Morbus Perthes – ein Update

Eine Prognose über den Verlauf des Morbus Perthes ist schwierig, weil nahezu alle Klassifikationen erst in der späten Fragmentationsphase eingesetzt werden können, wenn eine Hüftkopfdeformierung bereits vorlag. Eine frühe Prognose ist nun durch ein Perfusions-MRT möglich, und es verdichten sich die Anzeichen, dass bei ungünstiger Prognose die Ergebnisse der Behandlung besser sind, wenn Therapiemaßnahmen früh durchgeführt werden können.

Kernaussagen

• Die Ätiologie des Morbus Perthes ist nach wie vor unklar.

• Medikamentöse Behandlungsverfahren sind erfolgversprechend, haben sich jedoch in der Therapie noch nicht etabliert.

• Zur Einschätzung der Prognose der Erkrankung hat sich das Perfusions-MRT bewährt. Bei Perfusionsstörungen > 50% sollten operative Maßnahmen in Erwägung gezogen werden.

• Kinder unter 6 Jahren haben in der Regel eine gute Prognose. Operative Maßnahmen sind selten erforderlich.

• Eine Orthesenbehandlung hat sich in der Behandlung des Morbus Perthes nicht bewährt und hat keinen Einfluss auf den natürlichen Verlauf der Erkrankung.

• Containment-erhaltende operative Maßnahmen sollten in der Frühphase der Erkrankung durchgeführt werden, bevor signifikante Deformierungen des Hüftkopfes eingetreten sind.

• Die Triple-Osteotomie, Shelf-Azetabuloplastik und Arthrodiastase werden vielfach erfolgreich eingesetzt. Das Indikationsspektrum ist jedoch noch unklar.

Schlüsselwörter

Morbus Perthes - Perfusions-MRT - modifizierte Waldenström-Klassifikation - Containment

