Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Legg – Calve – PerthesLegg – Calve – Perthes
DiseaseDisease
Presenter – Dr. Maulik T PatelPresenter – Dr. Maulik T Patel
O...
DefinitionDefinition
It is a self limiting disorder of the hipIt is a self limiting disorder of the hip
produced by ische...
SynonymsSynonyms
Coxa PlanaCoxa Plana
Pseudocoxalgia (Calve)Pseudocoxalgia (Calve)
Arthritis deformans juvenilis (Perth...
HISTORYHISTORY
Reidel in 1890 presented the first case ofReidel in 1890 presented the first case of
osteochondritis desse...
HISTORYHISTORY
Waldenstorm In 1909 described theWaldenstorm In 1909 described the
disorder in 10 children . He thought it...
HISTORYHISTORY
 Arthur LeggArthur Legg of theof the
United StatesUnited States
HISTORYHISTORY
 Jacques CalveJacques Calve ofof
FranceFrance
HISTORYHISTORY
 Georg PerthesGeorg Perthes ofof
GermanyGermany
HISTORYHISTORY
In the Early years treatment consisted onIn the Early years treatment consisted on
non weight bearing with...
Blood supply to femoral headBlood supply to femoral head
 Retinacular arteriesRetinacular arteries
 Metaphyseal arteries...
Blood supply to femoral headBlood supply to femoral head
 InfantsInfants
1.1. Medial ascending cervical or inferiorMedial...
Blood supply to femoral headBlood supply to femoral head
 4 yrs to 7 years4 yrs to 7 years
Epiphyseal plate forms a barri...
IncidenceIncidence
 Male : Female = 4-5:1Male : Female = 4-5:1
 2.5:1 in India2.5:1 in India
 Age of onset earlier in f...
EtiologyEtiology
The exact etiology of Legg Calve PerthesThe exact etiology of Legg Calve Perthes
disease in not known bu...
EtiologyEtiology
 Coagulation disorders.Coagulation disorders.
 Arterial status of femoral head.Arterial status of femor...
Coagulation disordersCoagulation disorders
 Glueck et al showed that 75% of their series ofGlueck et al showed that 75% o...
Coagulation disordersCoagulation disorders
Kaeley et al found no causal relationshipKaeley et al found no causal relation...
Arterial status of femoral headArterial status of femoral head
 Angiographic studies have shown obstruction ofAngiographi...
Abnormal venous drainageAbnormal venous drainage
Venous drainage normally flows through theVenous drainage normally flows...
Abnormal growth and developmentAbnormal growth and development
A delay in Bone age of 1.5 to 2 yearsA delay in Bone age o...
TraumaTrauma
In the developing femur , the major lateralIn the developing femur , the major lateral
epiphyseal artery mus...
Hyperactivity or attention deficitHyperactivity or attention deficit
disorderdisorder
A high prevalence of this disorder ...
Genetic componentGenetic component
Familial association has been reported.Familial association has been reported.
Burch ...
Environmental influencesEnvironmental influences
Low socioeconomic status has been seenLow socioeconomic status has been ...
Sequel to synovitisSequel to synovitis
Synovitis of the hip occurs early in LCPSynovitis of the hip occurs early in LCP
...
Truetta’s HypothesisTruetta’s Hypothesis
He postulated that the solitary bloodHe postulated that the solitary blood
suppl...
Caffey’s HypothesisCaffey’s Hypothesis
Intraepiphyseal compression of bloodIntraepiphyseal compression of blood
supply to...
PATHOGENESISPATHOGENESIS
 LOSS OF BLOOD SUPPLY PRODUCESLOSS OF BLOOD SUPPLY PRODUCES
AVN OF THE EPIPHYSEAL OSSCIFICATIONA...
ICIPIENT OR SYNOVITISICIPIENT OR SYNOVITIS
STAGESTAGE
LAST 1-3 WEEKS . SYNOVIUM ISLAST 1-3 WEEKS . SYNOVIUM IS
SWOLLEN , H...
Increase
joint space
STAGE OF AVNSTAGE OF AVN
 AVN INVOLVES PORTION OF OSSIFIC NUCLEUSAVN INVOLVES PORTION OF OSSIFIC NUCLEUS
SITUATED ANTERIO...
STAGE OFSTAGE OF
FRAGMENTATION ORFRAGMENTATION OR
REGENERATIONREGENERATION RADIOGRAPHIC FRAGMENTED APPEARANCERADIOGRAPHIC...
HEALED OR RESIDUALHEALED OR RESIDUAL
STAGESTAGE
 FORMATION OF NORMAL BONE ALONGSIDEFORMATION OF NORMAL BONE ALONGSIDE
REP...
 APPERANCE OF GREATERAPPERANCE OF GREATER
TROCHANTERTROCHANTER:- IT BECOMES:- IT BECOMES
STRIKINLY LARGE IN SOME CASES. S...
Avascular necrosisAvascular necrosis
Temporary cessation of growthTemporary cessation of growth
Of epiphysisOf epiphysis
P...
Pathological fracturePathological fracture
Resorption of underlying boneResorption of underlying bone
Replacement by biolo...
CLINICAL FEATURESCLINICAL FEATURES
SYMPTOMSSYMPTOMS
 MOST CHILDERN PRESENT WITH MILD ANDMOST CHILDERN PRESENT WITH MILD A...
EXAMINATION:-EXAMINATION:-
 ANTALGIC GAITANTALGIC GAIT
 MUSCLE SPASM SECONDARY TO IRRITABLE HIP.MUSCLE SPASM SECONDARY T...
InvestigationInvestigation
X-Ray –AP & Frog leg Lat viewX-Ray –AP & Frog leg Lat view
USGUSG
ArthrographyArthrography
...
RADIOGRAPHIC STAGESRADIOGRAPHIC STAGES
FOUR WALDENSTROM STAGES:FOUR WALDENSTROM STAGES:
1) INITIAL STAGE1) INITIAL STAGE...
INITIAL STAGEINITIAL STAGE
 EARLY RADIOGRAPHICEARLY RADIOGRAPHIC
SIGNS:SIGNS:
 FAILURE OF FEMORALFAILURE OF FEMORAL
OSSI...
X-RayX-Ray
 Cresent Sign orCresent Sign or
Salters sign orSalters sign or
Caffey’s signCaffey’s sign
FRAGMENTATION STAGEFRAGMENTATION STAGE
BONY EPIPHYSISBONY EPIPHYSIS
BEGINS TOBEGINS TO
FRAGMENTFRAGMENT
AREAS OFAREAS OF...
X-RayX-Ray
 Fragmentation ofFragmentation of
epiphysisepiphysis
REOSSIFICATION STAGEREOSSIFICATION STAGE
NORMAL BONENORMAL BONE
DENSITY RETURNSDENSITY RETURNS
ALTERATIONS INALTERATIONS...
X-RayX-Ray
 MetaphysealMetaphyseal
widening and cysticwidening and cystic
changes in femoralchanges in femoral
neckneck
X-RayX-Ray
 Lateral extrusion ofLateral extrusion of
femoral head andfemoral head and
changes inchanges in
acetabulum.ace...
X-RayX-Ray
 Sagging rope sign inSagging rope sign in
adults with history ofadults with history of
perthes – radio densepe...
ArthrographyArthrography
 Indicated to know the contour of headIndicated to know the contour of head
and congruity of art...
