Transcript Legg-Calve-Perthes Disease

Legg-Calve-Perthes
Disease
(coxa plana, osteochondrosis capitis femoris
avascular necrosis of the femoral head)
Definition
Idiopathic osteonecrosis of the capital
femoral epiphysis of the femoral head of
unknown aetiology.
It is a self-limited disease.
Etiology
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Infection, trauma, synovitis
Disruption of blood flow to capital
femoral epiphysis (CFE)
Systemic disorder (delayed skeletal
maturation, abnormalities of thyroid
hormone and insulin like growth factor
Hereditary influence, environmental
influence, hyperactivity
Blood flow to CFE
Epidemiology
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One in 1200 children younger than 15
years is affected by LCPD
Males are affected 4-5 times more
often than females
LCPD most commonly is seen in
persons aged 4-8 (2-12) years, with a
average age of 7 years
Bilateral involvment 10 -15%
Pathology
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The blood supply to the capital femoral epiphysis
is interrupted (arteries and veins).
Bone infarction occurs, especially in the
subchondral cortical bone, while articular
cartilage continues to grow. (Articular cartilage
grows because its nutrients come from the
synovial fluid.)
Revascularization occurs, and new bone
ossification starts.
Changes to the epiphyseal growth plate occur
secondary to the subchondral fracture.
Symptoms
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Painless limp
Hip or groin pain, which may be
referred to the thigh
Mild or intermittent pain in anterior
thigh or knee
Usually no history of trauma
Symptoms
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Decreased range of motion (ROM),
particularly with internal rotation and
abduction
Painful gait
Atrophy of thigh muscles secondary to
disuse
Muscle spasm- mild hip contracture of
10-20 degrees may be present
Symptoms
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Leg length inequality due to collapse
Thigh atrophy: Thigh circumference on
the involved side will be smaller than
on the unaffected side secondary to
disuse (Trendelenburg sign)
Trendelenburg sign
Diagnosis
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Clinical presentation, physical
examination
RTG- A-P, frog-leg lateral views (every
6 weeks at the beginning, every 3-6
months later)
USG- synovitis
MRI, artrography
Stages – radiographic
presentation
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2.
3.
4.
Ischaemia / Necrosis
Fragmentation / Resorption
Reossification / Healing
Residual stage
Initial stage- necrosis
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Decreased size of
ossification center
Lateralization of
femoral head
Subchondral
fracture
Physeal
irregularity
Fragmetation- resorption
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Fragmented
epiphysis
More irregular
acetabular
contour
Reossification- healing
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New bone
formation- the
bone density
returns
Residual stage
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Reossified femoral
head
Remodeling of the
head shape
Remodeling of the
acetabulum
Catterall classification
Stage 1:
 Antero-medial portion of head involved and no
collapse, metaphyseal changes do not occur and
the epiphyseal plate is not involved
 Heal without significant sequelae
Stage 2:
 More head involved and may - fragmentation of
the involved segment
 The involved segment shows increased density
and uninvolved pillars of normal bone prevent
significant collapse - regeneration without much
loss of height and the end result is usually good.
Metaphyseal reaction localised
Catterall classification
Stage 3:
 More of the head involved - collapse as uninvolved
pillars not large enough t prevent collapse
 May show head within a head
 The metaphysis is usually diffusely involved - broad neck
and the epiphyseal plate is unprotected and also usually
involved - results poorer
Stage 4:
 Whole head involvement and severe collapse occurs
early and restoration of the femoral head usually less
complete
 The metaphyseal changes may be extensive
 The epiphyseal plate is often involved - abnormal growth
(coxa magna, coxa breva, coxa vara and coxa valga)
Herring classification
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Lateral pillar
clasification
Detrmine
treatment and
prognosis
Salter - Thompson
Classification
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Stage A: - Lateral portion of femoral
capital epiphysis present - less than
50% head involved
Stage B: - Lateral portion of femoral
capital epiphysis absent - more than
50% head involved (Lateral margin of
epiphysis protects epiphysis from
stress)
Differential diagnosis
Mose method
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If head conforms to a
single ring in both XRay planes - good
prognosis
If head varies from
perfect circle by no
more than 2mm - fair
results
If head varies by more
than 2mm in any plane
- poor results
Neck-shaft angle
Centre-edge angle (Wiberg`s
angle)
Centre-edge angle
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5-8 years ~19 degrees
9-12 years ~25 degrees
13-20 years 26-30 degrees
Goal of treatment
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Preservation of the roundness of the
femoral head and prevention of deformity
while the condition runs its course.
Conservative treatment
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Relieve weight bearing
Achieve and maintain ROM
Containment of the femoral epiphysis
within the confines of the acetabulum
(Petrie-style casts, Atlanta /Scottish
Rite/ brace, Toronto brace and other
orthotic devices)
Conservative treatment
Conservative treatment
Conservative treatment
Surgical treatment
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Femoral osteotomy = varus +/derotation to reduce the degree of
anteversion & extension.
Pelvic osteotomy (Salter, Chiari, Shelf)
or Femoral osteotomy have similar
results
Surgical treatment
Shelf acebuloplasty
Surgical treatment
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Salter osteotomy
Very good radiographic results
befrore surgery (7 years 2 months)
Very good radiographic results
3 years after surgery
Very good radiographic results
6 years after surgery
Poor radiographic result
before surgery (7 years 8 months)
Poor radiographic result
6 months after surgery
Poor radiographic result
8 years after surgery