Table 1

Description of previous studies examining the use of antiresorptive agents in children with LCPD

Study	Study type	Diagnosis/ aetiology of avascular necrosis	Patients (n)	Age of patients	Severity at treatment initiation	Antiresorptive used	Other therapy used	Outcome measures	Follow-up length	Radiologic/ metabolic outcome	Functional outcome	Conclusion
McQuade and Houghton15	Case report	LCPD	1	6.5 years	Unilateral; lateral pillar group C.	Zoledronte: 0.025 mg/kg administered 5 times in 9 months.	Abductor tenotomy and broomstick casts (6 weeks), hip abduction brace 20 hours/day for 3 months) plus non-weight bearing for 6 months	Bone mineral density, mineral homeostasis, X-rays, pain and function.	20 months following the start of treatment	Progressed to remodelling phase on X-ray 11 month post completion of therapy, and from laterall pillar group C to group B. No abnormalities on renal ultrasound. Mild decreases in serum calcium noted postinfusion.	Pain rated zero 2 weeks postinfusion. At the time of reporting, contact sports were still restricted with follow-up planned in 6 months.	Zolendronate therapy for LCPD produced a positive radiologic response and positive responses for function and pain control. There was also a positive emotional response from family regarding the treatment.
Johannesen et al 16	Prospective case series	LCPD or slipped capital femoral epiphysis	37 (17 with LCPD)	10.8 years +/-2.76 years	LCPD diagnosed by standard radiologic criteria	Zoledronate, first dose 0.0125 mg/kg; subsequent doses 0.025 mg/kg (second dose given 6 weeks later, subsequently at 12 week intervals): for at least 12 months Average number of treatments per patient was 6.	Non-weight bearing for the first 6 months of Zoledronate therapy; 400 IU vitamin D and calcium supplementation if intake <recommended.	Bone mineral density, bone morphometry/markers of turnover, and mineral homeostasis.	18 months	PTH increased during treatment, 25OHD unchanged. Greatest increase in Bone mineral density in the lumbar spine of children with LCPD. No radiologic (X-ray/MRI) outcome of hip reported.	Not reported.	Zoledronate increased bone mineral density in children with avascular necrosis without any symptomatic side effects. More trials are warranted.
Meiss et al 26	Case report	LCPD	1	9 years	>50% of epiphysis, severe (surgery recommended)	Denosumab: 60 mg, single injection	Varus osteotomy (1 year after onset and 7 months post-denosumab injection)	X-ray and MRI	2 years 8 months	MRI 2 years post diagnosis showed well contained head with re-ossification.	The boy could comfortably carry out daily activities with no pain or limp. Normal hip motion.	Denosumab may have had positive effect on the outcome, but the patient was also treated with an osteotomy.
Jamil et al 17 (currently underway)	Randomised clinical trial	LCPD	100	5 years– 16 years	Lateral pillar >50% of the contralateral side	Zoledronate: five courses, 3-monthly doses of 0.025 mg/kg (12 month treatment)	Standard of care + non-weight bearing (wheel chair) first 6–12 months	Deformity index, bone density, MRI	Plan to follow-up to 24 months	Not yet completed.	Not yet completed.	Not completed, still underway
Present study	Case report	LCPD	1	6 years	Lateral pillar >50% involvement, bilateral. Catterall IV (right hip)	Pamidronate: nine courses, 1 mg/kg	Abductor tenotomies, broomstick casts (21 weeks total), Scottish Rite braces (1 year)	X-ray, bone density, MRI, pain	11 years	Bone mineral density (DEXA) Z-scores increased alongside treatment. Femoral heads show complete improvement with normalised joint spaces (X-ray/MRI).	No functional limitations, no pain, normal hip motion.	Pamidronate therapy showed positive effect on LCPD and likely helped avoid surgery. No negative effects seen in a case study at 11 years.