 RADIOGRAPHY
 MAGNETIC RESONANCE IMAGING
 BONE SCINTIGRAPHY
 ULTRASONOGRAPHY
 ARTHOGRAPHY
 COMPUTEDTOMOGRAPHY
 Plain X ray of PELVISWITH BOTH HIP JTS
 AP view
 Lowenstein’s frog-leg lateral view
 Abduction – Adduction views
 Kn...
 Waldenstrom’s classification – four stages
 INITIAL STAGE
 FRAGMENTATION STAGE
 REOSSIFICATION (HEALING) STAGE
 RESI...
 Smaller osiffic
nucleus
 Lateralization
of femoral head
in the
acetabulum
 Widening of
medial jt space
 Waldenstrom / caffeys sign
 Vaccum phenomenon
 Radio-dense
femoral head
 Cyst & leucency in
metaphysis
 END OF STAGE:
appearance of
lucencies in
nucleus
 6m( up to1...
 Lucent areas appear in the ossific nucleus of
femoral head
 Demarcation of femoral segments (pillars) –
often central d...
 Milder form – only ant segement seen on frog-
leg lateral
 More severe – no demarcation of pillars
 END OF STAGE – appearance of new bone in
subchondral area
 8m(2 – 35m)
 STARTSWITH - appearance of new bone in
subchondral area
 first in center of head – then expands medially
and laterally
...
 mild gradual flatenning – children < 5 yrs whose
femoral head is totally involved
 most improve
 51m(2-122m)
 femoral head is fully reossified
 head remodels so does the acetabulum
 Head – normal / extremely flat / aspherical
 ...
 Gill(1940) – metaphyseal necrosis & lucencies
(“holes of decalcification”)
 Ponseti – cystic
changes in neck
 Prognostic value –
poor outcome
 Sagging rope sign
 radiodense line in prox
femoral metaphysis
 Metaphyseal response to
physeal damage
 Premature physeal closure
 With central arrests:
 Round head
 Short neck
 Troch overgrowth
 With lateral arrest:
 ...
 Morphological changes in acetabulum in perthes
described by BENJAMIN JOSEPH (JBJS 1989)
 Osteoporosis of acetabular roo...
 BICOMPARTMENTALIZATION –
 When femoral head protrudes from acetabulum -
medial wall may form
 And look like a second c...
On plain xray -
bicompartmental
acetabulum appears to be
composed of 2 arc partly
overlapping each other –
interpreted as ...
 Used for early diagnosis of LCP disease
 Detects –
 Configuration of femoral head & acetabulum
 Congruity of articula...
 Synovial hypertrophy
 Epiphyseal involvement
 True extent of femoral head necrosis
 helps in
 diagnosis of early stages
 visualization of early
reperfusion
 Transphyseal reperfusion, occurring by
neova...
 Effective tool for diagnosis of pre-radiological
early stages
 Revascularization patterns
 Findings of
 Configuration of head
 Widening of joint space due to thickend cartilage
 Lateral shifting of head
 Con...
 Currently, mainly
used in early
diagnosis of
HINGED
ABDUCTION
 In early stages - Joint effusion
 In later stages – assess shape of cartilagenous
femoral head
 provides acurate 3 D images of shape of femoral
head & acetabulum
1. LEGG
2. WALDENSTROM
3. GOFF
4. SALTERTHOMPSON
5. CATERALL
6. HERRING’S LATERAL PILLAR
7. MOSE
8. STULBERG
 LEGG – two types of head
 A “cap” & a “mushroom”(more severe)
 WALDENSTROM – classified head 3 categories
 Type 1 & 2...
 Extent of subchondral # in both AP &
lowenstein frog leg lateral xrays
 reliable indicator in the group with
fractures
 extent of the fracture (line) is less than
50% of the superior dome of the
femoral head
› good results can be expected.
 Extent of the fracture is
more than 50% of the
dome,
› fair or poor results can
be expected
 In 1971
 used radiological findings of epiphyseal
involvement to identify 4 groups
 anterior femoral
head involvement
 no evidence of
sequestrum,
subchondral fracture
line, or metaphyseal
abnormalities
 anterolateral
involvement
 Central sequestrum
 Well demarcated
 metaphyseal lesions
 Subchondral fracture
line – Ant...
 large sequestrum - 3/4th
of head.