Bone ScanBone Scan
Indicated to diagnose in early stages andIndicated to diagnose in early stages and
to classify the sev...
Bone ScanBone Scan
 Convay et alConvay et al
classificationclassification
 Stage 1 is total lack ofStage 1 is total lack...
Bone ScanBone Scan
 Revascularisation atRevascularisation at
lateral columnlateral column
 Failure to revasculariseFailu...
Bone ScanBone Scan
 Gradual filling ofGradual filling of
anterolateral partanterolateral part
Bone ScanBone Scan
 Return to normalReturn to normal
MRIMRI
Accurate in early diagnosis.Accurate in early diagnosis.
Shows congruity, containment, synovialShows congruity, c...
ClassificationClassification
Waldenstroms classification.Waldenstroms classification.
Catterall classification.Catterall...
Waldenstroms classificationWaldenstroms classification
1.1. Incipient stage – 1-3 wksIncipient stage – 1-3 wks
2.2. Avascu...
Catterall classification (1971)Catterall classification (1971)
I – only anterior portion of epiphysisI – only anterior po...
Catterall described head at risk factors toCatterall described head at risk factors to
predict prognosis:predict prognosi...
Gage’s signGage’s sign
 Rarefaction in theRarefaction in the
lateral part of thelateral part of the
epiphysis andepiphysi...
Salter ClassificationSalter Classification
Type A = I & II CatterallType A = I & II Catterall
Type B = III & IV Catteral...
Herring Lat PillarHerring Lat Pillar
 Group-A hips are defined as those with noGroup-A hips are defined as those with no
...
Lateral Pillar group ALateral Pillar group A
Lateral Pillar group BLateral Pillar group B
Lateral Pillar group CLateral Pillar group C
Modified ElizabethtownModified Elizabethtown
classificationclassification
 Stage Ia: Part orStage Ia: Part or
whole of th...
Modified ElizabethtownModified Elizabethtown
classificationclassification
 Stage Ib: TheStage Ib: The
epiphysis isepiphys...
Modified ElizabethtownModified Elizabethtown
classificationclassification
 Stage IIa: TheStage IIa: The
sclerotic epiphys...
Modified ElizabethtownModified Elizabethtown
classificationclassification
 Stage IIb:Stage IIb:
Fragmentation isFragmenta...
Modified ElizabethtownModified Elizabethtown
classificationclassification
 Stage IIIa: EarlyStage IIIa: Early
new bonenew...
Modified ElizabethtownModified Elizabethtown
classificationclassification
 Stage IIIb: TheStage IIIb: The
new bone is ofn...
Modified ElizabethtownModified Elizabethtown
classificationclassification
Stage IV the healing is complete and there isSt...
Prognostic FactorsPrognostic Factors
1.1. Age at diagnosisAge at diagnosis
2.2. Extent of involvementExtent of involvement...
Classification of PrognosisClassification of Prognosis
Uniplanar methodsUniplanar methods
- CE angle of Weiberg.- CE angl...
CE angle of WeibergCE angle of Weiberg
 Indicator of acetabular depth It isIndicator of acetabular depth It is
the angle ...
Salters extrusion IndexSalters extrusion Index
 If AB is moreIf AB is more
than 20% of CDthan 20% of CD
it indicates ait ...
Epiphyseal index & quotientEpiphyseal index & quotient
Epiphyseal index = greatest height of theEpiphyseal index = greate...
Stulberg classificatonStulberg classificaton
 Class I – Shape of the femoral head wasClass I – Shape of the femoral head ...
Stulberg classificatonStulberg classificaton
 Class IClass I
Shape ofShape of
the femoralthe femoral
head ishead is
basic...
Stulberg classificatonStulberg classificaton
 Class IIClass II
Loss ofLoss of
headhead
height butheight but
within 2withi...
Stulberg classificatonStulberg classificaton
 Class IIIClass III
DeviatesDeviates
more thanmore than
2 mm2 mm
Stulberg classificatonStulberg classificaton
 Class IVClass IV
HeadHead
FlattenedFlattened
Stulberg classificatonStulberg classificaton
 Class VClass V
Collapse ofCollapse of
femoralfemoral
head,head,
AcetabularA...
Differential diagnosisDifferential diagnosis
Tuberculosis of the hipTuberculosis of the hip
SCFESCFE
Transient synoviti...
TreatmentTreatment
ObjectivesObjectives
- To produce a normal femoral- To produce a normal femoral
head and neckhead and ...
TreatmentTreatment
GOAL :GOAL :
Treatment efforts are directed towardsTreatment efforts are directed towards
- Restorati...
TreatmentTreatment
 Caterall group 1 andCaterall group 1 and
group 2 ( < 7 years)group 2 ( < 7 years)
No activeNo active
...
TreatmentTreatment
Treatment is divided into 3 phasesTreatment is divided into 3 phases
Initial Phase – restore & maintai...
Treatment ( Initial Phase )Treatment ( Initial Phase )
Physiotherapy – active and passivePhysiotherapy – active and passi...
Treatment ( Active Phase )Treatment ( Active Phase )
Consists of containment of the femoralConsists of containment of the...
Treatment (Orthosis)Treatment (Orthosis)
 Non Ambulatory weight releivingNon Ambulatory weight releiving
1.1. Abduction b...
Treatment (Orthosis)Treatment (Orthosis)
 Atlanta Scotish RiteAtlanta Scotish Rite
BraceBrace
Atlanta Scotish Rite BraceAtlanta Scotish Rite Brace
Newington orthosisNewington orthosis
Birmingham braceBirmingham brace
 Toronto BraceToronto Brace
 Tachdjian trilateralTachdjian trilateral
socket orthosissocket orthosis
Treatment (Orthosis)Treatment (Orthosis)
 Orthotic treatment is discontinued when theOrthotic treatment is discontinued w...
Treatment ( Surgical)Treatment ( Surgical)
Femoral varus osteotomy.Femoral varus osteotomy.
Inominate osteotomy.Inominat...
Femoral varus osteotomyFemoral varus osteotomy
IndicationsIndications: 1.>6yrs of age: 1.>6yrs of age
2.hip with normal or...
Femoral varus osteotomyFemoral varus osteotomy
Femoral varus osteotomyFemoral varus osteotomy
Femoral varus osteotomyFemoral varus osteotomy
 Varus should not beVarus should not be
exced less than 110*exced less tha...
Femoral varus osteotomyFemoral varus osteotomy
Femoral varus osteotomyFemoral varus osteotomy
Femoral varus osteotomyFemoral varus osteotomy
Inominate osteotomyInominate osteotomy
 IndicationsIndications::
1.>6 yrs1.>6 yrs
2.mod. Or severely affected head with l...
Valgus OsteotomyValgus Osteotomy
 Indication:hingedIndication:hinged
abduction of hipabduction of hip
Shelf ArthroplastyShelf Arthroplasty
Performed to enlarge the volume ofPerformed to enlarge the volume of
acetabulum.acet...
Shelf ArthroplastyShelf Arthroplasty
Chiari osteotomyChiari osteotomy
 Capsular interpositionalCapsular interpositional
arthroplastyarthroplasty
 Deepens the...
Trochanteric advancementTrochanteric advancement
 IndicationsIndications::
- Trochanteric over- Trochanteric over
growthg...
