congenital
COXA VARA
By
Dr. Tejaswi Dussa
Post Graduate In Ms Ortho
GH, Sec-bed
Coxa Vara
• Coxa vara is a complex
3-Dimensional deformity
includes varus and
retroversion of prox.femur
• Normal neck sha...
• Congenital/Developemental coxa vara
-Infancy
-Childhood
• Acquired
Congenital Coxa Vara
• INFANCY:
-rare
-at birth
-asso.with prox.femoral focal deficiency
cleido cranial dysostosis
other c...
• PATHOLOGICALLY IT CONSISTS OF :
-Progressive increasing acuteness of neckshaft
angle
-shortness of the femoral neck
-A v...
• Due to a defect of enchondral ossification in
the medial part of the femoral neck
• When child starts to crawl or stand,...
2 yrs old pt with congenital coxa vara
Developmental Coxa Vara
• Developmental coxa vara is a descriptive
term referring to the angular relation
between the femo...
Developmental Coxa Vara
•
•
•
•
•

Not present at birth
Not asso.with other sk.manifestations
Present after walking age 2n...
epidimiology
•
•
•
•

•
•
•
•
•

Developmental coxa vara is rare;
1 in 25,000 live births
There is no racial predilection....
ETIOLOGY
• Idiopathic
• Congenital
• Infections
• Trauma
• Tumors
• Scfe
• Epiphyseal Dysplasia
• Secondary To Vascular In...
Other Causes:
•
•
•
•
•

Metabolic bone disorders-paget’s ds
Post perthes deformity
Osteomyelitis
Post traumatic
Shepherd ...
• Exact Etiology:
– Currently remains unknown
– The most popular theory, proposed by Dylkkanes in
1960, states that the de...
CLINICAL PRESENTATION
• most commonly seen between when the child begins
to ambulate and age six
• most common complaint i...
• abduction and internal rotation of the affected hip are limited.
• With increasing coxa vara, the tip of the greater tro...
Physical Examination:
- prominent and elevated greater trochanter
- positive Trendelenburg test
- limb-length inequality (...
Clinical Evaluation

Quantification of the extent of radiographic deformity of the proximal
femur in developmental coxa va...
Radiographs
• AP- radiographs demonstrate a
- decreased neck–shaft angle of the affected hip,
- a widened radiolucent line...
This Radiograph Shows –
relative overgrowth of the
greater trochanter,

shortening of the femoral
neck,
varus deformity of...
• Histologic studies have shown that there are
abnormalities in both cartilage production and
metaphyseal bone formation. ...
• Coxa vara because of
short femoral neck
Biomechanics Of Congenital Coxa Vara
• Because of decreased neck shaft angle there will be
-decreased joint reaction force...
• To Achieve Optimal Biomechanical Reconstruction Of Hip
Joint In Coxa Vara‘’lateral Transposition Of Abductors,tenotomy o...
COMPLICATIONS OF UNTREATED COXA VARA
•
•
•
•

Acetabular dysplasia
Hip subluxation
Degenerative arthritis
In b/l cases inc...
• b/l developmental coxa
vara at age of 3yrs and
16 yrs who received no
treatment
-gait was extraordinarliry
good
• At the age of 40yrs with out treatment
• Marked deformity with secondary osteoarthritis
Indications For Surgery
•
•
•
•
•
•
•

Progressive varus deformity
Painful limp
Trendelenberg gait
Unilateral progressive ...
Goals Of Surgery
• Correction of femoral varus and retroversion
• Restoration of articulotrochantric distance
(abductor le...
•
•
•
•

HILGENREINER’S EPIPHYSEAL ANGLE
Normal is 30-40 deg
Increased on abnormal side
IncreasedHE angle 45-60deg calls f...
TIMING OF SURGERY
• The timing of surgery remains controversial. Several
authors recommend delay surgery until 5 6 years o...
OPERATIVE TREATMENT
• The presence of symptoms and the extent of proximal
femoral deformity as quantified by the H-E angle...
• F I X AT I O N O P T I O N S include
- Steinmann pins to the proximal and distal fragments incorporated in
plaster;
- tr...
CORRECTIVE VALGUS OSTEOTOMIES
• Valgus osteotomy of the upper femur at the
intertrochanteric or subtrochanteric level is
t...
• The amount of valgus correction clearly plays an
important role in the recurrence of deformity
with growth, which has be...
COMPLICATIONS:
• Recurrence of proximal femoral varus deformity-many
feel that this is due to undercorrection at surgery
...
• Acetabular dysplasia-found to be increase in
patients with premature physeal closure and
inpatients who have had an unde...
• Vitallium mold
arthroplasty done on
right side for
degenerative changes
• Valgus osteotomy and
Fixed angle blade plate
o...
WAGNER FIXATION
• It is performed with a bifurcated plate
driven through the intramedullary
surface of the proximal fragme...
CONTRAINDICATIONS TO OSTEOTOMY
•
•
•
•
•
•
•

