ArticlePDF Available

Legg‐Calvé‐Perthes Disease: Past and Present

February 2025
International Journal of Osteoarchaeology 35(2)

DOI:10.1002/oa.3388

Authors:

Ryan James Geoffrey Frederick

University of York

Paola Ponce

University of York

Legg–Calvé–Perthes disease (LCPD) is a rare idiopathic condition that primarily affects the femoral head. It is characterized by a sudden necrosis, which leads to permanent and irreversible changes of its normal anatomy. Likely due to its rarity and complex etiology, there is a lacuna of its study in archaeological literature. This paper attempts to address this issue by aiming to (1) gather all known examples of LCPD in the archaeological record worldwide; (2) based on etiological speculation, analyze how individuals may have developed LCPD in the past; (3) assess how LCPD may have affected these individuals; and (4) how they may have managed the effects. In this study, a wide range of resources pertaining to archaeology, osteology, paleopathology, and clinical studies were consulted. The information was extracted from a number of available case studies and osteological site reports despite data‐access difficulties. In the archaeological record, there are 73 reported cases of LCPD affecting individuals, spanning from the Neolithic to the Postmedieval period, across the globe, with its highest peak in the Late Medieval period. Modern clinical literature has provided an empirical platform to investigate what may have caused LCPD in the past, though etiological conjecture continues to prevent any certainty in these extrapolations. The resulting prevalence of the cases of LCPD are also skewed by issues concerning skeletal preservation and inaccessible data, ultimately affecting its representation and the evaluation of the disease's laterality and sex preponderance. Nonetheless, physical debilitation caused by LCPD would have variably inhibited the individuals' mobility, causing pain, compromised quality of life, decline in mental state, and an inability to fully engage in ambulatory activities. However, coexisting osteological markers suggest methods of managing the disease's symptoms, such as resorting to an antalgic gait and/or using upper limb apparatus (crutch).

| Anterior view of left and right proximal femur (RLP05, Context 40207, Museum of London). The right femoral head retains its spherical shape while the left has flattened into a characteristic mushroom shape resulting from LCPD. [Colour figure can be viewed at wileyonlinelibrary.com]

…

| Posterior view of left and right acetabula (RLP05, Context 40207, Museum of London). The left acetabulum is shallower and wider than its right counterpart with additional osteophytic lipping (coxarthrosis). [Colour figure can be viewed at wileyonlinelibrary.com]

…

| Anterior view of a bilateral case of LCPD affecting both femoral heads (SRP98, Context 27608, Museum of London). [Colour figure can be viewed at wileyonlinelibrary.com]

…

| Medial view of left femoral head affected by LCPD (RLP05, Context 40207, Museum of London). [Colour figure can be viewed at wileyonlinelibrary.com]

…

| Diagram summarizing studied agents that may cause or possibly increase the risk of developing LCPD by initiating the ischemic episode. COLA21-Collagen type 2, alpha 1; IGF-I-insulin-like growth factor-I. [Colour figure can be viewed at wileyonlinelibrary.com]

…

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International Journal of Osteoarchaeology, 2025; 0:e3388

https://doi.org/10.1002/oa.3388

International Journal of Osteoarchaeology

RESEARCH ARTICLE

Legg- Calvé- Perthes Disease: Past and Present

RyanFrederick | PaolaPonce

Department of Archaeolog y, PalaeoHub, University of York, Wentworth Way, Heslington York, UK

Correspondence: Ryan Frederick (ryanfrederick2009@hotmail.com)

Received: 19 August 202 4 | Revised: 7 January 2025 | Accepted: 10 January 2025

Funding: This work was supported by BABAO Commercial Grant.

Keywords: femoral head necrosis| LCPD| Legg–Calvé–Perthes disease| osteochondrosis

ABSTRACT

Legg–Calvé–Perthes disease (LCPD) is a rare idiopathic condition that primarily affects the femoral head. It is characterized by

a sudden necrosis, which leads to permanent and irreversible changes of its normal anatomy. Likely due to its rarity and com-

plex etiology, there is a lacuna of its study in archaeological literature. This paper attempts to address this issue by aiming to (1)

gather all known examples of LCPD in the archaeological record worldwide; (2) based on etiological speculation, analyze how

individuals may have developed LCPD in the past; (3) assess how LCPD may have affected these individuals; and (4) how they

may have managed the effects. In this study, a wide range of resources pertaining to archaeology, osteology, paleopathology,

and clinical studies were consulted. The information was extracted from a number of available case studies and osteological site

reports despite data- access difficulties. In the archaeological record, there are 73 reported cases of LCPD affecting individuals,

spanning from the Neolithic to the Postmedieval period, across the globe, with its highest peak in the Late Medieval period.

Modern clinical literature has provided an empirical platform to investigate what may have caused LCPD in the past, though

etiological conjecture continues to prevent any certainty in these extrapolations. The resulting prevalence of the cases of LCPD

are also skewed by issues concerning skeletal preservation and inaccessible data, ultimately affecting its representation and the

evaluation of the disease's laterality and sex preponderance. Nonetheless, physical debilitation caused by LCPD would have varia-

bly inhibited the individuals' mobility, causing pain, compromised quality of life, decline in mental state, and an inability to fully

engage in ambulator y activities. However, coexisting osteological markers suggest methods of managing the disease's symptoms,

such as resorting to an antalgic gait and/or using upper limb apparatus (crutch).

1 | Introduction

This study aims to explore the global distribution of Legg–

Calvé–Perthes disease (LCPD) in the past and assess its poten-

tial etiological factors through the application of modern clinical

interpretations. Furthermore, by analyzing the skeletal changes

of LCPD we may also evaluate how the condition affected indi-

viduals and how they may have attempted to manage its physical

detriments. By drawing upon a large variety of diverse sites from

different periods, a timeline of the disease's known occurrences

was constructed, noting period, location, and historical context.

Consulting modern clinical literature likewise permitted the

creation of a diagram that summarizes the current understand-

ing of its possible pathogenesis.

LCPD is an extensively ill- understood idiopathic orthopedic

affliction of the hip joint that has eluded the field of clinical

pathology since it was first analyzed in the early 20th century

by the respective physicians, Arthur Legg, Jacques Calvé, and

Georg Perthes (Kuo, Wu, Smith, Shih, and Altiok2011). It af-

fects children 14 years of age and under with the highest inci-

dences occurring in those between 5 and 7 years old (Barker and

Hall 1986; Pillai, Atiya, and Costigan2005; Perry etal.2012a).

The condition is generally considered to be a rare disease (Fuchs

2 of 17 International Journal of Osteoarchaeology, 2025

etal.2021), with varying annual incidence rates globally, rang-

ing from 1:250,000 in Hong Kong, 1:18,000 in the UK, and

1:3500 on the Faroe Islands (Orphanet: Legg- Calvé- Perthes dis-

ease, Date of access: 9th October 2024). It has been postulated

that this variance in frequency is ancestrally and/or geographi-

cally dependent (Perry2013). However, even on a regional scale

this can vary even more considerably. For instance, with regards

to LCPD in the UK, Wessex, in the south of England, had an an-

nual incidence rate of 5.5:100,000, while Merseyside (Liverpool)

in the north had 11.1:100,000 (Perry2013).

General consensus posits that LCPD represents the obstruction

of the main arterial blood supply to the femoral head initiated by

a form of trauma, leading to bone cell death in the femoral head

(Lauritzen 1975; Inoue etal. 1976; Jensen and Lauritzen1976;

Douglas and Rang 1981; Herring 2011; Berthaume etal.2016;

Pinheiro etal.2018).

Causative links between various agents and the prevalence rate

of LCPD have been explored among global populations. Such

agents include skeletal immaturity and resulting biomechan-

ics (Berthaume et al.2016; Pinheiro et al. 2018), genetic pre-

dispositions: ancestry, endocrinopathies and collagenopathies

(Catterall, Roberts, and Wynne- Davies1971; Rayner, Schwalbe,

and Hall 1986; Ortner 2003; Crofton et al. 2005; Miyamoto

etal.2007; Su etal.2008; Su etal.2010; Perry etal. 2012a; Li

etal.2014; Lindblad etal.2024), socioeconomic effects (Barker,

Dixon, and Taylor1978; Joseph etal.1988; Hall and Barker1989;

Kealey et al. 2000; Pillai, Atiya, and Costigan 2005; Perry

etal.2012b), and pollution exposure to tobacco smoke (García

Mata etal.2000; Gordon etal.2004; Bahmanyar etal.2008) and

to wood smoke (Daniel etal.2012).

