PRESENTED BY-PRESENTED BY- DR.NAVEEN RATHORDR.NAVEEN RATHOR RESIDENT DOCTORRESIDENT DOCTOR

DEPT. OF ORTHOPAEDICSDEPT. OF ORTHOPAEDICS RNT MEDICAL RNT MEDICAL

COLLEGE,UDAIPURCOLLEGE,UDAIPUR

SynonymsSynonymsCoxa PlanaCoxa PlanaPseudocoxalgia (Calve)Pseudocoxalgia (Calve)Arthritis deformans juvenilis Arthritis deformans juvenilis

(Perthes)(Perthes)Osteochondroses of the hipOsteochondroses of the hipCoronary disease of the hipCoronary disease of the hipPRECOXALGIAPRECOXALGIA

Blood supply to femoral headBlood supply to femoral head Retinacular arteriesRetinacular arteries Metaphyseal Metaphyseal

arteriesarteries Artery of the teres Artery of the teres

ligamentligament

Blood supply to femoral headBlood supply to femoral head Infants Infants

1.1. Medial ascending cervical or inferior Medial ascending cervical or inferior metaphyseal arteries of trueta.metaphyseal arteries of trueta.

2.2. Lat epiphysealLat epiphyseal3.3. Lig teres – insignificantLig teres – insignificant

4 mts – 4 years4 mts – 4 years1.1. Lat epiphysealLat epiphyseal2.2. Med epiphyseal decrease in number.Med epiphyseal decrease in number.

Blood supply to femoral headBlood supply to femoral head 4 yrs to 7 years4 yrs to 7 years

Epiphyseal plate forms a barrier to Epiphyseal plate forms a barrier to metaphyseal vessels.metaphyseal vessels.

Pre-adolescentPre-adolescentAfter 7 yrs arteries of lig teres become After 7 yrs arteries of lig teres become

more prominent and anastomose with more prominent and anastomose with the lateral epiphyseal vessels.the lateral epiphyseal vessels.

IncidenceIncidence Male : Female = 4-5:1Male : Female = 4-5:1 2.5:1 in India2.5:1 in India Age of onset earlier in females.Age of onset earlier in females. Age – Age – Range – 2-13 years.Range – 2-13 years. Most common 4-8 years.Most common 4-8 years. Average – 6 years.Average – 6 years. Bilateral in 10-12 %Bilateral in 10-12 % Incidence more in Caucasians compared to Incidence more in Caucasians compared to

Negroid, mongoloid, Polynesians.Negroid, mongoloid, Polynesians. In India it is most prevalent in the west coast In India it is most prevalent in the west coast

especially in Udupi district.especially in Udupi district.

EtiologyEtiologyThe exact etiology of Legg Calve The exact etiology of Legg Calve

Perthes disease in not known but Perthes disease in not known but many factors related to etiology of many factors related to etiology of this disease have been mentioned.this disease have been mentioned.

1.1. Vascular supply:Vascular supply: - Angiograms and laser studies have shown - Angiograms and laser studies have shown

medial circumflex artery is missing or medial circumflex artery is missing or obliterated and obturator artery or the lateral obliterated and obturator artery or the lateral epiphyseal artery also affected.epiphyseal artery also affected.

2. 2. Increased intra-articular pressureIncreased intra-articular pressure3. 3. Intraosseous pressureIntraosseous pressure - - Patients has shown that the venous drainage in Patients has shown that the venous drainage in

the femoral head is impaired, causing an the femoral head is impaired, causing an increase in intraosseous pressure.increase in intraosseous pressure.

ETIOLOGYETIOLOGY

4. 4. Coagulation disorderCoagulation disorder - - Associated with absence of factor C or S.Associated with absence of factor C or S. - Increase in serum levels of lipoproteins,thrombogenic - Increase in serum levels of lipoproteins,thrombogenic

substance.substance.55. . Growth hormonesGrowth hormones - - Studies have shown reduced levels of growth hormones, Studies have shown reduced levels of growth hormones,

somatomedin A and C.somatomedin A and C.66. . Social conditionsSocial conditions - - Usually belong to lower socioeconomic status, reflects Usually belong to lower socioeconomic status, reflects

dietary and environmental factorsdietary and environmental factors..77. Trauma. Trauma

8.8.. . Abnormal growth and developmentAbnormal growth and development - - Bone age is lower than chronological age by 1-3 yrs,.Bone age is lower than chronological age by 1-3 yrs,. Ex: carpal bone age: 2 yrs (Triquetral and lunateEx: carpal bone age: 2 yrs (Triquetral and lunate)) - Usually shorter than their peers.- Usually shorter than their peers.9. 9. Genetic factorsGenetic factors - - Inheritance 2-20%;inconsistent pattern.Inheritance 2-20%;inconsistent pattern. - - More Incidence of low birth weight, abnormal birth More Incidence of low birth weight, abnormal birth

presentations.presentations. - First degree relatives have 35% more risk , 2- First degree relatives have 35% more risk , 2ndnd and and 33rdrd

degree relatives are 4 times more prone for degree relatives are 4 times more prone for perthes perthes disease.disease.

