Classification perthes Disease

Classification of LCPD

1. Dr. ANOOP G.C.
Junior Resident in orthopedics
MCH Kozhikkode


Classifications for Legg
Calve Perthes Disease

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

2. DEFINITION
•PERTHES DISEASE : is a self-limiting
form of osteochondrosis of the femoral capital
epiphysis
•of unknown etiology that develops in children
commonly between the ages of 4 – 12 years
•caused by impaired circulation in the femoral
head
•necrosis of the femoral epiphysis and its
replacement by new bone
•resulting in deformation of the femoral head.

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

3. HISTORY
Described first by Waldenstrom in 1909
who mistakenly ascribed it to tuberculosis.
In 1910 was independently described by
Arthur Legg , U. S. A - February
Jacques Calve , France - July
George Perthes ,Germany - October
Hence name – “Legg Calve Perthes Disease”
In 1922 Waldenstrom gave the correct
interpretation and described the stages .




Dr.Anoop G.C.,JR,Orthopaedics,GMCK

4. LEGG CALVE PERTHES
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

5. PATHOLOGY
 By Waldenstrom in 1922
 4 stages
based on microscopic
and gross pathology
Paul_Petter_Waldenström
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

6. Stages
Stage 1 : Incipient or synovitis stage
•Lasts for 1-3 week
•synovium is swollen edematous and
hyperemic
• joint fluid is increased
•Inflammatory cell are notably absent

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

7. Stages
Stage 2 : Avascular necrosis
•Lasts for 6 month to 1year
•Significant necrosis of bone
• trabeculae are crushed into minute fragments.
•Absent/pyknotic nuclei in the osteocytes
•No evidence of bone regeneration
•Degenerative changes in the basal layer of
articular cartilage
•Thickened peripheral cartilagenois cells
•Gross contour of femoral head is unchanged


Dr.Anoop G.C.,JR,Orthopaedics,GMCK

8. Stages
Stage 3 : Fragmentation or Regeneration
–Lasts for 2- 3 year.
–Dead bone infested with vascular connective
tissue was actively resorbed by osteoclasts
and replaced by newly formed immature
bone.
–Loss of epiphyseal height due to collapse of
bony trabeculae and resorption of fragmented
necrotic bone


Dr.Anoop G.C.,JR,Orthopaedics,GMCK

9. Stages
Stage 4 : Healed or Residual Stage

•Normal bone starts replacing necrotic bone.
•Ossific nucleus is deformed assuming
mushroom contour
•Femoral head enlarges, flattens and
subluxate.


Dr.Anoop G.C.,JR,Orthopaedics,GMCK

10. CLASSIFICATION
•A classification system is needed to
understand natural hitory of LCPD, to predict
functional outcomes and prescribe treatment
•Three categories: those defining the stage of
the disease, those attempting to prognosticate
outcome, and those defining outcome
•All classifications are based on Radiological
appearance
•Both AP and FROG LEG views required

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

11. RADIOGRAPHY
AP View
FROG LEG View
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

12. CLASSIFICATION
•LEGG
•WALDENSTROM
•GOFF
•CATERALL
•SALTER THOMPSON
•HERRING’S
• ELIZABETHTOWN
•STULBERG
•MOSE
•CE angle



Dr.Anoop G.C.,JR,Orthopaedics,GMCK

Historic



Prognotic


Stage


outcome

13. HISTORIC CLASSIFICATION
•LEGG
–two types of head
–A “cap” & a “mushroom”(more severe)
•WALDENSTROM
–classified head 3 categories
–Type 1 & 2 with good results
–Type 3 – altered shape leading to restriction of
ROM to only flexion & extension (conical)
•GOFF
–3 types of head
–Spherical, cap, irregular

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

14. PROGNOSTIC CLASSIFICATION
•CATERALL

•SALTER THOMPSON

•HERRING’S

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

15. CATTERALL

•Publihed in 1971
•the first widely accepted
prognostic classification
•Based on extent of
involment of femoral
head.
•IV groups
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

16. Catterall Group I
25% involvement
No metaphyseal Reaction
No sequestrum
No subchondral fracture line
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

17. Catterall Group II
50% involvement
Sequestrum present - junction Clear
Metaphyseal reaction - antero lateral
Subchondral fracture line - anterior half
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

18. Catterall Group III
75% involvement
Sequestrum large - junction sclerotic
Metaphyseal reaction - diffuse or antro lateral
Subchondral fracture line - posterior half
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

19. Catterall Group IV
Whole head involvement
Metaphyseal reaction - central or diffuse
Posterior remodelling present
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

20. Catterall’s - Head at Risk Signs

•Lateral epiphyseal calcification
•Lateral subluxation
•Gage’s sign
•Cage sign
•Caffey’s or Salter Sign
•Metaphyseal cysts
•Horizontal growth plate

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

21. Lateral subluxation
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

22. GAGE’S SIGN
•small osteoporotic segment forming a
translucent V- shaped trough in the lateral
part of the epiphysis
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

23. CAGE SIGN
•Calcification of the lateral epiphysis
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

24. Salter’s or Caffey’s sign
•a subchondral # may occur in the anterolateral
aspect of the femoral capital epiphysis. This
produces a crescentic radiolucency known as the
crescent, Salter’s or Caffey’s sign


