Transcript Legg Calve Perthes Disease

Legg Calve Perthes Disease
Joseph Donnelly, M.D.
December 10, 2001
Overview
 History
 Epidemiology/ Etiology
 Pathogenesis
– Radiographic stages
 Presentation/ Exam
 Imaging
 Treatment
History
 Late 19th century: “hip infections” that
resolved without surgery
 First described in 1910
 Early path studies: cartilaginous islands in
the epiphysis
Epidemiology
 Disorder of the hip in young children
 Usually ages 4-8yo
 As early as 2yo, as late as teens
 Boys:Girls= 4-5:1
 Bilateral 10-12%
 No evidence of inheritance
Etiology
 Unknown
 Past theories: infection, inflammation,
trauma, congenital
 Most current theories involve vascular
compromise
– Sanches 1973: “second infarction theory”
Etiology: blood supply
Pathogenesis
 Histologic changes described by 1913
 Secondary ossification center= covered by
cartilage of 3 zones:
– Superficial
– Epiphyseal
– Thin cartilage zone
 Capillaries penetrate thin zone from below
Pathogenesis: cartilage zones
Pathogenesis
 Epiphyseal cartilage in LCP disease:
– Superficial zone is normal but thickened
– Middle zone has 1)areas of extreme
hypercellularity in clusters and 2)areas of loose
fibrocartilaginous matrix
 Superficial and middle layers nourished by
synovial fluid
 Deep layer relies on blood supply
Pathogenesis
 Physeal plate: cleft formation, amorphis
debris, blood extravasation
 Metaphyseal region: normal bone
separated by cartilaginous matrix
 Epiphyseal changes can be seen also in
greater trochanter, acetabulum
Radiographic Stages
 Four Waldenstrom stages:
– 1) Initial stage
– 2) Fragmentation stage
– 3) Reossification stage
– 4) Healed stage
Initial Stage
 Early radiographic signs:
– Failure of femoral ossific nucleus to grow
– Widening of medial joint space
– “Crescent sign”
– Irregular physeal plate
– Blurry/ radiolucent metaphysis
Initial Stage
Initial Stage
Fragmentation Stage
 Bony epiphysis begins to fragment
 Areas of increased lucency and density
 Evidence of repair aspects of disease
Fragmentation Stage
Fragmentation Stage
Reossification Stage
 Normal bone density returns
 Alterations in shape of femoral head and
neck evident
Reossification Stage
Reossification Stage
Healed Stage
 Left with residual deformity from disease
and repair process
 Differs from AVN following Fx or
dislocation
Presentation
 Often insidious onset of a limp
 C/O pain in groin, thigh, knee
 17% relate trauma hx
 Can have an acute onset
Physical Exam
 Decreased ROM, especially abduction and
internal rotation
 Trendelenburg test often positive
 Adductor contracture
 Muscular atrophy of thigh/buttock/calf
 Limb length discrepency
Imaging
 AP pelvis
 Frog leg lateral
 Key= view films
sequentially over
course of dz
 Arthrography
 MRI role undefined
Differential Diagnosis
 Important to rule out infectious etiology
(septic arthritis, toxic synovitis)
 Others:
–
–
–
–
Chondrolysis
JRA
Osteomyelitis
Lymphoma
-Neoplasm
-Sickle Cell
-Traumatic AVN
-Medication
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
Group I
Group II
Group III
Group IV
Lateral Pillar Classification
 3 groups:
– A) no lateral pillar
involvment
– B) >50% lat height
intact
– C) <50% lat height
intact
Salter-Thompson Classification
 Simplification of Catterall
 Based on status of lateral margin of capital
femoral epiphysis
 Group A (Catterall I & II equivalent)
 Group B (Catterall III & IV equivalent)
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
Prognosis
 Flat femoral head incongruent with
acetabulum= worst prognosis
 Do not treat in reossification stage
(>15mos)
Non-operative Tx
 Improve ROM 1st
 Bracing:
– Removable abduction orthosis
– Pietrie casts
– Hips abducted and internally rotated
 Wean from brace when improved x-ray
healing signs
Bracing
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
Operative Tx
 If non-op tx cannot maintain containment
 Surgically ideal pt:
– 6-9yo
– Catterral II-III
– Good ROM
– <12mos sx
– In collapsing phase
Surgical Tx
 Surgical options:
– Excise lat extruding head portion to stop
hinging abduction
– Acetabular (innominate) osteotomy to cover
head
– Varus femoral osteotomy
– Arthrodesis
Varus Osteotomy
Late Effects of LCP
 Coxa magna
 Physeal arrest patterns
 Irregular head formation
 Osteochondritis dessicans
The End