Legg-Calve-Perthe’s Legg-Calve-Perthe’s DiseaseDisease
Dr.E.Kaizar EnnisDr.E.Kaizar Ennis
DEFINITIONDEFINITION
It is a self-limited non-infectious disease of the hip joint occuring in children characterised pathologicaly by avascular
necrosis of the ossification center of capital femoral epiphysis which is alternately resolved and replaced resulting
in variable degrees of deformity of the femoral head and restricted movements
of the hip joints.
HISTORYHISTORY Described first by Waldenstrom in 1909 who Described first by Waldenstrom in 1909 who
mistakenly ascribed it to tuberculosis.mistakenly ascribed it to tuberculosis.
In 1910In 1910 Arthur Legg , U. S. AArthur Legg , U. S. A
Jacques Calve , FranceJacques Calve , France George Perthes ,GermanyGeorge Perthes ,Germany
described and recognized it as non-infectious in origin.
In 1922 Waldentrom gave the correct In 1922 Waldentrom gave the correct interpretation and described the stages.interpretation and described the stages.
INCIDENCEINCIDENCE
1:1200 1:1200 1:12000 1:12000 4M:1F4M:1F 2- 12 years (mean 7 years)2- 12 years (mean 7 years) 5-20% bilateral5-20% bilateral (In bilateral cases changes appear in one
hip at least one year earlier than the other)
British Isles: Catterall 1970(388 cases)British Isles: Catterall 1970(388 cases)
Aetiological TheoriesAetiological Theories
Arterial occlusionArterial occlusion• Mechanical obstructionMechanical obstruction• TraumaTrauma
Venous congestionVenous congestion Thrombophilia & hypofibrinolysisThrombophilia & hypofibrinolysis Disorder epiphyseal cartilageDisorder epiphyseal cartilage The aetiology may be ultimately
multifactorial Salter & Bell JBJS 1968 Glueck et al JBJS 1996 Ponseti JBJS 1983
BS of the infant femoral head
Metaphyseal vessels Lateral Epiphyseal
vessels Vessels of the
ligamentum teres.
STAGES OF PATHOLOGICAL PROCESS
1. Stage of synovitis
2. Stage of AVN
3. Stage of fragmentation
4. Stage of regeneration
5. Stage of healing.
SIGNSSIGNS Stage of AVN Waldenstrom signWaldenstrom sign
crescent sign crescent sign • Stage of regeneration A growth arrest line that outlines the ossific nucleusA growth arrest line that outlines the ossific nucleus
at the time of initial infarction is represented by aat the time of initial infarction is represented by a
‘‘head within a head’ SIGNhead within a head’ SIGN
The greater Trochanter becomes hypertrophied and elevate proximally, elevation impairs the power of The greater Trochanter becomes hypertrophied and elevate proximally, elevation impairs the power of abductor muscles and leads positive trendelenburg.abductor muscles and leads positive trendelenburg.
• The combination of a short femoral neck and a high greater The combination of a short femoral neck and a high greater
trochanter is considered ‘functional coxa vara’trochanter is considered ‘functional coxa vara’
HEAD AT RISK SIGNS-HEAD AT RISK SIGNS- CLINICAL CLINICAL
LOSS OF HIP MOTION IS PERSISTANT AND LOSS OF HIP MOTION IS PERSISTANT AND PROGRESSIVEPROGRESSIVE
INCREASED ADDUCTION CONTRACTURE INCREASED ADDUCTION CONTRACTURE OF HIPOF HIP
THE OBESE CHILDTHE OBESE CHILD FEMALE CHILDFEMALE CHILD AGE >7YRSAGE >7YRS
SYMPTOMS Mild intermittent pain in the hip,thigh or knee
Onset of pain is acute or insidious
The classical presentation has been described as “painless limp”
Because the presenting symptoms are usually mild, the parents do not seek medical attention long after the onset of symptoms.• A small % of children have a history of trauma
Clinical Examination
Antalgic gait
Tenderness Muscle spasm
Limitation of movement (abduction and internal rotation)
Muscle wasting
Leg length inequality
DIFFERENTIAL DIAGNOSIS UNILATERAL CASES Septic arthritis
Sponondyloepiphyseal dysplasia
Rheumatoid arthritis
Tuberculosis
Juvenile rheumatoid arthritis
BILATERAL CASES
Hypothyroidism
Multiple epiphyseal dysplasia
Mucopolysacharidosis
Sickle cell disease
Spondyloepiphyseal dysplasia