 Junction is sclerotic.
 Diffuse Metaphyseal
lesions , anterolaterally
 Subchondral...
 Entire head
 Diffuse or central
metaphyseal
lesions
 posterior
remodeling of the
epiphysis
1. Gage sign : Described by COURTNEY
GAGE(1933) small osteoporotic segment which
forms a radiolucentV-shaped defect on lat...
2. Speckled calcification lateral to epiphysis
3. Lateral subluxation of femoral head
4. Horizontally oriented physis
5. D...
 Based on radiographic changes in lateral portion
of femoral head during fragmentation stage on
AP view
 LATERAL PILLAR ...
 Group A – no involvement
 Group B – at least 50 % of height maintained
 Group C – less than 50% of height
maintained
 Advantage
 Easy application in active disease
 High correlation bet lat pillar height and amount of
head flattening at...
 Based on fitting of contour
of healed femoral head to
template of concentric
circles in both AP & Frog
leg lateral views...
 described in 1981
 Alike MOSE classification, its also
classification of THE END RESULTS
 Used to predict the onset of...
 I – Shape is normal
 II – loss of head height
< 2 mm deviation of concentric circles
 Group I & II – “Spherical Congru...
 III – Elliptical head
> 2 mm deviation
Contour matches (“Incongrous/Aspherical
congruency”)
 IV – Flattened
head, >1 cm of
flattening
Contour matches
(“Incongrous/Asph
erical congruency”)
 Resemblence with
Cow’s ...
 V – Collapsed head,
Contour mismatch (“Incongrous/Aspherical
Incongruency”)
 AIMS:
 Prevention of femoral head deformity
 Prevention of secondary degenerative
osteoarthritis.
 Psychological & Ph...
 Elimination of hip irritability.
 Containment of the head.
 Restoration good ROM
 Prevention subluxation.
 Attainmen...
 For < 2 to 3 yrs – Observation
 For >3 yrs –
 Parents counseling
 Intermittent symptomatic treatment
 Home traction ...
 Petrie cast
“Broomstick cast”
 Snyder sling
TORONTO
BRACE
TACHDJIAN
BRACE
NEWINGTON
BRACE
BIRMINGHAM
BRACE
 Indication:
 Age of clinical onset > 8yrs of age
 Herring type B
 Radiological evidence of loss of
containment by con...
 CONTRAINDICATIONS:
 Herring’s type A and C
 Herring’s type B if child less than 8 yrs
 Healed cases.
 Hinged abducti...
 ADVANTAGES
 Ability to obtain permanant containment
of head.
 Period of Restriction is only 2 months.
 Innominate Osteotomy
 Varus Derotational Osteotomy
 Lateral Shelf procedure
 Arthrodiastasis
 Advantages:
 Anterolateral coverage
 Lengthening of shortened limb
 No second operation
 Disadvantages:
 Improper c...
 Indications:
 Failed conservative for containment
 8 – 10 yrs
 Uncovered head on MRI / Arthrogram
 Excessive femoral...
 Adv:
 Maximal coverage in old
 Excessive femoral anteversion
 Disadv:
 Excessive varus angulation
 Shortening
 Glu...
 INDICATION:
 Lateral
subluxation
 Insufficient
coverage
 Hinged abduction
 COMPLICATION:
 Loss of hip flexion
 lat...
 Rationale:
 Widening
 Unloads the joint space
 Reduces pressure over head
 Articular cartilage repair
 Maintain con...
 Indications & Choice of surgery:
1. Hinged abduction – Valgus subtrochanteric
osteotomy
2. Malformed head in catterall g...
 Failure of lateral end of
epiphysis to slide under
the edge of acetabulum on
an internally rotated &
abducted AP X rays ...
 Combination of
 VALGUS FLEXION INTERNAL ROTATION
OSTEOTOMY
 Coxa vara & hinged abduction - valgus
 Changes articular ...
 Indication:
 Large mushroom head
(coxa plana)
 Lateral protruberance
 Disadv:
 Physeal slippage
 Postop joint stiff...
