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Leg Calve Perthes disease

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Leg Calve Perthes disease

  1. 1. DR Darshan.C.K JSS Medical College
  2. 2. Overview  Definition  Vascular supply of femoral head  Natural History of the disease  Pathogenesis  Classification  Symtoms  Diagnosis  Management Conservative Management Containment procedures Salvage procedures
  3. 3.  Perthes disease may be defined as the self limiting form of osteochondrosis of capital femoral epiphysis of unwnown etiology that develops in children  Age group: 3-10 years  Sex: males 4-5 times more than girls  Bilateral in 10-12% of patients DEFINITION
  4. 4. SYNONYMS  Legg Calve-perthe’s disease  Legg’s stress fracture of femoral head  Osteochondritis deformans juvenalis  Osteochondrosis of hip joint  Pseudocoxalgia  Coxa plana
  5. 5. Epidemiology  M : F ratio 4 : 1  Children between 4- 8 years of age.Occasionally as young as 2 years and teenagers have been reported.  10 % of the cases have a positive family history.  Abnormal presentations breech, tranverse lie.  more common in Japanese, Eskimos, and Central Europeans and uncommon in native Australians, Polynesians, American Indians, and blacks.  Low socio economic status, 3rd or the 4th child ususally affected. Mean parental age is also higher than normal
  6. 6.  Affected children have short stature, retarded bone age, delay in skeletal maturation  Anthropometric measurements confirmed the affected children were smaller in all dimensions except the head circumference with distal extremities affected more than the proximal ones.  Onset of disease at an early age may culminate in normal growth in adult life, but a child with later onset tends to remain small throughout life. Epidemiology
  8. 8. Etiology  Coagulation disorders.  Arterial status of femoral head.  Abnormal venous drainage.  Abnormal growth and development.  Trauma.  Hyperactivity or attention deficit disorder.  Genetic component.  Environmental influences.  As a sequel to synovitis.
  9. 9. 1. Vascular supply 2. Increased intra-articular pressure 3. Intraosseous pressure - Patients has shown that the venous drainage in the femoral head is impaired, causing an increase in intraosseous pressure. 4. Coagulation disorder - Associated with absence of factor C or S. - Increase in serum levels of lipoproteins,thrombogenic substance. ETIOLOGY
  10. 10. 5. Growth hormones - Studies have shown reduced levels of growth hormones, somatomedin A and C. 6. Social conditions - Usually belong to lower socioeconomic status, reflects dietary and environmental factors. 7. Trauma-the lateral epiphyseal artery which courses through a narrow passage is susceptible to damage
  11. 11. 8.. Abnormal growth and development - Bone age is lower than chronological age by 1-3 yrs,. Ex: carpal bone age: 2 yrs (Triquetral and lunate) - Usually shorter than their peers. 9. Genetic factors - Inheritance 2-20%;inconsistent pattern. - More Incidence of low birth weight, abnormal birth presentations. - First degree relatives have 35% more risk , 2nd and 3rd degree relatives are 4 times more prone for perthes disease.
  12. 12. Blood supply to femoral head  Retinacular arteries  Metaphyseal arteries  Artery of the teres ligament
  13. 13. Blood supply to femoral head  Infants 1. Medial ascending cervical or inferior metaphyseal arteries of trueta. 2. Lat epiphyseal 3. Lig teres – insignificant  4 mts – 4 years 1. Lat epiphyseal 2. Med epiphyseal decrease in number.
  14. 14. Blood supply to femoral head  4 yrs to 7 years Epiphyseal plate forms a barrier to metaphyseal vessels.  Pre-adolescent After 7 yrs arteries of lig teres become more prominent and anastomose with the lateral epiphyseal vessels.
  15. 15. Truetta’s Hypothesis  He postulated that the solitary blood supply in the age group 4-8 yrs makes them suceptible to ischemia.  Compression of Lat epiphyseal arteries by ext.rotators.
  16. 16. CAFFEY’S HYPOTHESIS  this theory is incompatible with the high predominance of the disease in males, since the vascular supply is identical in both sex  The radiologic features are more consistent with an AVN resulting from intraepiphyseal compression of blood supply to the ossification center  Recently in POSICON 2016 they have come across DVT as one of the cause for vasularity.
