classification & management of legg calve perthes disease

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  • 1. RADIOGRAPHY MAGNETIC RESONANCE IMAGING BONE SCINTIGRAPHY ULTRASONOGRAPHY ARTHOGRAPHY COMPUTEDTOMOGRAPHY

2. Plain X ray of PELVISWITH BOTH HIP JTS AP view Lowensteins frog-leg lateral view Abduction Adduction views Knee joints AP / Lat Wrist joints AP / Lat 3. Waldenstroms classification four stages INITIAL STAGE FRAGMENTATION STAGE REOSSIFICATION (HEALING) STAGE RESIDUAL STAGE 4. Smaller osiffic nucleus Lateralization of femoral head in the acetabulum Widening of medial jt space 5. Waldenstrom / caffeys sign Vaccum phenomenon 6. Radio-dense femoral head Cyst & leucency in metaphysis END OF STAGE: appearance of lucencies in nucleus 6m( up to14m) 7. Lucent areas appear in the ossific nucleus of femoral head Demarcation of femoral segments (pillars) often central dense 8. Milder form only ant segement seen on frog- leg lateral More severe no demarcation of pillars 9. END OF STAGE appearance of new bone in subchondral area 8m(2 35m) 10. STARTSWITH - appearance of new bone in subchondral area first in center of head then expands medially and laterally Anterior segment last to reossify Process- lucent/necrotic areas of fragmentation stage replaced by WOVEN BONE which then ossifies , remodels in to TRABECULAR BONE 11. mild gradual flatenning children < 5 yrs whose femoral head is totally involved most improve 51m(2-122m) 12. femoral head is fully reossified head remodels so does the acetabulum Head normal / extremely flat / aspherical Physis is inlvolved overgrowth of greater trochanter 13. Gill(1940) metaphyseal necrosis & lucencies (holes of decalcification) 14. Ponseti cystic changes in neck Prognostic value poor outcome 15. Sagging rope sign radiodense line in prox femoral metaphysis Metaphyseal response to physeal damage 16. Premature physeal closure With central arrests: Round head Short neck Troch overgrowth With lateral arrest: Femoral head tilted Laterally Elongation of medial neck Overgrowth of troch 17. Morphological changes in acetabulum in perthes described by BENJAMIN JOSEPH (JBJS 1989) Osteoporosis of acetabular roof Irregularity of contour Premature fusion of triradiate cartilage ( bicomparmentalisation) Hypertrophy of articular cartilage & changes in dimension 18. BICOMPARTMENTALIZATION When femoral head protrudes from acetabulum - medial wall may form And look like a second compartment for the head Bicompartmental acetabulum in perthes disease (JBJS 87-B aug 2005) 19. On plain xray - bicompartmental acetabulum appears to be composed of 2 arc partly overlapping each other interpreted as the subluxated femoral head articulating only with the lateral half of the acetabulum moulding it into 2 compartments 20. Used for early diagnosis of LCP disease Detects Configuration of femoral head & acetabulum Congruity of articular surface Femoral head containment Joint effusion 21. Synovial hypertrophy Epiphyseal involvement True extent of femoral head necrosis 22. helps in diagnosis of early stages visualization of early reperfusion Transphyseal reperfusion, occurring by neovascularization through the physis, is known to be a strong predictor of growth deformity. 23. Effective tool for diagnosis of pre-radiological early stages Revascularization patterns 24. Findings of Configuration of head Widening of joint space due to thickend cartilage Lateral shifting of head Containment of head within acetabulum Major Advantage assessment of congruity of joint in different range of movement 25. Currently, mainly used in early diagnosis of HINGED ABDUCTION 26. In early stages - Joint effusion In later stages assess shape of cartilagenous femoral head 27. provides acurate 3 D images of shape of femoral head & acetabulum 28. 1. LEGG 2. WALDENSTROM 3. GOFF 4. SALTERTHOMPSON 5. CATERALL 6. HERRINGS LATERAL PILLAR 7. MOSE 8. STULBERG 29. LEGG two types of head A cap & a mushroom(more severe) WALDENSTROM classified head 3 categories Type 1 & 2 with good results Type 3 altered shape leading to restriction of ROM to only flexion & extension (conical) GOFF 3 types of head Spherical, cap, irregular 30. Extent of subchondral # in both AP & lowenstein frog leg lateral xrays reliable indicator in the group with fractures 31. extent of the fracture (line) is less than 50% of the superior dome of the femoral head good results can be expected. 32. Extent of the fracture is more than 50% of the dome, fair or poor results can be expected 33. In 1971 used radiological findings of epiphyseal involvement to identify 4 groups 34. anterior femoral head involvement no evidence of sequestrum, subchondral fracture line, or metaphyseal abnormalities 35. anterolateral involvement Central sequestrum Well demarcated metaphyseal lesions Subchondral fracture line Ant lateral column is intact. 36. large sequestrum - 3/4th of head. Junction is sclerotic. Diffuse Metaphyseal lesions , anterolaterally Subchondral fracture line - post 1/2 The lateral column is involved. 