1. Legg-Calve-Perthes Assoc. Prof. Melih Güven
Yeditepe University Hospital
Department of Orthopaedics and Traumatology

2. Learning Objectives
Should be able to explain the etiopathogenesis of osteonecrosis of the femoral head in children.
Should be able to list the stages and clinical, radiographic features of the stages.
Should be able to define the risk factors of Perthes’ disease.
Should be able to list the radiographic features of the femoral head under risk.
Should be able to make differential diagnosis of Perthes’ disease.
Should be able to explain the clinical findings of Perthes’ disease.
Should be able to list conservative and surgical treatment methods of Perthes’ disease.

3. Perthes disease
Idiopathic juvenile avascular necrosis of the femoral head
Waldenström disease
1/1200
E/K = 7-8/1
Most commonly is seen in children aged 4-8 (2-12) years, with an average age of 7 years
%10-15 bilateral

4. Etiology ??? Synovitis Joint effusions (e.g. infection) Trauma
Cartilage hypertrophy
Congenital vascular hypoplasia
Steroids
Coagulation defects
Systemic disorders
Hereditary influence, environmental influence, hyperactivity

5. Etiology
Disruption of blood flow to capital femoral epiphysis (CFE)‏

6. Pathology
The blood supply to the capital femoral epiphysis is interrupted (arteries and veins)
Bone infarction occurs, especially in the subchondral cortical bone, while articular cartilage continues to grow. (Articular cartilage grows because its nutrients come from the synovial fluid)‏
Revascularization occurs, and new bone ossification starts
Changes to the epiphyseal growth plate occur secondary to the subchondral fracture

7. Clinical symptoms
Hip and groin pain, which may be referred to the thigh
± knee pain !!!
Limp – with or without pain
Especially Trendelenburg test (+)
Limitation in abduction and internal rotation (decreased range of motion)
Atrophy of thigh muscles
Flexion contracture

8. Radiological examination
Conventional radiographs
Pelvis AP and frogleg
USG
Bone scan (scintigraphy)
MRI

9. Radiographic presentation (Stages)
Synovitis ( 4 – 6 weeks )
Avascular necrosis ( 6 months )
Fragmentation ( 1 – 2 years )
Reossification
Residual stage ( 3 – 4 years )

10. Synovitis
Effusion in joint capsule, edema and thickening of the capsule
Increased medial joint space
Cresent sign
Demineralization in metaphysis

11. Avascular necrosis Lateralization of the femoral head; sclerosis
Decreased size of ossification center
Decreased height of epiphysis
Collapse of the epiphysis
Physeal irregularity
Metaphyseal cysts
Superolateral Gage sign

12. Fragmentation - resorption
Resorption of avascular bone
Fragmented epiphysis
More irregular acetabular contour
Reossification – regeneration (revascularation)

13. Residual stage Healing of the metaphyseal cysts
Reossified femoral head
Remodeling of the femoral head and acetabulum
Sometimes disrupted relationship between femoral head and acetabulum
Coxa magna, plana, breva

14. Differential diagnosis
Synovitis
Toxic synovitis
Septic arthritis
Acute rheumatic fever
Juvenile arthritis
Tbc arthritis
Osteoid osteoma

15. Differential diagnosis
Avascular necrosis
Sickle cell anemia
Gaucher disease
Traumatic avascular necrosis

16. Differential diagnosis
Fragmentation
Tbc arthritis
Multiple epiphyseal dysplasia
Hypothyroid

17. Prognostic factors Age Gender Time to diagnose and treatment
Amount of femoral head involvement
“Head at risk” signs

18. Classifications After occurance of subchondral cresent sign
Salter - Thompson
At the fragmentation stage
Catterall
Herring-Lateral pillar
After skeletal maturity
Stulberg

19. Salter – Thompson
Group A
Group B

20. Catterall
C C C C-4

21. Herring-Lateral pillar
Group A
Lateral pillar intact
Group B
Head involvement < 50%
Group C
Head involvement > %50
Detrmine treatment and prognosis

22. “Head at risk” signs
Lateralization of the femoral head from the acetabulum
Calcifications in the lateral portion of the epiphysis
Diffuse metaphyseal cysts
Horizontally aligned epiphyseal plate
Gage sign (large metaphyseal cyst)

23. Goal of treatment
Preservation of the roundness of the femoral head and prevention of deformity while the condition runs its course

24. Treatment algorithm
< 7 years of age, C-1 and C-2 or Herring lateral pillar group A – No treatment
> 7 years of age, C-3 and C-4, Herring lateral pillar group B and C – Treatment

25. Treatment algorithm

26. Phases of treatment Initial period Containment provider modalities
Reconstructive procedures (salvage methods)

27. Phases of treatment Initial period Observation Bed rest
Manual or skin traction
NSAI

28. Phases of treatment Containment provider modalities
Containment of the femoral epiphysis within the confines of the acetabulum
Orthoses

29. Phases of treatment Containment provider modalities
Containment of the femoral epiphysis within the confines of the acetabulum
Femoral varization ± derotation osteotomy
Iliac osteotomy

30. Phases of treatment Reconstructive procedures (salvage methods)
Shelf acetabuloplasty
Double or triple iliaca osteotomies
± femoral osteotomies

31. Thanks !