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 AVN •Frejka classification • •1. st. latency 6 - 18 months •2. st. necrosis •3. st. decalcination •4. st. recovery •5. st. consequences • • •Obr. 3 •Perthes disease- stages AVN AVN •Obr. 4 •Obr. 5 •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 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 •Salter classification • •A Catterall I. a II. • less then one half of the epiphysis • short subchondral fracture • lateral column intact • conservative treatment • Necro- caterall 1 necro- caterall2 •Obr. 12 •Obr. 13 •B Caterall III. a IV. • more then one half of the epiphysis • long subchondral fracture • lateral column is absent • operative treatment •Salter classification Necro- caterall3 Necro- caterall 4 •Obr. 14 •Obr. 15 •Examination • •X-ray •Artrography •CT - 3 D reconstruction •MRI •Scintigraphy •Ultrasonography •Prognosis • •I. a II. stage good prognosis •III. a 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 Management -containment of the head in the acetabulum -good range of motion - Conservative methods - Atlanta orthesis - Operative methods Osteotomy of the pelvis (Salter, Steel, Sutherland, Dungl) Shelf plasty Osteotomy of the femur A perthes 2 •Stulberg classification of deformity •of the femoral head in Perthes disease •Conservative methods •Rest in bed •Crutches •Atlanta orthesis • Necro-Atlanta •Obr. 16 •Atlanta orthesis •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 •Hemoglobinopatie •Trombofilie •kortikosteroidy 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 •Vaskul fibul graft • 5 y. ON8 •Preop. ON8 •Trabecular metal Tantal rods • 4 y. post op ON7 •Vascular 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 •Obr. 41 Gaža 15 •Necrosis of the femoral head •after coxitis •Obr. 42 •M. Ahlbäck – necrosis of medial condyle of the femur • •m. Osgood- Schlatter – proximal apophysis • of the tibia • •Necrosis of sesamoid bone • •M. Panner – osteonecrosis of humeral head • •Vertebra plana Calvé • •Necrosis of apophysis of calcaneus • • •Literature •Janíček, P.: Ortopedie. Lékařská fakulta MU v Brně, • 2001. •Spoluautoři: Dufek, P., Chaloupka, R., Krbec, M., • Poul, J.,Procházka, P., Rozkydal, Z. •Figures •Edmonson A.S., Crenshaw, A.H. : Campbell´s •Operative Orthopaedics. Sixth Edition, •The C.V. Mosby Company, 1980. •Obr. 19,20,27,33,34,35. • •Netter, F.: The CIBA collection of medical illustrations •Vol. 8, part. I, II., Ciba- Geigy Corporation, 1990. •Obr. 5,8,9,10,11,12,13,14,15,16,17,18,22,24,25,30,31,32. • •Bartoníček, J., Heřt, J.: Základy klinické anatomie •Pohybového aparátu. Maxdorf, Jesenius, 2004. •Obr. 2 •Figures •Turek, S.: Orthopaedics. J.B. Lippincott Company, •Third Edition, 1977 •Obr. 6,38,40. • •Frejka, B.: Základy ortopedické chirurgie. Avicenum •Praha, 1970 •Obr. 3,21,26,28,29,36,37. • •Janíček, P.: Ortopedie. Masarykova univerzita, 2001. •Obr. 4. • •