PERTESA DISEASE ( G. G. Perthes , it is mute. surgeon, 1869 — 1927; synonym disease of Legga — Kalva — Pertesa) — aseptic necrosis of a head of a femur. P. is for the first time described by G. Pertes in 1910. treats group osteochondropathies (see). Makes 1 — 3% among diseases of a musculoskeletal system at children. Aged up to 5 years the most struck age of 6 — 10 years meets seldom. Boys are ill 4 — 5 times more often. The disease usually has unilateral character.
the Aetiology remains not clear. There are different views on the reason of an aseptic necrosis of a head of a femur (the postponed infection, disturbances of exchange, endocrine frustration, anomaly of development of vessels, an injury). The proximate cause of an aseptic necrosis of a head of a hip should be considered disturbance of local blood circulation, in Krom the injury can play a part.
A clinical picture
the First wedge, symptoms of a disease are uncharacteristic, changeable, poorly expressed. There is lameness which quickly disappears during the unloading of an extremity, but then again renews. Moderate pains in the field of the struck hip joint quite often irradiate in a knee joint. Pains usually arise in the afternoon, during walking. The wedge, a research reveals an insignificant atrophy of soft tissues of a hip and shin, a small flexion contracture of a hip joint, restriction of assignment and internal rotation of a hip. The palpation of a hip joint is slightly painful. With unloading of a joint (bed rest) the specified complaints quickly disappear. Alexandrov's symptom (see. Tuberculosis extra pulmonary, tuberculosis of bones and joints ) poorly positive or is absent. Length of an extremity is, as a rule, not changed, but small shortening or its lengthening in connection with oppression or irritation of a rostkovy cartilage can be observed. A symptom of Trendelenburga (see. Hip joint ) in most cases positive. The general condition of the child does not suffer. Temperature is not increased, blood is normal.
Due to the lack of characteristic a wedge, P.'s signs. often diagnose with delay. Plays a crucial role in diagnosis rentgenol, a research, at the same time the X-ray analysis of both hip joints in a direct projection and in Lauenstein's position is obligatory (see. Hip joint). Item. it is characterized by a certain sequence morfol, the changes happening in a head of a femur that radiological is expressed by 5 stages of process (S. A. Reynberg).
In the first stage (a stage of a podkhrya-shchevy necrosis) note osteoporosis of a head and a neck of a hip, expansion of a joint crack. The head gets out of spherical shape, under its dome there is a narrow strip of an enlightenment that testifies to initial stages of flattening. All these changes are visible on the roentgenogram of a hip joint in Lauenstein's position more clearly.
The second stage — a stage of an impression change: the head of a femur is flattened, condensed, deprived of the structural drawing, has uneven twisting contours (fig. 1).
Third stage, the most characteristic of P. — a stage with formation of sekvestropodobny shadows. Necrotic masses is split and gradually resolves. The remained islands of a homogeneous necrosis surrounded with again formed connecting fabric and a cartilage remind sequesters (fig. 2, a). If the child continues to use an extremity, the head of a hip is even more flattened, the joint crack becomes wider, than in the second stage. The crack of an epiphyseal cartilage extends, gets twisting friable contours. The neck is thickened and shortened as a result of disturbance of processes of enchondral growth. In hard cases in its subchondral departments the centers of depression come to light. According to deformation of a head of a hip also the form of an acetabular hollow, its roof changes. The proximal end of a hip can be displaced in a provision of a small incomplete dislocation of a knaruzha and up.
The fourth stage — a reduction stage of structure (fig. 2, b). Sekvestropodobny shadows are not defined, but the structure of a head long time remains uneven, gradually acquiring the normal spongy drawing. Deformation of a head remains for the rest of life. Clear radiological boundary between the described four stages does not exist.
The fifth stage — a stage of effects of P. Despite a complete recovery of structure of a head of a femur, its form in most cases, especially at late treatment, remains much changed — the head is flattened, is gribovidno deformed, has uneven wavy contours. The neck is shortened, expanded, noticeable varus deformation (fig. 3). Respectively also the form of an acetabular hollow changes. Its roof is flattened, mown that gradually leads to an incomplete dislocation of a hip up and knaruzh. As the joint cartilage does not suffer, width of a crack of a joint long time remains normal or even increases. Typical symptoms of the deforming arthrosis in the form of the expressed sclerosis, regional bone growths, narrowing of a joint crack develop slowly and do not reach considerable degree.
