legg-calve-perthe’s disease-kaizar

of 48/48
Legg-Calve-Perthe’s Legg-Calve-Perthe’s Disease Disease Dr.E.Kaizar Ennis Dr.E.Kaizar Ennis

Post on 27-Nov-2014

368 views

Category:

Documents

3 download

Embed Size (px)

TRANSCRIPT

Legg-CalveLegg-Calve-Perthes DiseaseDr.E.Kaizar Ennis

DEFINITION

It is a self-limited non-infectious disease of the hip joint occuring in children characterised pathologicaly by avascular necrosis of the ossification center of capital femoral epiphysis which is alternately resolved and replaced resulting in variable degrees of deformity of the femoral head and restricted movements of the hip joints.

HISTORY

Described first by Waldenstrom in 1909 who mistakenly ascribed it to tuberculosis. In 1910 Arthur Legg , U. S. A Jacques Calve , France George Perthes ,Germany described and recognized it as non-infectious in origin. In 1922 Waldentrom gave the correct interpretation and described the stages.

INCIDENCE

1:1200 p 1:12000 4M:1F :1F 2- 12 years (mean 7 years) 5-20% bilateral (In bilateral cases changes appear in one hip at least one year earlier than the other)

British Isles: Catterall 1970(388 cases)

Aetiological Theories

Arterial occlusion Mechanical obstruction Trauma

Venous congestion Thrombophilia & hypofibrinolysis Disorder epiphyseal cartilage The aetiology may be ultimately multifactorial Salter & Bell JBJS 1968 Glueck et al JBJS 1996 Ponseti JBJS 1983

BS of the infant femoral headMetaphyseal vessels Lateral Epiphyseal vessels Vessels of the ligamentum teres.

STAGES OF PATHOLOGICAL PROCESS1. Stage of synovitis 2. Stage of AVN 3. Stage of fragmentation 4. Stage of regeneration 5. Stage of healing.

SIGNS

Stage of AVNWaldenstrom sign crescent sign

Stage of regenerationA growth arrest line that outlines the ossific nucleus at the time of initial infarction is represented by ahead within a head SIGN

The greater Trochanter becomes hypertrophied and elevate proximally, elevation impairs the power of abductor muscles and leads positive trendelenburg. trendelenburg. The combination of a short femoral neck and a high greater trochanter is considered functional coxa vara vara

HEAD AT RISK SIGNSSIGNSCLINICAL

LOSS OF HIP MOTION IS PERSISTANT AND PROGRESSIVE INCREASED ADDUCTION CONTRACTURE OF HIP THE OBESE CHILD FEMALE CHILD AGE >7YRS

SYMPTOMS

Mild intermittent pain in the hip,thigh or knee Onset of pain is acute or insidious The classical presentation has been described as painless limp

Because the presenting symptoms are usually mild, the parents do not seek medical attention long after the onset of symptoms. A small % of children have a history of trauma

Clinical ExaminationAntalgic gait Tenderness Muscle spasm Limitation of movement (abduction and internal rotation) Muscle wasting Leg length inequality

DIFFERENTIAL DIAGNOSIS

UNILATERAL CASES Septic arthritis Sponondyloepiphyseal dysplasia Rheumatoid arthritis Tuberculosis Juvenile rheumatoid arthritis

BILATERAL CASES Hypothyroidism Multiple epiphyseal dysplasia Mucopolysacharidosis Sickle cell disease Spondyloepiphyseal dysplasia

Investigations

CBC ESR CRP Urine RE RADIOGRAPHY BONE SCINTIGRAPHY MRI USG ARTHROGRAM ANGIOGRAPHY

Classification systems

Catterall Salter and Thompson Herrings lateral pillar Stulberg

Catterall Classification

Group 1 anterior portion of the epiphysis Group 2-anterior and central 2 Group 3-Most of the epiphysis is 3sequestrated Group 4-All of the epiphysis is 4sequestrated

Salter Thompson classification

Type A Extent of subchondral fracture < 50% of superior dome of HOF Good prognosis

Type B Extent of subchondral fracture > 50 % of superior dome of HOF Fair or poor prognosis

Lateral Pillar Classification by Herring

Based on radiographic changes in the lateral portion of the femoral head when it enters the fragmentation stage as seen in AP view

Herrings

Group A-Minimal density change in the Alateral pillar-good outcome pillarGroup B- height loss upto 50%- moderate B50%outcome Group C- height loss > 50%-worst C50%outcome

Stulberg Classification

Group I Shape of HOF is normal Group II within 2 mm to a concentric circle Group III more than 2 mm (congruous incongruity) Group IV HOF flattened area > 1 cm in length(congruous incongruity) Group V Collapse of HOF (incongruous incongruity)

Determination of final outcome

MOSEMOSE-AP & LAT VIEWS with Mose templateFinal shape of the head may be compared to a perfect circle:When the head contour is within 1 mm of a given circle ,the result is deemed good. When the head contour is within 2 mm ,the result is deemed fair. When the head contour is greater than 2 mm ,the result is deemed poor.

