Legg-Calvé-Perthes’ Disease


Initial stage

Resorption stage

Reparative stage

Articular cartilage

Necrosis in deep layer

Cessation of endochondral ossification

Separation from underlying subchondral bone

Vascular invasion

New accessory ossification

Irregularly hypertrophied articular cartilage

Bony epiphysis

Necrosis of marrow space and trabecular bone

Invasion of vascular connective tissue

Compression fracture of trabeculae

Osteoclastic resorption of necrotic bone

Assymetric appearance of normal bone


Irregularity in the columnisation of cartilaginous growth cells

May extend inferiorly

Growth disturbance apparent



Fat necrosis

Vascular proliferation

Disorganised ossification


The majority of patients present with mild hip pain of insidious onset, a limp and/or reduced hip movements. Pain is usually activity related and localised to the groin but can be referred to the thigh and knee area.

On examination, an antalgic or Trendelenburg gait may be observed. Hip motion is usually maintained at the early stages but both synovitis and abductor spasm may result in some hip irritability. Initially, hip internal rotation and abduction are limited followed by limitation of other hip movements. During the fragmentation stage, hip motion can become severely restricted with the development of flexion and abduction contractures in some patients. Atrophy of the thigh and calf muscles may be present from disuse, secondary to pain. There may be a leg length discrepancy either from true shortening at the collapsed femoral epiphysis or apparent shortening due to an abduction contracture.


The primary imaging modality for LCPD is plain radiographs; standing anteroposterior and frog-leg lateral views of both hips. These X-rays aid in initial diagnosis, staging of the disease and in providing information about the prognosis.

Additional imaging studies to consider:

  • Bone scanning may reveal the avascularity of the femoral head in the early stages of the disease.

  • MRI can detect changes in bone perfusion when X-ray changes are not apparent. However the clinical and prognostic relevance of MRI has yet to be formally defined in the management of LCPD.

  • Arthrography is useful to assess the shape of the femoral head in relation to the acetabulum and is used to plan surgical management.

Radiographic Stages

LCDP has been divided into four radiographic stages according to characteristic features initially described by Waldenstrom:


Initial Stage:

  • Lateralisation of the femoral head.

  • Decreased size of the ossification centre.

  • Subchondral fracture.

  • Metaphyseal lucencies.



Fragmentation Stage:

  • Fragmented epiphyses.

  • Areas of radiolucency and radiodensity.

  • This stage lasts about 1 year.



Re-ossification (Healing) Stage:

  • Bone density returns to normal.

  • This stage usually lasts 3–5 years.



Residual (Healed) Stage:

  • Femoral head fully re-ossified.

  • Remodelling of the head and acetabulum until skeletal maturity.


Classification Systems

Four different classification systems have been described:


Based on the amount of capital femoral epiphysis (CFE) involvement on X-rays taken at the fragmentation stage of the disease

  • Group I – Anterior CFE involvement only

  • Group II – up to 50% involvement with metaphyseal cysts

  • Group III – up to 75% involvement with large sequestrum

  • Group IV – The whole of femoral head involved

Stulberg Outcome Classification

Stulberg outcome classification is determined using both AP and frog lateral radiographs at skeletal maturity (Table 7.2).

Table 7.2
Stulberg classification summary




I – Spherical congruency

Completely normal hip joint


II – Spherical congruency with less than 2 mm loss of head shape

Spherical femoral head with a concentric circle on radiographs, with 1 or more of the following abnormalities:

 Coxa magna

 Short femoral neck

 Abnormally steep acetabulum


III – Aspherical congruency with greater than 2 mm loss of head shape

Non-spherical (ovoid/mushroom shaped), but not a flat femoral head. With class II characteristics

Mild to moderate osteoarthritis

IV – Aspherical congruency

Flat femoral head with abnormalities of the femoral head, neck and acetabulum

Mild to moderate osteoarthritis

V – Aspherical incongruency

Flat femoral head with a normal neck and acetabulum

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Sep 18, 2016 | Posted by in ORTHOPEDIC | Comments Off on Legg-Calvé-Perthes’ Disease

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