  18. 18. PATHOGENESIS 1) INCIPIENT OR SYNOVITIS STAGE lasts for 1 to 3 weeks. The synovium is swollen, hyperemic and odematous. There is notable absence of inflammatory cells, joint fluid is increased
  19. 19. 2) STAGE OF AVASCULAR NECROSIS  lasts for 6 months to 1 year.  It involves only a portion of the ossific nucleus usually situated anteriorly or involves the entire nucleus.  The bone architecture remains normal but lacunae are vacant  Bone trabeculae are crushed into minute fragments and compressed into a compact mass.  The gross appearance and contour of the femoral head remains unchanged
  20. 20. 3) STAGE OF FRAGMENTATION OR RESORPTION  Lasts for 2 to 3 years and characterised by resorption of the necrotic bone and replacement by viable bone.  Subchondral fracture of necrotic bone result in multiple trabecular fragments being compressed together
  21. 21. 4) HEALED OR RESUDIAL STAGE  The normal bone is forming along side and replacing slowly resorbing bone  The newly formed bone is immature formed of slender trabeculae and early compressed together with necrotic fragments  The entire ossific nucleus may be deformed assuming mushroom shaped contour  Finally an enlarged femoral head (coxa magna) emerges varying in contour from a normally spherical and concentrically lodged head to a deformed flattened and eccentrically placed head
  22. 22.  APPERANCE OF GREATER TROCHANTER:- It becomes strikinly large in some cases. Since longitudinal growth of the femoral neck may cease completely at 12 -14 years of age , whereas growth of the greater trochanter continues until 17 -18 years, a discerpancy in growth neck and the greater trochanter may result.The elevation impairs the power of pelvitrochanteric abducter muscles, manifested by positive trendelberg sign.
  23. 23. CLINICAL FEATURES SYMPTOMS  Most childern present with mild and intermittent pain in the thigh or a limp or both.  The onset of pain may be acute or insidious  The classical presentation is described as a “painles limp” the child limps but does not complains of discomfort.  Pain is agrravated by movement of hip and relived by rest.  H/o of trauma usually a mild is present.
  24. 24. EXAMINATION:-  Antalgic gait  Muscle spasm secondary to irritable hip.  Limitation of abduction and internal rotation  Short stature  Ffd may be present  DIFFERENTIAL ROTATION .  TRENDELENBERG TEST POSITIVE
  25. 25. Investigation  X-Ray –AP & Frog leg Lat view  USG  Arthrography  Bone Scan  CT  MRI
  26. 26. Arthrography  Indicated to know the contour of head and congruity of articular surface  Provides reliable information regarding containment.  We can assess congruity of hip in many different positions.  Not routinely used .  Arthrography is important only in the fragmentatory and reparative stages
  27. 27. CT SCAN  Not as sensitive as nuclear medicine or MRI.  CT may be used for follow-up imaging in patients with LPD.
  28. 28. MRI SCAN  It allows more precise localization of involvement than conventional radiography.  MRI is preferred for evaluating the position, form, size of the femoral head and surrounding soft tissues.  MRI is as sensitive as isotopic bone scanning.
  29. 29. Bone Scan  Indicated to diagnose in early stages and to classify the severity.  Diagnosis possible months before signs appear on X- Ray.  Avascular areas show cold spots.  Revascularisation can be detected much before radiographic evidence.
  30. 30. Radiographic Classification  Waldenstroms classification.  Catterall classification.  Salter classification  Herrings lateral pillar classification.  Modified Elizabethtown classification.
  31. 31. I) Stage 1(stage of increased density) - Ossific nucleus initially smaller; femoral head becomes uniformly dense; - Convex rounded enlargement develops at superior margin of neck( Gage’s sign). - A subchondral fracture may be seen; - radiolucencies appear in the metaphysis II) Stage 2(fragmentation stage) - Lucency appear in epiphysis; - Segments (pillars) of the femoral head demarcate the femoral head may flatten and widen - Metaphyseal changes resolve; - Acetabular contour may change WALDENSTROM’S CLASSIFICATION BASED ON RADIOGRAPHIC CHANGES
  32. 32. III) Stage 3(healing or reossification stage) - New bone appears in femoral head which gradually reossifies; - Epiphysis becomes homogeneous. IV) Stage 4( healed or remodelling stage) - Femoral head is fully reossified and remodels to maturity; - Acetabulum also remodels
  33. 33. CRESCENT/CAFFEY SIGN 'segmental fracture' also termed by Caffey as submarginal fracture which is represented by a localized area of increased density continuous with the remainder of the EOC.
