Causes of development and symptoms of Perthes' disease DTB 58041
Calve Perthes Leg Leg disease, or osteochondropathy of the head of the hip joint, is considered a serious childhood illness of the musculoskeletal system. This disease is characterized by the presence of necrosis of the head of the hip joint, but there are no signs of joint damage to the infection. The disease always begins in childhood and without proper treatment leads to the development of deforming arthrosis.
Consequences of Legg Calve Perthes' disease DTB 580418 in case of its untimely diagnosis can give information about yourself throughout the life of a person, since this disease leads to disability. The thing is that aseptic necrosis, developing in the region of the head of the hip joint, which occurs in childhood, can lead not only to a violation of the motor ability of the joint, but also cause the development of the limb. As a rule, in children under 6 years, the chances of a full recovery are significantly higher than those in patients whose disease manifested itself much later.
Causes of the disease Legga Calve Pertesa
Osteochondropathy of the femoral head is found exclusively in children aged 3 to 14 years. The boys most often suffer from this disease, but for them, as a rule, the outcome of the disease is more optimistic than for girls. Perthes' disease in girls is always more complex than that of boys, and often leads to severe consequences that appear already in adulthood, especially when planning family and children.
Necrosis of tissues in Perthes' disease develops due to insufficient blood supply to the tissues of the femoral head. Subsequently, necrotic processes can be transferred to other components of the joint, which leads to its dysfunction. Currently, necrosis of the thigh in the case of Perthes' disease is idiopathic, that is, it is still unknown what causes trigger the death of the hip-head tissues and the whole process of joint destruction. Perthes' disease, the cause of which has not yet been determined, is being investigated by many doctors who have built a lot of theories of the origin of this disease. Observations of patients and information from the medical theory of the origin of Perthes' disease made it possible to identify the risk group of children and some factors that are presumably predisposing to the development of necrosis of the head of the femur.
- Traumatism. Most young children are often prone to falls, especially during periods of walking. During a fall in the joint, there may be micro-dislocations or dislocations of the head, which leads to the transmission of blood vessels. Inadequate nutrition of tissues leads to their withering away and the development of Perthes' disease with all the symptoms inherent in it. Such an outcome from injuries can be observed in school-age children who also prefer active types of games and are often fans of cycling, skating and roller skating, which can result in injuries due to a fall.
- Autoimmune reaction. It is believed that in children with not yet formed immunity any infectious disease can lead to disruptions in the work of antibodies, under normal circumstances, protecting the body from pathogenic microbes. In an autoimmune reaction, antibodies are knocked out of the way and begin to attack healthy joint tissues, which they identify as foreign tissue. This theory is especially relevant for children with weakened immunity, often exposed to infectious diseases.
- Hormonal shift. The appearance of signs of Perthes' disease in a transitional age is associated with the adaptation of the organism to a new hormonal status. A sharp change in the amount of hormones in the body can lead to a disruption in metabolic processes in the tissues of the hip bones.
- Metabolic disorders. Violation of calcium-phosphorus metabolism in bone tissue can lead to their thinning. In addition, such a symptomatology can cause a lack of other minerals and vitamins, which are involved in the formation of bone and cartilaginous tissues.
- Hereditary factor. Currently, there are many described cases where members of one family experienced this disease. As a rule, such inheritance occurs either on the male line, then only boys are ill or in the female, when the symptoms of Perthes' disease are observed in girls.
- Previously rickets. Approximately 10% of children who have had rickets subsequently fall ill with Perthes' disease.
Among other things, children at risk are children of small stature, characterized by excessive mobility. In this case, there is a significant overload of the joints, which can cause disruptions in the development of blood vessels. The predisposing factors of the development of Perthes disease include the presence of dysplasia, that is, the inherent underdevelopment of the joint or blood vessels responsible for its supply of nutrients.
The main symptomatic manifestations of Legg Calvet Perthes 'disease
In the early stages of the development of Perthes' disease, most children do not feel any painful symptoms that can cause concern or complaint to their parents. It is believed that the first symptom of Perthes disease is a reduction in motor activity and a feeling of light weight in the pelvic region, which leads to the fact that the normally active child quickly feels fatigue and switches to less mobile kinds of games. As necrosis develops, symptoms appear in the head of the thigh, which are felt not only by the child, but also visible to the parents. We can distinguish a number of symptoms that are characteristic of different stages of the course of Perthes disease in children of different ages.
- Moderate pain. Typically, the child feels pain in the hip, in the groin, in the inside of the thigh or in the knees. These pains are transient and manifest in most cases after prolonged physical activity. Often, the interval between the manifestations of pain symptoms can be quite long and exceed a week, and in some cases, a month.
- Violation of gait. In some children, even if there are no painful sensations, there is an attack on one leg. This is quite noticeable from the outside, but the child himself may not notice that his gait has changed a little, and not to experience any discomfort.
It should be noted that in cases when the disease develops rapidly, the symptoms manifest themselves in a more pronounced form, as there are changes in the anatomy of the joint, which entails a number of manifestations. The most frequent symptoms of a rapid course of the disease include the following manifestations:
- Severe pain in walking or minimal activity.
- Weakness in the muscles of the buttocks.
- Reduced leg mobility.
