A case review to describe variation in care following diagnosis of Perthes' disease

Abstract

Aims Perthes’ disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children’s Orthopaedic Surgery through the James Lind Alliance’s prioritization of work to determine/identify surgical versus non-surgical management of Perthes’ disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018. Methods Five UK NHS centres, including those from the NEWS (North, East, West and South Yorkshire) orthopaedic group, contributed to this case review, with each entre providing clinical data from a minimum of five children. Information regarding both orthopaedic and physiotherapeutic management over a two-year post-diagnosis period was reviewed. Results Data were extracted from the clinical records of 32 children diagnosed with Perthes’ disease; seven boys and 25 girls. The mean age of the children at diagnosis was 6.16 years (standard deviation (SD) 3.001). In all, 26 children were referred for physiotherapy. In the two-year period following diagnosis, children were seen a median of 7.5 times (interquartile range (IQR) 4.25 to 11) by an orthopaedic surgeon, and a median of 9.5 times (IQR 8 to 18.25) by a physiotherapist. One centre had operated on all of their children, while another had operated on none. Overall, 17 (53%) of the children were managed conservatively in the two-year follow-up period, and 15 (47%) of the children underwent surgery in the two-year follow-up period. Conclusion The results of this case review demonstrate a variation of care provided to children in the UK with Perthes’ disease. Further national and international understanding of current care is required to underpin the rationale for different treatment options in children with Perthes’ disease. Cite this article: Bone Joint Open 2020;1-11:691–695.

“Waiting for the best day of your life”. A qualitative interview study of patients’ and clinicians’ experiences of Perthes’ disease

“…Variation within centres treating children with Perthes' disease in the UK has been demonstrated previously, 3 but the factors driving this variation were yet to be explored. Throughout the interviews, participants told us how the variation was driven, in part, by training and evolving experience at managing the condition (e.g.…”

“…Widespread variation of clinical care in the UK has been described. 3 The recent British Orthopaedic Surgery Surveillance study provided insight into the management of Perthes’ disease in 143 of the 144 NHS hospitals treating children’s hip disease in the UK. 4 Definitive non-surgical treatment remains the most common approach for children affected by Perthes’ disease, however there is a lack of robust evidence or consensus on the type, timing, or duration of any intervention.…”

The British Orthopaedic Surgery Surveillance study: Perthes’ disease

“…The incidence is believed to be approximately five per 100,000 zero- to 14-year-olds per year, 4 , 5 suggesting that there are approximately 500 new cases throughout the UK annually. The origins of the disease are very closely linked to socioeconomic deprivation, 2 , 5 - 7 though the aetiology and mechanism are so far unknown.…”