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

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