The resulting femoral head's necrosis proceeds to under-

mine the bone's microstructures and then deteriorates further

through resorption during the repair process, inducing biome-

chanical weakness and increasing susceptibility to subchondral

fracturing (Herrerín and Garralda2012), which subjects the hip

joint to subluxation, altering directional stressors. In the next

stage, the femoral head will flatten to a variable degree, typi-

cally into a mushroom- like shape, and the acetabulum will at-

tempt to remodel to cater for this change. This morphological

alteration affects the level of femoro- acetabular congruency, and

subsequently, the individual's capacity for mobility. Areas of the

proximal femur af fected include the femoral head, femoral neck,

and greater trochanter. Detriments to the changes in these areas

are dependent on variations of weight- bearing and locomotory

activity. Physiological limitations of the disease report an af-

fected gait and range of motion at differing rates, involving ab-

duction, adduction, f lexion, and rotational movement. The level

of recovery from LCPD is generally defined by how it affects the

individual's quality of life, which is determined by the severity of

morphological changes within the affected areas and the result-

ing congruency of the femoro- acetabular joint (Catterall1971).

With regards to age and sex, LCPD is a pediatric condition ex-

clusively diagnosed in infants and juveniles up to the age of

14, most commonly between ages of four and eight, and av-

eraging at 6 years (Aufderheide and Rodríguez- Martín 1998;

Van Campenhout, Moens, and Fabry 2007; Murray, Holmes,

and Misra 2008). The age of the individual at the beginning

of the disease's onset and its duration is fundamental in in-

fluencing LCPD's various signs, symptoms, and prognoses

(Weinstein2000). The older the individual during the onset of

LCPD yielded the worst outcomes due to the eventual inability

of the femoral head and acetabulum to remodel due to bone mat-

uration, preventing proper rectification of the altered morphol-

ogy (Stulberg, Cooperman, and Wallensten 1981). In contrast,

sex does not appear to hold considerable influence over the se-

verity of the disease but is rather distinct for its male preponder-

ance, averaging 5:1 relative to females (Grauer2019).

Unilateral involvement is the most common presentation of

LCPD cases (c. 80%–90%) while bilateral instances are compar-

atively low (c. 10%–35%) in prevalence, and those with bilateral

LCPD are also predominantly male, though the condition does

not behave differently from unilateral cases regarding progno-

sis (Catterall 1971; Ortner 2003). Furthermore, in these bilat-

eral cases, the onset of LCPD does not occur simultaneously

but rather successfully within an interval range between 2 and

4 years, developing femoral heads that can equally be of the

same group classification or be different entirely, resulting in

prognoses that differ accordingly (Catterall 1971; Aufderheide

and Rodríguez- Martín1998).

1.1 | Paleopathological Diagnosis

In contrast to modern clinicians who have the living individual,

musculature, and radiographs to examine, paleopathologists are

left only with skeletal remains to identify the presence of LCPD.

In addition, differential diagnoses pose a risk due to LCPD's

pathological ambiguity with other diseases, namely, slipped

capital femoral epiphysis (SCFE), developmental dysplasia of

the hip (DDH), and aseptic necrosis, which develop in childhood

and persist throughout adulthood (Aufderheide and Rodríguez-

Martín 1998; Ortner2003; Waldron2009). Other diseases with

the same risk extend to Gaucher's disease, Meyer dysplasia,

multiple epiphyseal dysplasia (MED), spondyloepiphyseal dys-

plasia (SED), coxarthrosis (secondary osteoarthritis), hyperthy-

roidism, and infantile coxa vara (Meyer 1964; Khermosh and

Wientroub 1991; Amirfeyz, Clark, and Gargan 2005; Smrčka

etal.2009; Anthony etal.2015). Despite these difficulties, there

are certa in osteological markers paleopathologists us e to identify

LCPD (Ortner and Putschar1985; Smrčka etal.2009). Arguably,

its most fundamental trait is the deformity of the femoral head

and its recognizable flattening into a mushroom- type shape,

which is caused by compressional fracturing and paucity of

endochondral growth occurring during the onset (Aufderheide

and Rodríguez- Martín 1998; Ortner 2003; Grauer 2019; see

Figures1, 2, 3, and 4). The volume of the femoral head could also

be considered as a marker if it exceeds the space of the acetabular

socket (acetabular coverage) either through coxa magna or con-

siderable flattening (Aufderheide and Rodríguez- Martín 1998;

Waldr on 2009). Circumferential wideness and/or shortness of

the femoral neck are equally key, ref lecting both subchondral

fracturing and loss of endochondral growth for varying lengths

of time (Grauer2019).

However, the physical changes are not limited to just the proxi-

mal femur. A secondary effect of the flattening and widening of

3 of 17

the femoral head is the followi ng deformation of the acetabulum,

which is characterized by the flattening, shallowing, and elon-

gation of the acetabular fossa and lunate surface. These changes

are the result of the bone attempting to remodel to the now de-

formed femoral head (Aufderheide and Rodríguez- Martín1998;

see Figure 2). Changes made to the proximal femur without

noticeable differences to its corresponding acetabulum are in-

dicative of a late onset due to bone maturation preventing the

acetabulum from remodeling.

Secondary signs of LCPD include early onset osteoarthritis

(Wa ldr on 2009) and atrophy and/or increased density (robust-

ness) of the lower limbs. Coxarthrosis is detectable through sev-

eral osteological sig ns including osteophytic lipping surroundi ng

the margins of the femoral epiphysis or within the acetabulum,

epiphyseal eburnation, subchondral pitting, and joint contour

changes. All are consequences of abnormal/repetitive locomo-

tion and the weight- bearing detriments of LCPD (Ortner2003).

Atrophy, or tissue wasting, can also be detected by a visibly re-

duced circumference in the metaphysis and/or diaphysis of the

femur. This is likely due to limb disuse. Robusticity, because of

ill- dependency on the afflicted lower limb, can sometimes be

seen in the contralateral leg elements (femur, tibia, and fibula);

an increase of bone mass has generally been associated with

enduring constant heavy weight or loads, building strength in

a particular area to manage a resulting increase in stress and

strain (Yang et al.2019). The effects of both primary and sec-

ondary signs of LCPD, that paleopathologists are confronted

with, are examined in the archaeological cases of this study. The

methods used to evaluate all available cases of LCPD published

and unpublished literature are explained below.

2 | Materials and Methods

The materials used to carry out this study included all available

published and unpublished case studies and osteological/site re-

ports that found ex amples of LCPD. Books a nd monographs were

also consulted in addition to the raw site data from the Museum

of London Collections (Centre for Human Bioarchaeology).

2.1 | Search Strategy

This search took place until October 2024; any cases recorded

after were not included in this study. Cases of LCPD reported

have most commonly been described as possible occurrences in

site reports due to the ambiguities of the disease's characteristics

and bone preservation. Research platforms (PubMed, Google

Scholar, JSTOR, Science Direct, and Wiley Online Library) were

used to collate all the available paleopathological literature on

LCPD. Sources were searched using keywords such as “circu-

latory diseases,” “coxa plana,” “femoral head necrosis,” “Legg-

Calvé- Perthes' disease,” “osteochondrosis of the hip,” “Perthes

palaeopathology,” “Perthes' disease in archaeology,” “Perthes'

classifications,” and the acronym “LCPD”.

2.2 | Methods to Standardize the Collected Data

For the sake of brevity, all archaeological cases were placed

within standardizations of chronological dating familiar to the

British Isles, i.e., Neolithic (4000 –2600 BC); Bronze Age (2600–

800 BC); Iron Age (800 BC–100 AD); Roman (43–410 AD); Early

Medieval (410–1050 AD); Late Medieval (1050–1550 AD); and

Postmedieval (1550–1900 AD).