Head at Risk Factors-Radiological Factors1. 2.

3.

4. 5.

Lateral subluxation of femoral head Gages sign a radioluscent V in the lateral aspect of the epiphysis Calicification lateral to the epiphysis (*Cage sign) A horizontal physeal line Diffuse metaphyseal reaction (Metaphyseal cyst)

Gage Sign

Small osteoporotic segment forming a translucent VVshaped trough in the lateral part of the epiphysis

CAGE SIGN

Calcification of the lateral epiphysis.

Crescent sign/Salter sign/Caffreys

Trabeculae in dead bone may fracture in subchondral region

Lateral subluxation

Sagging Rope Sign

TREATMENT

Goals of Treatment1.

Elimination of hip irritability Restoration & maintenance of hip motion Prevention of extrusion and collapse. Attainment of a spherical HOF

2.

3.

4.

PRINCIPLES

Full mobility Containment of the femoral head Resume wt. bearing & activity as soon as possible.

Phases of Treatment

Phase 1 Initial phase Phase 2 Containment and maintenance of HOF within acetabulum and restoration of full ROM Phase 3 Reconstructive surgery

Phase 1

Restore full ROM Traction at home B/L counterpoised split Russels traction with a medial rotation stop on the thigh Investigation Analgesics Observation

Phase 2(Containment by orthoses/surgery)

Containment using Orthoses All braces abduct the affected hip, allows for hip flexion and control rotation of the limb Before starting containment, restore normal ROM byBed rest Traction Analgesics Decrease weight bearing by crutches

ORTHOSES

PREREQUISITESFULL RANGE OF MOTION WITH RELIEF OF MUSCLE SPASM ENTIRE FEMORAL HEAD SHOULD BE CONCENTRIC AND FULLY CONTAINED WITH IN THE ACETABULUM MOTOR STRENGTH AND BALANCE TO USE THE ORTHOSES REASSESS EVERY 4-8 WEEKS FOR 4

GAIT RANGE OF MOTION XRAY

TYPES OF ORTHOSIS

NON AMBULATORY BROOMSTICK PLASTIC CAST BIVALVED HIP SPICA CAST

AMBULATORY STATIC HARRISON HIP CONTAINTMENT

DYNAMIC

BILATERAL NEWINGTON HIP CONTAINMENT SCOTTISH RITE

UNILATERAL TRILATERAL SOCKET HIP ABDUCTION

Adujustable broomstick plaster

NEWINGTON HIP CONTAINMENT

Atlanta Scottish Rite Brace

Containment by orthosis:Signs of healingAppearance of irregular ossification in the capital femoral epiphysis No new radio opaque areas Medial segment of femoral head should increase in height There should be an intact lateral column

COMPLICATIONS

PERSISTENT OR RECURRENT LOSS OF HIP MOTION PROGRESSIVE COLLAPSE AND SUPEROLATERAL EXTRUSION OF FEMORAL HEAD

SURGICAL CONTAINMENT

SURGERY

ADVANTAGES NO END POINT OF TREATMENT IS REQUIRED RAPID RESUMPTION OF ACTIVITY

DIS ADVANTAGES SECOND OPERATION TO REMOVE IMPLANT COMPLICATION OF SURGERY

PREREQUISITES

ABSENCE OF IRRITABILITY OR RESTRICTION OF HIP MOTION ABSENCE OR MINIMAL DEFORMITY OF FEMORAL HEAD CONCENTRIC CONTAINMENT BY ABD,MEDIAL ROTATION AND FLEXION

CONTAINMENT PROCEDURESInnominate Osteotomy (Salter) Femoral Osteotomy

Lateral opening wedge osteotomy Varus derotation osteotomy

Combined Femoral & Innominate osteotomy LATERAL SHELF PROCEDURE

Arthrodiastasis

Phase 3 Reconstructive SurgeriesLOWER LIMB INEQUALITY GREATER TROCHANTER OVERGROWTH AND COXA BREVA HINGED ABDUCTION COXA MAGNA INCONGROUS HIP OSTEOCHONDRITIS DISSECANS

Phase 3 Reconstructive SurgeriesValgus extension osteotomy Valgus flexion and internal rotation osteotomy Cheilectomy Shelf procedure by Staheli

Salvage procedures

Garceaus cheilectomy Chiaris osteotomy Trochanteric epiphyseodesis Trochanteric advancement Valgus osteotomy Hip replacement

PROGNOSIS

AGE EXTENT PROTRUSION OF FEMORAL HEAD GROWTH DISTURBANCE OF PHYSIS METAPHYSEAL CHANGES STAGE IN THE NATURAL COURSE OF THE DISEASE PERSISTENT LOSS OF HIP MOTION OBESE CHILD

THANK YOU.