Prof. Anisuddin Bhatti Paediatric Orthopaedic surgeon Dr. Ziauddin University hospital Clifton Karachi Pakistan Presented how to take clinic examination short case on Congenital Knee dislocation, at AKU Karachi Orthopaedic Review course on August .2023. Acknowledged for some text 7 Photo taken from Published literature.

1. Perthes’ Containment Principles August 2023

2. L. C. PERTHES’
Principles of Containment Surgery
Does FVO has a role to play
Anisuddin Bhatti
Professor, Ziauddin University Hospital, Clifton
President [Past], POA & Paeds Ortho Society Pakistan
Focal Person, Ponseti International, Pakistan
Founding Director PORP_Registry

3. Perthes’ Pathogenesis

4. Natural History
• A Self-limiting disease, that takes 3-5 years to restore complete
healing with or without deformity.
• Re-vascularization is the rule: That progress through 4 stages. i.e.
is classified by Waldenstrom (1922) & Elizbethtown):
Resorption, Regeneration, Remodeling, Healing.
Nevelos & Ratliff grouped Fragmentating variety & non-fragmentation variety
• Ultimate deformity & Prognosis depends on preservation of
sphericity, i.e. described by:
Stulberg, Catterrall, Herring –Lateral pillar.

5. Prognostic factors
Clinical Factors & Preservation of Sphericity
Clinical Factors:
OAge at the onset: worse in age > 8 year, moderate
in 6-8 years and good In <6 years.
OGender: FM > ML
ODecreased hip ROM
ODuration of Active disease
OSeverity of disease (Catterral’shead at risk signs)
OSaturn Phenomenon

6. CATTERALL’S HEAD AT RISK SIGNS
Severity of disease
1. GAGE’S signs = V on lateral side of epiphysis due to
osteoporosis
2. Calcification lateral to epiphsis – Speckled
3. Lateral subluxation (Extrusion) of caput femoris
4. Diffuse metaphyseal cysts
5. Horizontal proximal femoral physis
6. Female + Age > 6-7 years
Additional Risk factor: SATURN Phenomenon

7. Catterall's at Head at Risk Signs
Gage sign / Lateral
Rarefication
(White Arrow)
Extrusion,
Lateral Subluxation
(Red Arrow).
Metaphyseal Reaction
(yellow arrow)

8. Head at Risk Signs
[sclerotic epiphysis surrounded
by ring of lucency]
Saturn Phenomenon

9. Waldenstrom Classification1
i. Early part of disease (I-IIa)=
before femoral head deformation
begins.
ii. Late part of disease (IIb IIIa)=
after the femoral head has begun
to deform
Perthes’ Life
Cycle
Described by Waldenstrom
Waldenstrom H. 1938; 20;559-
66.Nevelos Acta Orthop 1977
Benjamin Josef 2015 Ind J Orthop

10. Pathogenesis of
Extrusion & Deformation
Saddle deformation
Hinged abduction
Griffin 1980 Cln Orthop Rel Res

11. Pathogenesis of
Extrusion & Deformation
Extrusion appears to be a prime
factor that predisposes to
femoral head deformation; the
greater the extrusion, the
greater the propensity for
femoral head deformation.
B Josef 2015
If extrusion is 20% of width of
epiphysis, the irreversible
deformation of Fm head is inevitable.
Griffin 1980, Josef 2005
In untreated childrenfemoral head extrusion increases as the disease progresses;in the initial stages of
the disease the increase in extrusion isgradual but extrusion abruptly increases in the late stage of
fragmentation (Stage IIb), often exceeding the critical 20%. Griffin 1980

12. LC Perthes’ Rx Principles
To achieve Concentric, Anatomical
Reduction of Femoral head within
acetabulum without significant pressure to:
o Prevent extrusion … maintain containment
o Decrease stresses on soft head to prevent
deformation…. no weight bearing.
Future Prospects:
o Prevent resorption by osteoclast
o Perfusion MRI that Help in planning to achieve promising results

13. LC Perthes’ Rx.
Ultimate Objectives of:
• Preserve Optimum Height, Size & Sphericity of
Caput Femoris
• Prevent early development of degenerative
changes.
• Restore of Good ROM
• Achieve normal Psycho-social & Physical
development.

