Slide 015 — Perthes disease

Clean FRCS notes with inline figures

Perthes disease

•Xray pelvis of skeletally immature patient with left hip pathology

•Left femoral proximal epiphysis appeared flattened and irregular, fragmented with lateral extrusion, cystic changes over metaphyseal area. The medial joint space is also widened. There is also lucency over lateral epiphysis, consistent with Gage sign.

•Contralateral hip not involved (10% bilateral, never same time)

•Working diagnosis would be Perthes disease. According to Waldenstrom classification, it looks to me the patient is in the fragmentation phase

*Waldenstrom classification

•Initial

•Fragmentation

•Reossification

•Remodeling

•Ddx are 1. septic arthritis, 2 Meyer’s disease 3. MED

•(bilateral Ddx: hypothyroid, lipid storage disease, meyers dysplasia, MED, sickle cell)

•Hx and PE would focus on

•Age, gender, body built

•Onset of symptoms

•Clinical at risk signs (FOOBS)

•R/O Ddx

•ROM (reduced abduction and IR, Trendelenburg gait, Catterall sign: hip flexion with obligatory external rotation)

Further investigations

**Fig 1.** Radiograph / imaging - Perthes radiographtop left

•WBC (infection), lipid (storage disorder), ESR, CRP, bone profile (tumour), TSH (hypothyroid), peripheral smear (sickle cell)

XR: Frog leg lateral

•+/- USG, aspiration if suspecting infection

Aim of treatment

•Pain control (rest analgesics)

•Maintain ROM (physio, temporary NWB)

•Contain hip during critical period of “biologic plasticity”, during creeping substitution, so the femoral head remodels with less incongruity (limits deformity and loss of sphericity) *abduction and IR*

Natural history:

•Classic Iowa study with a 50yr FU that 40% need arthroplasty if left untreated. Counsel patient regarding containment. Still has a possibility of future OA

•Nonsurgical containment: in abduction and IR

Indication for surgical containment

For this case:

Lateral pillar classification Class B or B/C

•>8yo treat surgically for containment→ improve outcome according to Herring’s study

•Proximal femoral varus osteotomy

•Prerequisites include

•- Timing – fragmentation phase

•- Containable

•→ Sx – good range

•→ XR – spherical and congruent reduction, containable upon abduction XR / intraop arthrogram

Operative steps

•Good preop plan to estimate the amount of varus needed to obtain good containment

•GA

•Adductor release may be indicated if tight

Lateral subvastus approach

•Periosteum elevated

•Choose appropriate size of paediatric proximal locking plate (3.5mm if <35kg, 5mm if >35kg)

•Set guiding jig based on plate angle and desired amount of varus (jig angle (current neck shaft angle) = plate angle (smaller)+ desired amount of varus produced)

•Fix plate proximally then remove it

•Mark rotation before osteotomy

•Use 2 k wires, one above and one below the osteotomy for rotational correction

•Perform femoral osteotomy using an oscillating saw

•Fix plate proximally then distally

•Add some internal rotation or extension for better containment

•Postop

•NWB walking

•HKAFO

•FU till maturity

Outcome depends on Stulberg classification:

•I normal

•II spherical congruent

•III non spherical (mushroom), congruent

•IV non spherical (concave articular surface) congruent

•V non spherical (flat), incongruent

•Other problems: LLD, trendelenburg, pain (labral tear, loose body, hinged abduction, FAI)

the etiology:

•1. Anatomical

•2. Hydrostatic pressure

•3. Thrombophilic

What is the blood supply to the femoral head in 4-9yo patients?