Recommended Indications for diff.Recommended Indications for diff.
surgeriessurgeries
Hinged abduction - valgus subtrocha...
Recent AdvancesRecent Advances
AnticoagulantAnticoagulant
Botulinum toxinBotulinum toxin
 Ibadronate :this has shown th...
ReferencesReferences
Campbell’s operative Orthopaedics – 10Campbell’s operative Orthopaedics – 10thth
editionedition
Tac...
Thank you
for your
patient
listening
perthes disease
perthes disease
perthes disease
perthes disease
perthes disease
perthes disease
Upcoming SlideShare
Loading in …5
×

perthes disease

6,718 views

Published on

PERTHES DISEASE IN ORTHOPEDICS

Published in: Health & Medicine
  • Be the first to comment

perthes disease

  1. 1. Legg – Calve – PerthesLegg – Calve – Perthes DiseaseDisease Presenter – Dr. Maulik T PatelPresenter – Dr. Maulik T Patel Orthopedic surgeonOrthopedic surgeon
  2. 2. DefinitionDefinition It is a self limiting disorder of the hipIt is a self limiting disorder of the hip produced by ischemia and varyingproduced by ischemia and varying degrees of necrosis of the femoral head.degrees of necrosis of the femoral head.
  3. 3. SynonymsSynonyms Coxa PlanaCoxa Plana Pseudocoxalgia (Calve)Pseudocoxalgia (Calve) Arthritis deformans juvenilis (Perthes)Arthritis deformans juvenilis (Perthes) Osteochondroses of the hipOsteochondroses of the hip Coronary disease of the hipCoronary disease of the hip
  4. 4. HISTORYHISTORY Reidel in 1890 presented the first case ofReidel in 1890 presented the first case of osteochondritis dessecans in the hip.osteochondritis dessecans in the hip. Preiser in Germany presented a patientPreiser in Germany presented a patient with osteoartritis deformans.with osteoartritis deformans.
  5. 5. HISTORYHISTORY Waldenstorm In 1909 described theWaldenstorm In 1909 described the disorder in 10 children . He thought it to bedisorder in 10 children . He thought it to be tubercular in origin and named it “Dertubercular in origin and named it “Der Obere Tuberculose Collumherd”Obere Tuberculose Collumherd” In 1910 this disorder was recognised asIn 1910 this disorder was recognised as an independent entity by three men…an independent entity by three men…
  6. 6. HISTORYHISTORY  Arthur LeggArthur Legg of theof the United StatesUnited States
  7. 7. HISTORYHISTORY  Jacques CalveJacques Calve ofof FranceFrance
  8. 8. HISTORYHISTORY  Georg PerthesGeorg Perthes ofof GermanyGermany
  9. 9. HISTORYHISTORY In the Early years treatment consisted onIn the Early years treatment consisted on non weight bearing with Ischial weightnon weight bearing with Ischial weight bearing Caliperbearing Caliper Parker started the use of broomstick cast inParker started the use of broomstick cast in 1929.1929. Eyre-Brook introduced traction in bed for 18-Eyre-Brook introduced traction in bed for 18- 24 months.24 months. In 1966 Salter induced avascular necrosis inIn 1966 Salter induced avascular necrosis in Pig model and proved that best result wasPig model and proved that best result was with weightbearing with hips held inwith weightbearing with hips held in abduction.abduction.
  10. 10. Blood supply to femoral headBlood supply to femoral head  Retinacular arteriesRetinacular arteries  Metaphyseal arteriesMetaphyseal arteries  Artery of the teresArtery of the teres ligamentligament
  11. 11. Blood supply to femoral headBlood supply to femoral head  InfantsInfants 1.1. Medial ascending cervical or inferiorMedial ascending cervical or inferior metaphyseal arteries of trueta.metaphyseal arteries of trueta. 2.2. Lat epiphysealLat epiphyseal 3.3. Lig teres – insignificantLig teres – insignificant  4 mts – 4 years4 mts – 4 years 1.1. Lat epiphysealLat epiphyseal 2.2. Med epiphyseal decrease in number.Med epiphyseal decrease in number.
  12. 12. Blood supply to femoral headBlood supply to femoral head  4 yrs to 7 years4 yrs to 7 years Epiphyseal plate forms a barrier to metaphysealEpiphyseal plate forms a barrier to metaphyseal vessels.vessels.  Pre-adolescentPre-adolescent After 7 yrs arteries of lig teres become moreAfter 7 yrs arteries of lig teres become more prominent and anastomose with the lateralprominent and anastomose with the lateral epiphyseal vessels.epiphyseal vessels.
  13. 13. IncidenceIncidence  Male : Female = 4-5:1Male : Female = 4-5:1  2.5:1 in India2.5:1 in India  Age of onset earlier in females.Age of onset earlier in females.  Age –Age – Range – 2-13 years.Range – 2-13 years. Most common 4-8 years.Most common 4-8 years. Average – 6 years.Average – 6 years.  Bilateral in 10-12 %Bilateral in 10-12 %  Incidence more in Caucasians compared toIncidence more in Caucasians compared to Negroid, mongoloid, Polynesians.Negroid, mongoloid, Polynesians.  In India it is most prevalent in the west coastIn India it is most prevalent in the west coast especially in Udupi district.especially in Udupi district.
  14. 14. EtiologyEtiology The exact etiology of Legg Calve PerthesThe exact etiology of Legg Calve Perthes disease in not known but many factorsdisease in not known but many factors related to etiology of this disease haverelated to etiology of this disease have been mentioned.been mentioned.
  15. 15. EtiologyEtiology  Coagulation disorders.Coagulation disorders.  Arterial status of femoral head.Arterial status of femoral head.  Abnormal venous drainage.Abnormal venous drainage.  Abnormal growth and development.Abnormal growth and development.  Trauma.Trauma.  Hyperactivity or attention deficit disorder.Hyperactivity or attention deficit disorder.  Genetic component.Genetic component.  Environmental influences.Environmental influences.  As a sequel to synovitis.As a sequel to synovitis.
  16. 16. Coagulation disordersCoagulation disorders  Glueck et al showed that 75% of their series ofGlueck et al showed that 75% of their series of children with perthes disease had abnormalities ofchildren with perthes disease had abnormalities of coagulation (protein C or S deficiency, thrombophilia,coagulation (protein C or S deficiency, thrombophilia, increased lipoprotein a, hypofibrinolysis)increased lipoprotein a, hypofibrinolysis) -- JBJS Am Jan 1996-- JBJS Am Jan 1996  Valder Aruda et al reported factor 5 leiden mutationValder Aruda et al reported factor 5 leiden mutation in children with Perthesin children with Perthes -- Journal of paed orthopedics-- Journal of paed orthopedics Jan/feb 1999Jan/feb 1999
  17. 17. Coagulation disordersCoagulation disorders Kaeley et al found no causal relationshipKaeley et al found no causal relationship -JBJS Br July 2000-JBJS Br July 2000 Vinod Balasa, Charles Glueck et al foundVinod Balasa, Charles Glueck et al found causal relationship between Factor 5 Leidencausal relationship between Factor 5 Leiden mutation, Anticardiolipin antibodies in Perthesmutation, Anticardiolipin antibodies in Perthes disease.disease. --JBJS Am Dec 2004--JBJS Am Dec 2004 Mc Dougall also found no linkMc Dougall also found no link Clearly more studies are needed to resolveClearly more studies are needed to resolve this issue.this issue.
