Treatments of Perthes Disease
Perthes disease is a highly variable and relativlely uncommon condition so it is best treated by a pediatric orthopaedic surgeon who has the clinical interest and expertise treating Perthes. In general, treatment decisions are based on the age at the onset of the disease, the stage of Perthes that the patient is currently in (Waldenström staging- see About Perthes), the amount of femoral head that is involved, and patient's symptoms and loss of hip motion.
The goals of treatment for patients of all ages with Perthes disease are to:
Restore and maintain good hip motion
Decrease the chance of hip arthritis later in life by preventing or minimizing deformity of the femoral head (ball part of hip joint) and help it reform as round as possible
Please note that the treatments discussed in this section are generalizations and not all treatments mentioned are appropriate for every patient.
- Pain control: take analgesic (like Tylenol) or anti-inflammatory medications (like Motrin or Naprosyn) if needed for short time (few days)
- Activity restrictions: avoid running, jumping, long walks, and sports
- Crutches or walker: minimize pressure on hip while walking
Wheelchair: takes the pressure off the hip
- Physical therapy: maintain hip motion and flexibility
- Traction: improve motion and flexibility and decrease pain
- Casts and braces: help to improve motion and keep the ball positioned in the socket
Children may benefit from surgery to keep the ball in the socket and improve the chances of achieving a more round ball as the bone regrows.
- Adductor tendon release – A tight groin muscle is released to increase the hip motion called abduction and allow the ball to be put into the socket. Petrie casts are placed to hold the hip in this position.
- Osteotomy – femoral, pelvic, or both bones of the hip are cut surgically for re-orientation. This will allow the ball to be better covered by the socket. This may help the ball regrow into a more round in shape.
What new treatments are being performed?
It is important to note that newer treatments offer potential benefit of improving bone healing but they do not have the track record yet and they have not been researched to the same extent as the conventional treatments described above.
Hip distraction – Pins are temporarily placed through the skin into the pelvic and the femur bone to increase the space between the ball and socket (i.e. distraction or pull apart slightly). The increased space reduces pressure on the ball and decreases the chance of the ball healing with a flattened shape. This procedure is also known as hip arthrodiastasis.
Core decompression is a treatment used in adult avascular necrosis in which a hole is drilled into the femoral head and the dead bone is removed. Drilling this hole is thought to relieve pressure inside the femoral head to help alleviate pain. It also provides a potential new pathway for new blood vessels and healing cells to enter the femoral head. Core decompression has been utilized successfully in adults with early stage avascular necrosis of the hip before femoral head deformity occurs.
Multiple epiphyseal drilling and femoral neck tunneling are variation of this concept of providing new pathway for new blood vessels and healing cells to enter the femroal head. In multiple epiphyseal, many small holes are made instead of one large hole to increase the number of pathways. The holes can be targeted to the area of femoral head that is most affected on MRI.
Bone marrow aspirate concentrate (BMAC) injection involves taking a child’s own bone marrow cells which are then concentrated by removing some cells (the plasma and red cells). The remaining cells are injected into the femoral head through a core decompression. The injected cells potentially differentiate into blood cells, bone cells, and fibrous cells which may speed up the healing process.
Bisphosphonates are medications that slow down bone loss and are used frequently in the treatment of osteoporosis. Investigators are trying to determine if bisphosphonates, either taken by mouth, intravenously (IV) or by direct injection into the femoral head will slow down femoral head collapse in Perthes disease and lead to a better long-term outcome. This treatment is considered experimental at this time. IPSG is planning to perform a clincial study using bisphosphonate in the future.