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Causes, symptoms and treatment of Legg-Calvet-Perthes disease in children, hip surgery

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Perthes hip disease develops in children between the ages of two and thirteen, this ailment is very dangerous if you do not start treatment in time, because the child can remain disabled for life. At the early stage, Perthes disease is very difficult to diagnose, it all starts with small periodic pains in the hip joint.

Currently, the exact causes of the disease are unknown, the most likely cause of injury in the hip joint.

Even if the treatment is started on time, it is likely that the child will not be able to bear the burden until the end of his life and his work should not be standing. About what symptoms are present in Perthes disease in children, methods of diagnosis and treatment, read later in this article.

Perthes disease - what is it

Perthes disease is a pathological process characterized by impaired blood supply and subsequent necrosis of the femoral head. It is a fairly common disease and accounts for about 17% of the total number of osteochondropathies. Suffer children aged 3 to 14 years. Boys are sick 5-6 times more often than girls, however girls have a tendency to more severe course. Both unilateral and bilateral lesions are possible, with the second joint usually suffering less and recovering better.

Currently, a single cause of Perthes disease has not been identified. It is believed that this is a polyetiological disease, in the development of which a certain role is played by both the initial predisposition and metabolic disorders, as well as the influence of the external environment.

According to the most common theory, Perthes disease is observed in children with myelodysplasia - congenital hypoplasia of the lumbar spinal cord, a common pathology that may not manifest itself or cause various orthopedic disorders.

In myelodysplasia, the innervation of the hip joints is disturbed, and the number of vessels delivering blood to the tissues of the joint decreases. Simplified, it looks like this: instead of 10–12 large arteries and veins in the region of the femoral head, the patient has only 2–4 underdeveloped vessels of smaller diameter.

  • Because of this, the tissues constantly suffer from insufficient blood supply. A change in vascular tone due to a violation of innervation also has a negative effect.
  • In relatively unfavorable conditions (with partial clamping of the arteries and veins due to inflammation, trauma, etc.) in a child with a normal number of vessels, the blood supply to the bone deteriorates, but remains sufficient.
  • In a child with myelodysplasia in similar circumstances, blood completely stops flowing to the head of the thigh.
  • Due to the lack of oxygen and nutrients, part of the tissue dies off - a site of aseptic necrosis is formed, that is, necrosis, which develops without germs and signs of inflammation.

Perthes symptoms

At an early stage in the development of Perthes disease, most children do not feel any painful symptoms that may be cause for concern or complaints to parents.

It is believed that the first symptom of Perthes disease is a decrease in motor activity and a feeling of lightness in the pelvic region, which leads to the fact that usually an active child quickly feels tired and switches to less mobile types of games.

As necrosis develops in the head of the hip, symptoms appear that are felt not only by the child, but also noticeable to the parents. There are a number of symptoms characteristic of the different stages of the Perthes disease in children of different ages.

  1. Moderate pain. As a rule, the child feels pain in the hip, groin, inner thigh or knees. These pains are transient and manifest in most cases after prolonged physical activity. Often, the gap between the manifestations of pain symptoms can be quite long and exceed a week, and in some cases a month.
  2. Lameness.
  3. Gait disturbance. In some children, even in the absence of painful sensations, crouching on one leg is observed. This is quite noticeable from the outside, but the child himself may not notice that his gait has changed somewhat, and not experience any discomfort.

The manifestation of the rapid development of the disease

It should be noted that in cases where the disease develops rapidly, the symptoms appear in a more pronounced form, as there are changes in the anatomy of the joint, which entails a number of manifestations. The most common symptoms of the rapid course of the disease include the following manifestations:

  1. Severe pain when walking or minimal activity.
  2. Weakness in the muscles of the buttocks.
  3. Decreased leg mobility.
  4. Swelling in the joint area.
  5. Severe lameness.
  6. Increase in body temperature to 37.5 ° C.
  7. Leukocytosis.
  8. Cold feet.
  9. Foot sweats.
  10. Desensitization in the toes.
  11. Wrinkling of the skin of the legs.

Symptoms in the acute course of Perthes disease are almost not relieved after a long rest. Such overt symptoms are a strong cause for concern.

Stages of development of Perthes disease

Perthes disease during its development goes through 5 stages, each of which is characterized by its changes in the structure of the joint. At the first stage of the development of the disease, it is still impossible to identify any changes in the condition of the joint in X-ray photos.

Despite the fact that there are no visible abnormalities on the X-ray photo, the development of the joint and blood vessels slows down in the first stage. Reduced blood supply leads to the beginning of the destruction of the tissues of the femoral head, but the affected areas are insignificant in area, and therefore do not affect the X-ray photo.

  • At stage 2 of development, a so-called secondary fracture of the head of the same femur appears. When conducting X-ray studies on the photo already visible deformation changes, and in addition, there are external symptoms in children, in particular, the heaviness in the pelvic region and fatigue.
  • The manifestations of thinning and shortening of the femoral neck are characteristic of the 3 stages of the development of Perthes disease, which can lead to its fracture. Deformation processes at this stage are already visible on X-ray photos, there are characteristic external symptoms of the disease, and if adequate treatment is not prescribed at this stage, the outcome can be very unfavorable.
  • At stage 4 of the development of Perthes disease, there is a replacement of the cartilage tissue of the hip joint with connective tissue. This process leads to the complete destruction of the joint and extensive necrosis, since the connective tissue replaces precisely those cartilage tissues that are destroyed due to aseptic necrosis. This process is adaptive, since in this way the child’s body tries to compensate for the damaged cartilage tissue.
  • At stage 5 of the development of Perthes disease, connective tissue ossification occurs, which completely violates the mobility of the joint. In addition, many patients have observed the appearance of minor inflammatory processes in the area of ​​tissues adjacent to the injured joint.

An anatomical change in the structure of the joint, observed in the development of Perthes disease, responds well to treatment only in cases when the disease is diagnosed at stages 1-4. At stage 5 of the development of the disease, it is extremely difficult to completely get rid of the consequences of the disease, since there is an ossification of tissues that is difficult to correct.

Possible consequences of Legg's disease Calvet Perthes

Perthes disease is a serious disease of the musculoskeletal system, which does not always disappear without a trace. The favorable outcome of the treatment largely depends on the stage at which the disease developed and was diagnosed, and how much the hip joint was damaged at that time.

The most common effects of Perthes disease include osteoarthritis of the femoral head and residual permanent deformity of the femoral head.

Osteoarthritis of the femoral head is a complication characterized by a change in the parameters of the head of the tibia and the acetabulum.

