Download MBBS Orthopaedics PPT 10 Legg?Calve?Perthes Disease Lecture Notes

Legg?Calv?Perthes disease

Learning objectives

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It is a self limiting disorder of the hip

produced by ischemia and varying

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degrees of necrosis of the femoral head.

It is a self limiting disorder of the hip produced by ischemia and varying degrees of necrosis of the

femoral head.

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Epidemiology
? Incidence : 1:1000
? Usual age : 4-8 years
? Boys:girls ? 5:1

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? Higher incidence in Caucasian, Chinese,

Japanese, Inuits, Northern Europe
Aetiology-

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Coagulation disorders.

Arterial status of femoral head.

Abnormal venous drainage.

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Abnormal growth and development.

Trauma.

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Hyperactivity or attention deficit disorder.

Genetic component.

Environmental influences.

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As a sequel to synovitis.

Pathogenesis
? Ischemia of femoral head

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Up to 4 months

1. Metaphyseal vessels

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2. Lateral epiphyseal

3. Scanty vessels in ligamentum

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teres

4-7 years

1. Lateral epiphyseal vessels

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2. Metaphyseal supply DISSAPEAR

Susceptible to ischemia,

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as it depend entirely on

lateral epiphyseal vessel.

7 years

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1. Vessels in ligamentum teres have

developed

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Pathology-Stage 1-Ischaemia

Pathological process 3-4
years1 ? ischemia and bone

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death

? Al /part of bony nucleus

of femoral head is dead

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? Cartilaginous part ?

remains viable and

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thicker

? Thickening and edema of

synovium and capsule

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Stage 2 ? revascularization and repair

Stage 3 ? Distortion and remodeling

? Repair process

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- Rapid and complete :

shape is restored

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- Tardy : bony collapse

and growth distortion
Clinical feature

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Symptoms

? Typically male ? 4-8 years

? Painless limping ? continues for weeks or

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recur intermittently

? Pain in groin, thigh and knee ? activity related,

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relieved by rest

Signs

? Hip pain with passive range of movement

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? Reduced range of movement (abduction &

internal rotation)

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? Hip flexion contracture

? Leg length discrepancy

? Mild muscle wasting ? thigh, calf, buttock

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? Tredenlenburg test ; positive
Investigation
? X-ray of both hips (AP & Frog lateral view)

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? Bone scan

? CT scan ? follow up

? Arthrography : to see congruity, head deformity

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and determine method of treatment

? Blood inflammatory marker

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- FBC

- ESR

- CRP

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X-ray
? Widening of joint space
? Sclerosis
? Necrotic phase : increase density of ossific nucleus

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? Fragmentation : alternating patches of density and

lucency

? Lateral uncovering of femoral head

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? Acetabular remodelling
Waldenstr?m classification based on

radiographic changes
Stage 1 ( increased density)

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- ossific nucleus smaller and denser

- subchondral fracture

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- radiolucencies in the metaphysis

Caffey's sign

Subchondral fracture

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in the anterolateral

aspect of the femoral

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capital epiphysis

Produces crescentic

radiolucency

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Waldenstr?m classification based on

radiographic changes

Stage 2 (fragmentation

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and revascularization)

- lucency in epiphysis

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- pil ars are

demarcated

- metaphyseal changes

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resolve

-acetabular contour

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change


Stage 3 (healing or reossification stage)

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- new bone formation
- homogenous epiphysis

Stage 4 (remodel ing)

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- femoral head is reossified and remodels
- acetabular remodel ing
Classification

According to radiologic stage of

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disease ?

Waldenstr?m classification

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According to prognostic outcome ?

? Herring lateral pil ar

According to defining outcome ?

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Stulberg classification

The Herring lateral pil ar classification?

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lateral pil ar not

>50% of height of

<50% of height of

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affected

lateral pil ar preserved lateral pil ar preserved

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Herring stage A

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Good prognosis

Herring stage B

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Herring stage C

Prognostic features
? Child under 6 years ? excel ent
? Age on higher side

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? Progressive loss of hip motion more so abduction
? Obese child
? Progressive uncovering of the epiphysis

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Differential diagnosis
? Multiple epiphyseal dysplasia
? Spondyloepiphyseal dysplasia
? Mucopolysaccharidoses
? Hypothyroidism

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? Other Causes of Avascular Necrosis

? Sickle cell disease
? Steroid medication
? Sequela of traumatic hip dislocation

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? Treatment of developmental dysplasia of the hip

? Septic arthritis

D/D-Hypothyroidism

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D/D-Multiple Epiphyseal dysplasia

Management-Principles

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1. Prevent deformity to femoral head before

remodel ing phase

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2. Restore and maintain ROM
3. Concept of containment
4. Relief of symptoms
Guidelines to treatment
? Decision are based on :

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? Stage of disease
? Prognostic x-ray classification
? Age and clinical feature particularly range of

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abduction and extension

Guidelines by Herring (1994)

? Child <6 years(age at onset)

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? Symptomatic treatment-Rest/Analgesics

? Operative intervention-no added benefit
Age at onset 6-8 years

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Group B

Group A

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Uncontained/Restricted

Symptomatic

abduction

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Contained

Medial capsular

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release

Surgical

Symptomatic

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Petrie casting for 6

containment

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weeks

Age at onset 8-11 years

? Surgical treatment gives better outcome

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? In very early stage when fragmentation yet to

appear,do perfusion MRI

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? If severe ischaemic changes-Surgical

containment

? Group B,B/C-Surgical containment

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Symptomatic
? Pain control
? Hospitalization for bed rest and short period

traction

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? Gentle exercise to maintain movement

Containment

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Harrison and Menon stated ;

`if the head is contained within the acetabular

cup, then like jelly poured into a mold the head

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should be the same as the cup when it is

al owed to come out after reconsitution `

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Containment ? non operative

Containment ? surgical

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? Done before irreversible deformation of femoral

head occurs (early in fragmentation stage )

Varus 20

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Femoral VDRO osteotomies

Surgical

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Derotation 20-30

containment

Pelvic

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Salters

osteotomies

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osteotomies
Femoral varus derotational osteotomy

Pelvic osteotomy

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Summary