Presentation contain etiology, blood supply of femoral head & neck,pathogenesis ,classification system ,clinical features,diagnosis,managment, pelvic & femoral osteotomies in detail

1. PRESENTED BY-PRESENTED BY-
DR.NAVEEN RATHORDR.NAVEEN RATHOR
RESIDENT DOCTORRESIDENT DOCTOR
DEPT. OF ORTHOPAEDICSDEPT. OF ORTHOPAEDICS
RNT MEDICAL COLLEGE,UDAIPURRNT MEDICAL COLLEGE,UDAIPUR

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
PRECOXALGIAPRECOXALGIA

4. Blood supply to femoral headBlood supply to femoral head
 Retinacular arteriesRetinacular arteries
 Metaphyseal arteriesMetaphyseal arteries
 Artery of the teresArtery of the teres
ligamentligament

19. 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.

20. 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.

21. 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.

22. 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.

23. 1.1. Vascular supply:Vascular supply:
- Angiograms and laser studies have shown- Angiograms and laser studies have shown
medial circumflex artery is missing ormedial circumflex artery is missing or
obliterated and obturator artery or the lateralobliterated and obturator artery or the lateral
epiphyseal artery also affected.epiphyseal artery also affected.
2.2. Increased intra-articular pressureIncreased intra-articular pressure
3.3. Intraosseous pressureIntraosseous pressure
-- Patients has shown that the venous drainage inPatients has shown that the venous drainage in
the femoral head is impaired, causing anthe femoral head is impaired, causing an
increase in intraosseous pressure.increase in intraosseous pressure.
ETIOLOGYETIOLOGY

24. 4.4. Coagulation disorderCoagulation disorder
-- Associated with absence of factor C or S.Associated with absence of factor C or S.
- Increase in serum levels of lipoproteins,thrombogenic- Increase in serum levels of lipoproteins,thrombogenic
substance.substance.
55.. Growth hormonesGrowth hormones
-- Studies have shown reduced levels of growth hormones,Studies have shown reduced levels of growth hormones,
somatomedin A and C.somatomedin A and C.
66.. Social conditionsSocial conditions
-- Usually belong to lower socioeconomic status, reflectsUsually belong to lower socioeconomic status, reflects
dietary and environmental factorsdietary and environmental factors..
77. Trauma. Trauma

25. 8.8... Abnormal growth and developmentAbnormal growth and development
-- Bone age is lower than chronological age by 1-3 yrs,.Bone age is lower than chronological age by 1-3 yrs,.
Ex: carpal bone age: 2 yrs (Triquetral and lunateEx: carpal bone age: 2 yrs (Triquetral and lunate))
- Usually shorter than their peers.- Usually shorter than their peers.
9.9. Genetic factorsGenetic factors
-- Inheritance 2-20%;inconsistent pattern.Inheritance 2-20%;inconsistent pattern.
-- More Incidence of low birth weight, abnormal birthMore Incidence of low birth weight, abnormal birth
presentations.presentations.
- First degree relatives have 35% more risk , 2- First degree relatives have 35% more risk , 2ndnd
andand 33rdrd
degree relatives are 4 times more prone fordegree relatives are 4 times more prone for perthesperthes
disease.disease.

26. 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.

27. 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

28. Hypothesis for development ofHypothesis for development of
AVN of femoral headAVN of femoral head
TRUETA’S HYPOTHESISTRUETA’S HYPOTHESIS
 - Age < 3 yrs: blood supply contributed- Age < 3 yrs: blood supply contributed
by metaphyseal and retinacular arteries.by metaphyseal and retinacular arteries.
 - Age 4-8 yrs: Retinacular arteries which- Age 4-8 yrs: Retinacular arteries which
enters head as lateral epiphyseal arteriesenters head as lateral epiphyseal arteries
gets compressed by lateral rotationgets compressed by lateral rotation
muscles.muscles.
Thus trueta postulates that solitary bloodThus trueta postulates that solitary blood
supply during 4-8 yrs makes vulnerable forsupply during 4-8 yrs makes vulnerable for
AVN of head.AVN of head.

