DECISION MAKING IN PERTHES · PDF fileDECISION MAKING IN PERTHES DISEASE: Putting together the...
Transcript of DECISION MAKING IN PERTHES · PDF fileDECISION MAKING IN PERTHES DISEASE: Putting together the...
DECISION MAKING IN PERTHES DISEASE:Putting together the jigsaw!Putting together the jigsaw!
DR. ALARIC AROOJISM.S. (Orth), D’Orth, DNB (Orth)
Fellowship in Pediatric Orthopaedics (USA, Singapore, Australia)
Consultant Paediatric Orthopaedic Surgeon
Kokilaben Dhirubhai Ambani Hospital & Bai Jerbai Wadia Hospital for Children
Mumbai
Putting together the jigsaw!Putting together the jigsaw!
Why the confusion?
Catterall ?
Herring?Reimer ?
Salter ?
Mose?
Stulberg?
Head at risk?
Perthes News
Half the patients will recover and have little
disability over their lifetime
The other half will function well with occasional
discomfort through most of their adulthood and in discomfort through most of their adulthood and in
their 5th or 6th decade of life require hip replacement
Only the most severely involved patients will have
early hip disability
- Herring JA 1996; Weinstein SL, 1985
Few long-term studies
All retrospective
Small number of patients
NATURAL HISTORY
Small number of patients
Poor retrieval of data
Absence of controls
Subjective assessment of outcome
20 – 40 yrs : 70 – 90% of patients are active & pain free
Good ROM despite abnormal Xrays
Av. 48 yrs F/U: 50% have disabling pain and osteoarthritis requiring THR
By 6th – 7th decade : Majority have evidence of DJDBy 6th – 7th decade : Majority have evidence of DJD
McAndrew, Weinstein. JBJS 1984
Yrjonen. Acta Orthop Scand 1992; Lecuire. JBJS 2002
GOALS OF TREATMENT
Relief of pain : NSAIDs / Bed rest
Traction
Range of motion
Physical therapy
Improve function
Minimize femoral head deformity at
completion of healing
RESIDUAL DEFORMITY AT SKELETAL MATURITY
CLASS XRAY CONGRUENCY
I NORMAL SPHERIC
II SPHERICAL but coxa magna, coxa breva
SPHERIC
III OVOID / mushroom ASPHERIC III OVOID / mushroom shaped
ASPHERIC
IV FLAT HEAD & acetabulum
ASPHERIC
V FLAT HEAD / normal acetabulum
ASPHERIC INCONGRUENCY
Stulberg, Cooperman. JBJS 1981;63:1095
S 1 S2 S3
S4 S5
Age of the child
Range of hip motion
Stage of evolution of the disease
(Mod.Elizabethtown)
PROGNOSTIC(Mod.Elizabethtown)
Grade of epiphyseal involvement
(Salter / Catterall)
Extent of epiphyseal collapse / extrusion
(Herring / Reimer)
C
FACTORS
Age of the child
The age of the child at onset of symptoms
(chronological age)
Under 6 yearsUnder 6 years
Between 6 & 9 years
Over 9 years
Hip Range of Motion
The range of hip motion
All movements restored
Internal rotation restricted
Limitation of Abd and IR
Stiff hip
Modified Elizabethtown Classification
Stage of evolution of the disease at presentation
JPO Sep 2003
Benjamin Joseph, Manipal
Stage Ia
AVASCULAR STAGE
Stage Ib
The epiphysis is avascularand appears denseThere is no loss of height of the epiphysis
There is some loss of height of the dense sclerotic epiphysisThe epiphysis is in one piece
Stage IIa
FRAGMENTATION STAGE
Stage IIb
One or two fissures appear in the epiphysis
The epiphysis is frankly fragmentedThis is the stage at which there is maximal collapse of the epiphysis
Stage IIIa
RE-OSSIFICATION STAGE
Stage IIIb
> 1/3
New bone which is immature & woven begins to form at the periphery of the avascular epiphysis
Lamellar bone of normal texture covers at least 1/3 of the circumference of the epiphysis
The process of revascularisation and repair is complete
HEALED STAGE
Stage IV
repair is complete
There is no evidence of any avascular bone in the epiphysis
The extent of epiphyseal involvementLess than half the femoral epiphysisHalf or more of the epiphysis
Grade of the disease
II
II
III
IV
Catterall
20-30% 50% 20-30%
Extent of collapseHerring
A B C
THE TREATMENT PLANWhen to consider containment??When to consider containment??
REPORT OF MULTI-CENTER STUDY GROUP ON PERTHES DISEASE
HERRING JBJS 2004
< 5 years Consider containment only if extrusion occurs
Age at onset of symptoms
6 to 12 yearsConsider containment even before extrusion
occurs
Over 12 years of age Do NOT consider containment
Less than half the epiphysis
Do not consider containment
Extent of epiphyseal involvement
epiphysis containment
Half or more of the epiphysis Consider containment
Stage Ia, Ib, IIa Consider containment
Stage of evolution of the disease
Stage IIb ? Consider containment
Stage IIIa, IIIb, IV Do not consider containment
The odds ratio for obtaining a spherical femoral head at healing was 16.58 times higher if surgery was done before Stage IIb(Joseph JPO 2003)
All movements restoredConsider containmentBy varus + derotation
Range of hip motion
Internal rotation alone restricted
Consider containmentBy varus + extension
Internal rotation & abduction restricted(Hinged abduction)
Do not consider containment
Variable Contain Don’t contain
Age > 5 or < 5 with extrusion
<5 (no extrusion)
Extent of involvement
Half or more than half of epiphysis
Less than half of epiphysisinvolvement half of epiphysis epiphysis
Stage of evolution of the disease
Stage Ia, Ib, IIa& ?Stage IIb
Stage IIIa, IIIb, IV
Extrusion Present Absent
Range of hip motion
Normal Restricted
AGE < 6 YEARS
RANGE : > 50% ABD / IR
EXTENT OF INVOLVEMENT < 50 %
LATERAL PILLAR COLLAPSE < 50%