 Indications:
 Older children with painful
hip
 Significant femoral head
flattenning.
 Elevation of GT
 Shortening of neck
 Vertical pull of
muscles
 Impingement of GT
on rim of aceta –
“GEAR STICK SIGN”
 Trochanteric
Advancement
 GT epiphysiodesis
 Trapezoidal
osteotomy of GT
 Lateral calcification
 Extent of uncovering of head
 Lateral head displacement
 Widening of head & neck during early ...
 Saturn phenomenon (sclerotic epiphysis
surrounded by ring of lucency)
 Premature physeal closure
 Shape of Femoral head & congruency with
acetabulum – most imp predictor
 Age of onset of disease & duration
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
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Classification & management of legg calve perthes disease

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Classification & management of legg calve perthes disease

  1. 1.  RADIOGRAPHY  MAGNETIC RESONANCE IMAGING  BONE SCINTIGRAPHY  ULTRASONOGRAPHY  ARTHOGRAPHY  COMPUTEDTOMOGRAPHY
  2. 2.  Plain X ray of PELVISWITH BOTH HIP JTS  AP view  Lowenstein’s frog-leg lateral view  Abduction – Adduction views  Knee joints – AP / Lat  Wrist joints – AP / Lat
  3. 3.  Waldenstrom’s classification – four stages  INITIAL STAGE  FRAGMENTATION STAGE  REOSSIFICATION (HEALING) STAGE  RESIDUAL STAGE
  4. 4.  Smaller osiffic nucleus  Lateralization of femoral head in the acetabulum  Widening of medial jt space
  5. 5.  Waldenstrom / caffeys sign  Vaccum phenomenon
  6. 6.  Radio-dense femoral head  Cyst & leucency in metaphysis  END OF STAGE: appearance of lucencies in nucleus  6m( up to14m)
  7. 7.  Lucent areas appear in the ossific nucleus of femoral head  Demarcation of femoral segments (pillars) – often central dense
  8. 8.  Milder form – only ant segement seen on frog- leg lateral  More severe – no demarcation of pillars
  9. 9.  END OF STAGE – appearance of new bone in subchondral area  8m(2 – 35m)
  10. 10.  STARTSWITH - appearance of new bone in subchondral area  first in center of head – then expands medially and laterally  Anterior segment – last to reossify  Process- lucent/necrotic areas of fragmentation stage replaced by WOVEN BONE which then ossifies , remodels in to TRABECULAR BONE
  11. 11.  mild gradual flatenning – children < 5 yrs whose femoral head is totally involved  most improve  51m(2-122m)
  12. 12.  femoral head is fully reossified  head remodels so does the acetabulum  Head – normal / extremely flat / aspherical  Physis is inlvolved – overgrowth of greater trochanter
  13. 13.  Gill(1940) – metaphyseal necrosis & lucencies (“holes of decalcification”)
  14. 14.  Ponseti – cystic changes in neck  Prognostic value – poor outcome
  15. 15.  Sagging rope sign  radiodense line in prox femoral metaphysis  Metaphyseal response to physeal damage
  16. 16.  Premature physeal closure  With central arrests:  Round head  Short neck  Troch overgrowth  With lateral arrest:  Femoral head tilted Laterally  Elongation of medial neck  Overgrowth of troch
  17. 17.  Morphological changes in acetabulum in perthes described by BENJAMIN JOSEPH (JBJS 1989)  Osteoporosis of acetabular roof  Irregularity of contour  Premature fusion of triradiate cartilage ( bicomparmentalisation)  Hypertrophy of articular cartilage & changes in dimension
  18. 18.  BICOMPARTMENTALIZATION –  When femoral head protrudes from acetabulum - medial wall may form  And look like a second compartment for the head  Bicompartmental acetabulum in perthes disease (JBJS 87-B aug 2005)
  19. 19. On plain xray - bicompartmental acetabulum appears to be composed of 2 arc partly overlapping each other – interpreted as the subluxated femoral head articulating only with the lateral half of the acetabulum moulding it into 2 compartments
  20. 20.  Used for early diagnosis of LCP disease  Detects –  Configuration of femoral head & acetabulum  Congruity of articular surface  Femoral head containment  Joint effusion
  21. 21.  Synovial hypertrophy  Epiphyseal involvement  True extent of femoral head necrosis
  22. 22.  helps in  diagnosis of early stages  visualization of early reperfusion  Transphyseal reperfusion, occurring by neovascularization through the physis, is known to be a strong predictor of growth deformity.