These processes lead to the fact that there is a thinning of cartilage tissue at a young age, although such processes are usually inherent in older people. With this complication, most young patients need a complete replacement of the damaged hip joint with a prosthesis, otherwise the outcome will be extremely unfavorable.

Residual permanent deformation of the femoral head is observed in children who have undergone Perthes disease in late childhood, that is, in the period from 7 to 14 years.

In this case, an operation for a hip replacement of the joint and part of the femoral head may be prescribed, as otherwise the problem will only worsen, leading to a breakdown in the gait and gradual destruction of the joint.

Diagnosis of Perthes disease in children

In the event of the occurrence (even if partial) of this symptom in a child aged from two to twelve years, you should immediately consult a doctor. Perthes disease is reliably diagnosed with x-rays. X-rays reveal typical bone disorders. Concomitant complications (if any) that could worsen the prognosis for the course of the disease and its treatment are also identified. Among such complications:

  • lateralization (transition of the disease to the other side)
  • defeat of the metaphysis (adjacent to the head of the bone)
  • chalking head
  • horizontal position of the head (in normal form it should be directed diagonally upwards from the femoral tube)

Additional diagnostic examinations are also needed to determine the extent and nature of damage to the cartilage tissue of the joint.

Modern diagnostic methods are increasingly based on ultrasound. Innovative ultrasound equipment with digital decoding of signals and high resolution allows to assess the condition of the joint in more detail than an X-ray.

In the course of the diagnosis, thorough differentiating assessments should be conducted to eliminate suspicions of a range of diseases with similar symptoms:

  • aseptic or bacterial coxitis
  • hip head epiphysis
  • hip dysplasia
  • multiple epiphyseal dysplasia
  • spondioepiphysial dysplasia
  • Mayer's dysplasia
  • hypothyroidism (lack of thyroid hormones)
  • tumor formation

Basic method

The basic diagnostic method is still X-ray examination. We draw attention to the important possibilities of such, which are not always realized. If Perthes disease is suspected, radiography of both hip joints on a single film in a direct projection and in the position of Lauenstein must be made.

If structural changes in the epiphysis of the femoral head are not detected, comparative densitometry of both epiphyses and X-rays of both hip joints should be performed also in the rear projection in a mode that allows visualization of soft tissues (thickening of the shadow of the capsule, muscles), including by increasing the distance medial contour of the femoral neck - capsule, and thus identify the effusion in the joint.

The second basic method of early diagnosis is ultrasound (US).

  • This method, first of all, provides detection of effusion in the joint also by increasing the distance of the cervix-capsule.
  • In addition, it is possible to determine the infiltration (thickening) of the capsule, adjacent muscles and intermuscular spaces, proliferation of the synovial membrane.
  • All signs are evaluated in comparison with the contralateral joint.
  • The non-invasiveness of the ultrasound allows you to repeat the study after 2-4-6 weeks.
  • If the changes in the soft tissues cease to be visualized, this indicates transient synovitis, with which most often it is necessary to differentiate Perthes disease.

The above symptoms are characteristic of stage I of Perthes disease, which begins or is accompanied by synovitis, but not specific for it. However, all arthritis of any etiology combined, including transient synovitis, is less common than Perthes disease.

The main thing is that the treatment of all these diseases involves rest, unloading of the hip joint.

In the future, dynamic observation using R-graphy and ultrasound, along with clinical, laboratory and physiological studies, allows for differential diagnosis.

Diagnosis of individual cases

In some cases, we also used computed and magnetic resonance tomography (CT and MRI) for diagnosis. The sensitivity of these techniques, especially MRI, is higher and structural changes that are invisible on an ordinary radiograph can be visualized. However, not all hospitals have this equipment.

  • The study is expensive and time consuming. Sometimes it is necessary to perform anesthesia in children, so it is non-invasive only conditionally.
  • For the same reasons, we did not use scintigraphy. We consider its use in children only if a tumor process is suspected.
  • In addition to radiation diagnosis, laboratory diagnosis is important.
  • In any arthritis, as a rule, there is an accelerated ESR, leukocytosis, a shift of the formula to the left, with tuberculosis - lymphocytosis.

For Perthes disease, these changes are not typical. The changes in this case are moderate. Characteristic of the onset of Perthes disease is a change in the rheology of the blood, an increase in coagulability, which may be one of the causes of ischemia and heart attack of the bone. Physiological studies, computer thermography, reoplatysmography, polarimetry show a violation of regional blood circulation.

Perthes disease treatment

Perthes disease treatment primarily depends on the stage of development of the disease, as well as the age of the child. Treatment is usually complex and conservative. The total duration of conservative treatment is from 2 to 4 years.

As already mentioned, the duration and outcome of treatment depend on the age of children to the beginning of the disease, as well as on the stage of the disease to the beginning of treatment.

Thus, the lower the child’s age and the earlier the treatment is started, the faster and more complete the completion of the femoral head recovery process is.

In the early stages of the disease, the focus is on reducing the load on the joints, for which the following methods are used:

  1. use of special orthopedic insoles
  2. crutches
  3. physiotherapy
  4. special complex of exercises in Perthes disease in children
  5. massage
  6. healing mud.

In addition to all this, the orthopedic physician prescribes medication treatment (use of vasodilators - nicotine and ascorbic acid, nikoshpan, no-spa, etc.), special daily stretching and other methods of treatment, due to which blood circulation is improved in the affected areas, stimulation of resorption necrotic bone tissue and bone formation processes, as well as maintaining joint function and maintaining the overall tone of all muscles and limb muscles in particular.

  • In addition, the doctor prescribes and vitamin therapy.
  • As a rule, girls with this disease receive more intensive treatment.
  • However, forecasts are much worse than boys.

If a child is from 2 to 6 years old and has weak signs of the disease on the initial radiograph, then the treatment tactic is reduced to a simple observation.

Older children are treated to restore movements in the hip joint.

Reduction of inflammation

In order to reduce inflammation in the hip joint and synovial membrane, nonsteroidal anti-inflammatory drugs (ibuprofen) are prescribed to patients. There are cases when these drugs are used for many months. Depending on the intensity with which the affected tissue is restored, the treatment regimen changes.

As a result of a significant limitation of movement or due to progressive hip deformity (according to X-ray data), it is possible to apply a plaster cast that keeps the head of the femur inside the acetabulum.

This plaster bandage is called - Petri bandage and is a two-sided plaster bandage on both legs with a wooden crossbar in the middle. It helps to keep the legs in the divorced position (like the letter "A").

As a rule, the original Petri plaster cast is applied in the operating room — the surgeon inserts a small amount of dye into the cavity of the hip joint and takes an X-ray (arthrogram), which helps to assess the degree of flattening of the femoral head.