- Edema in the joint region.
- Severe limp.
- Increases body temperature to 37.5 ° C.
- Coldness of the feet.
- Perspiration of the feet.
- Decreased sensation in the toes.
- Wrinkling of the skin on the legs.
Symptoms with an acute form of Perthes disease are almost not alleviated after a long rest. Such obvious symptoms are a strong cause for concern.
Morphological changes in the structure of the hip joint in Legg Calve Perthes disease
Perthes disease during its development passes through 5 stages, each of which differs by its changes in the structure of the joint. At the first stage of the development of the disease, it is still impossible to identify any changes in the joint state on X-ray photos. Despite the fact that there are no visible deviations on the X-ray photo, the development of the joint and blood vessels is slowing at the first stage. Decreased blood flow leads to the beginning of destruction of the head of the femoral head, but the affected areas are insignificant in area, so do not affect the X-ray photo.
In the 2 stages of development, there is a so-called secondary fracture of the head of the same femur. When carrying out an X-ray study, the deformities are already visible on the photo, and in addition, external symptoms appear in children, in particular, the pelvic gravity and fatigue.
For the third stage of the development of Perthes' disease, thinning and shortening of the neck of the thigh are characteristic, which can lead to its fracture. Deformational processes at this stage are already visible on X-ray photos, there are characteristic external symptoms of the course of the disease, and if at this stage no adequate treatment is prescribed, the outcome can be very unfavorable.
In 4 stages of the development of Perthes disease, the cartilage of the femoral joint is replaced by a connective tissue. This process leads to complete destruction of the joint and extensive necrosis, since connective tissue replaces those cartilage tissues that are destroyed due to aseptic necrosis. This process is adaptive, because in this way the child's organism tries to compensate for the destroyed cartilaginous tissue.
At the 5th stage of the development of Perthes disease, ossification of the connective tissue occurs, which completely disrupts the mobility of the joint. In addition, many patients experience the appearance of minor inflammatory processes in the tissues adjacent to the damaged joint.
The anatomical change in the joint structure observed with the development of Perthes' disease is well treatable only in cases when the disease is diagnosed in stages 1-4.At the 5 stage of the disease, it is extremely difficult to completely get rid of the consequences of the disease, as there is a tissue ossification that is difficult to correct.
Possible consequences of the disease Legg Calve Pertesa
Perthes disease is a serious illness of the musculoskeletal system, which does not always pass without a trace. The favorable outcome of treatment in many respects depends on at what stage of the disease development it was diagnosed and how much the femoral joint was severely damaged at this time. The most common consequences of Perthes' disease include osteoarthritis of the head of the femur bone and permanent permanent deformation of the femoral head.
Osteoarthritis of the femoral head is a complication that is characterized by a change in the parameters of the tibia head and acetabulum. These processes lead to the fact that thinning of the cartilaginous tissue occurs at a young age, although such processes, as a rule, are inherent in the elderly. In the presence of this complication, most young patients require a complete replacement of the damaged hip joint with a prosthesis, otherwise the outcome will be extremely unfavorable.
Residual permanent deformation of the femoral head is observed in children who have undergone Perthes' disease in late childhood, that is, from 7 to 14 years. In this case, an operation to replace the joint and part of the femoral head may be prescribed, otherwise the problem will be only aggravated, which will lead to disruption of the gait and gradual destruction of the joint.
The main forms of treatment of Legg Calve Pertesa's disease
The treatment complex with Perthes' disease is prescribed depending on the extent of the extensive necrosis of tissues and the specific features of the course of the disease. First, a number of tests and studies should be performed, including X-rays and CT scans, as well as anamnesis and physical examination. After diagnosing and determining the stage of the disease, the doctor prescribes complex treatment, which can include physiotherapy, the use of medications, surgical intervention, joint fixation and so on. Each of these treatments, individually or in combination, can solve a particular problem, which is why, in each case, an appropriate treatment is necessary in order for the outcome to be positive.
Drug therapy involves taking NSAID anti-inflammatory drugs that help reduce pain and inflammation. These drugs are needed to improve the mobility of the joint and its recovery. Surgical operation is justified when there is a shortening of the muscles, displacement of the head of the thigh and a strong violation of joint mobility. The use of crutches can reduce the burden on the hip joint, relieve pain and reduce the risk of complications. The application of tires or gypsum is used to fix the hip joint. In this case, the legs are fixed in the diluted state with the help of the restraints, which contributes to the immobilization of the joint and accelerates the recovery.
Perthes disease in children
Perthes disease, or Legg-Calvet-Perthes disease - is a disease in which blood supply to the bone tissue in the region of the femoral head is violated, followed by its necrosis( necrosis).This pathology is one of the most common diseases of the hip joint in children from three to fourteen years old. Boys are more often ill, but in girls the osteochondropathy of Legga-Perthes has a heavy course.
The disease has several stages and in the beginning it is practically asymptomatic, which greatly complicates its diagnosis. In 5% of cases, Perthes' disease is bilateral. If treatment is not started on time, the consequences can be very severe. Secondary coxarthrosis, deformity of the limb, its shortening, ankylosis, various abnormalities of the gait may develop, which often becomes the cause of disability even in childhood or in adults.
