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Legg calvé-perthes disease
1.
2. Degenerative disease of the hip joint
growth/loss of bone mass some degree of
collapse of the hip joint and deformity of the
head of the femur and acetabulum.
3. Typically found in young children, may lead
to OA in adults.
Syn: Ischemic necrosis of the hip, coxa plana,
osteochondritis and avascular necrosis of the
femoral head, Legg–Perthes Disease.
4. Idiopathic capital femoral epiphyseal
ischaemia temporary cessation of
epiphyseal growth epiphyseal
revascularization occurs from periphery
resumption of growth.
Potential form (no subchondral #).:- no
epiphyseal resorption, no subluxation, no
deformity, asymptomatic, good range of hip
movements, x-ray shows head within head
appearance.
5. True form (subchondral #) :- trauma and
vigorous. Characteristic clinical and
radiographic features.
6. Genetic aspect.
Abnormal growth and development.
Poor socio economic class
80% are males
Trauma.
7. Capital femoral epiphysis
Epiphyseal growth plate
Metaphysis :- adipose tissue,osteolytic
lesions,disorganised ossification and
extrusion of growth plate.
8. Altered longitudinal growth of proximal
femur.
Coxa vara and coxa magna.
High greater trochanter and short femoral
neck results in functional coxa vara.
Shortening by 1-2cm
Trendelenberg gait.
9. 4-8yr old boys.
If older than 12-not true perthes.
10. Painless limp
Mild pain in the hip or anterior thigh or knee.
h/o trauma.
Pain may be a/c or c/c.
11. Antalgic gait.
Muscle spasm.
Proximal thigh atrophy.
Limitation of abduction and internal rotation.
Short stature.
12. Internal rotation test.
Trendelenberg test.
Abduction test.
Roll test.
Thomas test-15 degree flexion deformity.
13. Cessation of growth of the capital femoral
epiphysis.
Subchondral #.
Resorption
Re-ossification.
14.
15. Group I
Antero-medial portion of the head and no
collapse.
Epiphyseal plate not involved.
No metaphyseal change
Heals without significant sequelae.
16. Group II
More head involved and fragmentation of the
involved segment.
The involved segment show increased
density, but the uninvolved pillar of the
normal bone prevent its significant collapse.
The metaphyseal reaction is localized.
Regeneration occurs without much loss of the
height and the result is usually good.
17. Group III
More of the head involvement, collapse
occurs as the un-involved pillars are not large
enough to prevent collapse.
May show head-with-in head appearance
(Crescent sign).
Metaphyseal involvement is usually
widespread
Result is poorer.
18. Group IV
Severe collapse
Extensive metaphyseal changes
Epihyseal plate often involved – abnormal
growth occurs - coxa magna, coxa vara or
coxa valga may occur.
19. Group A (Catterall Gr I and Gr II) :- < half of
the capital femoral epiphysis is involved.
Group B (Catterall Gr III and Gr IV):- > half of
the capital femoral epiphysis involved.
20. A.- No collapse of lateral pillar
B.- Lateral pillar margin - more than 50% of
original height is maintained
C.- Laterall pillar - collapse of more than
50%.
21. 1. Lateral subluxation of head from
acetabulum
2. Speckeled calcification lateral to the capital
epiphysis
3. Diffuse metaphyseal reaction (Met cysts)
4. Horizontal growth plate
5. Gage’s sign – radiolucent V shaped defect in
the lateral epiphysis and adjacent
metaphysis.
22.
23. Arthrography – early resorption stage of the
disease.
Radionuclide bone scan-potential form of
perthes’.
MRI-epiphyseal infarction and femoral head
contour.
24. Primary aim Containment of femoral head
within the acetabulum.
If this is achieved, femoral head can reform
(Biological plasticity- Salter)
Prognosis cannot be estd: accurately all
children with total head involvement must be
Rx actively.
Colter recommended that surgery be reserved
for children of age > 6 yrs with at least 2
head at risk signs except those who refuse to
wear casts due to psycho-social reasons.
29. Advantages
Anterolateral coverage of
femoral head
Lengthening of extremity
(possibly shortened by
avascular process)
Avoidance of second
operation for plate
removal
Disadvantages
Possibility of inability to
attain proper
containment of femoral
head
Increase in acetabular
and hip joint pressure
resulting in further
avascular changes in the
femoral head
Increase in limb length
on operated side which
may lead to relative
adduction of the hip and
femoral head uncovering.
30. Saw cut made horizontally and anteriorly
through illeum as close as possible to the
capsular attachment of the acetabulum.
Graft placed on osteotomy site; stabilise with
threaded pins
31.
32. Immobilization 10-12 weeks in spica cast
Range of motion exercises and full weight
bearing ambulation are then started.
33. Advantages
Ability to obtain
maximum coverage of
femoral head
Ability to correct
excessive femoral
anteversion at the same
osteotomy
Disadvantages
Excessive varus
angulation which may
not correct with growth
Further shortening of
already shortened limb
Possibility of gluteal
lurch due to decrease in
length of the lever arm of
gluteal musculature
Possibility of non union
of the osteotomy
Requirement of a second
operation to remove the
internal fixation.
35. Containment of the femoral head cannot be
achieved for psychosocial reasons
Child is from 8-10yrs old
Without leg length inequality,
On arthrogram a majority of the femoral head
is uncovered
Significant amount of femoral anteversion.
36.
37. Cheilectomy- head is mushroom shaped,hip
is painful and lack of abduction or clicking
sensation on abduction.
Chiari osteotomy- head is mushroom shaped
as in coxa plana and subluxating from the
acetabulum,hip is painful.
Greater trochanter advancement.
38. Malformed femoral head in late groupIII or
residual group IV for which cheilectomy may
be used.
A large malformed femoral head with
subluxation laterally for which chiari’s
osteotomy considered.
Capital femoral growth plate arrest for which
trochanteric advancement may be performed.
39. 1. Coxa Magna
2. Hanging rope sign. - indicative of severe
epiphyseal disturbance, seen on x-ray as line
present in neck droping down distally.
3. Coxa Brevis: Short neck with overgrowth of the
trochanter as a result of premature physeal
arrest.
4. Coxa irregularis : collapse and lateral extrusion
of the femoral head, forming a groove under the
lateral edge of the acetabulum.
5. Osteochondritis dessicans.
40. Female sex
Age of clinical onset >6yrs.
Catterall grp III and IV.
Loss of femoral head containment.
Persistant loss of motion.
Premature epiphyseal growth plate closure.
