2009.10.09 legg calve perthes disease 2

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  • Legg-Calve-Perthes Disease (coxa plana, osteochondrosis capitis femoris avascular necrosis of the femoral head)

  • DefinitionIdiopathic osteonecrosis of the capital femoral epiphysis of the femoral head of unknown aetiology.It is a self-limited disease.

  • EtiologyInfection, trauma, synovitisDisruption of blood flow to capital femoral epiphysis (CFE)Systemic disorder (delayed skeletal maturation, abnormalities of thyroid hormone and insulin like growth factorHereditary influence, environmental influence, hyperactivity

  • Blood flow to CFE

  • EpidemiologyOne in 1200 children younger than 15 years is affected by LCPD Males are affected 4-5 times more often than females LCPD most commonly is seen in persons aged 4-8 (2-12) years, with a average age of 7 years Bilateral involvment 10 -15%

  • PathologyThe blood supply to the capital femoral epiphysis is interrupted (arteries and veins).Bone infarction occurs, especially in the subchondral cortical bone, while articular cartilage continues to grow. (Articular cartilage grows because its nutrients come from the synovial fluid.)Revascularization occurs, and new bone ossification starts.Changes to the epiphyseal growth plate occur secondary to the subchondral fracture.

  • SymptomsPainless limpHip or groin pain, which may be referred to the thighMild or intermittent pain in anterior thigh or kneeUsually no history of trauma

  • SymptomsDecreased range of motion (ROM), particularly with internal rotation and abductionPainful gaitAtrophy of thigh muscles secondary to disuseMuscle spasm- mild hip contracture of 10-20 degrees may be present

  • SymptomsLeg length inequality due to collapseThigh atrophy: Thigh circumference on the involved side will be smaller than on the unaffected side secondary to disuse (Trendelenburg sign)

  • Trendelenburg sign

  • DiagnosisClinical presentation, physical examinationRTG- A-P, frog-leg lateral views (every 6 weeks at the beginning, every 3-6 months later)USG- synovitisMRI, artrography

  • Stages radiographic presentationIschaemia / Necrosis Fragmentation / ResorptionReossification / HealingResidual stage

  • Initial stage- necrosisDecreased size of ossification centerLateralization of femoral headSubchondral fracturePhyseal irregularity

  • Fragmetation- resorptionFragmented epiphysisMore irregular acetabular contour

  • Reossification- healingNew bone formation- the bone density returns

  • Residual stageReossified femoral headRemodeling of the head shapeRemodeling of the acetabulum

  • Catterall classificationStage 1:Antero-medial portion of head involved and no collapse, metaphyseal changes do not occur and the epiphyseal plate is not involved Heal without significant sequelae Stage 2:More head involved and may - fragmentation of the involved segment The involved segment shows increased density and uninvolved pillars of normal bone prevent significant collapse - regeneration without much loss of height and the end result is usually good. Metaphyseal reaction localised

  • Catterall classificationStage 3:More of the head involved - collapse as uninvolved pillars not large enough t prevent collapse May show head within a head The metaphysis is usually diffusely involved - broad neck and the epiphyseal plate is unprotected and also usually involved - results poorer Stage 4:Whole head involvement and severe collapse occurs early and restoration of the femoral head usually less complete The metaphyseal changes may be extensive The epiphyseal plate is often involved - abnormal growth (coxa magna, coxa breva, coxa vara and coxa valga)

  • Herring classificationLateral pillar clasification Detrmine treatment and prognosis

  • Salter - Thompson Classification Stage A: - Lateral portion of femoral capital epiphysis present - less than 50% head involvedStage B: - Lateral portion of femoral capital epiphysis absent - more than 50% head involved (Lateral margin of epiphysis protects epiphysis from stress)

  • Differential diagnosis

  • Mose methodIf head conforms to a single ring in both X-Ray planes - good prognosis If head varies from perfect circle by no more than 2mm - fair results If head varies by more than 2mm in any plane - poor results

  • Neck-shaft angle

  • Centre-edge angle (Wiberg`s angle)

  • Centre-edge angle5-8 years ~19 degrees9-12 years ~25 degrees13-20 years 26-30 degrees

  • Goal of treatmentPreservation of the roundness of the femoral head and prevention of deformity while the condition runs its course.

  • Conservative treatmentRelieve weight bearingAchieve and maintain ROMContainment of the femoral epiphysis within the confines of the acetabulum (Petrie-style casts, Atlanta /Scottish Rite/ brace, Toronto brace and other orthotic devices)

  • Conservative treatment

  • Conservative treatment

  • Conservative treatment

  • Surgical treatmentFemoral osteotomy = varus +/- derotation to reduce the degree of anteversion & extension.Pelvic osteotomy (Salter, Chiari, Shelf) or Femoral osteotomy have similar results

  • Surgical treatmentShelf acebuloplasty

  • Surgical treatmentSalter osteotomy

  • Very good radiographic resultsbefrore surgery (7 years 2 months)

  • Very good radiographic results3 years after surgery

  • Very good radiographic results6 years after surgery

  • Poor radiographic resultbefore surgery (7 years 8 months)

  • Poor radiographic result6 months after surgery

  • Poor radiographic result 8 years after surgery

    DDH 25%