  34. 34. Sagging rope sign  -radio dense line overlying proximal femoral metaphysis, a result of growth plate damage with metaphysial response.
  35. 35. WALDENSTROM SIGN -Slight lateral displacement of the femoral head and smallness of theE0C -best determined in the Lauenstein (frogleg) view
  36. 36.  Radiographic changes in metaphysis. - Apparent very early in the disease process. - Changes are of prognostic value, hips with cystic changes were twice likely to have poor outcomes as hips without cysts.  Changes in neck of femur - Deformity in neck can develop earlier than head. - Upper part of neck is expanded and metaphyseal end becomes rounded. - neck progressively becomes shorter and wider
  37. 37.  Changes in acetabular cavity - Distance between medial pole of head and floor of socket is increased(Waldenstrom’s sign) - Ligamentum teres grossly swollen and congested. - Floor is altered to adapt shape of head, hollowed out abruptly. - There may be irregular ossification, cystic and increased radiodense areas
  38. 38. Catterall classification (1971)  I – only anterior portion of epiphysis affected.  II – anterior segment involved, central sequestrum present  III – most of epiphysis sequestered with unaffected portions located medial and lateral to central segment  IV – all of epiphysis sequestered.
  39. 39. Catterall's Classification GRADE 1 : Only the anterior part of the epiphysis is involved. It differs from the other group that no collapse occurs and there is complete absorption of the involved segment without sequestrum formation and height of the epiphysis is maintained.
  40. 40. Catterall's Classification  GROUP 2 :- In this variety more of the anterior part of the epiphysis is involved  Collapse with the formation of a dense collapsed segment or sequestrum.  Despite collapse occurs the viable fragments maintain the epiphyseal height.  Metaphyseal change -usually a well defined cyst which is transitory and disappears with healing.  The sequestrum is separated from the viable posterior-- segments by a V which when present, is characteristic of this group.
  41. 41. Catterall's Classification  Group-3 : Only a small part of the posterior epiphysisis is involved.  Ap view shows a appearance of a "head within a head".  In the later stages there is a collapsed sequestrum centrally placed with very small amount of normal appearing bone on the medial and lateral sides.  Metaphyseal changes - more generalised and when extensive are frequently associated with broadening of the neck.
  42. 42. Catterall's Classification  GROUP 4 : whole epiphysis is sequestrated. On AP view total collapse of the epiphysis may be seen producing a dense fine.  Displacement of the epiphysis can occur not anteriorly but posteriorly producing a mushroom like apperance of the head.  The metaphyseal changes may be extensive
  43. 43. HEAD AT RISK  Gage's sign –triangular section of osteoporosis on lateral femoral head  lateral calcification  lateral subluxation  horizontal alignment of the growth plate  Diffuse metaphyseal reaction.
  44. 44. Caterall “head-at-risk” sign metaphyseal cysts
  45. 45. Gage’s sign  Rarefaction in the lateral part of the epiphysis and subjacent metaphysis.
  46. 46. SALTER AND THOMSON’S CLASSIFICATION  Type A = I & II Catterall  Type B = III & IV Catterall.
  48. 48. Prognostic Factors 1. Age at diagnosis 2. Extent of involvement 3. Sex 4. Catterall “head at risk” clinical signs  Clinical 1. Progressive loss of hip motion 2. Increasing abduction contracture 3. Obese child
  49. 49. Classification of Prognosis  Uniplanar methods - CE angle of Weiberg. - Salters extrusion Index. - Epiphyseal index. - Epiphyseal quotient.  Biplanar methods - Stulberg classification.
  50. 50. CE angle of Weiberg  Indicator of acetabular depth It is the angle formed by a perpendicular lines through the midportion of the femoral head and a line from the femoral head center to the upper outer acetabular margin.  Normal = 20 to 40 degrees  Angle >25 = good,  20-25= fair,  < 20 = poor
  51. 51. Salters extrusion Index  If AB is more than 20% of CD it indicates a poor prognosis
  52. 52. Epiphyseal index & quotient  Epiphyseal index = greatest height of the epiphysis divided by its width.  Epiphyseal quotient = Epiphyseal index of involved hip divided by the index for uninvolved hip. >0.6 = good 0.4-0.6 = fair <0.4 = poor
  54. 54. Stulberg Classification Prognosis Prognosis is poor if;  Extensive involvement of EOC  More than 6 years of age.  Early closure of epiphyseal plate  Advanced stage of disease when first seen.  Female patient.  The short term prognosis - Concerns femoral head deformity at the completion of healing stage.  The long term prognosis - concern with the late development of secondary degenerative osteoarthritis of the hip in adult life.
