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Treating Perthes Disease

Treating Perthes Disease

by | May 18, 2022 | Hip Disorders

Perthes disease, also known as Legg-Calvé-Perthes disease, is a childhood disorder of the hip. The disease affects the ball portion of the hip joint, known as the femoral head. Perthes is uncommon — approximately five to 10 children per 100,000 will be diagnosed each year — and it more commonly affects boys — 1 in 760 boys. Here are some interesting facts about this pediatric hip condition.

What Happens to the Hips in Perthes Disease
In a normal hip joint, the round femoral head of your femur fits perfectly into the round socket of the pelvis. Perthes disease interrupts the blood flow to the femoral head, causing all or part of it to die due to the lack of blood. The bone death is medically referred to as osteonecrosis.

Once the bone dies, the femoral head is more prone to breakage and heals poorly in older children. As a result, the pressure and weight on the bone from normal rigorous activities can cause the round portion to become flat over few months to a year after the diagnosis. For one to two years after bone death occurs, new bone gradually begins to fill in the areas where the body has removed the dead bone.

The Cause of Perthes Is Still Unknown
While we know what happens to the hip to alter the round shape of the femoral head, we still don’t know what causes the precipitating interruption of blood flow. We also know that Perthes is not heritable, since less than five percent of the patients have a family history of the disease. However, some other heritable hip conditions or blood disorder can mimic Perthes, such as inherited bone dysplasia like multiple epiphyseal dysplasia and sickle cell disease. History of taking corticosteroid for treatment of asthma, inflammatory conditions or cancer can also produce bone necrosis that mimics Perthes.

Diagnosing Perthes Disease
Because so many other diseases can mimic the symptoms of Perthes, it is known as a disease of exclusion. Doctors will rule out other conditions by taking a careful medical history and performing a physical exam. The physician will typically ask about the following diseases to rule them out:

  • Family history of hip disorders or early joint replacement
  • Steroid use, such as for asthma
  • Prior hip surgeries
  • History of sickle cell disease
  • History of hip infection
  • History of endocrine or clotting disorders

To confirm a potential Perthes diagnosis, doctors will perform X-rays of the hips. If an X-ray is taken too soon after symptoms have begun, it may appear normal. In that case, physicians can order a very sensitive diagnostic test called perfusion MRI if they still suspect Perthes.

Treatments and Complications
The body will naturally remove and replace the dead bone of the femoral head with new bone, so, to some extent, Perthes is self-healing. However, the healing process may be slow and even after healing has taken place, the femoral head may not return to its original round shape. When that fails to happen, patients may experience long-term complications, such as pain, stiffness and arthritis later in life.

Until the healing phase is complete, nonsurgical treatments might include crutches, wheelchairs, casting and/or bracing, and reduced physical activity. Surgical treatments might include pelvic or femoral osteotomy a process that re-orient the pelvis or femur. In older children, another treatment option is to make bone channels to speed up healing and to inject bone marrow stem cells.

While Perthes is in some ways self-healing, femoral heads sometimes don’t heal properly but there are other treatment options are available. With the interventions we have today and new treatment knowledge about the condition, those with Perthes can usually return to daily activities and sports activities without problems.

Learn more about the various hip conditions our experts treat.

Get to Know our Staff: Vivek Kalia, M.D., M.P.H., M.S., Radiology

Get to Know our Staff: Vivek Kalia, M.D., M.P.H., M.S., Radiology

by | May 17, 2022 | Spotlight

What is your job title/your role at Scottish Rite for Children?  
I am the Medical Director of Radiology and a Staff Radiologist.

What do you do on a daily basis or what sort of duties do you have at work? (You can also include a brief description of your department)
I provide imaging services to our pediatric orthopedic patient population. I also image patients from other services, such as rheumatology and neurology. My team provides imaging services, such as X-ray, CT, MRI, ultrasound and fluoroscopy. As a staff radiologist, I interpret the imaging exams that our technologists perform. As the Medical Director of Radiology, I am responsible for overseeing the operations of the department and ensuring we are providing timely and high-quality, evidence-based care.