•<4yo: equal contribution by MFCA and LFCA

•4-10yo: LFCA regress and supply metaphysis only

•10-14yo: ligamentum teres contribution further decrease

•>14yo: anastomosis between the three systems (epiphyseal, metaphyseal, ligamentum teres)

•*What are the at risk sign (FOOBS)

•Clinical and radiological

•Clinical

•Female

•Old

•Obese

•Bilateral

•Stiffness

Radiological (Caterall at risk signs)

•Gage sign (inverted v shape radiolucency lateral to epiphysis)

•Horizontal physis

•Lateral subluxation of femoral head

•Calcification lateral to epiphysis

•Metaphyseal cyst (later added)

Lateral Pillar Classification (based on AP Xray, compare both sides, by Herring, guide management and prognosis)

•Lateral pillar: 25%, lateral to lucent line

•Central pillar: 50%

•Medial pillar: 20-35%

•A = normal height

•B = >50%

•B/C = exactly 50% + depressed relative to central pillar, very narrow lateral pillar >50% of original height, very little ossification but > 50% original height

•C = <50%

Treatment

Nonoperative containment

•Observation, activity restriction, NWB and ROM exercise (abd +IR)

•Petri cast. A frame (need to wear if for 6 months to 1 year) (problem, cannot guarantee abduction)

Operative containment

•1. Proximal femoral VDRO (varus) (at most 20deg) or ROWO (rot open wedge osteot.). Problems: short limb and Trendelenburg gait

•2. Pelvic osteotomy (for old child >8, as proximal femur does not remodel as much)

•Containable: re-directional (Salter) [problem: potential lengthening leading to increase pressure on head leading to AVN]

•Combination with femoral osteotomy increase coverage by 20%

•Shelf to prevent lateral subluxation / no longer containable,

•Chiari

•Valgus osteotomy for hinged abduction (reposition hinge, correct shortening from fixed adduction, improve abductor function)

•*** Advantage of surgical containment is the patient will go through fragmentation phase faster according to B Joseph

Herring’s study

•Prospective multi center study of 450 affected hips with patients of age 6+

•2004 JBJS

Prognosis depends on age and Herring stage

•A and B <8 did well regardless of treatment

•B, B/C > 8 improve outcome with surgery

•B/C <8, C poor regardless of treatment

no difference in outcomes between nonop treatment

•no difference in outcomes between femoral or acetabular osteotomies

•no significant effect regardless of treatment in those <8yo

•Limitation: AP view, 7 month of symptoms before reliable classification, 1/3 need upgrade grading, with only 4% belonging to group A on final grading, difficult in bilateral

*Benjamin Joseph’s study

•Containment aims at preventing or correcting femoral head extrusion

•Factors: age at onset of symptom, femoral head extrusion (>20% Reimer migration index), ROM

•B Joseph suggested containment ASAP for

•>7, contain ASAP if still in fragmentation phase

•If reduced ROM – restore motion by traction / abduction cast for 6 weeks, treat by containment once motion is restored

•<7, monitor and contain when there is presence of extrusion

•<8: Femoral osteotomy as more remodelling and less likely to have Trendelenburg gait later

•>8: Acetabular osteotomy as there will be less shortening.

Indication for containment surgery by BJ:

•>7 or <7 with extrusion

•Stage 1a 1b 2a (still in fragmentation phase)

•Extrusion present

•Normal ROM

Contraindication

•<7 without extrusion

•Stage 2b or above

•Absent extrusion in <7 years

•Restricted ROM

Healed Perthes:

Stulberg classification

•A la carte approach

•Trendelenburg: GT osteotomy

•Hinged abduction: osteochondroplasty

•Impingement, stiffness: Valgus osteotomy

•LLD

•Coxa brevia

•Coxa vara

•Coxa plana: Pelvis osteotomy

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Perthes disease
2	0	None	None	0	Xray pelvis of skeletally immature patient with left hip pathology
3	0	None	None	0	Left femoral proximal epiphysis appeared flattened and irregular, fragmented with lateral extrusion, cystic changes over metaphyseal area. The medial joint space is also widened. There is also lucency over lateral epiphysis, consistent with Gage sign.
4	0	None	None	0	Contralateral hip not involved (10% bilateral, never same time)
5	0	None	None	0	Working diagnosis would be Perthes disease. According to Waldenstrom classification, it looks to me the patient is in the fragmentation phase
6	0	None	None	0	*Waldenstrom classification
7	1	685800	-228600	2	Initial
8	1	685800	-228600	2	Fragmentation
9	1	685800	-228600	2	Reossification
10	1	685800	-228600	2	Remodeling
11	0	None	None	0	Ddx are 1. septic arthritis, 2 Meyer’s disease 3. MED
12	0	None	None	0	(bilateral Ddx: hypothyroid, lipid storage disease, meyers dysplasia, MED, sickle cell)
13	0	None	None	0	Hx and PE would focus on
14	0	228600	-228600	1	Age, gender, body built
15	0	228600	-228600	1	Onset of symptoms
16	0	228600	-228600	1	Clinical at risk signs (FOOBS)
17	0	228600	-228600	1	R/O Ddx
18	0	228600	-228600	1	ROM (reduced abduction and IR, Trendelenburg gait, Catterall sign: hip flexion with obligatory external rotation)
19	0	None	None	0	Further Investigation
20	0	None	None	0	WBC (infection), lipid (storage disorder), ESR, CRP, bone profile (tumour), TSH (hypothyroid), peripheral smear (sickle cell)
21	0	None	None	0	XR: Frog leg lateral
22	0	None	None	0	+/- USG, aspiration if suspecting infection
23	0	None	None	0	Aim of treatment
24	0	228600	-228600	1	Pain control (rest analgesics)
25	0	228600	-228600	1	Maintain ROM (physio, temporary NWB)
26	0	228600	-228600	1	Contain hip during critical period of “biologic plasticity”, during creeping substitution, so the femoral head remodels with less incongruity (limits deformity and loss of sphericity) abduction and IR
27	0	0	0	0	Natural history:
28	0	0	0	0	Classic Iowa study with a 50yr FU that 40% need arthroplasty if left untreated. Counsel patient regarding containment. Still has a possibility of future OA
29	0	0	0	0	Nonsurgical containment: in abduction and IR
30	0	0	0	0	Indication for surgical containment
31	0	0	0	0	For this case:
32	0	None	None	0	Lateral pillar classification Class B or B/C
33	0	None	None	0	>8yo treat surgically for containment→ improve outcome according to Herring’s study
34	0	None	None	0	Proximal femoral varus osteotomy
35	0	None	None	0	Prerequisites include
36	0	0	0	0	- Timing – fragmentation phase
37	0	0	0	0	- Containable
38	0	0	0	0	→ Sx – good range
39	0	None	None	0	→ XR – spherical and congruent reduction, containable upon abduction XR / intraop arthrogram
40	0	None	None	0	Take me through the surgery
41	0	228600	-228600	1	Good preop plan to estimate the amount of varus needed to obtain good containment
42	0	228600	-228600	1	GA
43	0	228600	-228600	1	Adductor release may be indicated if tight
44	0	228600	-228600	1	Lateral subvastus approach