  55. 55. Differential diagnosis  Tuberculosis of the hip  SCFE  Transient synovitis  Spondylodysplasia  AVN due to leukemia, lymphoma, gauchers disease, Hemoglobinopathies etc
  56. 56. DIFFERENTIAL DIAGNOSIS • Unilateral 1. Septic hip 2. Toxic synovitis 3. Slipped femoral capital epiphysis 4. Lymphoma • Bilateral 1. Hypothyroidism 2. Sickle cell 3. Multiple epiphyseal dysplasia 4. Spondyloepiphyseal dysplasia
  57. 57. Treatment  Objectives - To produce a normal femoral head and neck(prevent deformation & enlargement) - To produce a normal acetabulum - A congruous hip which is fully mobile - To prevent degenerative arthritis of the hip later in life
  58. 58. Treatment  Perthes disease is a local, self - healing disorder  Goals of Treatment:  Containment of the head.  Elimination of hip irritability.  Restoration and maintenance of a good range of hip motion.  Prevention of epiphyseal extrusion and subluxation.  Attainment of a spheric femoral head on healing
  59. 59. CONTAINMENT  CONTAINMENT aims at repositioning the extruded anterolateral part of the femoral epiphysis into the confines of the acetabulum  This can be achieved by ABDucting & flexing or ABDucting & Internal Rotating the hip  Containment needs to be ensured until the healing process beyond the stage where the epiphysis is vulnerable to deformation(stage 3b)
  60. 60. Treatment  Caterall group 1 and group 2 ( < 7 years) No active  Herring group 1 & Treatment group 2 (< 6 years)
  61. 61. Treatment Treatment is divided into 3 phases  Initial Phase – restore & maintain mobility  Active Phase – Containment and maintainance of full mobility.  Reconstructive phase – correct residual deformities.
  62. 62. 1) Onset <6yrs of age, regardless of extent of capital femoral epiphyseal involvement. 2) Age<6yrs of age: Catterall’s group 1 and 2. or Salter thomson group A. 3) They should have clinical and radiographic examination at frequent intervals( 3 months) 4) If unsuccessful, may necessaite a short course (2- 6 months) of non surgical treatment. Observation
  63. 63.  The two primary means of symptomatic treatment are bed rest and traction.  NSAIDS and crutches  Stretching exercises with observation used.  Beneficial effects are greatest around time of development of subchondral fracture.  Various traction methods include simple longitudinal traction with leg on bed, balanced suspension and traction and “slings and springs”. Symptomatic treatment
  64. 64.  Hip irritability with decrease of hip motion: 1-2 week period of bed rest with abduction traction if recurs 2-3 months period of surgical non containment to decrease risk of extrusion. X-ray taken bi-monthly for evaluation.
  65. 65. Indications  Age at clinical onset 6yrs or older.  Catterall Group 3 or 4/ Salter thomson Group B.  When loss of containment manifested by extrusion seen on AP view. Contraindications  Group 1cases,group2&3cases less than 5 yrs, with no signs of head at risk.  Severe flattening of head  Healed cases and cases with hinged abduction. DEFINITIVE EARLY TREATMENT
  66. 66. Orthosis  Non Ambulatory weight releiving 1. Abduction broomstick plaster cast 2. Hip spica cast 3. Milgram hip abduction orthosis  Ambulatory Both limbs included 1. Petrie Abduction cast 2. Toronto orthosis 3. Newington orthosis 4. Birmingham brace 5. Atlanta Scotish Rite Brace  Ambulatory unilateral 1. Tachdjian trilateral socket orthosis
  67. 67. Orthosis CONTRAINDICATION  Incompliant patient.  Psycho socially unacceptable for the patient or parents.  Bilateral involvement at different times requring prolonged brace wear. Disadvantages  Stiffness of the knee and ankle joint with adaptive articular changes,  Restricted ambulation,  Pressure sores and need for frequent changes
  68. 68.  Preliminary traction given  Extremity placed in brace (abd: 45 & int. rot.)  Child encouraged to walk because weight bearing movements are essential for successful remodelling  X-rays taken at regular intervals  Discontinued when evidence of new subchondral bone seen(20 months) Treatment regimen at Newington Children’s hospital
