Consensus Statements on the Management of Perthes Disease

	Consensus Statement	Agree	Agree with Minor Change	Agree/Disagree in Part	Disagree
Goals of Treatment of Legg-Calvé-Perthes Disease
1.	The primary long-term goal of treatment of Legg-Calvé-Perthes disease is to try to prevent secondary degenerative arthritis of the hip in adult life by achieving the short-term goal cited next (2)	GT, I-HC, TH, GH, JH-S, HK, DE, DGL, CP, BJ
2.	The primary short-term goal of treatment of Legg-Calvé-Perthes disease is to try to ensure that when the disease is completely healed the femoral head is spherical, and minimally enlarged (ie, prevent the femoral head from getting deformed)	GT, I-HC, TH, GH, HK, DGL, CP, BJ	JH-S, DE
TREATMENT OF LEGG-CALVÉ-PERTHES DISEASE: TIME FRAMES
3.	The treatment of Legg-Calvé-Perthes disease needs to be divided into 3 distinct time frames: a. Early in the course of the disease : this first and most vital frame is from the onset of the disease to the early fragmentation stage b. Late in the course of the disease : this second time frame is from the late fragmentation stage to full reossification of the femoral head (complete healing) c. After complete healing : the third time frame is after the disease has healed and residual sequelae are present The aims of treatment will necessarily vary in each of these 3 time frames. The options and the strategies of treatment will also vary in each of these 3 time frames	GT, I-HC, TH, GH, JH-S, HK, DGL, CP, BJ		DE
TREATMENT EARLY IN THE COURSE OF THE DISEASE
4.	The goal of treatment early in the course of the disease is to retain the normal shape of the femoral head by: a. Identifying patients at risk for a poor outcome as soon as possible b. Containing the femoral head as early as possible in patients at risk of a poor outcome	GT, I-HC, GH, JH-S, CP, BJ	TH, DE	HK, DGL
5.	Containment may be achieved by nonoperative or operative means and surgical options include femoral and /or pelvic surgery	GT, I-HC, TH, GH, JH-S, HK, DGL, CP, BJ	DE
6.	Containment may or may not be combined with weight relief	I-HC, TH, GH, JH-S, HK, DGL, CP, BJ	DE		GT
7.	In order for containment to be successful, it should be achieved before the late stage of fragmentation	GT, I-HC, TH, GH, JH-S, HK, DGL, CP, BJ		DE
8.	Containment should be maintained until the late reconstitution (reossification) stage	GT, I-HC, TH, GH, JH-S, HK, DGL, CP, BJ	DE
9.	The decision to consider containment treatment early in the course of the disease is primarily governed by the age of onset of the disease with patients divided into 4 age groups. (The chronologic age is used in most centers in the decision making as skeletal age atlases are not available for several ethnic populations and because there is a lack of natural history data based on skeletal age)	GT, I-HC, TH, GH, JH-S, DGL, CP, BJ	HK		DE
10.	Children less than 5 years of age at the onset of the disease: treatment is seldom needed regardless of severity of involvement of the femoral head. (However, if femoral head extrusion occurs treatment will be needed)	GT, GH, JH-S, DGL, CP, BJ	I-HC, TH, DE, HK
11.	Children 5 years or older but less than 8 years of age at onset of the disease: a. Early containment is indicated if it is possible to determine that more than half the femoral epiphysis is necrotic b. Early determination cannot be made in most patients. These patients should be monitored with periodic (∼4-monthly) radiographs to detect early extrusion of the femoral head c. Containment treatment should be considered as soon as extrusion of the femoral head is detected (provided the disease has not progressed into the late stage of fragmentation) d. Extrusion is determined by a break in the Shenton line or the Reimer migration index >20% e. No containment is need in this age group when extrusion does not occur	GT, GH, JH-S, CP, BJ	I-HC, TH, DE	HK, DGL
12.	Children 8 years or older but less than 12 years of age at onset of the disease: a. Should be treated by containment as soon as the disease is diagnosed regardless of the extent of necrosis. Containment should be initiated before the fragmentation stage and before extrusion whenever possible b. Alternative methods should be considered when the patient presents in the late stage of fragmentation	GT, I-HC, GH, JH-S, CP, BJ	TH, HK, DE		DGL
13.	Children 12 years of age or older at the onset of the disease: containment should NOT be considered in these adolescents as it does not work. Treatment considerations should be similar to treatment of adults with osteonecrosis	GT, I-HC, GH, CP, BJ	TH, JH-S, DE, HK, DGL
TREATMENT LATE IN THE COURSE OF THE DISEASE
14.	The goal of treatment of Legg-Calvé-Perthes late in the course of the disease is to attempt to minimize the extent of deformation of the femoral head that has already developed from extrusion	GT, I-HC, TH, GH, HK, DE, DGL, CP, BJ
15.	The treatment in the late fragmentation stage may be remedial or salvage depending on the deformity of the femoral head or the presence of hinge abduction. In children who have hinge abduction the goal of treatment is to correct hinge abduction and facilitate some remodeling of the femoral head	GT, I-HC, TH, GH, JH-S, HK, DGL, CP, BJ		DE
16.	Containment may be considered if the femoral head can be contained without hinge abduction. (In these late cases, the prognosis for obtaining a spherical femoral head is guarded)	GT, I-HC, TH, GH, JH-S, HK, DGL, CP, BJ	DE
17.	If hinge abduction is present, containment is unlikely to improve the femoral head shape. A valgus femoral osteotomy is a reliable choice to improve motion and reduce pain	GT, I-HC, GH, JH-S, CP, BJ	TH, DE	HK, DGL
TREATMENT AFTER HEALING OF THE DISEASE
18.	The goals of treatment of adolescents or young adults with healed Legg-Calvé-Perthes disease and deformity of the femoral head is to improve function, relive pain, and delay the onset of secondary degenerative arthritis	GT, I-HC TH, GH, JH-S, HK, DE, DGL, CP, BJ
19.	The treatment approach depends on the specific cause of pain, dysfunction, or deformity	GT, I-HC, TH, GH, JH-S, HK, DE, DGL, CP, BJ
20.	If the femoral head is spherical or ovoid and there is coxa brevis with a Trendelenburg gait, consider trochanteric advancement with or without lengthening the femoral neck	GT, I-HC, TH, GH, JH-S, HK, DGL, CP, BJ	DE
21.	If there is pain on account of femoro-acetabular impingement consider repairing the labral pathology and/or correcting impingement	GT, I-HC, TH, JH-S, DE, DGL, CP, BJ		HK
22.	A deficient acetabular roof may require labral support or pelvic osteotomy with or without realignment of the proximal femur	GT, I-HC, TH, GH, JH-S, DE, DGL, CP, BJ		HK
23.	Symptoms caused by osteochondritis dessicans can sometimes be relieved by removing the loose fragment	GT, I-HC, TH, GH, JH-S, H, DGL, CP, BJ	DE
24.	The role of reshaping a grossly deformed femoral head is uncertain although in a few selected cases of moderate deformity, it may be of benefit	GT, I-HC, TH, GH, JH-S, DE, CP, BJ		HK, DGL
25.	When the articular surface is severely damaged salvage procedures such a total hip replacement should be considered	GT, I-HC, TH, GH, JH-S, DGL, CP, BJ	HK, DE