TraumaTrauma In the developing femur , the major In the developing femur , the major

lateral epiphyseal artery must course lateral epiphyseal artery must course through a narrow passage ,which through a narrow passage ,which could make it susceptible to could make it susceptible to disruption in case of trauma.disruption in case of trauma.

Sequel to synovitisSequel to synovitisSynovitis of the hip occurs early in Synovitis of the hip occurs early in

LCPLCP

A controversial school of thought A controversial school of thought says that the increased pressure in says that the increased pressure in synovitis may cause a tamponade synovitis may cause a tamponade effect on the vasculatureeffect on the vasculature

Hypothesis for development Hypothesis for development of AVN of femoral headof AVN of femoral head

TRUETA’S HYPOTHESISTRUETA’S HYPOTHESIS - Age < 3 yrs: blood supply contributed by - Age < 3 yrs: blood supply contributed by

metaphyseal and retinacular arteries.metaphyseal and retinacular arteries. - Age 4-8 yrs: Retinacular arteries which enters - Age 4-8 yrs: Retinacular arteries which enters

head as lateral epiphyseal arteries gets head as lateral epiphyseal arteries gets compressed by lateral rotation muscles.compressed by lateral rotation muscles.

Thus trueta postulates that solitary blood supply Thus trueta postulates that solitary blood supply during 4-8 yrs makes vulnerable for AVN of head.during 4-8 yrs makes vulnerable for AVN of head.

After 8 yrs foveolar arteries of ligamentum teres After 8 yrs foveolar arteries of ligamentum teres contribute blood. contribute blood.

Caffey’s HypothesisCaffey’s Hypothesis Intraepiphyseal compression of blood Intraepiphyseal compression of blood

supply to ossification centersupply to ossification center

CausesCauses

PATHOGENESISPATHOGENESIS

LOSS OF BLOOD SUPPLY PRODUCES LOSS OF BLOOD SUPPLY PRODUCES AVN OF THE EPIPHYSEAL OSSCIFICATION AVN OF THE EPIPHYSEAL OSSCIFICATION CENTRE FOLLOWED BY RESORPTION OF CENTRE FOLLOWED BY RESORPTION OF DEAD BONE AND REPLACEMENT WITH DEAD BONE AND REPLACEMENT WITH NEWLY FORMED IMMATURE BONE.NEWLY FORMED IMMATURE BONE.

THE PROCESS IS DESCRIBED IN STAGESTHE PROCESS IS DESCRIBED IN STAGES

RADIOGRAPHIC STAGESRADIOGRAPHIC STAGES

FOUR WALDENSTROM STAGES:FOUR WALDENSTROM STAGES:1) INITIAL STAGE1) INITIAL STAGE2) FRAGMENTATION STAGE2) FRAGMENTATION STAGE3) REOSSIFICATION STAGE3) REOSSIFICATION STAGE4) HEALED STAGE4) HEALED STAGE

INITIAL STAGEINITIAL STAGE EARLY RADIOGRAPHIC EARLY RADIOGRAPHIC

SIGNS:SIGNS: FAILURE OF FEMORAL FAILURE OF FEMORAL

OSSIFIC OSSIFIC NUCLEUS TO GROWNUCLEUS TO GROW

WIDENING OF MEDIAL WIDENING OF MEDIAL JOINT SPACEJOINT SPACE

““CRESCENT SIGN”CRESCENT SIGN” IRREGULAR PHYSEAL IRREGULAR PHYSEAL

PLATEPLATE BLURRY/ RADIOLUCENT BLURRY/ RADIOLUCENT

METAPHYSISMETAPHYSIS

X-RayX-Ray Cresent Sign or Cresent Sign or

Salters sign or Salters sign or Caffey’s signCaffey’s sign

Caffey’s signCaffey’s sign As the disease progresses, a As the disease progresses, a

subchondral # may occur in subchondral # may occur in the anterolateral aspect of the anterolateral aspect of the femoral capital epiphysis.the femoral capital epiphysis.

Is an early radiographic Is an early radiographic feature best seen on the feature best seen on the frog-lateral projection. frog-lateral projection.

This produces a crescentic This produces a crescentic radiolucency known as the radiolucency known as the crescent, Salter’s or Caffey’s crescent, Salter’s or Caffey’s signsign

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Gage’s signGage’s sign Rarefaction in the Rarefaction in the

lateral part of the lateral part of the epiphysis and epiphysis and subjacent subjacent metaphysis.metaphysis.

‘‘Sagging Rope Sign’ Sagging Rope Sign’ This a curvilinear This a curvilinear

sclerotic line running sclerotic line running horizontally across the horizontally across the femoral neck.femoral neck.

It is confirmed by 3D CT It is confirmed by 3D CT studies.studies.

It is a finding in AP It is a finding in AP radiograph in a mature radiograph in a mature hip with Perthes’ hip with Perthes’ disease.disease.

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X-RayX-Ray Sagging rope sign in Sagging rope sign in

adults with history adults with history of perthes – radio of perthes – radio dense line overlying dense line overlying proximal femoral proximal femoral metaphysis, a result metaphysis, a result of growth plate of growth plate damage with damage with metaphysial metaphysial response.response.