Neuropathic arthropathy
Inflammatory arthropathy
Active infections
Severe os...
PAUWEL’S VALGUS OSTEOTOMY
• Preoperative tracking on
pelvic radiograph
• P=plane of physis
• H=horizontal line drawn
below...
• A ‘Y’ shaped osteotomy
will obtain a valgus
position
• By this method static
forces are converted
from shearing to
impac...
INTERTROCHANTRIC VALGUS
OSTEOTOMY
• BORDEN AND COLLEAGUES
described a technique of
valgus osteotomy in which
the trochante...
• The guide pin is used as a
landmark while the blade
of a blade plate of
appropriate size with an
angle of 140 degrees is...
• The level of osteotomy should
be 2 to 2.5 cm distal to the
angle of the blade.

• The lateral surface of the
proximal fr...
• Adductor tenotomy or
muscle release may be
necessary to facilitate
correction of the
deformity.
• The plate of the blade...
SUBTROCHANTRIC VALGUS OSTEOTOMY
• Here the length of the femoral head and neck doesnot
change,only the angle anf limb leng...
table
Procedure
• Perform an adductor tenotomy through a
small medial incision
• Expose the gr. Trochanter and prox.shaft
throug...
• Drill ahole just distal to
gr.trochanter and check its
placement
• Place an intermediate hip
compression screw
• If the ...
• Bilateral
subtrochanteric
osteotomy and internal
fixation with coventry
lag screw fixation.
After Treatment:
• A spica cast can be worn until union is
complete
• Cast can be removed at 8-12 wks
• Regardless of meth...
TAKE HOME MESSAGE
• Clinical evaluation at infancy/childhood to identify coxa vara ealry
and timely intervention as per de...
Thank you
congenital coxa vara
congenital coxa vara
congenital coxa vara
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congenital coxa vara