What was your first job? What path did you take to get here or what led you to Scottish Rite? How long have you worked here?
My first job was as a part-time cancer researcher in the Department of Pharmacology & Toxicology at the University of Alabama at Birmingham during college. It was great to get some experience under my belt. Through my medical training years, I have meandered around the country. I did 4 years of college in Birmingham, AL, 5 years of medical school and public health school in Baltimore, MD, 4 years at a diagnostic radiology residency in Burlington, VT, and one year at a musculoskeletal radiology fellowship in New York, NY. Then, I took my first faculty position as an MSK radiologist at the University of Michigan in 2017. I came to Scottish Rite just about 2.5 months ago, with an initial start date of Jan 31, 2022.

What do you enjoy most about Scottish Rite?
The culture and the people! Even when I interviewed for the position of Medical Director, I knew that what would make me sign on the dotted line was the daily interactions I would have with colleagues (and now friends) here. I love the patients as well, of course.

Tell us something about your job that others might not already know.
I prepare way more than some may realize for all of the meetings I’m a part of now. And, I do my absolute best to follow-up with each person I’ve made a commitment to.

Aside from necessities, what one thing could you not go a day without?
Kissing my 3-year-old daughter and my wife goodbye in the morning when I leave for work.

What is something that always makes you smile?
My daughter, without fail.

What’s one fun fact about yourself?
Believe it or not, I once (i.e. in high school) was a break-dancer. I even did a few shows in my high school.

How do you identify within the Asian American and Pacific Islander community?
I was born in India but moved to the US when I was just 3 years old and have lived here ever since. I practice Hinduism as my religion. My wife was born and brought up in India until the age of 23. We both have strong cultural influences from India and try to keep our heritage and culture at the forefront of our minds, particularly as we raise our young daughter.

What brings you joy about your heritage and culture?
The focus on familial ties is a big thing for me. I love how everything in our culture is centered around the family, and there is immense respect put on parents and grandparents. In my culture, it is routine and even normal for parents to live with their children once they reach a certain age and are no longer able to care for themselves (rather than go to an assisted living facility or nursing home.) I love my parents so much and would gladly welcome them into my home.

Favorite travel destination?
Hawaii for sure because of its unmatched beauty.

Favorite meal or special recipe?
I love Thai food!

Exercises for Hip Pain

Exercises for Hip Pain

by | May 11, 2022 | Hip Disorders

Hip pain can be caused by a variety of underlying factors. Weak hip muscles can cause poor body mechanics when walking or performing other activities, which can eventually lead to pain. Muscles that are too tight may also cause pain and/or popping sounds in the hip during movement. Stretching and exercises can help improve the strength and flexibility of the hip muscles, decreasing pain and improving overall hip health.
 
Working with your child on proper stretching and exercises can help prevent hip pain. We recommend the following exercises and stretches to strengthen hip muscles:

Quadruple Fire Hydrant

  • Get down on all fours.
  • Keeping your knee bent, lift your hip out to the side.

Single-Leg Bridge

  • Lie on your back with knees bent.
  • Lift your hips off of the ground and then lift and straighten one leg.
  • Lower leg and repeat on the other side.

      Side-Lying Hip Abduction

      • Lie on your side with the bottom leg straight or bent.
      • Tighten the muscles on the top of your leg, in the front part of your thigh.
      • Lift the top leg while keeping the muscle tight and your knee straight.

          Half-Kneeling Hip Flexor Stretch

          • Kneel on one leg.
          • Slowly push your pelvis down while slightly arching the back until a stretch is felt on the front of your hip.

                      Supine Hamstring Stretch

                      • Lie on your back with one leg on the ground and one leg extended straight.
                      • Hook a strap on the extended leg to reach a maximum stretch.
                      • Straighten the extended knee further by tightening your front thigh muscles (quadriceps.)
                      • Slowly press the other leg down as close to the floor as possible.

                          Standing ITB Stretch

                          • Stand with one leg crossed behind the other leg.
                          • Bending at the waist, reach toward your back foot.

