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com
1
Department of Family Medicine,
Ataturk University, Erzurum,
Turkey
2
Maras Acupuncture and Laser
Therapy Center, Camlica,
Istanbul, Turkey
Correspondence to
Dr Turan Set,
Ataturk University Faculty of
Medicine, Erzurum 25240,
Turkey;
turanset@gmail.com
Received 10 October 2012
Revised 9 November 2012
Accepted 15 November 2012
To cite: Set T, Maras I,
Khan AS, et al. Acupuncture
in Medicine Published Online
First: 11 December 2012
doi:10.1136/acupmed-2012-
010255
Set T, et al. Acupuncture in Medicine 2012;0:1–3. doi:10.1136/acupmed-2012-010255
Copyright 2012 by British Medical Journal Publishing Group.
Management of Legg–Calve–Perthes
disease with acupuncture:
a case report
Turan Set,1 Ismail Maras,2 Abdul Sattar Khan,1 Hakan Ozdemir2
ABSTRACT
Legg–Calve–Perthes disease (LCPD) is a rare
temporary hip joint deformity mostly effecting
young children from 4–10 years of age. It
involves mainly the head of the femur, which
softens and breaks down due to interruption of
blood supply (avascular necrosis). We report a
case of LCPD that was treated late and had a
poor prognosis, but improved significantly during
a prolonged course of acupuncture. A 12-year-
old boy reported to an orthopaedic clinic in 2006
with limping and was diagnosed with LCPD.
Surgeons applied orthosis without improvement
and decided to perform surgery in 2008.
However, the parents declined the surgical
option and took the boy to an acupuncture clinic
the same year. Needle acupuncture for 20 min
and laser acupuncture locally on the hip joint
area for 5 min were applied. After 30 sessions of
acupuncture, the boy started to improve
clinically. Imaging studies showed that new bone
cells started to develop in the femoral head.
After 130 sessions in 2010 the radiographic
appearance showed almost 90% improvement,
and after 196 sessions, in August 2012, he was
fully recovered. Needle acupuncture treatment
combined with laser acupuncture may be an
option for the management of LCPD.
INTRODUCTION
Legg–Calve–Perthes disease (LCPD) is an
idiopathic hip disorder that produces
ischaemic necrosis of the growing
femoral head; as a result, the femoral
head collapses.1 Apart from the obvious
disadvantages of being significantly
shorter in height for their age and having
one leg longer than the other, resulting in
a slight limp, in some cases the sufferers
experience stiffness, swelling in the hip
and leg, and may develop arthritis of the
knees. Permanent femoral head deformity
is the most significant outcome. We
report a case of LCPD that was treated
CASE REPORT
late and had a poor prognosis, but
improved significantly during a pro-
longed course of acupuncture.
CASE REPORT
A 12-year-old boy was admitted to an
orthopaedic clinic in 2006 with limping,
and was diagnosed as having LCPD
(figure 1A). At hospital surgeons had
applied a splint and orthosis without
improvement, and therefore in 2008
offered to perform surgery with full
replacement of the femoral head (figure
1B). The parents declined this option,
and instead decided to visit an acupunc-
ture clinic the same year. The boy had no
relevant family history; he was born nor-
mally with a weight of 3.2 kg. His family
had no history of chronic disorders. At
6 years of age LCPD was identified clinic-
ally as there was a restriction in move-
ment at the left hip joint; this diagnosis
was supported by imaging studies (see
figure 1A, showing sagging rope sign
and, flattened head and short neck of
left femur). His full blood count and C
reactive protein level were normal. He
complained of pain that increased on
movement. On examination, internal
rotation of the left hip was painful and
his left lower limb was shortened by 1 cm
compared to the right leg.
A course of acupuncture was offered in
September 2008 that included a needle
acupuncture application for 20 min
(stainless steel needles of 0.25 mm diam-
eter and 25 mm length) at all the follow-
ing body points, bilaterally where
appropriate: GV4, GV5, GV6, GV13,
GV14, GV20, Yintang, Taiyang, SI18,
BL10, BL11, BL13, GB20, GB30, GB31,
GB34, BL17, BL18, BL23, BL60, ST25,
ST36, ST40, CV6, CV7, CV11, CV12,
LI4, LI11, SP6, KI3, KI8 and LR2, plus
1
 Downloaded from aim.bmj.com on December 13, 2012 - Published by group.bmj.com
Case report

