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Premium member Presentation Transcript Perthes disease: Perthes disease By Dr. Majde AlnigrishSlide 2: FIRST DESCRIBED BY LEGG , AND WALDENSTORM IN 1909, AND BY PERTHES AND CALVE IN 1910DEFINITION: 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 pressureCauses: 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 DeformityClinical : 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 traumaClinical: 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 collapseDifferentials: Differentials Unilateral Septic hip Toxic synovitis Slipped femoral capital epiphysis Spondyloepiphyseal dysplasia Metaphyseal dysplasia Lymphoma Bilateral Hypothyroidism Multiple epiphyseal dysplasia Spondyloepiphyseal dysplasia Sickle cell diseaseWorkup : Workup Lab Studies : CBC Erythrocyte sedimentation rate - May be elevated if infection presentWorkup: 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 RemodelingSlide 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 metaphysisRadiographic stages: Radiographic stages Subchondral fracture; linear radiolucency within the femoral head epiphysisFragmentation Stage: Fragmentation Stage Bony epiphysis begins to fragment Areas of increased lucency and density Evidence of repair aspects of diseaseReossification Stage: Reossification Stage Normal bone density returns Alterations in shape of femoral head and neck evidentHealed Stage: Healed Stage Left with residual deformity from disease and repair process Differs from AVN following Fx or dislocationRadiographic 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 systemsGroup I: Group IGroup II: Group IIGroup III: Group IIIGroup IV: Group IVLateral Pillar Classification: Lateral Pillar Classification 3 groups: A) no lateral pillar involvement B) >50% lat height intact C) <50% lat height intactCatterall 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 phaseSalter 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 scanningOther Imaging Studies: Other Imaging Studies Magnetic resonance (MR) imagingOther Imaging Studies: Other Imaging Studies ArthrographyPrognosis: 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 prognosisThe 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 signsSlide 39: Analgesia Bed rest Traction Physical therapy Adductor tenotomy Serial Petrie abduction castsNon surgical containment: Non surgical containmentBracing: BracingSlide 42: Scottish Rite abduction braceSlide 43: Japenes modification of petrie abduction castNon-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 sideChildren 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 proceduresThe 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 coverageSurgical containment: Surgical containmentVarus Osteotomy: Varus OsteotomyComplications : Complications Femoral Shortening stiffness Malrotation Limp Positive trendelenburg Pelvic Lenghtening Stiffness Chondrolysis Failure of containmentSlide 58: THANKS You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.