37. Entire head Diffuse or central metaphyseal lesions posterior remodeling of the epiphysis 38. 1. Gage sign : Described by COURTNEY GAGE(1933) small osteoporotic segment which forms a radiolucentV-shaped defect on lateral epiphysis & adjacent metaphysis on AP xray . 39. 2. Speckled calcification lateral to epiphysis 3. Lateral subluxation of femoral head 4. Horizontally oriented physis 5. Diffuse metaphyseal reaction (metaphyseal cysts) 40. Based on radiographic changes in lateral portion of femoral head during fragmentation stage on AP view LATERAL PILLAR - lateral 15-30% of epiphysis on AP xray 41. Group A no involvement Group B at least 50 % of height maintained Group C less than 50% of height maintained 42. Advantage Easy application in active disease High correlation bet lat pillar height and amount of head flattening at skeletal maturity 43. Based on fitting of contour of healed femoral head to template of concentric circles in both AP & Frog leg lateral views Good - < 1 mm Fair - < 2 mm Poor - > 2 mm 44. described in 1981 Alike MOSE classification, its also classification of THE END RESULTS Used to predict the onset of degenerative joint disease following LCPD 45. I Shape is normal II loss of head height < 2 mm deviation of concentric circles Group I & II Spherical Congruency 46. III Elliptical head > 2 mm deviation Contour matches (Incongrous/Aspherical congruency) 47. IV Flattened head, >1 cm of flattening Contour matches (Incongrous/Asph erical congruency) Resemblence with Cows hip 48. V Collapsed head, Contour mismatch (Incongrous/Aspherical Incongruency) 49. AIMS: Prevention of femoral head deformity Prevention of secondary degenerative osteoarthritis. Psychological & Physical development. 50. Elimination of hip irritability. Containment of the head. Restoration good ROM Prevention subluxation. Attainment of spherical head at end of disease 51. For < 2 to 3 yrs Observation For >3 yrs Parents counseling Intermittent symptomatic treatment Home traction & physical therapy Hospitalization loss of ROM Bed Rest SkinTraction slings & springs NSAIDs 52. Petrie cast Broomstick cast Snyder sling 53. TORONTO BRACE TACHDJIAN BRACE NEWINGTON BRACE BIRMINGHAM BRACE 54. Indication: Age of clinical onset > 8yrs of age Herring type B Radiological evidence of loss of containment by conservative modes 55. CONTRAINDICATIONS: Herrings type A and C Herrings type B if child less than 8 yrs Healed cases. Hinged abduction 56. ADVANTAGES Ability to obtain permanant containment of head. Period of Restriction is only 2 months. 57. Innominate Osteotomy Varus Derotational Osteotomy Lateral Shelf procedure Arthrodiastasis 58. Advantages: Anterolateral coverage Lengthening of shortened limb No second operation Disadvantages: Improper coverage in older child Limb length inequality AVN due to raised pressure in joint 59. Indications: Failed conservative for containment 8 10 yrs Uncovered head on MRI / Arthrogram Excessive femoral anteversion 60. Adv: Maximal coverage in old Excessive femoral anteversion Disadv: Excessive varus angulation Shortening Gluteal lurch Non / delayed union 2nd sx reqd. for implant removal Trochanteric overgrowth 61. INDICATION: Lateral subluxation Insufficient coverage Hinged abduction COMPLICATION: Loss of hip flexion lateral femoral cutaneous nerve 62. Rationale: Widening Unloads the joint space Reduces pressure over head Articular cartilage repair Maintain congruency Allows 50 degree flexion 63. Indications & Choice of surgery: 1. Hinged abduction Valgus subtrochanteric osteotomy 2. Malformed head in catterall gr 3 Garceau cheilectomy 3. Coxa magna shelf augmentation 4. Large malformed head with subluxation VDRO + Pelvic osteotomy 5. Capital physeal arrest & troch overgrowth 64. Failure of lateral end of epiphysis to slide under the edge of acetabulum on an internally rotated & abducted AP X rays is s/o HINGED ABDUCTION. 65. Combination of VALGUS FLEXION INTERNAL ROTATION OSTEOTOMY Coxa vara & hinged abduction - valgus Changes articular relations valgus & flexion External rotation of limb internal rotation Improve anterolateral head coverage 66. Indication: Large mushroom head (coxa plana) Lateral protruberance Disadv: Physeal slippage Postop joint stiffness 67. Indications: Older children with painful hip Significant femoral head flattenning. 68. Elevation of GT Shortening of neck Vertical pull of muscles Impingement of GT on rim of aceta GEAR STICK SIGN 69. Trochanteric Advancement GT epiphysiodesis Trapezoidal osteotomy of GT 70. Lateral calcification Extent of uncovering of head Lateral head displacement Widening of head & neck during early stages (mushroom head) 71. Saturn phenomenon (sclerotic epiphysis surrounded by ring of lucency) Premature physeal closure 72. Shape of Femoral head & congruency with acetabulum most imp predictor Age of onset of disease & duration