InvestigationsInvestigations CBCCBC ESRESR CRPCRP Urine REUrine RE RADIOGRAPHYRADIOGRAPHY BONE SCINTIGRAPHYBONE SCINTIGRAPHY MRIMRI USGUSG ARTHROGRAMARTHROGRAM ANGIOGRAPHYANGIOGRAPHY
Classification systemsClassification systems
CatterallCatterall Salter and ThompsonSalter and Thompson Herring’s lateral pillarHerring’s lateral pillar StulbergStulberg
Catterall ClassificationCatterall Classification
Group 1 –anterior portion of the Group 1 –anterior portion of the epiphysisepiphysis
Group 2-anterior and centralGroup 2-anterior and central Group 3-Most of the epiphysis is Group 3-Most of the epiphysis is
sequestratedsequestrated Group 4-All of the epiphysis is Group 4-All of the epiphysis is
sequestratedsequestrated
Salter Thompson classificationSalter Thompson classification
Type A Type A • Extent of subchondral fracture < 50% of Extent of subchondral fracture < 50% of
superior dome of HOFsuperior dome of HOF• Good prognosisGood prognosis
Type BType B• Extent of subchondral fracture > 50 % Extent of subchondral fracture > 50 %
of superior dome of HOFof superior dome of HOF• Fair or poor prognosisFair or poor prognosis
Lateral Pillar Classification by Lateral Pillar Classification by HerringHerring
Based on radiographic changes in Based on radiographic changes in the lateral portion of the femoral the lateral portion of the femoral head when it enters the head when it enters the fragmentation stage as seen in AP fragmentation stage as seen in AP viewview
Herring’s…Herring’s…
Group A-Minimal density change in the Group A-Minimal density change in the lateral pillar-good outcomelateral pillar-good outcome
Group B- height loss upto 50%- moderate Group B- height loss upto 50%- moderate outcomeoutcome
Group C- height loss > 50%-worst Group C- height loss > 50%-worst outcomeoutcome
Stulberg ClassificationStulberg Classification
Group I – Shape of HOF is normalGroup I – Shape of HOF is normal Group II –within 2 mm to a concentric Group II –within 2 mm to a concentric
circlecircle Group III –more than 2 mm (congruous Group III –more than 2 mm (congruous
incongruity)incongruity) Group IV – HOF flattened area > 1 cm in Group IV – HOF flattened area > 1 cm in
length(congruous incongruity)length(congruous incongruity) Group V – Collapse of HOF Group V – Collapse of HOF
(incongruous incongruity)(incongruous incongruity)
Determination of final outcomeDetermination of final outcome
MOSE-MOSE-AP & LAT VIEWS with Mose templateAP & LAT VIEWS with Mose template
Final shape of the head may be compared to a Final shape of the head may be compared to a perfect circle:perfect circle:
When the head contour is within 1 mm of a given When the head contour is within 1 mm of a given circle ,the result is deemed good.circle ,the result is deemed good.
When the head contour is within 2 mm ,the result is When the head contour is within 2 mm ,the result is deemed fair. deemed fair.
When the head contour is greater than 2 mm ,the result is When the head contour is greater than 2 mm ,the result is deemed poor.deemed poor.
Head at Risk Factors-RadiologicalHead at Risk Factors-Radiological
1.1. Lateral subluxation of femoral headLateral subluxation of femoral head
2.2. Gage’s sign – a radioluscent ‘V’ in Gage’s sign – a radioluscent ‘V’ in the lateral aspect of the epiphysisthe lateral aspect of the epiphysis
3.3. Calicification lateral to the epiphysis Calicification lateral to the epiphysis (*Cage sign)(*Cage sign)
4.4. A horizontal physeal lineA horizontal physeal line
5.5. Diffuse metaphyseal reaction Diffuse metaphyseal reaction (Metaphyseal cyst)(Metaphyseal cyst)
Gage SignGage Sign
Small osteoporotic Small osteoporotic segment forming a segment forming a translucent V- translucent V- shaped trough in shaped trough in the lateral part of the lateral part of the epiphysisthe epiphysis
CAGE SIGNCAGE SIGN
Calcification of the Calcification of the lateral epiphysis.lateral epiphysis.
