Epiphyseal disorders Z. Rozkydal Epiphyseal disorders • •Idiopathic avascular •necrosis of epiphysis •of long bones • •Etiology unkown • • Epiphysis Metaphysis Diaphysis Metaphysis Epihysis Obr. 1 Perthes disease It is a complication of the necrosis of proximal epiphysis of the femur 4 -12 years 10 % bilateral More often in boys Symptoms: limping, pain limited ROM (rotation, abduction) Obr. 2 Perthes disease- stages AVN AVN Obr. 4 Obr. 5 AVN Frejka classification 1. st. latency 6 - 12 months 2. st. necrosis 3. st. decalcination 4. st. recovery- fragmentation 5. st. consequences Perthes 1 Ischemic necrosis of epiphysis Loss of vascularity of epiphysis Necrosis of cartilage Microdamage in osseus part- resorption Diminished mechanical strength Damage of the physeal plate- coxa vara, coxa brevis Radiolucent lesions in metaphysis Perthes disease Ischemia of the whole epiphysis Articular cartilage continues to grow Bone is resorbed and replaced by wowen bone The bone is soft and vulnerable Subchondral fracture - showes the extent of damage New bone is gradualy revascularised New bone is plastic- can be deformed AVN subchondr Obr. 6 Subchondral fracture of femoral epiphysis M. Perthes 1. Ischemic stage: avascular necrosis growth arrest of epiphysis revascularisation from periphery ossification 2. Ischemic stage: trauma, subchondral fracture resorption under the fracture replacement by plastic woven bone subluxation, deformity Catterall classification AVN Caterall I. 25 % II. 50 % med.- lateral column III. 75 % IV. 100 % Obr. 7 C:\Users\PC\Pictures\Perthes 1.jpg A Caterall Subchondral fx less than one half Subchondral fx more than one half Necro- caterall 1 necro- caterall2 Catterall I Catterall II Obr. 9 Obr. 8 Necro- caterall3 Necro- caterall 4 Catterall III Catterall IV Obr. 10 Obr. 11 Examination X-ray MRI Scintigraphy Ultrasonography C:\Users\PC\Pictures\perthes 2.jpg C:\Users\PC\Pictures\perthes 3.jpg X-ray MRI C:\Users\PC\Pictures\pertzes 5.jpg MRI Prognosis I. and II. stage good prognosis III. and IV. stage wrong prognosis Risk factors: Older age Loss of containment, subluxation Large extent Limited movements A Perthes 1 Types of deformity in Perthes disesase A perthes 2 Stulberg classification of deformity of the femoral head in Perthes disease Management -containment of the head in the acetabulum -good range of motion - Conservative methods - Atlanta orthesis, no weightbearing - Operative methods Osteotomy of the pelvis (Salter, Steel, Sutherland, Dungl) Osteotomy of the femur Conservative methods Rest in bed Crutches Atlanta orthesis Necro-Atlanta Obr. 16 Atlanta orthesis Perthes 4 Experiment: Ibandronate + BMP Perthes 3 Experiment: Osteoprotegerin Operative methods Salter pelvic osteotomy Varus osteotomy of the femur Necro- Salter op Necro- varisace u Perthesu Obr. 17 Obr. 18 AVN-Salter AVN Salter osteotomy Obr. 19 Obr. 20 A perthes 3 Perthes disease on the right hip after Salter osteotomy Almost normal hip in 18 years of age A perthes 3 Consequences of Perthes disease Coxa plana Shortening of the leg Limited movements Early osteoarthritis Better prognosis Younger age Less extent of danage No subluxation AVN Obr. 21 Tibia vara Blount Disorder of proximal epiphysis of the tibia Early arrest of growth plate on medial side with smaller epiphysis Infantile – up to 3 years Juvenile - up to 10 years Th: orthesis, osteotomy Osteo- Blount1 Obr. 22 Osteo- Blount 1 Necro- Blount 2 