In terms of acute symptoms, LCPD is a pediatric condition and

therefore presents with specific diagnostic characteristics that

are only attainable during childhood. The individuals examined

in this study were predominantly adults, and so mostly exhib-

ited the condition in its healed stage. Evaluating the age demo-

graphics of those with LCPD was thereby deemed inappropriate

for this study and was omitted.

FIGUR E  | Anterior v iew of left and r ight proximal femur (RLP05,

Context 40207, Museum of London). The right femoral head retains its

spherical shape while the left has flattened into a characteristic mush-

room shape resulting from LCPD. [Colour figure can be viewed at wi-

leyonlinelibrar y.com]

FIGUR E  | Posterior view of left and right acetabula (RLP 05,

Context 40207, Museum of London). The left acetabulum is shallower

and wider than its right counterpart with additional osteophytic lipping

(coxarthrosis). [Colour figure can be viewed at wileyonlinelibrary.com]

4 of 17 International Journal of Osteoarchaeology, 2025

Socioeconomic status of individuals was predominantly inferred

by the sources in which they came, where available, which looked

at factors both bioarchaeological (Berger et al. 2017; García-

Moreno, López- Costas, and Dorado Fernández 2022) and an-

thropological (i.e., funerary practices; Booth etal.2010; Connell

etal.2012; Jones2012; Cooper, Heinzle, and Reitmaier2019), or

a mixture of the two (Fuchs etal.2021). Status was standardized

as follows: low, middle, high, and unknown status.

3 | Results

Archaeological cases of LCPD were found in 22 countries world-

wide. The total number of cases reported in the paleopatholog-

ical literature was 73 individuals out of 6999 analyzed, giving a

crude prevalence rate of 1.0% (see Table1). Studies and reports

examined varied in their depth of the description of the disease,

and this was reflected in the following dataset.

The earliest archaeological evidence of LCPD came from a

Neolithic site in Poço Velho, Carcais, Portugal (Antunes-

Ferreira2005), and the most recent from the Realta Correctional

Facility and Asylum cemetery in Switzerland—dating between

1858 and 1917 AD (Cooper, Heinzle, and Reitmaier2019). Most

of the individual cases in this study were adults, just two were

children and four were adolescents.

Regarding sex, 53/73 (72.6%) were male, 9/73 (12.3%) female,

and 11/73 (15.1%) were either unknown sex or were assessed as

indeterminate sex.

Unilateral cases were 60/73 (82.2%), bilateral cases were 6/73

(8.2%), and 7/73 (9.6%) were unknown. Concerning those with

a known side affected, LCPD was present in 35/68 (51.5%) of the

left femur and 37/68 (54.4%) of the right. It was unknown whether

7/73 (9.6%) of individuals were affected either unilaterally or

bilaterally. Overall, 21/73 (28.8%) individuals exhibited positive

signs of coxarthrosis, 14/21 (66.7%) of which were male, 4/21

(19.0%) were female, and 3/21 (14.3%) were of unknown sex.

FIGUR E  | Medial v iew of left femoral head af fected by LCPD

(RLP05, Context 40207, Museum of London). [Colour figure can be

viewed at wileyonlinelibrary.com]

FIGUR E  | Anterior view of a bilateral case of LCPD affecting both femoral heads (SRP98, Context 27608, Museum of London). [Colour figure

can be viewed at wileyonlinelibrary.com]

5 of 17

TABLE  | Record of sites and individuals with cases and possible cases of LCPD. Key: P†. Case study. R†. Osteological/site report. Child (1–11 years); Adolescent (12–17 years); YA: young adult (18–

25 years); YMA: young middle adult (26–35 years); OMA: old middle adult (36–45 years); MA: mature adult (46 + years). “Adult” description provided when this was the only information given with no

specific age parameters. M—male, I—intermediate, F—female, and U—unknown. L/R—left/right hip. Social status is divided into low, middle, high, and unknown. MoLC, CHB—Museum of London

Collections, Centre for Human Bioarchaeology. ‡—minimum number of individuals. The crude prevalence rate (CPR) was calculated by the number of cases affected by LCPD/total population.

Site Location

Ind iv idual ID/

context No. Age Sex

Hip

affected

Socioeconomic

status CPR References

Neolithic

(c. 4000–2600 BC)

P†. Poço Velho, Carcais, Portugal Femur 233.2444 Adult U — Unknown 1.7%

(2/115)

Antunes- Ferreira(2005)

Femur 233 2445 and

Os coxa 233 2129

Adult U R Unknown

Bronze age

(c. 2600–800 BC)

P†. Northern Caucasus,

Kudachurt cemetery, Russia

Grave 67 YMA–OMA M L Low 0.8% (1/130) Fuchs etal.(2021)

P†. Agizór, Türkiye M4B M L Unknown 5.6% (1/18) Açikkol Yildirim etal.(2003)

P†. Karagündüz, Türkiye K1 Adult M — Unknown (2/- ) Sevim etal.(2002)

K8 Adult M — Unknown

2.7%

(4/148)

Iron age

(c. 800 BC- 100 AD)

P†. Egypt (unknown site) Mummy No. 8 YMA F L Unknow n 1.9% (1/52) Fritsch etal.(2015)

P†. Valle Pega, Ferrara, Italy 92D OMA–MA ?M LUnknown 0.3% (1/300) Manzon etal.(2017)

P†. Shijahe cemetery, China SHSM22 YMA M R Low 2.7% (1/37) Berger etal.(2017)

R†. Westerhausen, Harz, Germany 3oo 4- 3 YMA M R Unknown 4.2% (1/24) Jacobi etal.(2009)

R†. Danebury Hillfort,

Hampshire, England

Deposition 46 YA M L Unknow n 1. 4% (1/70) Hooper(1984)

R†. Melton, East Yorkshire, England SK 4 OMA M L Unknown 2.3% (1/44) Ponce and Holst(2020)

1.1%

(6/52 7)

Roman

(c. 43 –410 A D)

R†. Baldock, Hertfordshire, England SK 469a OMA M R Unknown 3.5% (2/57) Keefe, Challanáin,

and Holst(2015)

SK 563 YMA M R Unknown

R†.Lankhills, Winchester, England SK 109 MA ?M RMiddle 0.2 % (1/451) Booth etal.(2010)

P†. Ampliación del MNAR

cemetery, Mérida, Spain

SK ME249 YA M R Low 0.5% (1/118) García- Moreno, López- Costas,

and Dorado Fernández(2022)

0.6%

(4/626)

(Continues)

6 of 17 International Journal of Osteoarchaeology, 2025

Site Location

Ind iv idual ID/

context No. Age Sex

Hip

affected

Socioeconomic

status CPR References

Early medieval

(c. 410 –1050 A D)

P†. Wadi Halfa, Nubia, Sudan — Adult ?M LUnknown 0.5% (1/218) Armelagos(1969)

P†. Kefevi, Sinop, Türkiye M38 Adult F L Unknown 0.9% (1/118) Çirak and Şarbak(2021)

P†. Lužice, Hodonín

District, Czechia

G. No. 2 OMA M L Unk nown 0. 8% (1/120) Smrčka etal.(2009)

P†. Brandỷsek Kladno

District, Czechia

No. 9 Adult M L Unknown 2.1% (1/47) Smrčka etal.(2009)

P†. Duratón, Segovia, Spain No. 12 MA M R Unknown 0.3%

(1/3 4 5 +)

Herrerín and Garralda (2012)

R†. St. Tugual's Chapel,

Herm, Guernsey

SK 003 OMA F R Unknow n 2.5% (1/40) De Jersey and Cataroche(2012)

R†. Filton, Bristol, England SK 140 OMA U L Unknown 1.9% (1/52) Caffell and Holst(2005)

P†. Tiszafűred, Hungar y — YMA–OMA M L Unknown (1 /- ) Józsa and Pap (2014)

R†. Westness, Rousay,

Orkney Islands, Scotland

Grave 25 Child U R Unknown 3.5% (1/29) Sellevold(1999)

P†. Olympia, Greece Individual 1 YMA–OMA M L and R Unknown 4.2 % (1/24) Ahlbrecht, Pilz, and Gresky(2024)

