The "sagging rope sign" in avascular necrosis in children's hip diseases--confirmation by 3D CT studies

Growth disturbance of the proximal femoral epiphysis and physis secondary to avascular necrosis (AVN) in a variety of children's hip disorders produces changes in the femoral head and neck that make radiographic interpretation difficult. The enlarged overhanging femoral head produces radiographic markings on the femoral neck which are sometimes confusing. These have sometimes been misinterpreted as growth arrest lines. Apley and Wientroub reintroduced Perkins' description of the "sagging rope" sign in AVN of the femoral head, and Clarke clarified that this puzzling radiographic transverse metaphyseal line overlying the femoral neck in fact represents the margin of the femoral head rather than a growth arrest line. Their report was made after studying plain and stereoscopic radiographs alone. Our review of 23 cases of femoral head AVN in children, documented by 3 dimensional computerized tomographic (3D CT) radiographs of the femoral head and pelvis, confirms Clarke's view of the nature of the "sagging rope" sign. These sophisticated radiographic studies provide new detail and understanding of head-neck relationship in AVN which allows better planning for surgical correction of hip disorders in children.