Juvenile osteochondropathy of the femoral head can cause disability
The diagnosis of Calve-Perthes disease is established based on the patient's age, typical complaints and symptoms, and X-ray diagnosis data. Treatment is long, conservative. In especially severe cases or in the presence of complications resort to reconstructive and restorative operations on the hip joint.
According to the International Classification of Diseases 10 revision( ICD 10), juvenile osteochondropathy of the femoral head is under the M91.1 code.
Causes and mechanism of development of
At the moment there is no single theory of the development of Perthes' disease. It is believed that this ailment has a polyethological origin, that is, it is associated with a congenital predisposition of the organism and the impact of negative environmental factors.
According to the most common hypothesis of the origin of pathology, it is caused by a defect in prenatal development, such as myelodysplasia of mild degree. This is the underdevelopment of the lumbar segments of the spinal cord, which in most cases is not manifested throughout life, but is associated with a variety of orthopedic ailments, including the youthful osteochondropathy of the femoral head.
With Perthes' disease, the blood vessels of the femoral head are underdeveloped.
What is the connection between the spinal cord and the hip joint? The fact is that this part of the nervous system controls the growth and development of the blood vessels that feed the head of the femur. Under normal conditions( in people without myelodysplasia), these vessels are 10-12, they have a relatively large caliber and manage their task well, providing the bone with all the necessary substances.
In children with myelodysplasia of such arteries, only 2-4, their caliber is shallow. Therefore, the head of the thigh is constantly in a state of deficiency of nutrients and oxygen.
Important! In order to develop Perthes disease in children, one myelodysplasia and hypoplasia of the hip joints is not enough. To do this, the blood flow in the joint should completely stop, which is facilitated by certain environmental factors.
Factors that contribute to the development of Perthes' disease:
- mechanical trauma of the hip area, even insignificant( jump, light bruise, somersault, fall, clumsy and abrupt movement, etc.);
- inflammatory lesions of the hip joint( viral, bacterial, allergic nature);
- hormonal imbalance in the child's body, for example, during the period of hormonal adjustment in the transition years;
- is a violation of the mineral metabolism in the body.
Most often, parents associate the appearance of symptoms of hip injury with a previous acute respiratory infection. Some children manage to trace and hereditary predisposition to ailment.
Even a regular jump can trigger Perthes' disease in susceptible children
Stages and symptoms of
Five consecutive stages are recognized throughout the course of the disease.
The stage of osteonecrosis
It is at this point that the blood supply to the head of the femur is stopped and its focal necrosis develops. The affected area rarely reaches 10% of the entire bone mass of the femoral head. This stage is asymptomatic. Very rarely there can be a minimum disruption of the child's gait by the type of foot dragging, hitting on one limb. Also, sometimes, low-intensity pain develops in the hip area.
Stage of impression fracture of the femur head
Under the influence of usual loads, a part of the bone tissue is gradually destroyed - a depressed fracture develops and deformation of the femoral head is formed. The area of structural changes reaches 10-30%.At this stage, pain and discomfort develops in the hip and knee area during movements, the baby begins to limp.
In the picture, the
femoral head impression is noticeable.
fragmentation stage. During this period, part of the broken bone begins to fragment and disintegrate. The amount of damage increases to 30-50%.The pain is pronounced, does not pass and at rest. The restriction of movements in the hip, swelling of soft tissues develops. Gait changes, limping becomes distinct, sometimes the supporting function of the limb is broken. Some children have fever and other symptoms of intoxication.
reparation stage Gradually, the processes of healing and recovery begin to predominate over the processes of destruction. Between the separate fragments of bone tissue connective tissue develops, blood vessels grow, a new cat tissue is formed. The structure of the newly formed bone is close to normal, but, unfortunately, its mechanical strength is much lower.
Also at this stage, the growth of the femoral head resumes. Sometimes, in the absence of adequate treatment of Perthes disease, head growth causes further deformities, as it often does not acquire a normal spherical shape, but, for example, a mushroom shape. Such changes lead to subluxation and secondary coxarthrosis.
Stage of outcome of
At this stage, the effects of Perthes' disease develop, if they occur. Perhaps complete recovery without any residual effects.
An important point is the integrity of the cartilaginous growth zone. In children, it provides the growth of the femur in length. In the case of extensive necrosis, this zone can be completely or partially destroyed. As a result, the formation of the upper end of the femur is impaired, the true shortening of the leg, the violation of gait and the supporting function of the limb develop.
Perthes disease may be the cause of shortening of the limb, which subsequently requires a complex surgical correction of
. In the case of the formation of deformation of the femoral head at the 4 th stage, a clinical picture of progressive deforming arthrosis of the hip joint develops.
The main diagnostic method, which allows to confirm or deny the diagnosis, is the radiography of the hip joints. Apply two projections:
- projection of Lauenstein.
This is the required minimum of studies that are needed for diagnosis. It allows you to recognize the disease with high probability even in the first stage. In case of doubt, the specialist may additionally be assigned to the child a joint ultrasound and magnetic resonance imaging.
Differential diagnosis in children is necessary with such diseases as neurodysplastic coke and infectious-allergic arthritis of the hip joint.
