‫ِ‬
‫كم مِّن ضع ٍ‬
‫َّ‬
‫َّ‬
‫ق‬
‫ل‬
‫خ‬
‫ي‬
‫ذ‬
‫ل‬
‫ا‬
‫ه‬
‫ل‬
‫ال‬
‫ف ثُمَّ َج َعلَ ِمن‬
‫(‬
‫•‬
‫ُ‬
‫َ‬
‫َ‬
‫َ‬
‫ُ‬
‫َْ‬
‫ف قُوَّةً ثُمَّ جعل ِمن بع ِد قُوٍَّ‬
‫بع ِد ضع ٍ‬
‫ض ْعف ًا‬
‫ة‬
‫ََ َ َْ‬
‫َْ َ ْ‬
‫َ‬
‫وشيبةً يخلُق ما يشاء وهو ا ْلعلِيم ا ْلقَ ِ‬
‫دير) صدق‬
‫العظيم َ ُ‬
‫َ َ ْ َ َ ْ ُ َ َ َ اهللَ ُ َ‬
MANAGEMENT OF
CONGENITAL COXA VARA
By
Salah Mahmoud Abdelkader
M.B.B.Ch
Supervisors
Prof. Dr. Abdelfatah Kotb Ismail Wali
Professor of Orthopaedic Surgery
Faculty of Medicine
Zagazig University
Dr. Hossam Mohammed Khairy
Assistant Professor of Orthopaedic Surgery
Faculty of Medicine
Zagazig University
Dr. Mohammed Elsadek Attia
Lecturer of Orthopaedic Surgery
Faculty of Medicine
Zagazig University
Before and above all thanks to "Allah" to whom I always pray to bless my work.
It is a great honor for me to work under supervision of Prof. Dr. Abdelfatah Kotb
Ismail Wali, Professor of Orthopaedic Surgery, Faculty of Medicine, Zagazig
University. For kindly accepting to supervise this work and for the valuable advice
and encouragement he honestly offered throughout the course of this work.
I'm very grateful to Dr. Hossam Mohammed Khairy, Assistant Professor of
Orthopaedic Surgery, Faculty of Medicine, Zagazig University. For his sincere
continuous help, true advice, valuable guidance, kind supervision and constant
purposeful encouragement which provided me all facilities during the conduction of
this work.
I would like to express my profound gratitude and deep appreciation to Dr. Mohammed
Elsadek Attia, Lecturer of Orthopaedic Surgery, Faculty of Medicine, Zagazig
University. Without his precious advice and guidance, this work wouldn't have
come to light.
I'm also grateful to all members of the Orthopaedic Department, Zagazig University for
their kind help and support. Without their cooperation, this work wouldn't have
come to light.
Coxa vara
Coxa vara includes all forms of decrease of the
femoral neck shaft angle to less than 120-135°.
This condition has many causes including:
congenital, acquired, and developmental.
Conganital coxa vara
Developmental abnormality
Primary cartilagenous defect in femoral neck with
•
•
•
•
Abnormal decrease in femoral neck shaft angle
Shortning of femoral neck
Relative overgrowth of greater trochanter
Shortening of affected lower limb
ANATOMY OF THE HIP
The hip joint is a synovial joint formed by the
articulation of the rounded head of the femur
and the cup-like acetabulum of the pelvis
Upper Femoral Epiphysis
The upper femoral epiphysis is a pressure epiphysis
which is applied at the upper end of the femur and
subjected to pressure transmitted through the hip
joint into which it enters
Resting Zone
Proliferating Zone
Hypertrophic Zone
Ossification Zone
Trabecular bone
HIP JOINT BIOMECHANICS
A multi-axial ball-and-socket hip provides motion in
three planes. Flexion-extension occurs within the
transverse plane, abduction-adduction within the
sagital plane, and internal-external rotation within the
coronal plane
Because the acetabulum and femoral head are
incongruent and neither is strictly spherical, rolling
and gliding occur within the hip joint. In a pure
ball-and-socket only gliding occurs
Etiology
Unknown may be.
1. Mechanical intrauterine stresses affecting hip development
2. Avascular necrosis involving selected areas of the proximal
femoral physis/head and neck
3.Metabolic abnormalities causing deficient production of, or a
delay in, the normal ossification process of the proximal end of
the femur.
4. Primary cartilagenous defect in femoral neck• Remains the most widely accepted theory on the cause of
CCV
Pathophysiology of Coxa Vara
• the normal hip the compressive force is
perpendicular to the center of the hip joint. As
a result, the physeal cartilage and hyaline
cartilage of the acetabulum are under
compressive force, which is distributed
throughout.
• Stresses on the medial side of the femoral neck
are compressive, whereas those on the lateral
side are tensile.
The upper femoral epiphysis tends to tilt and
become displaced medially, and the tensile
stresses increase.growth of the femoral neck is
less on the medial side than on the lateral side.
