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Case Study XV

Case Study XV. Megan Ivy, SPT Will Herritage , SPT. Presentation Outline. Patient Presentation Diagnosis Epidemiology Pathogenesis Examination Findings Risk Factors Classification Treatment Options Goals Specific Interventions. Patient Presentation. 9 y/o male

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Case Study XV

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  1. Case Study XV Megan Ivy, SPT Will Herritage, SPT

  2. Presentation Outline • Patient Presentation • Diagnosis • Epidemiology • Pathogenesis • Examination Findings • Risk Factors • Classification • Treatment Options • Goals • Specific Interventions

  3. Patient Presentation • 9 y/o male • Status post VDRO c many complications • PICC line for antibiotics • Peripherally Inserted Central Catheter • Long term use • Home health nursing/PT • School not acknowledging requests for homebound services • Small for his age • R “Trendelenburg limp” before sx • Considering testing for possible learning disorder

  4. And the diagnosis is . . .

  5. Legg-Calve Perthes Disease An American, Frenchman, and German all walk into a bar…

  6. History of LCPD 6,7,15 • 1909- Dr. Arthur Legg of Boston, Massachusetts • Pressure from the injury caused a flattening of the femoral head • “Obscure affectation of the hip” • 1909- Dr. Jacques Calve of France • noninflammatoryself-limiting condition • Postulated abnormal or delayed osteogenesis • 1909- Dr. Georg Perthes of Germany • “arthritis deformans juveniles” • Postulated this was an inflammatory condition • 1909- Dr. Waldenstrom • Postulated the condition he observed was a form of TB

  7. LCPD Today • Definition: AvascularNecrosis of the ossific nucleus of the femoral head caused by loss of blood supply • AKA: ischemic necrosis of the hip, coxaplana, osteochondritis, or avascular necrosis of the femoral head • Commonly: Legg-Calve-Perthes Disease or PerthesDz • Leads to a collapse and flattening of the femoral head if not treated properly → Hip subluxation • Self-limiting condition • Etiology unknown

  8. Epidemiology6,7,15 • Occurs in children 3 to 12 year old • Most common age of diagnosis = 6 y/o • 1 in 1,200 children affected • Males are 3-5 times more likely to have LCPD • Bilateral LCP in 10-20% of cases • Do not occur at the same time • Do not necessarily follow the same course

  9. Pathogenesis1

  10. 4 Stages6,7,15

  11. What does it look like?6,7,15

  12. Psychosocial Component14 • Increased incidence of learning disabilities • Reported up to 33% have co-morbid ADHD • 3-5% in general population • Characterized by . . . • developmentally inappropriate activity level • low frustration tolerance • impulsivity • poor organization of behavior • Distractibility • inability to sustain attention and concentration.

  13. Referred Pain • Hip pain commonly refers to the anterior groin or knee • Pt may be referred to PT to treat “knee pain” • Careful examination • Hip ROM • Gait analysis • Aggs & Eases • May need to refer back to MD for proper Dx

  14. DifferentialDiagnosis

  15. Risk Factors5,12 • Smoking During Pregnancy • 67% increased risk • Dose-dependent trend • Low birth weight • Cesarian Section • Thrombophilia • Small Head Circumference • Small for Gestational Age • Pre-term Birth • Complication during delivery

  16. Classification Systems6,7,15

  17. Salter-Thompson/ Catteral

  18. Herring/Lateral Pillar

  19. Stulburg16 AsphericalIncongruency Spherical Congruency Aspherical Congruency

  20. ABC’s?

  21. Radiographs

  22. To Operate or Not to Operate . . .

  23. Surgical vs. Conservative2 • Selection depends on many factors • Pt’s age, classification, stage, previous tx, etc. • Maintain spherical shape of the femoral head -may flatten if not addressed • Prevent extrusion of enlarged femoral head -coxa magna • Prevent premature degenerative arthritis Ultimate Goal of Tx Selection = Containment of Femoral Head in Acetabulum& Limit Complications

  24. Treatment Algorithm7 Diagnosis LP ‘B’ & ‘C’/ LP ‘A’ + intolerable +ROM↓ Clinical Assessment/ XR LP ‘A’ + tolerable + ROM ok EUA + Arthrogram Hip contained in all positions Hip Contained only in abduction Activity restriction and Review Hip Contained Hinging? <9 y? Non-operative: Abduction splints, PT, Rest No Yes No Yes Abduction/Extension Osteotomy + Shelf Procedure VarusOsteotomy or InnominateOsteotomy Shelf Arthroplasty

  25. Catteral’s Head-at Risk Signs10

  26. Treatment: Conservative6,7,15 • Modalities for pain control • Meds/ NSAID’s • Limit complications • Bracing • Atlanta Scottish Rite Brace • ROM Exercises • Petrie Casts • Abd and IR • Observation • Patients must understand sequence of events • This Dz cannot be ‘hurried’ • Avoid repetitive high impact forces