14. 1. Early-stage (I-IIa)
Preventive Intervention
2. Late stage (IIb-IIIa)
Remedial Surgery
3. Healed Stage (IIIb-IV)
Salvage surgery
Rx. When & How
1. Waldenstrom H. 1938;20;559-66. 2. Benjamin Josef 2015 Ind J
Orthop

15. * Early part of the disease (I-IIa)
Rx aimedat preventing femoral head
deformation by preventing extrusion
with non-operative methods,if it is to be
effective.
* late stageof disease,stageof
fragmentation (Stage IIb) or thereafter
(III-IV), Remedial or Salvage Surgery be
instituted, to contain the femoral head.
Rx Interventions
Griffin 1980, Clin Orthop N Am
Benjamin Josef 2015 Ind J Orthop

16. To Bypass the stage of
Fragmentation aimed to:
* Improve Containment
* Diminish duration of
aggressive disease
* Reduce metaphyseal width
* Diminish size of coxa magna
* Reduce chance of Early OA
1. Nevelos AB, et al Acta Orthop Scand 1977; 48:411–421
2. Josef B.. J Pedter Ortho.2005
Altered Natural Healing by Containment

17. Bypassing stage of fragmentation
O Nevelos identified some children (average
age 5 yrs) with Perthes’ disease who did not
pass-throughstage II or the fragmentation
stage.
O Josef observed, It is possible that Perthes’
disease behaves differently in children of
different ages, with the stage of
fragmentation being bypassed
spontaneously in some young children and
following early surgery in older children i.e
average age 8 yrs.
1. Nevelos AB, et al Acta Orthop Scand 1977; 48:411–421
2. Josef B. et al . J Pedter Ortho.2005

18. Favourable Consequences with
Bypassing stage of fragmentation
OI: in the absence of fragmentation the integrity of the
lateral pillar is maintained, since collapse of the lateral
pillar occurs in the stage of fragmentation.
OII: duration of the disease may be reduced.
OIII. adverse metaphyseal and acetabular changes that
tend to appear most frequently in the stage of
fragmentation may not develop.
1. Nevelos AB, et al Acta Orthop Scand 1977; 48:411–421
2. Josef b.. J Pedter Ortho.2005

19. Favourable Consequences with
Bypassing stage of fragmentation
OSome other investigators also indicate
that, children in whom the stage of
fragmentation is bypassed are likely to
have a favorable outcome, with
spherical head at healing
1. Axer A, et al. Clin Orthop 1980; 150:78–87. 2.Trias A. Clin Orthop 1978;137:195–207
3. Nevelos AB, et al Acta Orthop Scand 1977; 48:411–421. 4. Josef b. et Al . J Pedter Ortho.2005

20. Containment
procedures to alter
the diseae progress
with bypassing
stage of
fragmentation

21. Containment ?
1. Griffin PP . Orthop Clin North Am 1980;11:127-39. 2. Joseph B et al. J Pediatr Orthop 2003;23:590-
600.
3. Josef B. 2015 Ind. J Orthop
• Defined: as to prevent the femoral head from
bearing forces across the acetabular margin
by either preventing or reversing extrusion of
the femoral head.
• Method: by Placing antero-lateral part of the
femoral epiphysis well into acetabulum, to
protect the vulnerable part of epiphysis from
being subjected deforming forces.
• Options: 1. Non-operative 2. Operative

22. Conservative vs
Operative Containment
• In children under < 7 years at the onset of the
disease extrusion may or may not occur; these
children needto be monitored closely with antero-
posterior and frog-lateralradiographs, every 3 or 4
months and containment ensuredas soon as
extrusion is identified without any delay.
1. Fabry K, Moen G J Pedtr Orthop B. 2003. 2. Canavese F JBJS Br.2008

23. Conservative vs
Operative Containment
• In children over the age of > 7 years
Extrusion invariably occurs sooner or
later at the onset of the diseaseand
hence containment should be
ensured as soon as the disease is
diagnosed. MuirheadA W, CatterallA. JBJS 1982.

24. Outcome of Containment
with reference to Disease stage
OThe odds ratio of avoiding femoralhead
deformation is 16.58 times higher if
containment is achieved early in the
disease (Stage IIa or earlier) than if itis
achieved late in the disease (Stage IIb or
later).1-4
1.Axer 1980 Clin Orth Rel Res. 2. Hoika 1991 Acta Orthop.
3. Lack W 1989 J Pedtr Orthop. 4. Joseph b 2003 J. Pedtr Orthop

25. J
Pediatr
Orthop
2012;32:697–705
23 studies, 1232 patients, and 1266 hips
• Operative Rx is more likely to yield a spherical
congruent Fm.head than Non-operative Rx in patients
>6 yrs or older.
• Amongst patients younger than <6 yrs, Operative &
Non-operative Rx have the same likelyhood to yields a
good outcome.

