Classification perthes Disease

Dr. ANOOP G.C.
Junior Resident in orthopedics
MCH Kozhikkode
Classifications for Legg
Calve Perthes Disease
Dr.Anoop G.C.,JR,Orthopaedics,GMCK

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.

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 .

LEGG CALVE PERTHES

PATHOLOGY
 By Waldenstrom in 1922
 4 stages
based on microscopic
and gross pathology
Paul_Petter_Waldenström

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

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

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

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.

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

RADIOGRAPHY
AP View FROG LEG View

CLASSIFICATION
• LEGG
• WALDENSTROM
• GOFF
• CATERALL
• SALTER THOMPSON
• HERRING’S
• ELIZABETHTOWN
• STULBERG
• MOSE
• CE angle
Historic
Prognotic
Stage
outcome

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

PROGNOSTIC CLASSIFICATION
• CATERALL
• SALTER THOMPSON
• HERRING’S

CATTERALL
• Publihed in 1971
• the first widely accepted
prognostic classification
• Based on extent of
involment of femoral
head.
• IV groups

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

Catterall Group II
50% involvement
Sequestrum present - junction Clear
Metaphyseal reaction - antero lateral
Subchondral fracture line - anterior half

Catterall Group III
75% involvement
Sequestrum large - junction sclerotic
Metaphyseal reaction - diffuse or antro lateral
Subchondral fracture line - posterior half

Catterall Group IV
Whole head involvement
Metaphyseal reaction - central or diffuse
Posterior remodelling present

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

Lateral subluxation

GAGE’S SIGN
• small osteoporotic segment forming a
translucent V- shaped trough in the lateral
part of the epiphysis

CAGE SIGN
• Calcification of the lateral epiphysis

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

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

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

Herring
Group A
• Normal Height of lateral
pillar maintained
• Uniformly good
outcome
• No intervention
required

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

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

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

MODIFIED ELIZABETHTOWN
Stage Ia
• The epiphysis is
avascular and
appears dense.
• There is no loss of
height of the
epiphysis.

Stage Ib
• There is some loss of
height of the dense
sclerotic epiphysis.
• The epiphysis is in
one piece.

Stage IIa
• One or two fissures
appear in the
epiphysis

Stage IIb
• The epiphysis is
frankly fragmented.
• This is the stage at
which there is
maximal collapse of
the epiphysis.

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

Stage IIIb
• Lamellar bone of
normal texture covers
at least 1/3 of the
circumference of the
epiphysis
>1/3

Stage IV
• The process of
revascularisation and
repair is complete.
• There is no evidence
of any avascular bone
in the epiphysis

CLASSIFICATION DEFINING OUTCOME
• STULBERG
• MOSE
• CE angle

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.

 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

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

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.

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

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

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

 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

THANK YOU

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