This document discusses Legg-Calvé-Perthes disease (LCPD), a condition where the blood supply to the femoral head is disrupted, causing bone cell death. As the necrotic bone breaks down and is reabsorbed, the femoral head can become misshapen. The summary is: LCPD involves avascular necrosis of the femoral head, leading to bone resorption and potential deformity. Treatment aims to contain the femoral head within the acetabulum during healing to restore its shape, and may include bracing, osteotomies or arthrodiastasis. Surgical options depend on the stage, extent of involvement and deformity present.

1. PERTHE’S DISEASE
Dr.HARSHA NANDINI TALASILA

2. Legg-Calvé-Perthes disease (LCPD) is a condition in
which the blood supply of the capital femoral
epiphysis (head) is disrupted, resulting in
epiphyseal osteonecrosis and chondronecrosis with
cessation of growth of the ossific nucleus.

3. The necrotic epiphyseal bone is eventually
resorbed and replaced by new bone.
During the resorptive phase of the healing, the
mechanical properties of the femoral head are
weakened such that some femoral heads develop a
flattened deformity (coxa plana).
Over time, the femoral head reossifies,resumes
growth with some overgrowing (coxa magna),and
remodels to a variable degree of roundness until
skeletal maturity.

4. SYNONYMS
• Osteochondritis deformans juvenalis
• Coxa plana

5. • AGE GROUP : 4–10years
• Male : female – 4:1
• Unilateral more common than bilateral
• Bilateral incidence is 12-16%

6. BLOOD SUPPLY TO THE FEMOR
HEAD
LESS THAN 4years:
• Metaphyseal artery
• Retinacular artery
4 to 8 years:
• Retinacular arteries
MORE THAN 8years:
• Retinacular arteries
• Foveal artery

7. Adolescence:
• Retinacular arteries
• Foveal arteries
• Metaphyseal arteries

8. 1. Vascular supply:
- Angiograms and laser studies have shown
medial circumflex artery is missing or obliterated
and obturator artery or the lateral epiphyseal
artery also affected.
2. Increased intra-articular pressure
3. Intraosseous pressure
- Patients has shown that the venous drainage in
the femoral head is impaired, causing an
increase in intraosseous pressure.

9. 4. Coagulation disorder
- Associated with deficiency of factor C or S.
- They normally inhibit coagulation.
5. Social conditions
-Usually belong to lower socioeconomic status,
reflects dietary and environmental factors.
6. Trauma

10. 8.Abnormal growth and development
- Usually shorter than their peers.
- Indicates retarded skeletal growth
9. Genetic factors
-First degree relatives have 35times more risk

11. CLINICAL FEATURES
• Mild to moderate hip pain radiating to the medial
aspect of thigh and knee.
• Limp is often painless.
• Muscle spasm evident and restricted hip motion,
especially in abduction.

12. PATHOGENESIS
1. INCIPIENT STAGE OR SYNOVITIS STAGE:
• Synovium is hyperaemic.
2. STAGE OF AVASCULAR NECROSIS:
• Dead trabecular bone
• Collapsed trabeculae
• Thickened articular cartilage
• Physeal disruption
• Cartilage extending from the physis into the
metaphysis

13. 3. FRAGMENTATION STAGE:
• Invasion of vascular granulation tissue.
• New bone forming on old trabeculae.
• Woven new bone formation.

14. 4. HEALING STAGE:
• Normal forming bone alongside replacing slowly
resorbing bone.
• Return to normal architecture.

15. WALDENSTORM STAGING OF
PERTHE’S DISEASE
1. AVASCULAR NECROSIS:
• Widened joint space
• Femor head is denser than normal and slightly
flattened
• Lateralization of femor head.
2. STAGE OF RESORPTION :
• Femor head breaks into fragments
• Lucent areas in the femor head
• Increased density resolves
• Acetabular contour is more irregular

16. 3. STAGE OF REOSSIFICATION:
• New bone formation occurs in the femor head.
4. HEALING STAGE:
• Heals with or without defect.
• Defects like coxa magna,coxa plana

17. METAPHYSEAL CHANGES
• An overabundance of fatty marrow
• Circumscribed osteolytic lesions with a
sclerotic border,
• A wide growth plate with disarrayed
ossification and columns of unossified
cartilage coursing down into the
metaphysis.