P†. Maiorca, Portugal —Adult U U Unknown 4.7% (1/21) Marques and Cunha(1999)

1.0%

(1 0// 9 9 0)

Late medieval

(c. 105 0–15 50 AD)

P†. Dilkaya Mound, Türkiye DK 88 BMD, R48 MA M R Unknown 0.3% (1/319) Şahin(2019)

P†.R†.St Marys Spital,

London, England

23126 YA M L Low 11.3%

(14/12 4‡)

Connell etal.(2012)

24011 YA ?M LLow

27651 ?Adolescent I R Low

30298 YA ?M RLow

31395 YA M R Unknow n

11328 YA ?M LUnknown

12251 OMA ?M RLow

19543 MA I R Low

25009 YMA M L Unknown

(Continues)

TABLE  | (Continued)

7 of 17

Site Location

Ind iv idual ID/

context No. Age Sex

Hip

affected

Socioeconomic

status CPR References

25477 YMA ?M LLow

27608 YMA ?M L and R Low

28114 YMA ?M RUnknown

28227 YA M R Low

10110 YA F R Unknown

R†. St. John's Hospital,

Staffordshire, England

SK 197 OMA M L Unknown 2.2% (1/46) Holst and Loeffelmann(2017)

P†. Dominican Friary,

London, England

Context: 30 6 YA M R Unknown 1.8% (1/57) MoLC, CHB

R†. St. James' Abbey,

Northampton, England

SK 3173 OMA M L Unknown 0.7% (2/278) Anderson, Hodgins, and

Andrews(2000a); Anderson,

Hodgins, and Andrews(2000b)

SK 3154 YA ?M RUnknown

R†. Blackfriars' Friary,

Suffolk, England

SK 1892 Adult M L and R Unknown 0.8% (2/250) Mays(1991)

SK 1917 OMA F L Unk nown

P†. St. James and St. Mary

Magdalene, West Sussex, England

UB C- 13 OMA M L and R Unknown (1/- ) Ortner(2003)

P†. Mudéjar de Uceda cemetery,

Guadalajara, Spain

—YMA M L Unknow n (1/- ) Dorado- Fernández etal.(2015)

R†. Lorrha, Co. Tipperarry, Ireland No. 29 YMA M — Unknow n 2.3% (1/44) Bolger, Moloney, and Troy(2012)

R†. Dunbar, East Lothian, Scotland SK 72 YMA–OMA M L and R Unknown 0.8% (1/127) Moloney etal.(2001)

P†. San Nicolao di Pietra

Colice, Liguria, Italy

T34 US2614 SN06 ind. A YMA F L Unknown 25.0 % (1/4) Cesana, Benedictow,

and Bianucci(2017)

R†. Largo da Sé- Praça

dos Mártires, Silves,

Portugal

Burial 23 Adult M L Unknown 0 .5% (1/193) Lopes Dos Santos and

Ramos(2004)

R†. Grasshopper Pueblo,

Arizona, USA

Burial 191 Adolescent M L Unknown 0. 2% (1/390) Hinkes(1983)

R†. Qilakitsoq, Uummannaq

district, Greenland

Mummy 2 Child M — Unknown 12 .5% (1/8) Hansen and Nordkvist(1996);

Bourbou(2005)

P†. St. Agostino, Caravate, Italy T 18 MA M R Unknown 5. 0% (1/20) Fusco, Larentis, and Tesi(2021)

(Continues)

TABLE  | (Continued)

8 of 17 International Journal of Osteoarchaeology, 2025

Site Location

Ind iv idual ID/

context No. Age Sex

Hip

affected

Socioeconomic

status CPR References

P†. Paucarcancha Cave, Peru — Adult M L Unknow n (2/- ) MacCurdy(1923),

Rothhammer(1990)

—Adult F R Unknown

1.7%

(32/1860)

Postmedieval

(c. 1 550–19 00 AD)

P†. Santa Maria dos Olivais'

Church, Tomar, Portugal

Context: SMOL- 271 OMA M R Unknown 1. 4% (1/7 3) Curto and Fernandes(2013)

P†. St. Ilija Church. Serbia No. 7 YMA–OMA M L Unknown 0.2% (1/522) Durić etal.(2004)

P†. Patallacta, Peru — YA M — Unknown (1/23‡) MacCurdy(1923),

Rothhammer(1990)

P†. Fairport, Ohio, North America B8.1 YMA F R Unknown 1.6% (1/62) Clark, Bargielski, and

Reich(2020)

P†. Necropolis of Santa

Maria, Sintra, Portugal

Grave 35 Adult U L Unknown 0.8% (1/120) Wasterlain and Umbelino(2014)

P†. Lagos, Algarve, Portugal B No. 2 Adult U R Unknown 9.1% (1/11) Ferreira, Neves, and

Wasterlain(2013)

P†. San Carlos, Mendoza

province, Argentina

Context: 12CA Adolescent U R Unk nown 5.3% (1/19) Ponce and Novellino(2014)

R†. Realta Correctional Facility

and Asylum, Switzerland

g56 YA–Y MA M R Low 1.0 % (1/103) Cooper, Heinzle, and

Reitmaier(2019)

P†. Radom, Poland No. 317/13 OMA M L and R Unknown (1/- ) Myszka etal. (2023)

R†. St. Benet Sherehog,

London, England

Context: 179 Adolescent U R Unknow n 0.4% (1/231) MoLC, CHB

R†. St. Thomas' Hospital,

London, England

Context: 115 MA M L Low 0.5% (1/193) MoLC, CHB

R†. Queens Chapel of the

Savoy, London, England

SK 1090 YA–YMA ?M RUnknown 0.2% (1/609) MoLC, CHB

R†. Royal London Hospital,

London, England

Context: 40207 YMA M L Unknown 0 .2% (1/639) MoLC, CHB

0.4%

(12/2732)

(Continues)

TABLE  | (Continued)

9 of 17

4 | Discussion

4.1 | Sex Distribution

Concerning sex, worldwide analysis of known past individuals

with LCPD revealed a demographic aligning with that found

in modern clinical literature (Molloy and MacMahon 1966;

Catterall 1971; Gray, Lowry, and Renwick 1972; Stulberg,

Cooperman, and Wallensten 1981; Wiig et al. 2006; Murray,

Holmes, and Misra2008; Wiig2009), reflecting a distinct male

preponderance (72.6% vs. 12.3%, respectively). There are several

posited theories for this tendency including sex- related activity,

femoral- acetabular anatomy (Lauritzen 1975), and/or earlier

bone maturation in females (Rampal, Clément, and Solla2017).

However, these theories are yet to be proven, leaving the sex dis-

parity seen in LCPD's prevalence rate inexplicable.

4.2 | Unilateral vs. Bilateral

The quantitative comparison between right and left hip afflic-

tion exhibited no marked difference as the right hip was affected

by 54.4% (37/68) and left hip by 51.5% (35/68). Unilateral cases

were predominant (84.5%) relative to bilateral cases (5.6%),

which, like the disparity in sex prevalence, closely aligns with

trends provided by clinical literature (Catterall 1971; Murray,

Holmes, and Misra 2008). However, it was unknown whether

7/73 individuals (9.6%) were affected unilaterally or bilater-

ally. This absence of data in the sources may have been due to

post- depositional variables (i.e., preservation, taphonomy, and

completeness).

4.3 | Etiology

Based on the clinical literature analyzed, LCPD appears to

be a multifaceted, systemic disease. Due to LCPD's etiologi-

cal complexities, a diagram was created to demonstrate the

different pathomechanisms explored in related studies (see

Figure 5) consisting of a variety of agents postulated to con-

tribute to or be associated with LCPD's cause. Environmental

factors and genetic predispositions were fundamental in our

research to provide insights into the possible causes of LCPD

in the past.