В некоторых случаях на длинной отводящей мышце бедра делается небольшой разрез, благодаря которому эта мышца удлиняется и облегчается приведение нижней конечности в наиболее подходящее положение.

Immobilization can continue until the full restoration of range of motion in the hip joint or the completion of tissue healing.

Orthopedic treatment

As for orthopedic treatment, it begins with a complete unloading of the limb, which is appointed immediately after the diagnosis has been made. To this end, in the hospital or at home, a patient is applied a light traction over a plaster or roller removable splint, which are fixed on the foot and ankle joint.

  • In the later stages of the development of Perthes' disease, surgical intervention is already necessary, during which joint disorders are corrected by a doctor.
  • It should be noted that surgical treatment for this disease is not used so often and is aimed at accelerating the treatment time.
  • Thanks to the surgical treatment of Perthes disease, the correct location of the bones in the hip joint is restored: the head of the femur is placed deep in the acetabulum.
  • This position is fixed by means of surgical bolts and plates, which are removed after some time.

In special cases, a surgical deepening of the acetabulum is necessary, because as a result of tissue repair, an increase in the volume of the femoral head occurs. After surgery, the patient is put on a plaster cast-corset from the chest to the feet for 6-8 weeks.

Therapeutic sports complex

After removing the dressing can be carried out complex exercise therapy in Perthes disease in children. In this case, the program should be constructed so that the load on the affected hip joint is incomplete. And already with the help of periodic radiography, the doctor needs to control how the recovery period proceeds.

Perthes disease can lead to very problematic in terms of recovery effects, such as contractures (limited movement in the joints), gluteus muscle hypotrophy, which is expressed in the lack of muscle mass, as well as a visual reduction in the width of the limbs.

Therefore, throughout the entire period of treatment, the following activities should be carried out: massage for Perthes disease in children, therapeutic exercises for Perthes disease in children, physiotherapy (UHF, ultrasound, diathermy, electrophoresis with potassium iodide, phosphorus, calcium), thermal procedures (paraffin, ozocerite, mud applications, thermal water procedures), acupuncture.

And, of course, necessary therapeutic exercise in Perthes disease, which includes simple exercises that must be performed until complete recovery.

Also, as mentioned above, at all stages of treatment, medical gymnastics for children with Perthes disease is performed. It is very important to know that the duration of the course of the disease depends on the full use of therapeutic gymnastics. And in children who are characterized by mobility, the treatment time is significantly reduced.

Therapeutic physical culture (exercise therapy)

Gymnastics for the upper and lower extremities (excluding the affected limb), as well as for the muscles of the back and abdominal wall begins with the first stage of treatment and continues continuously. At this time, the child should produce active contractions of the gluteus and quadriceps muscles on the affected side, perform active movements in the ankle joint.

First and second stage

Physical therapy in cases of Perthes disease in children in the first and second stages of treatment is assigned to restore the general tone of the diseased organism, normalize its emotional sphere, combat hypodynamia, and also successfully solve special problems of accelerating resorption of pathologically altered tissues, prevent the development of hip head deformity, and prevent the formation of contractures.

Exercise therapy classes in Perthes disease are held in the initial position, which corresponds to immobilization, general development and breathing exercises, exercises for the affected limb in the form of light flexions in the hip joint and any - in the knee and ankle are included in the classes.

Gradually special exercises with Perthes disease for the affected joint increase, passive (with help) and active exercises for the hip joint are introduced in all axes, they are still in the unloading state, as a rule, in horizontal initial positions. General developmental exercises in Perthes disease in children gradually increase, in accordance with the increased adaptation to physical activity.

Fourth stage

With the onset of the fourth stage, the patient is prepared to stand up and walk on crutches, into classes PH (remedial gymnastics) in Perthes disease in children enter the original sitting position. Classes consist mainly of exercises for large muscles of the body, which form the correct posture.

  • Special exercises for Perthes disease are conducted from various starting positions.
  • Movement is performed on all axes with increasing load, exercises are introduced with burdening and resistance, thanks to which optimal formation of the articular surfaces and the head occurs.
  • A full load on the limb is allowed to be done only after the last two radiographs taken at intervals of 2-3 months after the start of treatment, it will be seen that the structure of the head and neck of the femur remains unchanged.
  • Rehabilitation for Perthes disease in children is that the load on the limb without crutches, in the first year after the end of treatment, is increased gradually.
  • It is necessary to completely eliminate jumps, transitions over long distances, weight lifting, squats.

It is very good at this time to use walks on a bicycle, swimming. And in the future, people who have suffered Perthes disease, you must avoid excessive loads on the joint, and you should regularly conduct morning exercises, mainly lying, completely eliminating squat exercises.

For those who have suffered Perthes disease, it is very useful to stay at sea in the summer and swimming in the pool - in the winter. All these measures are necessary in order to further prevent the development of early deforming arthrosis in the hip joint.

Rehabilitation

Rehabilitation for Perthes disease also includes a massage, which in this case has the following actions:

  1. Helps to change the shape of muscles and mechanically destroys the gluing of intramuscular connective tissue, which arise as a result of prolonged inactivity.
  2. Contributes to the stretching of the muscle, which is the most adequate stimulation for sensitive receptors of muscle spindles, which come into a state of excitement. The result is a reflex increase in muscle tone, which as a result of the disease is reduced (normalization of tone).
  3. It contributes to increased blood circulation in the atrophied muscle (local vascular action), and also creates prerequisites for the restoration of normal (functional) metabolism.

Thanks to these actions, a massage for Perthes disease is a prerequisite for the subsequent strengthening of the muscles through exercise.

Massage for Perthes disease in children must be performed in the position of the patient lying on his stomach, on his side, on his back, while the muscles surrounding the joint should be as relaxed as possible.

For this purpose, the massage rollers are used. If the patient is worried about the pain in the joint, then in this case, a massage is carried out above and lower parts, in which light, shallow techniques are used.

Massage techniques are as follows:

  1. Stroking the lumbar region and buttocks. Run 8-10 times.
  2. Squeezing the edge of the palm or the base of the palm. Run 4-5 times.
  3. Kneading the muscles around the hip joint with the base of the palm (5-6 times), then kneading with the pads of four fingers (run 3-4 times), with the fingers apart, and the rotation is done in the direction of the little finger. With each subsequent grinding, the pressure force in the massaged area should increase, but it should not be brought to the reflex voltage.
  4. If the pain is not very severe, then in this case, after kneading, rubbing is performed around the hip joint:
    a) dotted - with pads of four fingers in all directions (2-3 times)
    b) circular - a comb of one finger (bent). Run 3-4 times.