Radiography of the hip joints - the main diagnostic method for osteochondropathy of the femoral head
Treatment of Perthes 'disease
Treatment of Perthes' disease in children is mostly conservative and prolonged. The minimum period is one year. On average, the therapy takes 2.5 years, and in some cases increases to four. The operation is prescribed only in the presence of severe complications to children after 6 years.
Conservative treatment, as a rule, begins in specialized orthopedic centers with the subsequent supervision at the children's orthopedist in an out-patient department on a residence.You can also read: Pediatric dysplasia of the hip
- complete unloading of the hip joint for the required time;
- application of traction, plaster casts, special orthopedic structures and beds to prevent deformation of the femoral head;
- improvement of blood flow in the hip joint area with the help of medications and non-drug ways;
- stimulation of restoration of normal structure of bone tissue;
- formation and strengthening of the muscular corset of the thigh with the help of therapeutic gymnastics and exercise therapy.
In establishing the diagnosis, support for the leg is partially or completely eliminated. To do this, the child is prescribed a strict bed rest, and the older children are given a semi-bed with walking on crutches during wakefulness. The main treatment is physiotherapy, massage, special medical exercises.
With Perthes' disease, the child is given a long-term immobilization with special spacer strips
If there is a need for skeletal traction or immobilization with gypsum bandages, struts, tires, then an electromyostimulation is used to maintain the tone of the skeletal muscles.
Medical treatment includes the appointment of angioprotectors, chondroprotectors, microelements, vitamins. The motor mode is expanded at the 4th stage of the disease. All exercises are selected only by a specialist and monitor their implementation.
Reconstructive reconstructive surgery is used only from the age of 6 in patients with an extensive osteonecrosis zone, development of severe deformation of the femoral head, dislocation.
Most often, such interventions as rotational acetabular transposition according to Salter, correcting medializing osteotomy of the femur. After surgical treatment it is necessary to undergo a long rehabilitation period.
Adult people who have suffered Perthes disease, it is necessary throughout life to limit the load on the hip, because they have an increased risk of deforming arthrosis. It is also desirable to regularly undergo therapeutic and preventive courses of therapy and sanatorium treatment.
Diseases of the hip joint, which are manifested by the clinic of arthritis, occur quite often. For diseases that are attributed to this group are characterized by almost identical symptoms. The first is usually pain, which is amplified by movement, that is, when there is an axial load on the lower limbs. The nature of the pain may be different, but most often there is aching and periodically stitching pain;occurs in the upper third of the thigh, sometimes transmitted to the groin. Local increase in temperature, like redness, is almost impossible to detect due to a significant layer of subcutaneous tissue on the hips. Dysfunction develops with pain and consists in limiting the movements( both flexion and extension, and rotation along the axis).
Diseases of the hip joint with the arthritis clinic
A feature of rheumatoid arthritis is the increased pain in the joints in the morning. With this pathology, arthritis often passes into a chronic stage with the development of deformation and a significant restriction of functions.
As for rheumatoid arthritis, this pathology is characterized by multiple lesions, that is, always in parallel with the hip joints, small joints of the hands, shoulders, feet are affected.
Infectious-allergic inflammatory process affects the hip joints quite rarely and is a consequence of immune disorders caused by a microorganism that provoked inflammation in the body( most often with various angina, staphylococcal infection).The signs of pathology are poorly expressed and therefore the patient does not always notice the limited movements in the joints.
Specific infectious arthritis occurs most often against the background of syphilis, tuberculosis, brucellosis, gonorrhea, viral and fungal infections. Symptoms are similar for classical arthritis, however it is effective in case of removal of the pathogen from the body. Tuberculosis arthritis most often from this group has the ability to change into a chronic form. Symptoms of the disease are more common in men.
Symptomatic of arthrosis
Arthrosis is a process of gradual destruction and dystrophy. The cartilage is destroyed and dissolves, contributes to the appearance of friction between the bones. There is a change in shape, gradually limited mobility, and with progression - no movement.
Diseases of the hip joint with arthrosis clinic
The symptoms of arthrosis of the hip joint( coxarthrosis) are relatively specific. This pathology is first manifested by stiffness in the joint, which is especially amplified in the morning. Characteristic are also starting pains - when a person, for example, gets up from the couch after a long sitting, he has a pain that passes after a while walking. If there is no timely and effective treatment there is a significant restriction of movement, pain increases. Disease of the hip joint sharply limits the performance. At the last stages, the joint is completely immobilized.
Osteochondropathy of the head of the femur has another name - Perthes disease. The very term chondropathy means a dystrophic process in the joint and bone, which occurs for no apparent reason. This hip joint disease occurs in children aged 4 to 14 years. Signs of pathology depend on its stage. At the initial manifestations, the child marks the pain and there is lameness after a long walk, the movements in the hips are limited. After a while, lameness becomes permanent and contracture appears( fixation of the hip in the flexion position).With proper treatment of this pathology, the articulation function can fully recover after 5-7 years.
Special forms of
Special forms of pathologies include pathologies not associated with infection and trauma.
Congenital diseases arise from exposure to pathogenic factors during pregnancy or childbirth.
Hip dysplasia is congenital or develops by the end of the first year of life of the baby. Symptoms in most cases can be detected only by a doctor. The main symptoms are the presence of additional folds and their asymmetric positioning on the inner surface of the hips and limiting the removal of the baby's hips.