• In coxa vara with a progressive decrease in the
femoral neck–shaft angle the physis changes its
position from horizontal to vertical, The shearing
force across the physis gradually increases
• Coxa vara the femoral neck–shaft angle is
decreased;the tip of the greater trochanter is
elevated, and the position and direction of
muscular force are altered.The resultant
compressive force diverges more than normal in
coxa vara, and the lever arm of the abductor
muscles is lengthened.
Clinical Presentation
• Usually present with gait abnormalities
• Affected children generally present between
the time they begin ambulation and age 6
years. (does not manifest until after birth
and usually not until walking age)
Unilateral Case
• Painless Limp (due to combination of
trendlenburg gait and limb length inequality)
• Easy fatigability , aching pain around gluteal
muscles
Bilateral Case• Waddling gait
• With or without fatigue or muscular pain
On Examination
• Abduction
(decreased
articulo-trochanteric
distance) and internal rotation (decreased femoral
anteversion or true retroversion associated with
this condition) limited on affected side
• Trendlenburge test positve
• No telescoping end negative Ortolani’s sign (DD
from. DDH)
• Shortening in unilateral case (seldom exceeds 3
cm at skeletal maturity even in untreated patient)
• Evidence of genrelized skeletal dysplasia should
be sought especially if family history positive
Radiographic Findings
CCV is differentiated radiographically from other
forms of proximal femoral varus by
• The characteristic finding of an inverted Yshaped lucency
This lucency is made up of the proximal physeal
plate and a fragment of bone inferolateral to the
physis, which represents a contained area of
abnormal calcification
Other more generic radiographic features are
shared with the other causes of coxa vara.
These include:
 decreased neck shaft angle, often approaching
or less than 90°
 smaller and flatter femoral head
 more vertical orientation of the physeal plate
 decreased femoral anteversion or even
retroversion of the head on the femoral neck
 shallow acetabulum with a more oval shape.
Characteristic radiographic findings of congenital coxa vara.
(A) Decreased neck shaft angle.
(B) Smaller and flatter femoral head.
(C) More vertical orientation of physeal plate.
(D) Coxa brevis.
(E) Abnormal bony fragment inferolateral to physeal plate and contained in inverted Yshaped lucency
• CT scan, with possible 3-dimensional reconstructions
– CT scan can be used to help delineate the proximal
femoral defect. It commonly reveals displacement
of the proximal femoral epiphysis and associated
metaphyseal spike of bone, from its normal
superior-anterior position on the femoral neck to
an inferior-posterior position. This results in
relative femoral retroversion with respect to the
head-shaft relationship.
– CT scan may provide useful information regarding
femoral anteversion or retroversion and the amount
of bone stock in the area, which is important
information for preoperative surgical planning.
• MRI
– MRI findings include widening of the growth
plate with expansion of cartilage medio-distally
between the capital femoral epiphysis and
femoral metaphysis.
– The usefulness of MRI as a preoperative
imaging modality, in both diagnosis and
surgical planning, is relatively limited.
Treatment
1-Non surgical
2-Surgical
Non-surgical
• Non surgical treatment during childhood has
historically been unsuccessful in achieving the
objectives of proper treatment. Surgical correction
is essential
• Spica cast immobilization with the affected limb
in abduction for 6 to 12 months have been
reported to be unhelpful.
Surgical Treatment
Indications of Surgery
• If the Hilgenireiner epiphyseal (HE) angle greater than 60
degrees corrective surgery should be performed.
• If the angle is less than 45degrees spontaneous correction will
occur without surgery
• Between 45 to 60 degrees represent a gray zone and the
outcome is uncertain and careful observation is requiring
before any decision is made.
• A proximal femoral neck-shaft angle of less than or equal to
90 to 100 degrees.
• A documented progressive decrease in the proximal femoral
neck-shaft angle.
• Development of a Trendelenburg gait.
Diagram of Hilgenreiner’s epiphyseal
angle in CCV and normal hip
Aims of treatment
•
•
•
•
•
•
Correction of the neck shaft angle to a more
physiologic angle and HEA to less than 35-40°.
Changing of the loading characteristics seen by the
abnormal femoral neck from shear to compression.
Correction of limb-length inequality.
Reestablishment of a proper length tension
relationship for the abductor muscle.
Correction of femoral anteversion (or retroversion)
to more normal values.
Ossification and healing of the defective
inferomedial femoral neck fragment.
Timing of surgery
• Corrective osteotomy is best performed not at
a particular age but rather as soon as the
criteria for surgical intervention are manifest.