                              While daily exercises and stretches may prevent or alleviate hip pain, in some cases physical therapy might be needed. At Scottish Rite for Children, our Physical Therapy experts can work with your child to create a custom home-exercise program to address their specific needs. The home exercise program can be adjusted based on your child’s pain, progress and goals.

                              Learn more about our Physical Therapy services.

                              World-Renowned Hip Care

                              World-Renowned Hip Care

                              by | May 3, 2022 | Hip Disorders

                              Scottish Rite for Children’s Center for Excellence in Hip has a long tradition of providing the highest-quality medical care to thousands of children, from newborns to adolescents and young adults. Led by director and pediatric orthopedic surgeon Harry Kim, M.D., M.S., the team provides a coordinated and comprehensive approach to care that brings together hip specialists from orthopedics, radiology, physical therapy, psychology and more. This multidisciplinary team approach allows us to offer a broad spectrum of operative and nonoperative care options to preserve, improve and repair the native hip joint. At the Forefront of Innovation  Our experts are committed to advancing clinically important research to provide the best care to our patients. Several of the center’s research projects have led to revolutionary, life-changing results. Patients who had evaluation and treatment at our center have the opportunity to participate in large patient registries to allow for evaluation of treatment outcomes for a variety of conditions. These studies lead to new insight and significant improvement as our team modifies treatment algorithms based on these results. In addition, doctors and researchers are involved in multicenter hip research groups with peers at top-tier institutions around the country. They regularly collaborate to discuss the latest innovations and treatment techniques regarding patients diagnosed with pediatric hip conditions and injuries. Movement Science Laboratory The accredited movement science laboratory is an integral part of the treatment of our patients. The multidisciplinary team of engineers and kinesiologists use leading-edge technology to evaluate and identify joint motion, net joint forces, muscle activity, strength, foot plantar pressures and oxygen consumption. These analyses guide the development of individualized treatment plans for our patients and support research. The clinical research team partners with movement science to study the changes experienced with surgical intervention to ensure each patient continues to maintain improved hip functions. Multidisciplinary Complex Hip Clinic This clinic brings all of our hip experts together in one clinic to review and evaluate each patient in person together. The history, physical examination and images are evaluated, and various options are discussed for treatment. The multidisciplinary approach also includes experts in the fields of physical therapy, psychology, pain management and nursing. A comprehensive diagnostic (if necessary) and treatment plan is then developed specifically for each patient. If surgical treatment is necessary, the full range of procedures are available with the experts in the field to include hip preservation surgery (both open and arthroscopic options) as well as the potential for utilizing total hip arthroplasty (replacement) when appropriate. This clinic occurs every month and only those patients requiring this multidisciplinary approach are included. Patients may request to be seen in this clinic. Hip Team All of our pediatric orthopedic surgeons are board certified in orthopedic surgery and also completed a fellowship in pediatric orthopedics. Several of our medical staff have a particular interest in treating and studying pediatric and adolescent hip conditions. Harry Kim, M.D., M.S. 
                              • Special interest in treating patients with Perthes disease, adolescent and young adult avascular necrosis, and developmental dysplasia of the hip (a member of International Hip Dysplasia Institute).
                              • Leader and chair of the International Perthes Study Group – multicenter research study focused on advancing the care of children diagnosed with Perthes disease.
                              • Extensive basic and clinical research on Perthes disease and avascular necrosis.
                              Daniel J. Sucato, M.D., M.S. 
                              • Special interest in treating adolescent patients with various hip conditions including hip dysplasia, adolescents and young adults with Perthes disease, slipped capital femoral epiphysis and femoroacetabular impingement.
                              • A member of the Academic Network of Conservational Hip Outcomes Research (ANCHOR) study. A multi-center project that analyzes hip function and pain, quality of life and other factors on patients who undergo hip preservation surgeries.
                              Henry B. Ellis, M.D. 
                              • Special interest in treating femoral acetabular impingement, labral tears and other sport-related injuries and conditions in the hip.
                              • Involved in multi-center research projects with a special interest in hip arthroscopy.
                              • A member of the Academic Network of Conservational Hip Outcomes Research (ANCHOR) study.
                              David A. Podeszwa, M.D. 
                              • Special interest in treating patients with hip dysplasia, slipped capital femoral epiphysis and femoroacetabular impingement.
                              • A member of the Academic Network of Conservational Hip Outcomes Research (ANCHOR) study.
                              William Z. Morris, M.D. 
                              • Special interest in treating patients with hip dysplasia, slipped capital femoral epiphysis and femoroacetabular impingement.
                              • Extensive clinical research in the pediatric and adolescent developing hip with expertise in the pathogenesis of slipped capital femoral epiphysis and femoroacetabular impingement.
                              Corey S. Gill, M.D. 
                              • Special interest in treating infants with hip dysplasia and patients with cerebral palsy with various hip disorders/dysplasia.
                              • Other common hip conditions seen include slipped capital femoral epiphysis, Perthes disease, transient synovitis of the hip, osteoid osteoma and proximal femur cysts.
                              Learn more about the Center for Excellence in Hip.
                              Pediatric Sports Neurology Perspective on Headaches and Migraines

