Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

with acute pain

1st line – supportive care

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ACUTE
|
with acute pain
1st line – 

supportive care

Any acute pain should be managed with nonsteroidal anti-inflammatory drugs or acetaminophen. A short period of rest is recommended during acute exacerbations. This may be followed by a period of limited activities and/or sports until the pain resolves and hip motion is restored. Full resumption of normal activities are only allowed following this. A short and variable period (up to 6 weeks) in abduction plaster(s) may be required if symptoms are severe.

Primary options

acetaminophen: children <12 years of age: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children <12 years of age: 10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

ONGOING

under 5 years

1st line – mobilization plus monitoring

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ONGOING
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under 5 years
1st line – 

mobilization plus monitoring

The healing potential is very good at this age and the outcome is very favorable. A full range of motion is maintained and the child is monitored.

Plus – nonsurgical containment

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ONGOING
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under 5 years
|
with lateral extrusion
Plus – 

nonsurgical containment

Treatment recommended for ALL patients in selected patient group

If the radiographs suggest lateral extrusion, nonsurgical containment is considered as children up to 5 years of age can typically tolerate it well.

Containment brings in an increased area of femoral head articular cartilage under the weight-bearing portion of the acetabulum. This ensures maximal contact between the immature femoral head and the acetabulum during the period of growth.

A dynamic radiographic screening arthrogram allows assessment of the optimal position in which to contain the hip. This position is then maintained in an abduction cast, splint, or brace, or a combination of all 3 where a spica and adductor tenotomy is followed by a period in an abduction brace.[72] It is essential to maintain motion during the course of the disease process, therefore a prolonged hip spica is not favored. Bracing should be balanced with a daily range of motion exercises to minimize stiffness. Patients are then weaned back to normal activities once lateral epiphyseal reossification is evident.

5 to 7 years

1st line – mobilization plus monitoring

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ONGOING
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5 to 7 years
|
epiphyseal involvement less than 50%
1st line – 

mobilization plus monitoring

The healing potential is very good at this age and the outcome is very favorable. A full range of motion is maintained and the child is monitored.

1st line – surgical containment

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ONGOING
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5 to 7 years
|
epiphyseal involvement 50% or greater
1st line – 

surgical containment

Containment brings in an increased area of femoral head articular cartilage under the weight-bearing portion of the acetabulum. This ensures maximal contact between the immature femoral head and the acetabulum during the period of growth.

Proximal femoral osteotomy is a versatile procedure in bringing the hip into a contained position. This is achieved by a lateral varus opening wedge osteotomy.

In selected cases, where the femoral head involvement exceeds 50% but the head is not deformed, an innominate osteotomy may be performed. In severe cases a combination of both these procedures may be considered.

In patients aged under 6 years, pelvic osteotomies have better radiologic outcome than femoral osteotomies, whereas in patients aged 6 years and older, femoral and pelvic osteotomies are equally likely to yield a spherical congruent head.[70]

[Figure caption and citation for the preceding image starts]: Surgical containmentFrom the personal collection of Jwalant S. Mehta, MS (Orth), MCh (Orth), FRCS, FRCS (Orth) [Citation ends].com.bmj.content.model.Caption@207175fc

over 7 years to 12 years

1st line – surgical containment

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ONGOING
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over 7 years to 12 years
|
stages I or II
1st line – 

surgical containment

The remodeling potential is decreasing in this age group and there is controversy regarding the benefit of surgical intervention. It is important to get the hip contained as early as possible to allow for remodeling.

Containment brings in an increased area of femoral head articular cartilage under the weight-bearing portion of the acetabulum. This ensures maximal contact between the immature femoral head and the acetabulum during the period of growth.

Proximal femoral osteotomy is a versatile procedure in bringing the hip into a contained position. This is achieved by a lateral varus opening wedge osteotomy.

In selected cases, where the femoral head involvement exceeds 50% but the head is not deformed, an innominate osteotomy may be performed. In severe cases a combination of both these procedures may be considered.