Congenital dislocation of the hip
If dysplasia is treated ineffectively, a dislocation of the femur can occur. Disease of the hip joint has more vivid symptoms, which manifests itself in the expressed asymmetry of the skin folds on the buttocks, the relative shortening of the affected limb and the presence of a specific click symptom which the doctor checks. The symptom is caused by the following: the legs of the child are bent in the hip and knee joints, after which they are diluted. If the doctor feels a click, the symptom is considered positive.
Tumors of the hip joints are rare, mostly in children. The signs are not specific for this group of pathologies, therefore, additional methods of examination play an important role here. For this group, there are 2 types of symptoms: symptomatology of the joints and the manifestation of the tumor process in the body. Typically, the pain is predominantly aching in nature and restriction of movement as in arthrosis, deformation. The manifestations of the tumor process in the body include: weight loss, general weakness, anemia and others.
The last group of pathologies treats hip joint damage as a consequence of various diseases.
In allergic pathologies, hip joints are rarely affected and in most cases, after the relief of the underlying disease, the inflammatory process in the joints is also eliminated.
Collagenosis( systemic lupus erythematosus, scleroderma, Bekhterev's disease, etc.) affects the connective tissue structure of all joints, so the manifestations are almost the same as with arthrosis.
With obesity, there is an increased strain on the joints, which gradually causes symptoms of arthrosis of the largest joints of the lower extremities.
In the case of leukemia, pain in the hip joints first has a volatile character, and in the future - permanent. Often the disease causes the development of joint contractures.
Diseases of the nervous system
In pathology of the nervous system, trophic tissue suffers, metabolic processes slow down and arthrosis gradually develops, due to the exclusion of muscle work - contracture.
Crohn's disease provokes defeat of the lower limbs. After a long time after the onset of the disease, there are persistent aching pains and deformities of the hip joints.
Paraneoplastic syndromes are a group of diseases that develop as a consequence of the growth of a cancerous tumor in the body. When the hip arthritis is affected, patients note aching pain both in the joints and in the muscles of the thigh. Sometimes there is deformation due to periarticular edema, which is often noted in men.
In general, for the diseases of this group, the signs may be similar for both arthritis and arthrosis, but there is always a link between the exacerbation of the underlying disease and the pathology of the hip joints.
Author of article: Site expert Hurts Sustav.ru
Thank you. Very informative article. At me the actor, I rescue from it or him an exercise stress( pool and driving on a bicycle), I observe a regimen of day and a delivery. Well, I smear ointment when an exacerbation happens. But it was already possible to achieve a long remission. Olivia, what kind of ointment? And then my mother also has arthritis, does not know what to try. The doctor generally wrote a list of ointments, said - choose.
This ointment is for external use, which includes the poison of the adder( Viprosal B).I like it because it not only anaesthetizes, it also treats the joints, which prevents the disease from developing.
Legg-Calve-Perthes disease( osteochondropathy of the head of the thigh bone) on Medside.ru
Perthes disease ( completely this disease is called by Legg-Calvet-Perthes disease ) is a relatively common hip joint pathologychildhood. Aseptic necrosis of the femoral head , which is observed in this disease, mainly occurs in patients whose age is from 3 to 15 years old .However, in adults this disease also occurs. In the process of its progression the supply of blood to the cartilaginous tissue of the joint is disrupted. The manifestation of necrosis is aseptic in nature and has nothing to do with the effects of infections on the human body. Disturbance of blood supply is temporary. However, under its influence, the tissues of the femoral head gradually die off. As a result, irritation and inflammation are observed. With Perthes disease , one joint is most often affected, but in some cases, bilateral lesions of the joints are possible.
Approximately five times more often, Legg-Calve-Perthes disease is diagnosed in boys. At the same time, this ailment for girls has a more severe course. The first time the description of this disease appeared about a hundred years ago. Then it was defined as the specific form of the arthritis of the hip joint in children.
Peters's disease develops in the child if he has some congenital and acquired factors. The background on which necrosis of the femoral head is manifested, often is the underdevelopment of the lumbar spinal cord( of myelodysplasia ).This part of the spinal cord provides innervation of the hip joints. Such pathology can be congenital due to hereditary conditioning. It is observed in many children, it is determined by several of its degrees of severity.
An easy degree of myelodysplasia can remain undiagnosed during the course of a person's life. But more severe disorders in the development of the spinal cord subsequently cause orthopedic diseases, including Perthes disease.
In myelodysplasia, the structure of the hip joints differs somewhat from the normal version. This pathology is expressed in children in a smaller number and caliber of nerves and vessels, which causes a decrease in blood flow in the tissues of the joint. The consequence of this phenomenon is insufficient supply of nutrients, as well as a decrease in the tone of the vascular wall.
But Perthes' disease in a child begins to develop only when the supply of blood to the head of the hip is completely stopped. This can occur due to a number of factors. This is a trauma that leads to clotting of the vessels, an inflammatory process in the hip joint that develops under the influence of infection. In the joint, the infection gets sometimes even with colds or other infectious ailments.
As a result, the blood supply is completely blocked, and foci of necrosis form in the head of the thigh.
