presenters: dr. maina/dr. ondari facilitator: dr. t. mogire 01/08/2013 legg-calve-perthes disease...

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  • PRESENTERS: DR. MAINA/DR. ONDARIFACILITATOR: DR. T. MOGIRE01/08/2013Legg-Calve-Perthes Disease


  • Georg Perthes (1869-1927)

  • First described by Karel Maydl

  • Epidemiology Incidence 1-4/10,000

    Age 4 - 10years; average 7 yrsAs early as 2yrs as late as teens

    Boys : girls 4:1

    Bilateral 10-12%

    No evidence of inheritance

    Common in Caucasians; rare in black races

  • Etiology Idiopathic

    Past theoriesInfection, inflammation, trauma, congenital

    Most theories involve vascular compromise

  • Pathophysiology Rapid growth occurs in relation to devt of blood supply

    Interruption of blood supply results in necrosis, removal of necrotic tissue, and its replacement with new bone.

    Bone replacement may be so complete and perfect that completely normal bone may result

    The adequacy of bone replacement depends on Age of the patientCongruity of the involved joint

  • Sources of blood supplyUp to 4yearsMetaphyseal vesselsRetinacular vesselsLigamentum teres scanty

    4 to 7 yearsMetaphyseal vessels ceases

    Above 7yearsVessels in ligamentum teres have developed

  • Pathology Goes through stages which may last 3 to 4 years

    Stage1Ischaemia and bone death, cartilage thickensStage 2Revascularization and repairDead marrow replaced by granulation tissueBone revascularized and new bone laid downDead bone resorbed, replaced by fibrous tissue, fragmentation Stage 3Distortion and remodellingRestoration of femoral archtecture or collapseFemoral head displaces laterally in relation to acetabulum

  • Classification Waldenstrom classification

    Catterall classification

    Salter and thompson classification

    Herring classification

  • Caterall classificationBased on amt of involvement of femoral epiphysisGroup I1/2 of head involved with sclerosis, fragmentation and collapse of headGroup IVEntire epiphysis involved

  • Caterall head-at-risk signsAssociated with poor results

    lateral subluxation (most important)

    calcification lateral to the epiphysis

    Gage's sign: V shaped defect laterally

    metaphyseal cysts

    horizontal growth plate

  • Caterall head-at-risk signsmetaphyseal cysts

  • Gage's sign

  • Salter and thompson classificationDescribes extent of subchondal fracture in the superolateral portion of femoral head

    Type A - 50% of femoral head

    can be observed radiographically earlier and more readily tan caterall classification

    Can be applied early in course of dz to determine management

  • Herring classificatin/lateral pillarBased on degree of collapse of lateral pillar during fragmentation stage

    Goup A No collapse, no progressive flattening

    Group B50% collapseRitterbusch 1993Has the highest predictive value and interobserver reliability

  • Bilateral involvementMore severe dz than unilateral

    Boys and girls equally affected

    Independent event

    Bone age delayed in perthes disease

  • ExaminationShort statureDelayed bone age

    EarlyDecreased ROMAntalgic gait

    LateDecreased ROM of motion from acetabular impingementDisuse atrophy of thigh musclesLeg lenght descrepancyTrendelenburg gait

  • Investigations Blood testshaemogram, ESR, CRPImagingPlain X-raysHip U/SBone scintigrpahyMRIDynamic arthrographyAssess spherity of femoral headHinge abductionBilateral perthesSkeleta survey as part of work-up

  • Song et al MRI findings on widened medial joint spaceInitial stageOvergrowth of cartilage

    Fragmentation stageOvergrown cartilage with widened true medial joint space

    Healing stageWidened true medial joint space

  • Treatment Goals of tratmentMaintain femoral head spherity containmentAvoid severe degenerative arthritis

    Guided byAgeSeverityLimitation in ROM

  • Treatment cont.Initial Mx determined by sympts severity


    Modification of activities

    Bedrest and short period of traction

    Wheelchair/crutch walking discouraged

    Preserve abduction

    Determine bone age

  • Treatment: Two main choicesConservativePain controlGentle exercisesRegular re-assessmentAvoid sport and strenous activities

    ContainmentHold hips widely abducted in cast/brace >1yrOperationVarus osteotomy of femurInnominate osteotomy of pelvis Both

  • Herring Guidelines to treatmentChildren 6years; bone age more imp than chronological ageBone age at or
  • oseoclast-osteoblat interaction

  • Prognostic featuresAge 10yrs; questionable benefit from containment, poor prognosisGenderGirls have worse prognosisClassification gradeHerrings lateral pillar classificationSalter and thompson grade B worse prognosisCaterral classification gradeCaterral head-at-risk signsThe five signs carry worse prognosisOthers Body weight, decreased ROM

  • crescent sign (Caffey's sign**