  69. 69. Petrie abduction/ broom stick
  70. 70. SCOTISH RITE ABDUCTION BRACE With hips ABDucted, legs are flexed & externally rotated when patient walks
  71. 71. Newington orthosis  Metal A frame with a central support for thighs
  72. 72. Birmingham brace  Knealing bar & chain to keep the foot off the ground while a specially altered crutch allows the abducted, internally rotated limb to clear the body when patient walks
  73. 73. Toronto Brace  Universal joints  Hip ABDucted while allowing hip & knee flexion
  74. 74.  Tachdjian trilateral socket orthosis
  75. 75. SURGICAL CONTAINMENT • INDICATIONS: – Age of clinical onset > 8yrs of age – Herring type B – Radiological evidence of loss of containment by conservative modes • CONTRAINDICATIONS: – Herring’s type A and C – Herring’s type B if child less than 8 yrs – Healed cases. – Hinged abduction • ADVANTAGES – Ability to obtain permanent containment of head. – Period of Restriction is only 2 months. Age at surgery: - Should be done in the increased density or early fragmentation phase
  76. 76. COMPLICATIONS Femoral  Shortening  Stiffness  Malrotation  Limp  Positive trendelenburg Pelvic  Lenghtening  Stiffness  Chondrolysis  Failure of containment Femoral-ABD+IR/ Flexion Pelvic-augment acetabulum / reorient to cover ant lateral part of epiphysis
  77. 77. Treatment ( Surgical)  Femoral varus osteotomy.  Inominate osteotomy.  Combined femoral and inominate osteotomy  Valgus osteotomy  Shelf arthroplasty  Chiari osteotomy  Cheilectomy.  Trochanteric advancement or arrest.
  78. 78. CONTAINMENT SURGERIES – Varus Derotational Femoral Osteotomy –Innominate or Salter osteotomy –Shelf procedure –Combination of femoral and innominate osteotomy –Combination of innominate osteotomy and shelf -Trochanteric arrest
  79. 79. VARUS DEROTATION FEMORAL OSTEOTOMY (VDO)  Procedure of choice in 8 – 10 yrs without limb shortening  Prerequsite-reasonable ROM  osteotomy in increased density or early fragmentation stage • Types - Open wedge or closed wedge • Technique - Osteotomy at subtrochantric level & Distal femur is fixed in varus(ADD) and external rotation using plate and screws  20 -30 degree derotation & 20 degree varus  Hip spica for 8-12 weeks
  80. 80. varus derotational osteotomy  Limit varus correction 10-15degree at early stage  At later stage-greater varus correction needeed  If only internal rotation restricted-varus extension osteotomy Complications 1. Persistant ext.rotation 2. Shortening of extremity 3. Incresed abductor lurch 4. Trochanteric over growth 5. Delayed or non union 6. Excessive varus
  81. 81. Level of osteotomy Insertion of guide pin and reaming of femur First depth marking flush with lateral cortex Removal of wedge to customize it
  82. 82. Plate and compression screw application Insertion of bone screws.
  83. 83. Inominate osteotomy  Indications: 1.>6 yrs 2.mod Or severely affected head with loss of containment Requirement: • Able to abduct 45 deg • femoral head to be contained in position Complications : loss of fixation, leg-lengthening ,dec. hip flx, jt.stiffness, second procedure for k wire removal
  84. 84. INNOMINATE OSTEOTOMY – SALTER • Advantages: – Anterolateral coverage – Lengthening of shortened limb – No second operation for I/R • Technique – Iliac osteotomy is made just above acetabulum extending from greater sciatic notch to anterior inferior Iliac pine – Entire acetabulum with pelvis is rotated downward and outwards – Bone graft from ilium is applied to osteotomy site • Hip Spica for 8-12 weeks.
  86. 86. SHELF PROCEDURE • Catterall proposes this as the primary method of management in children over 8 years of age Used to improve acetabular lateral cover of femoral head INDICATION: • Lateral subluxation • Insufficient coverage • Hinged abduction Contra indication: Dysplastic hip with spherical congruity COMPLICATION: • Loss of hip flexion • lateral femoral cutaneous nerve injury Technique: • bone graft is harvested from the ilium and inserted into the roof of the acetabulum.