26. Variable Rx Contain Don’t Contain
Age >7 or <7yr. with
Extrusion
< 7 yr. (no extrusion)
Disease stage Stage Ia, Ib, IIa Stage IIb, IIIa, IIIb, IV
Extrusion Present Absent (<7yr)
ROM Hip Noraml Restricted
B. Josef. IJO 2015

27. Perthese with Gross limitation of ROM
In patient with stiff hip, it is mandatory to:
ORestore ROM before effective containment can be
achieved.
OApply Skin traction for a week, that to restoresmotion.
OApply a broom-stick cast in wide abduction in case of non-
cooperative patients, preferably under general anesthesia
and retained for 6 weeks; hip motion improves once the cast
is removed.
Thompson GH 1979. Clin Ortho Rel Res & Benjamen Josef 2003, 2005, 2015

28. Methods of Containment Surgeries
OInnominate Salter’s Osteotomy /
Pemberton PAO
OFemoral Varus Derotation Osteotomy
OStaheli’s Shelf Acetabuloplasty
OTriple Pelvic osteotomy
OArthrodiastasis
OFemoral (Valgus in hinged abduction)
Regarding Pelvis vs Femoral osteotomy, No consensus yet exists
about the type of surgical containment.

29. Does FVO has a role to play
References:
1. Joseph et al. J Pediatr Orthop (2005) B 14:10–15
2. Josef. B et al J Pedtiatr Ortho
3. Josef B. 2015 Ind J Orthop
4. Terjesen T. et al.; Clin Orthop Relaxt Res (2012) 470:2394-2401
5. Nhu An T. et al. J Pediatr Orthop (2012);32:697–705
6. Axer 1980 Clin Orth Rel Res.
7. Nevelos AB, et al Acta Orthop Scand 1977; 48:411–421.

30. STUDY:
• Total 640 children, under age 12 years & at different stage of
disease.
• 314 patients underwent surgery and 317 of these patients
had a proximal femoral osteotomy, which was performed at
different stages of thedisease.
• 3 patients with bilateral disease had surgery on both hips.
• 323 patients were only treated symptomatically during the
initialphase of the disease to relieve pain
How does a Femoral varus osteotomy alter the natural
evolution of Perthes’ disease?
Joseph et al. J Pediatr Orthop B 14:10–15 2005

31. Conclusion
• The results of this study reaffirm the impression that
these beneficial effects of a varus osteotomy, for
Perthes’ disease in the older child, are most evident if
the operation is performed either in the stage of
avascular necrosis or in the early stage of fragmentation.
• Collapse of the lateral pillar was not seen in any child
who bypassed the stage of fragmentation.
• Every effort must, therefore, be made to undertake the
surgery before the disease has progressed beyond the
early stage of fragmentation.
How does a Femoral varus osteotomy alter the natural
evolution of Perthes’ disease?
Joseph
et
al.
J
Pediatr
Orthop
B
14:10–15

32. Terjesen Norwegian prospective study
• 70 patients (unilateral LCPD) Catterall 3 & 4, older 6 years
• Varus femoral osteotomy improves sphericity of the femoral head in older
children with severe form of Legg-Calvé-Perthes Disease
Terjesen
T.
et
al.;
Clin
Orthop
Relaxt
Res
(2012)
470:2394-2401

33. J
Pediatr
Orthop
2012;32:697–705
23 studies, 1232 patients, and 1266 hips
Femoral vs Pelvic Osteotomy vs age:
• In context to Femoral or Pelvic osteotomy the patients
aged 6 yrs or older yield same radiographic outcome.
• Amongst patients younger than 6 yrs, Pelvic
osteotomy more likely to result in good radiographic
outcome than Femoral procedures.

34. Case examples

35. (Tqr) Male, 7 years of age (July 2019).
Waldenstrom Ia

36. TrQ. 7 yr age. August 2019
O Limp & tolerable Pain left hip at rest
O Abduction Brace and partial weight
bearing,
O Analgesics
O No sports activities
O Radiological evaluation revealed
progressive disease
O Sclerosis & Flatening started
Ia to Ib

37. 8 yrs + December 2019
O Clinical Symptoms & sign worsened
O Abduction Brace continued
O Difficulty to maintain abduction ---
Despite adjustment of brace
O Radiological evaluation revealed
progressive disease
O Flatening segnificant + fragmentation
started
O He was advised for Containment
Surgery again that Parents refrained
Thereafter Lost to Followup for 1 year
II B

38. Feb. 2021. 8 yrs
(Follow up 1 year Plus later)
O Clinical Symptoms & sign worsened in 2
years since initial history
O Not using brace
O Full weight bearing
O Doctors shopping during this period
O Radiological evaluation revealed
significantly progresed disease
O Necrosis, extrusion started.
O Waldenstrom III-B
II B + Extrusion

39. Disease
Progression
in 2 yrs
August 2018
December 2019
February 2021
July 2019
IA
II B
II B
Extrusion

40. Feb 2021,FEB
Staheli’s Shelf
Acetabuloplasty
Staheli’s Shelf procedure & Petrie cast

41. Post-Staheli Follow up
O Non weight bearing
O Rest in bed
O At 6 months FU: Allowed
Full ROM exercises &
Partial weight bearing
with walker
O At 12 months: Full weight
bearing & ROM exercises.
3 Weeks Post Operative

