Legg Calve Perthes disease

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					Legg Calve Perthes disease

         Karen Daly FRCS (Orth)‫‏‬
   Consultant‫‏‬in‫‏‬Children’s‫‏‬Orthopaedics
           St Georges Hospital
  How does it present?

• A limping child
• Acute onset of hip pain
• Incidental finding
  – in childhood
  – as an adult
      What do I do?

• Don’t‫‏‬panic
• Assessment
  – History
  – Examination
  – X-rays
What do I tell the parents?

 • Avascular necrosis of the
   capital femoral epiphysis
 • Cause unknown
 • A prognosis
 • A proviso
   How can I do this?

• Avascular necrosis
     • Phemister DB Arch Surgery 2:221-
      230, 1921
   How can I do this?

• Radiological changes
  – Necrosis
  – Fragmentation
  – Reossification
  – Remodelling
     • Waldenstrom H J Bone Joint Surg
      20: 559-566, 1938
What else do I need to know?

  • Differential diagnosis
    – Infection/ transient synovitis
    – Hypothyroidism
    – Storage diseases
    – Multiple epiphyseal dysplasia
    – etcetera
What else do I need to know?

  • Aetiology
    – Genetic
    – Developmental
    – Trauma
    – Environmental
What else do I need to know?

  • Prognosis
    –   Age
    –   Sex
    –   Stage
    –   Classification (severity)‫‏‬
         • Herring JA et al J Pediatr Orthop 13:281-
           285, 1993
What else do I need to know?

  • Proviso
    – Not all young patients do well
    – Not all older patients do badly
    – All need follow-up
    – X-rays look bad even if things
      are going well
        What next?

• Activity vs rest
• Analgesia vs NSAIDs
• Physiotherapy or not?
        What next?

• Symptomatic treatment
          Follow-up

• Clinical assessment
  – Pain and limp?
         Follow up

• Pain and limping
• Trendelenburg sign
• Range of movement
• X-rays
  When it goes wrong

• Arthrography
  – Assess deformity
  – Assess containabilty
  – “Best‫‏‬fit”
  When it goes wrong

• Arthrography
• MRI
  When it goes wrong

• What stage of disease?
  – Necrosis
  – fragmentation (=
    revascularisation)‫‏‬
     • suitable for reconstruction
     What can I do?

• Containment by cast or brace
• Containment by surgery
  – Femoral varus osteotomy
  – Acetabular extension or
    realignment
  When it goes wrong

• What stage of disease?
  – Reossification
  – remodelling
     • suitable for salvage procedures
  When it goes wrong

• Valgus osteotomy
• Hip arthroplasty!
                    What I do
                    Stiff painful hip



                                                     Waldenstrom
        Waldenstrom stage 1/2                         stage 3/4



                                                   Valgus osteotomy




          Age < 8                             Age > 8




Hip contains        Hip hinges
on arthrogram       on arthrogram




Varus osteotomy                   Shelf Acetabuloplasty
            Outcome

• Femoral head shape at
 maturity
  – Stuhlberg et al JBJS 63A: 1095-
    1108, Sept 1981
           Outcome

• Sphericity
• Congruence
  – Catterall JBJS 53B; 37-53, 1971

				
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