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congenital coxa vara

  1. 1. congenital COXA VARA By Dr. Tejaswi Dussa Post Graduate In Ms Ortho GH, Sec-bed
  2. 2. Coxa Vara • Coxa vara is a complex 3-Dimensional deformity includes varus and retroversion of prox.femur • Normal neck shaft angle 120-140 deg • Neck shaft angle of <120deg is called coxa vara • at birth it is 160 deg decreasing to 125deg in adult life
  3. 3. • Congenital/Developemental coxa vara -Infancy -Childhood • Acquired
  4. 4. Congenital Coxa Vara • INFANCY: -rare -at birth -asso.with prox.femoral focal deficiency cleido cranial dysostosis other conginital anomolies • CHILD HOOD: -more common -not discovered until the child is walking during 2nd -3rd yr of age -asso.with cong.short femur
  5. 5. • PATHOLOGICALLY IT CONSISTS OF : -Progressive increasing acuteness of neckshaft angle -shortness of the femoral neck -A vertical direction of the epiphyseal plate -relative over growth of gr.trochanter • An oblique defect in the neck ‘proximal medial’ to ‘distal lateral border’ • Triangular bony defect in inferior medial corner of the neck (this is compare to salter harris type-II physeal defect)
  6. 6. • Due to a defect of enchondral ossification in the medial part of the femoral neck • When child starts to crawl or stand, the femoral neck bends or get fractured because of stress forces • With continued wieght bearing it colapses increased in to varus and retroversion • There will be -varus -Retroversion -shortening & bowing of shaft
  7. 7. 2 yrs old pt with congenital coxa vara
  8. 8. Developmental Coxa Vara • Developmental coxa vara is a descriptive term referring to the angular relation between the femoral head or neck, or both, and the femoral shaft, which is less than the normal value for the patient's age.
  9. 9. Developmental Coxa Vara • • • • • Not present at birth Not asso.with other sk.manifestations Present after walking age 2nd-3rd yr Present with painful limb b/l cases progressive waddling gait/ trendelenberg gait • Limitation of hip abduction & internal rotation
  10. 10. epidimiology • • • • • • • • • Developmental coxa vara is rare; 1 in 25,000 live births There is no racial predilection. occurrence is equal in males to females and left to right bilateral involvement is note in 1/3of patients recent reports have shown increase incidence in black population compared with whites reports have also shown a familial pattern with an autosomal dominant form of transmission There are reports of the condition in families and in both homozygous and heterozygous twins Bilateral cases may be more likely to be associated with a generalized skeletal dysplasia.
  11. 11. ETIOLOGY • Idiopathic • Congenital • Infections • Trauma • Tumors • Scfe • Epiphyseal Dysplasia • Secondary To Vascular Insult
  12. 12. Other Causes: • • • • • Metabolic bone disorders-paget’s ds Post perthes deformity Osteomyelitis Post traumatic Shepherd crook deformity-severe form of coxa vara neck shaft angle <90deg -osteogenesis imperfecta -paget’s ds -osteomyelitis -tumours -tumour like conditions (fibous dysplasia)
  13. 13. • Exact Etiology: – Currently remains unknown – The most popular theory, proposed by Dylkkanes in 1960, states that the deformity is caused by a defect of enchondral ossification of the femoral neck. Weight bearing causes shearing stresses which result in fatigue of the dystrophic one and progressive varus deformity results – Other proposed theories include: Metabolic abnormalities cause a deficiency or delay in the ossification process
  14. 14. CLINICAL PRESENTATION • most commonly seen between when the child begins to ambulate and age six • most common complaint is a progressive gait abnormality in unilateral involvement this is due to both abductor muscle weakness and limb length inequality • patients with bilateral involvement have a waddling gait and increased lumbar lordosis (similar to that seen in bilateral DDH)
  15. 15. • abduction and internal rotation of the affected hip are limited. • With increasing coxa vara, the tip of the greater trochanter translates proximally relative to the center of the femoral head, and the origin and insertion of the hip abductors approach each other. • The Trendelenburg test is positive • In contradistinction to developmental dysplasia of the hip, no telescoping of the hip or other signs of instability, such as Ortolani's sign, are present. • Shortening is present in unilateral cases but seldom exceeds 3 cm at skeletal maturity, even in untreated patients.
  16. 16. Physical Examination: - prominent and elevated greater trochanter - positive Trendelenburg test - limb-length inequality (usually less 2.5 cm) - decreased ROM with restrictions noted with abduction and internal rotation
  17. 17. Clinical Evaluation Quantification of the extent of radiographic deformity of the proximal femur in developmental coxa vara. A, The neck–shaft angle is the angle between the axis of the femoral shaft and the axis of the femoral neck. B, The head–shaft angle is the angle between the axis of the femoral shaft and a perpendicular line drawn to the base of the capital femoral epiphysis. C, The Hilgenreiner–epiphyseal angle is the angle between Hilgenreiner's line and a line drawn parallel to the capital femoral physis
  18. 18. Radiographs • AP- radiographs demonstrate a - decreased neck–shaft angle of the affected hip, - a widened radiolucent line corresponding to the proximal femoral physis, - characteristically, but not universally, a triangular metaphyseal fragment in inferior femoral neck surrounded by radiolucent bands traversing the neck and forming an inverted Y • The superior, more horizontal radiolucent line is the capital femoral physis; • The inferior, more vertical line is an abnormal area of faulty maturation of cartilage and irregular ossification
