2009.10.09 legg calve perthes disease 2
TRANSCRIPT
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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)
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Definition
Idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head of unknown aetiology.
It is a self-limited disease.
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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
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Blood flow to CFEBlood flow to CFE
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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%
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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.
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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
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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
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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)
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Trendelenburg signTrendelenburg sign
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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
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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
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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
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Fragmetation- Fragmetation- resorptionresorption Fragmented Fragmented
epiphysisepiphysis More irregular More irregular
acetabular acetabular contourcontour
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Reossification- healingReossification- healing
New bone New bone formation- the formation- the bone density bone density returnsreturns
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Residual stageResidual stage
Reossified Reossified femoral headfemoral head
Remodeling of Remodeling of the head shapethe head shape
Remodeling of Remodeling of the acetabulumthe acetabulum
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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
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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)
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Herring classificationHerring classification
Lateral pillar Lateral pillar clasification clasification
Detrmine Detrmine treatment and treatment and prognosisprognosis
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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)
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Differential diagnosisDifferential diagnosis
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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
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Neck-shaft angleNeck-shaft angle
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CentCentrere-edge angle -edge angle (Wiberg`s angle)(Wiberg`s angle)
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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
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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..
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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)
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Conservative Conservative treatmenttreatment
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Conservative Conservative treatmenttreatment
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Conservative Conservative treatmenttreatment
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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
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Surgical treatmentSurgical treatment
Shelf acebuloplasty
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Surgical treatmentSurgical treatment
Salter osteotomySalter osteotomy
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Very good radiographic Very good radiographic resultsresultsbefrore surgery (7 years 2 months)befrore surgery (7 years 2 months)
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Very good radiographic Very good radiographic resultsresults3 years after surgery3 years after surgery
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Very good radiographic Very good radiographic resultsresults6 years after surgery6 years after surgery
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Poor radiographic resultPoor radiographic resultbefore surgery (7 years 8 months)before surgery (7 years 8 months)
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Poor radiographic resultPoor radiographic result6 months after surgery6 months after surgery
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Poor radiographic resultPoor radiographic result 8 years after surgery 8 years after surgery