29. Caffey’s HypothesisCaffey’s Hypothesis
Intraepiphyseal compression of bloodIntraepiphyseal compression of blood
supply to ossification centersupply to ossification center

30. CausesCauses

31. 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

32. 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

33. 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

34. X-RayX-Ray
 Cresent Sign orCresent Sign or
Salters sign orSalters sign or
Caffey’s signCaffey’s sign

35. Caffey’s signCaffey’s sign
 As the disease progresses, aAs the disease progresses, a
subchondral # may occur insubchondral # may occur in
the anterolateral aspect ofthe anterolateral aspect of
the femoral capital epiphysis.the femoral capital epiphysis.
 Is an early radiographicIs an early radiographic
feature best seen on thefeature best seen on the
frog-lateral projection.frog-lateral projection.
 This produces a crescenticThis produces a crescentic
radiolucency known as theradiolucency known as the
crescent, Salter’s or Caffey’screscent, Salter’s or Caffey’s
signsign March 18, 2016March 18, 2016 Dr.Ratan M.P.T.,(Ortho & Sports)Dr.Ratan M.P.T.,(Ortho & Sports)3535

36. Gage’s signGage’s sign
 Rarefaction in theRarefaction in the
lateral part of thelateral part of the
epiphysis andepiphysis and
subjacentsubjacent
metaphysis.metaphysis.

37. ‘‘Sagging Rope Sign’Sagging Rope Sign’
This a curvilinearThis a curvilinear
sclerotic line runningsclerotic line running
horizontally across thehorizontally across the
femoral neck.femoral neck.
It is confirmed by 3DIt is confirmed by 3D
CT studies.CT studies.
It is a finding in APIt is a finding in AP
radiograph in a matureradiograph in a mature
hip with Perthes’hip with Perthes’
disease.disease.
March 18, 2016March 18, 2016 Dr.Ratan M.P.T.,(Ortho & Sports)Dr.Ratan M.P.T.,(Ortho & Sports)3737

38. 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.

39. FRAGMENTATION STAGEFRAGMENTATION STAGE
BONY EPIPHYSISBONY EPIPHYSIS
BEGINS TOBEGINS TO
FRAGMENTFRAGMENT
AREAS OFAREAS OF
INCREASEDINCREASED
LUCENCY ANDLUCENCY AND
DENSITYDENSITY
EVIDENCE OFEVIDENCE OF
REPAIR ASPECTSREPAIR ASPECTS

40. X-RayX-Ray
 Fragmentation ofFragmentation of
epiphysisepiphysis

41. X-RayX-Ray
 MetaphysealMetaphyseal
widening and cysticwidening and cystic
changes in femoralchanges in femoral
neckneck

42. X-RayX-Ray
 Lateral extrusion ofLateral extrusion of
femoral head andfemoral head and
changes inchanges in
acetabulum.acetabulum.

43. REOSSIFICATION STAGEREOSSIFICATION STAGE
NORMAL BONENORMAL BONE
DENSITY RETURNSDENSITY RETURNS
ALTERATIONS INALTERATIONS IN
SHAPE OF FEMORALSHAPE OF FEMORAL
HEAD AND NECKHEAD AND NECK
EVIDENTEVIDENT

44. 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.

45. In 1971In 1971
used radiological findings of epiphysealused radiological findings of epiphyseal
involvement to identify 4 groupsinvolvement to identify 4 groups

46. anterior femoralanterior femoral
headhead involvementinvolvement
no evidence ofno evidence of
sequestrum,sequestrum,
subchondralsubchondral
fracture line, orfracture line, or
metaphysealmetaphyseal
abnormalitiesabnormalities

47.  anterolateralanterolateral
involvementinvolvement
 Central sequestrumCentral sequestrum
 Well demarcatedWell demarcated
 metaphyseal lesionsmetaphyseal lesions
 Subchondral fractureSubchondral fracture
lineline – Ant ½– Ant ½
 lateral column is intact.lateral column is intact.