  19. 19. This Radiograph Shows – relative overgrowth of the greater trochanter, shortening of the femoral neck, varus deformity of the femoral head and neck, vertical orientation of the capital physis, a radiolucent inverted V isolating a segment of the medial superior femoral neck.-
  20. 20. • Histologic studies have shown that there are abnormalities in both cartilage production and metaphyseal bone formation. These findings are similar to those found in the proximal tibia in patients with Blount's disease. • mechanical abnormalities may occur development and early ambulation during • partial vascular insult to the inferior aspect of the femoral neck • developmental abnormality which causes faulty cartilage formation and maturation
  21. 21. • Coxa vara because of short femoral neck
  22. 22. Biomechanics Of Congenital Coxa Vara • Because of decreased neck shaft angle there will be -decreased joint reaction forces -Increased shearing forces across the neck -altered mescle tension because of shortened leg -Altered resting length of hip abductors may cause persistant limp • Increased abductor lever arm • There is decreased joint forces across the hip during one leg stance as less muscle force is required to keep the pelvis horizontal position
  23. 23. • To Achieve Optimal Biomechanical Reconstruction Of Hip Joint In Coxa Vara‘’lateral Transposition Of Abductors,tenotomy of psoas And Adductors Tendon, Shortening of femur’’ Is Required • So valgus osteotomy my move trochanter laterally, -improving the strength of abductor contraction but joint forces may increase -Adducted position restores improved wieght bearing area to the diseased hip joint -Shortening of abductor lever arm -Lengthening of limb
  24. 24. COMPLICATIONS OF UNTREATED COXA VARA • • • • Acetabular dysplasia Hip subluxation Degenerative arthritis In b/l cases increased lordosis suggests dislocation of hip
  25. 25. • b/l developmental coxa vara at age of 3yrs and 16 yrs who received no treatment -gait was extraordinarliry good
  26. 26. • At the age of 40yrs with out treatment • Marked deformity with secondary osteoarthritis
  27. 27. Indications For Surgery • • • • • • • Progressive varus deformity Painful limp Trendelenberg gait Unilateral progressive shortening Asso.leg length discrepancy Neck shaft angle <110deg HE angle >60deg • TREATMENT : – aimed at the prevention of the secondary deformities caused by the disease's natural history on the proximal femur
  28. 28. Goals Of Surgery • Correction of femoral varus and retroversion • Restoration of articulotrochantric distance (abductor lever arm) • Create HE angle of <40 deg • Converting the abnormal shearing streses to compressive forces at femoral neck • Efficiency of g.medius muscle has been improved by lowering gr.trochanter • Rapidly progressive coxa vara is best treated by proposed surgery • Surgery can be delayed until the child 4-5yrs old to make internal fixation easier
  29. 29. • • • • HILGENREINER’S EPIPHYSEAL ANGLE Normal is 30-40 deg Increased on abnormal side IncreasedHE angle 45-60deg calls for careful followup • HE angle >60deg, proggresive shortening indication for surgery
  30. 30. TIMING OF SURGERY • The timing of surgery remains controversial. Several authors recommend delay surgery until 5 6 years of age. Others state that surgery may be performed after 18 months if the below criteria are met. • goal of surgical treatment is to produce an overcorrection of valgus angle to >150 - 160 degrees, as well as, correction of epiphyseal angle to less than 30 degrees
  31. 31. OPERATIVE TREATMENT • The presence of symptoms and the extent of proximal femoral deformity as quantified by the H-E angle are the primary determinants of the need for surgical correction of the deformity. • Normal HE angle is 30-40 deg that is increased on abnormal side • Valgus osteotomy of is recommended in hips with an H-E angle of 60 degrees or greater • is not usually required in patients with an angle less than 45 degrees, • and may or may not be required in patients with angles between 45 and 59 degrees
  32. 32. • F I X AT I O N O P T I O N S include - Steinmann pins to the proximal and distal fragments incorporated in plaster; - transfixing crossed Steinmann pins; - external fixation with monolateral half-pin fixators; - hybrid circular external fixation with wires and half-pins, - bifid plates (as described in Muller, Allgower, and Willenegger), - vitallium mold arthroplasty for degenerative disease - standard blade plates, - dynamic hip compression plates. – - pauwels valgus osteotomy - subtrochantric valgus osteotomy - inter trochantric valgus osteotomy The latter forms provide the most secure forms of internal fixation in a child with adequate bony development.
  33. 33. CORRECTIVE VALGUS OSTEOTOMIES • Valgus osteotomy of the upper femur at the intertrochanteric or subtrochanteric level is the most effective way to correct the varus deformity, - to rotate the proximal femoral physis from a vertical to horizontal position (relieving shear stress on it), - to enhance ossification of the defect
  34. 34. • The amount of valgus correction clearly plays an important role in the recurrence of deformity with growth, which has been estimated to occur in 30% - 70% of cases • Treatment of coxa vara in chindren with cervico trochantric # a closing wedge osteotomy just distal to gr.trochanter using a pediatric lag screw with a side plate for internal fixation
  35. 35. COMPLICATIONS: • Recurrence of proximal femoral varus deformity-many feel that this is due to undercorrection at surgery while others feel that it is due to failure to place the osteocartilaginous defect into a compressive mode • Premature physeal closure-the incidence may be as high as 89% and has not been found to be related to physeal injury at the time of surgery • Greater trochanteric overgrowth-associated with premature capital femoral physeal closure and is commonly treated by greater trochanter transfer or epiphysiodesis
