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Legitimately in Fr CS. Occasionally, you can say authoritatively, not only, I don't know, but we don't know. And indeed, it, the Perthes was first described as I'm sure all of, you know, in 1912, shortly before the first World War and one of my mentors who's the fabulous professor David Little at Sydney Children's Hospital. I'll show you a photo of him in a minute. David Little was one of a group of per researchers who was invited to attend the Centenary um celebration of the, the discovery or the, the naming of Perthes disease. And in 2012, the consensus summary was that they had not discovered terribly much in 100 years. It, it, it is, it's a condition which is not well understood and about which, um, ah, there are legitimate controversies about best treatment. Um How do I go forward as Lowington one? Yeah. Yeah. Um, so what we'll cover briefly is a bit of the history which I've already touched on. We'll talk about the epidemiology, the pathophysiology, the stages, the differentiation, the classification and the treatment principles such as they are, um, the evidence that we have for what we do um, some thoughts about the future and then we will summarize the symbol that you can see on the screen at the moment is that of the birthdays Kids Foundation. Those of you who have worked with Children with birthdays, I would actually very strongly recommend you to put them in touch with the Perthes Kids Foundation because it is a rather amazing charity which provides great fun camps, camps for kids and support for their families. Um Per Perthes was um first described um uh actually in 1912, I believe, um I put 1910, I might be, it might be 1910 and by these three different authors, um in France, America and in Germany, we've chosen to stick with just the surname of the German descriptor. But in the States, it's actually, it's usually referred to as LCP, like half a Perthes disease. And actually, then shortens to LCP. It was actually described shortly before the publications of and Perthes by Waldenstrom in 1909, we remembered Waldenstrom for Waldenstrom's stages, which we will mention shortly. But in fact, actually, Waldenstrom made the mistake of, of concluding that the condition was essentially a manifestation of tuberculosis of the hip. And then when that was demonstrated not to be true. Um using cops postulate as I'm sure you'll remember from medical school. Um Oh, I like it does. He just canceled, uh Becky's computer is doing a firm update. Hopefully, we can carry on regardless I can't see the screen Vicky. That's the only problem I can just put it over there somewhere. Sorry. Brief second of today's minor technical problems. Um, the, uh, um, the, these are the people who have influenced my understanding of Perthes disease is, is who, who's coming up to the exam? Um, most iIn Rosie. Are you? How far away from the exam? Are you? Not very close? But I'm, I'm happy to answer and I was just wondering if you could identify any of the um II, there are many women researching in birth too, but these, these are three fairly prominent Perthes researchers and authors. Top left. There's a clue because he's standing next to the the venue named after himself. Not that I can see on my screen, it's too small to see on your screen. So top left is Tony Tony Catterall who worked his entire career at Royal National Orthopedic Hospital and also at Great Ormond Street actually has now settled in Norfolk. He has a lovely house in Norfolk. And so he very generously gives up his time to come to East Anglian orthopedic club, pediatric orthopedic group meetings and offer us his wisdom is incredibly wise and experienced man. Top right is Tony Herring. Tony Herring is probably the most widely um published author um on Herring's Disease in the world. And then I'm, I'm seated there, a younger version of myself with Professor David Little actually doing some basic science research um in Perthes disease, in fact, looking at the effect of, of sclerostin knockout mice in a birth A model. So, looking at bone preservation pharmacological agents in the use of in the, in the treatment of birth. A um Perthes has an incidence of about one in 1000. That means that in the scheme of um some of the more esoteric pediatric orthopedic things that I deal with, it's actually relatively common. Um, in, you know, in a, in a, in a large comprehensive school, there will probably be one or two people with Perthes disease. It's, it's not super common, but it's relatively common. It has actually a very wide um age of presentation all the way from two through to about 12. Um And what we do know about the prognosis unequivocally is that actually the time at which you acquire per is predictive of the long term outcome. If you're younger, when you acquire it, then you do better. If you're older. When you acquire it, you do worse. Also, it's worth mentioning that women are more mature than men. Girls are more mature than boys, they reach skeletal maturity more at an earlier age. And that means that the age rules relating to prognosis mean that boys and girls of a similar age, boys do better than girls because which reflects the fact, as I say, girls are more mature. Nevertheless, girls are much less frequently affected. It's a 4 to 1 ratio, other risk factors include um social class, um family history. Um And we're well aware that it does have this characteristic of occasionally being bilateral. So whatever systemic risk factors lead to birth on one side, actually also potentially provoke the same thing. On the other side, I show you the young man with the earring and the, and the football shirt on because that is the the the phenotype of most birth kids. Ok. Birth kids are the most delightful, busy, slightly cheeky, slightly caricaturing here, you know, sort of seven and eight year old boys who come into my clinic and they crawl under the desk to see if there's anything that's interesting there. And then they crawl on top of the desk and start playing with the computer. And even in December in Cambridge, they come in with t-shirts and with mud on their knees, t-shirts and shorts and mud on their knees. They're busy active Children. And we actually now veering away from the stereotype. We, we do, we do believe that, um, that actually there is a characteristic in Children with Perthes to continue on with physical activity, even if they are experiencing some pain. In fact, they very rarely report pain. Perthes disease. Children normally present actually because the games teacher or the parents have noticed a limp. And actually, um, the Perthes lads say, no, I'm still going to play footy