Containment Surgery For Early Legg-Calve-Perthes Disease



Containment Surgery For Early Legg-Calve-Perthes Disease


Benjamin J. Shore



I. Hip Arthrogram Including Botox/Phenol to the Adductor/Obturator Nerve and Petrie Casting


Operative Indications



  • Early stage of Legg-Calve-Perthes (LCP) disease, classified by the Modified Waldenstrom Classification (sclerosis, flattening, and/or early fragmentation), confirmed by sequential plain radiographs and/or contrast enhanced magnetic resonance imaging


  • Radiographic evidence of early stage with concern for subluxation of the femoral head


  • Clinical suggestion of decreasing hip range of motion, abduction, and internal rotation


  • Pain and limp seen on clinical examination


  • Inability to limit physical activity for a child who is in the early stage of LCP



    • Age range can be as young as 2 to 4 years but typically between 4 and 8 years of age


    • Males more commonly affected than females


    • Often an underlying history of overactivity/attention-deficit hyperactivity disorder


    • Goal of surgery is to gather dynamic information regarding the shape of the femoral head and if the femoral head “fits” into the acetabulum and to “contain” or protect the femoral head in the acetabulum


    • Arthrogram rarely done in isolation, commonly performed in addition to soft-tissue or bony containment


    • Phenol/botulinum toxin is preferred as a first line as there is less morbidity than associated with open soft-tissue lengthening




Positioning



  • Supine on radiolucent table


  • Can place a small folded towel under buttock if necessary


  • Pad all other bony prominences


  • Prep out limbs so that you can take the leg through an arc of motion to dynamically inspect the hip


Surgical Approach—Arthrogram



  • Prep and drape limbs out so that groin is sterile and you are able to move the legs


  • A subadductor approach is preferred for arthrography


  • Spinal needle is initially localized with fluoroscopy, with needle resting on skin under the adductor to confirm direction toward the hip joint


  • Typically, the direction is toward the patient’s ipsilateral nipple and an angle of 45° from the horizontal of the bed or floor


  • Needle is advanced until images confirm that joint has been penetrated; if uncertain, a small amount of sterile saline can be injected first into the hip. If intra-articular, the fluid will slowly extravasate out of the needle


  • A mix of Optiray and sterile saline (1:1) is used to perform our arthrogram


  • It is important to put enough Optiray into the joint to perform an adequate arthrogram, which is typically 6 to 10 cc


  • Once the dye is in place, perform examination under anesthesia—pay close attention to range of motion of the hip in flexion, abduction, adduction, internal and external rotation in both flexion and extension


  • Great care is spent looking at the location and relationship between the femoral head and the labrum—the goal is to visualize that with abduction the femoral head can be seen sliding under the lateral labrum and not “hinging” on the lateral labrum and staying outside of the hip joint


  • Simulated position of the femoral head in abduction and internal rotation is done to help visualize what position in Petrie cast or after proximal femur osteotomy would look like


Technique in Steps


Botulinum Toxin/Phenol Injection



  • Patient setup is the same as above


  • We prefer to do injections prior to arthrogram, but they can be done either before or after arthrography


  • If using botulinum toxin, it is injected prior to the phenol into the adductor longus and brevis neuromuscular junctions


  • Using a nerve stimulator, the anterior obturator nerve is identified about 1 cm from the adductor tubercle in the adductor compartment


  • The goal is to identify the anterior obturator nerve with as small an electric current as possible (typically under 1 mA)


  • Anterior branch of the obturator nerve lies between the fascia of adductor brevis and pectineus muscles


  • Typically inject phenol to the branch of the anterior obturator nerve, less than 2 cc and titrated to effect; look for loss of conduction with simultaneous stimulation


Petrie A-Frame Casting

Jun 9, 2022 | Posted by in Reconstructive surgery | Comments Off on Containment Surgery For Early Legg-Calve-Perthes Disease
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