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

2. 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

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

4. 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

5. 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

6. 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

7. 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.

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

9. Case Study: Bernard Pain in R leg 2 months prior to 8th birthday6
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

10. 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

11. 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.

12. Sources
Smith C. Increasing awareness of Legg-Calve-Perthes disease. Br J School Nurs. 2014;9(1): doi: /bjsn
Legg-Calve-Perthes Disease. Boston Children's Hospital. treatments/conditions/l/legg-calve-perthes-disease/symptoms-and-causes. Accessed July 5, 2016.
Legg-Calve-Perthes disease. Mayo Clinic. disease/basics/definition/con Accessed July 5, 2016.
Maxwell S, Lappin K, Kealey W, McDowell B, Cosgrove A. Arthrodiastasis in Perthes' disease. J Bone Joint Surg (Br) ;86(2): doi: / x.86b
Legg Perthes Disease Brochure. Nonforg Available at: Accessed July 6, 2016.
Bernard: Legg-Calve-Perthes Disease | David S. Feldman, MD. David S Feldman, MD Available at: Accessed July 6,
Hardesty CK, Liu RW, Thompson GH. The role of bracing in Legg-Calve-Perthes disease. Journal of Pediatric Orthopaedics ;31:S178–S181. doi: /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.