FRAGMENTATION STAGEFRAGMENTATION STAGE

BONY EPIPHYSIS BONY EPIPHYSIS BEGINS TO BEGINS TO FRAGMENTFRAGMENT

AREAS OF AREAS OF INCREASED LUCENCY INCREASED LUCENCY AND DENSITYAND DENSITY

EVIDENCE OF REPAIR EVIDENCE OF REPAIR ASPECTS OF DISEASEASPECTS OF DISEASE

X-RayX-Ray Fragmentation of Fragmentation of

epiphysisepiphysis

X-RayX-Ray Metaphyseal Metaphyseal

widening and widening and cystic changes in cystic changes in femoral neckfemoral neck

X-RayX-Ray Lateral extrusion of Lateral extrusion of

femoral head and femoral head and changes in changes in acetabulum.acetabulum.

REOSSIFICATION STAGEREOSSIFICATION STAGE

NORMAL BONE NORMAL BONE DENSITY RETURNSDENSITY RETURNS

ALTERATIONS IN ALTERATIONS IN SHAPE OF FEMORAL SHAPE OF FEMORAL HEAD AND NECK HEAD AND NECK EVIDENTEVIDENT

ClassificationClassificationWaldenstroms classification.Waldenstroms classification.Catterall classification. Catterall classification. Salter classificationSalter classificationHerrings lateral pillar classification.Herrings lateral pillar classification.Modified Elizabethtown classification.Modified Elizabethtown classification.

In 1971 In 1971 used radiological findings of used radiological findings of

epiphyseal involvement to identify epiphyseal involvement to identify 4 groups4 groups

anterior femoral anterior femoral head head involvement involvement

no evidence of no evidence of sequestrum, sequestrum, subchondral subchondral fracture line, or fracture line, or metaphyseal metaphyseal abnormalitiesabnormalities

anterolateral anterolateral involvementinvolvement

Central sequestrum Central sequestrum

Well demarcatedWell demarcated

metaphyseal lesionsmetaphyseal lesions

Subchondral Subchondral fracture line fracture line – Ant ½– Ant ½

lateral column is lateral column is intact.intact.

large sequestrum - large sequestrum - 3/43/4thth of head. of head.

Junction is sclerotic. Junction is sclerotic.

Diffuse Metaphyseal Diffuse Metaphyseal lesionslesions , , anterolaterallyanterolaterally

Subchondral fracture Subchondral fracture lineline - post 1/2 - post 1/2

The lateral column is The lateral column is involved.involved.

Entire headEntire head

Diffuse or Diffuse or central central metaphyseal metaphyseal lesionslesions

posterior posterior

remodelingremodeling of of the epiphysisthe epiphysis

Catterall classificationCatterall classification Groups I and IIGroups I and II had a had a good prognosisgood prognosis

(in 90%) and required no intervention. (in 90%) and required no intervention. Groups III and IVGroups III and IV had a had a poor poor

prognosisprognosis (in 90 %) and required (in 90 %) and required treatment. treatment.

The classification is applied to the frog The classification is applied to the frog lateral and AP film during the lateral and AP film during the fragmentation phase fragmentation phase

CATERALL’S HEAD AT RISK SIGNSCATERALL’S HEAD AT RISK SIGNS

Extent of Extent of subchondral #subchondral # in both AP in both AP & lowenstein frog leg lateral xrays& lowenstein frog leg lateral xrays

reliable indicator in the group with reliable indicator in the group with fracturesfractures

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

Based on radiographic changes in Based on radiographic changes in lateral portion of femoral headlateral portion of femoral head during during fragmentation stage on AP viewfragmentation stage on AP view

LATERAL PILLAR - lateral 15-30%LATERAL PILLAR - lateral 15-30% of of epiphysis on AP xrayepiphysis on AP xray

Group A Group A – – nono involvement involvement

Group B Group B – – at least 50 % at least 50 % of height of height maintained maintained

Group C Group C – – less than 50% less than 50% of height of height maintainedmaintained

AdvantageAdvantage

Easy application Easy application in active diseasein active disease

High correlation bet High correlation bet lat pillar height and lat pillar height and amount of head flattening amount of head flattening at skeletal at skeletal maturitymaturity

described in 1981described in 1981Used to predict the Used to predict the onset of onset of

degenerative joint diseasedegenerative joint disease following LCPDfollowing LCPD

I – I – Shape is normalShape is normal II – II – loss of head heightloss of head height

< 2 mm < 2 mm deviation of concentric deviation of concentric circlescircles

Group I & II – Group I & II – “Spherical Congruency”“Spherical Congruency”

III – III – Elliptical headElliptical head> 2 mm > 2 mm deviationdeviationContour matches Contour matches (“Incongrous/Aspherical (“Incongrous/Aspherical

congruency”)congruency”)

IV – IV – Flattened Flattened head, >1 cm of head, >1 cm of flatteningflattening

Contour Contour matches matches (“Incongrous/As(“Incongrous/Aspherical pherical congruency”)congruency”)

Resemblence Resemblence with with Cow’s hipCow’s hip

V – V – Collapsed head,Collapsed head,Contour mismatch Contour mismatch (“Incongrous/Aspherical (“Incongrous/Aspherical

Incongruency”)Incongruency”)

CLINICAL FEATURESCLINICAL FEATURESSYMPTOMSSYMPTOMS

MOST CHILDERN PRESENT WITH MILD AND MOST CHILDERN PRESENT WITH MILD AND INTERMITTENT PAIN IN THE THIGH OR A LIMP OR BOTH.INTERMITTENT PAIN IN THE THIGH OR A LIMP OR BOTH.