  23. 23.  Effective tool for diagnosis of pre-radiological early stages  Revascularization patterns
  24. 24.  Findings of  Configuration of head  Widening of joint space due to thickend cartilage  Lateral shifting of head  Containment of head within acetabulum  Major Advantage – assessment of congruity of joint in different range of movement
  25. 25.  Currently, mainly used in early diagnosis of HINGED ABDUCTION
  26. 26.  In early stages - Joint effusion  In later stages – assess shape of cartilagenous femoral head
  27. 27.  provides acurate 3 D images of shape of femoral head & acetabulum
  28. 28. 1. LEGG 2. WALDENSTROM 3. GOFF 4. SALTERTHOMPSON 5. CATERALL 6. HERRING’S LATERAL PILLAR 7. MOSE 8. STULBERG
  29. 29.  LEGG – two types of head  A “cap” & a “mushroom”(more severe)  WALDENSTROM – classified head 3 categories  Type 1 & 2 with good results  Type 3 – altered shape leading to restriction of ROM to only flexion & extension (conical)  GOFF – 3 types of head  Spherical, cap, irregular
  30. 30.  Extent of subchondral # in both AP & lowenstein frog leg lateral xrays  reliable indicator in the group with fractures
  31. 31.  extent of the fracture (line) is less than 50% of the superior dome of the femoral head › good results can be expected.
  32. 32.  Extent of the fracture is more than 50% of the dome, › fair or poor results can be expected
  33. 33.  In 1971  used radiological findings of epiphyseal involvement to identify 4 groups
  34. 34.  anterior femoral head involvement  no evidence of sequestrum, subchondral fracture line, or metaphyseal abnormalities
  35. 35.  anterolateral involvement  Central sequestrum  Well demarcated  metaphyseal lesions  Subchondral fracture line – Ant ½  lateral column is intact.
  36. 36.  large sequestrum - 3/4th of head.  Junction is sclerotic.  Diffuse Metaphyseal lesions , anterolaterally  Subchondral fracture line - post 1/2  The lateral column is involved.
  37. 37.  Entire head  Diffuse or central metaphyseal lesions  posterior remodeling of the epiphysis
  38. 38. 1. Gage sign : Described by COURTNEY GAGE(1933) small osteoporotic segment which forms a radiolucentV-shaped defect on lateral epiphysis & adjacent metaphysis on AP xray .
  39. 39. 2. Speckled calcification lateral to epiphysis 3. Lateral subluxation of femoral head 4. Horizontally oriented physis 5. Diffuse metaphyseal reaction (metaphyseal cysts)
  40. 40.  Based on radiographic changes in lateral portion of femoral head during fragmentation stage on AP view  LATERAL PILLAR - lateral 15-30% of epiphysis on AP xray
  41. 41.  Group A – no involvement  Group B – at least 50 % of height maintained  Group C – less than 50% of height maintained
  42. 42.  Advantage  Easy application in active disease  High correlation bet lat pillar height and amount of head flattening at skeletal maturity
  43. 43.  Based on fitting of contour of healed femoral head to template of concentric circles in both AP & Frog leg lateral views  Good - < 1 mm  Fair - < 2 mm  Poor - > 2 mm
  44. 44.  described in 1981  Alike MOSE classification, its also classification of THE END RESULTS  Used to predict the onset of degenerative joint disease following LCPD
  45. 45.  I – Shape is normal  II – loss of head height < 2 mm deviation of concentric circles  Group I & II – “Spherical Congruency”
  46. 46.  III – Elliptical head > 2 mm deviation Contour matches (“Incongrous/Aspherical congruency”)
  47. 47.  IV – Flattened head, >1 cm of flattening Contour matches (“Incongrous/Asph erical congruency”)  Resemblence with Cow’s hip
  48. 48.  V – Collapsed head, Contour mismatch (“Incongrous/Aspherical Incongruency”)
  49. 49.  AIMS:  Prevention of femoral head deformity  Prevention of secondary degenerative osteoarthritis.  Psychological & Physical development.
