Today we’ll discuss one disease or one process that occurs in children and adults, sometimes for different reasons, but it definitely is pretty common, and that’s avascular necrosis of the hip. That means that the blood supply to the hip has gone away; it may have returned but it’s causing a problem with the hip, which almost always leads to arthritis of the hip. In a very young child this is called Perthes disease or Legg-Calve-Perthes disease. That’s a different process, the adult and adolescents, which we’ll talk about in a minute.
Perthes disease, the younger the patient, under the age of six or seven, they can do very well with no surgery often, and they will present with a limp, and then oftentimes we can treat them with physical therapy, perhaps casting, or perhaps just crutches, and oftentimes they will get better by themselves. As the child gets older, and as this becomes more set the child is more skeletally mature, even Perthes disease will sometimes require us to intervene. The one thing we should generally know about Perthes disease or avascular necrosis of the hip is that the earlier we treat it, the better. The earlier that I can get in and do something, the better the results, even if that something is not surgery, the earlier that we treat it, the better the result that we have. I think that that’s the take home message today.
Perthes disease and avascular necrosis is one of the few diseases that I will even treat adults for. If I see an adult who has early avascular necrosis, I mean early, in the first stages, I can often prevent that from going on to collapse by minimal surgical techniques, by using new medication out there. We can actually, hopefully, prevent this from progression, prevent the arthritis. I ask you, if you have early diagnosis of Legg Calve Perthes disease or early diagnosis of avascular necrosis, then come in early and I can treat it. Oftentimes if we wait until the end stage, the results are never as good. For adults it means they need hip replacements (which actually I don’t do) and I’m trying to save the hip so we can only do that if we treat it early.
Now we can get into some of the treatments now, whether that be core decompression, which has been used for many years. Core decompression with drugs like zoledronate, which is utilized to prevent collapse and progression of avascular necrosis or perhaps core decompressions, zoledronate, and using a distraction of the joint, which is called arthrodiastasis, putting a device on and actually saving the hip from hip replacement. I think young patients, below the age of 40, saving the hip from hip replacement is a goal, should be a goal of all physicians. I think in this day and age, we can do that for avascular necrosis.
Therefore, if you have a hip that is early onset of avascular necrosis, whether it’s from unknown causes or from causes because you had a femoral neck fracture from an accident, or from a hip accident, or it occurs because there is some disease, oftentimes if it’s treated early, we can prevent the inevitable arthritis and prevent the need for hip replacement. If you have an early diagnosis of avascular necrosis, I advise you to come in at this time to be treated, and not just be treated with crutches and non-weight bearing. I think avascular necrosis in 2013 is changing, and I think there’s a lot more we can do now to prevent what used to be an inevitable outcome of arthritis.
David S. Feldman, MD is Chief of Pediatric Orthopedic Surgery and a professor of orthopedic surgery & pediatrics at NYU Langone Medical Center / NYU Hospital for Joint Diseases, specializing in the care of children with complex scoliosis, arthrogryposis, hip dysplasia, Legg-Calve-Perthes disease, and lower limb deformities.
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