legg- calve – perthes disease. anatomy acetabular retroversion

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Legg- Calve Perthes disease

Legg- Calve Perthes disease

Anatomy

Acetabular retroversion

Etiology of Legg-Calve-Perthes Disease

Factors That May Be EtiologicTraumaSusceptible childHereditary factorsCoagulopathyHyperactivityPassives smoking

Factors Unlikely To Be EtiologicEndocrinopathyUrban environmentSynovitis

Clinical Features of Legg-Calve-Perthes Disease

Onset: between 18months of age andskeletal maturity (most prevalent between 4-8years )12years of age Male sex prevalence: the disease is four orfive times more likely to develop in boys thanin girls Involvement: bilateral in 10%to 12% of patientsClinical Features of Legg-Calve-Perthes DiseaseSymptoms -limp that is exacerbated by activity and alleviated with rest -pain, which may be located in the groin,anterior hip region, medial knee joint or laterally around the greater Trochanter- history of antecedent trauma

Clinical Features of Legg-Calve-Perthes Disease SignsAbductor limp

Decreased range of motion of the hip, especially on abduction and internal rotation - Flexion/extension less affectedSymptoms and Signs of Legg-Calve-Perthes DiseaseSymptomsLimpingHip painKnee painHistory of trauma (?)SignsLimpDecreased hip range of motionSpasm of long muscle around hip joint

Differential Diagnosis for Legg-Calve-Perthes DiseaseOther Causes of Avascular NecrosisSickle cell diseaseOther hemoglobinopathiesThalassemiaSteroid medicationAfter traumatic hip fracture & dislocationTreatment of developmental dysplasia of the hipPathologic Findings of Legg-Calve-Perthes Disease

Early StageDead trabecular bone , Collapsed trabeculaeThickened articular cartilage , Physeal disruptionCartilage extending from the physis into the metaphysisFragmentation StageInvasion of vascular granulation tissueNew bone forming on old trabeculaeWoven new bone formationHealing StageNew bone, woven and lamellarReturn to normai architecture

Differential Diagnosis for Legg-Calve-Perthes DiseaseEpiphyseal DysplasiasMuitiple epiphyseal dysplasiaSpondyloepiphyseal dysplasiaMucopolysaccharidosesHypothyroidismDifferential Diagnosis for Legg-Calve-Perthes DiseaseOther SyndromesOsteochondromatosisMetachondromatosisSchwartz-Jam pel syndromeTrichorhinophalangeal syndromeMaroteaux-Lamy syndromeCaterall classification Group I, partial head or less than half head involvement; Groups II and III, more than half head involvement and sequestrum formation Group IV, involvement of the entire epiphysisLateral pillar classification

Imaging Evaluation

Imaging Evaluation

X-Ray

Imaging EvaluationMRIBone scanArthrographyX-ray

Treatment

The primary aim of treatment of Legg-Calv-Perthes disease is containment of the femoral head within the acetabulumBracing

Bracing

Varus Derotational Osteotomy

Proximal femoral varus osteotomy

2 -(A) A 6.5-year-old boy 1 month after onset of symptoms. Initially, observation is recommended in this age group. (B, C) Radiographs 6 months after presentation show fragmentation stage of disease with progressive lateral migration with loss of height of the femoral head. (D) Arthrogram demonstrates containment without hinge abduction. Note deformity of femoral head even though it can still be contained. (E) Intraoperative radiographs show excessive varus with neck-shaft angle less than 115. The patient was immobilized in a hip spica cast for 4 weeks. (F) Scanogram 1 year postoperative (8 years 1 month) demonstrates persistent varus with 2-cm limb-length discrepancy. (G) Scanogram at age 11 years demonstrates less than 1-cm limb-length discrepancy. (H, I) Anteroposterior (AP) radiograph standing and lateral radiograph at 14 years of age demonstrate Stulberg 2outcome with spherical femoral head and improvement in articulo-trochanteric distance. Clinical examination demonstrated a normal gait, negative Trendelenburg test, and loss of 30 internal rotation and 20 of abduction compared with the opposite hip.25

