RADIOGRAPHY

MAGNETIC RESONANCE IMAGING

BONE SCINTIGRAPHY

ULTRASONOGRAPHY

ARTHOGRAPHY

COMPUTED TOMOGRAPHY

Plain X ray of PELVIS WITH BOTH HIP JTS AP view Lowenstein’s frog-leg lateral view Abduction – Adduction views

Knee joints – AP / Lat Wrist joints – AP / Lat

Waldenstrom’s classification – four stages INITIAL STAGE FRAGMENTATION STAGE REOSSIFICATION (HEALING) STAGE RESIDUAL STAGE

Smaller osiffic nucleus

Lateralization of femoral head in the acetabulum

Widening of medial jt space

Waldenstrom / caffeys sign Vaccum phenomenon

Radio-dense femoral head

Cyst & leucency in metaphysis

END OF STAGE: appearance of lucencies in nucleus

6m( up to14m)

Lucent areas appear in the ossific nucleus of femoral head

Demarcation of femoral segments (pillars) – often central dense

Milder form – only ant segement seen on frog-leg lateral

More severe – no demarcation of pillars

END OF STAGE – appearance of new bone in subchondral area

8m(2 – 35m)

STARTS WITH - 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

mild gradual flatenning – children < 5

yrs whose femoral head is totally involved

most improve 51m(2-122m)

femoral head is fully reossified head remodels so does the

acetabulum Head – normal / extremely flat /

aspherical Physis is inlvolved – overgrowth of

greater trochanter

Gill(1940) – metaphyseal necrosis & lucencies (“holes of decalcification”)

Ponseti – cystic changes in neck Prognostic

value – poor outcome

Sagging rope sign

radiodense line in prox femoral metaphysis

Metaphyseal response to physeal damage

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

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

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)

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

Used for early diagnosis of LCP disease

Detects – Configuration of femoral head &

acetabulum Congruity of articular surface Femoral head containment Joint effusion

Synovial hypertrophy Epiphyseal involvement True extent of femoral head necrosis

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.

Effective tool for diagnosis of pre-radiological early stages

Revascularization patterns

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

Currently, mainly used in early diagnosis of HINGED ABDUCTION

In early stages - Joint effusion

In later stages – assess shape of cartilagenous femoral head

provides acurate 3 D images of shape of femoral head & acetabulum

1. LEGG2. WALDENSTROM3. GOFF4. SALTER THOMPSON 5. CATERALL 6. HERRING’S LATERAL PILLAR7. MOSE8. STULBERG

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

Extent of subchondral # in both AP & lowenstein frog leg lateral xrays

reliable indicator in the group with fractures

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

Extent of the fracture is more than 50% of the dome, › fair or poor results can

be expected

In 1971 used radiological findings of

epiphyseal involvement to identify 4 groups

anterior femoral head involvement

no evidence of sequestrum, subchondral fracture line, or metaphyseal abnormalities

anterolateral involvement

Central sequestrum

Well demarcated

metaphyseal lesions

Subchondral fracture line – Ant ½

lateral column is intact.

large sequestrum - 3/4th of head.

Junction is sclerotic.

Diffuse Metaphyseal lesions , anterolaterally

Subchondral fracture line - post 1/2

The lateral column is involved.

Entire head

Diffuse or central metaphyseal lesions

posterior

remodeling of the epiphysis

1. Gage sign : Described by COURTNEY GAGE(1933) small osteoporotic segment which forms a radiolucent V-shaped defect on lateral epiphysis & adjacent metaphysis on AP xray .

2. Speckled calcification lateral to epiphysis

3. Lateral subluxation of femoral head4. Horizontally oriented physis5. Diffuse metaphyseal reaction

(metaphyseal cysts)

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

Group A – no involvement

Group B – at least 50 % of height maintained

Group C – less than 50% of height maintained

Advantage

Easy application in active disease

High correlation bet lat pillar height and amount of head flattening at skeletal maturity

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

described in 1981 Alike MOSE classification, its also

classification of THE END RESULTS Used to predict the onset of

degenerative joint disease following LCPD

I – Shape is normal II – loss of head height

< 2 mm deviation of concentric circles Group I & II – “Spherical Congruency”

III – Elliptical head> 2 mm deviation

Contour matches (“Incongrous/Aspherical congruency”)

IV – Flattened head, >1 cm of flattening

Contour matches (“Incongrous/Aspherical congruency”)

Resemblence with Cow’s hip

V – Collapsed head,Contour mismatch (“Incongrous/Aspherical

Incongruency”)

AIMS: Prevention of femoral head deformity

Prevention of secondary degenerative osteoarthritis.

Psychological & Physical development.

Elimination of hip irritability.

Containment of the head.

Restoration good ROM

Prevention subluxation.

Attainment of spherical head at end of disease

For < 2 to 3 yrs – Observation

For >3 yrs –

Parents counseling

Intermittent symptomatic treatment Home traction & physical therapy Hospitalization – loss of ROM Bed Rest Skin Traction – slings & springs NSAIDs

Petrie cast “Broomstick cast”

Snyder sling

TORONTO BRACE

TACHDJIAN BRACE

NEWINGTON BRACE

BIRMINGHAM BRACE

Indication:

Age of clinical onset > 8yrs of age

Herring type B

Radiological evidence of loss of containment by conservative modes

CONTRAINDICATIONS: Herring’s type A and C

Herring’s type B if child less than 8 yrs

Healed cases.

Hinged abduction

ADVANTAGES Ability to obtain permanant

containment of head.

Period of Restriction is only 2 months.

Innominate Osteotomy Varus Derotational Osteotomy

Lateral Shelf procedure

Arthrodiastasis

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

Indications:

Failed conservative for containment

8 – 10 yrs

Uncovered head on MRI / Arthrogram

Excessive femoral anteversion

Adv: Maximal coverage in old Excessive femoral anteversion

Disadv: Excessive varus angulation Shortening Gluteal lurch Non / delayed union

2nd sx reqd. for implant removalTrochanteric overgrowth

INDICATION:

Lateral subluxation

Insufficient coverage

Hinged abduction

COMPLICATION: Loss of hip

flexion

lateral femoral cutaneous nerve

Rationale: Widening Unloads the joint

space Reduces pressure

over head Articular cartilage

repair Maintain congruency Allows 50 degree

flexion

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 – Trochanteric advancement or arrest

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.

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

Indication: Large mushroom head

(coxa plana) Lateral protruberance

Disadv: Physeal slippage Postop joint stiffness

Indications:

Older children with painful hip

Significant femoral head flattenning.

Elevation of GT Shortening of

neck Vertical pull of

muscles Impingement of

GT on rim of aceta – “GEAR STICK SIGN”

Trochanteric Advancement

GT epiphysiodesis

Trapezoidal osteotomy of GT

Lateral calcification

Extent of uncovering of head

Lateral head displacement

Widening of head & neck during early stages (mushroom head)

Saturn phenomenon (sclerotic epiphysis surrounded by ring of lucency)

Premature physeal closure

Shape of Femoral head & congruency with acetabulum – most imp predictor

Age of onset of disease & duration