y./5 m.) with an average follow up of 21.5 months (6 to 77 months). RESULTS: For the conservatively treated children we achieved good results (still well contained hips with 4/5 coverage, no decrease of function, no increase of pain) in 85.7% (18 of 21 cases). In 85.7% (24 of 28 cases) we found good results (well contained hips, increase of coverage, no decrease of function, no increase of pain) in the operation group. CONCLUSIONS: The presented concept of therapy in Perthes' disease was practicable for all patients and included the possibility of decision for operative or non-operative treatment. In both groups we achieved good results in 85.7% of the cases.

Efeito biológico da osteotomia de Alter sobre o curso da doença de Legg-Calvé-Perthes, nos estágios de necrose e fragmentaçäo / Biologic effect of Salter\"s inominate osteotomy in legg-Calvé-Perthes diseases during the stages of necrosis and fragmentation

Os autores trataram um total de 43 pacientes portadores da doença de Legg-Calvé-Perthes (DLCP), sendo 18 deles (19 quadris) em estágio de necrose e 25 em est gio de fragmentaçäo. O método de tratamento utilizado foi a osteotomia de Salter. Todos os pacientes (19 quadris) em estágio de necrose foram incluídos no grupo B de Salter & Thompson. Dentre aqueles que se encontravam na fase de fragmentaçäo, 18 pacientes (18 quadris) foram classificados no grupo 3 de Catterall e sete (sete quadris), no grupo 4. Em relaçao à classificaçäo artrogr fica de Laredo, 31 quadris pertenciam ao grupo III e 13 quadris, ao grupo IV. Os pacientes deste estudo foram acompanhados radiograficamente até que a epífise femoral proximal mostrasse sinais de reossificaçäo, tendo sido analisado o tempo necessário para que tal fato ocorresse. As crianças operadas durante o estágio de necrose evoluíram rapidamente para o estágio de fragmentaçäo (tempo médio de 3,01 meses); a passagem deste último estágio para a reossificaçäo näo foi abreviada (6,36 meses, em média). A duraçäo total da doença, desde a fase de necrose até a de reossificaçäo, foi diminuída (9,25 meses, em média) à custa do efeito biológico da osteotomia de Salter durante o estágio de necrose da DLCP. Esta operaçäo, quando realizada no estágio de fragmentaçäo, promoveu reossificaçäo mais rápida da cabeça femoral, a qual ocorreu num tempo médio de 3,5 meses.

[A treatment principle with questionable effectiveness in Perthes disease]. / Ein Behandlungsprinzip mit fragwürdiger Wirksamkeit bei Morbus Perthes.

The reduction of hip joint forces is a generally accepted part of the conservative treatment of Perthes disease. To reach this effect with help of splints (e.g. Thomassplint and the following models) does not seem to be efficient enough even from a clinical point of view. Theoretical considerations of former investigations of other authors point out the insufficient effect of these splints regarding the hip joint force reduction during the weight bearing phase in walking. The effect of these splints during the non-weight bearing phase in walking with regard to the hip joint forces has not been investigated so far. Therefore this paper is dealing with the forces onto the hip joint during the swinging phase of the leg with a splint, shown in a simplified, mechanical model. The results reveal significantly higher hip joint forces if the splint is used compared to the physiological forces during the swinging phase which in a static situation rise up to twice the body weight. These joint loadings are important because they occur during hip flexion and therefore cause pressure on the ventro-cranial part of the head of the femur, a region which unfortunately is often involved in Perthes' disease and therefore especially vulnerable to these forces. From a biomechanical point of view the principle of reducing the hip joint forces with splints has to be abandoned.

O valor da reabilitaçäo no tratamento de pacientes portadores de doença de Legg-Calvé-Perthes submetidos à osteotomia de Salter modificada / The value of rehabilitation in treatment of patients with Legg-Calvé-Perthes disease submitted to modified Salter osteotomy

No período compreendido entre janeiro de 1987 e agosto de 1990, 28 pacientes portadores de DLCP foram tratados cirurgicamente pela osteotomia de Salter modificada e acompanhadas no Setor de Fisiatria do Departamento de Ortopedia e Traumatologia da Escola Paulista de Medicina, no sentido de se verificar a influência de um tratamento fisiátrico reabilitacional sobre os resultados clínicos finais. Os pacientes foram avaliados clinicamente de modo padronizado em relaçäo aos dados mensuráveis, que chamamos de grau de disfunçäo articular (goniometria, força muscular e discrepância de membros), e àqueles observáveis (postura e marcha), denominados por nós grau de alteraçäo de postura e marcha em três ocasiöes pré-operatório, pós-operatório e avaliaçäo final. No pré-operatório foram feitos exames radiológico e artrográfico, objetivando a determinaçäo da fase da doença e do grau de comprometimento da cabeça do fêmur. Pôde-se observar uma média de idade de 6,9 anos, variando de 3 a 10 anos, com predomínio do sexo masculino (75%). No pós-operatório, todos os pacientes foram encaminhados para tratamento de reabilitaçäo. Nessa ocasiäo, de modo espontâneo, foram estabelecidos dois grupos de pacientes: os que fizeram reabilitaçäo (grupoI) e os que näo fizeram (grupo II). Na análise dos resultados, pôde-se notar que, clinicamente, todas as crianças estavam piores do ponto de vista cinético postural na avaliaçäo pós-operatória em relaçäo à avaliaçäo inicial, e que elas melhoraram por ocasiäo da avaliaçäo final, especialmente as do grupo I, que fizeram tratamento reabilitacional. O tratamento reabilitacional foi positivo nos pacientes considerados inicialmente graves e moderados, tanto para o grau de disfunçäo articular como para o grau de alteraçäo de postura e marcha. A ausência desse tratamento influenciou negativamente mesmo os pacientes iniciais leves, especialmente quanto ao grau de alteraçäo de postura e marcha, que notamos ser a disfunçäo mais persistente. Além disso, o tratamento reabilitacional favoreceu especialmente as crianças novas, notadamente as do sexo masculino

[Splint treatment of Perthes disease]. / Schienenbehandlung bei Morbus Perthes.

In Perthes' disease the necessity of any treatment and its management has to be considered carefully. Good results are reported after treatment with various splints as well as after surgery. According to Imhäuser we prefer a position for the hip joint in the splint in 30 degrees flexion, abduction and external rotation respectively. In this position the lowest intraarticular pressure was measured. If deterioration of the containment develops while using a splint, we recommend surgical treatment.