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Avascular Necrosis Of Growing Epiphyses (Treatment (DEFORMITY PREVENTING…
Avascular Necrosis Of Growing Epiphyses
Synonym: Aseptic Necrosis, Osteochondrosis, Epiphysitis
Legg-Calvé-Perthes Disease (Coxa Plana)
idiopathic AVN of femoral head, presents at 3-12 yr of age
M>F
10-20% BILATERAL
worsening prognosis: females and onset after 10 years of age
associations
family history, low birth weight, abnormal pregnancy/delivery, ADHD, delayed bone age, second-hand smoke exposure
Clinical Features
child with antalgic or Trendelenburg gait ± pain.
intermittent knee, hip, groin, or thigh pain
stiff hip (THOMAS TEST )
limb length discrepancy (late)
limp.
muscle defense=spasm (roll test)
limited range of motion (rom)
thigh atrophy
Investigations
x-ray: frog leg (lauenstein position).
MRI
radiographic time-related stages
INITIAL (2 to 4 MONTHS)
JOINT SPACE WIDER (ELONGATION OF WALDENSTRÖM LINE)
OSSIFIC NUCLEUS SMALLER (CESSATION OF GROWTH)
SUBCHONDRAL FRACTURE
SCLEROTIZATION (6 TO 10 MONTHS)
PART OF THE NUCLEUS UNDER SUBCHONDRAL FRACTURE RADIODENSE due to active hyperaemia around hip
FRAGMENTATION (6 TO 18)
NECROTIC EPIPHYSEAL BONE BENEATH SUBCHONDRAL FRACTURE GRADUALLY AND IRREGULARLY RESORBED
REPLACED BY VASCULAR FIBROUS TISSUE
REOSSIFICATION & HEALING (6 TO 24 MONTHS)
NEWLY FORMED AREAS OF BONE COALESCE AND CAPITAL FEMORAL EPIPHYSIS REGAINS NORMAL STRENGTH
NORMAL BONE DENSITY RETURNS
CATTERALL’S CLASSIFICATION
GROUP IV
100% OF HEAD INVOLVED
CENTRAL OR DIFFUSE METAPHYSEAL REACTION
GROUP I
LESS THAN 25% OF HEAD INVOLVED IN ANTEROCENTRAL REGION (CYST)
GROUP III
75% OF HEAD INVOLVED WITH LATERAL PILLAR LOSS
DIFFUSE ANTEROLATERAL METAPHYSEAL REACTION
GROUP II
50% OF HEAD INVOLVED IN ANTEROLATERAL REGION WITH LATERAL & MEDIAL PILLAR INTACT
„HEAD AT RISK” SIGNS
LATERALIZATION (LATERAL SUBLUXATION)
METAPHYSEAL CYSTS
HORIZONTAL PHYSEAL ANGLE
CALCIFICATIONS LATERAL TO EPIPHYSIS
GAGE SIGN (1933)
SALTER - THOMPSON CLASSIFICATION
GROUP „A”
CATT. I & CATT. II
LESS THAN 50% OF FEMORAL HEAD INVOLVED
VIABLE LATERAL MARGIN: LATERAL PILLAR PRESENT
GOOD PROGNOSIS
GROUP „B”
CATT. III & CATT. IV
MORE THAN 50% OF FEMORAL HEAD INVOLVED
INVOLVED LATERAL MARGIN:LOSS OF LATERAL PILLAR PRESENT
POORER PROGNOSIS
Treatment
preserve ROM and keep femoral head contained in acetabulum
non-operative: physiotherapy- ROM exercises
operative: femoral or pelvic osteotomy (>8 yr of age or severe)
OBSERVATION ONLY
(CATT. I/II, NO SUBLUXATION)
INTERMITTENT SYMPTOMATIC TREATMENT
FOR LOSS OF ROM - BRIEF PERIODS (1-2 WEEKS) SPRINGS AND SLINGS OR CRUTCHES COMBINED WITH ABDUCTION STRETCHING EXERCISES
DEFORMITY PREVENTING TREATMENT – „CONTAINMENT”
NONOPERATIVE:
A. PLASTER CASTS (PETRIE CAST)
B. ABDUCTION SPLINTS (e.g. SCOTTISH-RITE = ATLANTA)
INDICATION
LATERAL SUBLUXATION
SURGICAL
INTERTROCHANTERIC VARUS OSTEOTOMY
SALTER’S INNOMINATE OSTEOTOMY
LATE DEFORMITY – HIP SALVAGE
ACETABULOPLASTY
DISTAL TRANSFER OF GREATER TROCHANTER
ABDUCTION & EXTENSION INTERTROCHNATERIC OSTEOTOMY
ETIOLOGY
UNKNOWN
increased intracapsular pressure
microthrombi i femoral head vessels
increased blood coagulability (alfa-1-antytrypsyn)