Dr.

Ankush Bansal
M.S.(Orthopaedics)
Kasturba Medical College, Mangalore

Arthur Legg Boston Jacques Calve Berck-sur-mer Georg Perthes Tubingen

A self limiting, non-inflammatory condition, affecting the capital femoral epiphysis with stages of degeneration and regeneration, leading to a restoration of the bone nucleus.

Perthes 1913

Schwarz 1914

described femoral blood supply

Suggested that primary epiphyseal necrosis was due to multiple infarcts as a result of thrombosis or embolism

Usually occurs age 3 -12 years y Most common age 5 - 7 years y Bilateral in 10% - 20 % y Boy 3-5 : 1 Girl y Familial in 8%-12%*
y

*(Wansbrough et al. JBJS 1959, 41-A: 135-146.)

Delayed bone age Retarded growth soon after diagnosis with later catch up growth

(Kristmundsdottir et al: Acta Orthop Scand 1987;58:277-279)

Undersized at diagnosis
(Wynne-Davies et al JBJS 1978;60B:6-14)

Small hands & feet

(Hall et al 1988;70B:611-613)

Limp Pain in groin radiating to knee Limited abduction Limited internal rotation Flexion with abduction and external rotation Trendelenberg

Transient synovitis Septic arthritis Slipped femoral epiphysis MED/SED Systemic Steroids Abnormal Coagulation
y y y

Sickle cell Thalassaemia Leukaemia

Lymphoma ITP Haemophilia

Bloods FBC, ESR, CRP, Blood Culture Radiographs Ultrasound Scan Bone Scan

Decreased bone scan uptake before radiographic changes

(Rutskii el al Ortop Travmatol Protez 1989;10:35-39)

MRI

Earlier diagnosis than plain radiography More information regarding extent of necrosis than bone scanning

(Henderson et al. JPO 1990; 10: 287-297)

Sclerosis

Fragmentation

Re-ossification

Healing

I III

II IV
Groups I & II Good Prognosis Groups III & IV Poor Prognosis

Lateral epiphyseal calcification Lateral subluxation Gages sign Metaphyseal cysts Horizontal growth plate

Catterall I & II III & IV

Salter A B

Prognosis good bad

Group A
Normal Height of lateral pillar maintained

Group B
> 50% of lateral pillar height maintained

Group C
< 50% of lateral pillar height maintained

Significantly better predictor of outcome than Catterall* Stronger determinant of final outcome than age** Inter observer variability better than Catterall grading or head at risk signs**

* Ritterbusch et al.JPO 1993; 13: 200-202 **Herring et al JPO 1992; 12: 143-150

Spherical congruency
Arthritis does not develop

Aspherical congruency
Mild to moderate arthritis mid -late adulthood

Aspherical incongruency
Severe arthritis before age fifty years.

Early Disease
While the femoral head is still plastic

Late Disease
When the femoral head is no longer plastic

Observation Non weight bearing Containment

Brace Femoral osteotomy Pelvic osteotomy

1966
Harrison & Menon reported results of Broomstick Plaster (Petrie Cast)
Harrison & Menon JBJS1966;48A:1301-1318

1965 Varus femoral osteotomy

Axer A. JBJS(A) 1965;47A:489-499

1962
Salter osteotomy first used for Perthes

Pre requisites

Near normal ROM

Traction Serial Abduction Splintage Adductor tenotomy

Containable hip

Arthrogram

Normal Neutral

Containable

Hinging

Abduction

Femoral epiphysis deformed and no longer plastic Principle complication is hinge abduction Short leg Short femoral neck with high trochanter Limited abduction Gluteal insufficiency symptoms

Objective - maintenance of full pain free ROM Clinical indications that patient doing badly

Increasing symptoms Short limb Abduction limited to < 10o - 20o Limited rotations Flexion with external rotation & abduction

It is difficult if not impossible to compare the results of these (published) studies

Extent of epiphyseal involvement Age at onset of disease Sex

50% - 70% do well without treatment No evidence that treatment alters outcome Treat symptomatically to regain ROM Regular outpatient assessment

Consider containment for : Persistent loss of ROM with Herring C (Catterall III IV at risk) (Salter Thompson B)

Observe: Patients maintaining ROM with Herring A (Catterall I & II not at risk) (Salter Thompson A) Consider containment for : Persistent loss of ROM with Herring B (Catterall III IV at risk) (Salter Thompson B)

50% of Catterall III & IV had good results

Hoikka et al.Acta Orthop Scand 1991; 62: 549-553.

Observe: Patients maintaining ROM with Herring A (Catterall I not at risk) (Salter Thompson A) Most patients have: Persistent loss of ROM with Herring B/C (Catterall III IV at risk) (Salter Thompson B)

Principle complication is hinge abduction Short femoral neck with high trochanter Gluteal insufficiency symptoms Limited abduction/Short leg

Neutral

Abduction

Pre requisites Hinging Good range of adduction Arthrogram Congruent hip in adduction

26/26 improved post op

Quain & Catterall. JBJS 1986; 68B; 61-64

Legg Calve Perthes

Discovered a century ago Aetiology? Treatment?

Randomized Controlled Trial? Coagulopathy as a cause? Arthrodiatasis Osteoplasty