This document summarizes Legg-Calvé-Perthes disease, a childhood hip disorder characterized by temporary loss of blood supply to the femoral head. It describes the disease stages including initial sclerosis, fragmentation as new bone forms, and healing. Risk factors include age 4-8 years and delayed bone age. Symptoms include limping and pain. Treatments aim to contain the femoral head through bracing or surgery to prevent joint damage. Prognosis depends on age and deformity, with older children and severe deformity having worse outcomes.

2. 
FIRST DESCRIBED BY
LEGG (USA), AND
WALDENSTORM IN
1909, AND BY
PERTHES(GERMANY)
AND
CALVE(FRANCE) IN
1910

3. 





Disorder of the hip in young children
Usually ages 4-8yrs
As early as 2yrs, as late as teens
Boys:Girls= 4-5:1
Bilateral 10-12%
No evidence of inheritance

4. 


Unknown
Past theories:
infection, inflammation, trauma, congenital
Most current theories involve vascular
compromise
◦ Sanches 1973: “second infarction theory”

sometimes called as “coronary artery disease
of hip”

7. 
Infants
1. Metaphyseal arteries .
2. Lat epiphyseal arteries
3. Lig teres – insignificant

4 mts – 4 years
1. Lat epiphyseal
2. Metaphyseal art. decrease in number
(due to appearance of growth plate).

8. 
4 yrs to 7 years
1. Epiphyseal plate forms a barrier to metaphyseal
vessels.

Pre-adolescent
1. After 7 yrs arteries of lig teres become more
prominent and anastomose with the lateral
epiphyseal vessels.

9. Susceptible child : delayed bone age
-- Trauma
-- Hereditary factors : controversial(HLA-A
antigens in lymphocytes)
-- Coagulopathy : protein c& s
-- Hyperactivity
-- Passive smoking
-- Synovitis
FACTORS UNLIKELY TO BE ETIOLOGY-- Endocrinopathy
-- Urban envt.
--

10. 

Histologic changes described by 1913
Secondary ossification center= covered by
cartilage of 3 zones:
◦ Superficial
◦ Epiphyseal
◦ Thin cartilage zone

Capillaries penetrate thin zone from below

12. 
Epiphyseal cartilage in LCP disease:
◦ Superficial zone is normal but thickened
◦ Middle zone has 1)areas of extreme hypercellularity
in clusters and 2)areas of loose fibrocartilaginous
matrix


Superficial and middle layers nourished by
synovial fluid
Deep layer relies on blood supply

13. 


Physeal plate: cleft formation, amorphis
debris(Bone dust), blood extravasation
Metaphyseal region: normal bone separated
by cartilaginous matrix
Epiphyseal changes can be seen also in
greater trochanter, acetabulum

14. 



Often insidious onset of a limp,excaberated
by activity.
C/O pain in groin, thigh, knee
Few relate trauma hx
Can have an acute onset

15. 




Decreased
ROM, especially abduction
and internal rotation:
initially due to muscle
spasm
Abductor limp
Trendelenburg test often
positive
Muscular atrophy of
thigh/buttock/calf
Limb length discrepency

16. Coxa magna
 Premature physeal growth arrest
Central-short neck,trochanteric overgrowth
Lateral-externally tilted head
trochantric overgrowth
acetublar deformity
Irregular head
Osteochondoirtis dessicans


17. 
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AP pelvis
Frog leg lateral
Key= view films
sequentially over
course of dz
Arthrography
MRI role
undefined

18. 
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
WALDENSTROM
Modified Elizabethtown Classification
Catterall classification
Salter-Thompson Classification
Lateral Pillar Classification

19. 
Four Waldenstrom stages:
◦
◦
◦
◦
1)
2)
3)
4)
Initial stage
Fragmentation stage
Reossification stage
Healed stage

20. Stage of Avascular Necrosis
Ischemia
A part ( anterior) or whole of capital
femoral epiphysis is necrosed.
On X-ray –
◦ The ossific nucleus looks smaller
◦ Classically of Perthes’, looks
dense
◦ The articular cartilage remains
viable & becomes thicker than
normal
– increased joint space.