THE ONSET OF PAIN MAY BE ACUTE OR INSIDIOUS THE ONSET OF PAIN MAY BE ACUTE OR INSIDIOUS THE CLASSICAL PRESENTATION IS DESCRIBED AS A THE CLASSICAL PRESENTATION IS DESCRIBED AS A

“PAINLES LIMP” THE CHILD LIMPS BUT DOES NOT “PAINLES LIMP” THE CHILD LIMPS BUT DOES NOT COMPLAINS OF DISCOMFORT.COMPLAINS OF DISCOMFORT.

PAIN IS AGRRAVATED BY MOVEMENT OF HIP AND PAIN IS AGRRAVATED BY MOVEMENT OF HIP AND RELIVED BY REST.RELIVED BY REST.

H/O OF TRAUMA USUALLY A MILD IS PRESENTH/O OF TRAUMA USUALLY A MILD IS PRESENT..

ClinicalClinicalPhysical:Physical: Painful gaitPainful gaitDecreased range of motionDecreased range of motion (ROM), (ROM),

particularly with internal rotation and particularly with internal rotation and abductionabduction

Atrophy of thigh musclesAtrophy of thigh muscles secondary secondary to disuseto disuse

Muscle spasmMuscle spasmLeg length inequalityLeg length inequality due to collapse due to collapse

ClinicalClinicalShort statureShort stature: Children with LCPD : Children with LCPD

often have delayed bone age.often have delayed bone age.Roll testRoll test

With patient lying in the supine position, With patient lying in the supine position, the examiner rolls the hip of the the examiner rolls the hip of the affected extremity into external and affected extremity into external and internal rotation.internal rotation.

This test should invoke guarding or This test should invoke guarding or spasm, especially with internal rotation.spasm, especially with internal rotation.

InvestigationInvestigationX-Ray –AP & Frog leg Lat viewX-Ray –AP & Frog leg Lat viewUSGUSGArthrographyArthrographyBone ScanBone ScanCTCTMRIMRIHAEMOGRAMHAEMOGRAM

Hematological parametersHematological parameters ESRESR CRPCRP Coagulability profile.Coagulability profile. X-raysX-rays USGUSG CT scanCT scan MRIMRI BONE SCANBONE SCAN ArthrographyArthrography Scintigraphy.Scintigraphy.

INVESTIGATIONSINVESTIGATIONS

Imaging – Radiographic Imaging – Radiographic FeatureFeature

Widening of the joint space and minor subluxationWidening of the joint space and minor subluxation Cresent sign/gaze sign/sagging rope signCresent sign/gaze sign/sagging rope sign Fragmentation and focal resorptionFragmentation and focal resorption Loss of sphericity of femoral headLoss of sphericity of femoral head Loss of height of lateral pillersLoss of height of lateral pillers Metaphyseal cyst formationMetaphyseal cyst formation Widening of the femoral neck & head (Coxa Magna)Widening of the femoral neck & head (Coxa Magna) Lateral uncovering &subluxation of the femoral headLateral uncovering &subluxation of the femoral head Head within head appearanceHead within head appearance Acetabular remodellingAcetabular remodelling

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Ultrasound features Ultrasound features Effusion, especially if persistentEffusion, especially if persistentSynovial thickeningSynovial thickeningCartilaginous thickeningCartilaginous thickeningAtrophy of the ipsilateral quadriceps Atrophy of the ipsilateral quadriceps

musclemuscleFlattening, fragmentation, irregularity Flattening, fragmentation, irregularity

of the femoral headof the femoral headNew bone formationNew bone formation

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Accurate imaging modality for early diagnosis Accurate imaging modality for early diagnosis of perthes disease.of perthes disease.

Evaluated congruity of articular surfaces, Evaluated congruity of articular surfaces, femoral head containment, joint effusion and femoral head containment, joint effusion and synovial hypertrophy.synovial hypertrophy.

Epiphyseal involvement clearly visualised on Epiphyseal involvement clearly visualised on MRI 3 to 8 months after first symptoms.MRI 3 to 8 months after first symptoms.

Diagnostic accuracy: 97-99%.Diagnostic accuracy: 97-99%. Also provides earlier and reliable information Also provides earlier and reliable information

on revascularisation and extent of femoral on revascularisation and extent of femoral head necrosis.head necrosis.

MRIMRI

Demonstrates actual contour of femoral head Demonstrates actual contour of femoral head and state of congruity of articular surfaces.and state of congruity of articular surfaces.

