DECISION MAKING IN PERTHES DISEASE:Putting together the jigsaw!Putting together the jigsaw!

DR. ALARIC AROOJISM.S. (Orth), D’Orth, DNB (Orth)

Fellowship in Pediatric Orthopaedics (USA, Singapore, Australia)

Consultant Paediatric Orthopaedic Surgeon

Kokilaben Dhirubhai Ambani Hospital & Bai Jerbai Wadia Hospital for Children

Mumbai

Putting together the jigsaw!Putting together the jigsaw!

Why the confusion?

Catterall ?

Herring?Reimer ?

Salter ?

Mose?

Stulberg?

Head at risk?

Perthes News

Half the patients will recover and have little

disability over their lifetime

The other half will function well with occasional

discomfort through most of their adulthood and in discomfort through most of their adulthood and in

their 5th or 6th decade of life require hip replacement

Only the most severely involved patients will have

early hip disability

- Herring JA 1996; Weinstein SL, 1985

Few long-term studies

All retrospective

Small number of patients

NATURAL HISTORY

Small number of patients

Poor retrieval of data

Absence of controls

Subjective assessment of outcome

20 – 40 yrs : 70 – 90% of patients are active & pain free

Good ROM despite abnormal Xrays

Av. 48 yrs F/U: 50% have disabling pain and osteoarthritis requiring THR

By 6th – 7th decade : Majority have evidence of DJDBy 6th – 7th decade : Majority have evidence of DJD

McAndrew, Weinstein. JBJS 1984

Yrjonen. Acta Orthop Scand 1992; Lecuire. JBJS 2002

GOALS OF TREATMENT

Relief of pain : NSAIDs / Bed rest

Traction

Range of motion

Physical therapy

Improve function

Minimize femoral head deformity at

completion of healing

RESIDUAL DEFORMITY AT SKELETAL MATURITY

CLASS XRAY CONGRUENCY

I NORMAL SPHERIC

II SPHERICAL but coxa magna, coxa breva

SPHERIC

III OVOID / mushroom ASPHERIC III OVOID / mushroom shaped

ASPHERIC

IV FLAT HEAD & acetabulum

ASPHERIC

V FLAT HEAD / normal acetabulum

ASPHERIC INCONGRUENCY

Stulberg, Cooperman. JBJS 1981;63:1095

S 1 S2 S3

S4 S5

Age of the child

Range of hip motion

Stage of evolution of the disease

(Mod.Elizabethtown)

PROGNOSTIC(Mod.Elizabethtown)

Grade of epiphyseal involvement

(Salter / Catterall)

Extent of epiphyseal collapse / extrusion

(Herring / Reimer)

C

FACTORS

Age of the child

The age of the child at onset of symptoms

(chronological age)

Under 6 yearsUnder 6 years

Between 6 & 9 years

Over 9 years

Hip Range of Motion

The range of hip motion

All movements restored

Internal rotation restricted

Limitation of Abd and IR

Stiff hip

Modified Elizabethtown Classification

Stage of evolution of the disease at presentation

JPO Sep 2003

Benjamin Joseph, Manipal

Stage Ia

AVASCULAR STAGE

Stage Ib

The epiphysis is avascularand appears denseThere is no loss of height of the epiphysis

There is some loss of height of the dense sclerotic epiphysisThe epiphysis is in one piece

Stage IIa

FRAGMENTATION STAGE

Stage IIb

One or two fissures appear in the epiphysis

The epiphysis is frankly fragmentedThis is the stage at which there is maximal collapse of the epiphysis

Stage IIIa

RE-OSSIFICATION STAGE

Stage IIIb

> 1/3

New bone which is immature & woven begins to form at the periphery of the avascular epiphysis

Lamellar bone of normal texture covers at least 1/3 of the circumference of the epiphysis

The process of revascularisation and repair is complete

HEALED STAGE

Stage IV

repair is complete

There is no evidence of any avascular bone in the epiphysis

The extent of epiphyseal involvementLess than half the femoral epiphysisHalf or more of the epiphysis

Grade of the disease

II

II

III

IV

Catterall

20-30% 50% 20-30%

Extent of collapseHerring

A B C

THE TREATMENT PLANWhen to consider containment??When to consider containment??

REPORT OF MULTI-CENTER STUDY GROUP ON PERTHES DISEASE

HERRING JBJS 2004

< 5 years Consider containment only if extrusion occurs

Age at onset of symptoms

6 to 12 yearsConsider containment even before extrusion

occurs

Over 12 years of age Do NOT consider containment

Less than half the epiphysis

Do not consider containment

Extent of epiphyseal involvement

epiphysis containment

Half or more of the epiphysis Consider containment

Stage Ia, Ib, IIa Consider containment

Stage of evolution of the disease

Stage IIb ? Consider containment

Stage IIIa, IIIb, IV Do not consider containment

The odds ratio for obtaining a spherical femoral head at healing was 16.58 times higher if surgery was done before Stage IIb(Joseph JPO 2003)

All movements restoredConsider containmentBy varus + derotation

Range of hip motion

Internal rotation alone restricted

Consider containmentBy varus + extension

Internal rotation & abduction restricted(Hinged abduction)

Do not consider containment

Variable Contain Don’t contain

Age > 5 or < 5 with extrusion

<5 (no extrusion)

Extent of involvement

Half or more than half of epiphysis

Less than half of epiphysisinvolvement half of epiphysis epiphysis

Stage of evolution of the disease

Stage Ia, Ib, IIa& ?Stage IIb

Stage IIIa, IIIb, IV

Extrusion Present Absent

Range of hip motion

Normal Restricted

AGE < 6 YEARS

RANGE : > 50% ABD / IR

EXTENT OF INVOLVEMENT < 50 %

LATERAL PILLAR COLLAPSE < 50%