The whole complex should be repeated 2-3 times and finished by shaking and stroking. The duration of the session should be at least 10-15 minutes - 2-3 times a month.

Surgical procedures in children under 6 years of age are used only in cases of large foci of necrosis with pronounced deformity and subluxation of the femoral head.

In recent years, the frequency of severe cases of osteochondropathy has increased significantly.

The main reconstructive surgical measures that are used to treat children with osteochondropathy are rotational transposition of the acetabulum according to Salter, as well as corrective medializing osteotomy of the hip, they are relatively less traumatic and lasting no more than one hour. Large volume interventions are much less common.

The likelihood of successful completion of the operation increases when the patient is operated on by surgeons who specialize in the pathologies of the children's hip joint and perform this kind of operation quite often. A great influence on the prognosis of Perthes disease is exerted by the child himself and his parents to give special recommendations for further treatment, data orthopedic specialist.

These include the exclusion of excessive physical exertion (running, jumping, lifting weights), as well as overweight throughout life. In this regard, these children are forbidden to engage in sports and physical education at school.

Recovery

Physical activity should be manifested by permissible loads: regular swimming in the pool, therapeutic exercises, exercises on a stationary bike and a sports bike.

  • In the opposite cases, hypodynamia develops, which leads to excess weight, and this in turn becomes another additional problem for the patient.
  • Regularity in conducting supportive courses of rehabilitation therapy (drug and physiotherapy) is considered important.
  • Neglect of these recommendations leads to the emergence of a clinical picture of deforming coxarthrosis, which manifests itself as a gait disturbance and pain syndrome.
  • In general, in Perthes disease, clinical manifestations of coxarthrosis occur rather late compared with other more severe hip diseases, or do not occur at all.

However, in cases where the patient does not remember to take care of the joint, they may suddenly appear at a young age, in such cases a decision can be made about hip joint arthroplasty (replacing the non-functioning organ with an artificial one).

The operation on endoprosthetics at a young age is considered highly undesirable - it should be carried out as late as possible. To great happiness, absolutely not all patients treated for Perthes disease require endoprosthetics.

The most common causes

To date, there is no definitive answer to the question about the causes of this disease. It is only known that Perthes disease begins to develop in case of complete cessation of blood supply in the femoral head.

Many experts are inclined to believe that the development of this pathology is inextricably linked with disorders in the lumbar spine, in particular, with the displacement of the fourth vertebra. This particular area is responsible for the flow of blood into the hip joint and its innervation.

But there are several other factors that are closely associated with the development of Perthes disease:

  • According to various sources, in 24 - 36% of all patients diagnosed with necrosis of the femoral head, in the past, cases of pelvic bones, hip and thigh injuries were found. Among them, 60-76% of such injuries were habitual.
  • More than 40% of children with Perthes disease are born from pregnancy, accompanied by any complications (severe toxicosis, threat of termination, drug preservation or correction of pregnancy, etc.). The birth of 17% of children with this disease was accompanied by buttock breech presentation.
  • Infectious diseases and metabolic disorders are present in a history of 11-14% of patients.
  • Hip dysplasia was registered in 4-9% of cases.

However, these factors are among the alleged provocateurs for necrosis of the femoral head, and the actual causes of the development of this disease remain to be seen.

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Legg-Calvet-Perthes disease: what is and what is dangerous for children?

The disease in children often develops between the ages of 4 and 12 years and is the most common form of destruction of the bone head in childhood. On average, 1 case per 1,200 children is diagnosed, the joint is usually affected on one side. With the development of this pathology, there is a disturbance in the blood supply in the bone tissue of the thigh, which leads to insufficient intake of substances into the bone tissue necessary for its normal growth and development. This manifests itself in the form of dystrophy and violation of the structure of the pineal gland (the end of the bone, where the articular surface is formed), and over time leads to its destruction.

Without timely diagnosis and treatment, hypotrophy develops (tissues do not receive sufficient nutrition) of the gluteal muscles, and subsequently of the entire lower limb. There is an increase in lameness, which is permanent, and increased pain. In some cases, limb shortening may be observed (a healthy leg is longer).

Causes of disease

To date, experts have not come to a common opinion regarding the main cause of the disease. As a rule, the disease develops under the influence of several factors at once. Some children have a predisposition to Perthes disease as a result of myelodysplasia.

Heredity plays a special role in the development of Perthes disease. Often the abnormal structure of the hip joint is caused by a genetic predisposition. Also, osteochondropathy of the femoral head may develop under the influence of the following factors:

  • infectious diseases (flu, sinusitis, tonsillitis, etc.),
  • prematurity or low birth weight
  • violation of bone metabolism and calcium-phosphorus metabolism,
  • malnutrition, rickets,
  • hormonal and metabolic disorders in adolescents,
  • increased stress on the joints during the period of illness (non-compliance with bed rest),
  • passive smoking (the baby is forced to be in the same room with smokers),
  • injury.

Symptoms in children

At first, the disease makes itself felt with moderate pain that occurs during walking or running. The child experiences discomfort in the hip or knee area. Sometimes pain permeates the entire leg. Parents begin to notice that the baby is limping. The disease causes the child to crouch on a sore leg or to wrap it. Usually, at an early stage of the disease, the parents do not take any active actions, they don’t even think of referring to an orthopedist, since the symptoms are mild and in most cases are due to trauma or increased stress.

As the head of the joint collapses and an impression fracture occurs, the symptoms increase. The pain is very strong, the child can not step on the sore leg, because of which the limp becomes pronounced. Sore spot swells up.

Children with this pathology can not turn the leg outward, they have severely limited rotational and flexor-extensor movements of the joint. Vegetative disorders of the distal extremities (sweating of the foot, pallor of the skin, etc.) are attached. Often the disease provokes a rise in body temperature to subfebrile values. In the future, the pain subsides, but the lameness persists, symptoms characteristic of progressive arthrosis appear. Often, children with such a pathology reveal shortening of the diseased limb.

X-ray examination

If Perthes disease is suspected, not only standard projection images are taken, but also an X-ray image of Lauenstein’s projection. Based on the results of the study, the doctor makes a diagnosis, most often using the classification of Salter Thomson and Catterol.

An orthopedist, studying a radiograph, reveals the structural features of the bones and the degree of deformity of the articular head.

Ultrasound procedure

Ultrasound is used to help if the disease is caused by rheumatism. Often at the initial stage, Perthes disease is difficult to diagnose with the help of X-rays, so they use ultrasound densitometry. This is a non-invasive, painless and safe diagnostic method that allows you to determine the quantitative mineral density of bone tissue. Благодаря УЗИ специалист определяет состояние костной ткани тазобедренного сустава, помогает оценить степень поражения костей.