4.3.1 | Physical Trauma

Physical trauma (Figure 5) causing an occlusion of the main

blood supply to the femoral epiphysis has been one of many dif-

ferent theories for initiating the onset of LCPD. Except for one

study (Clark, Bargielski, and Reich2020), examining those with

LCPD based on etiological speculation has not been the fore-

front of recent analyses. In Clark, Bargielski, and Reich(2020) it

was attempted to contextualize forms of trauma that could have

caused LCPD in the past, exploring the occupational activities

possibly undertaken by an individual of a late prehistoric Erie

community (17th c. North America). Based on the region's ag-

ricultural dependence, it was posited that their analyzed indi-

vidual, a young girl (B8.1), may have been exposed to repeated

microtrauma from prolonged strenuous activity (digging,

Site Location

Ind iv idual ID/

context No. Age Sex

Hip

affected

Socioeconomic

status CPR References

Undated P†. Chicama Valley, Peru Context: NMNH 265331 Adult ?F RUnknown (1/- ) Ortner(2003)

Total 1.0%

(73/6999)

TABLE  | (Continued)

10 of 17 International Journal of Osteoarchaeology, 2025

hoeing, carrying hay, bending, twisting, and lifting) that con-

stantly involved muscles used for hip flexion and extension, in-

creasing the risk of restricting blood flow to the femoral head

(Lauritzen1975).

Addressing the physical activities and/or occupations that chil-

dren would have contributed to in the past is a complex topic

that presents differences across periods and cultures. In past

agrarian and pastoralist societies, child labor was known to

have been common practice (García- Moreno, López- Costas, and

Dorado Fernández2022); children would carry out certain age-

appropriate tasks from as early as 3–5 years old that contribute

to their own subsistence (Nieuwenhuys1994; Röder2018). This

would include domestic and agricultura l activities, such as carr y-

ing messages, fetching and delivering goods, cleaning, crafting,

preparing food, and collecting water (Röder2015; Röder2018),

exposing them to biomechanical injury (Sundström, Mispelaere,

and Bäckström2018). These physical activities could have there-

fore increased the risk of an ischemic episode occurring, and

subsequently the development of LCPD.

4.3.2 | Socioeconomic Status

Modern epidemiological studies (Perry et al. 2012a; Perry

etal. 2012b; Perry 2013) have shown a probable link between

individuals of low- to mid- socioeconomic strata (Figure5) and

the development of LCPD. Socioeconomic status is a concept rid-

dled with ambiguity; it differs across cultures and can change

over an individual's lifetime. In general, it attempts to reflect

the role a person holds in their respective, typically hierarchi-

cal, society and usually entails a multitude of direct and indirect

factors that revolve around a standard of living. This can include

diet, income, occupation, education, access to healthcare, and

behavior (social norms). Climate and ecological factors can, in

turn, affect accessibility to each of these aspects. One's social

status can expand or restrict the individual's responsibilities and

capabilities, and influences how the individual perceives others

and how others perceive them. However, attempting to analyze

social status across different time periods on a global scale with-

out making generalizations or bias yields a challenge. Likewise,

compared to living populations, the social status of those in the

past cannot be easily assessed but rather examined and inferred

through anthropological (artifacts and burial practice) and bio-

archaeological (skeletal health and δ13C and δ15N isotope levels)

analysis. This proved difficult for this study. The social status of

the individuals in this study was therefore extracted from their

respective sources. The prevalence of those that could be inter-

preted as having low or possibly low status was 19.2% (14/73),

and those of middle status 1.4% (1/73). None was recorded as

high status. The social status of 79.5% (58/73) of individuals was,

however, either too arbitrary, not apparent or not provided for

FIGUR E  | Diagram summarizing studied agents that may cause or possibly increase the risk of developing LCPD by initiating the ischemic ep-

isode. COLA 21—Collagen type 2, alpha 1; IGF- I—insulin- like growth factor- I. [Colour figure can be viewed at wileyonlinelibrary.com]

11 of 17

by the sources in which they were analyzed. The social status

ascribed to these individuals in this study should also be consid-

ered with caution, as such interpretation of past individuals is

tentative and inherently problematic.

Likely influenced by the effects of one's socioeconomic status,

diet, or malnutrition, on the other hand, has also been made

suggestive as a possible contributory agent to LCPD (Figure5;

Burwell 1988; Perry2013). Conditions such as cribra orbitalia

(CO), porotic hyperostosis (PH), Harris lines (HL), and dental

enamel hypoplasia (DEH) have been attested to ref lect nu-

tritional stress during childhood (Goodman and Rose 1991;

Hillson2001; Roberts and Manchester2012), and were therefore

considered in this analysis. However, the crude prevalence of all

these conditions with those with LCPD in this study was rela-

tively low. CO and DEH were the most prevalent of the diseases

in this study (both 8.2%, 6/73), followed by PH (2.7%, 2/73), and

then HL (1.3%, 1/73). Because of such low prevalence, this study

could not address the link between these conditions and LCPD.

This was due to most of the LCPD cases being from isolated in-

stances or contexts where only one or two individuals (with ex-

ception to St. Mary's Spital) were reported. Site prevalence rates

of metabolic diseases were largely absent from population stud-

ies. When the information was available, the attempt to assess

whether LCPD had any connection to a comorbid prevalence of

metabolic diseases indicated that there were not enough cases

of LCPD or enough data pertaining to the prevalence of meta-

bolic diseases from each site to reinforce or disparage this no-

tion. Likewise, while individuals may have suffered with both

LCPD and metabolic diseases, the latter may be a representation

of socioeconomic conditions rather than a direct link to LCPD.

Another socioeconomically related agent found in these studies

was exposure to pollution, namely, smoke (Figure5), and its re-

lation to increased LCPD incidence rates, particularly concern-

ing the effects of firewood- stove smoke from cooking in India

(Daniel etal.2012) and tobacco smoke (García Mata etal.2000;

Gordon etal.2004; Bahmanyar etal.2008). While there is no ev-

idence of direct cause and effect, these correlations may instead

collectively represent detriments of polluted air having a p ossible

inf luence on LCPD development. Notably increased p ollutant ac-

tivity in the past would have most likely begun in the Neolithic,

which saw the introduction and control of agriculture and per-

manent settlements. With structures being built to inhabit and

work in, indoor pollution would have been borne with the fir-

ing of wood to heat and cook. The main fuels for domestic and

craftsmen use during the periods up until the mid- 1800s would

have been exclusively charcoal and timber (Camuffo, Daffara,

and Sghedoni 2000). Wood- burning hearths in homes would

have produced smoke, carbon monoxide, and aldehydes. In 14th

century London, for instance, it was estimated that 40,000 t of

wood and 6000 t of sea- coal were burned annually (Dyer1989).

This may partially ref lect the relatively high prevalence (19.2%,

14/73) of LCPD cases in this study coming from Late Medieval

London's St. Mary's Spital burial site, though this statistic and

interpretation could be (and likely is) skewed by issues linked

to the overall low prevalence of individuals with LCPD in the

archaeological record (see Section4.6). Nonetheless, if pollution

is contributory towards LCPD's etiology, domestic cooking prac-

tices, heating, and occupations that involve the production of

airborne pollutants may hold pertinence to its prevalence.

4.3.3 | Genetic Predispositions

In clinical literature, there have been several case studies

(Miyamoto etal.2007; Su etal.2008; Su etal.2010; Li etal.2014)

that make links between LCPD and collagenopathies concern-

ing issues with collagen synthesis. These are either based on

a COL2A1 (a major structural protein in cartilage) mutation,

which has shown an alteration to the collagen fibril matrix

and the overall structure of articular cartilage; or low levels of

insulin- like growth factor- I (IGF- I), which lowered the rate of

collagen synthesis and increased collagen breakdown. Both con-

ditions represented a compromise with collagen synthesis form-

ing the articulatory cartilage that may or may not contribute to

the development of LCPD. However, a recent study (Lindblad

etal.2024) has suggested that there is no strong correlation be-

tween LCPD and collagenopathies, though it could not provide

definitive answers as no specific collagenopathy could be iden-

tified. Given that the results of these studies are the products

of invivo testing, if collagenopathies such as the COL2A1 mu-

tations or low levels of IGF- I are pertinent to causing LCPD, it

is unknown whether paleopathologists are able to explore this

particular agent any further.

4.4 | Disease Effects and Management

Maintaining balance and locomotion with a defective hip

joint could only have produced a lot of pain, and potentially

altered gait and posture permanently leading to secondary

effects of LCPD, such as coxarthrosis. Clinical studies found

a high prevalence of coxarthrosis development after suffer-

ing from the primary effects of LCPD (Mose1980; Stulberg,

Cooperman, and Wallensten 1981), developing during early

or middle adulthood and, more commonly, in mature adults.

