Perthes Disease Treatment in Germany

Perthes disease (Legg–Calvé–Perthes disease, Morbus Perthes) is avascular necrosis of the ossification center of the femoral head in children. The disease develops due to disrupted blood supply to the femoral epiphysis, leading to femoral head deformation and early coxarthrosis. It most commonly affects boys aged 4–8 years (M:F ratio = 4:1). Bilateral involvement occurs in 10–15% of cases. German clinics employ precise staging methods, containment therapy, and innovative MIBRAR® therapy to stimulate bone tissue regeneration.

What is Perthes Disease

In Perthes disease, blood supply to the epiphysis (head) of the femur is disrupted. The epiphysis is the bony nucleus that in children is still in the process of growth and formation. Without adequate blood flow, the bone tissue of the epiphysis dies (necrosis), then gradually resorbs and is replaced by new bone (reossification). The entire cycle takes 2–4 years. The main problem is that during the fragmentation phase, the softened femoral head deforms under load. If the head loses its spherical shape, joint incongruence develops → early arthrosis in adulthood.

The goal of treatment is to preserve the spherical shape of the femoral head by ensuring its containment within the acetabulum throughout the entire disease cycle.

Disease Stages

Critical phase — stage II (fragmentation). It is during this period that the softened head is susceptible to deformation. All treatment efforts are directed at preserving the head shape during this phase.

Causes and Risk Factors

1. Disrupted epiphyseal blood supply — the exact cause is unknown. Thrombosis or spasm of the vessels supplying the femoral head (medial circumflex artery) is suspected.
2. Heredity — familial predisposition in 5–10% of cases.
3. Constitutional features — children with Perthes disease are often shorter and thinner than their peers. Delayed bone age.
4. Parental smoking — passive smoking is associated with increased risk (microcirculation impairment).
5. Hyperactivity and injuries — repeated microtraumas of the hip joint.
6. Thrombophilia — congenital coagulation disorders (protein C and S deficiency, Factor V Leiden mutation).

Symptoms

• Limping — the main symptom! Painless or mildly painful limping in a child aged 4–8 years is a reason for examination.
• Groin or knee pain — hip joint pain often radiates to the knee. "Knee pain" in a child — always check the hip joint!
• Restricted movement — decreased abduction and internal rotation of the hip. Adductor muscle spasm.
• Fatigue while walking — the child asks to be carried, refuses long walks.
• Leg length discrepancy — with femoral head deformation and femoral neck "collapse".
• Thigh and gluteal muscle atrophy — on the affected side.

Important: the disease develops gradually, without fever or signs of infection. Limping lasting > 2 weeks in a child is an absolute indication for hip X-ray.

Diagnostics

1. Clinical examination — gait assessment (Trendelenburg limp), range of motion (decreased abduction and rotation), limb length, muscle atrophy.
2. Hip X-ray — AP and Lauenstein views. Waldenström staging. Assessment of head shape, epiphyseal height, Shenton line.
3. MRI — early diagnosis (before radiographic changes). Visualization of the necrosis zone, viable tissue, cartilage condition. "Head at risk" assessment.
4. Ultrasound — quick method for detecting hip joint effusion (transient synovitis as a differential diagnosis).
5. Arthrography — contrast study of cartilaginous head shape (wider than bony). Performed before surgery for containment planning.
6. Laboratory tests — ESR, CRP, leukocytes — to rule out septic coxitis and juvenile arthritis.

Classifications

Herring classification (lateral pillar): assesses the height of the lateral pillar of the epiphysis during the fragmentation phase. The most prognostically significant:

• Group A — lateral pillar not affected. Good prognosis.
• Group B — lateral pillar height > 50%. Moderate prognosis.
• Group B/C — borderline. Requires careful monitoring.
• Group C — lateral pillar height < 50%. Poor prognosis without treatment.

Catterall classification: assesses the extent of head involvement (4 groups). Catterall risk factors ("head at risk"): lateral calcification, horizontalization of the growth plate, subluxation, metaphyseal cysts.

Conservative Treatment

Indicated with favorable factors: age < 6 years, Herring group A or B, small extent of involvement:

• Observation — regular radiographic monitoring every 3–4 months. In Herring group A children < 6 years — good prognosis without active treatment.
• Weight-bearing restriction — reducing axial load (crutch walking), avoiding jumping and running.
• Containment bracing — abduction braces (Atlanta brace, Scottish Rite brace) keep the femoral head within the acetabulum, protecting it from deformation. Worn for 12–18 months.
• Physical therapy — exercises to maintain range of motion, adductor stretching, strengthening of abductor muscles.
• NSAIDs — for pain management.
• Traction — for severe muscle spasm and subluxation.

MIBRAR® Therapy

Perthes disease (Morbus Perthes) is included in the list of indications for MIBRAR® technology (individual assessment). Professor Babayan's method offers a fundamentally new approach — stimulating epiphyseal bone tissue regeneration with autologous material.

MIBRAR® for Perthes disease:

• Revascularization stimulation — ARK (autologous regenerative concentrate) growth factors stimulate angiogenesis — restoration of blood supply to the necrosis zone.
• Accelerated reossification — mesenchymal stem cells differentiate into osteoblasts, accelerating replacement of necrotic bone with new bone.
• Head shape preservation — faster reossification reduces the period during which the softened head is susceptible to deformation.
• Microinvasiveness — Sono Control Arm™ ensures precise ARK delivery to the necrosis zone through a puncture (without incision), which is critically important for a child's growing bone.

The procedure is outpatient, without general anesthesia (sedation is possible). Only autologous material is used — full biocompatibility, no side effects.

Surgical Treatment

Surgery is indicated with unfavorable factors: age > 8 years, Herring group B/C or C, "head at risk", subluxation, loss of containment:

1. Varus intertrochanteric femoral osteotomy — tilting the femoral neck, "deepening" the head into the acetabulum. The most common operation for Perthes disease.
2. Pelvic osteotomy (Salter, Triple) — rotation of the acetabulum for better head coverage. Indicated for lateral coverage deficiency.
3. Combined (femur + pelvis) — for severe cases with bilateral deficiency.
4. Arthrodiastasis — application of an external fixator with joint distraction. Unloads the head during the fragmentation period.
5. Shelf procedure — a bony "shelf" over the femoral head for additional coverage.

Treatment Cost

All treatment prices in Germany.

Clinics