Osteo-Blount 3 Osteo- Blount 4-6 Tibia vara Blount Obr. 25 Obr. 24 Slipped upper femoral epiphysis Growth plate of proximal epiphysis of the femur is weak and soft Imbalance of growth hormon and sexual hormons Obese patients Fröhlich syndrom Adiposogenital syndrom 9-15 years Bilateral in one third AVN-CVA 4 Obr. 26 AVN- CVA3 Slipping of epiphysis down and backwards to varus and to retroversion Metaphysis goes proximaly and to external rotation Slipped upper femoral epiphysis Obr. 27 AVN-CVA 4 Symptoms Pain in groin and in the thigh Limping Shortening of the leg Limited abduction and external rotation Positive Trendelenburg sign Obr. 28 Types 1. Preslip (6%) 2. Acute slip (11%) 3. Chronic slip (after two weeks, 60 %) 4. Acute slip on chronic sliping (23%) AVN-CVA 4 Obr. 29 Stages 1. 2. 3. Obr. 30 CVA 10 kopie Stages 1. Slight: slip up to 30% 2. Moderate : slip 30-60 % 3. Severe: slip above 60 % Management Fixation in situ (K wires, Knowles pins) Closed reduction and K wires Open reduction Osteotomy of proximal femur - Southwick, Imhäuser-Weber AVN- CVA1 Fixation in situ Necro- CVA2 Obr. 31 Obr. 32 AVN Open reduction Obr. 33 Southwick osteotomy AVN- CVA southwick2 AVN- CVA Southwick3 Obr. 34 AVN- CVA 5 Pertrochanteric osteotomy Obr. 35 Complication of slipped upper femoral epiphysis Avascular necrosis of the femoral head Chondrolysis of the femoral head Osteoarthritis of the hip AVN - os lunatum Necrosis of os lunatum m. Kienbőck Therapy Rest Immobilisation Removal and replacement by tendon, by os pisiforme or by arteficial material Obr. 36 AVN M. Köhler I. - necrosis of navicular bone Therapy Rest Immobilisation Arthrodesis Obr. 37 AVN- Kohler 2 M. Köhler II. M. Freiberg-Köhler Necrosis of metatarsal head Therapy Rest, padding Surgery: Removal of necrotic part Osteotomy Obr. 38 AVN - hlavice fremuru Avascular necrosis of femoral head in adults Etiology unknown Pain Limited movements Limping Obr. 39 Avascular necrosis of femoral head AVN - nekróza hlavice femuru 2 Obr. 40 Etiology unknown 72 % bilateral Without management- 85 % progress into colaps of the femoral head 5-12 % indications to THA Genetic background Risk factors ON3 Hemoglobinopathy Trombofilia Corticosteroids ON2 ON 1 Diagnosis Bone infarction at the onset is asymptomatic Groin pain, around the hip, limping X-ray MRI ON4 X-ray Subchondral changes MRI Specimen ON5 Subchondral fracture Management Cons: crutches,bisphosphonates physiotherapy, drugs for promotion of vascularity Oper.: Forrage, decompression, drilling, bone grafting Long cylindrical bone graft Osteotomy –varus, valgus, rotation Free vascularized fibular graft - stage II , III. Nonvascularised bone grafts Drilling + stem cells + BMP THA ON9 Vascularised fibular graft 5 y. ON8 Preop. ON8 Trabecular metal Tantal rods 4 y. post op ON7 Vascularised fibular graft 11 y. postop. 10 y postop Asymptomatic. ON6 LED, percutaneous drilling – Steinman pin Olšová 15 Necrosis after fracture of the neck of the femur Gaža 15 Necrosis of the femoral head after coxitis M. Ahlbäck – necrosis of medial condyle of the femur m. Osgood- Schlatter – proximal apophysis of the tibia Osteochondrosis dissecans Necrosis of sesamoid bone M. Panner – osteonecrosis of humeral head Vertebra plana Calvé Necrosis of apophysis of calcaneus http://www.eorthopod.com/images/ContentImages/knee/knee_osteochondritis_dessicans/knee_OCD_symptoms 01.jpg http://ajs.sagepub.com/content/29/5/562/F2.large.jpg