Aseptic necrosis of the femoral head in children develops in stages. The is allocated five stages of the disease .At the first stage aseptic necrosis develops, on the second stage there is a secondary compression fracture. The third stage of Perthes disease is the process of fragmentation and resorption of the areas of dead spongy takna. At the fourth stage, recovery occurs, and on the fifth, secondary changes are observed.
Therefore, the symptoms depend on the stage of the disease, the level of spread of the necrosis and its degree. At the first stage of Perthes' disease, noticeable symptoms of the disease may not be noted at all, or they are insignificant. The child can talk about periodically manifested moderate pain in the hip or knee joint. Sometimes the children notice a change in their gait: they begin to drag the leg a little.
If the disease develops further, the thigh head gradually deforms, which, in turn, leads to biomechanical changes in the joint. As a consequence, the child begins to limp, suffers from pain in the joint or in the leg. And pain, and lameness manifested from time to time, sometimes a period when the patient does not bother, can last for weeks and months. Often the pain develops as a result of muscle spasm arising from irritation in the joint area. The pain becomes more intense while moving, sometimes it moves to the groin area, buttocks. After the child rests in a state of rest, the pain becomes less pronounced.
If aseptic necrosis of the femoral head is not treated, subsequently undergoes impression fractures in the necrosis zone. Then the affected limb in the child becomes shorter, which is noticeable even during visual inspection. The child gets tired during the walk, he has a pronounced lameness.
At the same time, in the first stage, the osteochondropathy of the femoral head is reversible, and given a relatively small focus of necrosis and rapid restoration of normal circulation, the disease is cured without going into the stage of deformation of the femoral head. Therefore, with the slightest suspicion of a similar pathology, you should undergo a thorough examination.
To determine the development of Perthes' disease already in the initial stage allows carrying out an X-ray study. If necessary, the specialist also prescribes magnetic resonance imaging and ultrasound of the hip joints. Such methods provide additional information.
In some cases, laboratory research is assigned to differentiate with other diseases. During the treatment, x-ray examinations are performed several times to track the dynamics of improvement.
Perthes' disease, diagnosed during the diagnosis, requires specific treatment. Treatment in children involves periods of immobilization of or restriction of motor activity. After the child is diagnosed with the disease, he immediately needs to adhere to bed rest, so as not to allow loads on the affected joint. Consequently, the patient can walk only with crutches. To provide the center , different orthopedic devices are used. Also, there are massage sessions, physiotherapy treatment. As a rule, the Pertes disease in children is cured, and after about 2 years the child can lead a completely normal life without any reason to make any motor restraints.
A more intensive treatment process for girls is being practiced, but the boys have a worse prognosis and the consequences of the disease.
If the children in the age group from 2 to 6 years of age test results indicate mild signs of the disease, the treatment of Perthes' disease consists exclusively in observation. If symptoms of the disease are observed in children at an older age, certain therapy is performed depending on the individual characteristics of the course of the disease.
Perthes' disease in adults is treated taking into account all individual characteristics of - age, concomitant diseases, severity. However, in adults this disease leads to irreversible changes, the consequence of which can sometimes be even disability. In adults, surgical treatment is most often practiced. At the first stages of the disease tunneling of the femoral head is carried out, and in severe cases it is possible to perform endoprosthetics .
Doctors try to treat Perthes' disease in children with non-surgical methods. In order to reduce the inflammatory process in the hip joint, a course of treatment with nonsteroidal anti-inflammatory drugs is prescribed. Sometimes such a medicine a child can take for even a few months. At the same time the doctor periodically conducts a study, tracking how much tissue is being regenerated. In the process of recovery, the child is shown performing simple exercises from a special complex of physical therapy.
Sometimes a doctor decides to use a cast bandage to hold the femur head in the acetabulum. The so-called Petri dressing is used. This is a two-sided gypsum bandage, which is superimposed on both legs. In the middle of the dressing there is a wooden crossbeam, which makes it possible to keep your legs in a dilute position. This bandage is first applied to a patient in the operating room.
Surgical treatment allows you to restore the normal position of the bones in the hip joint. For this, the surgeon carries out the necessary manipulations. After surgery, the patient is given a bandage made of plaster, which should be worn for about two months. After removal of the plaster bandage, a complex of exercise therapy is prescribed with a minimum load on the hip joint.
Prevention measures aimed at avoiding the prevention of Perthes' disease in children and adults do not exist. But it is very important to diagnose this disease as early as possible and provide the proper treatment. In this case, the therapy will be most effective.Section: Orthopedics and Traumatology Author: Marina Stepaniuc - pharmacist, medical journalist Specialization: Pharmaceuticals more
Education: Graduated from the Rivne State Basic Medical College with a degree in Pharmacy. Graduated from Vinnytsia State Medical University. MI Pirogov and internship on its base.
Work experience: From 2003 to 2013 - worked as a pharmacist and head of a pharmacy kiosk. She was awarded with diplomas and marks of distinction for her long and diligent work. Articles on medical topics were published in local publications( newspapers) and on various Internet portals.