Publication History

Article published online:
26 September 2022

• Literatur

• 1 Wiig O, Terjesen T, Svenningsen S. et al. The epidemiology and aetiology of Perthesʼ disease in Norway. A nationwide study of 425 patients. J Bone Joint Surg Br 2006; 88: 1217-1223
• 2 Kim KW, Herring JA. Legg-Calve-Perthes disease. In: Herring J. ed. Tachdjianʼs Pediatric Orthopaedics. 6th ed. Amsterdam: Elsevier; 2021
• 3 Kamiya N, Yamaguchi R, Adapala NS. et al. Legg-Calvé-Perthes disease produces chronic hip synovitis and elevation of Inerleukin-6 in the synovial fluid. J Bone Miner Res 2015; 6: 1109-1111
• 4 Kim HK, Aruwajoye O, Stetler J. et al. Effects of non-weight bearing on the immature femoral head following ischemic osteonecrosis: experimental investigation in immature pigs. J Bone Joint Surg Am 2012; 94: 2228-2237
• 5 Joseph B, Varghese G, Mulpuri K. et al. Natural evolution of Perthes disease a study of 610 children under 12 years of age at disease onset. J Pediatr Orthop 2003; 23: 590-600
• 6 Joseph B. Management of Perthesʼ disease. Indian J Orthop 2015; 49: 10-16
• 7 Waldenstrom H. The first stages of coxa plana. J Bone Joint Surg 1938; 20: 559-566
• 8 Hyman JE, Trupia EP, Wright ML. et al. Interobserver and intraobserver reliability of the modified Waldenstrom classification system for staging of Legg-Calvé-Perthes disease. J Bone Joint Surg Am 2015; 97: 643-650
• 9 Catterall A. The natural history of Perthesʼ disease. J Bone Joint Surg Br 1971; 53: 37-53
• 10 Salter RB, Thompson G. Legg-Calvé-Perthes disease. The prognostic value of the subchondral fracture and a two group classification of the femoral involvement. J Bone Joint Surg Am 1984; 66: 479-489
• 11 Herring JA, Neustadt JB, Williams JJ. et al. The lateral pillar classification of Legg-Calvé-Perthes disease. J Pediatr Orthop 1992; 12: 143-150
• 12 Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part I: classification of radiographs with use of the modified lateral pillar and Stulberg classification. J Bone Joint Surg Am 2004; 86-A: 2103-2120
• 13 Pietrzak S, Napiontek M. Tomaszewski M. Inter-observer variation of the Catterall and Herring classification in Perthes disease. Chir Narzadow Ruchu Ortop Pol 2000; 65: 33-38
• 14 Stulberg SD, Cooperman DR, Wallensten R. The natural history of Legg-Calve-Perthes disease. J Bone Joint Surg Am 1981; 63: 1095-1180
• 15 Ippolito E, Tudisco C, Farsetti P. The long-term prognosis of unilateral Perthesʼ disease. J Bone Joint Surg Br 1987; 69: 243-250
• 16 Theissen P, Rutt J, Linden A. et al. The early diagnosis of Perthes disease: the value of bone scintigraphy and magnetic resonance imaging in comparison with x-ray findings. Nuklearmedizin 1991; 30: 265-271
• 17 Kim HK, Kaste S, Dempsey M. et al. A comparison of non-contrast and contrast-enhanced MRI in the initial stage of Legg-Calvé-Perthes disease. Pediatr Radiol 2013; 43: 1166-1173
• 18 Du J, Lu A, Dempsey M. et al. MR perfusion index as a quantitative method of evaluating epiphyseal perfusion in Legg-Calve-Perthes disease and correlation with short-term radiographic outcome: a preliminary study. J Pediatr Orthop 2013; 33: 707-713
• 19 Kim HK, Wiseman KD, Kulkarni V. et al. Perfusion MRI in early stage of Legg-Calve-Perthes disease to predict lateral pillar involvement: a preliminary study. J Bone Joint Surg Am 2014; 96: 1152-1160
• 20 Rich MM, Schoenecker PL. Management of Legg-Calvé-Perthes disease using an A-frame orthosis and hip range of motion: a 25-year experience. J Pediatr Orthop 2013; 33: 112-119
• 21 Joseph B, Mulpuri RN, Varghese G. et al. How does a femoral varus osteotomy alter the natural evolution of Perthesʼ disease. J Pediatr Orthop B 2005; 14: 10-15
• 22 Adolf S, Manig M, Meurer A. Aktueller Stand der Therapie des Morbus Perthes. OUP 2014; 1: 10-16
• 23 Kim HK, da Cunha AM, Browne R. et al. How much varus is optimal with proximal femoral osteotomy to preserve the femoral head in Legg-Calvé-Perthes disease?. J Bone Joint Surg Am 2011; 93: 341-347
• 24 Mirovsky Y, Axer A, Hendel D. Residual shortening after osteotomy for Perthesʼ disease. A comparative study. J Bone Joint Surg Br 1984; 66: 184-188
• 25 Joseph B, Rao N, Mulpuri K. et al. How does a femoral varus osteotomy alter the natural evolution of Perthes disease?. J Pediatr Orthop B 2005; 14: 10-15
• 26 Sankar WN, Lavalva SM, Mcguire MF. et al. Does early proximal femoral varus osteotomy shorten the duration of fragmentation in Perthes disease? Lessons from a prospective multicenter cohort. J Pediatr Orthop 2020; 40: e322-e328
• 27 Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004; 86A: 2121-2134
• 28 Wiig O, Terjesen T, Svenningsen S. Prognostic factors and outcome of treatment in Perthesʼ disease: a prospective study of 368 patients with five-year followup. J Bone Joint Surg Br 2008; 90: 1364-1371
• 29 Mosow N, Vettorazzi E, Breyer S. et al. Outcome after combined pelvic and femoral osteotomies in patients with Legg-Calvé-Perthes disease. J Bone Joint Surg Am 2017; 99: 207-213
• 30 Pailhe R, Cavaignac E, Murgier J. et al. Triple osteotomy of the pelvis for Legg-Calvé-Perthes disease: a mean fifteen year follow-up. Int Orthop 2016; 40: 115-122
• 31 Stepanovich M, Upasani VV, Bomar JD. et al. Advanced containment with triple innominate osteotomy in Legg-Calvé-Perthes disease: a viable option even in severe cases. J Pediatr Orthop 2017; 37: 563-569
• 32 Hosalkar H, Munhoz da Cunha AL, Baldwin K. et al. Triple innominate osteotomy for Legg-Calvé-Perthes disease in children: does the lateral coverage change with time?. Clin Orthop Relat Res 2012; 470: 2402-2410
• 33 Willett K, Hudson I, Catterall A. Lateral shelf acetybuloplasty: an operation for older children with Perthesʼ disease. J Pediatr Orthop 1992; 12: 563-568
• 34 Carsi B, Judd J, Clarke NMP. Shelf acetabuloplasty for containment in the early stages of Legg-Calve-Perthes disease. J Pediatr Orthop 2015; 35: 151-156
• 35 Kruse RW, Guille JT, Bowen JR. Shelf acetabuloplasty in patients who have Legg Calve Perthes disease. A study of long-term results. J Bone Joint Surg Am 1991; 73: 1338-1347
• 36 Van der Geest IC, Kooijman MA, Spruit M. et al. Shelf acetabuloplasty fotr Perthesʼ disease: 12 year follow-up. Acta Orthop Belg 2001; 67: 126-131
• 37 Segev E, Ezra E, Wientroub S. et al. Treatment of severe late onset Perthesʼ disease with soft tissue release and articulated hip distraction: early results. J Pediatr Orthop B 2004; 13: 158-165
• 38 Maxwell SL, Lappin KJ, Kealey WD. et al. Arthrodiastasis in Perthesʼ disease. Preliminary results. J Bone Joint Surg Br 2004; 86: 244-250
• 39 Lloyd-Roberts GC, Catterall A, Salamon PB. A controlled study of the indications for and the results of femoral osteotomy in Perthesʼ disease. J Bone Joint Surg Br 1976; 58: 31-36