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Legg Calve Perthes Disease: Non Operative Treatment

- Discussion
    - principles of treatment are maintenance of ROM & containment of femoral head through the evolution of healing of the epiphysis;
          - in child > 5 yrs who has more than 1/2 of epiphysis involved, abduction bracing or surgery are methods of treatment currently employed;
    - improve ROM:
          - goal of treatment is containment w/ a well-covered femoral head w/ ROM of hips approaching normal;
          - initially PT may be required to reverse muscle spasm, and to regain abduction;
          - in younger child (< 5 yrs of age), this goal may be achieved by relief of wt bearing and supervising of ROM  exercises;
          - some patients may require several weeks of abduction traction;
    - containment:
          - theoretically, containment of the femoral head in the normal acetabulum during repair process may lead to a more sperical head and congruous joint;
                - containment is not clearly defined but generally implies 80 % coverage;
          - prevents extrusion and compression by acetabular rim;
          - bracing or surgery can achieve containment;
    - bracing:
          - wt bearing abduction orthosis is recommended for treatment of Perthes dz, but supporting data is controversial;
          - various types of braces are available but usually these consist of two long leg braces separated by an abduction bar;
          - keeping hip abducted and internally rotated, will transmit wt through acetabulum over a wide area of head, which prevents collapse of the bone;
          - bracing probably should not be started until abduction and internal rotation have been restored to the normal state (ie motion is restored);
                - initiation of bracing or surgical intervention when hip is stiff is avoided;
                - often, these patients will initially have a psoas and/or adductor contracture, and in  some cases, adductor tenotomy;
          - arthrography:
                - prior to bracing, consider arthrography to help judge congruency through out range of motion of the hip;
                - can demonstrate the best position for containment (ie full congruency), and can rule out hinge abduction;
                - coverage is adequate when abduction is at least 45 deg and lateral epiphyseal plate is covered by lateral margin of acetabulum;
          - improving radiographic signs of healing may indicate that patient may be weaned from bracing;
                - it takes from 2-3 years for complete reconstitution of child's femoral head following AVN;
          - cautions:
                - pain and spasm may lead to wide abduction of normal hip in orthosis, leaving LCP hip uncontained;
                - hinged abduction occurs when an enlarged femoral head is laterally extruded and impinges against the acetabular rim when the hip is abducted;
                - serial radiographs are needed every 3-4 months w/ ROM testing;
                - continue bracing until lateral column reossifies and sclerotic areas in epiphysis are gone;
                - should the uninvolved contralateral hip be included in the brace?
                       - in the study by Futami and Suzuki (1997), 6% of hips on the opposite side developed Perthes disease (98 hips), where as none of the children managed in bilateral casts developed Perthes disease (110);
                              - the authors felt that containment might prevent hips at risk for developing Perthes disease;
          - references:
                - Different methods of treatment related to the bilateral occurrence of Perthes' disease. 
                - The Scottish Rite abduction orthosis for the treatment of Legg-Perthes disease. A radiographic analysis.
                - The weight-bearing abduction brace for the treatment of Legg-Perthes disease.

 Current Concepts Review.  Legg-Calve-Perthes Disease.

 Current Concepts Review.  The Treatment of Legg-Calve-Perthes Disease.  A Critical Review of the Literature.

 Abnormalities of proximal femoral growth after severe Perthes' disease.

 Comparison of femoral and innomi of the femoral head.

 The arterial supply of the developing proximal end of the human femur.

 The natural history of Legg-Calve-Perthes disease.

 Legg-Calve-Perthes disease. The prognostic significance of the subchondral fracture and a two-group classification of the femoral head involvement.

 A long-term follow-up of Legg-Calve-Perthes disease.

 Growth disturbance in Legg-Calve-Perthes disease and the consequences of surgical treatment.

 Prognosis in Perthes'  disease after noncontainment treatment. 106 hips followed for 28-47 years.

 Association of antithrombotic factor deficiencies and hypofibrinolysis with Legg-Perthes disease.

 An evaluation of various methods of treatment for Legg-Calve-Perthes disease.

 Physeal slope in Perthes disease.