2.  RADIOGRAPHY
 MAGNETIC RESONANCE IMAGING
 BONE SCINTIGRAPHY
 ULTRASONOGRAPHY
 ARTHOGRAPHY
 COMPUTEDTOMOGRAPHY

3.  Plain X ray of PELVISWITH BOTH HIP JTS
 AP view
 Lowenstein’s frog-leg lateral view
 Abduction – Adduction views
 Knee joints – AP / Lat
 Wrist joints – AP / Lat

4.  Waldenstrom’s classification – four stages
 INITIAL STAGE
 FRAGMENTATION STAGE
 REOSSIFICATION (HEALING) STAGE
 RESIDUAL STAGE

5.  Smaller osiffic
nucleus
 Lateralization
of femoral head
in the
acetabulum
 Widening of
medial jt space

6.  Waldenstrom / caffeys sign
 Vaccum phenomenon

7.  Radio-dense
femoral head
 Cyst & leucency in
metaphysis
 END OF STAGE:
appearance of
lucencies in
nucleus
 6m( up to14m)

8.  Lucent areas appear in the ossific nucleus of
femoral head
 Demarcation of femoral segments (pillars) –
often central dense

9.  Milder form – only ant segement seen on frog-
leg lateral
 More severe – no demarcation of pillars

10.  END OF STAGE – appearance of new bone in
subchondral area
 8m(2 – 35m)

11.  STARTSWITH - appearance of new bone in
subchondral area
 first in center of head – then expands medially
and laterally
 Anterior segment – last to reossify
 Process- lucent/necrotic areas of fragmentation
stage replaced by WOVEN BONE which then
ossifies , remodels in to TRABECULAR BONE

12.  mild gradual flatenning – children < 5 yrs whose
femoral head is totally involved
 most improve
 51m(2-122m)

13.  femoral head is fully reossified
 head remodels so does the acetabulum
 Head – normal / extremely flat / aspherical
 Physis is inlvolved – overgrowth of greater
trochanter

14.  Gill(1940) – metaphyseal necrosis & lucencies
(“holes of decalcification”)

15.  Ponseti – cystic
changes in neck
 Prognostic value –
poor outcome

16.  Sagging rope sign
 radiodense line in prox
femoral metaphysis
 Metaphyseal response to
physeal damage

17.  Premature physeal closure
 With central arrests:
 Round head
 Short neck
 Troch overgrowth
 With lateral arrest:
 Femoral head tilted Laterally
 Elongation of medial neck
 Overgrowth of troch

18.  Morphological changes in acetabulum in perthes
described by BENJAMIN JOSEPH (JBJS 1989)
 Osteoporosis of acetabular roof
 Irregularity of contour
 Premature fusion of triradiate cartilage
( bicomparmentalisation)
 Hypertrophy of articular cartilage & changes in
dimension

21.  BICOMPARTMENTALIZATION –
 When femoral head protrudes from acetabulum -
medial wall may form
 And look like a second compartment for the head
 Bicompartmental acetabulum in perthes disease
(JBJS 87-B aug 2005)

22. On plain xray -
bicompartmental
acetabulum appears to be
composed of 2 arc partly
overlapping each other –
interpreted as the
subluxated femoral head
articulating only with the
lateral half of the
acetabulum moulding it
into 2 compartments

23.  Used for early diagnosis of LCP disease
 Detects –
 Configuration of femoral head & acetabulum
 Congruity of articular surface
 Femoral head containment
 Joint effusion

24.  Synovial hypertrophy
 Epiphyseal involvement
 True extent of femoral head necrosis

25.  helps in
 diagnosis of early stages
 visualization of early
reperfusion
 Transphyseal reperfusion, occurring by
neovascularization through the physis, is
known to be a strong predictor of growth
deformity.

26.  Effective tool for diagnosis of pre-radiological
early stages
 Revascularization patterns

27.  Findings of
 Configuration of head
 Widening of joint space due to thickend cartilage
 Lateral shifting of head
 Containment of head within acetabulum
 Major Advantage – assessment of congruity of
joint in different range of movement

28.  Currently, mainly
used in early
diagnosis of
HINGED
ABDUCTION

29.  In early stages - Joint effusion
 In later stages – assess shape of cartilagenous
femoral head

30.  provides acurate 3 D images of shape of femoral
head & acetabulum

31. 1. LEGG
2. WALDENSTROM
3. GOFF
4. SALTERTHOMPSON
5. CATERALL
6. HERRING’S LATERAL PILLAR
7. MOSE
8. STULBERG

32.  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

33.  Extent of subchondral # in both AP &
lowenstein frog leg lateral xrays
 reliable indicator in the group with
fractures

34.  extent of the fracture (line) is less than
50% of the superior dome of the
femoral head
› good results can be expected.

35.  Extent of the fracture is
more than 50% of the
dome,
› fair or poor results can
be expected

36.  In 1971
 used radiological findings of epiphyseal
involvement to identify 4 groups

37.  anterior femoral
head involvement
 no evidence of
sequestrum,
subchondral fracture
line, or metaphyseal
abnormalities

38.  anterolateral
involvement
 Central sequestrum
 Well demarcated
 metaphyseal lesions
 Subchondral fracture
line – Ant ½
 lateral column is intact.

39.  large sequestrum - 3/4th
of head.
 Junction is sclerotic.
 Diffuse Metaphyseal
lesions , anterolaterally
 Subchondral fracture
line - post 1/2
 The lateral column is
involved.

40.  Entire head
 Diffuse or central
metaphyseal
lesions
 posterior
remodeling of the
epiphysis

41. 1. Gage sign : Described by COURTNEY
GAGE(1933) small osteoporotic segment which
forms a radiolucentV-shaped defect on lateral
epiphysis & adjacent metaphysis on AP xray .

