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DR.GIRISH MOTWANI
M.S.ORTHOPAEDICS(GOLD MEDALIST)
FELLOW IN PAEDIATRIC
ORTHOPAEDICS
B.J.WADIA HOSPITAL FOR CHILDRENS
Curre...
Perthes disease
even after 100 years it remains an
enigma shrouded in controversies
 Pathology first……..
PATHOGENESIS
4 stages on the basis of evolution of disease
 Stage of Avascular Necrosis
 Stage of Revascularization / Fr...
PATHOGENESIS
Stage of Avascular Necrosis
Ischemia
A part ( anterior) or whole of capital
femoral epiphysis is necrosed.
On...
PATHOGENESIS
Stage of REVASCULARIZATION / FRAGMENTATION
 Ingrowths of highly vascular & cellular connective tissue.
 Nec...
It is at this stage that there is
collapse and loss of structural
integrity of the femoral head as
it is sort of softened ...
PATHOGENESIS
Stage of Ossification / Healing
New bone starts forming
and epiphyseal density
increases in the lucent
portio...
PATHOGENESIS
 Remodeling / Residual stage
This is the stage of remodeling and there is no
additional change in the densit...
 Gill(1940) – metaphyseal necrosis & lucencies
(“holes of decalcification”)
X-Ray
 Cresent Sign or
Salters sign or
Caffey’s sign
 Ponseti – cystic
changes in neck
 Prognostic value –
poor outcome
 Sagging rope sign
 radiodense line in prox
femoral metaphysis
 Metaphyseal response to
physeal damage
 Premature physeal closure
 With central arrests:
 Round head
 Short neck
 Troch overgrowth
 With lateral arrest:
 ...
 Morphological changes in acetabulum in perthes
described by BENJAMIN JOSEPH (JBJS 1989)
 Osteoporosis of acetabular roo...
On plain xray -
bicompartmental
acetabulum appears to
be composed of 2 arc
partly overlapping each
other – interpreted as ...
Whom should we treat actively??
 Extent of disease
 Stage of disease
 Head at risk signs
 Age
Extent of disease
 Catterall
 Salter & thompson
 Herring
 Elizabeth
Catterall classification
 Catterall Group I: Involvement only of the anterior epiphysis
(therefore seen only on the frog ...
Catterall:
 I – anterior epiphysis
 II – up to 50% with collapse
 III – only small posterior
portion not involved
 IV ...
Catterall I:
Catterall II:
Catterall III:
Catterall IV:
Catterall classification
 Groups I and II had a good prognosis (in 90%)
and required no intervention.
 Groups III and IV...
Salter and Thompson Classification
 Salter and Thompson recognized that Catterall's
first two groups and second two group...
 extent of the fracture (line) is less than
50% of the superior dome of the
femoral head
› good results can be expected.
 Extent of the fracture is
more than 50% of the
dome,
› fair or poor results can
be expected
Stulberg classification
(Herring) Lateral Pillar Classification
 Lateral Pillar Group A: There is no loss in height of the lateral
1/3 of the hea...
Herring A:
Herring B: Herring C:
And now there is “B/C Border” since
the ability to differentiate B / C
proved elusive
JBJS .
Conclusion of article :
Lays importance on the structural integrity of
superolateral – the principal load bearing part of
...
Conclusion was……
 Herring A - all do well without without treatment
 Herring B – bone age <8 years :uniform outcome
irre...
Supporting articles:
 Jbjs 2008
“HEAD AT RISK SIGNS”
 Gage's sign :- a V shaped lucency in the lateral epiphysis.
 Lateral calcification (lateral to the...
Lat subluxation / Calcification lat to
epipiphysis – HEAD AT RISK
GAGE`S SIGN
Salters extrusion Index
 If AB is more
than 20% of CD
it indicates a
poor prognosis
Modified Elizabethtown
classification
 Stage Ia: Part or
whole of the
epiphysis is
sclerotic. There is
no loss of height ...
Modified Elizabethtown
classification
 Stage Ib: The
epiphysis is
sclerotic and
there is loss of
epiphyseal
height. There...