48.  large sequestrum -large sequestrum -
3/43/4thth
of head.of head.
 Junction is sclerotic.Junction is sclerotic.
 Diffuse MetaphysealDiffuse Metaphyseal
lesionslesions , anterolaterally, anterolaterally
 Subchondral fractureSubchondral fracture
lineline - post 1/2- post 1/2
 The lateral column isThe lateral column is
involved.involved.

49. Entire headEntire head
Diffuse or centralDiffuse or central
metaphysealmetaphyseal
lesionslesions
posteriorposterior
remodelingremodeling of theof the
epiphysisepiphysis

50. Catterall classificationCatterall classification
 Groups I and IIGroups I and II had ahad a good prognosisgood prognosis
(in 90%) and required no intervention.(in 90%) and required no intervention.
Groups III and IVGroups III and IV had ahad a poor prognosispoor prognosis
(in 90 %) and required treatment.(in 90 %) and required treatment.
The classification is applied to the frogThe classification is applied to the frog
lateral and AP film during thelateral and AP film during the
fragmentation phasefragmentation phase

51. CATERALL’S HEAD AT RISK SIGNSCATERALL’S HEAD AT RISK SIGNS

52. Extent ofExtent of subchondral #subchondral # in both AP &in both AP &
lowenstein frog leg lateral xrayslowenstein frog leg lateral xrays
reliable indicator in the group withreliable indicator in the group with
fracturesfractures

53.  extent of the fracture (line) is less than
50% of the superior dome of the
femoral head
› good results can be expected.

54.  Extent of the fracture is
more than 50% of the
dome,
› fair or poor results can
be expected

55. Based on radiographic changes inBased on radiographic changes in laterallateral
portion of femoral headportion of femoral head duringduring
fragmentation stage on AP viewfragmentation stage on AP view
LATERAL PILLAR - lateral 15-30%LATERAL PILLAR - lateral 15-30% ofof
epiphysis on AP xrayepiphysis on AP xray

56. Group AGroup A –– nono involvementinvolvement
Group BGroup B –– at least 50 %at least 50 % of heightof height
maintainedmaintained
Group CGroup C –– less than 50%less than 50% of heightof height
maintainedmaintained

57. AdvantageAdvantage
Easy applicationEasy application in active diseasein active disease
High correlation betHigh correlation bet lat pillar height and amountlat pillar height and amount
of head flatteningof head flattening at skeletal maturityat skeletal maturity

58. described in 1981described in 1981
Used to predict theUsed to predict the onset ofonset of
degenerative joint diseasedegenerative joint disease followingfollowing
LCPDLCPD

59. I –I – Shape is normalShape is normal
II –II – loss of head heightloss of head height
< 2 mm< 2 mm deviation of concentric circlesdeviation of concentric circles
Group I & II –Group I & II – “Spherical Congruency”“Spherical Congruency”

60. III –III – Elliptical headElliptical head
> 2 mm> 2 mm deviationdeviation
Contour matchesContour matches (“Incongrous/Aspherical(“Incongrous/Aspherical
congruency”)congruency”)

61. IV –IV – FlattenedFlattened
head, >1 cm ofhead, >1 cm of
flatteningflattening
ContourContour
matchesmatches
(“Incongrous/As(“Incongrous/As
phericalpherical
congruency”)congruency”)
ResemblenceResemblence

62. V –V – Collapsed head,Collapsed head,
Contour mismatchContour mismatch (“Incongrous/Aspherical(“Incongrous/Aspherical
Incongruency”)Incongruency”)

63. 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.

