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LEGG-CALVÉ-PERTHES

Prepared by: Dr. Murat Taşçı

What is the cause of the disease?

Despite numerous studies, the exact cause of the disease remains unknown, and it is believed to develop on a multifactorial basis (due to multiple causes). Factors that may contribute to the disease include circulatory disorders in the arterial and venous systems of the femoral head, coagulation system issues, trauma, hyperactivity, passive smoking, low birth weight, delayed skeletal maturity, and genetic factors.

Who is affected?

While the disease's prevalence varies from 0.5 to 21 per 100,000 in different races and populations, its prevalence in Turkey is not known. Although the disease can theoretically occur at any age until skeletal development is complete, it is most commonly seen in children between the ages of 4 and 8, and it is 4 to 5 times more common in boys than in girls. Children with clotting disorders, attention deficit hyperactivity disorder (ADHD), or a history of trauma to the hip have an increased risk of developing the disease.

How is it diagnosed?

In children with symptoms of Perthes disease, the hip joint movements are assessed. Blood tests may be ordered to rule out other conditions causing the symptoms. The diagnosis can be made with an X-ray (radiograph) of the hip joint, and follow-up is also done with X-rays. However, since bone changes may not always be visible on X-rays in the early stages of the disease, an MRI (magnetic resonance imaging) may be required for further evaluation.

How is it treated?

The treatment and follow-up of the disease are managed by a pediatric orthopedic specialist or an orthopedic and trauma specialist. Appropriate painkillers may be given to relieve the child's pain. The main goal of treatment is to reduce the load on the hip joint, helping to minimize damage and promote better joint shaping. For this reason, children may need to avoid activities like running and jumping for a while. The use of crutches or a walker may be necessary for a period. Sometimes casting or the use of orthotics may be recommended. Physical therapy is aimed at preserving the range of motion. Special insoles may be used in the shoe to address leg length discrepancy that may develop in the affected leg. If conditions such as insufficient joint coverage develop during follow-up, surgical interventions may be required.

Our Pavlik Harness Treatment Journey

Diagnosis

During our baby's first pediatric examination right after birth, the doctor told us, "Everything looks normal and fine, except for a clicking sound in the hip. Get a hip ultrasound when the baby is 40 days old."

We didn't think much of it at the time.

When we went back to the same doctor a few days later, around day 3-4, she mentioned she no longer heard the clicking sound but still advised us not to neglect the ultrasound. She explained that even if there were hip dysplasia, it could be treated within 2-3 months with a device.

As time passed, with feeding, weight gain, and diaper changes, suddenly the 40 days had gone by. I found myself in the waiting room of a private hospital for the hip ultrasound.

In Turkey, hip ultrasound is a routine procedure, always recommended between 40-45 days, and midwives also guide you in this matter. I highly suggest not ignoring this, thinking, "The doctor didn't find any issue during the physical exam, so it's probably fine."

The reason for waiting 40 days is that the bone structure becomes more stable by then.

Ultrasound doesn't usually cause any pain for the baby. However, I realized that some ultrasound machines provide better quality imaging and can get results without putting too much pressure on the baby. At the first private hospital we visited, our baby cried a lot, and the doctor asked us to hold the baby's leg tightly while struggling to capture the image.

The images we finally managed to get didn't look great. The "alpha" values should be over 60, but ours were in the 40s. And in both hips. So, our baby's hips weren’t completely dislocated but were in a position where they could dislocate in the future.

Since the results were concerning, I started researching doctors and found a great one.

The doctor requested another ultrasound. We went to the office of a radiology professor in Aydın. This time, they managed to perform the ultrasound without making our baby cry. However, the results were still not promising. Our right hip was classified as type 2c, and the left was type 3, indicating developmental dysplasia of the hip.

Treatment

Our doctor was really warm, humorous, and kind. When you're in a desperate situation, you need to trust your doctor, and we trusted him. So, when he said, "Let’s start treatment immediately," we agreed. A medical supply store was contacted, and within 15 minutes, our baby was fitted with a Pavlik harness.

Pavlik Harness

We were caught off guard; our clothes were not suitable for the harness. Even though I had remained calm up until then, I couldn't hold back my tears when the harness was fitted.