Modified Elizabethtown
classification
 Stage IIa: The
sclerotic epiphysis
has just begun to
fragment. One or
two vertical...
Modified Elizabethtown
classification
 Stage IIb:
Fragmentation is
advanced. No new
bone is visible
lateral to the
fragme...
Modified Elizabethtown
classification
 Stage IIIa: Early
new bone
formation is visible
on the periphery of
the necrotic
e...
Modified Elizabethtown
classification
 Stage IIIb: The
new bone is of
normal texture and
has grown over a
third of the wi...
Modified Elizabethtown classification
 Stage IV the healing is complete and there is no
radiologically identifiable avasc...
Containment
 Importance ?
 Timing ?
 How long containment ?
 Candidates ?
 Types ?
 Results ?
Rational behind "containment"
 Containment of the head within the acetabulum is
reported to encourage spherical remodelli...
Timing of containment:
Deformation occurs during the phase of
revascularization (fragmentation) & early
regeneration (ossi...
 How long containment?
Needs to be ensured until the healing process
and beyond the stage where epiphysis is
vulnerable t...
 Methods of CONTAINMENT OF
HEAD
(a) Conservative methods
(b) Surgical methods
CONSERVATIVE METHODS
Weight relief & rest
In the past, treatment was primarily directed at avoiding
weight by bed rest for...
Treatment (Orthosis)
 Non Ambulatory weight releiving
1. Abduction broomstick plaster cast
2. Hip spica cast
3. Milgram h...
Treatment (Orthosis)
 Atlanta Scotish Rite
Brace
Atlanta Scotish Rite Brace
Newington orthosis
Birmingham brace
 Toronto Brace
 Tachdjian trilateral
socket orthosis
Treatment (Orthosis)
 Orthotic treatment is discontinued when the
disease enters the reparative phase and healing
is esta...
HIP ABDUCTION BRACE / CASTS
Broom stick casts
Scottish Rite orthosis
BROOMSTICK CASTS
SURGICAL METHODS
Femoral osteotomy – S/T or I/T.
Innominate osteotomy – Anterolateral coverage
Operative reconstruction pr...
FEMORAL OSTEOTOMY
 Up to 12 years of age an open wedge osteotomy
may be performed without the risk of delayed union /
non...
PELVIC OSTEOTOMY
 Redirectional Osteotomy
 Salter’s osteotomy to
reorient the acetabulum
 Shelf Operation
 To create a...
Perthes after primary healing……
Hinge abduction
 The Articular surface of the head and acetabulum are not
concentric.
 The femoral head hinges at the ac...
TREATMENT
Reconstructive procedures
 Valgus extension osteotomy
indication -hinge abduction of hip
 Cheilectomy
indicati...
Treatment
Treatment is divided into 3 phases
 Initial Phase – restore & maintain mobility
 Active Phase – Containment an...
Prognostic Factors
1. Age at diagnosis
2. Extent of involvement
3. Sex
4. Catterall “head at risk” clinical signs
 Clinic...
So finally…. before planning surgery,
first think of atleast 4 things …..
 Herring stage
 Pathological stage
 Age
 Ran...
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI
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CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI

NEW CONCEPTS IN PERTHES DISEASE

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CURRENT TRENDS IN MANAGEMENT OF PERTHES DISEASE BY DR.GIRISH MOTWANI

  1. 1. DR.GIRISH MOTWANI M.S.ORTHOPAEDICS(GOLD MEDALIST) FELLOW IN PAEDIATRIC ORTHOPAEDICS B.J.WADIA HOSPITAL FOR CHILDRENS Current trends in the Management of Legg-Calvé- Perthes Disease
  2. 2. Perthes disease even after 100 years it remains an enigma shrouded in controversies  Pathology first……..
  3. 3. PATHOGENESIS 4 stages on the basis of evolution of disease  Stage of Avascular Necrosis  Stage of Revascularization / Fragmentation  Stage of Ossification / Healing  Remodeling / Residual stage
  4. 4. PATHOGENESIS Stage of Avascular Necrosis Ischemia A part ( anterior) or whole of capital femoral epiphysis is necrosed. On X-ray –  The ossific nucleus looks smaller  Classically of Perthes’, looks dense  The articular cartilage remains viable & becomes thicker than normal – increased joint space.