This study found that 28.8% (21/73) of all individuals with

LCPD displayed skeletal changes compatible with coxarthro-

sis. Two severe examples are exhibited in the femoral heads of

Late Medieval individuals SK 3173 and SK 3154. Individual SK

3173's femoral head was locked into its acetabulum due to the

osteological defects caused by severe coxarthrosis, practically

rendering ambulatory activity impossible or considerably dif-

ficult, and SK 3154, while not ankylosed, would have been lim-

ited to 80° flexion (Anderson, Hodgins, and Andrews2000a,

2000b). It would therefore be accurate to assume that these

individuals not only suffered restricted movement (Hansen

and Nordkvist1996; Curto and Fernandes2013) but also con-

siderable pain after childhood (García- Moreno, López- Costas,

and Dorado Fernández 2022) up until their death. However,

for how long they suffered from these effects before perishing

cannot be gauged.

The detection of further degenerative joint disease (DJD), as

mentioned by some of the case studies analyzed (Marques and

Cunha 1999; Bolger, Moloney, and Troy2012; De Jersey and

Cataroche 2012; Curto and Fernandes 2013), could also be

suggestive of LCPD incurring further biomechanical injury.

However, it has also been posited that DJD affecting different

areas of the body may instead represent attempts to circum-

vent the detrimental effects of the disease. The prevalence

of those in this assemblage recorded with other DJD- related

pathologies, in addition to LCPD, was 31.5% (23/73), 87.0%

12 of 17 International Journal of Osteoarchaeology, 2025

(20/23) of which included the coxarthrosis of the afflicted

hip. These individuals were particularly affected in the mid-

upper skeletal regions, namely, the shoulders, humeri, spine,

and also the feet. In addition, increased biomechanical stress

may have also led to the simultaneous buttressing of bone

density within certain skeletal elements. An individual in an-

other study (Holst2010), for instance, suffered with DDH, an

affliction so similar to LCPD in its skeletal changes it poses

the risk of misdiagnosis in palaeopathology. This individual

(SK 15548) also had secondary problems, including the forma-

tion of an artificial hip joint with coxarthrosis, inflammation,

atrophy, and osteoarthritis of the spine, with the addition of

distinctly robust upper limbs. This occurrence of robust arms

combined with evident DJD in the shoulders, hip, and right

hand led analysts to posit these changes as being the result

of using a crutch to aid mobility and alleviate pain in daily

life (Holst 2010; Buckberry et al. 2014). This was also sug-

gested for individuals No. 12 and SK ME249 (Herrerín and

Garralda 2012; García- Moreno, López- Costas, and Dorado

Ferná ndez 2022) and, based on the similar pathological cir-

cumstance, could extend to individual 25477 from St Mary's

Spital (Connell etal.2012). Individual No. 12 appeared to have

a strong right humerus based on their robust muscular at-

tachments, indicating frequent use of the right arm (Herrerín

and Garralda 2012). Individual 25477 from St Marys Spital

also exhibited a robust right humerus as well as trauma to

the right clavicle. Individual No. 12 showed increased ro-

busticity in their contralateral femur and tibia (Herrerín and

Garralda2012), suggesting a thickening of bone due to addi-

tional weight- bearing/locomotory stressors transferring from

the afflicted limb. With or without the aid of a crutch, areas

affected by DJD or increased robusticity of bone will likely

have resulted from a restricted (Hinkes1983) or antalgic gait,

a natural consequence of LCPD to a considerably varying de-

gree. The nature of this gait would depend on the severity of

morphological change, joint congruency, level of pain, and ca-

pacit y for mobility.

On the other hand, atrophy of aff licted limbs, of both lower

limb bones (Anderson, Hodgins, and Andrews 2000a, 2000b;

Herrerín and Garralda 2012; Walker 2012; Keefe, Challanáin,

and Holst2015) and musculature (Ratliff1967), was also found

to be secondary to LCPD. Five individuals (No. 12, SK 469a and

3514, and ctxt. 23126 and 306; see Table1) were recorded to have

had atrophy affecting the proximal femur with LCPD in this

assemblage, which totaled 6.8% (5/73), with 60% (3/5) of those

having additional atrophy in their corresponding tibia. These

findings also paralleled with individual 25477 from the afore-

mentioned study (Holst 2010), who similarly exhibited atrophy

in their afflicted limb. Atrophy of bone and musculature may

indicate disuse of the affected limb (Yang etal.2019), likely due

to the secondary effects of LCPD causing discomfort, pain, and/

or general prevention of movement. Crutch use and increased

dependency on the contralateral lower limbs would have only

amplified the disuse of the afflicted leg.

4.5 | Place in Society

Whether the individual had the aid of apparatus for mobility,

a caregiver, or neither, the inability to physically function to

a degree that would be otherwise normative could have made

them a liability, or at least feel like one, particularly when

families often operated as socioeconomic units (Röder 2015;

Röder 2018; Sundström, Mispelaere, and Bäckström 2018).

Developments of further biomechanical complications such as

secondary DJD (i.e., coxarthrosis) in later life could only have

exacerbated such situations. Although we cannot evaluate the

psyche of the deceased, having a limited capacity to physically

participate in society could have had a profound effect on

the individual's mental well- being (McKenzie, Murphy, and

Watt 2022). For instance, chronic pain, restriction of move-

ment, and being unable to carry out physical functions could

have all led the individual to feel self- burdening (Cassileth

et al. 1984; Moussavi et al. 2007). The variation in severity

of LCPD's effects would also determine the extent to which

ambulatory activity is possible and the level of care that would

be required to function. However, the role of someone who is

disabled, their quality of life and place in society is not limited

nor defined by what they cannot do. How these individuals

functioned and how they were received by their respective

cultures is multifaceted, varying across time and geography.

In some cultures, those with disabilities have been outright

ostracized, outcasted, tolerated, or treated like an economic

liability, while in others they have been revered, provided

with a respected status and/or were allowed to participate to

their fullest capacity (Munyi 2012). Within these contexts,

individuals with limited physical capacity such as those af-

fected by LCPD could have faced either of these difficulties.

On the basis of the latter possibilities, whether living a more

sedentary life or not, or anything in between, individuals

could still contribute to their household and/or community,

both practically: housekeeping, cooking, cleaning, crafting, or

taking care of children or the elderly (Groce and Zola 1993),

and verbally, such as emotional support or administration.

Attesting to their value in society is the survival from child-

hood, when the disease is active, well into adulthood, which

applies to almost all of the individuals in this study, implying

social integration rather than ostracism (Fuchs etal.2021) in

the contexts from which they derive.

4.6 | Study Limitations

4.6.1 | Missing Data

Overall, this study encountered a low presence of global LCPD

cases reported in the archaeological literature. This was likely

due to a variety of intrinsic and extrinsic factors that influence

the level of preservation of individuals in the archaeological re-

cord. These include taphonomy, burial practices (cremation),

destruction, and/or disturbance of human remains, which are

all important contributors that represent a profound issue with

paleoepidemiology. Seven of the sources with cases of LCPD in

this study were not able to or did not provide data on overall

prevalence of individuals at their respective sites. The overall

prevalence of cases of LCPD yielded is, therefore, more than

likely smaller than what it should be, making it increasingly dif-

ficult to interpret the reality of the once- living (Waldron2007).

Due to these issues of skeletal preservation, a more comprehen-

sive analysis of the sex demographic and laterality of LCPD was

additionally problematic.

13 of 17

Inaccessible gray literature is also plausibly responsible for this

low representation of global cases of LCPD, and sources that

were consulted possessed considerable disparities in contextual

and pathological details. Osteological and site reports were both

largely descriptive, and case studies of LCPD focused on the dis-

ease in isolation, excluding the possible inference of other pa-

thologies present and wider cultural contexts.

4.6.2 | Differential Diagnosis

Clinical guidance of pathological diagnoses can only assist so

much in the analysis of human skeletal remains. While clini-

cians use radiography to identify the most acute symptoms of

LCPD during the condition's active phase in childhood, paleo-

pathologists have only osteological markers to identify LCPD.