In the prevailing most cases rentgenol, changes in a hip joint are so typical that differential diagnosis is not required. In certain cases, especially in initial stages of process, it is necessary to differentiate P. with tubercular damage of a joint. Unlike tuberculosis at P. there is no restriction of mobility in a joint, Alexandrov's symptom is negative or poorly positive, the atrophy of muscles insignificant, local temperature is not raised. Negative tuberkulinovy tests and normal blood count would testify in favor of P. Radiological diagnosis of P. confirms local defeat only of an epiphysis of a hip, expansion of a joint crack, absence of osteoporosis and an atrophy of bones of a hip joint and a hip on an extent.
Treatment is most effective in the conditions of specialized sanatorium. The conservative treatment shown at any stage of a disease first of all consists in unloading of the affected extremity for the prevention of deformation of a head of a femur (walking on crutches, a bed rest). In the presence of severe pains the immobilization by a plaster bandage or on Beler's tire is shown (see. Immobilization ). Unloading of an extremity is carried out against the background of fortifying therapy (good nutrition, vitamin therapy). From physiotherapeutic procedures the electrophoresis using a lidaza and chemical opsin is shown and. In the recovery period apply ozokerite, dirt, an ionogalvaniza-tion with Calcium chloratum on area of a hip joint. In the absence of acute the phenomenon from a joint carry out remedial gymnastics with the movements in the affected joint in a prone position, massage. Walking with full load is allowed only at radiological the confirmed recovery of structure of a head. Along with the basic, conservative, the method of treatment offered the operational methods directed to stimulation of vascularization and ossification of a head. Tunnelization of a neck of a femur consists in creation of the canal into which enter bone allotransplant or bring a periostal graft or muscles for improvement of blood supply of a head. Sometimes make subtrochanterian osteotomy (see). Operational methods of distribution did not receive because of small efficiency.
the Forecast for life favorable. Uncured P.'s duration. (I \The IV stages) from 3 to years. Early and correct treatment reduces terms to 1,5 — 2,5 years and gives incomparably the best funkts. results. Funkts, an outcome is various and depends on extent of anatomic recovery of a joint, i.e. timeliness of treatment. Full the wedge, recovery with recovery of a normal spherical head of a femur would be observed at 20 — 25% of sick P. In most cases in a varying degree restriction of mobility in a joint, hl remains. obr. assignments of a hip. Usually these changes are not followed by complaints, and patients after the postponed P. completely keep working capacity. Pains in a hip joint, restriction of mobility, limping which can appear at mature or advanced age are connected with the phenomena of arthrosis in the deformed joint.
Bibliography: M. V. and Dedov V. D wolves. Children's orthopedics, page 220, M., 1972; Gratsiansky V. P. Aseptic necroses of a head of a hip at children and adults, M., 1955; Zharkov of the Item JI. and d river. Early radiodiagnosis of an osteochondropathy of a head of a femur, Ortop, and travmat., No. 1, page 30, 1973; To and p and t of An and to and A. A., 4 e to and to about in M. V. and P about-z about in with to and y Yu. I. Early diagnosis of an osteochondropathy of a hip joint, Vestn, hir., t. 118, page 114, 1977; Mike about - va-Stroganova V. S. and Rokhlin D. G. Bones and joints in the x-ray image, the Extremity, L., 1957; Reynb e r S. A. Radiodiagnosis of diseases of bones and joints, book 2, page 252, M., 1964; Rubasheva A. E. Private radiodiagnosis of diseases of bones and joints, page 386, Kiev, 1967; O'G and of and J. A. The radiographic changes in Perthes’ disease, J. Bone Jt Surg., v. 41-B, p. 465, 1959, bibliogr.; Perthes G. tiber Arthritis deformans juvenilis, Dtsch. Z. Chir., Bd 107, S. Ill, 1910.
M. V. Volkov, O. L. Nechvolodova.