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Legg Calve Perthes Disease Synonyms Perthes Disease Osteochondritis Deformans Juvenilis Childhood Aseptic Necrosis of Femoral Head Dr. P. Ratan khuman (PT) M.P.T., (Ortho & Sports)

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  • 1.Synonyms Perthes Disease Osteochondritis Deformans Juvenilis Childhood Aseptic Necrosis of Femoral Head Dr. P. Ratan khuman (PT) M.P.T., (Ortho & Sports)

2. Definition Perthes disease is a self-limiting form of osteochondrosis of the capital femoral epiphysis of unknown aetiology that develops in children commonly between the ages of 5 12 years. It is a condition of immature hip caused by necrosis of the femoral epiphysis; the femoral head subsequently deforms as necrotic bone is replaced by living bone. It is Hip disease occurring during early childhood and caused by impaired circulation in the femoral head.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 2 3. Historical background The disease was described almost simultaneously, in 1910, by G. C. Perthes in Germany, J. Calve in France A.T. Legg in America. Hence name Legg Calve Perthes Disease The newly discovered x-ray technique allowed doctors to differentiate it from inflammatory forms of hip disease.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports)3 4. Etiological Factors that play a rolein development of illness Vascular supply Increased intra-articular pressure Intraosseous pressure Coagulation disorder Growth hormones Growth Social conditions Genetic factors22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 4 5. Vascular supply: Angiograms & laser Doppler flow measurements Medial circumflex artery is missing or obliterated in many cases Obturator artery or the lateral epiphyseal artery are also affected in some cases.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports)5 6. Increased intra-articular pressure: Animal experiments have shown that an ischemiasimilar to that in Perthes disease can be generatedby increasing the intra-articular pressure. However, the condition of transient synovitis of thehip does not appear to be a precursor stage of Perthesdisease as the increased pressure resulting fromthe effusion in transient synovitis does not leadto vessel closure.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 6 7. Intraosseous pressure: The measurement of intraosseous pressure inPerthes patients has shown that the venousdrainage in the femoral head is impaired, causingan increase in intraosseous pressure. In animal studies, the intraosseous injection offluid, and the associated increase in pressure,produced a condition similar to Perthes disease22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 7 8. Coagulation disorder : Study have found a coagulation disorder in 75%children with Perthes disease. In most cases the disorder was thrombophilia. Rarely the disorder involved elevated serumlevels of lipoprotein, a thrombogenic substance. Recent studies have questioned the significanceof clotting factors as an etiological component22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports)8 9. Growth hormones : While earlier studies found reduced levels of thegrowth hormone. Recent studies have not shown any differencefrom control groups in respect of hormone status22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports)9 10. Growth: Children with Perthes disease are shorter, onaverage, than their peers of the same age & showa retarded skeletal age (cartilaginous dysplasia). The maturation disorder occurs between the agesof 3 and 5 years. Both the trunk and extremities lag behind interms of growth.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports)10 11. Growth cont The shortening of the extremities is alsoaccompanied by small feet. Since this shortening is offset by excessivegrowth at a later age, patients who suffered fromPerthes disease as children are no shorter, asadults, than the population average. More recent experimental studies have shownthat the metaphyseal changes are based on agrowth disorder.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 11 12. Social conditions: Studies in the UK have shown that Perthesdisease is more common in the lower socialstatus. The authors suggest a poorer diet duringpregnancy as one possible explanation for thisphenomenon. A recent study did not confirm this theory22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports)12 13. Genetic factors: Studies have shown that first degree relatives ofchildren with Perthes disease are 35 times morelikely to suffer from the condition than thenormal population. Even second- and third-degree relatives show afourfold increased risk.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports)13 14. To sum up Genetic factors play an important role in theetiology of Perthes disease. The illness develops as a result of impairedcirculation in the medial circumflex artery inassociation with a skeletal maturationdisorder with delayed growth in childrenaged from 35 years.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 14 15. Occurrence In white population is 10.8 per 1,00,000 children & adolescents aged from 015 year In Asians is 3.8 per 1,00,000 In Mixed-race populations is 1.7 per 1,00,000 In Blacks is 0.45 per 1,00,000 The highest reported incidence was in city of Liverpool (UK) early 1980s, with 15.6 per 1,00,000 individuals under 15 years of age.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 15 16. A decline was subsequently observed in the 1990s possibly as a result of the improved social conditions. Similarly high incidence 15.4 per 1,00,000 was recently reported in a rural area of Southwest Scotland. In Sweden an annual incidence of 8.6 per 100,000 people under 15 yrs was Determined.