Non-surgical treatment of Perthes Disease: A systematic review

Purpose

Perthes disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged 4-9 years old, with recent statistics suggesting it affects around five per 100,000 children in the United Kingdom (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. There is significant variation in care with no consensus on which treatment option is best. In 2018 the British Society for Children’s Orthopaedic Surgery, working with the James Lind Alliance, identified research identifying the optimal interventions (surgical and non-surgical) for managing children with Perthes disease as the fourth highest priority for paediatric lower limb surgery research.

Approach

A systematic review was performed, studies were identified and evaluated according to their selected interventions and outcomes. Study designs included in the review were all but case control studies due to risk of selection bias and studies with only one group. Databases included in the review were Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, EMCARE, AMED and PEDro. The review looked for studies that had compared a non-surgical intervention for Perthes disease with another comparator intervention. Primary outcomes were radiological at end of intervention and were primarily Stulberg and Mose, secondary outcomes included functional outcomes such as ROM, strength and quality of life.

Outcomes

Results: 17 studies were deemed eligible for inclusion, seven prospective cohort studies, six retrospective cohort studies and two matched cohort studies and multi-centre prospective cohort studies. Interventions largely focussed on orthotic management (16 out of 17 studies) and physical interventions such as strengthening or stretching (5 out of 17 studies). Two studies reported statistically significant results for the Mose score of patients when treated surgically. One study reported statistically significant improvement in range of movement after physiotherapy compared with active observation.

Conclusion(s): There is a lack of high-quality trial evidence regarding which non-surgical treatments are the most acceptable, effective and cost-effective in the management of children with Perthes disease. Future research, employing randomised trial designs and reporting a wider range of patient outcomes, is urgently needed to inform clinical practice.

Cost and savings

None

Implications

This piece of work will inform current practice as to the lack of evidence to support any particular treatment in place of another. More importantly it highlights the need for more robust studies to measure the effect of non-surgical treatments.

Top three learning points

No further information. 

Funding acknowledgements

This work was completed as part of Adam Marco Galloway's NIHR/ICA Pre-doctoral Clinical Academic Fellowship