Honestly, I had imagined a more mobile device. Learning that the harness would stay on 24/7 and that my baby wouldn’t be bathed for a while was disappointing. I cried for two days but eventually pulled myself together. Over time, you get used to everything.

My sadness only lasted for two days because this was a condition that could be corrected.

In both my social circle and through my job, I’ve met people who are dealing with much worse. I’ve heard such terrible stories that I couldn’t even talk about our situation because it felt so minor in comparison.

I recommend thinking this way too. There are worse things out there. We were dealing with a condition that would most likely be cured without surgery or medication. What more could we ask for?

Concerns

Of course, the first week with the harness was challenging. Here are some of the questions that came to mind during that time:

The harness had stiff buckles that were positioned on the baby’s back. I used to be the type of mom who would carefully choose the softest clothing to avoid anything rubbing against my baby’s skin, and now my 45-day-old baby was going to sleep with hard buckles against her. I quickly learned that life doesn’t always allow for such meticulousness.

Our doctor told us that the baby would adjust to life with the harness within 2-3 days. Babies are more resilient than we think. The first days might be hard, but they adapt.

And sure enough, our baby quickly adapted, with minimal fuss. This was our biggest source of relief. If she had been upset, we might have approached the treatment with a more negative attitude.

We also worried that our baby might be uncomfortable in the harness, as her legs were constantly spread apart. But it turns out this is a natural position for babies. The key thing to watch for is adjusting the harness straps as the baby grows since babies grow very quickly at that age. We left the adjustments to the doctor during check-ups and didn’t meddle with it ourselves.

We wondered whether the harness would restrict our baby’s growth. While the harness was on, her height couldn’t be measured, but the doctor assured us that the treatment wouldn’t hinder growth. In fact, our daughter, who was slightly below average in height at birth, is now taller than most of her peers.

Since the baby’s legs were spread apart in the harness, we struggled to find clothes that fit. Our baby, born in mid-January, was suddenly without clothes! Over time, we found solutions, which I’ve written about in another post.

Bathing was another issue. Our doctor instructed that the harness shouldn’t be removed at all for the first month, meaning we couldn’t change her undershirt either. We visited the doctor 2-3 times in that first month, during which we wiped her down with wet cloths and changed her undershirt. By the end of the month, both our baby and the harness were quite smelly… Good thing it was winter.

To prevent diaper blowouts, I frequently changed her diaper, placing a cloth between the diaper and her undershirt to avoid stains. When changing poopy diapers, I usually asked for help since I didn’t want to bring her legs together while wiping.

Still, there were times when we soiled the undershirt. In the beginning, we would send pictures or videos to the doctor after putting the harness back on to make sure we had done it correctly. We always checked her hands and feet after fastening the harness to make sure we hadn’t tightened it too much.

Should I change breastfeeding positions? Our doctor said there was no need. The harness already kept her legs in the correct position. I simply avoided any positions that brought her legs together.

For instance, I chose an ergonomic baby carrier and was mindful of her leg position when putting her in the car seat.

Progress in Treatment

By the end of the first month, a follow-up ultrasound showed significant improvement in the alpha values, which was fantastic news for us.

We ditched the smelly harness and got a new Pavlik harness, one size bigger. The buckles were now positioned on the sides instead of the back. I preferred this new harness since the baby didn’t have to lie on the buckles. Even though our baby had already gotten used to the buckles, it was still a relief for me as a mom.

In the second month, we were allowed to bathe her once a week. Initially, we would make her cry while putting the harness on and off due to our inexperience, but we became more adept over time.

At the end of the second month, her results were almost back to normal. The condition was close to resolving on its own, but since we had already started treatment, we decided to continue for another month to reach the ideal values. The weather was warming up, and we could now bathe her every day if we wanted.

The third month passed even more smoothly. We had become proficient at removing and reattaching the harness, and our baby no longer smelled like vinegar…

By the end of the third month, her alpha values reached 60.

Our doctor had predicted a 2-3 month treatment. I had mentally prepared myself for 4-5 months, but by the end of the third month, the harness was off. We were fortunate that the diagnosis was made early. As the doctor said, the tree had been bent while young. Even if your treatment lasts longer, don’t worry—what matters is that the condition is cured. The hardest part is the first month.