  27. Atlanta Scottish Rite Brace

  28. Surgical Treatment6,7,15 Surgical Options . . . • Femoral VarusOsteotomy • With or without Derotation • InnominateOsteotomy • Shelf Acetabuloplasty • ValgusExtentionOsteotomy • Adductor Tenotomy

  29. InnominateOsteotomy • Containment by redirection of the acetabulum • Femoral head placed in flexion, abduction, and IR • Internal Fixaton • Prerequisites: • Full ROM • Nearly round femoral head • Joint congruency • Disadvantages: • Possibly in Spica cast x 6 wks • Possible loss of ROM due to change in acetabular orientation • Especially loss of flexion • May be combined with VDRO in severe cases

  30. Shelf Arthroplasty9 • Directly influences the acetabular size by adding bone to lateral acetabular rim • Used in children >8 y/o with . . . • Catterall group 2,3, or 4 • Lateral Pillar B,C, or D • Salter/Thompson Type B • Advantages: • Covers the anterolateral head to prevent subluxation • Deepens the anatomical socket

  31. VarusOsteotomy3 • Deep seating and varus positioning of femoral head • Reduces the forces on the head • 70-90% satisfactory results • Prerequisites: • Full ROM • Joint Congruency • Containable with abd and IR • Initial and Fragmentation Phases • Disadvantages • Internal fixation and possible immobilization VDRO

  32. APTA Practice Patterns • Musculoskeletal 4B: Impaired Posture • Musculoskeletal 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction • Musculoskeletal 4I: Impaired Joint Mobility, Motor Function, Muscle Performance and Range of Motion Associated with Bony or Soft Tissue Surgery

  33. NCMRR

  34. Physical Therapy

  35. Goals of Tx6,7,15 • Wound Management- monitor for s/s of infection • Transfers/ ADL’s/ Mobility • AD • Regain Hip ROM • Abduction • Internal Rotation • Maintain ROM & Integrity of distal joints • Strengthen weakened hip musculature • Pain Control • Endurance • Multidisciplinary • Psychologist, OT, School Services, etc.

  36. Pt Goals Immobilization (STG’s): • Pt. to demo bed->chair transfer c min assist in 1 week for safe home mobility. • Pt. to amb c walker bed ↔restroom c min assist in 1 week for safe restroom use. After cast removal (LTG’s): • Pt. to amb x 50ft c crutches s VC’s in 6 wks. • Pt. to build and complete 4 part obstacle course c 2 climbling tasks using GPDC approach in 8 wks • Pt to ↑ R Hip ROM to within 10° of L in 10 wks.

  37. Homebound School Services3 • AISD Special Education available for . . . • orthopedic impairment • other health impairment (medically disabled for a minimum of four weeks) • mental retardation • emotional disturbance • learning disability • speech impairment • autism • traumatic brain injury • auditory or visual impairment • Includes Homebound Services • Write a referral for Special Education Services • Contact Campus IMPACT Team -> Local Support Team (LST) Meeting, • Full and Initial Individual Evaluation (FIIE) • Admission Review and Dismissal (ARD) Meeting

  38. Intervention11: Weeks 1-6 • May be Immobilized/ NWB • Instruct pt/family in safe mobility and transfers • Manage surgical site • Walker training • AROM/PROM of knee/ankle • Isometric contractions • Glutes/HS/Quads

  39. Intervention: Week 7-DC • Gait Training • Progressive weight bearing activities • Aquatic Therapy • Obstacle course- ‘Top Down’ • Climbing • Stepping over objects • Dynamic surfaces • Quality movement • Balance Training/Vestibular • Balls/Platform Swing

  40. Intervention: Weeks 7-DC • Focus on regaining full ROM • Stretching • AAROM/AROM for all LE joints • Regain function of glutes/HS/quads • NDT to facilitate mm activity • Scooterboard Hockey • Forward Pulling • HS/Glutes • Backward Pushing • Quads

  41. Prognosis13,17 • Age at onset • Younger is better • Gender • Males have better prognosis • Head Involvement/Classification • If >8 years at the time of onset + hip in the lateral pillar B or B/C border group = better outcome with surgical treatment than with nonoperative treatment. (Herring et al. 2004) • Trend toward better radiographic outcomes when varusderotationalosteotomy (VDRO) was performed early. (Arkader et al. 2008) • http://www.youtube.com/watch?v=75VLsnk8RMc

