Legg calvé-perthes disease

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Legg calvé-perthes disease

  1. 1.  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.
  2. 2.  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.
  3. 3.  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.
  4. 4.  True form (subchondral #) :- trauma and vigorous. Characteristic clinical and radiographic features.
  5. 5.  Genetic aspect.  Abnormal growth and development.  Poor socio economic class  80% are males  Trauma.
  6. 6.  Capital femoral epiphysis  Epiphyseal growth plate  Metaphysis :- adipose tissue,osteolytic lesions,disorganised ossification and extrusion of growth plate.
  7. 7.  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.
  8. 8.  4-8yr old boys.  If older than 12-not true perthes.
  9. 9.  Painless limp  Mild pain in the hip or anterior thigh or knee.  h/o trauma.  Pain may be a/c or c/c.
  10. 10.  Antalgic gait.  Muscle spasm.  Proximal thigh atrophy.  Limitation of abduction and internal rotation.  Short stature.
  11. 11.  Internal rotation test.  Trendelenberg test.  Abduction test.  Roll test.  Thomas test-15 degree flexion deformity.
  12. 12.  Cessation of growth of the capital femoral epiphysis.  Subchondral #.  Resorption  Re-ossification.
  13. 13.  Group I  Antero-medial portion of the head and no collapse.  Epiphyseal plate not involved.  No metaphyseal change  Heals without significant sequelae.
  14. 14.  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.
  15. 15.  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.
  16. 16.  Group IV  Severe collapse  Extensive metaphyseal changes  Epihyseal plate often involved – abnormal growth occurs - coxa magna, coxa vara or coxa valga may occur.
  17. 17.  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.
  18. 18.  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%.
  19. 19. 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.
  20. 20.  Arthrography – early resorption stage of the disease.  Radionuclide bone scan-potential form of perthes’.  MRI-epiphyseal infarction and femoral head contour.
  21. 21.  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.
  22. 22. Group Type (Catterall) 1 2 3 4 I AB AB AB AB II - AB/OS AB/OS OS III - AB AB/OS AB/OS /PC IV - - - PC
  23. 23.  Abduction cast.  Abduction brace.  Salter stirrup crutch.
  24. 24.  Innominate osteotomy  Femoral Varus Osteotomy
  25. 25.  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.
  26. 26.  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
  27. 27.  Immobilization 10-12 weeks in spica cast  Range of motion exercises and full weight bearing ambulation are then started.
  28. 28.  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.
  29. 29.  Double spica is applied and removed after 6- 8weeks.
  30. 30.  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.
  31. 31.  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.
  32. 32.  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.
  33. 33. 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.
  34. 34.  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.
  35. 35. THANK YOU

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