  50. 50.  Elimination of hip irritability.  Containment of the head.  Restoration good ROM  Prevention subluxation.  Attainment of spherical head at end of disease
  51. 51.  For < 2 to 3 yrs – Observation  For >3 yrs –  Parents counseling  Intermittent symptomatic treatment  Home traction & physical therapy  Hospitalization – loss of ROM  Bed Rest  SkinTraction – slings & springs  NSAIDs
  52. 52.  Petrie cast “Broomstick cast”  Snyder sling
  53. 53. TORONTO BRACE TACHDJIAN BRACE NEWINGTON BRACE BIRMINGHAM BRACE
  54. 54.  Indication:  Age of clinical onset > 8yrs of age  Herring type B  Radiological evidence of loss of containment by conservative modes
  55. 55.  CONTRAINDICATIONS:  Herring’s type A and C  Herring’s type B if child less than 8 yrs  Healed cases.  Hinged abduction
  56. 56.  ADVANTAGES  Ability to obtain permanant containment of head.  Period of Restriction is only 2 months.
  57. 57.  Innominate Osteotomy  Varus Derotational Osteotomy  Lateral Shelf procedure  Arthrodiastasis
  58. 58.  Advantages:  Anterolateral coverage  Lengthening of shortened limb  No second operation  Disadvantages:  Improper coverage in older child  Limb length inequality  AVN due to raised pressure in joint
  59. 59.  Indications:  Failed conservative for containment  8 – 10 yrs  Uncovered head on MRI / Arthrogram  Excessive femoral anteversion
  60. 60.  Adv:  Maximal coverage in old  Excessive femoral anteversion  Disadv:  Excessive varus angulation  Shortening  Gluteal lurch  Non / delayed union 2nd sx reqd. for implant removal Trochanteric overgrowth
  61. 61.  INDICATION:  Lateral subluxation  Insufficient coverage  Hinged abduction  COMPLICATION:  Loss of hip flexion  lateral femoral cutaneous nerve
  62. 62.  Rationale:  Widening  Unloads the joint space  Reduces pressure over head  Articular cartilage repair  Maintain congruency  Allows 50 degree flexion
  63. 63.  Indications & Choice of surgery: 1. Hinged abduction – Valgus subtrochanteric osteotomy 2. Malformed head in catterall gr 3 – Garceau cheilectomy 3. Coxa magna – shelf augmentation 4. Large malformed head with subluxation – VDRO + Pelvic osteotomy 5. Capital physeal arrest & troch overgrowth –
  64. 64.  Failure of lateral end of epiphysis to slide under the edge of acetabulum on an internally rotated & abducted AP X rays is s/o HINGED ABDUCTION.
  65. 65.  Combination of  VALGUS FLEXION INTERNAL ROTATION OSTEOTOMY  Coxa vara & hinged abduction - valgus  Changes articular relations – valgus & flexion  External rotation of limb – internal rotation  Improve anterolateral head coverage
  66. 66.  Indication:  Large mushroom head (coxa plana)  Lateral protruberance  Disadv:  Physeal slippage  Postop joint stiffness
  67. 67.  Indications:  Older children with painful hip  Significant femoral head flattenning.
  68. 68.  Elevation of GT  Shortening of neck  Vertical pull of muscles  Impingement of GT on rim of aceta – “GEAR STICK SIGN”
  69. 69.  Trochanteric Advancement  GT epiphysiodesis  Trapezoidal osteotomy of GT
  70. 70.  Lateral calcification  Extent of uncovering of head  Lateral head displacement  Widening of head & neck during early stages (mushroom head)
  71. 71.  Saturn phenomenon (sclerotic epiphysis surrounded by ring of lucency)  Premature physeal closure
  72. 72.  Shape of Femoral head & congruency with acetabulum – most imp predictor  Age of onset of disease & duration

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