  42. Prognosis

  43. Prognosis

  44. Presentation Pearls • LCPD: Avascular necrosis of femoral head • Unknown etiology, Self-Limiting • Leads to the collapse of the femoral head and hip subluxation • Presentation: • Short Stature • Trendelenburg Gait- Limp • Decreased Hip ROM/STR • Pain in hip, groin, or knee • Classification guides treatment and prognosis • Surgical and non-surgical options • Tx Goals: RESTORE ROM, ↑ STR of Hip mm, Gait training, Pain management, wound management

  45. References • Alpaslan, AM, Aksoy, MC, Yazici, M. (2007). Interruption of the Blood Supply of the Femoral Head: An Experimental Study on the Pathogenesis of Legg-Calve-Perthes Disease. Arch Orthopedic Trauma Surgery. 2007; 127:485-491. • Arkader, A, Sankar WN, Amorim RM. (2008). Conservative versus surgical treatment of late-onset Legg-Calve-Perthes disease: a radiographic comparison at skeletal maturity. Journal of Child Orthopedics. 2008; 3:21-25. • Atlihan, D, Subai, M, Yildirim, H. (1999). Proximal Femoral VarusOsteotomoy for Perthes Disease. Clin Research. 1999; 10:155-159. • Austin Independent School District (AISD) Website. Available at: http://www.austinisd.org/academics/specialeduc/faq.phtml. Accessed: April 1, 2009. • Bahmanyar, S, Montgomery, SM, Weiss, RJ, Ekbom, A. (2008). Maternal Smoking During Pregnancy, Other Prenatal and Perinatal Factors, and the Risk of Legg-Calve-Perthes Disease. Pediatrics. 2008; 122: 459-464. • Banta, J.V., Scrutton, D. Hip Disorders in Childhood. Cambridge University Press, 2003. p. 97-115 • Campbell, SK, Vander Linden, DW, Palisano, RJ. Physical Therapy for Children. St. Louis, Ms: Saunders Elsevier; 2006. • Crofton, PM, Macfarlane, C, Wardhaugh, B, Ranke, MB, Elmlinger, MW, Kelnar, CJ, Macnicol, MF. (2005). Children with Acute Perthes’ Disease have Asymmetrical Lower Leg Growth and Abnormal Collagen Turnover. ActaOrthopaedica. 2005; 76:841-847. • Domzalski, ME, Glutting, J, Bowen, JR, Littleton, AG. (2006). Lateral Acetabular Growth Stimulation Following a Labral Support Procedure in Legg-Calve-Perthes Disease. The Journal of Bone and Joint Surgery. 2006; 88:321-329. • Forster, MC, Kumar, S, Rajan, RA, Atherton, WG, Asirvatham, R, Thava, VR. (2006). Head at Risk Signs in Legg-Calve-Perthes Disease Poor Inter and Intra Observer Reliability. ActaOrthopaedica. 2006; 77:413-417.

  46. References 11. HeftiF, Brunner R, Jundt G, Hasler CC. Pediatric Orthopedics in Practice. Springer, 2007. p 14-15. 12. Glueck, CJ, Roy, DR, Balasa, VV, Gruppo, RA, Wall, EJ, Mehlman, CT, Crawfod, AH. (2004). Legg-Calve-Perthes Disease and Thrombophilia. The Journal of Bone and Joint Surgery. 2004; 86:2642-2647. 13. Herring, JA, Kim, HT, Browne, R. (2004). Legg-Calvé-Perthes Disease Part II: Prospective Multicenter Study of the Effect and Treatment on Outcome. The Journal of Bone and Joint Surgery. 2004; 86:2121-2134. 14. Lahdes-Vasama, TT, Sipila, IS, Lamminranta, S, Pihko, SH, Merikanton, EO, Marttinen, EJ. (1997). Psychosocial Development and Premorbid Skeletal Growth in Legg-Calve-Perthes Disease: A Study of Nineteen Patients. J Pediatric Ortho. 1997; 6:133-137. 15. Lovell, WW, Winter, RB, Morrissy, RT, Weinstein, SL. Pediatric Orthopedics. 6th ed. Lippincott Williams & Wilkins; 2005. p 1039-1065. 16. Neyt, JG, Weinstein, SL, Spratt, KF, Dolan, L, Morcuende, J, Dietz, FR, Guyton, G, Hart, R, Kraut, MS, Lervick, G, Pardubsky, P, Saterbak, A. (1999). Stulberg Classification System for Evaluation of Legg-Calve-Perthes Disease: Intra-Rater and Inter-Rater Reliability. Journal of Bone and Joint Surgery. 1999; 81:441-447. 17. Sharma, S, Shewale, S, Sibinski, M, Sherlock, DA. (2008). Legg-Calve-Perthes Disease Affecting Children Less than Eight Years of Age: A Paired Outcome Study. International Orthopaedics. 2008; 33:231-235.

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