PT Classroom - Legg-Calve-Perthes Disease - A Pediatric Disease ׀ by Kristin Konicek, DPT

 

Kristin Konicek, DPT graduated in 2008 from Marquette University with her Doctorate in Physical Therapy and a B.S. in Exercise Science in 2005. Kristin has experience in a variety of ages and patient populations including geriatrics, sports medicine, accident or work related injury and a variety of orthopedic disorders. Kristin is enthusiastic about making a difference in the lives of her patients and improving their quality of life. Her training includes manual therapy and she remains committed to ongoing education for the most up to date care. She is currently a physical therapist for United Hospital System in Kenosha, WI.



Legg-Calve-Perthes Disease - A Pediatric Disease

 

Legg-Calve-Perthes Disease is a pediatric disease which affects the femoral head. The disease is an avascular necrosis of the femoral head always including the capital femoris epiphysis. Legg-Calve-Perthes Disease (LCPD) affects 1 in 1200 children with boys more than girls, 4:1 (6). LCPD shows up mostly in the Caucasian race. Most often the disease is unilateral but a small percentage of children with LCPD do develop the disease in bilateral hips. Most children are diagnosed between 6 to 9 years of age with a range from 2 to 12 years old (6). The disease will manifest itself and recover within a year or a few. The disease is also called coxa plan or osteochondritis of the femoral head.

The initial pathology which causes the avascular necrosis of LCPD remains unknown. Doctors have hypothesized LCPD may be initiated by trauma, synovial effusion, infection, vascular occlusion, constitutional predisposition, and genetic factors (8). The cause may be described as a vascular tamponade of the artery which supplies the femur. The femoral head and neck have limited blood supply so it is more susceptible to ischemia. The first signs and symptoms of LCPD may manifest at anytime in childhood. Some symptoms may be a limp or pain in the hip or referred pain to the inner thigh and knee area. Some signs may include limited hip range of motion especially limited hip abduction (7). There is usually not a precipitating incident which causes the pain. The onset is insidious in nature. Diagnosis of the disease must be done by radiographs, MRI, or bone scan (6).

There are four stages where Legg-Calve-Perthes Disease progresses through. The first stage lasts 6 to 12 months and the femoral head becomes more dense with possible fracture of supporting bone (exact). Phase two consists of fragmentation and reabsorbtion of the bone and takes one year or more. Phase three is reossification when new bone has regrown and may take years. Phase four is healing and may also take years (6).

The disease can affect part or all of the femoral head depending on severity of the case. The prognosis may be better in younger children because the regrowth of the femoral head is shaped better for congruency (6). The Catteral Classification has four different groups to classify defined by radiograph appearance in the greatest period of bone loss. An article by Van Dam et al. concluded that the Catteral Classification is valid, reliable and simple to use but needs to be classified after fragmentation of the capital epiphysis (9). The Salter-Thomson Classification takes the Catteral Classification and makes it only two groups for simplification purposes. Group A (formerly Catteral 1 and 2) which is less than 50% of the femoral head is involved. Group B (formerly Catteral 3 and 4) which is more than 50% of the femoral head is involved (6). A better prognosis is Group A over Group B. The Herring Classification looks at the lateral pillar of the ball of the femoral-acetabular ball and socket joint. In group A, there is slightly density change and no loss of height in the lateral 1/3 of the femoral head. Group B there is loss of height of less than 50% total height and lucency of the bone. Group C is when there is more than 50% of lateral height (6).

As children grow there are many different types of diagnoses besides LCPD which may cause hip pain in children. It is important to do a thorough history taking and physical examination to help determine what the cause of the hip pain is to differentially diagnose the disease. One of the first causes may be from a septic hip joint in which rapid diagnosis is important so as not to cause impaired blood flow to the joint. Major signs and symptoms of the sepsis will be fever, pain, and inability to stand. Radiographic findings include widening of the joint space. Treatment includes surgical drainage and antibiotics. Another reason for pediatric hip pain may be osteomyelitis. Osteomyelitis is inflammation of the bone and its structures secondary to infection. This diagnosis may have a history of trauma. This is characterized by fluid in the joint and signs include pain with standing, pain with hip range of motion, and maybe a low grade fever. Treatment is rest and analgesics for pain which may last for a few days. Another cause of hip pain may be slipped capital femoral epiphysis which is a fracture of the growth plate leading to slipping of the epiphysis. For 10-15 year olds, incidences in males are greater than in females. The child may often be overweight, ambulate with foot externally rotated, and have pain with internal rotation. Treatment is surgery to repair the joint. Another cause of pediatric hip pain is Osteoid Osteoma which is a benign bone tumor common in the demur and tibia. Treatment is surgery. Malignancy, rheumatologic disease. And trauma are other causes of hip pain (2).