  87. 87. i)Curved incision below iliac crest, strip glutei. ii) Mobilize and divide reflected head of rectus femoris iii) Trough in bone above insertion of capsule. iv) Strips of cancellous bone inserted into trough so that they form a canopy on superior surface of hip joint. v) Pack web space between flap and graft canopy with gratft vi)Repair rectus and lose the wound.
  88. 88. Combined femoral & innominate osteotomy  For severely affected hips at risk of poor outcome Indications  Lateral subluxation & calcification  Considerable changes in epiphysis
  89. 89. SALVAGE OPTIONS It is used for pain relief  Valgus osteotomy  Chiari osteotomy  Cheilecteomy  Trochanteric advancement  Arthrodesis
  90. 90. Recommended Indications for diff. surgeries  Hinged abduction - valgus subtrochanteric osteotomy  Severly Mal formed femoral head – cheilectomy  Coxa magna – shelf augmentation  A large malformed femoral head with lat.subluxation – Chiari’s pelvic osteotomy  Capital femoral physeal arrest – Trochanteric advancement
  91. 91. Valgus Osteotomy  Indication:hinged abduction of hip  Head & acetabulum congruent in Add but incongruent in neutral & Abd
  92. 92. Chiari osteotomy  It is used as a salvage procedure to accomplish coverage of a large flattened femoral head, in an older child when the femoral head is subluxating  acetabulum and the pelvis inferior to the osteotomy along with the femur is displaced medially.  The superior fragment of the osteotomy then becomes a shelf and capsule is interposed between it and the femoral head.
  93. 93. Chiari osteotomy  Capsular interpositional arthroplasty  Deepens the deficient acetabulum by medial displacement of distal pelvic fragment and improves sup.lat.femoral coverage.
  94. 94. Trochanteric advancement  Indications: - Trochanteric over growth - Capital femoral physeal growth arrest
  96. 96.  ARTHRODISTRACTION Illizarov half ring fixator in late onset perthes with total head involvement Unloads joint space Preserve congruency of femoral head  FENETRATION OF EPIPHYSEAL GROWTH PLATE Fenestration made in neck anteriorly with 3 or 4 drill holes or a curet through epiphyseal growth plate. Reduced time for resorption and regeneration.
  97. 97.  GROWTH FACTORS AND INDUCING DRUGS Stimulate healing to prevent deformity. Newer drugs that will slow down bone loss and stimulate new bone formation. (bisphosphonates)  HLA 1 RELATED TO CHILDREN WITH PERTHES DISEASE SHOWS IMMUNOLOGICAL RELATION WITH PERTHES  GENE THERAPY - Stahl gene responsible for perthes, further studies are yet to understand
  98. 98. Criteria of Final Result  Grading of the final result is done after four year of onset.  Good: The hip is asymptomatic with full range of motion, the femoral head is round and well centered, there is no acetabular change joint shape is not increased. A slight loss of epiphyseal height is permissible.  Fair: The hip is asymptomatic with motion is slightly restricted, especially in medial rotation. The femoral head is round with slight broadening that is not fully contained; less than one fifth of is uncovered some adaptive acetabular change is acceptable provided that head is round, epiphyseal height is reduced.
  99. 99.  Poor: The hip is symptomatic with motion always restricted femoral head is flat, broad, and irregular and at least one fifth is uncovered. There are adaptive acetabular changes and the joint space is widened at the inferior medial aspect.
  100. 100. ASSESSMENT OF END RESUTLT Grading (Mose)  Good : Femoral head spherical and of the same radius on AP and lateral view. CE angle of 20° or more.  FAIR : no more than 2mm deviation from sphericity on ap and lateral view and CE angle of 15 to 19 degree  POOR : greater than 2mm variation from sphericity on either ap or lateral view and CE angle less than 15 degree
  101. 101. Recent Advances  Anticoagulant  Botulinum toxin  Ibadronate :this has shown there importance in rat model by increase spericity of femoral head
  102. 102. Take home message  Localised manifestation of an generalized epiphyseal disorder  Non weight bearing & weight bearing have shown similar results  Always classify the disease grade & jump to treatment options  Age at onset,sex & amount of involvement for prognosis
  103. 103.  References 1) Tachdjian’s pediatric orthopaedics 2) Cambell’s operative orthopaedics 3) Hefti’s pediatric orthopaedics 4) Mercer’s orthopaedics 5) Turek’s orthopaedics 6) Pediatric orthopaedics Benjamin Joseph 7) POSICON 2016
  104. 104. Thank you for your patient listening