45	0	228600	-228600	1	Periosteum elevated
46	0	228600	-228600	1	Choose appropriate size of paediatric proximal locking plate (3.5mm if <35kg, 5mm if >35kg)
47	0	228600	-228600	1	Set guiding jig based on plate angle and desired amount of varus (jig angle (current neck shaft angle) = plate angle (smaller)+ desired amount of varus produced)
48	0	228600	-228600	1	Fix plate proximally then remove it
49	0	228600	-228600	1	Mark rotation before osteotomy
50	0	228600	-228600	1	Use 2 k wires, one above and one below the osteotomy for rotational correction
51	0	228600	-228600	1	Perform femoral osteotomy using an oscillating saw
52	0	228600	-228600	1	Fix plate proximally then distally
53	0	228600	-228600	1	Add some internal rotation or extension for better containment
54	0	None	None	0	Postop
55	0	None	None	0	NWB walking
56	0	None	None	0	HKAFO
57	0	None	None	0	FU till maturity
58	0	0	0	0	Outcome depends on Stulberg classification:
59	1	457200	0	1	I normal
60	1	457200	0	1	II spherical congruent
61	1	457200	0	1	III non spherical (mushroom), congruent
62	1	457200	0	1	IV non spherical (concave articular surface) congruent
63	1	457200	0	1	V non spherical (flat), incongruent
64	0	None	None	0	Other problems: LLD, trendelenburg, pain (labral tear, loose body, hinged abduction, FAI)
65	0	None	None	0	What is the etiology:
66	0	None	None	0	1. Anatomical
67	0	None	None	0	2. Hydrostatic pressure
68	0	None	None	0	3. Thrombophilic
69	0	None	None	0	What is the blood supply to the femoral head in 4-9yo patients?
70	1	None	None	1	<4yo: equal contribution by MFCA and LFCA
71	1	None	None	1	4-10yo: LFCA regress and supply metaphysis only
72	1	None	None	1	10-14yo: ligamentum teres contribution further decrease
73	1	None	None	1	>14yo: anastomosis between the three systems (epiphyseal, metaphyseal, ligamentum teres)
74	0	None	None	0	*What are the at risk sign (FOOBS)
75	0	None	None	0	Clinical and radiological
76	0	None	None	0	Clinical
77	1	685800	-228600	2	Female
78	1	685800	-228600	2	Old
79	1	685800	-228600	2	Obese
80	1	685800	-228600	2	Bilateral
81	1	685800	-228600	2	Stiffness
82	0	None	None	0	Radiological (Caterall at risk signs)
83	1	685800	-228600	2	Gage sign (inverted v shape radiolucency lateral to epiphysis)
84	1	685800	-228600	2	Horizontal physis
85	1	685800	-228600	2	Lateral subluxation of femoral head
86	1	685800	-228600	2	Calcification lateral to epiphysis
87	1	685800	-228600	2	Metaphyseal cyst (later added)
88	0	0	0	0	Lateral Pillar Classification (based on AP Xray, compare both sides, by Herring, guide management and prognosis)
89	1	457200	0	1	Lateral pillar: 25%, lateral to lucent line
90	1	457200	0	1	Central pillar: 50%
91	1	457200	0	1	Medial pillar: 20-35%
92	0	171450	-171450	1	A = normal height
93	0	171450	-171450	1	B = >50%
94	0	171450	-171450	1	B/C = exactly 50% + depressed relative to central pillar, very narrow lateral pillar >50% of original height, very little ossification but > 50% original height
95	0	171450	-171450	1	C = <50%
96	0	0	0	0	Treatment
97	0	0	0	0	Nonoperative containment
98	0	0	0	0	Observation, activity restriction, NWB and ROM exercise (abd +IR)
99	0	0	0	0	Petri cast. A frame (need to wear if for 6 months to 1 year) (problem, cannot guarantee abduction)
100	0	0	0	0	Operative containment