These markers will vary in their presence and are affected by

the conditions of the bone; for LCPD, this will rely on the level

of preservation of the proximal femur (greater trochanter and

epiphysis) and the acetabulum. In addition, pathological am-

biguities are a fundamental issue that can lead to differential

diagnoses, preventing the conclusive diagnosis of LCPD. For

these reasons, cases that were conclusive and those deemed

differential/possible cases of LCPD were documented with-

out distinction. It was not within the remit of the authors to

challenge the diagnoses of LCPD derived from the sources

examined.

4.6.3 | Modern Bias

The archaeological cases in this study represent the natural

history of untreated LCPD (Ahlbrecht, Pilz, and Gresky2024).

Today, treatment is prescribed when early onset signs appear,

meaning that modern experiences of the condition will differ

invariably to those in the past. Although the clinical litera-

ture provided a wide breadth for speculation, the interpretive

quality of individuals analyzed was, therefore, restricted by

current clinical conjecture and the bias effects of medical

intervention. Although it can be problematic to provide in-

terpretations despite the limitations of using a paleopatho-

logical approach, this study applied clinical knowledge to

past realities to attempt to understand the nature of LCPD.

Extrapolating clinical data to the past is ubiquitous for paleo-

pathologists (Grauer2019) and has not inhibited other paleo-

pathological studies from contextualizing other individuals

who have also suffered from LCPD and other diseases in

the past (Herrerín and Garralda 2012; Buckberry etal.2014;

McKenzie, Murphy, and Watt2022).

4.6.4 | Etiology

Furthermore, a part of the objectives of this study was to exam-

ine the clinical analyses into LCPD's etiology and unravel pos-

sible causes in the past based on this data. This proved difficult

due to the extent of clinical analyses that LCPD has undergone,

where connections are only hypothetical, typically involving

other pathological causes that also have an obscure or uncertain

pathogenesis.

Analysis of socioeconomic status exhibited a strong correlation

with those of low–mid socioeconomic strata and heightened

LCPD incidence and prevalence rates in modern epidemiol-

ogy (Perry etal.2012b; Perry2013). However, this study found

that determining the socioeconomic status of the individuals

was largely problematic. Conceptual ambiguity of social status,

intra- period and intra- regional differences, and gaps in liter-

ature (burial, site typology, and other pathological data) were

fundamental issues that posed a challenge to study the role of

socioeconomic status in relation to LCPD. As a result, the so-

cial status of most of the individuals in this study could not be

assessed.

The link of LCPD's etiology and ancestr y (Perry etal.2012a) also

limited the capacity to provide a paleopathological interpreta-

tion. The presumption of the ancestry and geographic origin of

the individuals in this study, based on their place of burial, was

found to be inappropriate, as the place of burial does not nec-

essarily reflect the individual's place of origin. Occurrences of

transmigration and periodic introgression in the past meant that

providing an exact provenance for the cases reported was not

possible. Resolution to this issue would have required ancient

DNA analysis, which was outside the scope of this study.

LCPD's complicated and inconclusive etiology has meant that

the interpretations made in this study are considerably specu-

lative. Extrapolating clinical expertise, especially when it con-

cerns a disease with a complex pathogenesis (with possible

links to other pathologies with equally uncertain etiologies), to

archaeological contexts has posed considerable challenges that

palaeopathology cannot easily overcome.

5 | Conclusion

Archaeological cases of LCPD totaled 73 in this study, predomi-

nantly from England. Cases unaccounted for are almost certain.

There is an explicit negligence of rare diseases such as LCPD

in paleopathological studies, and by extension, the archaeo-

logical record. Further interdisciplinary research and collabo-

ration are required for LCPD's further clinical exploration and

acknowledgment among other archaeological sites and regions.

Gray literature in osteological and site reports is considerably re-

sponsible for this lacuna in literature. In addition to this missing

information, true prevalence is prohibited by extrinsic and in-

trinsic factors pertaining to the issues borne by palaeoepidemi-

ology and the archaeological record. Its skeletal manifestations

are also both various and diagnostically ambiguous. However, it

is LCPD's etiological complexity that has ultimately allayed the

prospects of its contextualization in the past.

Despite offering no firm conclusions, modern clinical literature

has yielded a multiplicity of speculations as to LCPD's etiology.

These various hypotheses can allow us to navigate different so-

cial, economic, biological, and environmental aspects in pursuit

of etiological links of LCPD in the past.

Characteristics of LCPD and the differing levels of their severity

have also implicated the physical lives that sufferers may have

led, how they may have physically and/or mentally experienced

14 of 17 International Journal of Osteoarchaeology, 2025

the disease, and how their respective societies and cultures may

have cared for them, if they did at all. Analysis of the affliction's

osteological secondary effects further provided evidence for

speculation as to how they may have even personally managed

its symptoms.

Overall, while employing a speculative approach, this study

has shown that there is promise for future analysis of LCPD.

Following new, more holistic methods of research and synthesis

of interdisciplinary data is required, utilizing clinical studies,

paleopathological approaches and ethnographical information

where possible.

Acknowledgments

The authors would like to thank the BABAO (British Association for

Biological A nthropolog y and Osteoarchaeolog y) commercial g rants that

allowed us to spend time analyzing cases of LCPD from the Museum of

London. Special thank s are given to Jelena Bekvalak, curator of Human

Osteology at the Centre for Human Bioarchaeology at the Museum of

London, UK for help and support during our work at the Museum of

London, UK, and for her assistance in accessing data that would have

been otherwise difficult to obtain.

Conflicts of Interest

The authors declare no conflicts of interest.

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No correlation to collagen synthesis disorders in patients with Perthes’ disease: a nationwide Swedish register study of 3488 patients

Article

Full-text available

Jan 2024
BMC MUSCULOSKEL DIS

Background Mutations of the COL2A1 gene have been identified in patients with Perthes’ disease. Several studies have hypothesised a connection between Perthes’ disease and collagen synthesis disorders, especially COL2A1-related disorders, but no large studies on the subject have been made. The aim of this study was thus to discover if there is a connection between patients presenting with Perthes’ disease, and collagen synthesis disorders. A secondary aim was to see if the children with both disorders had less optimal birth characteristics than the rest. Methods Swedish national registers were used to collect data on children diagnosed with Perthes’ disease or a collagen synthesis disorder. These registers include all births in Sweden, and data from both outpatient and in-hospital visits. A wide range of data is included besides diagnoses. All children with follow-up data to the age of 15 years were included. Pearson’s chi-square was used for analysis. Statistical significance was further analysed with Fisher’s Exact Test. Results In total, 3488 children with either diagnosis were included. 1620 children had only Perthes disease, while 1808 children had only a collagen synthesis disorder. Five children were found to have both the diagnosis Perthes’ disease and a collagen synthesis disorder. One child was large for their gestational age and none of the children had a low birthweight. Two of the children were moderately preterm. Conclusions The distinct lack of overlap in such a large body of material raises doubt about a connection between the presentation of Perthes’ disease and collagen synthesis disorders, either COL2A1-related or not. We could not find an overrepresentation of less optimal birth characteristics either.

Un caso de enfermedad de Legg-Calvé-Perthes en la Necrópolis Romana-Tardoantigua de la Ampliación del MNAR (Mérida, España).

Article

Full-text available

Feb 2023

RESUMEN La enfermedad de Legg-Calvé-Perthes consiste en una necrosis de la cabeza femoral, que de forma característica modifica su morfología. En la literatura paleopatológica son pocos los casos registrados, la mayoría vinculados a la Península Ibérica. En el presente estudio se analiza el caso de un individuo se sexo masculino, entre 20 y 25 años, hallado en la Necrópolis de la Ampliación del MNAR, Mérida, España (ss. III-VII d.C.). El análisis se ha realizado a través del estudio macroscópico, osteométrico y radiológico, localizándose la lesión unilateralmente en la cabeza del fémur derecho. Tras realizar el diagnóstico diferencial se concluye como más probable la enfermedad de Legg-Calvé-Perthes, con los hallazgos morfológicos típicos de esta enfermedad como la cabeza en forma de hongo (mushroom shape), el acortamiento y ensanchamiento del cuello o la porosidad de la superficie articular de la cabeza femoral. Esta enfermedad habitualmente produce cojera y marcha antiálgica, por lo que pudo tener implicaciones sobre las responsabilidades sociales en la etapa de maduración del individuo.