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports)16 17. Epidemiology Disorder of hip in young children Usually ages 4-8yr As early as 2yr, as late as teenager Boys: Girls 4/5:1 Bilateral 10-12% No evidence of inheritance22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 17 18. Classification All known classifications of Legg-Calv- Perthes disease are based on the morphological findings on x-rays.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 18 19. Morphological classifications ofthe extent of the lesionClassification according to Catterall (Common)Classification according to Salter & ThompsonClassification according to Herring22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 19 20. Classification of extent of lesion - (Acc to Catterall)Grade CharacteristicsIOnly anterolateral quadrant affectedII Anterior third or half of the femoral head Up to 3/4 of the femoral head affected, III only the most dorsal section is intact IVWhole femoral head affected22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 20 21. Grade I Only anterolateral quadrant affected22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 21 22. Grade - II Anterior third or half of the femoral head22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 22 23. Grade III Up to 3/4 of the femoral head affected, only the most dorsal section is intact22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 23 24. Grade IV Whole femoral head affected22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 24 25. Classification according to Salter& Thompson Group CharacteristicsASubchondral # involving 50% of the femoral dome22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 25 26. 8-year old boy with subchondral fracture and incipient Legg-Calve- Perthes disease22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 26 27. Classification according to HerringGroup CharacteristicsALateral pillar not affected >50% of height of lateralB pillar preserved 50% of height of lateralpillar preserved22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 29 30. Classification according to Herring C 50% Increase ROM to > 75% of thelessof the uninvolved side uninvolved side Increase ROM to Increase strength to Increase strength to > 75% of >90% of the>50% of thethe uninvolved side uninvolved sideuninvolved side Progress from use of an Increase strength to > Patient to beassistive device if approved by 90% of the uninvolvedindependent with the physician and without adverse sideappropriate assistiveeffects Improve balance todevice and weight Independence with a step to >90% of the maximumbearing precautionspattern on stairs without UEPediatric Balance Scale Improve balance to support score or single limb>50% of the maximum Improved efficiency in walkingstance of the uninvolvedPediatric Balance Scale Improved balance to > 75% ofsidescore or single limb the maximum Pediatric Balance Ambulation with a non-stance of the uninvolved Scale score or single limb stance painful limp withside.of the uninvolved sidenormal efficiency 22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 69 70. Pain ManagementCLIPer Hot pack with stretching score Cryotherapy14 to 24 Medications as prescribed by the referring physician for painCLIPer Hot pack with stretching score Cryotherapy6 to 13 Medications as prescribed by the referring physician for painCLIPer Hot pack with stretching score Cryotherapy0 to 5 Medications as prescribed by the referring physician for pain 22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 70 71. ROM Management Static stretch for LE musculature with or without hot pack Dynamic ROM & AAROM if muscle guarding due to painCLIPer and is unable to achieve end ROM with static stretch. score Perform AROM and AAROM following passive stretching to14 to 24 maintain newly gained ROM . Stretching for hip IR, ER, Abd, Extensor, & any other lower extremity motion that is significantly limitedCLIPer score Same as above6 to 13 Dosage of may differ based on patient preference & comfort.CLIPer score Same as above0 to 5 Dosage of may differ based on patient preference & comfort.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 71 72. ROM cont Static Stretching Parameters 2 minutes of stretching/day/muscle group 30 second hold time 4 repetitions per muscle group If not tolerated, may do 10 to 30 second holdtime with repetitions adjusted to meet 2 minuterequirement e.g. if holding 15 seconds, would do 8 stretches22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports)72 73. ROM cont Dynamic Stretch Parameters 5 second hold 24 repetitions per muscle group per day to meet2 minute stretching time required Done if patient does not tolerate static stretch22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports)73 74. Strengthening Ex (CLIPer score 14 to 24) Isometric Ex -> Isotonic Ex in gravity lessened -> Isotonic Ex against gravity. It is appropriate to include concentric and eccentric contractions. Begin with 2 sets of 10 to 15 rep of each ex, progression to 3 sets of each exs. Note: If the patient is unable to perform 2 setsof 10 rep, the difficulty of the ex is to bedecreased either through weight or type of ex.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports)74 75. Strengthening Ex (CLIPer score 14 to 24) Focus on strengthening of HIP (Abd + Flexors + ER + IR + Extensors + or any other LE muscle group that displays significant strength deficits). Special attention to gluteus medius to min intra- articular pain & for pelvic control during single leg activities and ambulation . Weight bearing Vs Non-weight bearing ex is based on patients tolerance to weight bearing positions, and safety.