64. ClinicalClinical
Physical:Physical:
Painful gaitPainful gait
Decreased range of motionDecreased range of motion (ROM),(ROM),
particularly with internal rotation andparticularly with internal rotation and
abductionabduction
Atrophy of thigh musclesAtrophy of thigh muscles secondary tosecondary to
disusedisuse
Muscle spasmMuscle spasm
Leg length inequalityLeg length inequality due to collapsedue to collapse

65. ClinicalClinical
Short statureShort stature: Children with LCPD often: Children with LCPD often
have delayed bone age.have delayed bone age.
Roll testRoll test
With patient lying in the supine position, theWith patient lying in the supine position, the
examiner rolls the hip of the affected extremityexaminer rolls the hip of the affected extremity
into external and internal rotation.into external and internal rotation.
This test should invoke guarding or spasm,This test should invoke guarding or spasm,
especially with internal rotation.especially with internal rotation.

66. InvestigationInvestigation
X-Ray –AP & Frog leg Lat viewX-Ray –AP & Frog leg Lat view
USGUSG
ArthrographyArthrography
Bone ScanBone Scan
CTCT
MRIMRI
HAEMOGRAMHAEMOGRAM

67.  Hematological parametersHematological parameters
 ESRESR
 CRPCRP
 Coagulability profile.Coagulability profile.
 X-raysX-rays
 USGUSG
 CT scanCT scan
 MRIMRI
 BONE SCANBONE SCAN
 ArthrographyArthrography
 Scintigraphy.Scintigraphy.
INVESTIGATIONSINVESTIGATIONS

68. Imaging – Radiographic FeatureImaging – Radiographic Feature
 Widening of the joint space and minor subluxationWidening of the joint space and minor subluxation
 Cresent sign/gaze sign/sagging rope signCresent sign/gaze sign/sagging rope sign
 Fragmentation and focal resorptionFragmentation and focal resorption
 Loss of sphericity of femoral headLoss of sphericity of femoral head
 Loss of height of lateral pillersLoss of height of lateral pillers
 Metaphyseal cyst formationMetaphyseal cyst formation
 Widening of the femoral neck & head (Coxa Magna)Widening of the femoral neck & head (Coxa Magna)
 Lateral uncovering &subluxation of the femoral headLateral uncovering &subluxation of the femoral head
 Head within head appearanceHead within head appearance
 Acetabular remodellingAcetabular remodellingMarch 18, 2016March 18, 2016 Dr.Ratan M.P.T.,(Ortho & Sports)Dr.Ratan M.P.T.,(Ortho & Sports)6868

69. Ultrasound featuresUltrasound features
 Effusion, especially if persistentEffusion, especially if persistent
 Synovial thickeningSynovial thickening
 Cartilaginous thickeningCartilaginous thickening
 Atrophy of the ipsilateral quadriceps muscleAtrophy of the ipsilateral quadriceps muscle
 Flattening, fragmentation, irregularity of theFlattening, fragmentation, irregularity of the
femoral headfemoral head
 New bone formationNew bone formation
March 18, 2016March 18, 2016 Dr.Ratan M.P.T.,(Ortho & Sports)Dr.Ratan M.P.T.,(Ortho & Sports)6969

70.  Accurate imaging modality for early diagnosisAccurate imaging modality for early diagnosis
of perthes disease.of perthes disease.
 Evaluated congruity of articular surfaces,Evaluated congruity of articular surfaces,
femoral head containment, joint effusion andfemoral head containment, joint effusion and
synovial hypertrophy.synovial hypertrophy.
 Epiphyseal involvement clearly visualised onEpiphyseal involvement clearly visualised on
MRI 3 to 8 months after first symptoms.MRI 3 to 8 months after first symptoms.
 Diagnostic accuracy: 97-99%.Diagnostic accuracy: 97-99%.
 Also provides earlier and reliable informationAlso provides earlier and reliable information
on revascularisation and extent of femoralon revascularisation and extent of femoral
head necrosis.head necrosis.
MRIMRI

71. Demonstrates actual contour of femoralDemonstrates actual contour of femoral
head and state of congruity of articularhead and state of congruity of articular
surfaces.surfaces.
It provides reliable information regardingIt provides reliable information regarding
containment of femoral head withincontainment of femoral head within
acetabulum.acetabulum.
Major advantage is that examiner canMajor advantage is that examiner can
assess congruity of hip in differentassess congruity of hip in different
positions.positions.
Often used in early diagnosis of hingeOften used in early diagnosis of hinge
ARTHROGRAPHYARTHROGRAPHY

72. 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.

