Legg Calve Perthes Disease

Introduction

  • It is a self-limiting disorder that involves aseptic bone necrosis of the femoral head
  • Occurs most frequently in children between the ages of 3 and 10
  • The ratio between males and females has been frequently reported as 4:1 (Caterall 1971; Friedlander 2000; Gigante 2002; Guarniero 2005)
  • The adult condition has been associated with multple etiologies

Clinical Presentation

  • Groin, anterior thigh, or anterior knee pain, with an antalgic gait
  • Hip motions limited in capsular pattern, mainly in abduction, flexion, and medial rotation, which may lead to atrophy of the thigh for lack of use of the limb (Carpenter 1975)
  • Positive Trendelenberg Test (Edvardsen 1981)
  • Failure of abductor muscles due to increased growth of the greater trochanter (Bowen 1982)
  • Muscular flexion and abduction contracture of the hip (Tsao 1997)
  • X-rays in frog-legged position (Lauenstein position) reveal a collapsed femoral head
  • May produce a Drehmann sign (limited IR, increased ER, obligatory abduction and ER during passive flexion)

Stages (based on imaging) from Catterall

  • Stage I: 25% of the femoral head is involved and the clinician notes increased hip articular space
  • Stage II: 50% of the femoral head; subchondral fracture is produced in the shape of a half moon with an intact anterior pillar of the femoral head
  • Stage III: progressive femoral head collapse
  • Stage IV: Involvement of the entire head and plate

Treatment

  • Treatment is stage specific and concerned with prevention of further collapse of the femoral head
  • The earlier the treatment is started, the better the prognosis (Keret 2002)
  • Conservative treatment
    • Bed rest with traction in hip abduction , serial casting, and functional orthosis that allows WB while maintaining hip abduction and IR (Roposch 2003; Grzegorzewski 2003; Martinez 1992). Roposch does not recommend using this approach in patients older than 6 years with greater than 50% involvement of the femoral head
    • Exercise to increase hip abduction should be emphasized to promote containment (Carney 2004)
    • Brech (2006) showed physiotherapy produced significant improvement in articular range of motion, muscular strength, and articular dysfunction in patients with Legg-CalvĂ©-Perthes disease, but these improvements were not evident on radiographs.
  • Surgical Interventions
    • Salter procedure: an innominate osteotomy to increase acetabular coverage of the femoral head
    • Chiari procedure: acetabular rotation osteotomy
    • Medial or lateral wedge derotation osteotomy
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