(A) Anteroposterior pelvis diagram of a patient with Perthes disease with hip impingement. (B) Attemptedabduction causes tilting of the pelvis and hip pain. The lateral portion of the femoral head impinges on thelateral margin of the acetabulum and causes the joint to hinge open medially. (C) When planning a valgus osteotomya radiograph is obtained with the hip in an adducted position to indicate whether the anterolateral bumpcan be moved away from the acetabular rim. (D) Diagram demonstrates correction of impingement andimproved pelvic position after proximal femoral valgus osteotomy26

Proximal femoral valgus osteotomy

4 - A case treated by proximal femoral valgus osteotomy for irreducible hinge abduction. (A) A radiograph of a 7-year-4 month-old boy shows markedly collapsed, subluxated femoral head in the fragmentation stage. On arthrograms, the femoral head and acetabulum remain incongruent in a neutral (B) or abducted (C) position, but becomes congruent in adducted position (D). The labral position is assessed as uncomfortable (35 of Hilgenreiner-labral angle) in abduction (D). An abduction cast with tenotomy of adductor and psoas was followed by shelf acetabuloplasty (E). (F) A radiograph taken at 6 years and 10 months after surgery shows a round femoral head with Stulberg type 2 deformity, suggestive of satisfactory hip remodeling with increased acetabular depth growth and prevention of hip subluxation32Chiari osteotomy

10 -(AC) Anteroposterior, Abduction, and lateral radiographs of an 8-year-old boy with Perthes disease in early fragmentation phase. Abduction is limited to 15. Failure of the capital epiphysis to slide under the acetabulum is indicative of hinge abduction. (D,E) Six months later, the epiphysis is flattened, and hinge abduction is now obvious on the abduction view. (F) Arthrogram confirms hinge abduction. (G,H) Three years after Chiari osteotomy, the femoral head is ovoid but improving. Range of motion now matches the opposite side.33

(A) Depiction of femoral head deformity secondary to Perthes with risk for subluxation caused bya dysplastic acetabulum. (B) Risk for further subluxation may increase after proximal femoral valgus osteotomy.(C) Shelf acetabuloplasty to prevent femoral head migration after proximal femoral valgus osteotomy may beindicated for patients with an upward-sloping acetabular margin34Double-level osteotomy

8 - A case with a satisfactory outcome after double-level osteotomy for reducible hinge abduction. (A) A radiograph of an 8-year-9 month-old boy shows subluxated femoral head in the fragmentation stage. An abduction cast with tenotomy of adductor and psoas was performed as an initial surgery. Arthrograms (BD) at the time of femoral varus osteotomy and Dega osteotomy (E) suggest reducible hinge abduction; the labral position is assessed as uncomfortable (labral tip is at the same level with the tip of the epiphysis) in hip neutral (B) and adduction (C), but as comfortable (>35 of Hilgenreinerlabral angle) in abduction (D). (F) A radiograph taken 2 years after surgery shows a well-contained, round femoral head with Stulberg type 2 deformity.35Greater trochanteric advancement

11 -(A) Female, 13 years old, 5 years after hip distraction treatment for a Herring C stage Perthes disease with recurrent pain secondary to anterior hip impingement. (B) Postoperative: surgical dislocation of the hip demonstrating the anterior impingement excision and relative femoral neck-lengthening with greater trochanteric advancement. (Copyright 2011, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD.)36Treatment 1. Most patients can be treated by noncontainment methods and obtain good results (84%). 2. Satisfactory clinical results frequently can be obtained at long-term follow-up despite an unsatisfactory radiographic appearance (nine hips). 3. The Catterall classification is a valid indicator of results, but is not applicable as a therapeutic guide for an average of 8.1 months after onsetTreatment 4. Head-at-risk signs added little to the Catterall classification as a prognostic indicator or therapeutic guide. 5. All of the fair and poor results were in patients with Catterall III or IV involvement and onset of the disease at age 6 or older. (A Catterall III or IV classification is equivalent to Herring groups B and C.)

Scott Schlatter disease

Scott Schlatter disease