Perthes Disease is a hip disorder in which a portion of the ball-shaped head (femoral head) of the thigh bone (femur) loses blood supply and dies. The femur or thigh bone has a ball-shaped end that fits into the hip socket to create a ball-in-socket joint. In a healthy individual, the bones of the body, including the femoral head, are nourished by oxygen-rich blood. If something disrupts the blood supply to the femoral head, the bone dies. The femoral head can become soft and misshapen during this disease process. This can lead to hip pain and subsequent hip arthritis.
Perthes Disease is characterized by four main stages, which occur in this order:
|Phase||Medical Name||What Happens||Length|
|1||Necrosis||A portion of the femoral head dies. This changes the shape of the femoral head and can cause pain, stiffness, and inflammation.||Up to 1 year|
|2||Fragmentation||The dead cells are absorbed by the body and can be replaced by new, healthy bone cells. As the new femoral head is formed, it is “remodeled” producing varying femoral head shapes.||1-3 years|
|3||Reossification||The femoral head continues to grow with new bone cells.||1-3 years|
|4||Remodeling||The new bones cells are gradually replaced by normal bone cells, and remodeling continues.||1-3 years or more|
Perthes Disease is also called Legg-Calve-Perthes Disease, LCPD, ischemic necrosis of the hip, coxa plana, osteochondritis, and avascular necrosis of the femoral head. It is a form of osteonecrosis, and literally means “bone death.”
The underlying cause of Perthes Disease is not known. The various processes that occur in Perthes Disease are caused by an interruption of blood supply to the femoral head. With our present state of medical knowledge, Perthes Disease cannot be prevented.
Parents typically first notice that the child walks with a limp or complains of pain in the hip or groin. In some cases the pain occurs in other areas of the body (a phenomenon called “referred pain”) such as the knee. There may be limited mobility of the hip. When questioned by parents, the child usually cannot remember injuring the hip. Pain may be insignificant or absent in some patients with Perthes disease.
Any complaints of persistent hip pain should be evaluated by an orthopaedic surgeon. The evaluation should include a medical history, physical examination and x-rays of the hip. An MRI of the hip is also a common part of the hip evaluation.
Physicians use certain classification systems to help describe the progress of Perthes Disease. These classification systems analyze the extent of bone involvement, the location of the diseased bone and the shape of the femoral head and acetabulum. These characteristics of the hip assist in making an effective treatment plan. Children with Perthes Disease should be evaluated and treated by a pediatric orthopaedic surgeon. Adolescents and young adults with residual hip deformities from Perthes Disease should be evaluated by an orthopaedic surgeon with interest in joint preservation hip surgery. Dr. Clohisy has a specific interest in patients with residual Perthes deformities.
Patients with Perthes Disease may present for treatment in childhood with active disease or may present for treatment after skeletal maturity with residual Perthes Disease. In children, the goal of treatment is to make the resolution of the condition as speedy, painless, and successful as possible. If the remodeling of the femoral head is imperfect, patients are at risk of degenerative arthritis later in life. The results of treatment for Perthes are quite variable and largely depend upon the condition of the femoral head when the patient firsts consults with the physician. Active Perthes Disease in childhood is best managed by a pediatric orthopaedic surgeon.
There are some typical nonsurgical treatments for Perthes Disease:
In some instances, surgery may be appropriate. However, Dr. Clohisy does not treat Perthes Disease in young children. Surgical options (soft tissue releases, osteotomies and others) are best described by a pediatric orthopaedic surgeon.
Many patients seek care in adolescence or young adulthood (10-40 years) with hip problems from “residual” Perthes disease. These patients had Perthes during childhood producing a hip deformity that becomes problematic years later. These hips can have a variety of problems including a misshapen femoral head, short femoral neck, high greater trochanter, and a shallow hip socket. The hip may also have cartilage tears and/or arthritis. Treatment of these residual deformities is difficult and may include a surgical hip dislocation and/or a hip osteotomy. These procedures are outlined in other areas of the website. Joint preservation surgery to treat Perthes Disease is targeted at correcting the hip deformity, relieving pain, increasing activity and preserving the natural hip joint. Occasionally, the hip will be too arthritic for joint preservation surgery and a total hip replacement may have to be considered.
(Statistics from National Osteonecrosis Foundation.)