CT scan

The obtained X-rays allow us to study the structural features of the bone tissue, but at the initial stage of the disease they do not allow us to estimate the degree of damage to the soft tissues and bone structures. To diagnose Legg-Calvet-Perthes disease in young patients, you can use MRI or computed tomography of the hip joint.

CT scans determine the initial changes in the head of the femur. On the computer screen, the doctor sees layer-by-layer images of the problem area, which makes it possible to identify conditions characteristic of aseptic necrosis, for example, bone marrow edema.

Stage osteonecrosis

The disease is usually divided into five consecutive stages. The first, called the stage of osteonecrosis, is characterized by the cessation of the blood supply to a certain portion of the HBV, which leads to the development of focal necrosis. Usually the affected area is less than 10% of the total mass of the articular head. This stage is not accompanied by any unpleasant sensations, it is often asymptomatic. A child may experience subtle hip pain and minor gait disturbances.

Stage of Impression Fracture

The second stage of the HBR impression fracture is determined if the area of ​​structural changes in bone tissue exceeds 10%, but remains within 30% of the total mass of the hip joint head. A depressed fracture leads to the development of the second stage, followed by the deformation of the GBC, which can develop for no apparent reason under the influence of habitual loads. From this point on, the child experiences considerable discomfort while walking, which is reflected in his gait.

Fragmentation stage

The stage of fragmentation is determined by deformation of more than 30%. The pains accompany the baby when walking, and also remain in a calm state. There is swelling in the hip area, the movements of the GBC are limited. Due to a violation of the support function of the limb, the child begins to limp heavily on one leg. The inflammatory process leads to a rise in body temperature and the appearance of symptoms of intoxication of the body.

Reparation stage

In the repair stage, the processes of destruction are inferior to the processes of restoration. The vessels grow into separate fragments of damaged bones, a new bone tissue is formed, which in its structure is close to healthy bones, but does not have the same strength. The growth of HBB is resumed, which, if improperly treated, leads to further aggravation of the problem. The head acquires irregular shapes, it causes dislocations, subluxations and secondary coxarthrosis.

Final stage

At the outcome stage, it is possible to understand whether Perthes disease will lead to complications or the healing process will pass without consequences for the child. If the cartilaginous area was destroyed as a result of necrosis, then the child may experience irregularities associated with the growth of the femur in length. Due to the shortening of the limb, the child’s gait is disturbed; this pathology needs to be corrected surgically. If at stage 4 there was a deformation of the CGD, progressive arthrosis develops.

Conservative

  1. Children are usually given chondroprotectors. This group of drugs accelerates the regenerative processes in bone and cartilage tissues.
  2. The child should take mineral-vitamin complexes designed to strengthen and nourish the hip joints.
  3. Angioprotectors improve blood supply to bone and articular structures.
  4. In case of severe pain, pain relievers are prescribed. Inflammation and swelling relieve nonsteroidal anti-inflammatory drugs.

During medication therapy, the limb should be maximally unloaded. To immobilize the joint, a special splint or Petri bandage is applied to the child. Orthopedic constructions securely fix the GBC in the correct position, preventing it from shifting and deforming.

Operational

Surgery may be required only in severe cases. As a rule, it is performed for children over 6 years of age, when structural changes in the bone tissue lead to deformation of the GBC and subluxation of the hip.

During surgery, the surgeon uses two basic techniques for fixing the articular head in the correct position:

  • correcting hip osteotomy medializing,
  • rotational transposition of the acetabulum according to Salter.

During surgery, the articular head is fixed in the acetabulum with metal plates or bolts. If necessary, an additional depression deepens. After installing the plates, the child must be in a plaster corset for at least 6–8 weeks.

Forecast and consequences

With timely treatment of Perthes disease, the prognosis is good. The disease is treatable, and its effects do not pose a danger to the life and health of a small patient. If the disease is started and not treated for a long time, then this can lead to disability. The deformed areas of the GBC affect the performance of the entire limb.

For severe lesions, the buttocks and muscles of the limb atrophy. Insufficient muscle mass leads to cosmetic defects. A child with Perthes disease is experiencing stiffness in the joint, his gait deteriorates. Tissue necrosis leads to intoxication, which contributes to the development of complications.

The onset of the disease

Perthes disease (in other words, Perthes-Legg-Calve) is a disease in which the blood supply to the femoral head is disturbed with further aseptic necrosis. This disease appears in the period of maturation and, according to medical statistics, is one of the most widespread osteochondropathies.

The onset of malaise is slow, the first symptoms of Legg-Calvet-Perthes disease often go unnoticed. Small pains in the joint itself begin, there may be a slight limp or “podvolakivanie” sore legs. Then the pains become more intense, there is severe lameness, swelling and weakness of the muscles of the affected leg, and separate contractures develop. If treatment is not initiated, the most likely outcome will be a distortion of the head shape and the formation of coxarthrosis.

The diagnosis is determined on the basis of the noted symptoms and X-ray picture. The treatment process is a long one, often using a conservative approach. In the most difficult cases, it is necessary to go to reconstructive-restorative operations.

Who is sick?

The process associated with a painful deviation from the normal position and characterized by a breakdown in the blood supply and the onset necrosis of the femoral head is Legg-Calve-Perthes disease. Diseases of this type of joints are diagnosed quite often (approximately 17% of the total number of patients with osteochondropathy). Children are ill mainly. Boys usually suffer from this disease several times more often than girls, however, the latter have variants of the development of the disease, leading to a more severe course of the disease. There may be both unilateral disease and bilateral, while the other joint, as a rule, is sick less and is rehabilitated faster.

Disease in dogs

This ailment is common among some animals. Legg-Calvet-Perthes disease in dogs is similar to a human one in symptoms and ailment process. In general, orthopedic ailments in dogs often recur. This is especially true for large breeds. Often, sick dogs are killed because their back legs are completely out of order. However, the dog "small fry" from such troubles is not spared. In this case, the ending of her life is rather sad.

Risk factors

Despite the efforts of the medical community, there is still no single approach for the treatment of Perthes disease. Symptoms, stages, treatment at different schools differ. Doctors suggest that this malaise is polyetiological in nature, in the formation of which both the initial tendency and the disturbances of metabolic processes, as well as the adverse influence of the environment, are of some importance. In accordance with the most common concept, Perthes disease occurs in children with myelodysplasia - congenital severe underdevelopment of the lumbar part of the spinal cord, mass pathology, which in various forms may not be detected or, conversely, cause the development of various orthopedic abnormalities.

