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Perthes' disease: deprivation and decline
  1. Daniel C Perry1,2,
  2. Colin E Bruce2,
  3. Daniel Pope1,
  4. Peter Dangerfield3,
  5. Mary Jane Platt4,
  6. Andrew J Hall5
  1. 1School of Population, Community and Behavioural Science, University of Liverpool, Liverpool, UK
  2. 2Department of Children's Orthopaedic Surgery, Alder Hey Children's Hospital, Liverpool, UK
  3. 3Department of Anatomy and Cell Biology, University of Liverpool, Liverpool, UK
  4. 4Department of Medical Education, University of East Anglia, Norwich, UK
  5. 5Department of Epidemiology, London School Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Daniel C Perry, Department of Children's Orthopaedic Surgery, Alder Hey Children's Hospital, Eaton Road, Liverpool, L12 2AP, UK; danperry{at}


Introduction Perthes' disease is a childhood hip disorder which frequently precipitates premature osteoarthritis necessitating joint replacement in young adults. The highest incidence reported worldwide is in Merseyside, UK, where a unique disease register is maintained.

Objective To describe the temporal trends in disease incidence in a geographically defined area of Merseyside, and to examine the relationship to area deprivation.

Design Descriptive observational study utilising a regional disease register in Merseyside, UK, 1976–2009.

Patients 1082 children with Perthes' disease (682 from a geographically defined area).

Outcome Disease incidence by region, year and deprivation quintile (measured by the Index of Multiple Deprivation 2007, and the Child Well-Being Index 2009).

Results There was a dramatic decline in incidence over the study period in Liverpool, with rates falling from 14.2 to 7.7 cases/10 000 0–14-year-olds (p<0.001). Incidence rates halved in nearby Knowsley (p=0.01) but remained largely static in the more affluent region of Sefton, where the annual incidence remained at around 7.2 cases/10 000 0–14-year-olds (p=0.73). The association with area deprivation is striking, with the most deprived quintiles having over three times the incidence of the most affluent quintiles (11.5 vs 3.8 cases/10 000 0–14-year-olds; p<0.001). Incidence by electoral ward was strongly correlated to ward deprivation score (p<0.001).

Conclusion There was a marked decline in disease incidence over the study period, particularly in more deprived areas. The magnitude of the association with deprivation, and the changing incidence, strongly suggest that environmental factor(s) are a major aetiological determinant in Perthes' disease.

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  • Funding The study was funded by the John Monk Research Fund.

  • Competing interests None.

  • Ethics approval The Liverpool Perthes' disease register, and its subsequent analysis, have been approved by the Liverpool Children's ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.