Perthes disease is a childhood condition that affects the hip. It results from a temporary loss of blood supply to the femoral head. The key points are: - It typically affects children between the ages of 4-10 years old and is more common in boys. - The exact cause is unknown but theories involve vascular compromise to the femoral head. - Presentation includes limping, groin or thigh pain that increases with activity. Imaging shows changes to the femoral head over different stages. - Treatment depends on the stage and age of the child, ranging from non-operative bracing and casting to surgical procedures like osteotomies if containment is needed to prevent further deformity and damage.

1. PERTHES DISEAESE
Presentor-dr vashisth narayan

2. PERTHE’S DISEASE
• FIRST DESCRIBED BY
LEGG (USA), AND
WALDENSTORM IN
1909, AND BY
PERTHES(GERMANY)
AND CALVE(FRANCE) IN
1910
• Also known as pseudo-
coxalgia, osteochondritis
deformans, coxa-
juveniles

3. Epidemiology
• 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%

4. Etiology
• Unknown
• Past theories: infection, inflammation, trauma,
congenital
• Most current theories involve vascular
compromise
.

5. Blood supply to femoral head
• 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).
3. ligamentem teres not well developed.

6. Blood supply to femoral head
• 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.
2. so between age 4-7 head of femur is mainly
supplied by lateral epiphyseal vessels.

9. -- Susceptible child : delayed bone age
--haemarthosis due to trauma or haemophilia
-- septic arthitis of hip joint
-- Synovitis
Medical cause (gaucher’s disease, cretinism, rickettsial infection ,
caisson,s disease.)

10. Presentation
• Often insidious onset of painless
limp,increases by activity.
• May complain of pain in groin, thigh, knee
• Few relate trauma history
• Can have an acute onset

11. Physical Exam
• Decreased ROM,
especially abduction and
internal rotation
• Trendelenburg test often
positive
• Muscular atrophy of
thigh/buttock/calf
• Limb length discrepency

12. Imaging
• AP pelvis
• Frog leg and lateral
view
• ..bone scan -shows
decreased uptake

14. Radiographic Stages
• Four Waldenstrom stages:
– 1) Ischaemia and bone death(stage of avascular
necrosis)
– 2) Fragmentation stage
– 3) Reossification stage
– 4)Remodelling

15. 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.

17. 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 further increases
the density of ossific nucleus on
X-ray.
. cresent sign (curved subchondral
radiolucent line)
present

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

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

21. • 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 disease, speed of
repair , the residual shape of the head may be
spherical( coxa magna, coxa breva)
or distorted.

23. Modified Elizabeth Town classification
Stages
• 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
• 220 days
• 240 days
• 255 days

24. Salter-Thompson Classification
• BASED ON EXTENT OF SUBCHONDRAL
FRACTURE-
• A> LESS THAN HALF OF FEMORAL HEAD
INVOLVED
• B> MORE THAN HALF OF THE FEMORAL HEAD
INVOLVED

26. Herring Lateral Pillar Classification
• 3 groups:
–A) no lateral pillar
involvment
–B) >50% lat height intact
–C) <50% lat height intact

28. Catterall classification
• Based on extent of epiphyseal involvement
and percentage of collapse as seen in x-ray
(both AP and Lateral view)

32. Catteral ‘head at risk sign’
Clinical
• Female sex
• Obese
• Age is on higher
side
• Progressive fixed
flexion and
adduction
deformity
Radiographic
1) lateral subluxation of the
femoral head from the
acetabulum,
2) speckled calcification
lateral to the capital
epiphysis,
3) diffuse metaphyseal
reaction (metaphyseal
cysts),
4) a horizontal physis
5) Gage sign

33. Gage’s sign
• Rarefaction in the
lateral part of the
epiphysis and
subjacent
metaphysis.

37. DIFFERENTIAL DIAGNOSIS
• Tuberculosis hip
• Synovitis
• Slipped femoral capital
epiphys
• Low grade septic arthritis
• Monoarticular juvenile
rheumatoid arthritis.

38. Prognosis
• 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

39. Treatment in onset to early
fragmentation stage
 For age < 5 yr- treatment is not needed regardless of stage
 except when there is femoral sublaxation--- containment is
needed
 for age 5-8 yr--
 When <50% of femoral epiphysis is necrotic-- 3 monthly follow
up with xray to detect early sublaxation
 When >50% of femoral epiphysis is necrotic—containment is
done

40. Continued..
For age 8-12 yr containment is done as soon
as disease is diagnosed provided disease is
not in the late stage of fragmentation .
For age >12 yr- containment is useless,
treated as adult with osteonecrosis

41. continued
 Treatment ( late fragmentation stage to
complete healing and reossification)---
Depending on the deformity of the femoral
head or hinged abduction
 For hinged abduction- do valgus osteotomy
 For management of the sequele –
reconstructive procedure

43. Aims of Treatment
• CONTAINMENT( hold the femoral head in
acetabulum)
• Minimize enlargement of the femoral head
• Prevent or correct GT overgrowth
• Prevent secondary degenerative arthritis of
the hip

44. Treatment options
• Weight Relief
• Containment by bracing or casting
• Surgical Containment
• Greater trochanteric arrest

45. Non-operative Tx
• Improve ROM 1st
• Bracing:
• Removable abduction orthosis
• Pitrie cast
-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

46. Treatment (Orthosis)
• Atlanta
Scotish Rite
Brace

47. Petrie abduction cast

48. Operative Tx
• If non-op tx cannot maintain containment
• Surgically ideal pt:
– 6-9yo
– Catterral II-III
– Good ROM
– In collapsing phase

54. VARUS OSTEOTOMIES

55. 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
v

56. SALTER OSTEOTOMY

64. INNOMINATE OSTEOTOMY
• 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.
• 3)an increase in leg length on the operated side
compared with the normal side causing a relative
adduction of the hip and uncover the femoral head
• Eg.-Salter’s ostoeotomy

65. THE SHELF PROCEDURE (STAHELI)
IND.; -Severe dis ( CATTERALL-3/4) IN EARLY FRAG.
STAGE.

66. INNOMINATE OSTEOTOMY WITH MEDIAL DISPLACEMENT OF
ACETABULUM (CHIARI)

67. Salvage surgery for sequelae of Perthes’ds
• Aims of treatment
Relieve pain
Correct Trendelenburg gait
Minimize the risk of development of
degenerative arthritis

68. TREATMENT
Reconstructive procedures
• 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 & lack of acetabular
coverage

69. Thank you