It provides reliable information regarding It provides reliable information regarding containment of femoral head within acetabulum.containment of femoral head within acetabulum.

Major advantage is that examiner can assess Major advantage is that examiner can assess congruity of hip in different positions.congruity of hip in different positions.

Often used in early diagnosis of hinge abduction Often used in early diagnosis of hinge abduction of hip.of hip.

Useful in fragmentation and reparative stages.Useful in fragmentation and reparative stages.

ARTHROGRAPHYARTHROGRAPHY

Bone ScanBone Scan Indicated to diagnose in early stages Indicated to diagnose in early stages

and to classify the severity.and to classify the severity.Diagnosis possible months before Diagnosis possible months before

signs appear on X-Ray.signs appear on X-Ray.Avascular areas show cold spots.Avascular areas show cold spots.Revascularisation can be detected Revascularisation can be detected

much before radiographic evidence.much before radiographic evidence.

Bone ScanBone Scan Convay et al Convay et al

classificationclassification Stage 1 is total Stage 1 is total

lack of uptakelack of uptake

Bone ScanBone Scan Revascularisation at Revascularisation at

lateral columnlateral column Failure to Failure to

revascularise at lat revascularise at lat column is a grave signcolumn is a grave sign

Also called Also called “scintigraphic head at “scintigraphic head at risk sign”risk sign”

Precedes radiographic Precedes radiographic head at risk sign by 2-head at risk sign by 2-3 mths3 mths

Bone ScanBone Scan Gradual filling of Gradual filling of

anterolateral partanterolateral part

Bone ScanBone Scan Return to normalReturn to normal

AVN caused by variety of conditionsAVN caused by variety of conditions - Sickle cell anemia- Sickle cell anemia - Other hemoglobinopathies- Other hemoglobinopathies - Thalassemia- Thalassemia - Steroid medication- Steroid medication - After traumatic hip dislocation- After traumatic hip dislocation - Treatment of developmental dysplasia of - Treatment of developmental dysplasia of

hiphip

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

1)1) Transient synovitisTransient synovitis2)2) Slipped femoral epiphysisSlipped femoral epiphysis3)3) Congenital dysplasia of hipCongenital dysplasia of hip4)4) Congenital coxa varaCongenital coxa vara5)5) Early TuberculosisEarly Tuberculosis6)6) Rheumatoid arthritisRheumatoid arthritis7)7) EPIPHYSEAL DYSPLASIASEPIPHYSEAL DYSPLASIAS

COMPARISON BETWEEN COMPARISON BETWEEN TRANSIENT SYNOVITIS &LCPDTRANSIENT SYNOVITIS &LCPD

LCP DISEASE TRANSIENT SYNOVITIS LCP DISEASE TRANSIENT SYNOVITIS -Average duration of - average duration of-Average duration of - average duration ofSymptom is 6-8 wk symptomes in days Symptom is 6-8 wk symptomes in days -synovial thickening -synovitis with -synovial thickening -synovitis with

capsularcapsular distension distension -bony changes & -no bony changes-bony changes & -no bony changes necrosisnecrosis

Comparison chartComparison chart

COMPARISON CHARTCOMPARISON CHARTPERTHES DISEASE EPIPHYSEAL DYSPLASIAUnilateral Bilateral involvement

If B/L, marked asymmetry, disease in differing stages and severity

Symmetrical findings

No involvement of other joints Involvement of other joints or spine.

Acetabulum not involved Involved

Sclerotic and cystic changes in femoral head and cystic changes in metaphysis

Few sclerotic changes in femoral head.

More tendency towards lateral calcification and subluxation

Little tendency.

Prognostic FactorsPrognostic Factors1.1. Age at diagnosisAge at diagnosis2.2. Extent of involvementExtent of involvement3.3. SexSex4.4. Catterall “head at risk” clinical signsCatterall “head at risk” clinical signs

ClinicalClinical1.1. Progressive loss of hip motionProgressive loss of hip motion2.2. Increasing abduction contractureIncreasing abduction contracture3.3. Obese childObese child

Prognostic featuresPrognostic features Age Age

<6yrs; good regardless of treatment<6yrs; good regardless of treatment 6-9years; not always satisfactory with containment6-9years; not always satisfactory with containment >10yrs; questionable benefit from containment, >10yrs; questionable benefit from containment,

poor prognosispoor prognosis GenderGender

Girls have worse prognosisGirls have worse prognosis Classification gradeClassification grade

Herrings lateral pillar classificationHerrings lateral pillar classification Salter and thompson grade B worse prognosisSalter and thompson grade B worse prognosis Caterral classification gradeCaterral classification grade

Caterral “head-at-risk” signsCaterral “head-at-risk” signs The five signs carry worse prognosisThe five signs carry worse prognosis

Others Others Body weight, decreased ROMBody weight, decreased ROM

Classification of PrognosisClassification of Prognosis

- CE(Center-edge)angle of Weiberg.- CE(Center-edge)angle of Weiberg. - Salters extrusion Index.- Salters extrusion Index. - Epiphyseal index.- Epiphyseal index. - Epiphyseal quotient. - Epiphyseal quotient. - Stulberg classification.- Stulberg classification.

