lcp DISEASE

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Perthes disease:

Perthes disease By Dr. Majde Alnigrish

Slide 2:

FIRST DESCRIBED BY LEGG , AND WALDENSTORM IN 1909, AND BY PERTHES AND CALVE IN 1910

DEFINITION:

DEFINITION Idiopathic osteonecrosis of the capital femoral epiphysis in a child.

Epidemiology:

Epidemiology Race : Caucasians are affected more frequently than persons of other races. Sex : Males are affected 4-5 times more often than females. Age : LCPD most commonly is seen in persons aged 3-12 years , with a median age of 7 years.

Causes:

Causes Exact cause unknown . Proposed theories . Inherited protein C and/or S deficiency. Venous thrombosis Arterial occlusion Raised intra osseous pressure

Causes:

Causes Proposed theories . Excessive femoral antiversion. Synovitis. Generalized skeletal disorder. Arterial anomalies.

Pathophysiology :

Pathophysiology The capital femoral epiphysis always is involved. In 15-20% of patients with LCPD, involvement is bilateral. The blood supply to the capital femoral epiphysis is interrupted . Bone infarction occurs, especially in the subchondral cortical bone, while articular cartilage continues to grow. Revascularization occurs, and new bone ossification starts.

Pathophysiology:

Pathophysiology At this point, a percentage of patients develop LCPD, while other patients have normal bone growth and development. LCPD is present when a subchondral fracture occurs. This is usually the result of normal physical activity, not direct trauma to the area Changes to the epiphyseal growth plate occur secondary to the subchondral fracture.

Pathogenesis:

Pathogenesis Avascular necrosis Temporary cessation of growth Revascularization from periphery Resumption of ossification and trauma Pathological fracture Resorption of underlying bone Replacement of biologically plastic bone Sublaxation Deformity

Clinical :

Clinical History : Symptoms usually have been present for weeks. Hip or groin pain , which may be referred to the thigh Mild or intermittent pain in anterior thigh or knee Limp Usually no history of trauma

Clinical:

Clinical Physical: Painful gait Decreased range of motion (ROM), particularly with internal rotation and abduction Atrophy of thigh muscles secondary to disuse Muscle spasm Leg length inequality due to collapse

Differentials:

Differentials Unilateral Septic hip Toxic synovitis Slipped femoral capital epiphysis Spondyloepiphyseal dysplasia Metaphyseal dysplasia Lymphoma Bilateral Hypothyroidism Multiple epiphyseal dysplasia Spondyloepiphyseal dysplasia Sickle cell disease

Workup :

Workup Lab Studies : CBC Erythrocyte sedimentation rate - May be elevated if infection present

Workup:

Workup Imaging Studies : Plain x-rays of the hip are extremely useful in establishing the diagnosis. Frog leg views of the affected hip are very helpful. Plain radiographs have a sensitivity of 97% and a specificity of 78% in the detection of LCPD Multiple radiographic classification systems exist, based on the extent of abnormality of the capital femoral epiphysis. Waldenstrom, Catterall, Salter and Thompson, and Herring are the 4 most common classification systems.

Radiographic Stages. Waldenstrom identified 4 stages:

Radiographic Stages . Waldenstrom identified 4 stages Necrosis Fragmentation Healing revascularization Remodeling

Slide 17:

Five radiographic stages can be seen by plain x-ray :

Initial Stage:

Initial Stage Early radiographic signs: Failure of femoral ossific nucleus to grow Widening of medial joint space “Crescent sign” Irregular physeal plate radiolucent metaphysis

Radiographic stages:

Radiographic stages Subchondral fracture; linear radiolucency within the femoral head epiphysis

Fragmentation Stage:

Fragmentation Stage Bony epiphysis begins to fragment Areas of increased lucency and density Evidence of repair aspects of disease

Reossification Stage:

Reossification Stage Normal bone density returns Alterations in shape of femoral head and neck evident

Healed Stage:

Healed Stage Left with residual deformity from disease and repair process Differs from AVN following Fx or dislocation

Radiographic Classifications:

Radiographic Classifications Describe extent of epiphyseal disease Catterall classification= most commonly used 4 groups based on amount of femoral head involvement Also presence of sequestrum, metaphyseal rxn, subchondral fx Classification systems

Group I:

Group I

Group II:

Group II

Group III:

Group III

Group IV:

Group IV

Lateral Pillar Classification:

Lateral Pillar Classification 3 groups: A) no lateral pillar involvement B) >50% lat height intact C) <50% lat height intact

Catterall classification:

Catterall classification Groups I and II had a good prognosis (in 90%) and required no intervention. Groups III and IV had a poor prognosis (in 90 %) and required treatment. The classification is applied to the frog lateral and AP film during the fragmentation phase

Salter and Thompson Classification :

Salter and Thompson Classification Salter & Thompson Group A : Less than 1/2 head involved. Salter & Thompson Group B : More than 1/2 head involved.

“Head at risk signs” :

“ Head at risk signs ” 1. Gage's sign . a V shaped lucency in the lateral epiphysis. 2. lateral calcification (lateral to the epiphysis) (implies loss of lateral support) 3. lateral subluxation of the head .(implies loss of lateral support) 4. A horizontal growth plate .(implies a growth arrest phenomenon and deformity)

Other Imaging Studies:

Other Imaging Studies Technetium-99m bone scanning

Other Imaging Studies:

Other Imaging Studies Magnetic resonance (MR) imaging

Other Imaging Studies:

Other Imaging Studies Arthrography

Prognosis:

Prognosis 60% of kids do well without tx AGE is key prognostic factor: <6yo= good outcome regardless of tx 6-8yo= not always good results with just containment >9yo= containment option is questionable, poorer prognosis, significant residual defect Flat femoral head incongruent with acetabulum= worst prognosis

The goal of treatment:

The goal of treatment a spherical, well-covered femoral head. range of motion in the hips that approaches normal.

Children with less femoral-head involvement:

Children with less femoral-head involvement Maintenance of hip range of motion especially those under 6 years of age. No containment treatment is indicated unless there are poor prognostic indicators Persistent or recurrent synovitis lateral subluxation Involvement of the lateral pillar Involvement of nearly 50% of the femoral head Containment treatment for most children aged 6 years or older in whom there are more than two poor prognostic indicators.

Non-operative Tx:

Non-operative Tx Improve ROM 1 st Bracing: Removable abduction orthosis Pietrie casts Hips abducted and internally rotated Wean from brace when improved x-ray healing signs

Slide 39:

Analgesia Bed rest Traction Physical therapy Adductor tenotomy Serial Petrie abduction casts

Non surgical containment:

Non surgical containment

Bracing:

Bracing

Slide 42:

Scottish Rite abduction brace

Slide 43:

Japenes modification of petrie abduction cast

Non-operative Tx:

Non-operative Tx Check serial radiographs Q3-4 mos with ROM testing Continue bracing until: Lateral column ossifies Sclerotic areas in epiphysis gone Cast/brace uninvolved side

Children with more femoral-head involvement:

Children with more femoral-head involvement Should receive containment treatment. Use bracing for children under 7 years Surgical containment for those over 7 years.

Operative Containment:

Operative Containment Proximal femoral varus osteotomy, Innominate osteotomy, Acetabular-shelf procedure, Combination of femoral and pelvic procedures

The advantages of surgery:

The advantages of surgery Definitive treatment, Short period of limited activity, Avoidance of psychosocial issues arising from prolonged brace wearing.

Proximal femoral varus osteotomy:

Proximal femoral varus osteotomy if an abduction-internal rotation radiograph of the hip shows containment. A dynamic arthrogram is recommended to find the best position, Rotation, varus/valgus, and flexion/extension as needed. from a 15-degree-varus, 15- degree derotation osteotomy One may expect 15 to 20 degrees of increased lateral coverage and about 10 degrees of improved anterior coverage

Surgical containment:

Surgical containment

Varus Osteotomy:

Varus Osteotomy

Complications :

Complications Femoral Shortening stiffness Malrotation Limp Positive trendelenburg Pelvic Lenghtening Stiffness Chondrolysis Failure of containment

Slide 58:

THANKS