Case study of Legg-Calvé-Perthes disease observed in Radom (Poland, 18th–19th century) with literature review

Article

Full-text available

Mar 2023

The aim of this study is to present the pathological lesions observed in a skeleton (male, about 35–38 years old) from Radom (Poland), dated to the 18th–19th century. Bone changes were observed in both femurs and both pelvic bones. The head of the femur is enlarged and deformed, described as “mushroom-shaped”, with areas of smooth cortex and cavities, or possible cystic residues. The neck of femur is short and thick. The bone shaft and distal epiphysis do not show any changes. The changes were also observed in both acetabularies of the hip joint (marginal bone formation, subchondral bone remodelling). Radiographic images show bilateral necrosis of the femoral head. There is a significant sclerotization of the femoral head, with a discrete visible crescent sign. These macroscopic and radiological changes match the symptoms associated with Legg-Calvé-Perthes disease. This is the first case of the disease described in bioarchaeological materials from Poland.

Paleopathological evidence of Legg-Calve’-Perthes from the medieval cemetery of St. Agostino in Caravate, Northwestern Italy

Article

Full-text available

Feb 2022

Legg-Calvé-Perthes (LCPD) is a rare childhood disorder that induces the osteochondrosis of the femoral head. Almost all authors agree that the condition involves the obstruction to the bloody supply of the growing femoral head. The etiology is debated, as some authors claim that the triggering process of LCPD is unknown. Others argue that the onset of this affection can be prompted by several factors such as exogenous causes, trauma, metabolic issues, hematological disease, infections. LCPD has been recognized in archaeological material for nearly a century. The signs of the pathology are well described in the literature, but few paleopathological cases have been described. Here we report morphologic analyses of a skeleton retrieved during the archaeological investigations of the medieval cemetery of the church of St. Agostino in Caravate (Varese, Italy, 12th and 13th centuries). After an accurate differential diagnosis, the observed features suggest a conclusion of avascular necrosis of the right femoral head and unilateral evidence of LCPD.

Antik Anadolu’da nadir bir patoloji: Legg-Calvé-Perthes hastalığı

Article

Full-text available

Dec 2021

Legg-Calvé-Perthes hastalığı (LCP) 1909 ve 1990 yıllarında Legg, Calvé, Perthes ve Waldenström tarafından bağımsız olarak tanımlanan ve femur başının mantar şeklini almasıyla sonuçlanan patolojidir. Etiyolojisi tam olarak bilinmemekle birlikte genetik ve çevresel faktörlerin etkili olduğu düşünülmektedir. Çocukluk yıllarında ortaya çıkan bu patoloji bireyin yaşamı boyunca etkili olmakta ve ilerleyen yaşla birlikte porognoz seviyesi artmaktadır. Görülme sıklığı erkek bireylerde daha fazladır. Araştırmacılar, LCP’nin genellikle unilateral görüldüğünü ancak nadiren de olsa bilateral örneklerin de olduğunu belirtmektedir. Çalışmada, Bizans dönemi MTR toplumuna ait ileri erişkin kadın bireyde tespit edilen LCP’nin femur ve asetabulum üzerinde bırakmış olduğu etkiler araştırılmıştır. Bireyin sol femurunda görülen bu patoloji femur başı ve asetabulumda ileri derecede osteofit oluşumlarına neden olmuştur. Femur boynunun kısalması, femur gövdesinin incelmesi, gövde boyun açısının daralması, fovea capitisin yok olması LCP etkisiyle femurda meydana gelen bariz morfolojik değişikliklerdir. Ayrıca coxada asetabulum da ileri derecede etkilenmiş, oldukça daralmış ve femur kendisine yeni bir yüzey oluşturmuştur. Femur ve asetabulumdan alınan osteometrik ölçümler femur ve asetabulumdaki morfolojik değişikliği desteklemektedir. Ancak bireyin ayak bilek kemikleri ile tibia kemikleri LCP’den kaynaklanan duruş ve yürüme bozukluğundan etkilenmemiştir. LCP Antik Dönem toplumlarında oldukça nadir görülmektedir. Bu durum Antik Anadolu toplumları için de geçerlidir. Bu çalışma Antik Anadolu toplumları ile ilgili literatüre katkı sağlaması açısından önemlidir.

Testing the Digital Atlas of Ancient Rare Diseases (DAARD) using a new case of Legg-Calvé-Perthes disease from Early Byzantine (500–700 CE) Olympia, Greece

Article

Jul 2024

Julia Gresky

A-Z of Musculoskeletal and Trauma Radiology

Book

Aug 2009

A-Z of Musculoskeletal and Trauma Radiology is an invaluable reference to the key aspects of imaging for all conditions of bones, muscles, tendons and ligaments. It provides the clinician with practical guidance on the key presenting characteristics, clinical features, diagnosis and management. The description of each condition is provided in a standard template of Characteristics, Clinical Features, Radiology and Management, enabling the reader to find the relevant information quickly. All diagnostic modalities are included and a separate section is dedicated to musculoskeletal trauma. Written by a multidisciplinary team of radiologists and an orthopaedic surgeon, A-Z of Musculoskeletal and Trauma Radiology is an invaluable resource for radiologists, orthopaedic surgeons, rheumatologists and all clinicians managing musculoskeletal conditions.

Considering care: A traumatic obturator fracture dislocation of the hip in a middle-aged man from Gaelic Medieval Ballyhanna, Co. Donegal, Ireland

Article

Sep 2022

Objective This article explores the potential care provided to a middle-aged man who had a suite of injuries evident in his skeleton, most notably an obturator fracture dislocation in his left hip. Materials The skeleton derived from the Late Medieval Gaelic population buried at Ballyhanna, Co. Donegal, Ireland. Methods A transdisciplinary bioarchaeology of care approach was adopted to undertake a phenomenological study of an individual with an acquired disability. Results The man would have required intensive nursing care in the months following the initial injury, and longer-term accommodations may have been made by the wider community to support him. Conclusions Use of a transdisciplinary bioarchaeology of care approach enables important insights to be gained concerning the social impact of disability on the affected individual, his kin, and wider community. Significance This study achieves a new level of integration of bioarchaeological findings with archaeological, historical, and ethno-historical sources, thereby enabling a phenomenological approach to interpretation of life after acquired disability. This is the first study to allow such an intimate insight into lived experience and it provides a model for bioarchaeology of care analysis of individuals from historical eras. Limitations These include difficulties in identifying the nature of a long-standing complex injury. Suggestions for future research Further explorations of the bioarchaeology of care in historical time periods should incorporate a similarly wide range of transdisciplinary sources to enrich interpretations of the lived experiences of individuals, their care-givers and broader communities.

Legg–Calvè–Perthes kór középkori leleten

Article

Jan 2014

Középkori temetőben fellelt 21–40 éves kora között elhunyt férfi vázmaradványain Legg–Calvè–Perthes kór gyógyulása utáni combfej, combnyak és acetabulum elváltozást állapítottak meg. Részletesen elemzik a morfológiai és radiológiai tüneteket, és táblázatban foglalják össze az ásatag anyagon elvégezhető elkülönítő kórisme adatait.

Too small to be noticed? Children mummies reveal they stories

Article

Jan 1970

Chryssi Bourbou

The study of sub-adult remains, either skeletal or mummified, has been always a fairly neglected subject of bioarchaeology. Regarding mummified subadult remains, it mainly seems that fascinating stories (i.e., mountain sacrifice mummies) are usually discussed in detail. However, whilst childhood is a biological stage of human development, it is also a social construct and many past and present societies assign different values and meanings (i.e., cultural beliefs, social tensions) to the dead child. This presentation addresses the biocultural context of children mummies based on a meticulous survey of up-dated published reports. In addition, paleopathological observations are discussed, as well as the future need for systematic studies of subadult mummies (i.e., mortality patterns, maternal mortality).