18. CLASSIFICATIONS

19. SALTER THOMPSON
CLASSIFICATION
• TYPE A: extent of the
subchondral fracture
line is less than 50 % of
the superior dome of
the femor head.
• TYPE B: extent of the
subchondral fracture
line is more than 50 %
of the superior dome of
the femor head.

20. HERRING LATERAL PILLAR
CLASSIFICATION
• GROUP A: no involvement of the pillar
• GROUP B: 50% of the pillar is maintained
• GROUP C: less than 50% of the pillar is maintained

21. CATERRAL’S CLASSIFICATION
• GROUP 1: anterior part of the head is involved
• GROUP 2: anterior and partial lateral part
involved,sequestrum and mild metaphyseal
changes
• GROUP 3:Anterior and lateral head
involved,sequestrum,diffuse metaphyseal
changes,coxa magna
• GROUP 4:complete head involvement and collapse
of the head

22. STULBERG’S CLASSIFICATION
• GRADE 1: round head,normal hip
• GRADE 2: round head,coxa magna
• GRADE 3: oval,mushroom shaped head,coxa magna
• GRADE 4: flat head,congruent with acetabulum
• GRADE 5: flat head,incongruent

23. CATERALL’S HEAD AT RISK SIGNS
1. Lateral subluxation of the femoral head from
acetabulum.
2. Speckled calcification lateral to the capital
epiphysis.
3. Diffuse metaphyseal reactions or metaphyseal
cysts.
4. Horizontal physes
5. Gage sign: a radioluscent v shaped defect in the
lateral epiphyses and adjacent metaphyses.

24. • GAGE SIGN:radiolucent
V shaped defect in the
lateral epiphysis and
adjacent metaphysis.

25. DIFFERENTIAL DIAGNOSIS
• AVASCULAR NECROSIS:
Sickle cell syndrome
Thalassemia
Down syndrome
Achondroplasia
Steroid medication
• EPIPHYSEAL DYSPLASIA

26. Comparison chart
PERTHES DISEASE EPIPHYSEAL DYSPLASIA
Unilateral Bilateral involvement
If B/L, marked asymmetry, disease
in differing stages and severity
Symmetrical findings
No involvement of other joints Involvement of other joints or
spine.
Sclerotic and cystic changes in
femoral head and cystic changes in
metaphysis
Few sclerotic changes in femoral
head.
More tendency towards lateral
calcification and subluxation
Little tendency.

27. INVESTIGATIONS
• X rays
• MRI to delineate the extent of head involvement
• ARTHROGRAPHY: whether containment is possible

28. MANAGEMENT

29. GOALS OF TREATMENT
1. Elimination of hip irritability
2. Restoration and maintenance of good range of hip
motion.
3. Prevention of epiphyseal extrusion and
subluxation.( containment).
4. Attainment of spherical femoral head on healing.

30. OBSERVATION
 Onset <6yrs of age, regardless of extent of capital
femoral epiphyseal involvement.
 Age<6yrs of age: Catterall’s group 1 and 2 or
herring group A
 They should have clinical and radiographic
examination at frequent intervals( 3 months).
 If unsuccessful, may necessaite a short course (2-
6 months) of non surgical treatment.

31. SYMPTOMATIC TREATMENT
• BED REST
• SKIN TRACTION
• NSAIDS
• ABDUCTION BRACING

32. DEFINITIVE TREATMENT
• Age at clinical onset 6yrs or older.
• Catterall Group 3 or 4/ Salter thomson Group
B.
• When loss of containment manifested by
extrusion seen on AP view.