101	0	0	0	0	1. Proximal femoral VDRO (varus) (at most 20deg) or ROWO (rot open wedge osteot.). Problems: short limb and Trendelenburg gait
102	0	0	0	0	2. Pelvic osteotomy (for old child >8, as proximal femur does not remodel as much)
103	0	171450	-171450	1	Containable: re-directional (Salter) [problem: potential lengthening leading to increase pressure on head leading to AVN]
104	0	171450	-171450	1	Combination with femoral osteotomy increase coverage by 20%
105	0	171450	-171450	1	Shelf to prevent lateral subluxation / no longer containable,
106	0	171450	-171450	1	Chiari
107	0	171450	-171450	1	Valgus osteotomy for hinged abduction (reposition hinge, correct shortening from fixed adduction, improve abductor function)
108	0	0	0	0	*** Advantage of surgical containment is the patient will go through fragmentation phase faster according to B Joseph
109	0	0	0	0	Tell me about Herring’s study
110	0	0	0	0	Prospective multi center study of 450 affected hips with patients of age 6+
111	0	0	0	0	2004 JBJS
112	0	0	0	0	Prognosis depends on age and Herring stage
113	1	457200	0	1	A and B <8 did well regardless of treatment
114	1	457200	0	1	B, B/C > 8 improve outcome with surgery
115	1	457200	0	1	B/C <8, C poor regardless of treatment
116	0	171450	-171450	1	no difference in outcomes between nonop treatment
117	0	171450	-171450	1	no difference in outcomes between femoral or acetabular osteotomies
118	0	171450	-171450	1	no significant effect regardless of treatment in those <8yo
119	0	0	0	0	Limitation: AP view, 7 month of symptoms before reliable classification, 1/3 need upgrade grading, with only 4% belonging to group A on final grading, difficult in bilateral
120	0	0	0	0	*Benjamin Joseph’s study
121	0	0	0	0	Containment aims at preventing or correcting femoral head extrusion
122	0	0	0	0	Factors: age at onset of symptom, femoral head extrusion (>20% Reimer migration index), ROM
123	0	0	0	0	B Joseph suggested containment ASAP for
124	0	171450	-171450	1	>7, contain ASAP if still in fragmentation phase
125	1	628650	-171450	2	If reduced ROM – restore motion by traction / abduction cast for 6 weeks, treat by containment once motion is restored
126	0	171450	-171450	1	<7, monitor and contain when there is presence of extrusion
127	0	171450	-171450	1	<8: Femoral osteotomy as more remodelling and less likely to have Trendelenburg gait later
128	0	171450	-171450	1	>8: Acetabular osteotomy as there will be less shortening.
129	0	0	0	0	Indication for containment surgery by BJ:
130	0	228600	-228600	1	>7 or <7 with extrusion
131	0	228600	-228600	1	Stage 1a 1b 2a (still in fragmentation phase)
132	0	228600	-228600	1	Extrusion present
133	0	228600	-228600	1	Normal ROM
134	0	0	0	0	Contraindication
135	0	228600	-228600	1	<7 without extrusion
136	0	228600	-228600	1	Stage 2b or above
137	0	228600	-228600	1	Absent extrusion in <7 years
138	0	228600	-228600	1	Restricted ROM
139	0	0	0	0	Healed Perthes:
140	0	0	0	0	Stulberg classification
141	0	0	0	0	A la carte approach
142	1	628650	-171450	2	Trendelenburg: GT osteotomy
143	1	628650	-171450	2	Hinged abduction: osteochondroplasty
144	1	628650	-171450	2	Impingement, stiffness: Valgus osteotomy
145	1	628650	-171450	2	LLD
146	1	628650	-171450	2	Coxa brevia
147	1	628650	-171450	2	Coxa vara
148	1	628650	-171450	2	Coxa plana: Pelvis osteotomy