Myelodysplasia

In Legg-Calve-Perthes disease (traumatology and orthopedics - the sections of medicine that study this ailment), the supply of nerves to the hip joints is disturbed, and the volume of various vessels that deliver blood to the tissues of the joint decreases. In a primitive understanding, it looks like this: instead of the usual 10-12 large vessels, only 2-4 underdeveloped arteries and veins of smaller size work for the patient. Due to this, the tissues regularly suffer from insufficient blood supply. Changes in the state of the vessels due to innervation disorders also manifest their negative impact.

In comparatively less unfavorable circumstances (with partial disruption of the arteries and veins as a result of the influence of various causes) in a patient with a normal number of vessels, the blood supply to the bone weakens, but still remains normal. In a patient with myelodysplasia in the same conditions, the blood completely stops flowing to the head of the thigh. Due to the extreme lack of necessary substances, some of the damaged tissues die - a field of aseptic necrosis is created. And this is a sign of a classic joint disease.

Causes of

According to some doctors, the causes of the appearance of Legg-Calvet-Perthes disease can be such factors:

  1. Small mechanical damage (in particular, even a weak blow of the foot during children's games, etc.) In some cases, the injury is so weak that it can be overlooked by parents. Sometimes even one clumsy movement is enough.
  2. The appearance of even a small tumor of the damaged hip joint with various colds infections (in particular, such massive ones as the flu).
  3. Changes in hormonal levels in adolescence.
  4. Disorders of the metabolism of trace elements that are involved in the formation of bones, etc.

Features of the disease

There is a clear algorithm for determining the level of development of Perthes disease. Causes, symptoms, diagnosis are divided. Usually, the five main stages of malaise are considered, which determine the subsequent treatment:

  1. Stopping or disruption of blood supply, the formation of a site of aseptic necrosis.
  2. Secondary fractured femoral head fracture in the damaged area.
  3. Resorption of dead tissue, accompanying the narrowing of the femoral neck.
  4. The increase in the volume of connective tissue in the area of ​​necrosis.
  5. Replacement of the damaged connective tissue of the joint by an enlarged bone, recovery of the fracture site.

The end of Perthes disease fully depends on the extent and place of necrosis. With an insignificant focus, you can achieve a full recovery. With a significant damage, the head splits into a number of fragments and, after combining, can get an irregular shape: in some cases it can flatten, go beyond the location area, and so on. Disruption of typical physiological dimensions between the head and the adjacent acetabulum may cause new pathological changes.

It is not difficult to distinguish Legg-Calvet-Perthes disease. Causes, symptoms can be easily determined. At the beginning of the disease there is a slight dull pain when moving. As a rule, pain occurs in the region of the hip joint, but sometimes there may be pain in the region of the knee joint or along the length of the entire limb. The patient begins to limp slightly, leans on the injured leg or drains it. Usually at this time the clinical symptoms are so poorly discernible that parents do not even realize that it is necessary to consult a doctor.

With the subsequent destruction of the head and the transition to the stage of the impression fracture, the pain is significantly exacerbated, the lameness is clearly visible. Soft tissue in the area of ​​the joint swell. Obviously, the restriction of a number of movements: the child is not able to turn out a limb, does not move well in the hip joint. Movement is difficult. There are vegetative disorders in the damaged leg - the foot is too hot or cold, there is a certain pallor, increased sweating. Possible increase in total body temperature. In the future, pain is less severe, reliance on the leg is possible again, but other signs may persist. In some cases, shortening of the leg occurs.

Forms of therapy

The main forms of treatment for Legg-Calve-Perthes disease depend on the stage of development of the disease. Patients are prescribed certain medications, and at the second stage of the development of the disease, patients can already be sent to special sanatoria, to apply procedures, and not just medical treatment. Normal pressure on the affected leg is possible only after radiological evidence of the recovery of the fracture.

Any preparations can be used only after the head of the thigh is completely "plunged" into the cavity (as it should be in a healthy state). This is achieved using certain orthopedic appliances: functional tires, gypsum dressings, various types of traction, and the like. Therapeutic gymnastics is used as a stimulus to the bone recovery process. Maintain activity and prevent muscle volume reduction toning massage and electrical muscle stimulation.

As a rule, chondroprotectors and osteoprotectors are prescribed from drugs. They stimulate the blood supply to the diseased area, stimulate the formation of new tissue forming the articular surface, and bones.

At the fourth stage, patients are allowed to carry out active exercises; at the fifth stage, doctors use a complex of exercise therapy for muscles and a complex of movements in the joint. Surgery for this ailment is shown in difficult cases and only in children over six years old. As a rule, they make several typical operations. In the postoperative period, various physiological procedures are prescribed, etc.

Young patients with Legg-Calvet-Perthes disease for some time are sedentary, which often stimulates the appearance of excess weight and further increase the load on the affected joint. Because of this, all patients are prescribed a special diet to prevent obesity. At the same time nutrition should be rich in trace elements and various substances.

People with a history of Legg-Calvet-Perthes disease, regardless of the complexity of the disease, are recommended not to exert a lot of pressure on the affected part of the body throughout their lives. Strengthened physical exercises are contraindicated. Water procedures and cycling are allowed (but you can’t overload your limbs too much). You must constantly engage in sports, but in moderation. Do not work where there is great physical exertion or a long stay on his feet. It is necessary from time to time to undergo rehabilitation treatment on an outpatient basis and at sanatoriums.

Perthes disease development factors

With Perthes disease, the blood supply to the femoral head is disturbed, leading to its necrosis. This is a common pathology: the proportion of the total number of osteochondropathies is 17%. The disease affects children from 3 to 14 years. Girls suffer from Perthes disease 5-6 times less often than boys, but in girls the disease is more severe.

In Perthes disease in children, hip joint damage can be both unilateral and bilateral. With bilateral lesions, the second joint is less damaged and is easier to repair.

Modern medicine does not single out a single cause of the development of pathology, and the disease is considered to be polyetiological. Various factors can play a role: external influences, metabolic disorders, genetic propensity. The most famous theory claims that Perthes disease occurs against the background of myelodysplasia. This is a congenital underdevelopment of the spinal cord. Pathology is widely spread and manifests itself in different ways: myelodysplasia can either “lie low” or lead to various orthopedic disorders.

When myelodysplasia hip joints suffer: their innervation is disturbed, and the number of arteries and veins that feed the tissues becomes smaller. In the normal region of the femoral head provide blood 10-12 large vessels. In the opposite case, the vessels are only 2-4, they are inferior and cannot provide the tissue with the right amount of blood. Innervation disorders also negatively affect the tone of the arteries and veins.