  5. 5. PATHOGENESIS Stage of REVASCULARIZATION / FRAGMENTATION  Ingrowths of highly vascular & cellular connective tissue.  Necrotic trabecular debris is resorbed & replaced by vascular fibrous tissue the alternating areas of sclerosis and fibrosis appear on X- ray as fragmentation of epiphysis.  New immature bone laid on intact necrosed trabeculae by creeping substitution further increases the density of ossific nucleus on X-ray.
  6. 6. It is at this stage that there is collapse and loss of structural integrity of the femoral head as it is sort of softened due to bone resorption, collapse of necrotic bone and persistence of fibro-vascular tissue leading to deformation of epiphysis. The femoral head may extrude from the acetabulum at this stage. Stage of REVASCULARIZATION / FRAGMENTATION (contd.)
  7. 7. PATHOGENESIS Stage of Ossification / Healing New bone starts forming and epiphyseal density increases in the lucent portions of the femoral head.
  8. 8. PATHOGENESIS  Remodeling / Residual stage This is the stage of remodeling and there is no additional change in the density of the femoral head. Depending on the severity of the disease the residual shape of the head may be spherical or distorted.
  9. 9.  Gill(1940) – metaphyseal necrosis & lucencies (“holes of decalcification”)
  10. 10. X-Ray  Cresent Sign or Salters sign or Caffey’s sign
  11. 11.  Ponseti – cystic changes in neck  Prognostic value – poor outcome
  12. 12.  Sagging rope sign  radiodense line in prox femoral metaphysis  Metaphyseal response to physeal damage
  13. 13.  Premature physeal closure  With central arrests:  Round head  Short neck  Troch overgrowth  With lateral arrest:  Femoral head tilted Laterally  Elongation of medial neck  Overgrowth of troch
  14. 14.  Morphological changes in acetabulum in perthes described by BENJAMIN JOSEPH (JBJS 1989)  Osteoporosis of acetabular roof  Irregularity of contour  Premature fusion of triradiate cartilage ( bicomparmentalisation)  Hypertrophy of articular cartilage & changes in dimension
  15. 15. On plain xray - bicompartmental acetabulum appears to be composed of 2 arc partly overlapping each other – interpreted as the subluxated femoral head articulating only with the lateral half of the acetabulum moulding it into 2 compartments
  16. 16. Whom should we treat actively??  Extent of disease  Stage of disease  Head at risk signs  Age
  17. 17. Extent of disease  Catterall  Salter & thompson  Herring  Elizabeth
  18. 18. Catterall classification  Catterall Group I: Involvement only of the anterior epiphysis (therefore seen only on the frog lateral film)  Catterall Group II: Central segment fragmentation and collapse. However the lateral rim is intact and thus protects the central involved area.  Catterall Group III: The lateral head is also involved or fragmented and only the medial portion is spared. The loss of lateral support worsens the prognosis.  Catterall Group IV: The entire head is involved.  Catterall's classification has a significant inter and intra observer error.
  19. 19. Catterall:  I – anterior epiphysis  II – up to 50% with collapse  III – only small posterior portion not involved  IV – whole head involvement
  20. 20. Catterall I:
  21. 21. Catterall II:
  22. 22. Catterall III:
  23. 23. Catterall IV:
  24. 24. Catterall classification  Groups I and II had a good prognosis (in 90%) and required no intervention.  Groups III and IV had a poor prognosis (in 90 %) and required treatment.
  25. 25. Salter and Thompson Classification  Salter and Thompson recognized that Catterall's first two groups and second two groups were distinct and therefore proposed a two part classification.  Salter & Thompson Group A: Less than 1/2 head involved.  Salter & Thompson Group B: More than 1/2 head involved.  Again the main difference between these two groups is the integrity of the lateral pillar.
  26. 26.  extent of the fracture (line) is less than 50% of the superior dome of the femoral head › good results can be expected.