Shelf acetabuloplasty provides a good or fair Stulberg outcome when performed in early Perthes stages as a containment surgery; however, caution is advised in performing the shelf procedure in children older than 10 to 11 years of age.[76]

[Figure caption and citation for the preceding image starts]: Surgical containmentFrom the personal collection of Jwalant S. Mehta, MS (Orth), MCh (Orth), FRCS, FRCS (Orth) [Citation ends].com.bmj.content.model.Caption@deb793c

1st line – salvage procedure

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ONGOING
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over 7 years to 12 years
|
stages III or IV
1st line – 

salvage procedure

Containment is contraindicated and a salvage procedure is performed.

Salvage options address either the acetabulum to recreate or deepen the socket, or aim to improve congruence between the weight-bearing areas by altering the femoral head orientation with a femoral valgus osteotomy. Because the acetabulum is shallow and malformed, the salvaged hip does not have a roof lined by articular cartilage and the lateral part of the femoral head is uncovered. The purpose of surgery in these patients is to create a roof for the femoral weight-bearing portion.

Shelf arthroplasty and the Chiari osteotomy are the 2 common acetabular procedures undertaken to salvage the hip joint with or without the addition of the femoral osteotomy. The Chiari osteotomy is a suitable salvage option in an older child with very little remodeling potential. Shelf arthroplasty is employed in severe disease to prevent subluxation and improve acetabular coverage, although evidence for this is lacking.[75] A proximal valgus femoral osteotomy is also a useful salvage procedure to redirect the femoral head to improve congruence between two misshapen surfaces.

Shelf acetabuloplasty is associated with less favorable outcomes when used for reconstructive-salvage purposes in late Perthes disease stages. Caution is advised in performing the shelf procedure in children older than 10 to 11 years of age.[76]

over 12 years

1st line – salvage procedure

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ONGOING
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over 12 years
|
no arthritis
1st line – 

salvage procedure

Limited remodeling potential indicates that containment is not an option in this age group. Salvage procedures may be considered to improve congruence of the hips.

Salvage options address either the acetabulum to recreate or deepen the socket or aim to improve congruence between the weight-bearing areas by altering the femoral head orientation with a femoral valgus osteotomy. These techniques aim to increase the load-bearing area by attempting to improve congruence. Because the acetabulum is shallow and malformed, the salvaged hip does not have a roof lined by articular cartilage and the lateral part of the femoral head is uncovered. The purpose of surgery in these patients is to create a roof for the femoral weight-bearing portion.

Shelf arthroplasty and the Chiari osteotomy are the 2 common acetabular procedures undertaken to salvage the hip joint with or without the addition of the femoral osteotomy. The Chiari osteotomy is a suitable salvage option in an older child with very little remodeling potential. Shelf arthroplasty is employed in severe disease to prevent subluxation and improve acetabular coverage, although evidence for this is lacking.[75] A proximal valgus femoral osteotomy is also a useful salvage procedure to redirect the femoral head to improve congruence between two misshapen surfaces.

Shelf acetabuloplasty is associated with less favorable outcomes when used for reconstructive-salvage purposes in late Perthes disease stages. Caution is advised in performing the shelf procedure in children older than 10 to 11 years of age.[76]

1st line – replacement arthroplasty after skeletal maturity

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ONGOING
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over 12 years
|
with arthritis
1st line – 

replacement arthroplasty after skeletal maturity

It is estimated that 50% of untreated hips develop disabling arthritis by the sixth decade. The mechanics of a symptomatic hip can be suitably restored by a hip replacement, with similar functional outcomes to those in patients having a hip replacement because of primary osteoarthritis, although the revision rate at mid-term follow-up is slightly increased.[77] The essential deciding factors for replacement arthroplasty are the disability and symptoms. It is performed only after skeletal maturity. The techniques of replacement arthroplasty are constantly evolving. At present, cemented or uncemented components are used. Surface replacements are not suitable due to the femoral head deformity.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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