73. Bone ScanBone Scan
 Convay et alConvay et al
classificationclassification
 Stage 1 is total lack ofStage 1 is total lack of
uptakeuptake

74. 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

75. Bone ScanBone Scan
 Gradual filling ofGradual filling of
anterolateral partanterolateral part

76. Bone ScanBone Scan
 Return to normalReturn to normal

77. AVN caused by variety of conditionsAVN caused by variety of conditions
- Sickle cell anemia- Sickle cell anemia
- Other hemoglobinopathies- Other hemoglobinopathies
- Thalassemia- Thalassemia
- Steroid medication- Steroid medication
- After traumatic hip dislocation- After traumatic hip dislocation
- Treatment of developmental dysplasia of- Treatment of developmental dysplasia of
hiphip
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

78. 1)1) Transient synovitisTransient synovitis
2)2) Slipped femoral epiphysisSlipped femoral epiphysis
3)3) Congenital dysplasia of hipCongenital dysplasia of hip
4)4) Congenital coxa varaCongenital coxa vara
5)5) Early TuberculosisEarly Tuberculosis
6)6) Rheumatoid arthritisRheumatoid arthritis
7)7) EPIPHYSEAL DYSPLASIASEPIPHYSEAL DYSPLASIAS

79. COMPARISON BETWEENCOMPARISON BETWEEN
TRANSIENT SYNOVITIS &LCPDTRANSIENT SYNOVITIS &LCPD
LCP DISEASE TRANSIENTLCP DISEASE TRANSIENT
SYNOVITISSYNOVITIS
-Average duration of - average duration of-Average duration of - average duration of
Symptom is 6-8 wk symptomes in daysSymptom is 6-8 wk symptomes in days
-synovial thickening -synovitis with capsular-synovial thickening -synovitis with capsular
distensiondistension
-bony changes & -no bony changes-bony changes & -no bony changes
necrosisnecrosis

80. Comparison chartComparison chart
COMPARISON CHARTCOMPARISON 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.
Acetabulum not involved Involved
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.

81. 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

82. Prognostic featuresPrognostic features
 AgeAge
 <6yrs; good regardless of treatment<6yrs; good regardless of treatment
 6-9years; not always satisfactory with containment6-9years; not always satisfactory with containment
 >10yrs; questionable benefit from containment, poor>10yrs; questionable benefit from containment, poor
prognosisprognosis
 GenderGender
 Girls have worse prognosisGirls have worse prognosis
 Classification gradeClassification grade
 Herrings lateral pillar classificationHerrings lateral pillar classification
 Salter and thompson grade B worse prognosisSalter and thompson grade B worse prognosis
 Caterral classification gradeCaterral classification grade
 Caterral “head-at-risk” signsCaterral “head-at-risk” signs
 The five signs carry worse prognosisThe five signs carry worse prognosis
 OthersOthers
 Body weight, decreased ROMBody weight, decreased ROM

83. Classification of PrognosisClassification of Prognosis
- CE(Center-edge)angle of Weiberg.- CE(Center-edge)angle of Weiberg.
- Salters extrusion Index.- Salters extrusion Index.
- Epiphyseal index.- Epiphyseal index.
- Epiphyseal quotient.- Epiphyseal quotient.
- Stulberg classification.- Stulberg classification.

84. 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

85. 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

86. 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

87. 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

89. Rational behind "containment"Rational behind "containment"
 Containment of the head within the acetabulum isContainment of the head within the acetabulum is
reported toreported to encourage spherical remodelling during theencourage spherical remodelling during the
reossification and subsequent phases.reossification and subsequent phases.
 However if there isHowever if there is total head involvementtotal head involvement and the lateraland the lateral
pillar collapses then the effect of containment is probablypillar collapses then the effect of containment is probably
lessless..
 Therefore it seems that the extent of involvement of theTherefore it seems that the extent of involvement of the
head is thehead is the critical factorcritical factor and containment simplyand containment simply
optimizes the situation.optimizes the situation.