Figure 1 Radiographs of the patient prior to acupuncture.

laser acupuncture application (Everlase,
MedicTinedic, Varde, Denmark; helium neon soft
laser at 660 nm) locally on different acupuncture
points in the hip joint area for 5 min; at night an
abduction splint was applied, though the orthosis was
discontinued. Initially, he was offered three sessions
per week for 2 months, then two sessions per week
for 2 months and later one session per week, which
was continued until August 2012.
After having 30 sessions of acupuncture, the boy
started to improve clinically (started walking with a
stick with less limping) and imaging showed that new
bone cells had started to develop in the femoral head
(figure 2A). After 130 sessions, in 2010, radiographic
results depicted an almost 90% improvement, and
after 196 sessions in August 2012 he returned to the
full activities of daily life including participation in
sporting activities (figure 2B–D).
DISCUSSION
This case of LCPD improved significantly during a
prolonged course of acupuncture. LCPD is a rare idio-
pathic deformity.2 Experimental studies indicate that
the pathological repair process, which is marked by an
imbalance of bone desorption and formation, contri-
butes to the pathogenesis of femoral head deformity.3

Figure 2 Radiographs of the patient after acupuncture.

2 Set T, et al. Acupuncture in Medicine 2012;0:1–3. doi:10.1136/acupmed-2012-010255

 Downloaded from aim.bmj.com on December 13, 2012 - Published by group.bmj.com
It typically presents in boys aged 4–8 years.4 Affected
children are usually shorter than their peers5 and have
hyperactive tendency.6 There is increased incidence
with a positive family history, low birth weight and
abnormal pregnancy/delivery.7 Age is the key to prog-
nosis. Onset after 8 years indicates poor prognosis.
About 50% of involved hips do well with no treat-
ment. When the onset is under 6 years of age,
outcome is good regardless of treatment. Between 6–
8 years of age, results are not always satisfactory with
conservative management. Greater than 9 years of
age, there is questionable benefit from conservative
management.4
In the present case, our patient was diagnosed at the
age of 6 years. However, the outcome of conservative
treatment until the age of 8 years was not good.
Patients aged <6 years at onset are best managed non-
surgically, whereas older patients may benefit from
surgical treatment. Good surgical results have been
reported in 40% to 60% of older patients (>8 years),
indicating the need to develop more effective treat-
ment based on the pathobiology of the disease.4 If
symptoms persist, a technetium bone scan or MRI
scan can help to identify the pathology, which is seen
as an area of reduced perfusion on bone scan or a
signal change on MRI.8
There is a tendency to operate when the patient is
older with a poor range of motion, and to perform
operative treatment only when there is subluxation or
head at risk signs. One study showed that indications
for the treatment of LCPD are based more on the per-
sonal experience of the surgeon rather than on scien-
tific data.9
To date, the literature does not support the manage-
ment of LCPD with acupuncture and, to the best of
our knowledge, this is the first reported case managed
with acupuncture. The long-term natural history of
LCPD is also not known.10 The passage of time and
the use of an abduction splint at night could have
contributed to (or indeed may have been primarily
Set T, et al. Acupuncture in Medicine 2012;0:1–3. doi:10.1136/acupmed-2012-010255
Case report
responsible for) our patient’s improvement. However,
we conclude that acupuncture may be an option for
conservative treatment of LCPD, but more reliable
evidence will require further studies.
Funding None.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned;
externally peer reviewed.
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 Downloaded from aim.bmj.com on December 13, 2012 - Published by group.bmj.com

Management of Legg−Calve−Perthes
disease with acupuncture: a case report
Turan Set, Ismail Maras, Abdul Sattar Khan, et al.

Acupunct Med published online December 12, 2012

doi: 10.1136/acupmed-2012-010255

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References This article cites 10 articles, 3 of which can be accessed free at:
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