Legg-Calve-Perthes Legg-Calve-Perthes DiseaseDisease(coxa plana, osteochondrosis capitis (coxa plana, osteochondrosis capitis femorisfemorisavascular necrosis of the femoral head)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.

EtiologyEtiology

Infection, trauma, synovitisInfection, trauma, synovitis Disruption of blood flow to capital Disruption of blood flow to capital

femoral epiphysis (CFE)femoral epiphysis (CFE) Systemic disorder (delayed skeletal Systemic disorder (delayed skeletal

maturation, abnormalities of thyroid maturation, abnormalities of thyroid hormone and insulin like growth hormone and insulin like growth factorfactor

Hereditary influence, environmental Hereditary influence, environmental influence, hyperactivityinfluence, hyperactivity

Blood flow to CFEBlood flow to CFE

EpidemiologyEpidemiology

One in 1200 children younger One in 1200 children younger than 15 years is affected by LCPD than 15 years is affected by LCPD

Males are affected 4-5 times more Males are affected 4-5 times more often than females often than females

LCPD most commonly is seen in LCPD most commonly is seen in persons aged 4-8 (2-12) years, persons aged 4-8 (2-12) years, with a average age of 7 years with a average age of 7 years

Bilateral involvment 10 -15%Bilateral involvment 10 -15%

PathologyPathology

The blood supply to the capital femoral The blood supply to the capital femoral epiphysis is interrupted (arteries and epiphysis is interrupted (arteries and veins).veins).

Bone infarction occurs, especially in the Bone infarction occurs, especially in the subchondral cortical bone, while articular subchondral cortical bone, while articular cartilage continues to grow. (Articular cartilage continues to grow. (Articular cartilage grows because its nutrients come cartilage grows because its nutrients come from the synovial fluid.)from the synovial fluid.)

Revascularization occurs, and new bone Revascularization occurs, and new bone ossification starts.ossification starts.

Changes to the epiphyseal growth plate Changes to the epiphyseal growth plate occur secondary to the subchondral occur secondary to the subchondral fracture.fracture.

SymptomsSymptoms

Painless limpPainless limp Hip or groin pain, which may be Hip or groin pain, which may be

referred to the thighreferred to the thigh Mild or intermittent pain in Mild or intermittent pain in

anterior thigh or anterior thigh or kneeknee Usually no history of traumaUsually no history of trauma

SymptomsSymptoms

Decreased range of motion Decreased range of motion (ROM), particularly with internal (ROM), particularly with internal rotation and abductionrotation and abduction

Painful gaitPainful gait Atrophy of thigh muscles Atrophy of thigh muscles

secondary to disusesecondary to disuse Muscle spasm- mild hip Muscle spasm- mild hip

contracture of 10-20 degrees may contracture of 10-20 degrees may be presentbe present

SymptomsSymptoms

Leg length inequality due to Leg length inequality due to collapsecollapse

Thigh atrophy: Thigh Thigh atrophy: Thigh circumference on the involved circumference on the involved side will be smaller than on the side will be smaller than on the unaffected side secondary to unaffected side secondary to disuse (Trendelenburg sign)disuse (Trendelenburg sign)

Trendelenburg signTrendelenburg sign

DiagnosisDiagnosis

Clinical presentation, physical Clinical presentation, physical examinationexamination

RTG- A-P, frog-leg lateral views RTG- A-P, frog-leg lateral views (every 6 weeks at the beginning, (every 6 weeks at the beginning, every 3-6 months later)every 3-6 months later)

USG- synovitisUSG- synovitis MRI, artrographyMRI, artrography

Stages – radiographic Stages – radiographic presentationpresentation

1.1. Ischaemia / Necrosis Ischaemia / Necrosis

2.2. Fragmentation / ResorptionFragmentation / Resorption

3.3. Reossification / HealingReossification / Healing

4.4. Residual stageResidual stage

Initial stage- necrosisInitial stage- necrosis

Decreased size of Decreased size of ossification ossification centercenter

Lateralization of Lateralization of femoral headfemoral head

Subchondral Subchondral fracturefracture

Physeal Physeal irregularityirregularity

Fragmetation- Fragmetation- resorptionresorption Fragmented Fragmented

epiphysisepiphysis More irregular More irregular

acetabular acetabular contourcontour

Reossification- healingReossification- healing

New bone New bone formation- the formation- the bone density bone density returnsreturns

Residual stageResidual stage

Reossified Reossified femoral headfemoral head

Remodeling of Remodeling of the head shapethe head shape

Remodeling of Remodeling of the acetabulumthe acetabulum

Catterall classificationCatterall classification

Stage 1:Stage 1: Antero-medial portion of head involved and Antero-medial portion of head involved and

no collapse, metaphyseal changes do not no collapse, metaphyseal changes do not occur and the epiphyseal plate is not involved occur and the epiphyseal plate is not involved