  18. 18. Arterial status of femoral headArterial status of femoral head  Angiographic studies have shown obstruction ofAngiographic studies have shown obstruction of superior capsular arteries and decreased flow insuperior capsular arteries and decreased flow in medial circumflex femoral arteries in Perthes disease.medial circumflex femoral arteries in Perthes disease.  The intracapsular ring has been found to beThe intracapsular ring has been found to be incomplete more often in males than females.incomplete more often in males than females.  In Negroid infants the major source of blood supply toIn Negroid infants the major source of blood supply to the femoral head is from the inferior gluteal arterythe femoral head is from the inferior gluteal artery which could be a reason why Perthes is uncommon inwhich could be a reason why Perthes is uncommon in negroid race.negroid race.
  19. 19. Abnormal venous drainageAbnormal venous drainage Venous drainage normally flows through theVenous drainage normally flows through the medial circumflex femoral vein.medial circumflex femoral vein. In patients with perthes ,there is increasedIn patients with perthes ,there is increased venous pressure in the femoral neck andvenous pressure in the femoral neck and associated congestion in the metaphysis, andassociated congestion in the metaphysis, and venous outflow obstruction has been found .venous outflow obstruction has been found . In a dog model obstruction of venous outflowIn a dog model obstruction of venous outflow has reproduced the features of AVN.has reproduced the features of AVN.
  20. 20. Abnormal growth and developmentAbnormal growth and development A delay in Bone age of 1.5 to 2 yearsA delay in Bone age of 1.5 to 2 years has been seen in children with pertheshas been seen in children with perthes disease.disease. Low birth weight has been seen inLow birth weight has been seen in patients with Perthes Disease.patients with Perthes Disease. Boys with Perthes have been found toBoys with Perthes have been found to be 1 inch shorter and girls 3 inchbe 1 inch shorter and girls 3 inch shorter than their peers.shorter than their peers. Some investigators have found lowSome investigators have found low levels of growth factor Somatomedin C.levels of growth factor Somatomedin C.
  21. 21. TraumaTrauma In the developing femur , the major lateralIn the developing femur , the major lateral epiphyseal artery must course through aepiphyseal artery must course through a narrow passage ,which could make itnarrow passage ,which could make it susceptible to disruption in case ofsusceptible to disruption in case of trauma.trauma.
  22. 22. Hyperactivity or attention deficitHyperactivity or attention deficit disorderdisorder A high prevalence of this disorder hasA high prevalence of this disorder has been seen in patients with Perthesbeen seen in patients with Perthes Disease.Disease. But Its precise role has not been defined.But Its precise role has not been defined.
  23. 23. Genetic componentGenetic component Familial association has been reported.Familial association has been reported. Burch et al have found a X-LinkedBurch et al have found a X-Linked recessive inheritance in a few cases.recessive inheritance in a few cases.
  24. 24. Environmental influencesEnvironmental influences Low socioeconomic status has been seenLow socioeconomic status has been seen to be associated with Perthes Disease.to be associated with Perthes Disease.
  25. 25. Sequel to synovitisSequel to synovitis Synovitis of the hip occurs early in LCPSynovitis of the hip occurs early in LCP A controversial school of thought says thatA controversial school of thought says that the increased pressure in synovitis maythe increased pressure in synovitis may cause a tamponade effect on thecause a tamponade effect on the vasculaturevasculature
  26. 26. Truetta’s HypothesisTruetta’s Hypothesis He postulated that the solitary bloodHe postulated that the solitary blood supply in the age group 4-8 yrs makessupply in the age group 4-8 yrs makes them suceptible to ischemia.them suceptible to ischemia. Compression of Lat epiphyseal arteries byCompression of Lat epiphyseal arteries by ext.rotators.ext.rotators.
  27. 27. Caffey’s HypothesisCaffey’s Hypothesis Intraepiphyseal compression of bloodIntraepiphyseal compression of blood supply to ossification centersupply to ossification center
  28. 28. PATHOGENESISPATHOGENESIS  LOSS OF BLOOD SUPPLY PRODUCESLOSS OF BLOOD SUPPLY PRODUCES AVN OF THE EPIPHYSEAL OSSCIFICATIONAVN OF THE EPIPHYSEAL OSSCIFICATION CENTRE FOLLOWED BY RESORPTION OFCENTRE FOLLOWED BY RESORPTION OF DEAD BONE AND REPLACEMENT WITHDEAD BONE AND REPLACEMENT WITH NEWLY FORMED IMMATURE BONE.NEWLY FORMED IMMATURE BONE.  THE PROCESS IS DESCRIBED IN STAGESTHE PROCESS IS DESCRIBED IN STAGES
  29. 29. ICIPIENT OR SYNOVITISICIPIENT OR SYNOVITIS STAGESTAGE LAST 1-3 WEEKS . SYNOVIUM ISLAST 1-3 WEEKS . SYNOVIUM IS SWOLLEN , HYPEREMIC ANDSWOLLEN , HYPEREMIC AND EDEMATOUS.EDEMATOUS. JOINT FLUIDJOINT FLUID IS INCREASED ANDIS INCREASED AND ABSENCE OFABSENCE OF IMFLAMMATORY CELLS.IMFLAMMATORY CELLS.
  30. 30. Increase joint space
  31. 31. STAGE OF AVNSTAGE OF AVN  AVN INVOLVES PORTION OF OSSIFIC NUCLEUSAVN INVOLVES PORTION OF OSSIFIC NUCLEUS SITUATED ANTERIORLY AMORPHOUSSITUATED ANTERIORLY AMORPHOUS DEBRIES FILLS THE MARROW SPACES. TRABACUALESDEBRIES FILLS THE MARROW SPACES. TRABACUALES ARE CRUSHED INTO MINUTE FRAGMENTS AND COMPRESSEDARE CRUSHED INTO MINUTE FRAGMENTS AND COMPRESSED INTO A COMPACT BONE ACCOUNTING FORINTO A COMPACT BONE ACCOUNTING FOR INCREASED DENSITY ON RADIOGRAPH.INCREASED DENSITY ON RADIOGRAPH.  THE INCREASED OPACITY IS CONTRASTEDTHE INCREASED OPACITY IS CONTRASTED MARKED DIMINIRALISATION OF ADJACENT METAPHYSISMARKED DIMINIRALISATION OF ADJACENT METAPHYSIS RESULT OF HYPERVASCULARITYRESULT OF HYPERVASCULARITY CONSTITUTES PREPARATION FOR INVASIONCONSTITUTES PREPARATION FOR INVASION VASCULAR CONNECTIVE TISSUE TOWQRDS NECROTIC BONE.VASCULAR CONNECTIVE TISSUE TOWQRDS NECROTIC BONE.  THE CARTILAGE IS VIABLE NUTRITION ISTHE CARTILAGE IS VIABLE NUTRITION IS DERIVED FROM SYNOVIAL FLUID.DERIVED FROM SYNOVIAL FLUID. STAGE LASTSTAGE LAST 6 MONTHS TO 1 YEAR.6 MONTHS TO 1 YEAR.
