Prolonged non-weightbearing treatment decreases femoral head deformity compared to symptomatic treatment in the initial stage of Legg–Calvé–Perthes disease

Abstract

The purpose of this study is to investigate the potential benefit of using prolonged non-weightbearing (PNWB) as a treatment option for early-stage Legg–Calvé–Perthes disease (LCPD). An Institutional Review Board (IRB) approved this retrospective study of patients with LCPD and ≥2-year follow-up. Patients 6–12 years of age were included if treatment began in Waldenstrom stage 1 or 2A. PNWB consisted of ≥6 months of non- or toe-touch weightbearing. PNWB was recommended if perfusion MRI demonstrated ≥40% hypoperfusion of the femoral head and parents decided against operative treatment. The control group consisted of symptomatically treated patients. Deformity index and epiphyseal quotient were measured at 2-year follow-up. Stulberg classification and sphericity deviation score (SDS) were determined at skeletal maturity or at a minimum of 5-year follow-up. When treatment was initiated in Waldenstrom stage 1, the PNWB group had significantly less femoral head deformity, including deformity index (0.21 vs. 0.52; P < 0.001), epiphyseal quotient (69% vs. 43%; P < 0.001), SDS (18 vs. 52; P = 0.004), and Stulberg (50% good vs. 0% good; P = 0.044). The PNWB group mean hypoperfusion was 68%, indicating severe hypoperfusion. Duration of recommended non-weight bearing in the PNWB group was 11.5 months (range 7–17 months). Despite severe femoral head hypoperfusion, PNWB begun during the initial stage of LCPD decreased femoral head deformity. PNWB should be considered a treatment option for patients/parents who do not wish to pursue operative intervention in early-stage LCPD with substantial hypoperfusion. Level of Evidence III – retrospective comparative study.

Does Prolonged Weight Relief Increase the Chances of a Favourable Outcome After Containment for Perthes Disease?

“…However, experimental studies have shown that weight relief does have a definite protective effect on the shape of the femoral head following ischemic necrosis 15. Similarly, a few clinical studies have endorsed this view 3,4,16,17. The impression that weight-bearing in the early stages of LCPD predisposes to deformation of the femoral head has been recently supported by the findings in a novel MRI study 18.…”

“…15 Similarly, a few clinical studies have endorsed this view. 3,4,16,17 The impression that weight-bearing in the early stages of LCPD predisposes to deformation of the femoral head has been recently supported by the findings in a novel MRI study. 18 The study demonstrated flattening and widening of the epiphysis as soon as children with LCPD who were early in the course of the disease bore weight on the limb.…”

“…20 Secondly, most studies were case series without controls. Nevertheless, there appears to be a trend towards better results in studies that combined containment with prolonged weight relief 3,4,17 than when containment alone was performed. [21][22][23][24][25][26][27][28][29][30] Two reports of children treated in abduction, non-weightbearing braces worn for 18 months show that a high proportion had spherical hips when the disease healed, indicating that nonoperative containment when combined with prolonged weight relief may be equally effective as our approach of surgical containment combined with prolonged weight relief.…”

What’s New in Pediatric Orthopaedics

“…A study of prolonged non-weight-bearing for patients with severe hypoperfusion on MRI found that prolonged non-weight-bearing begun during early Legg-Calvé-Perthes disease decreased femoral head deformity 33 . Weight-bearing restrictions were not found to be associated with a meaningful increase in body mass index 34 , but were associated with increased depression and anxiety, in patients with Legg-Calvé-Perthes disease 35 .…”

Do Weightbearing Restrictions Cause Excess Weight Gain in Children With LEGG-Calvé-Perthes Disease?

“…12,13 Thus, some institutions recommend a prolonged non-weight bearing protocol up to 12 months from the start of treatment either alone, or in combination with containment surgery. [14][15][16] Families commonly express concern about weight gain that may occur subsequent to prolonged durations of non-weight bearing and physical activity restrictions. These concerns of weight gain and obesity are supported by cross-sectional 5,7,8 and longitudinal studies 9 revealing a high prevalence of overweight and obese children with LCPD.…”