Legg Calve Perthes Disease

By: DR YASH AGARWAL

DR HARENDRA SINGH

MODERATOR- DR RAHUL VERMA

WHY IS IT NAMED SO?

 AMERICA FRANCE GERMANY

 They found the disease simultaneously in 1919-

 Hence the name “LEGG CALVE PERTHES” disease.

INTRODUCTION
A self-limiting form of osteochondrosis of the
capital femoral epiphysis (blood supply)
unknown aetiology (? Coagulation disorder)
common between the ages of 5 – 12 years.
Boys: Girls – 4/5:1
Bilateral – 10-12%
PRESENTATION
 Complains of pain and limp of insidious onset
Clinical examination usually reveals a slight stiff,
protective limp.
The ROM of the affected hip is usually restricted, in
particular with reduced abduction and internal
rotation.
Subtle anthropometric abnormalities have been
noted.
In late sages Trendelenburg gait can be seen.
Classification

All known classifications of Legg-Calvé-Perthes

disease are based on the findings on x-rays.
Morphological classifications of the extent
of the lesion

Classification according to Catterall (Common)

Classification according to Salter & Thompson
Classification according to Herring
CATERALL
GRADE-I
< 50% affected
CATERALL
GRADE II
half of the femoral head
CATERALL
GRADE III
Half of the femoral head with sequestrum
CATERALL
GRADE IV
Whole femoral head affected
Classification according to Salter &
Thompson
Grou
p Characteristics

A
Subchondral # involving <50% of the femoral
dome
B
Subchondral # involving >50% of the femoral
dome
RADIOGRAPHIC FINDINGS

Salter Thompson type B

Classification “A”
according to Herring
Lateral pillar not affected
Classification“B”
according to Herring
>50% of height of lateral
pillar preserved
Classification“C”
according to Herring
<50% of height of lateral
pillar preserved
Imaging – Radiographic Feature
Widening of the joint space and minor subluxation
Sclerosis
Fragmentation and focal resorption
Loss of height
Metaphyseal cyst formation
Widening of the femoral neck & head (Coxa Magna)
Lateral uncovering of the femoral head
Sagging rope sign
Acetabular remodelling
Fragmentation and extrusion of femoral head
Sclerosis of epiphysis & widening of joint
space in the early stages
Metaphyseal cyst formation within the
femoral neck
‘Sagging Rope Sign’
This a curvilinear sclerotic line
running horizontally across
the femoral neck.
It is confirmed by 3D CT
studies.
It is a finding in AP radiograph
in a mature hip with Perthes’
disease.
GAGE SIGN
Head at risk signs
Clinical features: Radiological features:
Progressive loss of Lateral subluxation of
movement the femoral head (head
Adduction contractures partially uncovered)
Flexion in abduction Entire femoral head

Heavy child involved

Calcification lateral to
the epiphysis
Metaphyseal cysts
Gage's sign
Horizontal physis
Differential Diagnosis
D/D unilateral Perthes’ D/D bilateral Perthes’
disease: disease:
Transient synovitis Multiple epiphyseal
Septic arthritis dysplasia
 Tuberculosis of the hip Sickle cell disease
 SCFE Meyer’s dysplasia
Prognosis
60% of kids do well without Rx
AGE is key prognostic factor:
<6y – good outcome regardless of Rx
6-8y – not always good results with just containment
>9y – containment option is questionable, poorer
prognosis, significant residual defect
Blood supply to the epiphysis restores spontaneously
except if the onset is in adolescence
Stages of Perthe’s Disease (Waldenström
Staging)

1. Stage of Avascularity
2. Stage of Fragmentation
3. Stage of Regeneration
4. Stage of Complete healing
STAGE OF AVASCULARITY
Stage IA Stage IB
STAGE OF FRAGMENTATION
Stage IIA
Stage IIB
STAGE OF REGENERATION
Stage IIIA Stage IIIB
STAGE OF COMPLETE HEALING
Stage IV
Problems of Management
1. Deformation of the femoral head
2. Enlargement of the femoral head
3. Capital physeal growth impairment and altered
abductor mechanism.
4. Degenerative arthritis of the hip in early adult
life.
Case 1

Untreated healed
perthe’s disease in a
young adult
Case 2

Healed perthe’s
disease in a young
adult
Aims of treatment
1. Prevent deformation of femoral head(most
important)
2. Minimize enlargement of femoral head
3. Prevent or correct greater trochanteric
overgrowth
4. Prevent secondary degenerative arthritis of hip
(depends on 1 and 2)
Treatment options
Weight relief – not proven

Containment by bracing or casting

Surgical containment
WEIGHT RELIEF
Not proven effeective

1. TRACTION

2. BRACE

PATTEN BOTTOM BRACE

CONTAINMENT by Casting or Bracing

BROOMSTICK BRACE

In Abduction and flexion or abduction and internal rotation

SURGICAL CONTAINMENT
FEMORAL OSTEOTOMIES PELVIC SURGERIES
(acetabular reorientation or
augmentation)