Treatment of Legg-Calve-Perthes Disease will differ depending on progression and severity of disease. For mild LCPD treatment may only include physical therapy exercises to maintain range of motion. Non-surgical treatment can include crutches for non-weight bearing for decreased pain. Braces and casts can help to regain mobility of the hip joint. Braces may often help in hip abduction for better joint congruency. Surgical treatments may include tenotomies or osteotomies. Tenotomies may be needed to lengthen a shortened muscle due to antalgic gait (6). Osteotomies are done to reposition the femoral-acetabular joint for maximal congruency. Osteoomies are either done of the pelvis to reposition a shelf superior to the joint or to the femur to reposition the joint for congruency. The destruction of the bone from LCPD changes the shape of the femoral head. A prospective study by Herring et al. looks at the effects of treatment of Legg-Calve-Perthes Disease (3). The study looked at five different treatments of LCPD which included no treatment, brace treatment, range of motion exercises, femoral osteotomy, and innominate osteotomy. The study found that lateral pillar classification and age of onset were determining factors in outcome of the disease. There were no differences within conservative treatments of no treatment, bracing, or range of motion. There were also no differences in which osteotomy was performed. The study showed that treatment did not have a great effect if the children were less than 8 at age of onset. If the age of onset was greater than 8 years of age the treatments had a better outcome. In those patients in Herring lateral pillar B classification, operative treatments had better outcomes than non-operative treatment. In Herring C classification the treatment outcomes were poor for operative and non-operative treatments (3).

One study by Westhoff et al. looked at the gait abnormalities that can happen with LCPD. The study found a trendelenburg gait pattern or a compensated trendelenburg gait pattern in children with LCPD. The trendelenburg gait pattern consists of a drop in the contralateral pelvis in stance of the affected hip. Compensated trendelenburg gait pattern results in an ipsilateral trunk lean to the affected side. The compensated trendelenburg leads to a decreased hip abductor moment arm which is correlated with a decrease in loading of the ipsilateral hip joint (1). LCPD patients have weak hip abductors which lead to the deviations in gait.

One article by Koob et al. looks at the growth of bone and cartilage following ischemic osteonecrosis of the femoral head (5). The study produced ischemia in the femoral head of piglets and looked at an 8 week follow-up and studied different components of the bone. The bone core strength remained lower throughout the eight week study and became progressively lower in the ischemic head (5). The control for the study was the contralateral hip.

Patients with Legg-Calve-Perthes Disease may receive a variety of treatments from conservative to surgical. Since disease is insidious in onset and progressive, it may make any potential benefits from physical therapy hard to determine. In the study by Herring et al. (3), they found no significant evidence to support that physical therapy would help versus no treatment. However, children with LCPD may have functional deficits such as an antalgic gait with subsequent weakness and loss of range of motion. Physical therapy may help maintain range of motion and hip strengthening which are two factors that are decreased with this disease and worsen the antalgic gait. Patients will also need gait training with their orthoses or crutches for proper use. They may also benefit from aquatic therapy to allow for ambulation and strengthening exercises with decreased body weight that they need to support due to the buoyancy effects of the water. Physical therapy may also be beneficial after the disease has taken course and the bone rebuilding and regrowth has taken place. The children with LCPD will have disuse atrophy and will need to relearn gait so they no longer limp. Any additional exercises and stretching may be added to bone loading exercise to help the child back to pre-disease sate. Although physical therapy may not be needed consistently throughout the course of the disease, it may be beneficial at times for maintaining and regaining function.

 

Last revised: March 15, 2011
by Kristin Konicek, DPT

 

REFERENCES
1) Westhoff B et al. Computerized Gait Analysis in Legg-Calve-Perthes Disease: Analysis of the Frontal Plane. Science Direct. 2005;24:196-202.
2) http://pedclerk.bsd.uchicago.edu/hippain.html
3) Herring J eta al. Legg-Calve-Perthes Disease: Part 2 – Prosepctive Multicenter study of the Effect of Treatment Outcome. Journal of Bone and Joint Surgery. 2004;86:2121-2134.
4) Kim H et al. Histopathological Changes in Growth-Plate Cartilage following Ischmeic Necrosis of the Capital Femoral Epiphysis. Journal of Bone and Joint Surgery. 2001;83:688-697.
5) Koob T et al. Biomechanical Properties of Bone and Cartilage in Growing Femoral Head Following Ischemic Osteonecrosis. Wiley Interscience. 2006:750-757.
6) http://www.nonf.org/perthesbrochure/perthes-brochure.htm
7) http://www.emedicine.com/emerg/topic294.htm
8) Spect, E. Coxa Plana: Legg-Calves-Perthes Disease. Medical Progress. 1974:287-294.
9) Van Dam BE et al. Determination of the Catteral Classification in Legg-Calve-Perthes Disease. Journal of Bone and Joint Surgery. 1981;63:906-914.



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