Inflammations, injuries and other negative factors can impair blood circulation, but the bones of a child with a normal number of vessels still receive adequate nutrition. In myelodysplasia, adverse conditions aggravate the patient's condition, and the head of the thigh remains without oxygen and nutrients. “Starvation” is followed by aseptic necrosis, which develops without signs of inflammation and the participation of microorganisms.

Experts identify several reasons that (presumably) can provoke Perthes disease:

  1. Hormonal changes inherent in pubertal period.2. Нарушения метаболизма важных элементов (фосфора, кальция и т.д.), необходимых для здоровья костей.3. Транзиторный синовит на фоне бактериальных и вирусных инфекций (ангина, грипп, синусит).4. Небольшие травмы вроде ушиба или растяжения связок.Even awkward movement or practically invisible injury can be a trigger.

Stages and effects of the disease

There are 5 stages of pathology:

  1. First, the blood supply to the femoral head stops, then the center of necrosis is formed.
  2. A secondary impression fracture of the head occurs in the affected area.
  3. Necrotic tissues begin to dissolve, and the neck of the thigh becomes shorter.
  4. In place of necrosis connective tissue is formed.
  5. The connective tissue is replaced by new bone tissue, and the fracture grows together.

The outcome of Perthes disease depends largely on how the necrotic area is located, how large the lesion is. If the affected area is small, then there is the possibility of full recovery. If the destruction has become large, then the head splits into several separate parts.

Violation of the correct position of the head entering the acetabulum aggravates the patient's condition: contractures are formed more actively, and coxarthrosis develops at an accelerated rate.

Symptoms of Perthes disease in children

In the early stages of the disease, the patient experiences dull, non-intense pain while walking. As a rule, pain is localized in the hip joint, but sometimes pain gives to the knee or even the entire leg. The child begins to limp slightly, dragging his foot or crouching on it. Symptoms are expressed implicitly, so often parents do not worry and do not consider it necessary to urgently turn to an orthopedist. It is assumed that the child could be hurt that the lameness is caused by increased exertion or any previous illness.

The stronger the head collapses, the sooner the impression fracture occurs, after which both pain and lameness intensify. Periarticular tissues swell, movements become limited: the patient cannot rotate the leg, bend and unbend it in the hip joint. Walking is given to the patient with difficulty, the foot of the diseased leg becomes pale and cold, and its increased sweating is noted. Subfebrile temperature may occur. In the future, the pain subsides, the leg regains its functions, but the risk of lameness and limited movement remains. Sometimes the limb is shortened.

What it is?

Children's orthopedists call this disease Legg-Calvet-Perthes disease. Also, this pathology is called osteochondropathy of the femoral head. This disease is accompanied by necrosis (death) of cells that form bone and cartilage.

During the development of the disease occurs severe blood supply failure. This causes necrosis of the elements forming the hip joint. According to statistics, this pathology often sick boys.

The peak incidence occurs at the age of 4 to 14 years. It should be noted that in some cases, the disease may occur at an earlier age.

Children's orthopedists note that most often this disease affects the right hip joint. Double-sided lesions are also common. In this case, the course of the disease becomes very difficult. The prognosis of bilateral lesions is usually poor. In some cases, this can even lead to the development of signs of disability in a sick baby.

Causes

Doctors have not yet established the true cause of this disease. There are a huge number of different scientific theories that explain the occurrence of this disease:

  • Some experts believe that various traumatic injuries. The consequences of such injuries lead to the development of anatomical defects in the joints.
  • Strong hip load also contributes to the fact that the child in the future may receive various circulatory disorders. Frequent infectious diseases that occur especially in weakened babies lead to the development of necrotic changes in the head of the hip joint.

  • Congenital diseases large joints can also be a provoking cause of Perthes disease. In this case, the development of specific changes leads to a violation of the anatomical integrity of the structures that form the hip joint. In adolescents, the pronounced displacement of the fourth lumbar vertebra becomes a fairly common cause of this pathology. This situation provokes pinching of the intervertebral nerve and the supplying blood vessels.
  • Impaired blood supply contributes to the gradual development of dystrophic changes in the hip joint. After some time, the child develops pronounced necrosis of bone and cartilage tissue. This condition is manifested in violation of the architecture of the hip joint. A long course of the disease provokes the development of multiple adverse symptoms in a child.

Doctors identify several high-risk groups for the development of this disease:

premature babies and toddlers with a critically low birth weight,

kids who had rickets in early childhood,

babies who do not receive adequate nutrition, as well as babies who are on artificial feeding,

children, often ill with catarrhal and respiratory diseases,

babies with signs of malnutrition,

children suffering from various types of allergies.

In the development of the disease several clinical stages alternate. The initial one is accompanied by the appearance of necrosis of the nucleus of ossification of the femoral head. Stage 2 is characterized by the appearance of a compression fracture of the head of the hip bone.

Stage 3 causes multiple fragmentation and destruction of the main anatomical structures that form this bone joint. At the fourth stage, a large amount of connective tissue appears on the site of the former bone and cartilage tissue. The final stage 5 is accompanied by ossification of the newly formed areas, due to the deposition of calcium in the damaged areas.

The manifestation of clinical signs depends on the stage of development of the pathological process. All adverse syndromes develop gradually. Late stages are characterized by the presence of pronounced clinical signs, which are quite clearly manifested in a child.

A rather frequent manifestation of the disease is the appearance of pain in the hip joint. At first, the child feels only a pulling pain that spreads throughout the affected leg. The baby feels maximum pain in the area of ​​the head of the hip joint. At this time, the child often appears weakness of gluteus muscles.

Sick baby first starts to limp a little. During the development of the pathological process, the child begins to limp much more. This violation is particularly pronounced in a one-sided process. Double-sided damage may not appear for quite a long time.

Over time, the child’s gait begins to suffer. When walking, he tries not to step on the damaged leg and spares it. This leads to the fact that the child relies more on a healthy foot. This gait is preserved in the baby almost constantly.

As the inflammation in the joint develops, this symptom in a child only progresses.

Soreness when trying to turn a damaged leg outwards - Another characteristic symptom that develops in this pathology. Rotational motions are also disturbed. At first, this symptom is manifested by the appearance of soreness during the abduction or rotation of the leg. Then active and then passive movements are limited.

Restriction of hip joint flexion occurs in all babies with Perthes disease. The affected leg swells severely. This symptom is most pronounced when assessing a sore limb with a healthy one. If the process is bilateral, that edema appears immediately on both legs.

Circulatory impairment leads to pulsation of blood vessels is noticeably reduced. Doctors identify this clinical sign during a clinical examination of a sick child. The development of the pathological process of 2-3 degrees is accompanied by the appearance of a subfebrile condition in a child. In this case, the body temperature rises to 37.2-37.5 degrees.

