Denosumab and surgery for the treatment of Perthes’ disease
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A boy aged 9 years and 4 months developed a recurrent right-sided limp. His father, a radiologist, prompted a contrast magnetic resonance imaging (MRI) after 6 weeks and diagnosed early Perthes’ disease.

There were risk factors for a poor prognosis. The boy was relatively old for Perthes’ disease. He was a physically active child of small stature with uncertain compliance for non-weight bearing. Disseminated epiphyseal signal alterations in MRI suggested total involvement, Catterall group 4. 2 weeks later, a posteromedial epiphyseal-metaphyseal cyst was seen. At a new examination another 2 weeks later, radiographs and MR images showed a subchondral fracture, but the epiphysis was not sclerotic.

The disease was in early stage Ia according to the modified Waldenström classification Owing to the risk of a severe course, we suggested early containment surgery. The family, however, opted for a mainly conservative treatment with close follow-up by MRI. Thus, treatment consisted of minimal weight bearing by use of crutches or a wheelchair.

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