21. Stage of REVASCULARIZATION / FRAGMENTATION

Ingrowths of highly vascular & cellular connective tissue.

Necrotic trabecular debris is resorbed & replaced by vascular
fibrous tissue
the alternating areas of sclerosis and
fibrosis appear on X- ray as fragmentation of epiphysis.

New immature bone laid on intact
necrosed trabeculae by creeping
substitution
further increases
the density of ossific nucleus on
X-ray.

22. Stage of REVASCULARIZATION / FRAGMENTATION (contd.)
The femoral head may extrude from acetabulum
at this stage.

23. Stage of Ossification / Healing
New bone starts forming and epiphyseal
density increases in the lucent portions of
the femoral head.

24. 
Remodeling / Residual stage
This is the stage of remodeling and there is no
additional change in the density of the femoral
head.
Depending on the severity of the disease the
residual shape of the head may be spherical
or distorted.

25. 
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I Sclerotic
A: no loss of height
B: loss of height
II Fragmentation
A: early
B:late
III Healing
A: peripheral
B:>1/3epiphysis
IV Healed
Stages

220 days

240 days

255 days

26. 

Stage Ia - the initial stage of the
disease, characterized by sclerosis of the
epiphysis without any loss of epiphyseal
height .
Stage Ib - epiphysis is sclerotic and there is
loss of height of the epiphysis. In this stage
the epiphysis is still in a single piece and no
fragmentation is visible in either
anteroposterior or lateral views .

27. Stage Iia- epiphysis has just begun to
fragment; one or two vertical fissures in the
epiphysis are seen in either view .
In stage IIb - fragmentation of the epiphysis
is advanced, but there is no evidence of new
bone formation lateral to the fragmented
epiphysis .

28. In stage IIIa - evidence of new bone formation
at the periphery of the necrotic fr agment;
the new bone is not of normal texture and
covers less than one-third the circumference
of the epiphysis .
In stage IIIb - new bone is of normal texture
and covers more than one-third the
circumference of the epiphysis .
In stage IV the healing is complete and there is
no radiologically identifiable avascular bone

29. 

extent of epiphyseal involvement and
percentage of collapse as seen in x-ray (both
AP and Lateral view)
most commonly used
◦ 4 groups based on amount of femoral head
involvement
◦ Also presence of sequestrum, metaphyseal
rxn, subchondral fx

34. 
3 groups:
◦ A) no lateral pillar involvment
◦ B) >50% lat height intact
◦ C) <50% lat height intact

36. 
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

Simplification of Catterall
Based on status of lateral margin of capital
femoral epiphysis
Group A (Catterall I & II equivalent)
Group B (Catterall III & IV equivalent)

37. Clinical
Radiographic
(1)


Progressive loss
of movement
more of
ABduction
Pain
(2)
(3)
(4)
(5)
lateral subluxation of
the femoral head from
the acetabulum,
speckled calcification
lateral to the capital
epiphysis,
diffuse metaphyseal
reaction (metaphyseal
cysts),
a horizontal physis
Gage sign

40. 
Rarefaction in the
lateral part of the
epiphysis and
subjacent
metaphysis.

42. Unilateral
Bilateral






Tuberculosis hip
Synovitis
Slipped femoral capital
epiphysis
Lymphoma
Eosinophilic granuloma
Hypothyroidism

Multiple epiphyseal
dysplasia

Spondyloepiphyseal
dysplasia

Sickle cell disease

43. 

60% of kids do well without tx
AGE is key prognostic factor:
◦ <6yo= good outcome regardless of tx
◦ 6-8yo= not always good results with just
containment
◦ >9yo= containment option is questionable, poorer
prognosis, significant residual defect
◦ --Flat femoral head incongruent with acetabulum=
worst prognosis

44. 
CONTAINMENT of the femoral head

Minimize enlargement of the femoral head

Prevent or correct GT overgrowth

Prevent secondary degenerative arthritis of
the hip

45. 
Weight Relief

Containment by bracing or casting

Surgical Containment

Greater trochanteric arrest

46. 
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disease progresses and resolves stage
wise, which cannot be bypassed or hurried.
Improve ROM 1st
Bracing:
Removable abduction orthosis
Pietrie cst
-Wean from brace when improved x-ray healing
signs
 Check serial radiographs
◦ Q3-4 mos with ROM testing