 VARUS DEROTATION SHELF OPERATION

OSTOETOMY
REORIENTATION BY
 VARUS EXTENSION SALTER OSTEOTOMY
OSTEOTOMY
DISPLACEMENT BY CHIARI
Factors to be taken into consideration while planning
treatment
1. Age of the child-more the age worse is the prognosis
2. Extent of epiphyseal involvement -
more avascular the epiphysis more is the extrusion
-< 50% epiphyseal involvement—
generally favourable outcome without treatment
3. Stage of evolution of the disease-containment before IIB
or IIIA
4. Extent of extrusion- most important factor that
influences the outcome.
5. ROM of hip
PRIOR TO SURGERY
Traction for few days Check for ROM of hip

1. All movements are normal VDRO

2. Only IR is restricted Varus Extension
Osteotomy
3. All movements restricted Broomstick cast under
anaesthesia for 6 weeks
Recommended treatment for femoral head
containment

< 12 YEARS AGE

< HALF EPIPHYSEAL

INVOLVEMENT WITH
>=HALF EPIPHYSEAL
NO EXTRUSION WITH INVOLVEMENT
ANY STAGE

NO ACTIVE
INTERVENTION ONLY
EXTRUSION + STAGE 1/2 STAGE 3 WITH NO
PERIODIC REVIEW TILL EXTRUSION + STAGE 3
EXTRUSION
HEALING

7-12 YEARS– 7-12 YEARS–

< 5 YEARS --no active
CONTAINMENT + CONTAINMENT +
< 5 YEARS--- BRACE SALVAGE SURGERY intervention only periodic
TROCHANTERIC TROCHANTERIC
review till healing
EPIPHYSIODESIS1 EPIPHYSIODESIS
VARUS DEROTATIONAtOSTEOTOMY
6 months follow up
10 year old boy
VARUS EXTENSION OSTEOTOMY
GREATER TROCHANTERIC ARREST
Rationale of Treatment
1. Femoral osteotomy v/s Innonimate osteotomy

2. Open wedge v/s Closed wedge osteotomy

3. Containment not recommended in regeneration

stage

4. Even with no extrusion containment is done in child

> 7 years age.
SALVAGE SURGERY FOR SEQUELAE OF
PERTHES DISEASE

AIMS : Relieve pain

:correct trendelenburg gait
:minimize risk of degenerative arthritis
OPTIONS FOR SALVAGE SURGERY
 Hinged abduction--valgus osteotomy
 Severe perthe’s disease--Joint distraction
(arthrodiastasis)
 Very painful and grossly distorted hip--Arthrodesis
 Deformed femoral head--Cheilectomy
 Greater trochenteric advancement/arrest
 Large malformed head with lateral subluxation—
pelvic osteotomy
 Coxa magna – Shelf augmentation
Factors to be considered while planning
treatment of sequelae of perthes
disease
Presence of pain – abduction hinge or arthritis
Shape of femoral head
Size of femoral head
Congruity of hip
Recommended treatment for sequelae of perthes
disease
Healing not Healed disease Healed disease Healed disease Healed disease
complete OR healed + + + +
disease No pain No pain No pain Pain
+ + + + +
Pain present on Large spherical Large flattened Spherical head Irregular femoral
abduction femoral head with femoral head with + head
+ uncovering uncovering Hip congruent +
Spherical head + + + Hip not congruent
+ Hip congruent Hip not congruent Coxa breva +
Hip congruent in + Arthritic changes
adduction Trochanteric
+ overgrowth
demonstrable hinge
abduction

Valgus Innominate Shelf operation Trochanteric arthrodesis

intertrochanteric osteotomy OR advancement
osteotomy OR Chiari ostetomy
Shelf operation To improve femoral
OR head coverage
Acetabular
augmentation to
improve femoral head
coverage
VALGUS OSTEOTOMY
VALGUS OSTEOTOMY
VALGUS OSTEOTOMY
VALGUS OSTEOTOMY
SALTER OSTEOTOMY
SALTER OSTEOTOMY
SALTER OSTEOTOMY
SALTER OSTEOTOMY
SALTER OSTEOTOMY
SALTER OSTEOTOMY
SALTER OSTEOTOMY
SALTER OSTEOTOMY
CHIARI
CHIARI
THE SHELF PROCEDURE (STAHELI)
CHEILECTOMY
ARTHRODIASTASIS
ARTHRODESIS
REFERENCES
Paediatric Orthopaedics-A System Of Decision
Making - Benjamin Joseph
Tachdjian’s Paediatric Orthopeadics 4th edition
Campbell’s Operative Orthopaedics 13th edition
Mercer‘s Textbook of Orthopaedics and Trauma 10th
edition
 Apley’s System of Orthopaedics and Fractures 9th
edition
THANK YOU