CE angle of WeibergCE angle of Weiberg Indicator of acetabular depth Indicator of acetabular depth

It is the angle formed by a It is the angle formed by a perpendicular lines through perpendicular lines through the midportion of the femoral the midportion of the femoral head and a line from the head and a line from the femoral head center to the femoral head center to the upper outer acetabular upper outer acetabular margin. margin.

Normal = 20 to 40 degrees, Normal = 20 to 40 degrees, with an average of 36 with an average of 36 degrees. degrees.

This angle may be slightly This angle may be slightly larger in women and in older larger in women and in older persons.persons.

Angle >25 = good, 20-25= Angle >25 = good, 20-25= fair, < 20 = poorfair, < 20 = poor

Salters extrusion IndexSalters extrusion Index If AB is more If AB is more

than 20% of than 20% of CD it CD it indicates a indicates a poor poor prognosis prognosis

TreatmentTreatmentObjectivesObjectives - To produce a normal femoral - To produce a normal femoral head and neckhead and neck - To produce a normal acetabulum- To produce a normal acetabulum - A congruous hip which is fully - A congruous hip which is fully mobilemobile - To prevent degenerative arthritis - To prevent degenerative arthritis of the hip later in lifeof the hip later in life

TreatmentTreatmentGOAL :GOAL :Treatment efforts are directed towardsTreatment efforts are directed towards - Restoration and maintenance of - Restoration and maintenance of full mobility of the hipfull mobility of the hip - Containment of the femoral- Containment of the femoral head.head. - Resumption of weight bearing- Resumption of weight bearing and full activity as soon as and full activity as soon as possiblepossible

Rational behind "containment"Rational behind "containment"

Containment of the head within the acetabulum is Containment of the head within the acetabulum is reported to reported to encourage spherical remodelling encourage spherical remodelling during the reossification and subsequent phases. during the reossification and subsequent phases.

However if there is However if there is total head involvementtotal head involvement and and the lateral pillar collapses then the effect of the lateral pillar collapses then the effect of containment is probably containment is probably lessless..

Therefore it seems that the extent of involvement Therefore it seems that the extent of involvement of the head is the of the head is the critical factorcritical factor and containment and containment simply optimizes the situation. simply optimizes the situation.

Methods of CONTAINMENT OF Methods of CONTAINMENT OF

HEADHEAD (a) Conservative methods (a) Conservative methods (b) Surgical methods(b) Surgical methods

TreatmentTreatmentTreatment is divided into 3 phasesTreatment is divided into 3 phases

Initial Phase – restore & maintain Initial Phase – restore & maintain mobilitymobility

Active Phase – Containment and Active Phase – Containment and maintainance of full mobility.maintainance of full mobility.

Reconstructive phase – correct Reconstructive phase – correct residual deformities.residual deformities.

Treatment ( Initial Phase )Treatment ( Initial Phase )Physiotherapy – active and passive Physiotherapy – active and passive range of motionrange of motion exercises to restoreexercises to restore motionmotionTraction – B/L skin traction and Traction – B/L skin traction and gradually abducting over 1-2 gradually abducting over 1-2 weeks till full abduction isweeks till full abduction is regained.regained.

Treatment ( Active Phase )Treatment ( Active Phase )Consists of containment of the Consists of containment of the

femoral head within the acetabulum. femoral head within the acetabulum. This can be achieved by This can be achieved by

orthosis orthosis or byor by surgerysurgery

Hip irritability with decrease of hip motion:Hip irritability with decrease of hip motion:

1-2 week period of bed rest with abduction traction1-2 week period of bed rest with abduction traction if recursif recurs 2-3 months period of surgical non containment to 2-3 months period of surgical non containment to

decrease risk of extrusion.decrease risk of extrusion.

X-ray taken bi-monthly for evaluation.X-ray taken bi-monthly for evaluation.

Treatment (Orthosis)Treatment (Orthosis) Non Ambulatory weight releivingNon Ambulatory weight releiving

1.1. Abduction broomstick plaster castAbduction broomstick plaster cast2.2. Hip spica castHip spica cast3.3. Milgram hip abduction orthosisMilgram hip abduction orthosis

Ambulatory Both limbs includedAmbulatory Both limbs included1.1. Petrie Abduction castPetrie Abduction cast2.2. Toronto orthosisToronto orthosis3.3. Newington orthosisNewington orthosis4.4. Birmingham braceBirmingham brace5.5. Atlanta Scotish Rite Brace Atlanta Scotish Rite Brace

Treatment (Orthosis)Treatment (Orthosis) Atlanta Scotish Rite Atlanta Scotish Rite

BraceBrace

Atlanta Scotish Rite BraceAtlanta Scotish Rite Brace

Newington orthosisNewington orthosis

Birmingham braceBirmingham brace

Toronto BraceToronto Brace

Treatment (Orthosis)Treatment (Orthosis) Orthotic treatment is discontinued when Orthotic treatment is discontinued when

the disease enters the reparative phase the disease enters the reparative phase and healing is established.and healing is established.

