1. Surgical Treatment for Perthes Disease Mazloumi MD Associated professor Orthopaedic surgeon

2. A 14-year-old boy who had Legg-Calve´-Perthes disease at age 8 years and was treated with nonoperative methods

3. Pathomechanical environment Structural instability Femoroacetabular impingment Articular incongruity (localized joint overload) Abductor inefficiency (articular overload) Combinations

4. Perthes deformities Proximal femur ( spectrom and variabilities of deformities) Large and aspherical femoral head High grater throchanter (over growth) Short femoral neck Head neck offset deformity Varus neck- shaft angle Osteochondral disease

5. Perthes deformities Acetabulom ( spectrom and variabilities of deformities) Decreseade anterolateral and/or posterolateral femoral head coverage. Increased acetabular inclination. Relative acetabular deficiency. Variable acetabular version

6. Long term outcome of Legg-Calve-perthes at middle age Risk of sever OA and clinically poor outcome after 40-50 years of age irrespective of prior successful surgical treatment and good outcome at skeletal maturity Increased incidence of OA and THA in patients with a Stulberg class III / IV / V who were treated with conservative methods

7. Surgical approaches for treatment of sequelae of Perthes disease  Extraarticular methods  Intertrochanteric valgus osteotomy 1- Valgus extension: best corrects limb deformity 2- Valgus flexion: may better correct anterior impingement  Trochanteric transfer with relative neck lengthening To correct greater trochanteric abutment)  Noncontainment acetabular procedures 1- Shelf acetabuloplasty 2- Chiari procedure  Intraarticular methods  Osteochondroplasty of the head and neck (open or via arthroscopy) Note: residual dysplasia may also require treatment  Femoral head reduction (central “downsizing”) Unproved method  Excision of osteochondritis dissecans  Labral repair

11. Proximal femoral varus osteotomy

12. Proximal femoral valgus osteotomy

13. Valgus osteotomy

14. Triple pelvic osteotomy

15. Triple ost.

16. Double-level osteotomy

17. Shelf acetabuloplasty

18. Chiari osteotomy

19. Greater trochanteric advancement

20. Biomechanical effect of coxa breva

21. Coxa breva

22. Neck lengthening

24. Morscher osteotomy

27. biomechanical effects of the surgical reconstruction

28. Femoral head reduction osteotomy (FHRO) technique ( Coxa magna )

30. Femoral head reduction osteotomy

32. periactabular osteotomy

33. Thank you