Crescent sign/Salter sign/CaffreysCrescent sign/Salter sign/Caffreys
Trabeculae in dead Trabeculae in dead bone may fracture bone may fracture in subchondral in subchondral regionregion
Lateral subluxationLateral subluxation
Sagging Rope SignSagging Rope Sign
TREATMENTTREATMENT
Goals of TreatmentGoals of Treatment
1.1. Elimination of hip irritabilityElimination of hip irritability
2.2. Restoration & maintenance of hip Restoration & maintenance of hip motionmotion
3.3. Prevention of extrusion and collapse.Prevention of extrusion and collapse.
4.4. Attainment of a spherical HOFAttainment of a spherical HOF
PRINCIPLESPRINCIPLES
Full mobilityFull mobility
Containment of the femoral Containment of the femoral headhead
Resume wt. bearing & activity Resume wt. bearing & activity as soon as possible.as soon as possible.
Phases of TreatmentPhases of Treatment
Phase 1 – Initial phasePhase 1 – Initial phase Phase 2 – Containment and Phase 2 – Containment and
maintenance of HOF within maintenance of HOF within acetabulum and restoration of full acetabulum and restoration of full ROMROM
Phase 3 – Reconstructive surgeryPhase 3 – Reconstructive surgery
Phase 1Phase 1
Restore full ROMRestore full ROM Traction at homeTraction at home B/L counterpoised split Russel’s B/L counterpoised split Russel’s
traction with a medial rotation stop traction with a medial rotation stop on the thighon the thigh
InvestigationInvestigation AnalgesicsAnalgesics ObservationObservation
Phase 2(Containment by Phase 2(Containment by orthoses/surgery) orthoses/surgery)
Containment using OrthosesContainment using Orthoses• All braces abduct the affected hip, All braces abduct the affected hip,
allows for hip flexion and control allows for hip flexion and control rotation of the limbrotation of the limb
• Before starting containment, restore Before starting containment, restore normal ROM bynormal ROM by
Bed restBed rest TractionTraction AnalgesicsAnalgesics Decrease weight bearing by crutchesDecrease weight bearing by crutches
ORTHOSESORTHOSES
PREREQUISITESPREREQUISITES FULL RANGE OF MOTION WITH RELIEF OF FULL RANGE OF MOTION WITH RELIEF OF
MUSCLE SPASMMUSCLE SPASM ENTIRE FEMORAL HEAD SHOULD BE ENTIRE FEMORAL HEAD SHOULD BE
CONCENTRIC AND FULLY CONTAINED WITH CONCENTRIC AND FULLY CONTAINED WITH IN THE ACETABULUM IN THE ACETABULUM
MOTOR STRENGTH AND BALANCE TO USE MOTOR STRENGTH AND BALANCE TO USE THE ORTHOSES THE ORTHOSES
REASSESS EVERY 4-8 WEEKS FORREASSESS EVERY 4-8 WEEKS FOR GAITGAIT RANGE OF MOTIONRANGE OF MOTION XRAYXRAY
TYPES OF ORTHOSISTYPES OF ORTHOSIS
NON AMBULATORYNON AMBULATORY• BROOMSTICK PLASTIC CASTBROOMSTICK PLASTIC CAST• BIVALVED HIP SPICA CASTBIVALVED HIP SPICA CAST
AMBULATORYAMBULATORY• STATICSTATIC
• HARRISON HIP CONTAINTMENTHARRISON HIP CONTAINTMENT
• DYNAMICDYNAMIC BILATERALBILATERAL
• NEWINGTON HIP CONTAINMENTNEWINGTON HIP CONTAINMENT• SCOTTISH RITESCOTTISH RITE
UNILATERALUNILATERAL• TRILATERAL SOCKET HIP ABDUCTIONTRILATERAL SOCKET HIP ABDUCTION
Adujustable broomstick plasterAdujustable broomstick plaster
NEWINGTON HIP CONTAINMENTNEWINGTON HIP CONTAINMENT
Atlanta Scottish Rite BraceAtlanta Scottish Rite Brace