Dr.Anoop G.C.,JR,Orthopaedics,GMCK

25. Salter and Thompson
•In 1984 based on Extend of sub chondral fracture
•Subchondral fracture correlates with eventual extent of resorption

–GROUP A : Subchondral # involving <50% of the femoral dome - good

–GROUP B : Subchondral # involving >50% of the femoral dome - poor


Dr.Anoop G.C.,JR,Orthopaedics,GMCK

26. Herring
•Based on radiographic
changes in lateral portion of
femoral head during
fragmentation stage on AP
view
•The femoral head pillars are
derived by noting the lines
of demarcation between the
central sequestrum and the
remainder of the epiphysis
on the anteroposterior
radiograph
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

27. Herring
Group A

•Normal Height of lateral
pillar maintained
•Uniformly good
outcome
•No intervention
required
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

28. Herring
Group B

•> 50% of lateral pillar
height maintained
•Good to intermediate
outcome
•Intervention warranted

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

29. Herring
Group C

•< 50% of lateral pillar
height maintained
•Poor outcome
•Non surgical treatment

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

30. CLASSIFICATION DEFINING STAGE

•MODIFIED ELIZABETHTOWN:
–They aid in the timing of intervention and type
of intervention.
–The stages are

•Stage I a & I b
•Stage II a & II b
•Stage III a & III b
•Stage IV

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

31. MODIFIED ELIZABETHTOWN
Stage Ia
•The epiphysis is
avascular and
appears dense.

•There is no loss of
height of the
epiphysis.

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

32. MODIFIED ELIZABETHTOWN
Stage Ib

•There is some loss of
height of the dense
sclerotic epiphysis.

•The epiphysis is in
one piece.

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

33. MODIFIED ELIZABETHTOWN
Stage IIa

•One or two fissures
appear in the
epiphysis
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

34. MODIFIED ELIZABETHTOWN
Stage IIb

•The epiphysis is
frankly fragmented.

•This is the stage at
which there is
maximal collapse of
the epiphysis.
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

35. MODIFIED ELIZABETHTOWN
Stage IIIa

•New bone begins to
form at the periphery
of the avascular
epiphysis.
•This new bone is
immature woven bone
and the texture of this
bone is not normal
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

36. MODIFIED ELIZABETHTOWN
Stage IIIb

•Lamellar bone of
normal texture covers
at least 1/3 of the
circumference of the
epiphysis
Dr.Anoop G.C.,JR,Orthopaedics,GMCK
>1/3

37. MODIFIED ELIZABETHTOWN
Stage IV

•The process of
revascularisation and
repair is complete.
•There is no evidence
of any avascular bone
in the epiphysis
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

38. CLASSIFICATION DEFINING OUTCOME

•STULBERG

•MOSE

•CE angle

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

39. ASSESSMENT OF END RESUTLT
•Assessment of end result is done at 4 years
after onset.
•Based on sphericity and containment of
femoral head.
•Good – no arthritis develops
•Fair – mild to moderate arthritis will
develop in late adulthood
•Poor – severe arthritis will develop before
age of fifty.
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

40. ASSESSMENT OF END RESUTLT
SPHERICITY OF HEAD
MOSE CLASSIFICATION: Based on fitting
of contour of healed femoral head into
template of concentric circles in both AP & Frog
leg lateral views

•Good - < 1 mm
•Fair - < 2 mm
•Poor - > 2 mm
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

41. STULBERG CLASSIFICATION
•Described in 1981
•Alike MOSE, classification of THE
END RESULTS
•Used to predict the onset of
degenerative joint disease following
LCPD
•Based on size and shape of femoral
head


Dr.Anoop G.C.,JR,Orthopaedics,GMCK

42. STULBERG CLASSIFICATION

Spherical congruity ( I & II)
Arthritis does not develop

Aspherical congruity (III & IV)
Mild to moderate arthritis mid -late
adulthood

Aspherical incongruity (V)
Severe arthritis before age fifty years.

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

43. STULBERG CLASSIFICATION
•I – Shape is normal
•II – loss of head
height
–< 2 mm deviation of
concentric circles
•Group I & II –
“Spherical
Congruency”
•Outcome - Good

Dr.Anoop G.C.,JR,Orthopaedics,GMCK

44. STULBERG CLASSIFICATION
•III – Elliptical
head
–> 2 mm deviation
•IV – Flattened
head, >1 cm of
flattening
•Contour matches
(“Incongrous/Asph
erical congruency”)
•Outcome - Fair


Dr.Anoop G.C.,JR,Orthopaedics,GMCK

45. STULBERG CLASSIFICATION


•V – Collapsed head,
–Contour mismatch
(“Incongrous/Aspher
ical Incongruency”)

•Outcome - Poor
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

46. ASSESSMENT OF END RESUTLT
CONTAINMENT OF HEAD
CE Angle of Wiberg:
- A line is drawn from center of head C and edge of
acetabulum E called CE line

-The angle between CE
line and vertical
through center of
head is called the CE
angle.
Good - >20
Fair- 15-19
Poor- < 15
E
C
Vertical
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

47. THANK YOU
Dr.Anoop G.C.,JR,Orthopaedics,GMCK