A 3-year-old girl presented with a limp in her right leg and was diagnosed with coxa vara. Coxa vara is a decrease in the angle between the femoral neck and shaft to less than 120 degrees. It can be congenital, developmental, or secondary to other bone diseases. Surgical management involves subtrochanteric osteotomy to correct the angle, which is fixed internally with plates or screws. Postoperative care includes casting for 8-12 weeks until radiographic healing is seen. Complications can include recurrence, physeal injury, or leg length discrepancy.

1. Case presentation
 A full term girl was born via vaginal delivery, her
birth weight was 1800 g,she had anomalous
pulmonary venous drainage and for that reason she
was managed at the intensive care unit until the age
of 12 days and was operated for some cardiac and
pulmonary anomaly, the platelet count was within
normal range (150-400×103/ml), WBC count was
normal (10-20×103/ml) no fever was registered. She
subsequently did well and met all of her early
developmental milestones, including walking at age
12 months.

2. Case presentation cont..
 She had no orthopedic issues until she was 3 year-10
months-old, when she presented with limp related to
the right lower limb, with no pain. She had a leg-length
discrepancy of 2 cm (right - left), limited right
hip abduction to 25°, and internal rotation to 5°, also
had a positive Trendelenburg test. No
flexion/extension abnormalities.

3. DIAGNOSIS?

4. COXA VARA
DR ISMAIL KHAN
PG TRAINEE ORTHOPEDICS B UNIT
HMC PESHAWAR.

5. INTRODUTION
 Coxa vara is progressive decrease in the angle
between the femoral neck and shaft,less then 120
degrees
 Normal angle(120—135 degrees)
 Coxa vara is often bilateral
 A progressive shortening of the limb

6. Less then 120
degrees
Less
then 120

7. Epidemiology
 coxa vara(Congenital) is relatively rare condition
 incidence ranging from 1 per 13,000 population to 1
per 25,000 population
 Bilateral involvement seems to occur only half as
often as unilateral involvement
 No clear pattern of inheritance
 But familial involvement in a number of cases has
suggested an autosomal dominant genetic pattern of
transmission.

8. CLASSIFICATION
 idiopathic :
 congenital : mild or severe coxa vara, with associated short or bowed
femor.
 developmental : progressive, usually appearing between the ages of
two and six years
 rachitic : usually associated with active rickets.
 adolescent : secondary to slipped capital femoral
epiphysis.
 traumatic : usually following fracture of the femoral neck
(rare in children).
 inflammatory : secondary to tuberculosis or other
infection.

9. CLASSIFICATION cont..
 secondary to other underlying bone diseases such as
 osteogenesis imperfecta
 cretinism
 dyschondroplasia
 Paget's disease
 osteoporosis
 capital coxa vara : occasionally seen in severe
osteoarthritis and Legg-Perthes' disease

10. Etiology of congenital CV
 The exact cause of congenital coxa vara (CCV)
remains unknown
 Many hypotheses have been proposed
i. mechanical intrauterine stresses affecting hip
development
ii. avascular necrosis involving proximal femoral
physis/head and neck;
iii. Metabolic or endocrine abnormalities causing
deficient or a delay in, the normal ossification
process.

11. Pathophysiology
 Abnormal development of proximal femoral
cartilaginous physis.
 Microscopically tissue in this defect consists of
cartilage with irregular cell arrangement and
ossification within it is atypical.
 Metaphyseal bone is osteoporotic
 Its trabeculae being atrophic.
 When walking is begun, the forces that the
femoral neck must withstandare increased, and
because the neck is weak, varus deformity
gradually develops.

12. Presentation
Affected children generally present between 1 to 6
years of age.
 usually present with gait abnormalities
 Limp(unilateral) ,weddling gait(bilateral)
 The Trendelenburg sign is commonly elicited in the
affected hip or hips
 Shortenting of limb
 Trochanter is displaced upwards
 Decreased rotation and abduction of hip
 Pain stifness and flexion contracture

16. Figure . Abduction at the hip joint, viewed from behind. A, Normally, when
weight is borne on one (e.g., the right) limb (during the stance phase of
walking), the pelvis tends to sag on the free, or swing (left), side (because of
gravity). This is counteracted by abduction of the hip on the stance (right)
side, chiefly by strong contraction of the (right) gluteus medius, which acts
on the pelvis from a fixed femur. B, When abduction of the (right) hip is
interfered with on the supported side (positive Trendelenburg's sign)

17. Non surgical managment
 including spica cast immobilization and skeletal pin
traction with bed rest, with generally unsatisfactory
results

18. Surgical managment
 The treatment of choice is subtrochanteric osteotomy
 Surgery can be delayed until the child is 4 or 5 years old to
make internal fixation easier
 Indications
1. femoral neck-shaft angle less than 90 - 100
degrees
2. Hilgenreiner's-epiphyseal angle greater than 45-
60 degrees
3. documented decrease in the femoral neck-shaft
angle
4. Trendelenburg gait

20. Congenital coxa vara. Surgical methods of valgus-producing
proximal femoral osteotomies. (A) Pauwels
Y-shaped osteotomy. (B) Langenskiöld
intertrochanteric osteotomy. (C) Borden
subtrochanteric osteotomy.

21. Pauwels Y-shaped osteotomy

22. Pauwels Y-shaped osteotomy

23. Langenskiöld intertrochanteric osteotomy

24. Borden subtrochanteric osteotomy.

27.  The subtrochanteric osteotomy is fixed internally
with either
a) a blade plate or
b) screw and plate combination
 Although biomechanically this may provide enough
rigid internal fixation to eliminate the need for
postoperative immobilization,
 a spica cast can be worn until union is complete.

28. TECHNIQUE
■ Perform an adductor tenotomy through a small medial
 incision.
 ■ Expose the greater trochanter and proximal shaft of the
 femur through an 8- to 10-cm lateral, longitudinal
 incision.
 ■ If a screw and side plate device is used for internal fixation,
 insert the screw in the midline of the femoral neck
 as determined by image intensification or anteroposterior
 and lateral radiographs. Insert the screw as close as possible
 to the trochanteric apophysis without entering it. If
 possible, center the screw in the femoral neck distal to
 the abnormal physis. If this is technically impossible,
 center the screw in the femoral head.
 ■ Make a transverse osteotomy slightly distal to the screw
 at about the level of the lesser trochanter.
 ■ If necessary, take a small lateral wedge of bone to correct
 the neck-shaft angle to 140 to 150 degrees.
 ■ Fix the side plate to the femoral shaft in the usual manner.
 ■ Irrigate the wound, and close it in layers, inserting
 irrigation-suction drainage if desired.
 ■ Apply a one and one-half spica cast

29. POSTOPERATIVE CARE
 The cast is removed at 8 to 12 weeks, when
radiographic union of the osteotomy has occurred.
 Regular follow-up includes assessment of possible
recurrence of the deformity and the development of
 progressive limb-length discrepancy.

30. Complications
 Recurrence of proximal femoral varus deformity.
 Premature physeal closurerelated to physeal injury
at the time of surgery
 Greater trochanteric overgrowth-associated
 Acetabular dysplasia
 pseudarthrosis,
 avascular necrosis,
 leg-length discrepancy, and degenerative arthritis

31. THANKS