Therapy Options


At your appointments, your specialist will check your child's ROM (range of movement). This will include the following:~ lying on their back with legs straight, moving legs apart (external rotation), moving feet/toes together (internal rotation); whether the child can pull their knees up to their chest (hip flexion); lying on their stomach with legs straight, lifting the legs up straight (hip extension); lying on the stomach with knees bent to 90 degrees with legs splayed/apart (internal rotation), crossing legs/feet (external rotation).
He/She will then possibly recommend exercising to maintain ROM and your options are:~

Physiotherapy will involve exercises specifically for maintaining ROM. You will need to do these exercises at home between appointments too for maximum benefit

Swimming is the very best exercise for a Perthes child. There is no weightbearing and allows the child to move their legs freely. 

Bike riding is another great exercise for these kids, however there is the risk of them falling off their bikes and getting hurt, or needing to put their foot down suddenly and 'jarring' the hip (which can add to the pain).

Hydrotherapy can be hard to find, but is well worth it. This is usually a one-on-one or small class-size session, where specific exercises are done in the water. The added bonuses are that there is no weight-bearing and exercises are more fun done in the water than on land.

Hippotherapy (Therapeutic Horse Riding) is another option that might be available to you. A letter signed by your specialist is usually required and a thorough assessment of your childs abilities will be carried out before a horse and programme is chosen for your child. Riding a horse is the closest thing to walking, as horses backs move back and forwards, side to side as well as up and down. The horse will also be chosen based on the width of their back, how flat their back is and a number of other factors that are relevant to your child and their well-being. They may decide that other than riding in the 'normal' manner or upright, facing forward would be beneficial, so your child may end up facing backwards, lying down, sitting sideways, lying across the horses back and many, many other variations.  20 minutes horse riding is equivalent to two hours of physiotherapy. 



Treatment Options



NON-SURGICAL


Physiotherapy - you will be referred to a physiotherapist for instruction in a range of exercises designed to maintain your child's ROM (range of movement). These are to be done at home as well, as they are very important and can play an integral part in avoiding surgery.

Crutches - these are to minimise weightbearing on the affected leg. They can help, but long-term the child generally isn't walking properly on the crutches (most of them 'swing' on them) and may have some muscle atrophy as a result.  Also the amount of weight-bearing they actually do on crutches is unknown in most cases.

Walking frame - these are also used to minimise weight-bearing on the affected leg. Depends on what is available to borrow and also what your child is comfortable using, as to whether or not you use this or crutches.

Bed rest - the purpose of this is to reduce inflammation and therefore, pain. The child is generally only allowed up out of bed to go to the toilet and will have to use a wheelchair to get to and from the toilet, so that there is no real weightbearing at all.  If your child is very young, this can be very hard to achieve and your specialist may choose traction instead.

Traction - this is usually done in hospital and involves the child having a special device bandaged onto their legs from thigh to ankle and attached to weights that hang over the end of the bed. This gently pulls the hip joint open and gives the femoral head a rest from impact. Traction can last anywhere from two days to a few weeks, depending on how much muscle spasm was taking place prior.

Petrie Casts - a cast from thighs to ankles with two bars between the legs, one above the knees and the other below - which help maintain the optimum position for the hips. The purpose of this cast is to get the femoral heads deep into the acetabulum and can be used after a tenotomy has been performed, or if your specialist feels that the adductor tendon will stretch sufficiently to benefit from wearing this cast.

Brace - maintains the hips at optimum position and is good for containment. The biggest problem with braces are non-compliance, as it is easy to take off and children do remove it for longer than they are supposed to. Mostly braces are worn 24 hours a day except for showering/bathing and swimming. 

Bisphosphonates - are a group of drugs, which have been used extensively throughout the world for over 20 years to treat adults with osteoporosis. At CHW (Children's Hospital, Westmead, Sydney, Australia) over 200 children have been treated for osteoporosis with bisphosphonates since 1994 with favourable results in the treatment of osteoporosis. Osteoporosis is a disorder characterised by abnormal bone loss as a result of an imbalance between the bone forming cells (osteoblasts) and bone resorbing cells (osteoclasts). A localised form of osteoporosis can be found in Perthes Disease.

Bisphosphonates are a class of medicines, which increase bone density by reducing the rate of bone resorption (osteoclasts) and promote continuing formation of new bone via the bone-forming cells (osteoblasts). This generally results in increased bone mineral content, increased density and hence increased strength of bone.

Oral bisphosphonates have been used infrequently in children but are standard therapy for adults with osteoporosis. (Since clinical trials in 2002 they have been routinely used at CHW to treat Perthes disease of the hip). Six infusions are standard over 12 months and are most effective in the early stages ie: during early fragmentation. Accompanying treatments include, non-weight bearing with wheelchair or crutches until established regrowth. Surgery when necessary.

