AFTER MID
SURGERY
DR. ALI BAQER
Orthopaedic
Perthe’s Disease & SCFE
LECTURES 5
Dr. Ali BaQer
Perthe’s disease or Legg-Calve-Perthe’s disease
*Was described in 1910 , independently by 3 different people.
*It is painful disorder of the childhood characterized by avascular
necrosis of the femoral head.
*It is uncommon in any community , about 1 in 10,000 with a higher
incidence in Japanese , and central Europeans and a lower incidence in
native Americans
old.
10 years
-
4
*patients are usually
are affected 4 times as often as girls.
boys
*
ogenesis
ath
P
, but the cardinal step
unknown
*The exact cause of Perthe’s disease is
in the pathogenesis is ischemia of the femoral head.
, the femoral head is supplied by :
4 months
*Up to the age of
which penetrate the growth plate.
metaphyseal vessels
-
1
lateral epiphyseal vessels running in the retinacula.
-
2
scanty vessels in the ligamentum teres.
–
3
*the metaphyseal supply gradually declines until by the age of 4 years ,
it has virtually disappeared.
*by the age of 7 years , the vessels in the ligamentum teres have
developed.
, the femoral head may depend for its
*between 4 and 7 years of age
the lateral
blood supply and venous drainage almost entirely on
whose situation in the retinacula makes them
epiphyseal vessels
susceptible to stretching and to pressure from an effusion.
*although such pressure may be insufficient to block off the arterial
flow , it could easily cause venous stasis resulting in arise in intraosseous
pressure and consequent ischemia.
*the immediate cause of capsular tamponade may be an effusion
following trauma ( of which there is a history in over half the cases ).
or a non- specific synovitis.
Pathology
*the pathological process goes through several stages which in total may
last up to 3 or 4 years.
ischemia and bone death
Stage 1 :
- all or part of the bony nucleus of the femoral head is dead.
- it still looks normal on plain x- ray.
-the cartilaginous part of the femoral head , being nourished by
synovial fluid , remains viable and becomes thicker.
revascularization and repair
Stage 2 :
- within weeks or even days of infarction a number of changes begin
to appear.
- the bone is revascularized and new lamellae are laid down on the
dead trabeculae , producing the appearance of increased density on x-
ray.
- some of the dead trabecular fragments are resorbed and replaced
by fibrous tissue.The alternating areas of sclerosis and fibrosis appear on
the x- ray as fragmentation of the epiphysis.
: Distortion and remodeling :
Stage 3
- if the repair process is rapid and complete , the bony architecture
may be restored before the femoral head loses its shape.
- if it is tardy , the bony epiphysis may collapse and subsequent
growth of the femoral head and neck will be distorted .
- the head becomes oval or flattened like the head of a mushroom ,
and enlarged laterally, and the neck is often short and broad.
Clinical features
*the patient typically a boy of 4- 10 years complains of pain and starts
limping.
*symptoms may recur intermittently.
*in 4 % of cases , there is an associated urogenital anomaly.
**Early on , the joint is irritable so that all movements are diminished
and their extremes painful.
**Often the child is not seen till later , when most movements are full ,
but abduction ( especially in flexion ) , is nearly always limited and
usually internal rotation also.
Plain x – ray
**at first the x – ray may be normal .
**the classic feature of increased density of the ossific nucleus occurs
).
necrotic phase
somewhat later. (
*note : the radiographically dense areas are due to the new bone
formation that always follows bone necrosis.
) , in which there are
fragmentation phase
**then there will be (
alternating patches of density and lucency .
) , the femoral head may regain its normal or
healing phase
** With (
near normal shape , or it becomes mushroom- shaped, larger than
normal and laterally displaced in a dysplastic accetabular socket.
Prognostic features
prognostic factor .
is most important
age :
-
1
- in children under 6 years the outcome is almost always
excellent.
- the older the child , the less good is the prognosis.
girls have poorer prognosis than boys.
sex :
-
2
the greater the degree ,
the degree of femoral head involvement :
-
3
the worse the outcome.
the head at risk radiographic signs
-
4
A- progressive uncovering of the epiphysis.
B- calcification of the cartilage lateral to the ossific nucleus.
C- a radiolucent area at the lateral edge of bony epiphysis ( Gage’s
sign ) .
D- severe metaphyseal resorption.
Treatment
ility :
At stage of joint irritab
-
- analgesia and modification of activities are often sufficient , but
hospitalization for bed rest and short periods of traction are sometimes
necessary.
- wheelchair use and crutch walking should be discouraged in order to
avoid unnecessary joint stiffness and contracture.
-
which usually takes about 3
Once joint irritability has subsided :
weeks , movement is encouraged .
*The further treatment may include
means pain control ( if necessary by
:
symptomatic treatment
-
1
further spells of traction ) , gentle exercise to maintain movement and
regular reassessment.
ng active steps to seat the femoral head
means taki
containment :
-
2
congruently and as fully as possible in the acetabular socket , so that it
may retain its sphericality and not become displaced during the period
of healing and remodeling.
-
This is achieved by either holding the hips widely abducted in
plaster or removable brace or by operation.
-
Operations include either varus osteotomy of the femur or an
innominate osteotomy of the pelvis or both.
