Catterall classification: epiphyseal involvement and head-at-risk signs [54]

A radiographic classification of severity based on the epiphyseal involvement on anteroposterior and lateral radiographs. This classification system has a high intra- and inter-observer variation. There are 4 groups based on the geometric epiphyseal involvement:

I: less than 25% epiphysis involved with no metaphyseal changes and no femoral head collapse II: less than 50% epiphyseal involvement with fragmentation of the involved segment, a limited metaphyseal reaction, but no head collapse III: less than 100% of the head involved with extensive fragmentation and collapse, with metaphyseal osteolysis IV: Total head involvement with severe collapse, advanced metaphyseal changes and abnormalities in the growth plate.

Catterall classification: Group I shows anterior head involvement (hatched area), no sequestrum, no collapse of the epiphysis. Group II shows the anterior head involvement with a clearly demarcated sequestrum. Group III shows that only a small part of the epiphysis is not involved. Group IV shows a total head

involvement 1996 American Academy of Orthopaedic Surgeons. Reprinted from: J Am Acad Orthop Surg. 1996;4:9-16, with permission. Radiological signs of a head-at-risk are also described:

Lateral subluxation: due to articular cartilage overgrowth Calcification lateral to epiphysis: calcification in the overgrown cartilage Osteolysis in the superolateral part of the femoral metaphysis: Gage's sign Horizontal physis Metaphyseal cysts.

Salter Thompson criteria: extent of the subchondral fracture [55]

Based on the extent of the subchondral fracture, it divides Legg-Calv-Perthes' (Perthes') disease into 2 groups of severity, although it can be difficult to accurately visualise the fracture:

A, less than 50%: corresponds to the Catterall groups I and II with less than 50% head involvement and a subchondral fracture line extending less than halfway across the femoral head. B, greater than 50%: corresponds to Catterall groups III and IV, with 50% to 100% head involvement corresponding to the subchondral fracture line.

Herrings sub-types: lateral pillar comparison [56]

The femoral head consists of 3 pillars (medial 20% to 35%; central 50%; lateral 15% to 30%); the lateral pillar is the important weight transmission support. This classification system provides diagnostic and prognostic criteria based on anteroposterior radiographs only. It compares the lateral pillar of the affected side with the intact contralateral side. The criteria are easy to define and there is better inter-observer agreement. There are 3 types of involvement.

Original

Herring classification: Group A, no involvement of the lateral pillar which retains the original height with no density changes; Group B, lateral pillar shows lucency and a loss of height, not exceeding 50% of the original; Group C, characterises the lateral pillar with increased lucency and collapse of over 50% of the original height 1996 American Academy of Orthopaedic Surgeons. Reprinted from: J Am Acad Orthop Surg. 1996;4:916, with permission. Herring subsequently amended the original classification to include a B/C group in whom the amount of femoral head collapse was 50% of the original height. [57]

Elizabethtown stages: natural history [58]

Based on the radiographic representation of the natural history of the disease process, there are 4 stages:

Stage I: Initial phase with condensation, compression and an increased density of the epiphysis with a widened joint space. Stage II: Reparative phase with fragmentation of the epiphysis. Stage III: Healing phase with more pronounced fragmentation but also new bone that is maturing. Stage IV: Re-ossification is complete with a definitive end-pattern shape of the femoral head, with or without deformity.

Stulberg criteria: prognosis [50]

The criteria are based on the sphericity of the femoral head and the associated congruence with the acetabulum in forming hip articulation. There are 5 classes described.

Stulberg classification and prognosis of future hip arthritisFrom the personal collection of Jwalant S. Mehta, MS (Orth), MCh (Orth), FRCS, FRCS (Orth)