90.  Methods of CONTAINMENT OFMethods of CONTAINMENT OF
HEADHEAD
(a) Conservative methods(a) Conservative methods
(b) Surgical methods(b) Surgical methods

91. 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.

92. 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.

93. 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

94. Hip irritability with decrease of hip motion:Hip irritability with decrease of hip motion:
1-2 week period of bed rest with abduction1-2 week period of bed rest with abduction
tractiontraction
if recursif recurs
2-3 months period of surgical non2-3 months period of surgical non
containment to decrease risk of extrusion.containment to decrease risk of extrusion.

95. 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

96. Treatment (Orthosis)Treatment (Orthosis)
 Atlanta Scotish RiteAtlanta Scotish Rite
BraceBrace

97. Atlanta Scotish Rite BraceAtlanta Scotish Rite Brace

98. Newington orthosisNewington orthosis

99. Birmingham braceBirmingham brace

100.  Toronto BraceToronto Brace

101. 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.

102. So finally…. before planningSo finally…. before planning
surgery, first think of atleast 4surgery, first think of atleast 4
things …..things …..
Pathological stagePathological stage
AgeAge
Range of motionRange of motion
Catterall & herrings stagingCatterall & herrings staging

103. 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.

104. PELVIC OSTEOTOMYPELVIC OSTEOTOMY
 Redirectional OsteotomyRedirectional Osteotomy
 Salter’s osteotomy toSalter’s osteotomy to
reorient the acetabulumreorient the acetabulum
 Shelf OperationShelf Operation
 To create a bony shelf toTo create a bony shelf to
cover the extruded part ofcover the extruded part of
the epiphysis.the epiphysis.
 Displacement OsteotomyDisplacement Osteotomy
 Chiari osteotomy isChiari osteotomy is
another way to improveanother way to improve
the coveragethe coverage..

105. 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
containment(Catterall grade 3containment(Catterall grade 3rdrd
& 4& 4thth
))
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
ADVANTAGE :ADVANTAGE :
1)Anterolateral coverage of frmoral head1)Anterolateral coverage of frmoral head
2)Lengthening of extremity2)Lengthening of extremity
3)Avoidance of second surgery for implant removal3)Avoidance of second surgery for implant removal

106. COMPLICATIONS:-COMPLICATIONS:-
1)Inability to achieve containment in older1)Inability to achieve containment in older
childchild
2)Sometimes limb lenghtening2)Sometimes limb lenghtening
3)Increase hip pressure can cause further3)Increase hip pressure can cause further
AVNAVN

111. 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

112. ADVANTAGE:-ADVANTAGE:-
1)LATERAL ACETABULAR GROWTH1)LATERAL ACETABULAR GROWTH
STIMULATIONSTIMULATION
2)SHELF RESOLUTION AFTER2)SHELF RESOLUTION AFTER
FEMORAL EPIPHYSEAL OSSIFICATIONFEMORAL EPIPHYSEAL OSSIFICATION
3)PREVENTION FROM SUBLUXATION3)PREVENTION FROM SUBLUXATION
COMPLECATIONS:-COMPLECATIONS:-
1)LOSS OF HIP FLEXION1)LOSS OF HIP FLEXION
2)LATERAL CUTANEOUS NERVE AT2)LATERAL CUTANEOUS NERVE AT

113. i)Curved incision below iliac crest, strip glutei.
ii) Mobilize and divide reflected head of rectus femoris
iii) Trough in bone above insertion of capsule.
iv) Strips of cancellous bone inserted into trough so that they form a canopy on
superior surface of hip joint.
v) Pack web space between flap and graft canopy with gratft
vi)Repair rectus and lose the wound.