  32. 32. STAGE OFSTAGE OF FRAGMENTATION ORFRAGMENTATION OR REGENERATIONREGENERATION RADIOGRAPHIC FRAGMENTED APPEARANCERADIOGRAPHIC FRAGMENTED APPEARANCE RESULTS MANY TOUNGE LIKERESULTS MANY TOUNGE LIKE  SUBCHONDRAL FRACTURES OF NECROTICSUBCHONDRAL FRACTURES OF NECROTIC BONEBONE MULTIPLE MINUTEMULTIPLE MINUTE TRABECULAR FRAGMENTSTRABECULAR FRAGMENTS COMPRESSED TOGETHER. CARTILAGE REMAINSCOMPRESSED TOGETHER. CARTILAGE REMAINS NORMAL .NORMAL .  THE COUNTOR OF THE NEWLY FORMED SOFTTHE COUNTOR OF THE NEWLY FORMED SOFT BONE DEVELOPS IN RESPONSE TO THEBONE DEVELOPS IN RESPONSE TO THE EXTERNAL FORCES.EXTERNAL FORCES. STAGE EXTENTS OVERSTAGE EXTENTS OVER
  33. 33. HEALED OR RESIDUALHEALED OR RESIDUAL STAGESTAGE  FORMATION OF NORMAL BONE ALONGSIDEFORMATION OF NORMAL BONE ALONGSIDE REPLACING SLOWLY RESORBING BONE.REPLACING SLOWLY RESORBING BONE. NEWLY FORMED BONE IS IMMATURENEWLY FORMED BONE IS IMMATURE FORMED OF SLENDER TRABECULAE AND EASILYFORMED OF SLENDER TRABECULAE AND EASILY COMPRESSED TOGETHER WITH NECROTICCOMPRESSED TOGETHER WITH NECROTIC FRAGMENTSFRAGMENTS  THE COMPRESSION IS LIMITEDTHE COMPRESSION IS LIMITED ANTERIOR PORTION OF HEAD CREATING AANTERIOR PORTION OF HEAD CREATING A CUP SHAPED DEFECT SEEN ON FROGCUP SHAPED DEFECT SEEN ON FROG LEG VIEW THE OSSIFIC NUCELUSLEG VIEW THE OSSIFIC NUCELUS ASSUMES A MUSHROOM SHAPED COUNTOR.ASSUMES A MUSHROOM SHAPED COUNTOR.
  34. 34.  APPERANCE OF GREATERAPPERANCE OF GREATER TROCHANTERTROCHANTER:- IT BECOMES:- IT BECOMES STRIKINLY LARGE IN SOME CASES. SINCESTRIKINLY LARGE IN SOME CASES. SINCE LONGITUDINAL GROWTH OF THE FEMORALLONGITUDINAL GROWTH OF THE FEMORAL NECK MAY CEASE COMPLETELY AT 12 -14NECK MAY CEASE COMPLETELY AT 12 -14 YEARS OF AGE , WHEREAS GROWTH OF THEYEARS OF AGE , WHEREAS GROWTH OF THE GREATER TROCHANTER CONTINUES UNTILGREATER TROCHANTER CONTINUES UNTIL 17 -18 YEARS, A DISCERPANCY IN GROWTH17 -18 YEARS, A DISCERPANCY IN GROWTH NECK AND THE GREATER TROCHANTERNECK AND THE GREATER TROCHANTER MAY RESULT.THE ELEVATION IMPAIRS THEMAY RESULT.THE ELEVATION IMPAIRS THE POWER OF PELVITROCHANTERICPOWER OF PELVITROCHANTERIC ABDUCTER MUSCLES, MANIFESTED BYABDUCTER MUSCLES, MANIFESTED BY POSITIVE TRENDELBERG SIGN.POSITIVE TRENDELBERG SIGN.
  35. 35. Avascular necrosisAvascular necrosis Temporary cessation of growthTemporary cessation of growth Of epiphysisOf epiphysis PotentialPotential Revascularisation from periphery PerthesRevascularisation from periphery Perthes Resumption of ossificationResumption of ossification
  36. 36. Pathological fracturePathological fracture Resorption of underlying boneResorption of underlying bone Replacement by biologically TrueReplacement by biologically True Plastic bone PerthesPlastic bone Perthes SubluxationSubluxation DeformityDeformity
  37. 37. CLINICAL FEATURESCLINICAL FEATURES SYMPTOMSSYMPTOMS  MOST CHILDERN PRESENT WITH MILD ANDMOST CHILDERN PRESENT WITH MILD AND INTERMITTENT PAIN IN THE THIGH OR A LIMP ORINTERMITTENT PAIN IN THE THIGH OR A LIMP OR BOTH.BOTH.  THE ONSET OF PAIN MAY BE ACUTE OR INSIDIOUSTHE ONSET OF PAIN MAY BE ACUTE OR INSIDIOUS  THE CLASSICAL PRESENTATION IS DESCRIBED AS ATHE CLASSICAL PRESENTATION IS DESCRIBED AS A “PAINLES LIMP” THE CHILD LIMPS BUT DOES NOT“PAINLES LIMP” THE CHILD LIMPS BUT DOES NOT COMPLAINS OF DISCOMFORT.COMPLAINS OF DISCOMFORT.  PAIN IS AGRRAVATED BY MOVEMENT OF HIP ANDPAIN IS AGRRAVATED BY MOVEMENT OF HIP AND RELIVED BY REST.RELIVED BY REST.
  38. 38. EXAMINATION:-EXAMINATION:-  ANTALGIC GAITANTALGIC GAIT  MUSCLE SPASM SECONDARY TO IRRITABLE HIP.MUSCLE SPASM SECONDARY TO IRRITABLE HIP.  LIMITATION OF ABDUCTION AND INTERNALLIMITATION OF ABDUCTION AND INTERNAL ROTATIONROTATION  FFD IS PRESENTFFD IS PRESENT  AXIS DEVIATION IS PRESENT due to central collapseAXIS DEVIATION IS PRESENT due to central collapse  DIFFERENTIAL ROTATION .DIFFERENTIAL ROTATION .  TRENDELENBERG TEST POSITIVETRENDELENBERG TEST POSITIVE
  39. 39. InvestigationInvestigation X-Ray –AP & Frog leg Lat viewX-Ray –AP & Frog leg Lat view USGUSG ArthrographyArthrography Bone ScanBone Scan CTCT MRIMRI
  40. 40. RADIOGRAPHIC STAGESRADIOGRAPHIC STAGES FOUR WALDENSTROM STAGES:FOUR WALDENSTROM STAGES: 1) INITIAL STAGE1) INITIAL STAGE 2) FRAGMENTATION STAGE2) FRAGMENTATION STAGE 3) REOSSIFICATION STAGE3) REOSSIFICATION STAGE 4) HEALED STAGE4) HEALED STAGE
  41. 41. INITIAL STAGEINITIAL STAGE  EARLY RADIOGRAPHICEARLY RADIOGRAPHIC SIGNS:SIGNS:  FAILURE OF FEMORALFAILURE OF FEMORAL OSSIFICOSSIFIC NUCLEUS TO GROWNUCLEUS TO GROW  WIDENING OF MEDIALWIDENING OF MEDIAL JOINT SPACEJOINT SPACE  ““CRESCENT SIGN”CRESCENT SIGN”  IRREGULAR PHYSEALIRREGULAR PHYSEAL PLATEPLATE  BLURRY/ RADIOLUCENTBLURRY/ RADIOLUCENT METAPHYSISMETAPHYSIS
  42. 42. X-RayX-Ray  Cresent Sign orCresent Sign or Salters sign orSalters sign or Caffey’s signCaffey’s sign
  43. 43. FRAGMENTATION STAGEFRAGMENTATION STAGE BONY EPIPHYSISBONY EPIPHYSIS BEGINS TOBEGINS TO FRAGMENTFRAGMENT AREAS OFAREAS OF INCREASEDINCREASED LUCENCY ANDLUCENCY AND DENSITYDENSITY EVIDENCE OFEVIDENCE OF REPAIR ASPECTSREPAIR ASPECTS
  44. 44. X-RayX-Ray  Fragmentation ofFragmentation of epiphysisepiphysis
  45. 45. REOSSIFICATION STAGEREOSSIFICATION STAGE NORMAL BONENORMAL BONE DENSITY RETURNSDENSITY RETURNS ALTERATIONS INALTERATIONS IN SHAPE OF FEMORALSHAPE OF FEMORAL HEAD AND NECKHEAD AND NECK EVIDENTEVIDENT
  46. 46. X-RayX-Ray  MetaphysealMetaphyseal widening and cysticwidening and cystic changes in femoralchanges in femoral neckneck
  47. 47. X-RayX-Ray  Lateral extrusion ofLateral extrusion of femoral head andfemoral head and changes inchanges in acetabulum.acetabulum.