The radiographic evidence of healing areThe radiographic evidence of healing are1.1. Appearance of regular ossification in the Appearance of regular ossification in the

femoral head.femoral head.2.2. Increased density of femoral head should Increased density of femoral head should

disappear.disappear.3.3. Metaphyseal rarefaction involving the Metaphyseal rarefaction involving the

lateral cortex of the metaphysis should lateral cortex of the metaphysis should ossify.ossify.

4.4. There should be intact lateral column.There should be intact lateral column.5.5. There should be normal trabecular bone There should be normal trabecular bone

in the epiphysis.in the epiphysis.

So finally…. before planning So finally…. before planning surgery, first think of atleast 4 surgery, first think of atleast 4

things …..things …..Pathological stagePathological stageAge Age Range of motionRange of motionCatterall & herrings stagingCatterall & herrings staging

Treatment ( Surgical)Treatment ( Surgical)Femoral varus osteotomy.Femoral varus osteotomy. Inominate osteotomy.Inominate osteotomy.Combined femoral and inominate Combined femoral and inominate

osteotomyosteotomyValgus osteotomyValgus osteotomyShelf arthroplastyShelf arthroplastyChiari osteotomyChiari osteotomyCheilectomy.Cheilectomy.Trochanteric advancement or arrest.Trochanteric advancement or arrest.

PELVIC OSTEOTOMYPELVIC OSTEOTOMY Redirectional OsteotomyRedirectional Osteotomy

Salter’s osteotomy to Salter’s osteotomy to reorient the acetabulumreorient the acetabulum

Shelf OperationShelf Operation To create a bony shelf to To create a bony shelf to

cover the extruded part of cover the extruded part of the epiphysis.the epiphysis.

Displacement OsteotomyDisplacement Osteotomy Chiari osteotomy is Chiari osteotomy is

another way to improve the another way to improve the coveragecoverage..

Inominate osteotomyInominate osteotomy IndicationsIndications::1.>6 yrs1.>6 yrs2.mod. Or severely affected head with loss of 2.mod. Or severely affected head with loss of

containment(Catterall grade 3containment(Catterall grade 3rdrd & 4 & 4thth))

RequirementRequirement::Able to abduct 45 deg. And femoral head to be Able to abduct 45 deg. And femoral head to be

contained in positioncontained in positionADVANTAGE :ADVANTAGE :1)Anterolateral coverage of frmoral head1)Anterolateral coverage of frmoral head2)Lengthening of extremity2)Lengthening of extremity3)Avoidance of second surgery for implant removal3)Avoidance of second surgery for implant removal

COMPLICATIONS:-COMPLICATIONS:-1)Inability to achieve containment in 1)Inability to achieve containment in

older childolder child2)Sometimes limb lenghtening2)Sometimes limb lenghtening3)Increase hip pressure can cause 3)Increase hip pressure can cause

further AVNfurther AVN

Shelf ArthroplastyShelf ArthroplastyPerformed to enlarge the volume of Performed to enlarge the volume of

acetabulum.acetabulum.

Indication:A deficient acetabulum cannot Indication:A deficient acetabulum cannot be corrected by pelvic osteotomybe corrected by pelvic osteotomy

Contra indication: Dysplastic hip with Contra indication: Dysplastic hip with spherical congruity spherical congruity

ADVANTAGE:-ADVANTAGE:-1)LATERAL ACETABULAR GROWTH 1)LATERAL ACETABULAR GROWTH

STIMULATIONSTIMULATION2)SHELF RESOLUTION AFTER FEMORAL 2)SHELF RESOLUTION AFTER FEMORAL

EPIPHYSEAL OSSIFICATIONEPIPHYSEAL OSSIFICATION3)PREVENTION FROM SUBLUXATION3)PREVENTION FROM SUBLUXATIONCOMPLECATIONS:-COMPLECATIONS:-1)LOSS OF HIP FLEXION1)LOSS OF HIP FLEXION2)LATERAL CUTANEOUS NERVE AT RISK2)LATERAL CUTANEOUS NERVE AT RISK

i)Curved incision below iliac crest, strip glutei.ii) Mobilize and divide reflected head of rectus femoris

iii) Trough in bone above insertion of capsule.iv) Strips of cancellous bone inserted into trough so that they form a

canopy on superior surface of hip joint.v) Pack web space between flap and graft canopy with gratft

vi)Repair rectus and lose the wound.

Chiari osteotomyChiari osteotomy Capsular interpositional Capsular interpositional

arthroplasty(capsule is arthroplasty(capsule is interposed b/w newly interposed b/w newly formed acetabulum roof formed acetabulum roof & femoral head)& femoral head)

Usually after 10 yr of ageUsually after 10 yr of age Deepens the deficient Deepens the deficient

acetabulum by medial acetabulum by medial displacement of distal displacement of distal pelvic fragment and pelvic fragment and improves sup.lat.femoral improves sup.lat.femoral coverage.coverage.