114. Chiari osteotomyChiari osteotomy
 Capsular interpositionalCapsular interpositional
arthroplasty(capsule isarthroplasty(capsule is
interposed b/w newlyinterposed b/w newly
formed acetabulum roof &formed acetabulum roof &
femoral head)femoral head)
 Usually after 10 yr of ageUsually after 10 yr of age
 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.

115. FEMORAL OSTEOTOMYFEMORAL OSTEOTOMY
 Technically less demanding than innominate osteotomyTechnically less demanding than innominate osteotomy
 Usually 20Usually 2000
varus angulation & 20varus angulation & 2000
IR appears sufficient.IR appears sufficient.
 Good to decide abduction, internal rotation or flexion on aGood to decide abduction, internal rotation or flexion on a
pre-operative arthrogram.pre-operative arthrogram.

116. Femoral varus osteotomyFemoral varus osteotomy
IndicationsIndications: 1.>6yrs of age: 1.>6yrs of age
2.excessive femoral anteversion2.excessive femoral anteversion
3.catterall grade 33.catterall grade 3rdrd
& 4th& 4th
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

117.  varus should not bevarus should not be
 exceeds more than 110exceeds more than 110
 degree.degree.
Level of osteotomy
Insertion of guide pin and reaming of
femur
First depth marking flush with lateral
cortex
Removal of wedge to customize it

118. Uuuu uUuuu u
usually we use varususually we use varus
(medial closing wedge)(medial closing wedge)
osteotomy fixed with anosteotomy fixed with an
pediatric hip screwpediatric hip screw
Plate and compression screw application
Insertion of bone screws.

119. Valgus OsteotomyValgus Osteotomy
 Indication:hingedIndication:hinged
abduction of hipabduction of hip

120. CHEILECTOMYCHEILECTOMY
Large malformed femoral head outside theLarge malformed femoral head outside the
acetabulum causing painful sensation onacetabulum causing painful sensation on
abduction/lack of abductionabduction/lack of abduction
Removal of malformed femoral headRemoval of malformed femoral head
protruding outside acetabulumprotruding outside acetabulum
Result after short term follow up are goodResult after short term follow up are good
but detoriates with timebut detoriates with time

121. Widening of the jointWidening of the joint
Unloads the joint spaceUnloads the joint space
Reduces pressure overReduces pressure over
headhead
Articular cartilage repairArticular cartilage repair
Maintain congruencyMaintain congruency
Allows 50 degree flexionAllows 50 degree flexion

122.  TTROCHANTRIC OVERGROWTHROCHANTRIC OVERGROWTH
-due to premature closure of femoral epiphysis-due to premature closure of femoral epiphysis
- Elevation of trochanter decreases tension- Elevation of trochanter decreases tension
and mechanical efficiency of pelvic andand mechanical efficiency of pelvic and
trochantric muscles.trochantric muscles.
- Shortened femoral neck moves trochanter- Shortened femoral neck moves trochanter
closer to centre of rotation of hip, line of pullcloser to centre of rotation of hip, line of pull
of muscles becomes more vertical.of muscles becomes more vertical.
- Impingement of head to the roof limiting- Impingement of head to the roof limiting
abduction.abduction.

123. Normal growth pattern
Long. Growth arrested, greater
trochanter continues

124. GEAR STICK SIGNGEAR STICK SIGN
Differentiation b/w trochrntric impingmentDifferentiation b/w trochrntric impingment
& other cause of restricted hip abduction& other cause of restricted hip abduction
In case if trochentric impingment-In case if trochentric impingment-
hip extension-impingmented duringhip extension-impingmented during
abductionabduction
Hip flexion-no impingment during abductionHip flexion-no impingment during abduction

125. Trochanteric advancementTrochanteric advancement
 IndicationsIndications::
- Trochanteric over- Trochanteric over
growthgrowth
- Capital femoral physeal- Capital femoral physeal
growth arrestgrowth arrest

126. 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

127. 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

128. 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

129. Thank you
for your
patient
listening