Orthotic treatment is discontinued when the
disease enters the reparative phase and healing
is established

47. 
Atlanta Scotish Rite
Brace

48. petrie abduction

49. 
The radiographic evidence of healing are
1. Appearance of irregular ossification in the
femoral head.
2 . Increased density of femoral head should
disappear.
3 . Medial segment of femoral head should
increase in size and height.
4 . Metaphyseal rarefaction involving the lateral
cortex of the metaphysis should ossify.
5 . There should be intact lateral column.

50. 

If non-op tx cannot maintain containment
Surgically ideal pt:
◦
◦
◦
◦
6-9yo
Catterral II-III
Good ROM
In collapsing phase

51. 
Indicator of acetabular depth

It is the angle formed by a


perpendicular line through the
midpoint of the femoral head
and a line from the femoral
head center to the upper
outer acetabular margin.
Normal = 20 to 40 degrees
Angle >25 = good, 20-25=
fair, < 20 = poor

52. Surgical Containment
Femoral VDRO
osteotomies
Varus 20
Derotation 20-30
Pelvic
Shelf
Redirectional
Displacement

55. Contd.

varus osteotomy :◦ INDICATIONS- patients with a spherical femoral head,
little or no acetabular dysplasia (center-edge angle of at
least 15 to 20 degrees),lateral overloading, and a valgus
neck-shaft angle of more than 135 degrees.
◦ DISADVANTAGES-varus angulation that may not correct
with growth (especially in an older child),
◦ further shortening of an already shortened extremity,
◦ the possibility of a gluteus lurch produced by decreasing
the length of the lever arm of the gluteal musculature,
◦ the possibility of nonunion of the osteotomy,
◦ requirement of a second operation to remove the
internal fixation

57. 




ADVANTAGE-Anterolateral coverage of the femoral
head, lengthening of the extremity (possibly
shortened by the avascular process), and avoidance
of a second operation for plate removal.
DISADVANTAGES-1)inability sometimes to obtain
proper containment of the femoral head, especially
in older children;
2)an increase in acetabular and hip joint pressure
that may cause further avascular changes in the
femoral head;
3)an increase in leg length on the operated side
compared with the normal side that may cause a
relative adduction of the hip and uncover the
femoral head.
Eg.-Salter’s ostoeotomy

66. 
Aims of treatment
Relieve pain
Correct Trendelenburg gait
Minimize the risk of development of
degenerative arthritis

67. 
Valgus osteotomy

Joint distraction

Surgical dislocation and
osteochondroplasty

Cheilectomy(Osteochondroplasty)

Arthrodesis

68. 
Greater trochanter advancement

Lengthening of the femoral neck

Improving acetabular coverage of the femoral
head by periacetabular osteotomy

72. 
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Valgus extension osteotomy
indication -hinge abduction of hip
Cheilectomy
indication – malformed femoral head with lateral
protuberance Coxa plana
Chiari osteotomy
indication – malformed femoral head with lateral
subluxation
Trochanteric advancement
indication – premature capital femoral physeal arrest
Greater trochanteric epiphysiodesis
indication – premature capital femoral physeal arrest
Shelf augmentation procedure
indication – coxa magna coxa magna & lack of acetabular
coverage

73. 
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Patients presenting at 8+yrs
Have a worse prognosis
Severe femoral head deformity more likely
Deformity at maturity predicts outcome
Particularly if Catterall III or IV Or Herring C
(B/C)
Girls have a poorer prognosis

74. 
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In some patients collapse was more
pronounced in the middle pillar rather than
the lateral.
Neither the Catterall grouping nor the Herring
grading correlated with the final outcome
Osteoporosis
premature fusion of: the triradiate cartilage,
trochanteric growth plate and the capital
femoral growth plate.

75. 

The outcome of the disease in adolescents is
poor.
Many of the patients with the destructive
pattern required salvage surgery to relieve
pain. It is likely that patients with the other
patterns of the disease will develop
degenerative changes in due course.

76. Thank you for attention !
UMY