42. Post Staheli’s 12 months FU
25th March 2022
O CE angle >35 deg
O Wldenstrom stage:
Healing stage
O Contour restored

43. Post Stahli’s 12 moths FU
O Walks without Walker
O Pain free
O Walking without a limp
O ROM
O Flexion 130°
O Adduction 35°
O External rotaion 25°
O Internal rotation 25°
Bhatti’s FH Score= excellent

44. 6 yrs to 8 yrs: Out come of Acetabuloplasty..
Bypass from stage IIIB to Stage IV (Healed IA)
February 2021
IIB I A
March 2022

45. Wjht 9 yrs: ST Varus derotation Osteotomy
+ Staheli’s

46. If Left Alone: No Treatment
A. Normal hip
B. Coxa magna
C. Deformed
head
D. Early OA

47. Perthes’ Life Cycle
Kamran 8+ years
1st Visit: 21.12. 2019 & 19.01.2020
O Gradual onset of Pain, night
cramps, difficulty in Palthi &
limited walking disability.
O ROM: limited ROM (Rotational
Movements)
O Radiography: Waldontrom IB
O Rx: Opposite side shoe raise, No
sports, NSAIDs
19.01.2020
21.12.2019
(Late Avascular necrosis)
Crescent
Sign

48. Perthes’ Life Cycle
Kamran 9 years
2nd Visit: 09.12. 2020
O Pain on walk some distance,
Fatiguibility, difficulty in Palthi&
squat.
O ROM: limited ROM (Rotational
Movements)
O LLD 1cm
O Radiography: Waldontrom IIB
Rx: Staheli’s Shelf, No sports,
NSAIDs… refrained
O Lost to FU … Covid 19
09.12.2020
(late fragmentation)

49. Perthes’ Life Cycle
Kamran 11 years
3rd Visit: 03.12.2022
O Pain on walk some distance,
Fatiguibility>.
O ROM: Mild ROM (Rotational
Movements)
O LLD 1cm
O Radiography: Waldontrom IIIA
O Rx: Relative Neck lengthening
O Undecided Yet & Lost to FU
Early Reconstitution

50. Perthes’ Life Cycle
O Wldostrom IIIA
O Early
Reconstitution
Kamran @ 12 years,
3rd Visit 03.12.2022
3 yrs FU

51. Life Cycle
Kamran 12 years, 3rd Visit, 3 yrs FU
Waldostrom IIIA. Early Reconstitution
LLD 1cm, ROM mild rotational restriction
Rx: VDRO / Relative Neck Lengthening?
Parents Reluctant due to Excellent BFHS

52. Life Cycle Similar case as above with 10 yr FU.
2004 2004
2005 2010
• Non Surgical
treatment
• Restoration
with deformed
head
• Waldenstrom
IV.
• Hinged
abduction
Source / Courtesy ..

53. 10 yrs age, H/O 7 months, limp & Mild pain
Late onset Rapid progressive Perthes
January 2023 July 2023
May 2023

54. 10 yrs age, Male,
H/O 7 months, limp & Mild pain
Late onset Rapid progressive Perthes
PRE-Operative Evaluation PER-Operative Evaluation

55. 10 yrs age:Late onset Rapid progressive Perthes
Femoral ST VDRO + Salter’s Osteotomy

56. Outcome of containment vs age:
• Outcome is more favorable with age group < 6 years vs
over 6 years
• The collapse of the lateral pillar has not been seen, in
younger aged (<6 yrs) children who bypassed the stage
of fragmentation with or without surgical containment
• The beneficial effects of a varus osteotomy, in the older
child (>6yrs) , are most evident if the operation is
performed either in the stage of avascular necrosis (Ia)
or in the early stage of fragmentation (Ib).
Summary

57. Femoral vs Pelvic Osteotomy:
• In younger < 6 years age group the outcome with Pelvic
osteotomy is better than Femoral osteotomy.
• In age group >6 years and older the outcome is likely to
be same with Femoral Vs Pelvic
• However, Every effort must, therefore, be made to
undertake the surgery before the disease has progressed
beyond the early stage of fragmentation.
Summary

58. The VARUS OSTEOTOMY alters the natural evolution of
Perthes’ disease by:
(1) bypassing the fragmentation stage in one third / most
of the children who undergo the operation very early in
the course of the disease;
(2) reducing the duration of the stage of fragmentation;
(3) minimizing extrusion of the femoral head when it is
most vulnerable for deformation;
(4) reducing the extent of metaphyseal widening and
femoral head enlargement and
Conclusion

59. (5) retaining the sphericity of the femoral head in a large
proportion of children.
(6) Despite achieving adequate femoral head containment
at the time of surgery, the femoral head tended to
extrude again gradually till the disease healed.
(7) Henceforth, Regular monitoring till complete healing, is
mandatory
Conclusion