FEMORAL OSTEOTOMYFEMORAL OSTEOTOMY

Technically less demanding than innominate osteotomyTechnically less demanding than innominate osteotomy

Usually 20Usually 200 0 varus angulation & 20varus angulation & 200 0 IR appears sufficient.IR appears sufficient.

Good to decide abduction, internal rotation or flexion on a Good to decide abduction, internal rotation or flexion on a pre-operative arthrogram.pre-operative arthrogram.

Femoral varus osteotomyFemoral varus osteotomyIndicationsIndications: 1.>6yrs of age: 1.>6yrs of age 2.excessive femoral anteversion 2.excessive femoral anteversion 3.catterall grade 33.catterall grade 3rdrd & 4th & 4thComplicationsComplications:1.excessive post op varus:1.excessive post op varus2.Persistant ext.rotation2.Persistant ext.rotation3.Shortening of extremity3.Shortening of extremity4.Incresed abductor lurch4.Incresed abductor lurch5.Trochanteric over growth5.Trochanteric over growth6.Delayed or non union6.Delayed or non union

varus should not be varus should not be exceeds more than 110 exceeds more than 110 degree.degree.

Level of osteotomy

Insertion of guide pin and reaming of femur

First depth marking flush with lateral cortex

Removal of wedge to customize it

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usually we use varususually we use varus (medial closing wedge)(medial closing wedge) osteotomy fixed with an osteotomy fixed with an pediatric hip screwpediatric hip screw

Plate and compression screw application

Insertion of bone screws.

Valgus OsteotomyValgus Osteotomy

Indication:hinged Indication:hinged abduction of hipabduction of hip

CHEILECTOMYCHEILECTOMYLarge malformed femoral head Large malformed femoral head

outside the acetabulum causing outside the acetabulum causing painful sensation on abduction/lack painful sensation on abduction/lack of abductionof abduction

Removal of malformed femoral head Removal of malformed femoral head protruding outside acetabulumprotruding outside acetabulum

Result after short term follow up are Result after short term follow up are good but detoriates with timegood but detoriates with time

Widening of the jointWidening of the jointUnloads the joint Unloads the joint

spacespaceReduces pressure Reduces pressure

over headover headArticular cartilage Articular cartilage

repairrepairMaintain congruencyMaintain congruencyAllows 50 degree Allows 50 degree

flexionflexion

TTROCHANTRIC OVERGROWTHROCHANTRIC OVERGROWTH -due to premature closure of femoral epiphysis-due to premature closure of femoral epiphysis - Elevation of trochanter decreases tension - Elevation of trochanter decreases tension

and mechanical efficiency of pelvic and and mechanical efficiency of pelvic and trochantric muscles.trochantric muscles.

- Shortened femoral neck moves trochanter - Shortened femoral neck moves trochanter closer to centre of rotation of hip, line of pull closer to centre of rotation of hip, line of pull of muscles becomes more vertical.of muscles becomes more vertical.

- Impingement of head to the roof limiting - Impingement of head to the roof limiting abduction.abduction.

Normal growth pattern

Long. Growth arrested, greater trochanter continues

GEAR STICK SIGNGEAR STICK SIGNDifferentiation b/w trochrntric Differentiation b/w trochrntric

impingment & other cause of impingment & other cause of restricted hip abductionrestricted hip abduction

In case if trochentric impingment-In case if trochentric impingment-hip extension-impingmented during hip extension-impingmented during

abductionabductionHip flexion-no impingment during Hip flexion-no impingment during

abductionabduction

Trochanteric advancementTrochanteric advancement IndicationsIndications::

- Trochanteric over - Trochanteric over growthgrowth

- Capital femoral - Capital femoral physeal growth physeal growth arrestarrest

Recommended Indications for Recommended Indications for diff. surgeriesdiff. surgeries

Hinged abduction - valgus Hinged abduction - valgus subtrochanteric osteotomysubtrochanteric osteotomy

Severly Mal formed femoral head – Severly Mal formed femoral head – cheilectomycheilectomy

Coxa magna – shelf augmentationCoxa magna – shelf augmentationA large malformed femoral head with A large malformed femoral head with

lat.subluxation – Chiari’s pelvic lat.subluxation – Chiari’s pelvic osteotomyosteotomy

Capital femoral physeal arrest – Capital femoral physeal arrest – Trochanteric advancementTrochanteric advancement

Recent AdvancesRecent AdvancesAnticoagulantAnticoagulantBotulinum toxinBotulinum toxin Ibadronate :this has shown there Ibadronate :this has shown there

importance in rat model by increase importance in rat model by increase spericity of femoral headspericity of femoral head

Still lot more work to do in this fieldsStill lot more work to do in this fields

References References Campbell’s operative Orthopaedics – Campbell’s operative Orthopaedics –

1010thth edition editionTachdjian’s paediatric orthopaedics – Tachdjian’s paediatric orthopaedics –

33rdrd edition editionMercer’s Orthopaedic surgery – 9Mercer’s Orthopaedic surgery – 9thth

editionedition Journals of bone and joint surgeryJournals of bone and joint surgery InternetInternet

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