Legg Calve Perthes disease

1
Legg Calve Perthes disease

• Karen Daly FRCS (Orth)?
• Consultant in Childrens Orthopaedics
• St Georges Hospital

2
How does it present?

• A limping child
• Acute onset of hip pain
• Incidental finding
• in childhood
• as an adult

3
What do I do?

• Dont panic
• Assessment
• History
• Examination
• X-rays

4
What do I tell the parents?

• Avascular necrosis of the capital femoral
  epiphysis
• Cause unknown
• A prognosis
• A proviso

5
How can I do this?

• Avascular necrosis
• Phemister DB Arch Surgery 2221-230, 1921

6
How can I do this?

• Radiological changes
• Necrosis
• Fragmentation
• Reossification
• Remodelling
• Waldenstrom H J Bone Joint Surg 20 559-566,
  1938

7
What else do I need to know?

• Differential diagnosis
• Infection/ transient synovitis
• Hypothyroidism
• Storage diseases
• Multiple epiphyseal dysplasia
• etcetera

8
What else do I need to know?

• Aetiology
• Genetic
• Developmental
• Trauma
• Environmental

9
What else do I need to know?

• Prognosis
• Age
• Sex
• Stage
• Classification (severity)?
• Herring JA et al J Pediatr Orthop 13281-285,
  1993

10
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

11
What next?

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

12
What next?

• Symptomatic treatment

13
Follow-up

• Clinical assessment
• Pain and limp?

14
Follow up

• Pain and limping
• Trendelenburg sign
• Range of movement
• X-rays

15
When it goes wrong

• Arthrography
• Assess deformity
• Assess containabilty
• Best fit

16
When it goes wrong

• Arthrography
• MRI

17
When it goes wrong

• What stage of disease?
• Necrosis
• fragmentation ( revascularisation)?
• suitable for reconstruction

18
What can I do?

• Containment by cast or brace
• Containment by surgery
• Femoral varus osteotomy
• Acetabular extension or realignment

19
When it goes wrong

• What stage of disease?
• Reossification
• remodelling
• suitable for salvage procedures

20
When it goes wrong

• Valgus osteotomy
• Hip arthroplasty!

21
What I do
22
Outcome

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

23
Outcome

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