With the proper indications, a delay in surgical
intervention until an older age in hopes of
achieving better internal fixation is not
justified. The progressive proximal femoral
deformity and dysplastic changes at the
femoral head, neck, and acetabulum that occur
with time will make complete and lasting
correction much more difficult
Methods of Treatment
•
•
Femoral neck procedures
Intertrochanteric osteotomy
–
–
–
Wagner multiple K-wire osteosynthesis
Langenskiold’s osteotomy
Pauwels Y-shaped osteotomy
• Subtrochanteric osteotomies
• Trochanteric epiphysiodesis
• New techniques
1-Fixation using a modified veterinary plate
2-The use of external fixator (A low-profile
illizarov)
FEMORAL NECK PROCEDURES
• Historical surgical procedures included
attempts to fix the defect of the femoral neck
with pins or bone grafts; these approaches
failed because they did not correct varus
deformity, probably did not prevent
progression of the deformity, and could
produce growth arrest of the capital femoral
physis.
Intertrochanteric osteotomies
• Intertrochanteric osteotomies
- Wagner multiple K-wire osteosynthesis
-Pauwels Y-shaped
-Langenskiöld valgus-producing osteotomies
However these osteotomies have a somewhat
limited ability to correct the associated femoral
neck retroversion.
Wagner multiple K-wire Osteosynthesis
Langenskiold’s Osteotomy
• Langenskiold’s osteotomy was used only when
the neck shaft angle was lower than 80 degrees
Pauwels Y shaped osteotomy
SUBTROCHANTERIC VALGUS
OSTEOTOMIES
• The subtrochanteric valgus-producing osteotomies
have provided good and lasting clinical results
• The subtrochanteric osteotomy is fixed internally
with either a blade plate or screw and plate
combination.
A, Two-year-old girl with congenital coxa vara. B,
Preoperative radiograph shows neck-shaft angle of
less than 90 degrees bilaterally at age 5 years. C,
After bilateral subtrochanteric osteotomies and
internal fixation with pediatric hip screw
Fixation Using Modified Verterinary
Plate
• A lateral view of the Synthes five-hole
veterinary
plate. The plate on the left is in
its original form, whereas the plate on the right
has been pro-bent in the manner carried out
before surgical implantation in the child. The
plate accepts standard small fragment 3.5 mm
cortical screws
Percutaneous Triplaner Femoral
Osteotomy
Advantages
• include avoidance of large open exposure and
decreased potential for significant blood loss,
while achieving an accurate and sustained
correction of the triplanar deformity.
• With an opening wedge osteotomy, limb length
discrepancy is improved without compromising
the quality and time of bony union. By avoiding
the
need
for
any
supplemental
cast
immobilization, early mobilization with a short
hospital stay is possible.
• Problems associated with internal fixation such
as prominent hardware, implant failure, the
possibility of violating the proximal femoral
growth plate, the need for second major
surgical procedure for removing an internal
implant, and the potential for deep infection
are significantly decreased
Disadvantages
These include a need to be familiar with the use
of the llizarov fixator,The inconvenience of the
pin sites with the possibility of drainage around
the pins is another drawback:
• Despite well-performed the other osteotomy,
the literature cites recurrence rates as high as
30% to 70%.
N.B:
• More important is not the actual type of
osteotomy performed but the goals of surgical
correction are achieved or not
After Treatment
• Regular follow-up includes assessment of
possible recurrence of the deformity and the
development of progressive limb-length
discrepancy that requires additional treatment.
Complications
1.Recurrence
2.Development of coxa Valga
3.Premature epiphyseal plate closure
4.Avascular necrosis
5.Degenerative changes
Complications
1. Recurrence
• Regardless at the method of osteotomy the
deformity can recur and children should be
examined periodically after surgery; until their
growth is complete. Despite well done
osteotomies, however, recurrence is ranging
from 30- 70%.
2. Development of coxa Valga
• A more frequently seen complication of the
intertrochanteric osteotomy procedure is the
development of coxa-valga deformity
postoperatively: this can be attributed to injury of the
greater trochanteric epiphysis, resulting in premature
growth arrest. This gradual change to valgus is due to
the continued growth of the capital epiphysis after
healing of cervical defect without the normal
restraining influence of the greater trochanteric
epiphysis
3. Premature epiphyseal plate closure
• The premature epiphyseal plate closure has not been
documented to relate to surgical trauma, patient age
or degree of valgus osteotomy correction but more
likely it represents a possible surgically induced
acceleration of natural epiphyseal plate closure. It has
been reported that, from 50% to 89% of operated hips
will demonstrate a premature closure of the proximal
femoral epiphyseal plate, and this usually occurs
within 12 to 24 months of surgery.
4. Avascular necrosis
Avascular necrosis of the femoral head was
reported in osteotomies above the level of the
greater trochanter ,and it was attributed to
abnormal sublaxation of the femoral head or
impairment of the vascular supply of the
femoral head.
5. Degenerative changes
• The degenerative changes in developmental coxavara appear in only 28.5 % of the patients. The
changes develop late (after the age of 30-40 years)
and in 15.8% of patients they are mild in 12.6 % of
patients they reach a considerable degree. However
Osteoarthosis may be moderate even in cases a major
reduction in the neck-shaft angle that was not
properly corrected early correction usually prevents
the development of coxa arthrosis