Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopaedics PPT 10 Legg?Calve?Perthes Disease Lecture Notes
Legg?Calv??Perthes disease
Learning objectives
It is a self limiting disorder of the hip
produced by ischemia and varying
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.
Epidemiology
? Incidence : 1:1000
? Usual age : 4-8 years
? Boys:girls ? 5:1
? Higher incidence in Caucasian, Chinese,
Japanese, Inuits, Northern Europe
Aetiology-
Coagulation disorders.
Arterial status of femoral head.
Abnormal venous drainage.
Abnormal growth and development.
Trauma.
Hyperactivity or attention deficit disorder.
Genetic component.
Environmental influences.
As a sequel to synovitis.
Pathogenesis
? Ischemia of femoral head
Up to 4 months
1. Metaphyseal vessels
2. Lateral epiphyseal
3. Scanty vessels in ligamentum
teres
4-7 years
1. Lateral epiphyseal vessels
2. Metaphyseal supply DISSAPEAR
Susceptible to ischemia,
as it depend entirely on
lateral epiphyseal vessel.
7 years
1. Vessels in ligamentum teres have
developed
Pathology-Stage 1-Ischaemia
Pathological process 3-4
years1 ? ischemia and bone
death
? Al /part of bony nucleus
of femoral head is dead
? Cartilaginous part ?
remains viable and
thicker
? Thickening and edema of
synovium and capsule
Stage 2 ? revascularization and repair
Stage 3 ? Distortion and remodeling
? Repair process
- Rapid and complete :
shape is restored
- Tardy : bony collapse
and growth distortion
Clinical feature
Symptoms
? Typically male ? 4-8 years
? Painless limping ? continues for weeks or
recur intermittently
? Pain in groin, thigh and knee ? activity related,
relieved by rest
Signs
? Hip pain with passive range of movement
? Reduced range of movement (abduction &
internal rotation)
? Hip flexion contracture
? Leg length discrepancy
? Mild muscle wasting ? thigh, calf, buttock
? Tredenlenburg test ; positive
Investigation
? X-ray of both hips (AP & Frog lateral view)
? Bone scan
? CT scan ? follow up
? Arthrography : to see congruity, head deformity
and determine method of treatment
? Blood inflammatory marker
- FBC
- ESR
- CRP
X-ray
? Widening of joint space
? Sclerosis
? Necrotic phase : increase density of ossific nucleus
? Fragmentation : alternating patches of density and
lucency
? Lateral uncovering of femoral head
? Acetabular remodelling
Waldenstr?m classification based on
radiographic changes
Stage 1 ( increased density)
- ossific nucleus smaller and denser
- subchondral fracture
- radiolucencies in the metaphysis
Caffey's sign
Subchondral fracture
in the anterolateral
aspect of the femoral
capital epiphysis
Produces crescentic
radiolucency
Waldenstr?m classification based on
radiographic changes
Stage 2 (fragmentation
and revascularization)
- lucency in epiphysis
- pil ars are
demarcated
- metaphyseal changes
resolve
-acetabular contour
change
Stage 3 (healing or reossification stage)
- new bone formation
- homogenous epiphysis
Stage 4 (remodel ing)
- femoral head is reossified and remodels
- acetabular remodel ing
Classification
According to radiologic stage of
disease ?
Waldenstr?m classification
According to prognostic outcome ?
? Herring lateral pil ar
According to defining outcome ?
Stulberg classification
The Herring lateral pil ar classification?
lateral pil ar not
>50% of height of
<50% of height of
affected
lateral pil ar preserved lateral pil ar preserved
Herring stage A
Good prognosis
Herring stage B
Herring stage C
Prognostic features
? Child under 6 years ? excel ent
? Age on higher side
? Progressive loss of hip motion more so abduction
? Obese child
? Progressive uncovering of the epiphysis
Differential diagnosis
? Multiple epiphyseal dysplasia
? Spondyloepiphyseal dysplasia
? Mucopolysaccharidoses
? Hypothyroidism
? Other Causes of Avascular Necrosis
? Sickle cell disease
? Steroid medication
? Sequela of traumatic hip dislocation
? Treatment of developmental dysplasia of the hip
? Septic arthritis
D/D-Hypothyroidism
D/D-Multiple Epiphyseal dysplasia
Management-Principles
1. Prevent deformity to femoral head before
remodel ing phase
2. Restore and maintain ROM
3. Concept of containment
4. Relief of symptoms
Guidelines to treatment
? Decision are based on :
? Stage of disease
? Prognostic x-ray classification
? Age and clinical feature particularly range of
abduction and extension
Guidelines by Herring (1994)
? Child <6 years(age at onset)
? Symptomatic treatment-Rest/Analgesics
? Operative intervention-no added benefit
Age at onset 6-8 years
Group B
Group A
Uncontained/Restricted
Symptomatic
abduction
Contained
Medial capsular
release
Surgical
Symptomatic
Petrie casting for 6
containment
weeks
Age at onset 8-11 years
? Surgical treatment gives better outcome
? In very early stage when fragmentation yet to
appear,do perfusion MRI
? If severe ischaemic changes-Surgical
containment
? Group B,B/C-Surgical containment
Symptomatic
? Pain control
? Hospitalization for bed rest and short period
traction
? Gentle exercise to maintain movement
Containment
Harrison and Menon stated ;
`if the head is contained within the acetabular
cup, then like jelly poured into a mold the head
should be the same as the cup when it is
al owed to come out after reconsitution `
Containment ? non operative
Containment ? surgical
? Done before irreversible deformation of femoral
head occurs (early in fragmentation stage )
Varus 20
Femoral VDRO osteotomies
Surgical
Derotation 20-30
containment
Pelvic
Salters
osteotomies
osteotomies
Femoral varus derotational osteotomy
Pelvic osteotomy
Summary
This post was last modified on 07 April 2022