Containment by orthosis:Signs Containment by orthosis:Signs of healingof healing
Appearance of irregular ossification Appearance of irregular ossification in the capital femoral epiphysisin the capital femoral epiphysis
No new radio opaque areasNo new radio opaque areas Medial segment of femoral head Medial segment of femoral head
should increase in heightshould increase in height There should be an intact lateral There should be an intact lateral
columncolumn
COMPLICATIONSCOMPLICATIONS
PERSISTENT OR RECURRENT LOSS PERSISTENT OR RECURRENT LOSS OF HIP MOTIONOF HIP MOTION
PROGRESSIVE COLLAPSE AND PROGRESSIVE COLLAPSE AND SUPEROLATERAL EXTRUSION OF SUPEROLATERAL EXTRUSION OF FEMORAL HEADFEMORAL HEAD
SURGICAL CONTAINMENTSURGICAL CONTAINMENT
SURGERYSURGERY
ADVANTAGESADVANTAGES• NO END POINT OF TREATMENT IS NO END POINT OF TREATMENT IS
REQUIREDREQUIRED• RAPID RESUMPTION OF ACTIVITYRAPID RESUMPTION OF ACTIVITY
DIS ADVANTAGESDIS ADVANTAGES• SECOND OPERATION TO REMOVE SECOND OPERATION TO REMOVE
IMPLANTIMPLANT• COMPLICATION OF SURGERYCOMPLICATION OF SURGERY
PREREQUISITESPREREQUISITES
ABSENCE OF IRRITABILITY OR ABSENCE OF IRRITABILITY OR RESTRICTION OF HIP MOTIONRESTRICTION OF HIP MOTION
ABSENCE OR MINIMAL DEFORMITY ABSENCE OR MINIMAL DEFORMITY OF FEMORAL HEAD OF FEMORAL HEAD
CONCENTRIC CONTAINMENT BY CONCENTRIC CONTAINMENT BY ABD,MEDIAL ROTATION AND ABD,MEDIAL ROTATION AND FLEXIONFLEXION
CONTAINMENT PROCEDURESCONTAINMENT PROCEDURES
Innominate Osteotomy (Salter)Innominate Osteotomy (Salter) Femoral OsteotomyFemoral Osteotomy Lateral opening wedge osteotomyLateral opening wedge osteotomy
Varus derotation osteotomyVarus derotation osteotomy
Combined Femoral & Innominate osteotomyCombined Femoral & Innominate osteotomy
LATERAL SHELF PROCEDURELATERAL SHELF PROCEDURE
ArthrodiastasisArthrodiastasis
Phase 3Phase 3Reconstructive SurgeriesReconstructive Surgeries
LOWER LIMB INEQUALITYLOWER LIMB INEQUALITY GREATER TROCHANTER GREATER TROCHANTER
OVERGROWTH AND COXA BREVAOVERGROWTH AND COXA BREVA HINGED ABDUCTION HINGED ABDUCTION COXA MAGNACOXA MAGNA INCONGROUS HIPINCONGROUS HIP OSTEOCHONDRITIS DISSECANSOSTEOCHONDRITIS DISSECANS
Phase 3Phase 3Reconstructive SurgeriesReconstructive Surgeries
Valgus extension osteotomyValgus extension osteotomy Valgus flexion and internal rotation Valgus flexion and internal rotation
osteotomyosteotomy CheilectomyCheilectomy Shelf procedure by StaheliShelf procedure by Staheli
Salvage proceduresSalvage procedures
Garceau’s cheilectomyGarceau’s cheilectomy Chiari’s osteotomyChiari’s osteotomy Trochanteric epiphyseodesisTrochanteric epiphyseodesis Trochanteric advancementTrochanteric advancement Valgus osteotomyValgus osteotomy Hip replacementHip replacement
PROGNOSISPROGNOSIS
AGEAGE EXTENTEXTENT PROTRUSION OF FEMORAL HEADPROTRUSION OF FEMORAL HEAD GROWTH DISTURBANCE OF PHYSISGROWTH DISTURBANCE OF PHYSIS METAPHYSEAL CHANGESMETAPHYSEAL CHANGES STAGE IN THE NATURAL COURSE OF THE STAGE IN THE NATURAL COURSE OF THE
DISEASEDISEASE PERSISTENT LOSS OF HIP MOTIONPERSISTENT LOSS OF HIP MOTION OBESE CHILDOBESE CHILD
THANK YOU.THANK YOU.
Top Related