  27. 27.  Extent of the fracture is more than 50% of the dome, › fair or poor results can be expected
  28. 28. Stulberg classification
  29. 29. (Herring) Lateral Pillar Classification  Lateral Pillar Group A: There is no loss in height of the lateral 1/3 of the head and minimal density change. Fragmentation occurs in the central segment of the head.  Lateral Pillar Group B: There is lucency and loss of height in the lateral pillar but not more that 50% of the original (contralateral) pillar height. there may be some lateral extrusion of the head.  Lateral Pillar Group C: There is greater than 50% loss in the height of the lateral pillar. The lateral pillar is lower than the central segment early on.
  30. 30. Herring A:
  31. 31. Herring B: Herring C: And now there is “B/C Border” since the ability to differentiate B / C proved elusive
  32. 32. JBJS .
  33. 33. Conclusion of article : Lays importance on the structural integrity of superolateral – the principal load bearing part of the head  “Outcome relates strongly to the integrity of the lateral pillar”
  34. 34. Conclusion was……  Herring A - all do well without without treatment  Herring B – bone age <8 years :uniform outcome irrespective of type of treatment.  Herring B –bone age>8 years:surgery >brace  Herring C- bone age <8years: surgery > brace  Herring C –bone age > 8 years: poor outcome irrespective of type of containment
  35. 35. Supporting articles:  Jbjs 2008
  36. 36. “HEAD AT RISK SIGNS”  Gage's sign :- a V shaped lucency in the lateral epiphysis.  Lateral calcification (lateral to the epiphysis) (implies loss of lateral support)  Lateral subluxation of the head. (implies loss of lateral support)  A horizontal growth plate. (implies a growth arrest phenomenon and deformity)
  37. 37. Lat subluxation / Calcification lat to epipiphysis – HEAD AT RISK
  38. 38. GAGE`S SIGN
  39. 39. Salters extrusion Index  If AB is more than 20% of CD it indicates a poor prognosis
  40. 40. Modified Elizabethtown classification  Stage Ia: Part or whole of the epiphysis is sclerotic. There is no loss of height of the epiphysis.
  41. 41. Modified Elizabethtown classification  Stage Ib: The epiphysis is sclerotic and there is loss of epiphyseal height. There is no evidence of fragmentation of the epiphysis.
  42. 42. Modified Elizabethtown classification  Stage IIa: The sclerotic epiphysis has just begun to fragment. One or two vertical fissures are seen in either the AP or the lateral view
  43. 43. Modified Elizabethtown classification  Stage IIb: Fragmentation is advanced. No new bone is visible lateral to the fragmented epiphysis.
  44. 44. Modified Elizabethtown classification  Stage IIIa: Early new bone formation is visible on the periphery of the necrotic epiphysis and covers less than a third of the width of the epiphysis
  45. 45. Modified Elizabethtown classification  Stage IIIb: The new bone is of normal texture and has grown over a third of the width of the epiphysis.
  46. 46. Modified Elizabethtown classification  Stage IV the healing is complete and there is no radiologically identifiable avascular bone.
  47. 47. Containment  Importance ?  Timing ?  How long containment ?  Candidates ?  Types ?  Results ?
  48. 48. Rational behind "containment"  Containment of the head within the acetabulum is reported to encourage spherical remodelling during the reossification and subsequent phases.  However if there is total head involvement and the lateral pillar collapses then the effect of containment is probably less.  Therefore it seems that the extent of involvement of the head is the critical factor and containment simply optimizes the situation.
  49. 49. Timing of containment: Deformation occurs during the phase of revascularization (fragmentation) & early regeneration (ossification). It would therefore follow that if the containment is to succeed, it would need to be performed before the late phase of fragmentation, i.e., in stages of AVN or early fragmentation
  50. 50.  How long containment? Needs to be ensured until the healing process and beyond the stage where epiphysis is vulnerable to deformation that is until the late stage of regeneration phase ( 2 yrs)
  51. 51.  Methods of CONTAINMENT OF HEAD (a) Conservative methods (b) Surgical methods
  52. 52. CONSERVATIVE METHODS Weight relief & rest In the past, treatment was primarily directed at avoiding weight by bed rest for prolonged period (up to 2 yrs) or weight relieving calipers to prevent head deformation. Little evidence for efficacy. Containment by bracing & casting Plaster cast in abd. & internal rotation – broomstick casts Braces to keep hip in desired position. Weight bearing is allowed in braces. Casts - temporary form of containment till definitive treatment undertaken.