  48. 48. X-RayX-Ray  Sagging rope sign inSagging rope sign in adults with history ofadults with history of perthes – radio denseperthes – radio dense line overlyingline overlying proximal femoralproximal femoral metaphysis, a resultmetaphysis, a result of growth plateof growth plate damage withdamage with metaphysialmetaphysial response.response.
  49. 49. ArthrographyArthrography  Indicated to know the contour of headIndicated to know the contour of head and congruity of articular surfaceand congruity of articular surface Shows the configuration of the femoralShows the configuration of the femoral head and its relation with the acetabulum.head and its relation with the acetabulum. Provides reliable information regardingProvides reliable information regarding containment.containment. We can assess congruity of hip in manyWe can assess congruity of hip in many different positions.different positions. Not routinely used .Not routinely used .
  50. 50. Bone ScanBone Scan Indicated to diagnose in early stages andIndicated to diagnose in early stages and to classify the severity.to classify the severity. Diagnosis possible months before signsDiagnosis possible months before signs appear on X-Ray.appear on X-Ray. Avascular areas show cold spots.Avascular areas show cold spots. Revascularisation can be detected muchRevascularisation can be detected much before radiographic evidence.before radiographic evidence.
  51. 51. Bone ScanBone Scan  Convay et alConvay et al classificationclassification  Stage 1 is total lack ofStage 1 is total lack of uptakeuptake
  52. 52. Bone ScanBone Scan  Revascularisation atRevascularisation at lateral columnlateral column  Failure to revasculariseFailure to revascularise at lat column is a graveat lat column is a grave signsign  Also called “scintigraphicAlso called “scintigraphic head at risk sign”head at risk sign”  Precedes radiographicPrecedes radiographic head at risk sign by 2-3head at risk sign by 2-3 mthsmths
  53. 53. Bone ScanBone Scan  Gradual filling ofGradual filling of anterolateral partanterolateral part
  54. 54. Bone ScanBone Scan  Return to normalReturn to normal
  55. 55. MRIMRI Accurate in early diagnosis.Accurate in early diagnosis. Shows congruity, containment, synovialShows congruity, containment, synovial hypertrophy well.hypertrophy well. Subtraction MRI shows ischemia as wellSubtraction MRI shows ischemia as well as scintigraphy and also allows earlyas scintigraphy and also allows early recognition of reperfusion.recognition of reperfusion.
  56. 56. ClassificationClassification Waldenstroms classification.Waldenstroms classification. Catterall classification.Catterall classification. Salter classificationSalter classification Herrings lateral pillar classification.Herrings lateral pillar classification. Modified Elizabethtown classification.Modified Elizabethtown classification.
  57. 57. Waldenstroms classificationWaldenstroms classification 1.1. Incipient stage – 1-3 wksIncipient stage – 1-3 wks 2.2. Avascular stage – upto 1 yrAvascular stage – upto 1 yr 3.3. Regenerative stageRegenerative stage 4.4. Residual stageResidual stage Not scientifically valid.Not scientifically valid.
  58. 58. Catterall classification (1971)Catterall classification (1971) I – only anterior portion of epiphysisI – only anterior portion of epiphysis affected.affected. II – anterior segment involved centralII – anterior segment involved central sequestrum presentsequestrum present III – most of epiphysis sequestered withIII – most of epiphysis sequestered with unaffected portions located medialunaffected portions located medial and lateral to central segmentand lateral to central segment IV – all of epiphysis sequestered.IV – all of epiphysis sequestered.
  59. 59. Catterall described head at risk factors toCatterall described head at risk factors to predict prognosis:predict prognosis: 1- lat. subluxation of femoral head1- lat. subluxation of femoral head 3- Calcification lat. to epiphysis3- Calcification lat. to epiphysis 4- Horizontal physeal line4- Horizontal physeal line 5- gage sign5- gage sign 6- exetensive metaphyseal involvement6- exetensive metaphyseal involvement
  60. 60. Gage’s signGage’s sign  Rarefaction in theRarefaction in the lateral part of thelateral part of the epiphysis andepiphysis and subjacentsubjacent metaphysis.metaphysis.
  61. 61. Salter ClassificationSalter Classification Type A = I & II CatterallType A = I & II Catterall Type B = III & IV Catterall.Type B = III & IV Catterall.
  62. 62. Herring Lat PillarHerring Lat Pillar  Group-A hips are defined as those with noGroup-A hips are defined as those with no involvement of the lateral pillar, with no densityinvolvement of the lateral pillar, with no density changes and no loss of height of the lateral pillarchanges and no loss of height of the lateral pillar  Group-B hips have lucency in the lateral pillarGroup-B hips have lucency in the lateral pillar and may have some loss of height , but notand may have some loss of height , but not exceeding 50% of the original height.exceeding 50% of the original height.  Group-C hips are those with more lucency in theGroup-C hips are those with more lucency in the lateral pillar and >50% loss of heightlateral pillar and >50% loss of height
  63. 63. Lateral Pillar group ALateral Pillar group A
  64. 64. Lateral Pillar group BLateral Pillar group B
  65. 65. Lateral Pillar group CLateral Pillar group C
  66. 66. Modified ElizabethtownModified Elizabethtown classificationclassification  Stage Ia: Part orStage Ia: Part or whole of thewhole of the epiphysis isepiphysis is sclerotic. There issclerotic. There is no loss of height ofno loss of height of the epiphysis.the epiphysis.
  67. 67. Modified ElizabethtownModified Elizabethtown classificationclassification  Stage Ib: TheStage Ib: The epiphysis isepiphysis is sclerotic andsclerotic and there is loss ofthere is loss of epiphysealepiphyseal height. There isheight. There is no evidence ofno evidence of fragmentation offragmentation of the epiphysis.the epiphysis.