                              Pediatric Sports Neurology Perspective on Headaches and Migraines

                              by | Apr 28, 2022 | Sports Medicine

                              Mathew Stokes, M.D., is a pediatric sports neurologist and headache specialist at UT Southwestern Medical Center and also sees patients at Scottish Rite for Children in Frisco. These resources are designed to help medical professionals recognize and manage sport-related concussions and headaches in children and adolescents.

                              Sports Neurology: Concussion and Headache in Young Athletes

                              Mathew Stokes, M.D.

                              Watch now

                              Stokes presented this lecture as part of a monthly education series for medical professionals. He described common symptoms including physical, emotional and cognitive changes associated with sport-related concussion. He presented risk factors associated with delayed recovery from concussion. Finally, he provided criteria for diagnosis, management and prevention of common headache types in athletes including migraines.

                              Non-Pharmacological Management of Migraines

                              Victor Kaytser, M.D., and Mathew Stokes, M.D.

                              Stokes, M.D., co-authored this article with UT Southwestern Medical Center neurology fellow, Victor Kaytser, M.D. The article was originally published in a recent newsletter of the Pediatric Society of Greater Dallas.

                              Download the PDF of this article.

                              What Is a Migraine and How Are They Treated?

                              Migraines are a common neurological disorder affecting one in 10 children, with a higher incidence in teenage girls. (Symptoms of migraine or what is not considered a migraine?)

                              As we learn more about migraines, we are finding new and innovative ways to treat them. This is especially important for patients who cannot take or do not respond well to the traditionally prescribed pain-relieving and preventive medications. In addition, parents may feel hesitant to medicate their children and will seek non-pharmacological remedies first. Therefore, we will discuss some non-pharmacological options for the treatment of migraines including lifestyle modifications, supplements and devices.

                              Lifestyle Modifications

                              Lifestyle modifications are recommended regardless of what other treatments may already be in place and can be remembered using the mnemonic SEEDS: Sleep, Exercise, Eat, Diary, Stress.

                              Sleep
                              Migraines can be caused by too much or not enough sleep, and disruptions in the normal 24-hour sleep cycle, or circadian rhythm. Poor sleep habits can trigger migraines, and migraines, in turn, make it difficult to sleep, further exacerbating the pain cycle. A few sleep hygiene tips are as follows:

                              • Schedule a consistent sleep time and wake time, including weekends.
                              • Do not use the bed/bedroom for other activities, such as studying, watching TV, etc.
                              • Avoid staying in bed if wide awake; rise and do something else for a few minutes before trying to fall asleep again.
                              • Take time outside to help set a natural circadian rhythm.
                              • Do not exercise before sleep.
                              • Avoid stimulants, such as caffeine or nicotine.

                              Exercise
                              At least 30 minutes of moderate-intensity exercise, three times per week can help reduce migraine frequency and severity. Patients should note that overexertion can worsen headaches. Those involved in contact sports need to be mindful that injuries and head trauma can also worsen headaches.