  53. 53. Treatment (Orthosis)  Non Ambulatory weight releiving 1. Abduction broomstick plaster cast 2. Hip spica cast 3. Milgram hip abduction orthosis  Ambulatory Both limbs included 1. Petrie Abduction cast 2. Toronto orthosis 3. Newington orthosis 4. Birmingham brace 5. Atlanta Scotish Rite Brace  Ambulatory unilateral 1. Tachdjian trilateral socket orthosis
  54. 54. Treatment (Orthosis)  Atlanta Scotish Rite Brace
  55. 55. Atlanta Scotish Rite Brace
  56. 56. Newington orthosis
  57. 57. Birmingham brace
  58. 58.  Toronto Brace
  59. 59.  Tachdjian trilateral socket orthosis
  60. 60. Treatment (Orthosis)  Orthotic treatment is discontinued when the disease enters the reparative phase and healing is established.  The radiographic evidence of healing are 1. Appearance of regular ossification in the femoral head. 2. Increased density of femoral head should disappear. 3. Metaphyseal rarefaction involving the lateral cortex of the metaphysis should ossify. 4. There should be intact lateral column. 5. There should be normal trabecular bone in the epiphysis.
  61. 61. HIP ABDUCTION BRACE / CASTS Broom stick casts Scottish Rite orthosis
  62. 62. BROOMSTICK CASTS
  63. 63. SURGICAL METHODS Femoral osteotomy – S/T or I/T. Innominate osteotomy – Anterolateral coverage Operative reconstruction provides the advantage of improved containment & early mobilization and is a preferred method. No end point for discontinuing the treatment because the improved containment is permanent. Short term studies suggest an improvement in the natural course of the disease process with femoral osteotomy. (Salter’s )
  64. 64. FEMORAL OSTEOTOMY  Up to 12 years of age an open wedge osteotomy may be performed without the risk of delayed union / non-union. Also the amount of shortening is minimized.  Pre-requisites – near normal hip movements.
  65. 65. PELVIC OSTEOTOMY  Redirectional Osteotomy  Salter’s osteotomy to reorient the acetabulum  Shelf Operation  To create a bony shelf to cover the extruded part of the epiphysis.  Displacement Osteotomy  Chiari osteotomy is another way to improve the coverage.
  66. 66. Perthes after primary healing……
  67. 67. Hinge abduction  The Articular surface of the head and acetabulum are not concentric.  The femoral head hinges at the acetabulum when limb is abducted – the medial joint space is increased.  Best diagnosed on arthrography.
  68. 68. TREATMENT Reconstructive procedures  Valgus extension osteotomy indication -hinge abduction of hip  Cheilectomy indication – malformed femoral head with lateral protuberance Coxa plana  Chiari osteotomy indication – malformed femoral head with lateral subluxation  Trochanteric advancement indication – premature capital femoral physeal arrest  Greater trochanteric epiphysiodesis indication – premature capital femoral physeal arrest  Shelf augmentation procedure indication – coxa magna coxa magna & lack of acetabular coverage
  69. 69. Treatment Treatment is divided into 3 phases  Initial Phase – restore & maintain mobility  Active Phase – Containment and maintainance of full mobility.  Reconstructive phase – correct residual deformities.
  70. 70. Prognostic Factors 1. Age at diagnosis 2. Extent of involvement 3. Sex 4. Catterall “head at risk” clinical signs  Clinical 1. Progressive loss of hip motion 2. Increasing abduction contracture 3. Obese child
  71. 71. So finally…. before planning surgery, first think of atleast 4 things …..  Herring stage  Pathological stage  Age  Range of motion

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