  68. 68. Modified ElizabethtownModified Elizabethtown classificationclassification  Stage IIa: TheStage IIa: The sclerotic epiphysissclerotic epiphysis has just begun tohas just begun to fragment. One orfragment. One or two vertical fissurestwo vertical fissures are seen in eitherare seen in either the AP or thethe AP or the lateral viewlateral view
  69. 69. Modified ElizabethtownModified Elizabethtown classificationclassification  Stage IIb:Stage IIb: Fragmentation isFragmentation is advanced. No newadvanced. No new bone is visiblebone is visible lateral to thelateral to the fragmentedfragmented epiphysis.epiphysis.
  70. 70. Modified ElizabethtownModified Elizabethtown classificationclassification  Stage IIIa: EarlyStage IIIa: Early new bonenew bone formation is visibleformation is visible on the periphery ofon the periphery of the necroticthe necrotic epiphysis andepiphysis and covers less than acovers less than a third of the width ofthird of the width of the epiphysisthe epiphysis
  71. 71. Modified ElizabethtownModified Elizabethtown classificationclassification  Stage IIIb: TheStage IIIb: The new bone is ofnew bone is of normal texturenormal texture and has grownand has grown over a third of theover a third of the width of thewidth of the epiphysis.epiphysis.
  72. 72. Modified ElizabethtownModified Elizabethtown classificationclassification Stage IV the healing is complete and there isStage IV the healing is complete and there is no radiologically identifiable avascular bone.no radiologically identifiable avascular bone.
  73. 73. Prognostic FactorsPrognostic Factors 1.1. Age at diagnosisAge at diagnosis 2.2. Extent of involvementExtent of involvement 3.3. SexSex 4.4. Catterall “head at risk” clinical signsCatterall “head at risk” clinical signs  ClinicalClinical 1.1. Progressive loss of hip motionProgressive loss of hip motion 2.2. Increasing abduction contractureIncreasing abduction contracture 3.3. Obese childObese child
  74. 74. Classification of PrognosisClassification of Prognosis Uniplanar methodsUniplanar methods - CE angle of Weiberg.- CE angle of Weiberg. - Salters extrusion Index.- Salters extrusion Index. - Epiphyseal index.- Epiphyseal index. - Epiphyseal quotient.- Epiphyseal quotient. Biplanar methodsBiplanar methods - Stulberg classification.- Stulberg classification.
  75. 75. CE angle of WeibergCE angle of Weiberg  Indicator of acetabular depth It isIndicator of acetabular depth It is the angle formed by athe angle formed by a perpendicular lines through theperpendicular lines through the midportion of the femoral headmidportion of the femoral head and a line from the femoral headand a line from the femoral head center to the upper outercenter to the upper outer acetabular margin.acetabular margin.  Normal = 20 to 40 degrees, withNormal = 20 to 40 degrees, with an average of 36 degrees.an average of 36 degrees.  This angle may be slightly largerThis angle may be slightly larger in women and in older persons.in women and in older persons.  Angle >25 = good, 20-25= fair, <Angle >25 = good, 20-25= fair, < 20 = poor20 = poor
  76. 76. Salters extrusion IndexSalters extrusion Index  If AB is moreIf AB is more than 20% of CDthan 20% of CD it indicates ait indicates a poor prognosispoor prognosis
  77. 77. Epiphyseal index & quotientEpiphyseal index & quotient Epiphyseal index = greatest height of theEpiphyseal index = greatest height of the epiphysis divided by its width.epiphysis divided by its width. Epiphyseal quotient = Epiphyseal index ofEpiphyseal quotient = Epiphyseal index of involved hip divided by the index forinvolved hip divided by the index for uninvolved hip.uninvolved hip. >0.6 = good>0.6 = good 0.4-0.6 = fair0.4-0.6 = fair <0.4 = poor<0.4 = poor
  78. 78. Stulberg classificatonStulberg classificaton  Class I – Shape of the femoral head wasClass I – Shape of the femoral head was basically normal.basically normal.  Class II – Loss of head height but within 2 mmClass II – Loss of head height but within 2 mm to a concentric circle on AP and frogto a concentric circle on AP and frog leg X-Rayleg X-Ray  Class III – Deviates more than 2 mm andClass III – Deviates more than 2 mm and acetabulum contour matchesacetabulum contour matches the head contourthe head contour  Class IV – Head Flattened, Flattened areaClass IV – Head Flattened, Flattened area <1cm. Acetabulum contour matches<1cm. Acetabulum contour matches the head contourthe head contour  Class V – Collapse of femoral head, AcetabularClass V – Collapse of femoral head, Acetabular
  79. 79. Stulberg classificatonStulberg classificaton  Class IClass I Shape ofShape of the femoralthe femoral head ishead is basicallybasically normal.normal.
  80. 80. Stulberg classificatonStulberg classificaton  Class IIClass II Loss ofLoss of headhead height butheight but within 2within 2 mmmm
  81. 81. Stulberg classificatonStulberg classificaton  Class IIIClass III DeviatesDeviates more thanmore than 2 mm2 mm
  82. 82. Stulberg classificatonStulberg classificaton  Class IVClass IV HeadHead FlattenedFlattened
  83. 83. Stulberg classificatonStulberg classificaton  Class VClass V Collapse ofCollapse of femoralfemoral head,head, AcetabularAcetabular contourcontour does notdoes not change andchange and not matchenot matche
  84. 84. Differential diagnosisDifferential diagnosis Tuberculosis of the hipTuberculosis of the hip SCFESCFE Transient synovitisTransient synovitis SpondylodysplasiaSpondylodysplasia AVN due to leukemia, lymphoma,AVN due to leukemia, lymphoma, gauchers disease, Hemoglobinopathiesgauchers disease, Hemoglobinopathies etcetc
  85. 85. TreatmentTreatment ObjectivesObjectives - To produce a normal femoral- To produce a normal femoral head and neckhead and neck - To produce a normal acetabulum- To produce a normal acetabulum - A congruous hip which is fully- A congruous hip which is fully mobilemobile - To prevent degenerative arthritis- To prevent degenerative arthritis of the hip later in lifeof the hip later in life
  86. 86. TreatmentTreatment GOAL :GOAL : Treatment efforts are directed towardsTreatment efforts are directed towards - Restoration and maintenance of- Restoration and maintenance of full mobility of the hipfull mobility of the hip - Containment of the femoral- Containment of the femoral head.head. - Resumption of weight bearing- Resumption of weight bearing and full activity as soon asand full activity as soon as possiblepossible
  87. 87. TreatmentTreatment  Caterall group 1 andCaterall group 1 and group 2 ( < 7 years)group 2 ( < 7 years) No activeNo active  Herring group 1 &Herring group 1 & TreatmentTreatment group 2 (< 6 years)group 2 (< 6 years)
  88. 88. TreatmentTreatment Treatment is divided into 3 phasesTreatment is divided into 3 phases Initial Phase – restore & maintain mobilityInitial Phase – restore & maintain mobility Active Phase – Containment andActive Phase – Containment and maintainance of full mobility.maintainance of full mobility. Reconstructive phase – correct residualReconstructive phase – correct residual deformities.deformities.
  89. 89. Treatment ( Initial Phase )Treatment ( Initial Phase ) Physiotherapy – active and passivePhysiotherapy – active and passive range of motionrange of motion exercises to restoreexercises to restore motionmotion Traction – B/L skin traction andTraction – B/L skin traction and gradually abducting over 1-2gradually abducting over 1-2 weeks till full abduction isweeks till full abduction is regained.regained.