#	semantic level	section?	rewritten line
1	0		Perthes disease
2	1		Xray pelvis of skeletally immature patient with left hip pathology
3	1		Left femoral proximal epiphysis appeared flattened and irregular, fragmented with lateral extrusion, cystic changes over metaphyseal area. The medial joint space is also widened. There is also lucency over lateral epiphysis, consistent with Gage sign.
4	1		Contralateral hip not involved (10% bilateral, never same time)
5	1		Working diagnosis would be Perthes disease. According to Waldenstrom classification, it looks to me the patient is in the fragmentation phase
6	0	yes	*Waldenstrom classification
7	2		Initial
8	2		Fragmentation
9	2		Reossification
10	2		Remodeling
11	1		Ddx are 1. septic arthritis, 2 Meyer’s disease 3. MED
12	1		(bilateral Ddx: hypothyroid, lipid storage disease, meyers dysplasia, MED, sickle cell)
13	1		Hx and PE would focus on
14	1		Age, gender, body built
15	1		Onset of symptoms
16	1		Clinical at risk signs (FOOBS)
17	1		R/O Ddx
18	1		ROM (reduced abduction and IR, Trendelenburg gait, Catterall sign: hip flexion with obligatory external rotation)
19	0	yes	Further investigations
20	1		WBC (infection), lipid (storage disorder), ESR, CRP, bone profile (tumour), TSH (hypothyroid), peripheral smear (sickle cell)
21	0	yes	XR: Frog leg lateral
22	1		+/- USG, aspiration if suspecting infection
23	0	yes	Aim of treatment
24	1		Pain control (rest analgesics)
25	1		Maintain ROM (physio, temporary NWB)
26	1		Contain hip during critical period of “biologic plasticity”, during creeping substitution, so the femoral head remodels with less incongruity (limits deformity and loss of sphericity) abduction and IR
27	0	yes	Natural history:
28	1		Classic Iowa study with a 50yr FU that 40% need arthroplasty if left untreated. Counsel patient regarding containment. Still has a possibility of future OA
29	1		Nonsurgical containment: in abduction and IR
30	0	yes	Indication for surgical containment
31	0	yes	For this case:
32	0	yes	Lateral pillar classification Class B or B/C
33	1		>8yo treat surgically for containment→ improve outcome according to Herring’s study
34	1		Proximal femoral varus osteotomy
35	1		Prerequisites include
36	1		- Timing – fragmentation phase
37	1		- Containable
38	1		→ Sx – good range
39	1		→ XR – spherical and congruent reduction, containable upon abduction XR / intraop arthrogram
40	0	yes	Operative steps
41	1		Good preop plan to estimate the amount of varus needed to obtain good containment
42	1		GA
43	1		Adductor release may be indicated if tight
44	0	yes	Lateral subvastus approach
45	1		Periosteum elevated
46	1		Choose appropriate size of paediatric proximal locking plate (3.5mm if <35kg, 5mm if >35kg)
47	1		Set guiding jig based on plate angle and desired amount of varus (jig angle (current neck shaft angle) = plate angle (smaller)+ desired amount of varus produced)
48	1		Fix plate proximally then remove it
49	1		Mark rotation before osteotomy
50	1		Use 2 k wires, one above and one below the osteotomy for rotational correction
51	1		Perform femoral osteotomy using an oscillating saw
52	1		Fix plate proximally then distally
53	1		Add some internal rotation or extension for better containment
54	1		Postop
55	1		NWB walking
56	1		HKAFO
57	1		FU till maturity
58	0	yes	Outcome depends on Stulberg classification:
59	1		I normal
60	1		II spherical congruent
61	1		III non spherical (mushroom), congruent
62	1		IV non spherical (concave articular surface) congruent
63	1		V non spherical (flat), incongruent
64	1		Other problems: LLD, trendelenburg, pain (labral tear, loose body, hinged abduction, FAI)
65	0	yes	the etiology:
66	1		1. Anatomical
67	1		2. Hydrostatic pressure
68	1		3. Thrombophilic
69	0	yes	What is the blood supply to the femoral head in 4-9yo patients?
70	1		<4yo: equal contribution by MFCA and LFCA
71	1		4-10yo: LFCA regress and supply metaphysis only
72	1		10-14yo: ligamentum teres contribution further decrease
