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Morbus Perthes – Neuigkeiten in der Diagnostik und Behandlung

Perthes disease—news in diagnostics and treatment

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Zusammenfassung

Diagnostik

Der M. Perthes stellt nach wie vor eine Herausforderung für den behandelnden Orthopäden dar. Unverändert ist das Röntgenbild die Methode der Wahl zur Diagnostik und Verlaufskontrolle. Eine weitere Differenzierung der Waldenström-Stadien – insbesondere in frühes und spätes Fragmentationsstadium – ist möglicherweise relevant für die Optimierung des Operationszeitpunkts im Falle eines Containment-Verlusts. Sogenannte „Advanced“-MRT-Untersuchungen können möglicherweise frühzeitiger als konventionelle Röntgenaufnahmen Risikopatienten entdecken und damit diese früher einer operativen Therapie zuführen.

Behandlung

Bezüglich der Therapie sind aktuell keine Verfahren im klinischen Einsatz, die direkt die ossären Veränderungen beim M. Perthes normalisieren könnten. Konservative physiotherapeutische Maßnahmen mit Verbesserung der Gelenkbeweglichkeit und ggf. Entlastung sind die grundlegenden Standardverfahren zur Behandlung. Sie werden ergänzt durch eine analgetische und/oder antiphlogistische Medikation bei entsprechenden Symptomen oder Befunden. Bei Containment-Verlust ist insbesondere bei Kindern, die älter als 6 Jahre sind, ein operativer Eingriff indiziert. Dabei besteht aktuell ein Trend in Richtung azetabulärer Verfahren – insbesondere zur Triple-Osteotomie – um die biomechanischen Verhältnisse am proximalen Femur nicht zusätzlich negativ zu beeinflussen, wie es durch die Varisationsosteotomie erfolgt.

Abstract

Diagnostics

Perthes disease remains a challenge for paediatric orthopedic surgeons. X‑ray imaging is still the method of choice for diagnostics and follow-up examination. A more detailed differentiation of Waldenström’s classification, especially in early and late fragmentation stages, might be relevant to optimize timing of containment surgery. So-called “advanced MRI” imaging might help to detect patients at risk earlier than conventional x‑ray imaging, which could lead to earlier surgical intervention.

Treatment

Currently there is no treatment modality available which would improve the bone changes in Perthes disease. Non-operative treatment like improving hip range of motion as well as unloading is still the basic standard of care, with analgesic and/or anti-inflammatory medication, according to symptoms or findings. In the case of loss of containment, especially in children older than 6 years, surgery is indicated. Currently, there is a trend favoring acetabular reorientation techniques—especially the triple osteotomy, since the biomechanical relations would not be additionally impaired as in case of femoral varus osteotomy.

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Abbreviations

BMP:

„Bone morphogenetic protein“

DWI :

„Diffusion-weighted imaging“

EMA :

Europäische Arzneimittel-Agentur

FAI :

Femoroazetabuläres Impingement

HHS :

Harris Hip Score

MRT :

Magnetresonanztomographie

SA :

Shelf-Arthroplastik

SF-36 :

Short Form 36

SO :

Salter-Osteotomie

TEP :

Totalendoprothese

TO :

Triple-Osteotomie

VO :

Varisationsosteotomie

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Authors and Affiliations

  1. Orthopädische Klinik, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland

    B. Westhoff, C. Lederer & R. Krauspe

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Correspondence to B. Westhoff.

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B. Westhoff, C. Lederer und R. Krauspe geben an, dass kein Interessenkonflikt besteht.

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Westhoff, B., Lederer, C. & Krauspe, R. Morbus Perthes – Neuigkeiten in der Diagnostik und Behandlung. Orthopäde 48, 515–522 (2019). https://doi.org/10.1007/s00132-019-03737-2

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