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 75 76. Strengthening Ex (CLIPer score 14 to 24) Closed chain double limb exercises with light resistance (less than full body weight) It is not recommended to perform single limb closed chain ex on the involved side due to increased intra-articular pressure in the hip joint.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 76 77. Strengthening Ex (CLIPer score 6 to 13) Isotonic Ex in gravity lessened -> Isotonic Ex against gravity. Include concentric & eccentric contractions. Weight bearing and non-weight bearing activities can be used in combination based on the patients ability and goals of the treatment session.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 77 78. Strengthening Ex (CLIPer score 6 to 13) Upper extremity supported functional dynamic single limb activities may be performed. e.g. step ups, side steps Double limb closed chain ex may be used with light resistance if weight bearing allows. e.g. mini-squats22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 78 79. Strengthening Ex (CLIPer score 0 to 5) Isotonic Ex in gravity lessened -> Isotonic Ex against gravity. Include concentric & eccentric contractions. Functional dynamic single limb activities with UE support as needed for patient safety may be performed. e.g. step ups, sidesteps Closed kinetic chain single limb exercises with light resistance may be performed. E.g. leg press22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 79 80. Strengthening Ex Prescription Special attention should be given to: Hip abductors (especially gluteus medius) Hip internal rotators Hip external rotators Hip flexors Hip extensors22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 80 81. Isometric Strengthening Parameters 10 sec hold + 10 rep/muscle gr, total = 100 sec. Can adjust hold time to 5 sec + 20 rep to meet100 sec requirement Intensity Performed at approx. 75% maximal contraction Performed with hip in neutral position22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 81 82. Isotonic Strengthening Parameters High repetitions (10 to 15 reps) and 2 to 3 sets Perform both concentric & eccentric contraction Low resistance Rest 1 to 3 minutes between sets Rest can include exercise of a different muscle group or cessation of activity If pt is unable to perform 2 sets of 10 rep, exercise intensity should be decreased either through weight or type of exercise22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 82 83. Balance training (CLIPer score 14 24) If weight bearing status & symptoms allow Activities that include double limb stance and anarrowed base of support on stable surfaces maybe performed.It is not recommended to perform single limb activities due to increased intra-articular pressure in the hip joint.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 83 84. Balance training(CLIPer score 6 13 & 0 5) Same as previous stage Limit prolonged single limb activities due to excessive joint compressive forces22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 84 85. Gait training (CLIPer Score 14 24) Follow the referring physicians guidelines for weight bearing status. Begin gait training with Appropriate assistive device Weight bearing status as determined by thereferring physician or Based on the patients tolerance to full weightbearing due to pain or safety22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 85 86. Gait training (CLIPer Score 6 13) Continue to follow the referring physicians guidelines for weight bearing status. Progress to gait training without use of an assistive device as appropriate, focusing on minimizing deficits and improving efficiency of walking. Stair negotiation and other functional mobility.22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 86 87. Gait training (CLIPer Score 0 5) Continue to follow the referring physicians guidelines for weight bearing status Progress to gait training without the use of an assistive device as appropriate, focusing on minimizing deficits and improving the efficiency of walking. Stair negotiation & other functional mobility. Progress to walking on uneven surfaces with an emphasis on safety.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports)87 88. Weight Relief The load on the hip can basically be relieved by the following methods: Bed rest Wheelchair Walking with crutches, Bracing devices (Thomas splint , Mainz orthosis,etc.).22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 88 89. Petrie Cast22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 89 90. Broomstick Cast22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 90 91. Bracing22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 91 92. Discharge Criteria Children may be discharged when 4 of the 5 following criteria have been met: Pain rating 0 to 1/10 ROM 90 to 100% of the uninvolved side Strength 90 to 100% of the uninvolved side Balance 90 to 100% of the max score on thePediatric Balance Scale or maintaining balance withSLS 90 to 100% of the uninvolved side Gait presents with a non-painful limp and uses areciprocal pattern on the stairs.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 92 93. Prognosis 60% of kids do well without Rx AGE is key prognostic factor: 9y containment option is questionable, poorerprognosis, significant residual defect22 June 2012Dr.Ratan M.P.T.,(Ortho & Sports) 93 94. Operative Tx If non-op Rx cannot maintain containment Surgically ideal pt: 6-9yo Catterral II-III Good ROM