Perthes disease or osteochondropathy of the head of the femur |All articles by
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Perthes disease( full name of Legga-Calvet-Perthes Synonyms: osteopochondropathy of femoral head, aseptic necrosis of femoral head, subchondral necrosis of femoral head ossification) - disease of femur and hip jointwith a violation of the blood supply to the head of the femur and the violation of the nutrition of its articular cartilage with subsequent necrosis, belongs to the group of diseases united under the name of osteochondropathy.
The disease received this name in the name of three researchers Legg, Calvet, and Pertes, who in 1910 independently described this disease in children.
Perthes disease is one of the most common hip diseases in dogs of small breeds weighing less than 12 kg( that terrier, Yorkshire Terrier, Pomeranian Pomeranian, Manchester Terrier, dwarf pincher, poodle, west highland white terrier, core terrier, etc.)..
Fig.1. Anatomical structure of the hip joint.1. Epiphysis of the femoral head.2. Thigh neck.3. The acetabulum.4. Large spit.5. Small spit.6. Joint capsule.
The age at which the disease manifests varies from 4 to 13 months and is the most common pathology of the hip joint at a young age. The peak incidence falls at the age of 7 months.
Dogs do not have a sexual predisposition to this disease. The most commonly affected one joint and only 10-15% of cases, both joints. The term "aseptic necrosis" in this case means the necrosis of the bone tissue of the epiphysis( i.e., the upper hemisphere) of the femoral head of a noninfectious nature.
Etiology and pathogenesis
The views of different researchers on the etiology and pathogenesis( ie the origin and development) of Perthes' disease are still at variance.
Legg suggested that the vascular problem was associated with trauma, but Trueta described the disease as "epiphyseal anemia".He stressed the unstable blood supply of the epiphysis of the femoral head in children and the strengthening of this blood supply with the child's growing up. Ljunggren( 1967) proposed the endocrine theory of the development of necrosis of the head of the femur. During the study, it was found that with a high dosage of steroids( estrogens and / or testosterone), osteonecrosis occurs. Her hypothesis was based on the idea that the morphological patterns of the Legg-Calvet-Perthes disease in dogs are a manifestation of premature puberty.
Fig.2. Blood supply to the head and neck of the thigh( G.H. Thompson, R. B. Salter. "Legg-Calve-Perthes Disease", 1986): 1. External and internal arteries enveloping the femur. Ascending branches of the envelopes of the arteries, entering the neck and head of the thigh. Cartilaginous growth zone of the femoral head.
Although the experimental data in this study support this idea, there is no reason to explain the unilateral nature of the disease or the low frequency in the breed population characterized by premature puberty.
Extremely simplistic development of the disease can be represented as follows: instead of 10-12 relatively large arteries and veins entering and leaving the head of the thigh, the dog has 2-4 small( congenitally underdeveloped) arteries and veins, so the blood flow in the tissues of the joint is chronically lowered,and they experience a shortage of food.
Meanwhile, Perthes' disease develops only when the blood supply to the femoral head is completely stopped, which occurs under the influence of so-called producing factors. The productive factors of Perthes disease are most often an inflammation of the hip joint or a minor trauma that leads to compression( compression) from outside of the described small and underdeveloped vessels. A minor injury, such as a jump from a chair, or just an awkward movement, can go unnoticed by both the masters and the animal itself. As a result, there is a complete blockage of the blood flow( or infarction) of the femoral head, leading to its partial or complete necrosis, that is, the formation of a necrosis foci( Fig. 3).
Fig.3. Roentgenogram of the hip joint of a dog with Perthes disease.
Clinical manifestations of the disease at this stage are very scarce or nonexistent. Most often, animals limp from time to time, can lick the area of the joint. The hosts may notice some irregularities in the gait in the form of "hitting" on one paw or "dragging" the paw. Strong pains are noted much less often, rough lameness, as a rule, does not happen, therefore, going to the doctor in the first stage of the disease( osteonecrosis stage) is quite a rarity.
Fig.4. Deformation of the femoral head to the left.
In the future, the dead bone tissue of the upper hemisphere of the femoral head loses its normal mechanical strength, so that under the influence of the usual daily load( walking, jumping, etc.) or even in the absence of that, the deformation of the femoral head gradually develops, which is the main and most complexproblem( Fig. 4).
At the time of full development of Perthes disease, deformation of the femoral head may have a different degree of severity - from insignificant and barely noticeable on the roentgenogram and to the gross "mushroom" or "saddle".
Degree of deformation of the femoral head is determined by the size and location( location) of the focus of necrosis in the pituitary and directly determines the outcome of the disease - favorable or unfavorable. An unfavorable outcome of the disease is the appearance of clinical signs, the so-called deforming coxarthrosis( steadily progressing degenerative joint changes), in the form of severe pain syndrome and gait disturbance( Fig. 5).
Fig.5. Perthes disease of both hip joints. Deforming coxarthrosis
A favorable outcome is the situation where the joint functions for many years, without letting itself know.
During the course of the disease, the structure of the femoral head undergoes significant changes. After flattening in the second stage, it undergoes fragmentation( the third stage), that is, the existing focus of necrosis "breaks up" into several separate parts as a result of the ingrowth of connective tissue containing vessels and nerves into it.