73	1		>14yo: anastomosis between the three systems (epiphyseal, metaphyseal, ligamentum teres)
74	1		*What are the at risk sign (FOOBS)
75	1		Clinical and radiological
76	1		Clinical
77	2		Female
78	2		Old
79	2		Obese
80	2		Bilateral
81	2		Stiffness
82	0	yes	Radiological (Caterall at risk signs)
83	2		Gage sign (inverted v shape radiolucency lateral to epiphysis)
84	2		Horizontal physis
85	2		Lateral subluxation of femoral head
86	2		Calcification lateral to epiphysis
87	2		Metaphyseal cyst (later added)
88	0	yes	Lateral Pillar Classification (based on AP Xray, compare both sides, by Herring, guide management and prognosis)
89	1		Lateral pillar: 25%, lateral to lucent line
90	1		Central pillar: 50%
91	1		Medial pillar: 20-35%
92	1		A = normal height
93	1		B = >50%
94	1		B/C = exactly 50% + depressed relative to central pillar, very narrow lateral pillar >50% of original height, very little ossification but > 50% original height
95	1		C = <50%
96	0	yes	Treatment
97	0	yes	Nonoperative containment
98	1		Observation, activity restriction, NWB and ROM exercise (abd +IR)
99	1		Petri cast. A frame (need to wear if for 6 months to 1 year) (problem, cannot guarantee abduction)
100	0	yes	Operative containment
101	1		1. Proximal femoral VDRO (varus) (at most 20deg) or ROWO (rot open wedge osteot.). Problems: short limb and Trendelenburg gait
102	1		2. Pelvic osteotomy (for old child >8, as proximal femur does not remodel as much)
103	1		Containable: re-directional (Salter) [problem: potential lengthening leading to increase pressure on head leading to AVN]
104	1		Combination with femoral osteotomy increase coverage by 20%
105	1		Shelf to prevent lateral subluxation / no longer containable,
106	1		Chiari
107	1		Valgus osteotomy for hinged abduction (reposition hinge, correct shortening from fixed adduction, improve abductor function)
108	1		*** Advantage of surgical containment is the patient will go through fragmentation phase faster according to B Joseph
109	0	yes	Herring’s study
110	1		Prospective multi center study of 450 affected hips with patients of age 6+
111	1		2004 JBJS
112	0	yes	Prognosis depends on age and Herring stage
113	1		A and B <8 did well regardless of treatment
114	1		B, B/C > 8 improve outcome with surgery
115	1		B/C <8, C poor regardless of treatment
116	0	yes	no difference in outcomes between nonop treatment
117	1		no difference in outcomes between femoral or acetabular osteotomies
118	1		no significant effect regardless of treatment in those <8yo
119	1		Limitation: AP view, 7 month of symptoms before reliable classification, 1/3 need upgrade grading, with only 4% belonging to group A on final grading, difficult in bilateral
120	0	yes	*Benjamin Joseph’s study
121	1		Containment aims at preventing or correcting femoral head extrusion
122	1		Factors: age at onset of symptom, femoral head extrusion (>20% Reimer migration index), ROM
123	1		B Joseph suggested containment ASAP for
124	1		>7, contain ASAP if still in fragmentation phase
125	2		If reduced ROM – restore motion by traction / abduction cast for 6 weeks, treat by containment once motion is restored
126	1		<7, monitor and contain when there is presence of extrusion
127	1		<8: Femoral osteotomy as more remodelling and less likely to have Trendelenburg gait later
128	1		>8: Acetabular osteotomy as there will be less shortening.
129	0	yes	Indication for containment surgery by BJ:
130	1		>7 or <7 with extrusion
131	1		Stage 1a 1b 2a (still in fragmentation phase)
132	1		Extrusion present
133	1		Normal ROM
134	0	yes	Contraindication
135	1		<7 without extrusion
136	1		Stage 2b or above
137	1		Absent extrusion in <7 years
138	1		Restricted ROM
139	0	yes	Healed Perthes:
140	0	yes	Stulberg classification
141	1		A la carte approach
142	2		Trendelenburg: GT osteotomy
143	2		Hinged abduction: osteochondroplasty
144	2		Impingement, stiffness: Valgus osteotomy
145	2		LLD
146	2		Coxa brevia
147	2		Coxa vara
148	2		Coxa plana: Pelvis osteotomy

015. Perthes disease