Heal without significant sequelae Heal without significant sequelae Stage 2:Stage 2: More head involved and may - fragmentation More head involved and may - fragmentation

of the involved segment of the involved segment The involved segment shows increased The involved segment shows increased

density and uninvolved pillars of normal bone density and uninvolved pillars of normal bone prevent significant collapse - regeneration prevent significant collapse - regeneration without much loss of height and the end without much loss of height and the end result is usually good. Metaphyseal reaction result is usually good. Metaphyseal reaction localised localised

Catterall classificationCatterall classification

Stage 3Stage 3:: More of the head involved - collapse as uninvolved More of the head involved - collapse as uninvolved

pillars not large enough t prevent collapse pillars not large enough t prevent collapse May show head within a head May show head within a head The metaphysis is usually diffusely involved - The metaphysis is usually diffusely involved -

broad neck and the epiphyseal plate is unprotected broad neck and the epiphyseal plate is unprotected and also usually involved - results poorer and also usually involved - results poorer

Stage 4:Stage 4: Whole head involvement and severe collapse Whole head involvement and severe collapse

occurs early and restoration of the femoral head occurs early and restoration of the femoral head usually less complete usually less complete

The metaphyseal changes may be extensive The metaphyseal changes may be extensive The epiphyseal plate is often involved - abnormal The epiphyseal plate is often involved - abnormal

growth (coxa magna, coxa breva, coxa vara and growth (coxa magna, coxa breva, coxa vara and coxa valga) coxa valga)

Herring classificationHerring classification

Lateral pillar Lateral pillar clasification clasification

Detrmine Detrmine treatment and treatment and prognosisprognosis

Salter - Thompson Salter - Thompson Classification Classification Stage A: - Lateral portion of Stage A: - Lateral portion of

femoral capital epiphysis present femoral capital epiphysis present - less than 50% head involved- less than 50% head involved

Stage B: - Lateral portion of Stage B: - Lateral portion of femoral capital epiphysis absent - femoral capital epiphysis absent - more than 50% head involved more than 50% head involved (Lateral margin of epiphysis (Lateral margin of epiphysis protects epiphysis from stress)protects epiphysis from stress)

Differential diagnosisDifferential diagnosis

Mose methodMose method

If head conforms to If head conforms to a single ring in both a single ring in both X-Ray planes - good X-Ray planes - good prognosis prognosis

If head varies from If head varies from perfect circle by no perfect circle by no more than 2mm - more than 2mm - fair results fair results

If head varies by If head varies by more than 2mm in more than 2mm in any plane - poor any plane - poor results results

Neck-shaft angleNeck-shaft angle

CentCentrere-edge angle -edge angle (Wiberg`s angle)(Wiberg`s angle)

Centre-edge angleCentre-edge angle

5-8 years ~19 degrees5-8 years ~19 degrees 9-12 years ~25 degrees9-12 years ~25 degrees 13-20 years 26-30 degrees13-20 years 26-30 degrees

Goal of treatmentGoal of treatment

Preservation of the roundness of the Preservation of the roundness of the femoral head and prevention of femoral head and prevention of deformity while the condition runs its deformity while the condition runs its coursecourse..

Conservative Conservative treatmenttreatment Relieve weight bearingRelieve weight bearing Achieve and maintain ROMAchieve and maintain ROM Containment of the femoral Containment of the femoral

epiphysis within the confines of epiphysis within the confines of the acetabulum (the acetabulum (Petrie-style Petrie-style castscasts, , Atlanta /Scottish Rite/ Atlanta /Scottish Rite/ bracebrace, , Toronto braceToronto brace and other and other orthoticorthotic devices) devices)

Conservative Conservative treatmenttreatment

Conservative Conservative treatmenttreatment

Conservative Conservative treatmenttreatment

Surgical treatmentSurgical treatment

Femoral osteotomy = varus +/- Femoral osteotomy = varus +/- derotation to reduce the degree derotation to reduce the degree of anteversion & extension.of anteversion & extension.

Pelvic osteotomy (Salter, Chiari, Pelvic osteotomy (Salter, Chiari, Shelf) or Femoral osteotomy have Shelf) or Femoral osteotomy have similar results similar results

Surgical treatmentSurgical treatment

Shelf acebuloplasty

Surgical treatmentSurgical treatment

Salter osteotomySalter osteotomy

Very good radiographic Very good radiographic resultsresultsbefrore surgery (7 years 2 months)befrore surgery (7 years 2 months)

Very good radiographic Very good radiographic resultsresults3 years after surgery3 years after surgery

Very good radiographic Very good radiographic resultsresults6 years after surgery6 years after surgery

Poor radiographic resultPoor radiographic resultbefore surgery (7 years 8 months)before surgery (7 years 8 months)

Poor radiographic resultPoor radiographic result6 months after surgery6 months after surgery

Poor radiographic resultPoor radiographic result 8 years after surgery 8 years after surgery