Slipped capital femoral epiphysis
*Also called femoral capital epiphysiolysis
Displacement of the proximal femoral epiphysis ( SCFE )
uncommon 1-3 per 100 000 .
-
It is confined to children going through the pubertal growth spurt.
-
affected more than girls.
are
Boys
-
Left hip is affected more commonly than the right.
-
If one hip slips , there is a 25 – 40 % risk of the other side also
slipping.
Many of the patients are either fat and sexually immature or
excessively tall and thin.
*Aetiology :
hormonal imbalance theory :
-
1
- normally , pituitary hormone activity , which stimulates rapid growth
and increased physeal hypertrophy during puberty , is balanced by
increasing gonadal hormone activity , which promotes physeal
maturation and epiphyseal fusion.
-
A disparity between these two processes may result in the physis
being unable to resist the shearing stresses imposed by the
increase in body weight.
- Oestrogens produce a decrease in physeal width and increased physeal
strength , which may partly explain the lower incidence in girls and rare
occurrence after menarche.
the physis ) is
( the retaining collar around
the perichondrial ring
-
2
relatively thinned in this age group and provides less support for the
increased load transmitted through the physis during the growth spurt.
with an
plays a part , especially in the 30 % of the cases
trauma :
-
3
acute slip.
-in the other 70 % , there is a slow progressive displacement or a series
of slight displacements , chronic slip .
- Sometimes , acute on chronic slip can occur.
Pathology
-
external rotation
al shaft rolls into
In slipped epiphysis the femor
and the femoral neck is displaced forwards while the epiphysis
remains seated in the acetabulum.
-
Disruption occurs through the hypertrophic zone of the physis.
-
Relatively speaking , the epiphysis slips posteriorly on the femoral
neck.
-
If the slip is severe , the anterior retinacular vessels are torn.
-
At the back of the femoral neck the periosteum is lifted from the
bone with the vessels intact , this may be the main or the only
source of blood supply to femoral head. And if damaged by
manipulation or operation then avascular necrosis of the head
may result.
Clinical features :
-
Slipping usually occurs as a series of minor episodes rather than a
sudden acute event.
-
The patient is usually a child around puberty , typically overweight
or very tall and thin.
-
is almost pain , sometimes in the groin ,
The presenting symptom
BUT often only in the thigh or knee which can be very misleading.
-
The pain soon disappears only to recur with further exercise.
-
Limping also occurs early.
-
2 cm short ,
-
the leg is externally rotated and is 1
On examination
there is limitation of flexion , abduction and medial rotation.
-
A classic sign is the tendency to increasing external rotation as the
hip flexed.
-
Following an acute slip , the hip is irritable and all movements are
accompanied by pain.
Imaging :
ray
–
**X
-
In very early cases the x - ray may be reported as normal.
-
Then there will be - decreased in the epiphyseal height.
- physeal widening.
- lesser trochanter prominence due to
- increases external rotation of the femur.
a line drawn along the superior surface of the femoral
In AP view
neck should normally intersect the epiphysis.
In an early slip the epiphysis may be flush with or even below this line
( Trethowan s sign ).
measure the angle subtended by the epiphyseal base
In LATERAL view
and the femoral neck.
This is normally a right angle and anything less than 87 degrees means
the epiphysis is tilted posteriorly.
: has been used to detect the stage of avascular necrosis of the
MRI
**
femoral head.
can be used in the preoperative planning of
3 D CT scan
:
CT scan
**
-
realignment procedures for complex proximal femoral deformities.
may detect a hip effusion associated with an acute
:
Ultrasonography
**
event.
Treatment
:
The aim of treatment are
1- to preserve the epiphyseal blood supply.
2- to stabilize the physis.
3- to correct any residual deformity.
-manipulative reduction of the slip carries a high risk of avascular
necrosis and should be avoided.
-The choice of treatment depends on the degree of slip :
Minor slip :
-
1
- Less than one third of the epiphysis on AP x –ray and less than 20
degrees tilt in the LATERAL view.
-deformity is minimal and needs no correction.
-the position is accepted and the physis is stabilized by inserting one or
two screws or threaded pins along the femoral neck and into the
epiphysis , under fluoroscopic control.
Moderate slip :
-
2
-
Between one third and two thirds of the width of the epiphysis
on the AP x- ray and 20 – 40 degrees of the tilt in the lateral
view.
-
Deformity here is usually tempered by gradual bone modeling and
may in the end cause little disability.
-
So we can accept the position , fix the epiphysis in situ and then
wait .
-
If after a year or two , there is a noticeable deformity , a corrective
osteotomy is performed below the femoral neck.
severe slip :
-
3
-
More than two thirds of the width of the epiphysis on the AP x-
ray and 40 degrees of tilt in the lateral view.
-
This is unacceptable slip and causes marked deformity and if
untreated , it will predispose to secondary OA.
-
Closed reduction by manipulation is dangerous and should not be
attempted.
-
Open reduction by Dunn s method gives good results.
-
Alternative method is to fix the epiphysis as for a moderate slip
and then as soon as fusion is complete , to perform a
compensatory intertrochanteric osteotomy.
Complications
Slipping at the opposite hip
-
1
25 % - 40% of cases slipping occurs at the other hip.
.
Avascular necrosis of the femoral head
-
2
.
Articular chondrolysis
-
3
.
Coxa vara
-
4