33. Containment of femoral head
• Placing the femoral head into the acetabulum as fully as
possible so that it retains its Sphericity during period of
remodelling, healing.
• It can be
-non surgical
-surgical containment

34. Non surgical containment by orthotics
• Put affected Hip in Abduction
• Some allow Flexion and control rotation of limb
• It can be by casts or braces
• Before starting Containment it is important to restore normal
range of hip motion by Bedrest , Traction ,reduced weight
bearing.
• Throughout the bracing period hip range of motion must be
preserved.

35. Petrie casts
• Hips were abducted to 45 degrees and 5-10 degrees internally
rotated and casting done with bars inbetween.
• Casts changed every 3-4 months and adductor tenotomy done
when required.

36. Toronto brace
• Heavy and complicated brace which
keeps hip in abduction while allowing
hip and knee flexion

37. Atlanta scottish rite brace
• Commonly used today
• Consists of metallic pelvic band,thigh
cuffs,hip hinges and bar between thigh
cuffs

38. Femoral osteotomy: VARUS
DEROTATIONAL OSTEOTOMY
Indications :
-Age of onset > 6 yrs
-Hips with “at risk” signs even if head is not severely deformed
Pre requisites
-Good to full range of hip motion
-Minimally deformed head
-Usually done in Early and Fragmentation stages
Contraindications:
-Significant flattening with no containment in abduction and
internal rotation

39. Level of osteotomy
Insertion of guide pin and reaming
of femur
First depth marking flush with lateral
cortex
Removal of wedge to customize it

40. Plate and compression screw
application
Insertion of bone screws.

41. Complications
-Excessive varus
-Shortening of limb
-Delayed / Nonunion

42. Salter’s osteotomy
Indications
-Age > 6 yrs
-Moderate - Severe femoral head involvement
Contra indication
-Pre existing femoral head deformity

43. Complications :
Loss of fixation
Lengthening of limb
Joint stiffness

44. Arthrodiastasis
• DISTRACTION OF THE JOINT:
widens joint space.
reduces the pressure on the femoral head
allows fibrous repair of articular cartilage defects
preserves congruency of the femoral head.

45. 1.HINGED ABDUCTION:
Valgus subtrochanteric osteotomy
2.Malformed femoral head
Cheilectomy
3.Coxa magna
shelf augmentation would provide coverage
4.Large malformed femoral head with subluxation laterally
pelvic osteotomy
5.Capital femoral physeal arrest with trochanteric overgrowth
trochanteric advancement
Indications for reconstructive surgery

46. Valgus osteotomy
• For treating hinged abduction in which flattened head
interferes with abduction

47. Shelf arthroplasty
Indications
• Lateral subluxation of head
• Hinge abduction of hip
Complications
• Loss of hip flexion

48. Chiari osteotomy
• Reserved for healing femoral head that remains lateralised
• An osteotomy of the pelvis is performed at the superior
margin of the acetabulum.
• Pelvis inferior to the osteotomy along with the femur is
displaced medially.
• The superior fragment becomes a shelf, and the capsule is
interposed between it and the femoral head.

49. Cheilectomy
• Surgically removal of protruding femoral head fragments
• Done after closure of capital physis
• Procedure weakens attatchment of femoral head to neck
resulting in slipped epiphysis.
For malformed head
-Mushroom head
-Complete flattened head
-Lateral subluxated head

50. TROCHANTRIC OVERGROWTH
-Elevation of trochanter decreases tension
and mechanical efficiency of pelvic and
trochantric muscles.
-Shortened femoral neck moves trochanter
closer to centre of rotation of hip, line of pull of
muscles becomes more vertical.
-Impingement of head to the roof limiting
abduction

51. Trochanteric advancement
-Trochanteric osteotomy done and attached to lateral femoral cortex

52. Poor prognostic factors
1. Female sex
2. Age > 10yr
3. Uncovering of the femoral head.
4. > 50% head involved
5. Loss of the hip range of movement
6. Premature physeal closure

53. REFERENCES:
• Tachdjian’s pediatric orthopaedics
• Campbell’s operative orthopaedics

54. THANKYOU