42. 2. Speckled calcification lateral to epiphysis
3. Lateral subluxation of femoral head
4. Horizontally oriented physis
5. Diffuse metaphyseal reaction (metaphyseal
cysts)

43.  Based on radiographic changes in lateral portion
of femoral head during fragmentation stage on
AP view
 LATERAL PILLAR - lateral 15-30% of epiphysis
on AP xray

44.  Group A – no involvement
 Group B – at least 50 % of height maintained
 Group C – less than 50% of height
maintained

45.  Advantage
 Easy application in active disease
 High correlation bet lat pillar height and amount of
head flattening at skeletal maturity

46.  Based on fitting of contour
of healed femoral head to
template of concentric
circles in both AP & Frog
leg lateral views
 Good - < 1 mm
 Fair - < 2 mm
 Poor - > 2 mm

47.  described in 1981
 Alike MOSE classification, its also
classification of THE END RESULTS
 Used to predict the onset of degenerative
joint disease following LCPD

48.  I – Shape is normal
 II – loss of head height
< 2 mm deviation of concentric circles
 Group I & II – “Spherical Congruency”

49.  III – Elliptical head
> 2 mm deviation
Contour matches (“Incongrous/Aspherical
congruency”)

50.  IV – Flattened
head, >1 cm of
flattening
Contour matches
(“Incongrous/Asph
erical congruency”)
 Resemblence with
Cow’s hip

51.  V – Collapsed head,
Contour mismatch (“Incongrous/Aspherical
Incongruency”)

52.  AIMS:
 Prevention of femoral head deformity
 Prevention of secondary degenerative
osteoarthritis.
 Psychological & Physical development.

53.  Elimination of hip irritability.
 Containment of the head.
 Restoration good ROM
 Prevention subluxation.
 Attainment of spherical head at end of disease

54.  For < 2 to 3 yrs – Observation
 For >3 yrs –
 Parents counseling
 Intermittent symptomatic treatment
 Home traction & physical therapy
 Hospitalization – loss of ROM
 Bed Rest
 SkinTraction – slings & springs
 NSAIDs

55.  Petrie cast
“Broomstick cast”
 Snyder sling

56. TORONTO
BRACE
TACHDJIAN
BRACE
NEWINGTON
BRACE
BIRMINGHAM
BRACE

57.  Indication:
 Age of clinical onset > 8yrs of age
 Herring type B
 Radiological evidence of loss of
containment by conservative modes

58.  CONTRAINDICATIONS:
 Herring’s type A and C
 Herring’s type B if child less than 8 yrs
 Healed cases.
 Hinged abduction

59.  ADVANTAGES
 Ability to obtain permanant containment
of head.
 Period of Restriction is only 2 months.

60.  Innominate Osteotomy
 Varus Derotational Osteotomy
 Lateral Shelf procedure
 Arthrodiastasis

62.  Advantages:
 Anterolateral coverage
 Lengthening of shortened limb
 No second operation
 Disadvantages:
 Improper coverage in older child
 Limb length inequality
 AVN due to raised pressure in joint

63.  Indications:
 Failed conservative for containment
 8 – 10 yrs
 Uncovered head on MRI / Arthrogram
 Excessive femoral anteversion

66.  Adv:
 Maximal coverage in old
 Excessive femoral anteversion
 Disadv:
 Excessive varus angulation
 Shortening
 Gluteal lurch
 Non / delayed union
2nd
sx reqd. for implant removal
Trochanteric overgrowth

67.  INDICATION:
 Lateral
subluxation
 Insufficient
coverage
 Hinged abduction
 COMPLICATION:
 Loss of hip flexion
 lateral femoral
cutaneous nerve

68.  Rationale:
 Widening
 Unloads the joint space
 Reduces pressure over head
 Articular cartilage repair
 Maintain congruency
 Allows 50 degree flexion

69.  Indications & Choice of surgery:
1. Hinged abduction – Valgus subtrochanteric
osteotomy
2. Malformed head in catterall gr 3 – Garceau
cheilectomy
3. Coxa magna – shelf augmentation
4. Large malformed head with subluxation – VDRO +
Pelvic osteotomy
5. Capital physeal arrest & troch overgrowth –

70.  Failure of lateral end of
epiphysis to slide under
the edge of acetabulum on
an internally rotated &
abducted AP X rays is s/o
HINGED ABDUCTION.

71.  Combination of
 VALGUS FLEXION INTERNAL ROTATION
OSTEOTOMY
 Coxa vara & hinged abduction - valgus
 Changes articular relations – valgus & flexion
 External rotation of limb – internal rotation
 Improve anterolateral head coverage

72.  Indication:
 Large mushroom head
(coxa plana)
 Lateral protruberance
 Disadv:
 Physeal slippage
 Postop joint stiffness

73.  Indications:
 Older children with painful
hip
 Significant femoral head
flattenning.

75.  Elevation of GT
 Shortening of neck
 Vertical pull of
muscles
 Impingement of GT
on rim of aceta –
“GEAR STICK SIGN”

76.  Trochanteric
Advancement
 GT epiphysiodesis
 Trapezoidal
osteotomy of GT

77.  Lateral calcification
 Extent of uncovering of head
 Lateral head displacement
 Widening of head & neck during early stages
(mushroom head)

78.  Saturn phenomenon (sclerotic epiphysis
surrounded by ring of lucency)
 Premature physeal closure

79.  Shape of Femoral head & congruency with
acetabulum – most imp predictor
 Age of onset of disease & duration