LEGG CALVE PERTHES DISEASE

DR VANDANA G HARI RESIDENT KIMS TRIVANDRUM

Painful disorder of childhood characterised by avascular necrosis of femoral capital epiphysis.-Osteochondritis deformans juvenilis/Coxa plana-described 1910 independently by Legg, Calve, Perthes ,Waldenstrom

Legg Calve Perthes Disease

Pathogenesis

Precipitating cause unknown Predisposing factors-Genetic aspects 2-20%-Abnormal growth & development ,bone age

<1-3yrsPoor socio economic status

-Inherited thrombophilia-Males 4:1-Trauma

Cardinal cause ISCHEMIA OF FEMORAL HEAD

4-7yrs femoral head depend on lateral epiphyseal vessels(.upto 4 metphysea later ligamentum teres)

Epiphyseal vessels susceptible to stretching & pressure

Effusion

Venous flow blocked

Venous stasis

Intraosseous pressure rises Ischemia

Stages of Legg-Calves-Perthes (Waldenström

Initial -infarction produces a smaller, sclerotic epiphysis with medial joint space widening

-radiographs may remain occult for 3 to 6 mos

FragmentationDead marrow replaced with granulation

tissueBone revascularisedSome dead fragments replaced by fibrous

tissue Alternating areas of sclerosis &fibrosis –

Fragmentation of epiphysisHyperemic metaphysis-Rarefied / cystic in X-

ray-hip related symptoms are most prevalent-lateral pillar classification based on this stage

• Reossification -ossific nucleus undergoes reossification as new bone appears as necrotic bone is resorbed

-may last up to 18m

Healing or remodeling -femoral head remodels until skeletal maturity 

-begins once ossific nucleus is completely reossified trabecular patterns return

Rapid &complete repair- architecture maintained

Tardy epiphysis collapse –Distorted growth of Head and Neck

Head Oval flattened head of mushroom

Neck shor t and broad

Clinical Features-Classical presentationPainless limp (4-8yr old boy)-Pain a/c or insidious –

vague ,ache in groin, thigh or knee, aggravated by hip movements

Signs1.Antalgic gait2.Muscle spasm3.Limited abduction & internal

rotation4.Proximal thigh atrophy5. Trendelenburg gait (head

collapse leads to decreased tension of abductors

Radiology

Decreased size of left femoral capital epiphysis

Linear translucency

.wide joint space

Subchondral fracture

Small left femoral cap.epiphysis

Wide neck

Widened articular surface

Linear translucency CRESCENT SIGN

•Acetabular change

•widened right femoral neck

•smaller, sclerotic, flattened femoral subcapital epiphysis

Metaphyseal cyst rt.

In group I there is involvement (hatched areas) of the anterior head only, no sequestrum, and no collapse of the

epiphysis. In group II, only the anterior head is involved, and there is a sequestrum with a clear junction. In group III only a small part of the epiphysis is not involved. In group IV there is total head involvement

CATERALL CLASSIFICATION

Gp 3 & 4

◦Head at risk signs (indicate a more severe disease course) Gage sign 

V-shaped radiolucency in the lateral portion of the epiphysis and/or adjacent metaphysis

calcification lateral to the epiphysis lateral subluxation of the femoral head Horizontal growth plate

Gage sign

Lateral subluxation

Salter Thompson

GP A :<1/2 of capital femoral epiphysis involved

Gp B: >1/2 involved

Herring ClassificationFemoral head : 3 pillars by lines at medial and

lateral edge of central sequestrum

A : Normal ht of lateral pillarB: Partial prolapse >50% htC: Severe prolapse<50%ht

Other investigationsBone scan ◦can confirm suspected case of LCP◦decreased uptake (cold lesion) can predate

changes on radiographsMRI ◦can provide early diagnosis revealing

alterations in the capital femoral epiphysis and physis

Arthrogram ◦a dynamic arthrogram can demonstrate

coverage and containment of the femoral head

Treatment

The primary aim Containment of head with in acetabulam

Initial management:1. analgesia2.modification of activities3.preservation of abductionReassess

Containment

Holding hip widely abducted

• Newington brace,Toronto,Petri cast, Scottish Rite

Surgical procedures

VARUS DEROTATIONAL OSTEOTOMY –to provide containment

Reconstructive Procedures

Cheiloctomy –removal of protuberance

Chiari osteotomy-deepens acetabulam by medial displcement of distal pelvic fragment

Trocanteric advancement-distal transfer to normalise tension of trocanteric muscles

Guidelines

Children under 6Symptomatic treatment

6-8yrs

Bone age <=6yrs

LP A&B: symptomatic treatment

LP C:Ab.brace

>9yrsOperative containment

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