The aim of bisphosphonate therapy is to improve bone mineral density, reduce fracture rate, reduce resorption rate, reduce bone pain and improve mobility. Disappearance of bone pain has been noted to be an early indicator of the drug’s effectiveness in some people treated.
For more information on this option, please follow this link to Children's Hospital, Westmead

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SURGICAL

Tenotomy - involves cutting the adductor tendon to lengthen it, then usually six weeks in petrie casts. This helps to loosen up a stiff hip joint.

Core Decompression/Trans-Neck-Head Tunnelling - this procedure was developed by Dr Nuno Lopes in Portugal and involves making a small hole with a drill, up the femoral neck, across the growth plate and into the centre of the dead bone within the femoral head. The purpose of this, is to allow blood vessels from the upper femur to grow through the hole in the growth plate, to re-supply circulation to the femoral head (re-vascularisation).
Dr Lopes has been doing this procedure for over 15 years and has had success in halting the progression of the perthes process and re-vascularising the femoral head quickly. External bracing is used post-surgery to protect the fragile femoral head. It is felt that this procedure may have a special role in preventing bi-lateral Perthes. If the child is already under observation by a specialist, for Perthes in one hip, then doing this could stop progression in the pre-Perthes hip.  The main risks are fracture and growth arrest of the femoral neck and although there are no documented cases of this with Dr Lopes or Dr Paley in USA, it is important to keep this in mind. 

Femoral Varus Osteotomy - this involves making a cut in the upper femur and removing a wedge-shaped piece of bone, so that the neck of the femur tilts inwards, moving the femoral head deeper into the acetabulum (socket).
This procedure alters the hip mechanics by changing the tension of the hip abductor muscles as they attach to the greater trochanter. These muscles are responsible for maintaining the pelvis level when standing on one leg (which occurs every time we take a step). The side effect of this procedure, is to cause a limp called a Trendelenburg limp, even after the femoral head has healed from Perthes. The osteotomy may need to be reversed surgically at a later date. Also, it shortens the femur producing, or contributing to leg length discrepancy (LLD).

Femoral Valgus Osteotomy - this also involves making a cut in the upper femur and changing the angle, to a shallower position, that the femoral head sits in the acetabulum. This is also used as a reversal of the varus ostetomy, as the former can result in LLD (leg length discrepancy), so around the time the child is finishing growing, this is done to regain leg length.  Again, this alters the hip mechanics, but this time for the better, particularly if used as a reversal for the Varus Osteotomy.

Salter (Pelvic) Osteotomy - the innominate bone (part of the pelvis above the acetabulum) is cut through and a wedge of bone that has been harvested from the Iliac Crest is pinned into place in the cut. This alters the angle of the acetabulum slightly and allows for more coverage of the femoral head. The changes to the skeletal structure are minimal and have no longterm implications, especially as it adds length to the femur that will help compensate for any leg length discrepancy caused by Perthes.

Some feel that there is an increase in pressure on the soft, re-forming femoral head. However, if the psoas and adductor tendons are lengthened as recommended by Dr Salter who pioneered the Salter Osteotomy, this should not be an issue.  Younger children having this procedure may be placed in a hip spica cast (armpits to toes) for 6-7 weeks, whereas older children are on minimal weight-bearing throughout the early weeks post-surgery, although they do move around and do some physiotherapy, as this encourages healing.

Triple Osteotomy - this is where the pelvis is cut in three places and the acetabulum is re-attached in a manner to improve coverage of the femoral head. This is quite an extensive procedure that fewer specialists favour, however it is effective.

Combined Pelvic & Femoral Osteotomy - this is a very big procedure that gives extensive coverage of the femoral head. There is potential for large blood loss and an increased chance of morbidity and complications with this procedure.

Shelf Procedure (Chiari) - this involves adding a bone graft above the acetabulum to improve coverage and containment of the femoral head and helps to more evenly distribute the body's weight. This can be done through a fairly small incision.  This is considered one of the best procedures to prevent subluxation and does not distort the orientation of the upper femur or acetabulum.  It is mostly used for older children or those for whom there is nothing else that would work.

External Fixator - It consists of an external frame that has (usually) three pins attached through the skin to the femur and a further three pins through the skin to the pelvis. The frame maintains the femur at 15 degree abduction. There is a screw that is turned to open up the hip joint and unload the femoral head. When your specialist decides that the correct gap in the hip joint has been achieved, he or she will then 'lock' the frame so that no more adjustments can be made. The frame then remains in place for approximately four months and is the only procedure that completely unloads the femoral head and allows it to re-form cartilage.

The frame is put in place and removed, under general anaesthetic. When the frame is removed, the child is then placed in a modified Scottish-Rite brace, which they wear all day, every day for approximately six weeks. After that, the brace is worn at nights only for another 4-6 months. This is to ensure that the femoral head is well contained in the socket (acetabulum). Throughout this process, physio is maintained and swimming is encouraged, as this minimises muscle atrophy and the chemicals in the pool will help to keep the pinsites clean.
The disadvantages are having to clean the pinsites regularly; a reasonably high chance of a pinsite infection; issues with your child adjusting to the weight and changes in movement required for coping with the fixator.



PERTHES STRETCHES



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