Expressed stages of the pathological process are characterized by increasing pallor of the skin. The affected leg becomes cold to the touch. Some babies have severe sweating of the feet.

Causes of Legg-Calve-Perthes disease

The causes and pathogenesis of Legg-Calvet-Perthes disease are not completely understood. According to recent studies, the predisposing factors of Perthes disease are congenital dysplasia of the spinal cord and physiological alteration of the regional vascular system.

Congenital dysplasia of the spinal cord (at the level of the lower thoracic and upper lumbar segments) of varying severity causes impairment of innervation of the lower extremities. As a result, anatomical and functional changes in the vascular system occur in the region of the hip joints. Anatomical changes consist in a hypoplasia of all vessels feeding a joint, and a small number of anastomoses between them. Functional disorders - arterial spasm due to increased influence of the sympathetic system and reflex dilatation of the veins. They lead to a decrease in arterial inflow, obstruction of venous outflow and latent ischemia of the bone tissue of the head and neck of the thigh.

The physiological restructuring of the vascular system of the epiphysis of the femoral head from the pueril type of blood supply to the adult type significantly increases the likelihood of developing blood flow disorders.

Functional overloads, microdamages, injuries, hypothermia and infections are the leading factors leading to decompensation of the blood supply to the femoral head, the transition of bone ischemia to its necrosis and the clinical onset of the disease.

Symptoms of Legg-Calvet-Perthes disease

The early symptoms of Perthes disease are characteristic pain syndrome and associated sparing lameness and limitation of the range of motion in the joint.

Pain, as a rule, have a periodic nature and varying degrees of severity. Most often they are localized in the hip or knee, as well as along the thigh. Sometimes a child cannot lean on a sore leg for several days, and is therefore in bed, but walks more often, limping. A limp may be mild in the form of dragging the legs and lasts from several days to several weeks.

The periods of clinical manifestations usually alternate with periods of remission. In some cases, the disease pain syndrome is absent.

Diagnosis of Legg-Calve-Perthes disease

On examination, light outward rotational contracture and hypotrophy of the muscles of the lower limb are noted. As a rule, the abduction and internal rotation of the thigh are limited and painful. Clinical signs of lumbosacral spine spondylomydisplasia are often revealed, which is more likely to suggest Perthes disease.

When limiting the abduction or internal rotation of the thigh and the characteristic anamnestic data, perform an x-ray of the hip joints in two projections (anteroposterior projection and the projection of Lauenstein).

Instrumental diagnostic methods

The first X-ray symptoms of the disease are a small obliquity (flattening) of the outer lateral part of the affected epiphysis and the discharging of its bone structure with an expanded X-ray articular slit.

Somewhat later, the symptom of “wet snow” is revealed, which consists in the appearance of heterogeneity of the bone structure of the epiphysis with areas of increased and decreased optical density and indicating the development of osteonecrosis.

Then follows the stage of an impression fracture, which has a more distinct X-ray pattern and is characterized by a decrease in height and compaction of the bone structure of the pineal gland with the loss of its normal architectonics - a symptom of the “Cretaceous pineal gland”.

Often the onset of the stage of impression fracture is characterized by the appearance of a line of subchondral pathological fracture in the affected epiphysis — a symptom of the nail, according to the localization and extent of which it is possible to predict the size and localization of the potential center of necrosis - sequestration, and consequently, the severity of the disease.

It is considered that the first stage of the disease - the stage of osteonecrosis - is reversible and with a small focus of necrosis, which is rapidly revascularized, it does not go into the stage of impression fracture. The appearance in the epiphysis of the line of a subchondral pathological fracture indicates the beginning of a long, stepwise course of the pathological process, which can last for several years.

Recently, MRI is often used for the early diagnosis of osteochondropathy of the femoral head. This method has high sensitivity and specificity. Allows you to identify and determine the exact size and location of the center of necrosis in the head of the thigh a few weeks earlier than it is detected on the radiograph.

Sonography also makes it possible to suspect the disease early, but in the diagnosis of Perthes disease it has only auxiliary significance. Changes in the acoustic density of the proximal femoral metaepiphysis and articular effusion are determined using sonography. In addition, it helps to trace the dynamics of the restoration of the structure of the pineal gland.

The clinical and X-ray picture of Perthes disease at subsequent stages (impression fracture, fragmentation, recovery and outcome) is typical, and the diagnosis of the disease is not difficult, but the later the diagnosis is made, the worse the prognosis for the restoration of the normal anatomical structure and function of the hip joint.

Legg-Calve-Perthes disease treatment

Patients with osteochondropathy of the femoral head need complex pathogenetic treatment in conditions of complete elimination of the load on the sore leg from the moment of diagnosis. In most cases of the disease, the treatment is conservative. However, with a large focus of necrosis involving the lateral division of the epiphysis in children aged 6 years and older, it is desirable to perform surgical treatment on the background of conservative measures. This is due to severe deformity of the femoral head and a protracted (torpid) course of the disease. Severe deformity of the femoral head, in turn, can cause the formation of extrusion subluxation in the affected joint.

Necessary conditions for complex pathogenetic treatment:

  • elimination of compression of the hip joint, due to the tension of its capsular-ligamentous apparatus and the tension of the surrounding muscles, as well as the continuing axial load on the limb,
  • a change in the spatial position of the pelvic and / or femoral components of the affected joint (by conservative or surgical methods) in order to fully immerse the femoral head in the acetabulum, creating a degree of bone covering equal to one,
  • stimulation of regenerative processes (revascularization and re-ossification) and resorption of necrotic bone tissue in the head of the thigh, freed from compressing influences and immersed in the acetabulum.

Surgery

Reconstructive surgery for the treatment of children with Perthes disease:

  • medializing and corrective osteotomy of the hip,
  • rotational transposition of the acetabulum, which is performed as an independent intervention, and in combination with mediating osteotomy of the thigh.

Among the varieties of rotational transpositions of the acetabulum, the operation of Salter is most in demand.

Surgical intervention is performed with the purpose of centration (full immersion) of the femoral head in the acetabulum, reducing the compressive effects of the muscles of the hip joint and stimulating the reparative process.

High efficiency of remodeling operations in the most severe cases of Perthes disease - subtotal and total lesions of the epiphysis has been proven by extensive clinical experience. Surgical intervention provides a more complete recovery of the shape and size of the femoral head, as well as a significant reduction in the duration of the disease - the patient is put on his feet without supportive means on average 12 ± 3 months depending on the stage of the disease.

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