  90. 90. Treatment ( Active Phase )Treatment ( Active Phase ) Consists of containment of the femoralConsists of containment of the femoral head within the acetabulum. This can behead within the acetabulum. This can be achieved byachieved by orthosisorthosis or byor by surgerysurgery
  91. 91. Treatment (Orthosis)Treatment (Orthosis)  Non Ambulatory weight releivingNon Ambulatory weight releiving 1.1. Abduction broomstick plaster castAbduction broomstick plaster cast 2.2. Hip spica castHip spica cast 3.3. Milgram hip abduction orthosisMilgram hip abduction orthosis  Ambulatory Both limbs includedAmbulatory Both limbs included 1.1. Petrie Abduction castPetrie Abduction cast 2.2. Toronto orthosisToronto orthosis 3.3. Newington orthosisNewington orthosis 4.4. Birmingham braceBirmingham brace 5.5. Atlanta Scotish Rite BraceAtlanta Scotish Rite Brace  Ambulatory unilateralAmbulatory unilateral 1.1. Tachdjian trilateral socket orthosisTachdjian trilateral socket orthosis
  92. 92. Treatment (Orthosis)Treatment (Orthosis)  Atlanta Scotish RiteAtlanta Scotish Rite BraceBrace
  93. 93. Atlanta Scotish Rite BraceAtlanta Scotish Rite Brace
  94. 94. Newington orthosisNewington orthosis
  95. 95. Birmingham braceBirmingham brace
  96. 96.  Toronto BraceToronto Brace
  97. 97.  Tachdjian trilateralTachdjian trilateral socket orthosissocket orthosis
  98. 98. Treatment (Orthosis)Treatment (Orthosis)  Orthotic treatment is discontinued when theOrthotic treatment is discontinued when the disease enters the reparative phase and healingdisease enters the reparative phase and healing is established.is established.  The radiographic evidence of healing areThe radiographic evidence of healing are 1.1. Appearance of regular ossification in theAppearance of regular ossification in the femoral head.femoral head. 2.2. Increased density of femoral head shouldIncreased density of femoral head should disappear.disappear. 3.3. Metaphyseal rarefaction involving the lateralMetaphyseal rarefaction involving the lateral cortex of the metaphysis should ossify.cortex of the metaphysis should ossify. 4.4. There should be intact lateral column.There should be intact lateral column. 5.5. There should be normal trabecular bone in theThere should be normal trabecular bone in the epiphysis.epiphysis.
  99. 99. Treatment ( Surgical)Treatment ( Surgical) Femoral varus osteotomy.Femoral varus osteotomy. Inominate osteotomy.Inominate osteotomy. Combined femoral and inominateCombined femoral and inominate osteotomyosteotomy Valgus osteotomyValgus osteotomy Shelf arthroplastyShelf arthroplasty Chiari osteotomyChiari osteotomy Cheilectomy.Cheilectomy. Trochanteric advancement or arrest.Trochanteric advancement or arrest.
  100. 100. Femoral varus osteotomyFemoral varus osteotomy IndicationsIndications: 1.>6yrs of age: 1.>6yrs of age 2.hip with normal or near normal2.hip with normal or near normal hiphip ComplicationsComplications:1.excessive post op varus:1.excessive post op varus 2.Persistant ext.rotation2.Persistant ext.rotation 3.Shortening of extremity3.Shortening of extremity 4.Incresed abductor lurch4.Incresed abductor lurch 5.Trochanteric over growth5.Trochanteric over growth 6.Delayed or non union6.Delayed or non union
  101. 101. Femoral varus osteotomyFemoral varus osteotomy
  102. 102. Femoral varus osteotomyFemoral varus osteotomy
  103. 103. Femoral varus osteotomyFemoral varus osteotomy  Varus should not beVarus should not be exced less than 110*exced less than 110*
  104. 104. Femoral varus osteotomyFemoral varus osteotomy
  105. 105. Femoral varus osteotomyFemoral varus osteotomy
  106. 106. Femoral varus osteotomyFemoral varus osteotomy
  107. 107. Inominate osteotomyInominate osteotomy  IndicationsIndications:: 1.>6 yrs1.>6 yrs 2.mod. Or severely affected head with loss of2.mod. Or severely affected head with loss of containmentcontainment RequirementRequirement:: Able to abduct 45 deg. And femoral head to beAble to abduct 45 deg. And femoral head to be contained in positioncontained in position ComplicationsComplications :loss of fixation, leg-lengthening ,dec. hip:loss of fixation, leg-lengthening ,dec. hip flx. And jt.stiffness, second procedure for k wireflx. And jt.stiffness, second procedure for k wire remavalremaval
  108. 108. Valgus OsteotomyValgus Osteotomy  Indication:hingedIndication:hinged abduction of hipabduction of hip
  109. 109. Shelf ArthroplastyShelf Arthroplasty Performed to enlarge the volume ofPerformed to enlarge the volume of acetabulum.acetabulum. Indication:A deficient acetabulum cannotIndication:A deficient acetabulum cannot be corrected by pelvic osteotomybe corrected by pelvic osteotomy Contra indication: Dysplastic hip withContra indication: Dysplastic hip with spherical congruityspherical congruity
  110. 110. Shelf ArthroplastyShelf Arthroplasty
  111. 111. Chiari osteotomyChiari osteotomy  Capsular interpositionalCapsular interpositional arthroplastyarthroplasty  Deepens the deficientDeepens the deficient acetabulum by medialacetabulum by medial displacement of distaldisplacement of distal pelvic fragment andpelvic fragment and improves sup.lat.femoralimproves sup.lat.femoral coverage.coverage.
  112. 112. Trochanteric advancementTrochanteric advancement  IndicationsIndications:: - Trochanteric over- Trochanteric over growthgrowth - Capital femoral- Capital femoral physeal growth arrestphyseal growth arrest
  113. 113. Recommended Indications for diff.Recommended Indications for diff. surgeriessurgeries Hinged abduction - valgus subtrochantericHinged abduction - valgus subtrochanteric osteotomyosteotomy Severly Mal formed femoral head –Severly Mal formed femoral head – cheilectomycheilectomy Coxa magna – shelf augmentationCoxa magna – shelf augmentation A large malformed femoral head withA large malformed femoral head with lat.subluxation – Chiari’s pelvic osteotomylat.subluxation – Chiari’s pelvic osteotomy Capital femoral physeal arrest –Capital femoral physeal arrest – Trochanteric advancementTrochanteric advancement
  114. 114. Recent AdvancesRecent Advances AnticoagulantAnticoagulant Botulinum toxinBotulinum toxin  Ibadronate :this has shown thereIbadronate :this has shown there importance in rat model by increaseimportance in rat model by increase spericity of femoral headspericity of femoral head Still lot more work to do in this fieldsStill lot more work to do in this fields
  115. 115. ReferencesReferences Campbell’s operative Orthopaedics – 10Campbell’s operative Orthopaedics – 10thth editionedition Tachdjian’s paediatric orthopaedics – 3Tachdjian’s paediatric orthopaedics – 3rdrd editionedition Mercer’s Orthopaedic surgery – 9Mercer’s Orthopaedic surgery – 9thth editionedition Journals of bone and joint surgeryJournals of bone and joint surgery InternetInternet
  116. 116. Thank you for your patient listening

×