Legg-Calves Perthes (LCPD) Presented By: Caroline Kreuz and Katie Mullen

What It Is Temporary disease in which the proximal femoral head loses blood supply leading to avascular necrosis Insidious and idiopathic Leads to fractures and collapsing of the femoral head

Prevalence Rare! 4-10 per 100,000 children (Nelitz et al, 2009) 1

How It Presents Limp due to pain No known cause for pain Exam usually shows limitations in hip IR and ABD. Imaging is done 3 Stages of progression: Necrosis of femoral head (several months - 1 year) Fracture and fragmentation (1 - 3 years) Revascularization and remodeling (several years) 1

Who’s Affected? Most commonly diagnosed at 5 to 12 years of age, although LCPD can occur in younger children And in children up to 14 years of age (Dillman and Hernandez, 2009). More common in boys than girls the ratio has been estimated at four to one (Nelitz et al, 2009; Terjesen et al, 2010) Usually occurs unilaterally 10% of cases are bilateral

Clinical Ramifications Early recognition of LCPD is more likely to lead to prompt treatment, which increases ability to preserve the hip joint function, and thereby increasing the likelihood of a good clinical outcome (i.e. minimal function deficit to the joint) (Dillman and Hernandez, 2009). If LCPD develops before the age of 6, hip can self correct. If not properly treated (or treated too late) can cause degenerative arthritis in early adulthood. Treatment is going to vary depending on child’s age Aim of treatment: maintain the structural stability of the femoral joint in the hip retaining joint mobility. 4 1

The Use of Orthotics Orthoses in combination with PT are really the go-to non-surgical treatment Petrie Cast Scottish Rite Orthosis In the past, bed rest with traction and WBing brace was used Lack of loading, however can lead to muscle wasting Now, aim is to limit high impact activities Surgical treatment is also an option Osteotomy Tenotomy More likely for children with poor prognosis Older More damage to the femoral head 5 1 Petrie Cast: made with a bar between the legs to help maintain abduction. role in short-term treatment in patients with deformed femoral heads before complete reossification. Holds the femoral head in the optimal position in the socket for healing Scottish Rite: has hip hinges while still maintaining abduction. contains the femoral head in the acetabulum, prevent further deformity, and allowing remodeling without limiting activities The ideal brace provides abduction of each extremity great enough to prevent swinging and hip adduction on the involved side. Usually wore these braces from 1 year to 1 year and a half full time Family plays a pivital role in the the child wearing orthosis Overall: present literature does not provide evidence sufficient to support the use of bracing in LCPD.

ABC: Cameron’s Story https://www.youtube.com/watch?v=Q5B7MPfuvU8 Stop at 3 min

Case Study: Bernard Pain in R leg 2 months prior to 8th birthday 6 Pain in R leg 2 months prior to 8th birthday Parents thought he pulled a muscle in his quads Pain increased, R foot turned in & started limping Diagnosed with LCPD at 8 yrs, 2 months No pain and full ROM in L hip Abduction: 45° R Leg Painful Abduction: 25° Unable to IR hip Xrays showed LCPD increased in R leg over time

Determining Treatment Approach Arthrodiastasis vs. Osteotomy? Underwent arthrogram Osteotomy is the best option if an arthrogram shows a correction of twenty degrees or less is needed Arthrodiastasis is the best option if a correction of over twenty degrees is needed because an osteotomy is insufficient in such cases. Bernard’s arthrogram showed that over 20° was needed Arthrodiastasis was performed with mutliplanar EBI distraction External Fixator

Results Post Op Treatment Results Daily antibiotics to avoid infection. Physical therapy 2x per week to improve range of motion in knee and hip. Monthly follow-up appointments to check pin sites for signs of infection and progression of the right hip’s rehabilitation. Results Xrays showed Bernard’s hip was well positioned and there was an improvement in the hip’s range of motion. Over time his femoral head began to heal and take on a healthy rounded shape. However, he still limped External fixator was removed six months after surgery and he continued physical therapy to strengthen his hip and improve its range of motion. CONCLUSION By 10, Bernard had normal ROM and no pain in his hip He is now running and walking without limitations.

Sources Smith C. Increasing awareness of Legg-Calve-Perthes disease. Br J School Nurs. 2014;9(1):21-23. doi:10.12968/bjsn.2014.9.1.21. Legg-Calve-Perthes Disease. Boston Children's Hospital. http://www.childrenshospital.org/conditions-and- treatments/conditions/l/legg-calve-perthes-disease/symptoms-and-causes. Accessed July 5, 2016. Legg-Calve-Perthes disease. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/legg-calve-perthes- disease/basics/definition/con-20035572. Accessed July 5, 2016. Maxwell S, Lappin K, Kealey W, McDowell B, Cosgrove A. Arthrodiastasis in Perthes' disease. J Bone Joint Surg (Br). 2004;86(2):244-250. doi:10.1302/0301-620x.86b2.14284. Legg Perthes Disease Brochure. Nonforg. 2016. Available at: http://nonf.org/perthesbrochure/perthes-brochure.htm. Accessed July 6, 2016. Bernard: Legg-Calve-Perthes Disease | David S. Feldman, MD. David S Feldman, MD. 2016. Available at: http://www.davidsfeldmanmd.com/patient-education/case-studies/bernard-legg-calve-perthes#.V3xQe7grKhc. Accessed July 6, 2016. Hardesty CK, Liu RW, Thompson GH. The role of bracing in Legg-Calve-Perthes disease. Journal of Pediatric Orthopaedics. 2011;31:S178–S181. doi:10.1097/bpo.0b013e318223b5b1. Mazloumi SM, Ebrahimzadeh MH, Kachooei AR. Evolution in diagnosis and treatment of Legg-Calve-Perthes disease. Archives of Bone and Joint Surgery. 2014;2(2):86-92. https://www.youtube.com/watch?v=iF48euq1fZ0