This document discusses Legg-Calve-Perthes disease, a childhood condition characterized by avascular necrosis of the femoral head. It begins by describing the disease's pathogenesis, including that the cardinal cause is ischemia of the femoral head due to blocked blood flow in children aged 4-7 years. The document then outlines the stages of the disease from initial infarction to healing or remodeling. Clinical features, radiological findings, and classification systems are presented. Treatment aims to contain the femoral head within the acetabulum and may involve bracing, osteotomies or reconstructive surgeries depending on the child's age and stage of disease.

1. DR VANDANA G HARI
RESIDENT
KIMS TRIVANDRUM

2. Painful disorder of childhood characterised by
avascular necrosis of femoral capital epiphysis.
-Osteochondritis deformans juvenilis/Coxa plana
-described 1910 independently by Legg, Calve,
Perthes ,Waldenstrom
Legg Calve Perthes
Disease

3. Pathogenesis

 Precipitating cause unknown
 Predisposing factors
 -Genetic aspects 2-20%
 -Abnormal growth & development ,bone age
<1-3yrs
 Poor socio economic status
 -Inherited thrombophilia
 -Males 4:1
 -Trauma

4.  Cardinal cause ISCHEMIA OF
FEMORAL HEAD
 4-7yrs femoral head depend on lateral
epiphyseal vessels(.upto 4 metphysea
later ligamentum teres)
 Epiphyseal vessels susceptible to
stretching & pressure

 Effusion

5.  Venous flow blocked
 Venous stasis
 Intraosseous pressure rises

 Ischemia

6. Stages of Legg-Calves-
Perthes (Waldenström
 Initial -infarction produces a
smaller, sclerotic epiphysis with
medial joint space widening
-radiographs may remain occult for 3
to 6 mos

7.  Fragmentation
 Dead marrow replaced with granulation
tissue
 Bone revascularised
 Some dead fragments replaced by fibrous
tissue
 Alternating areas of sclerosis &fibrosis –
Fragmentation of epiphysis
 Hyperemic metaphysis-Rarefied / cystic in X-
ray-hip related symptoms are most prevalent
-lateral pillar classification based on this
stage

8. • Reossification -ossific nucleus
undergoes reossification as new
bone appears as necrotic bone is
resorbed
 -may last up to 18m

9.  Healing or remodeling -femoral head
remodels until skeletal maturity
 -begins once ossific nucleus is completely
reossified trabecular patterns return
 Rapid &complete repair- architecture
maintained
 Tardy epiphysis collapse –Distorted
growth of Head and Neck
 Head Oval flattened head of
mushroom
 Neck shor t and broad

10. Clinical Features
 -Classical presentation
 Painless limp (4-8yr old boy)
 -Pain a/c or insidious –vague ,ache in
groin, thigh or knee, aggravated by hip
movements

11.  Signs
 1.Antalgic gait
 2.Muscle spasm
 3.Limited abduction & internal
rotation
 4.Proximal thigh atrophy
 5. Trendelenburg gait (head collapse
leads to decreased tension of
abductors

12. Radiology
Decreased size
of left femoral
capital
epiphysis
 Linear
translucency
.wide
joint
space

13. Subchondral fracture

14. Small left femoral
cap.epiphysis
Wide neck
Widened
articular
surface
Linear
translucency
CRESCENT
SIGN

15. •Acetab
ular
change
•widene
d right
femoral
neck
•smaller,
sclerotic,
flattened
femoral
subcapital
epiphysis

16. Metaphyseal cyst rt.

17. In group I there is involvement (hatched areas) of the anterior head only, no sequestrum,
and no collapse of the epiphysis. In group II, only the anterior head is involved, and there is
a sequestrum with a clear junction. In group III only a small part of the epiphysis is not
involved. In group IV there is total head involvement
CATERALL
CLASSIFICATION

18. Gp 3 & 4
◦ Head at risk signs (indicate a more severe
disease course)
 Gage sign
 V-shaped radiolucency in the lateral portion of the
epiphysis and/or adjacent metaphysis
 calcification lateral to the epiphysis
 lateral subluxation of the femoral head
 Horizontal growth plate

19. Gage sign
Lateral subluxation

20. Salter Thompson
 GP A :<1/2 of capital femoral
epiphysis involved
 Gp B: >1/2 involved

21. Herring Classification
 Femoral head : 3 pillars by lines at medial and
lateral edge of central sequestrum
 A : Normal ht of lateral pillar
 B: Partial prolapse >50% ht
 C: Severe prolapse<50%ht

22. Other investigations
 Bone scan
◦ can confirm suspected case of LCP
◦ decreased uptake (cold lesion) can predate
changes on radiographs
 MRI
◦ can provide early diagnosis revealing
alterations in the capital femoral epiphysis
and physis
 Arthrogram
◦ a dynamic arthrogram can demonstrate
coverage and containment of the femoral
head

23. Treatment
 The primary aim Containment of
head with in acetabulam
 Initial management:
 1. analgesia
 2.modification of activities
 3.preservation of abduction
 Reassess

24. Containment
Holding hip widely abducted
• Newington brace,Toronto,Petri cast,
Scottish Rite

26. Surgical procedures
VARUS DEROTATIONAL OSTEOTOMY –to provide
containment

27. Reconstructive Procedures
 Cheiloctomy –removal of
protuberance
 Chiari osteotomy-deepens acetabulam
by medial displcement of distal pelvic
fragment
 Trocanteric advancement-distal
transfer to normalise tension of
trocanteric muscles

28. Guidelines
Children under 6
 Symptomatic treatment

29. 6-8yrs
Bone age
<=6yrs
LP A&B: symptomatic
treatment
LP C:
Ab.brace
Bone age
>6yrs
A&B :
Ab.brace/Oste
otomy
LP
C:unaffected
by treatment

30. >9yrs
 Operative containment

31.  Thank u