Gradually, the processes of repair( healing) begin to predominate over the processes of destruction, which consist in the formation of bone tissue in the focus of necrosis - the stage of recovery comes to replace the stage of fragmentation. The newly formed bone tissue as a result of ongoing restructuring over time acquires a beam structure and architectonics, approaching the normal( the stage of the outcome), but the mechanical strength of the bone remains reduced. In addition to neoplasm of bone tissue in the focus of necrosis, the recovery stage is characterized by the resumption of growth of the femoral head. With a large volume of the focus of necrosis and the lack of adequate treatment, the growth of the femoral head is the cause of the progression of the deformity. The head of the thigh, being before the beginning of the disease spherical( convex), becomes flat or concave;its antero-outer quadrant can stand out significantly from the articular cavity, so there is rarely a subluxation in the hip joint( Figure 6).There is a discrepancy between the shape of articular surfaces of the acetabulum and the femoral head, which plays a decisive role in the fate of the affected joint.
Fig.6. Yorkshire Terrier with Perthes disease. The affected joint is on the right. Fragmentation of the femoral head and subluxation of the hip joint
The head of the hip puppy contains a cartilaginous growth zone - this is the part of the femur, due to which the latter grows in length( Fig. 2).With extensive foci of necrosis in the epiphysis, the growth zone is involved in the pathological process, completely or partially destroyed. As a result, deformation of the entire upper end of the femur is formed, characterized by a shortening of the femoral neck and a high standing of the large trochanter, and a shortening of the hindlimb, which are also causes of abnormal gait.
Fig.7. Radiograph of the hip joints. This is a necessary minimum of the examination, which allows to confirm or exclude the presence of Perthes' disease with high accuracy even in the first stage of
. Appearance of lameness, hip pain, hip joint, and gait disturbance are grounds for contacting an orthopedic doctor who, after finding out an anamnesisappearance and development) of the disease and clinical examination of the animal assigns a radiograph of the hip joints in a direct projection( Figure 7).
There are some pathological conditions reminiscent of the onset of Perthes' disease in its clinical manifestations( dislocation of the knee cup, hip dislocation, infectious arthritis, hip dislocations, head and hip fractures, etc.).
Conservative and surgical treatment of
The only criterion on the basis of which the method of treatment is chosen is the radiographic examination of the affected limb. Clinical signs are considered in the second turn.
If the head of the thigh is round, the joint parallel space of the head of the femur and acetabulum is congruent, then conservative treatment can be offered.
Conservative treatment consists in placing the animal in a small space( cage).As a rule, this leads to the resolution of radiographic and clinical problems. During forced rest, the animal is released from the cage only to maintain its training to the toilet. Mandatory monthly radiographs in order to detect the progression of the disease. Immobilization of animals continues until there is complete resolution of clinical and radiologic problems. If the destruction of the head of the femur occurs during the maintenance of the animal in the cell, it is necessary to resort to surgical treatment.
Strict adherence to this form of treatment gives almost normal radiographic shape of the head of the femur and complete return of the function of painless movement and normal gait in the dog. This process takes 4 to 6 months. Any compromise of complete immobilization will lead to the destruction of the head of the femur.
Animals with pain and disintegration of the femoral head with an uneven joint space between the head and the articular cavity are candidates for surgical treatment.
Surgical treatment is of two types:
- Resection arthroplasty of the hip joint( surgical removal of the head and neck of the thigh bone)
- Total hip arthroplasty.
The second type of treatment is the most preferable, as it allows not only to save the animal from pain, but also to return the functions of the limb in full.
Fig.8. Implant of the hip joint for small dogs. Fig.9. X-ray of the dog immediately after resection of the head and neck of the thigh.
Resection of the head and neck of the hip is the most common method of treating patients with Perthes disease.(Fig. 9).
This procedure can be performed by an animal at any age. Although the biomechanics of the limb is not completely restored, the results of treatment in most cases suit the owners. There are several techniques for performing a resection of the head and neck of the hip. None of them have special advantages in comparison with others. After the operation, the physiotherapy and exercises will help to return the intelligent functions to the animal, the rehabilitation period can last from 2 weeks to one year. The earlier the operation is performed, provided that there is a mild muscle atrophy and a short period of application of non-steroidal anti-inflammatory drugs, the shorter it will be possible to restore the function of the animal's limb. The main task of the operation is to relieve the pain, but the small size of these patients usually provides a positive prognosis for the restoration of an adequate function of the limb.
In practice, unfortunately, animal owners rarely seek help at the initial stage of their pets' illness, when conservative treatment could be recommended. It should be noted that patients who managed to be cured by a conservative way( cell) are subsequently worse socialized, they have violations in their behavior.
- Calve J: Sur une forme particuliere de pseudocoxalgie greffee sur des deformations characteristiques de l'extremite superieure du femur. Rev Surg 42:54, 1910.
- Legg A: An obscure affection of the hip joint. Boston Med Surg J 162: 202, 1910.
- Perthes G: Uber arthritis deformans juvenilis. Dtsch Z Chir 101: 779, 1910.
- Ljunggren G: A comparative study of conservative and surgical treatment of L-P disease in the dog. Anim Hosp 2: 6, 1966.
- Ljunggren G: Legg-Perthes disease in the dog. Acta Orthop Scand( Suppl) 95: 1967.