Was there a risk of the hip dislocating again? No, we were on a path of irreversible recovery. However, we will continue to have periodic check-ups to monitor the development of the hip.

When our treatment ended, our daughter was 4.5 months old. From 6 months on, follow-ups will be done with X-rays, not ultrasounds. We took her for her first X-ray at 6 months, and everything looked good.

After the harness is removed, the baby’s legs remain in that spread position for another 2-3 weeks. It takes a little time to transition to regular baby clothes. Even now, I’m still careful not to put her in clothes that would restrict her legs too much.

Tips for a Smooth Treatment

There will be plenty of people around you who will be overly concerned about the situation. Distance yourself from those who act like the world is ending and that this is a catastrophe happening only to you.

Also, ignore those who say, “Let’s just take off the harness for a bit to let the baby breathe.”

We didn’t stray from the treatment plan at all. We removed the harness as little as possible. Comments like, “The baby isn’t growing because she’s not getting bathed” also went in one ear and out the other.

It’s well known that babies are very sensitive to their mother’s emotional state. It’s hard to have a calm baby if the mother is upset. Keep your spirits up so your baby can be calm too.

Just one week after the harness was removed, you’ll forget all about the harness days. You’ll relish holding your baby

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

The femur, or thigh bone, is one of the bones that forms the hip joint. In growing children, bones have growth plates, which are areas of cartilage that allow bones to lengthen. The epiphysis is the head of the bone, separated from the main part of the bone by the growth plate. Slipped capital femoral epiphysis (SCFE) occurs when the growing end of the femur (the epiphysis) slips off the main body of the bone. This displacement is usually in the forward and upward direction of the femoral neck and shaft. Less commonly, the displacement may be backward or downward. The slippage can occur suddenly or gradually.

SCFE is a common hip disorder in adolescents, with an incidence of 8-13 per 100,000. It is twice as common in males as in females, and it occurs more frequently on the left side. Bilateral involvement is seen in 14-40% of cases, but symptoms are often only felt on one side, making it important to evaluate both hips. It typically presents in males between 13 and 15 years old (average 13.5) and in females between 11 and 13 years old (average 11.5). Although the exact cause of SCFE is unknown, most cases are associated with obesity. Increased weight can lead to higher shearing forces on the growth plate, resulting in SCFE. Endocrine disorders such as hypothyroidism, growth hormone abnormalities, and hypogonadism are also linked to a higher incidence of SCFE. If it occurs in children under 10 or over 16, an endocrine evaluation should be conducted.

DIAGNOSIS

Diagnosis is made through a detailed history, physical examination, and hip X-rays. Patients often present with a limp that worsens with physical activity or sudden onset of hip pain. Pain may also be felt in the groin, inner thigh, or knee. Physical examination reveals limping, external foot progression when walking, reduced hip flexion, increased hip extension, decreased internal rotation, and a leg length discrepancy of 1-2 cm. Diagnosis is confirmed with anteroposterior and lateral hip X-rays. In cases where the slippage is mild and not visible on X-rays, MRI or CT scans may be required.

SCFE can be classified into two types: stable (fixed) and unstable (non-fixed). If a child can walk with or without assistance, the SCFE is considered stable, meaning the slippage will not progress. Over 90% of cases are stable. In these cases, children may have difficulty playing or performing tasks like tying their shoes. In unstable SCFE, where the child cannot walk even with assistance, the condition is more severe. This usually occurs following trauma, such as a fall or sports injury. A stable SCFE can become unstable due to trauma. Unstable SCFE causes severe pain, similar to a fracture, and the child is unable to move the affected leg. If unstable SCFE is suspected, the leg should not be moved, as this could worsen the slippage.

TREATMENT

Once diagnosed, the patient should be hospitalized and surgery is required. In most cases, gentle closed reduction and fixation with a single cannulated screw without opening the hip is sufficient. If there is a risk of slippage in the other hip, preventive fixation of that hip is recommended. In chronic cases, various bone surgeries may be needed. The key to successful treatment is early diagnosis, and treatment should be planned within 24-48 hours. If diagnosed early, particularly in stable SCFE, full recovery is highly likely.

The most significant complications include avascular necrosis (bone death), osteoarthritis (hip degeneration), continued slippage, and degeneration of the cartilage (chondrolysis).