                              Eat
                              Both high and low blood sugar levels can affect migraines. Therefore, eating smaller meals, increasing protein, fiber and healthy fat intake while also reducing processed foods can help maintain healthy glucose levels and reduce migraine frequency.

                              Maintaining a caffeine-free diet is ideal; however, if patients currently consume caffeine, stopping the consumption suddenly can lead to caffeine-withdrawal headaches. Therefore, a slow weaning of caffeine products is recommended. Other foods that are commonly migraine triggers include aged cheese, chocolate and MSG.

                              Water intake is also important. The daily goal is one ounce per kilogram of body weight. (1 KG = 2.2 pounds)

                              Diary
                              A headache diary can help to identify migraine triggers. Triggers can vary from environmental (e.g., bright lights, weather changes) to nutrition, sleep changes or stressors. Identifying migraine triggers can help patients focus their lifestyle change efforts. Options include Migraine Buddy and iHeadache mobile apps.

                              Stress
                              To effectively manage stress, many turn to cognitive behavioral therapy, meditation, mindfulness, massages and yoga. There are free websites, like www.dawnbuse.com, that provide various relaxation audio files, articles and podcasts.

                              Supplements

                              Nutraceuticals
                              Riboflavin (vitamin B2), CoQ10, magnesium, curcumin and feverfew (Tanacetum parthenium) are the most commonly used for migraines. These nutraceuticals have positive effects on mitochondrial metabolism, antioxidant properties and are vasoconstrictors, helping to prevent or relieve pain in migraine sufferers. Several proprietary products, like Migrelief and Dolovent, combine these supplements in a single formula.

                              Magnesium acts as a calcium channel antagonist and has the most robust body of literature supporting its effects on migraine with a relatively low side effect profile (abdominal discomfort and diarrhea).

                              Therapies

                              Essential oils
                              Peppermint oil contains menthol, which can help ease pain by relaxing the muscles around the head. Rosemary oil has anti-inflammatory and pain-easing characteristics. Lavender and chamomile oil is used to help relax and reduce stress. Eucalyptus oil helps to open and clear the sinuses, which, if congested from allergies, may provoke headaches.

                              Heating and cooling pads
                              Placing a hot compress on the neck can help relax tense muscles and relieve pain. A cold compress or ice pack can provide relief through its numbing effect, temporarily dulling the sensation of pain when placed on the neck and/or forehead.

                              Acupuncture
                              Used for centuries to treat pain and manage stress, acupuncture has been shown to be at least as effective as some standard drugs like beta blockers and topiramate, and it is safer and more cost effective.

                              Devices

                              Medical devices like gammaCore, an external vagus nerve stimulator, can also help. The device is held against the skin of the neck and transmits small electrical currents to stimulate the vagus nerve and block pain signals. The device works in as little as 30 minutes, and 30% of patients were pain-free at two hours. About one-third of patients achieved a 50% reduction in headache frequency.

                              Nerivio is a neuromodulation device for patients 12 and older, worn on the upper arm to stimulate small nerves that send pain signals to the brain. A third of patients were completely pain-free at two hours.

                              Cefaly is an external trigeminal nerve stimulation device for patients 18 and older and does not need a prescription. The device is magnetically connected to a reusable self-adhesive electrode that is placed on the center of the forehead and sends micro-impulses to the trigeminal nerve. Studies reported that 32% of patients were pain-free at one hour, and 38% saw at least 50% reduction in migraines per month.

                              Allay Lamp emits a precise narrow band of green light that helps reduce the light sensitivity associated with migraine, which can also help reduce stress, anxiety and improve sleep.

                              Conclusion

                              Helping patients identify migraine triggers and follow daily headache hygiene tips can go a long way in composing an effective treatment plan. In some cases, lifestyle changes may be enough to reduce migraine frequency considerably and avoid the need for devices or medications all together. For others, a combination of lifestyle changes with a device, supplement or medication may be the most effective. For the latest migraine management tips, the American Migraine Foundation website routinely publishes new articles to better manage migraines.