  36. 36. • Acetabular dysplasia-found to be increase in patients with premature physeal closure and inpatients who have had an undercorrection of the neck-shaft angle less than 140 degrees • other complications have included pseudarthrosis, avascular necrosis, leg-length discrepancy, and degenerative arthritis
  37. 37. • Vitallium mold arthroplasty done on right side for degenerative changes • Valgus osteotomy and Fixed angle blade plate on left side
  38. 38. WAGNER FIXATION • It is performed with a bifurcated plate driven through the intramedullary surface of the proximal fragment and secured to the distal fragment with screws • A variation of this technique is to perform the osteotomy slightly more proximally after insertion of an appropriate-sized screw of a dynamic compression hip screw device, • insert the lateral distal edge of the proximal fragment into the medullary canal of the distal fragment, and secure the distal fragment to the plate portion of the device
  39. 39. CONTRAINDICATIONS TO OSTEOTOMY • • • • • • • Neuropathic arthropathy Inflammatory arthropathy Active infections Severe osteopenia Advanced arthritis/ankylosis Advanced age *smoking, obesity
  40. 40. PAUWEL’S VALGUS OSTEOTOMY • Preoperative tracking on pelvic radiograph • P=plane of physis • H=horizontal line drawn below the lesser trochanter • Deside angle of closing wedge osteotomy from the proximal femur to correct the angle of inclination of physis
  41. 41. • A ‘Y’ shaped osteotomy will obtain a valgus position • By this method static forces are converted from shearing to impacting forces • Femoral head and neck are supported by calcar femorale • Union is more and recurrence is less likely
  42. 42. INTERTROCHANTRIC VALGUS OSTEOTOMY • BORDEN AND COLLEAGUES described a technique of valgus osteotomy in which the trochanteric region and the proximal shaft of the femur are exposed through a lateral longitudinal approach[. • Under image intensifier a guidewire is inserted into the center of the superior half of the femoral neck parallel to its upper border.
  43. 43. • The guide pin is used as a landmark while the blade of a blade plate of appropriate size with an angle of 140 degrees is inserted into the neck. • The blade should be parallel to the long axis of the femoral neck. • Predrilling a slot facilitates insertion of the blade. • Next, an intertrochanteric transverse osteotomy is made under radiographic control.
  44. 44. • The level of osteotomy should be 2 to 2.5 cm distal to the angle of the blade. • The lateral surface of the proximal fragment is roughened. • The head and neck of the femur are adducted by using the blade as a lever, and the femoral shaft is abducted. • The lateral cortex of the upper fragment is thus approximated to the upper end of the lower fragment.
  45. 45. • Adductor tenotomy or muscle release may be necessary to facilitate correction of the deformity. • The plate of the blade plate is fixed to the shaft with screws. • postoperative one-andone-half-hip spica cast should be applied. • The cast is removed when the osteotomy has healed.
  46. 46. SUBTROCHANTRIC VALGUS OSTEOTOMY • Here the length of the femoral head and neck doesnot change,only the angle anf limb length changes • Determine preoperatively the amount of valgus necessary to align the hip properly by comparing the radiograph of c/l hip • The estimted increase in leg length ‘Delta H’ is given for the desired angle obtained by the valgus osteotomy Delta h=L(cos@1-cos@) • When the angle of correction is determined the appropriate laterally based closing wedge osteotomy can be determined • First detrmine the diameter of the bone by drilling a guide pin transversely through the femur w=tangant angle x the diameter W=0.02 x diameter x angle
  47. 47. table
  48. 48. Procedure • Perform an adductor tenotomy through a small medial incision • Expose the gr. Trochanter and prox.shaft through 8-10 cm lateral incision • Make a transvberse osteotomy just distal to to the screw at about the level of lesser trochanter take lateral wedge of bone as per tangent formula • Fix the side plate in the usual manner
  49. 49. • Drill ahole just distal to gr.trochanter and check its placement • Place an intermediate hip compression screw • If the child is young avoid crossing the physis • If it is for nonunion coprerssion hip screw should cross the nonuion site, and if it is proximal, crossing the physis may be necessary for union • If grafting is necessary,is incerted by drilling a hole the size of the graft up through the femoral neck adjacent and parallel to the fixation divice
  50. 50. • Bilateral subtrochanteric osteotomy and internal fixation with coventry lag screw fixation.
  51. 51. After Treatment: • A spica cast can be worn until union is complete • Cast can be removed at 8-12 wks • Regardless of method of osteotomy the deformity can recur so children should be examined periodically after surgery until their growth is complete
  52. 52. TAKE HOME MESSAGE • Clinical evaluation at infancy/childhood to identify coxa vara ealry and timely intervention as per degree of severity • Non surgical interventions has got greater degree of failure and asso.complications • Surgery can be delayed until the child 4-5yrs old to make internal fixation easier • currently, the most effective surgical treatment is a valgus producing proximal femoral osteotomy (subtrochanteric and intertrochanteric procedures have similar results) • Postoperative followup is adviced in children until epiphyseal fusion is complete till adult age group • correction of coxa vara is not itself a curative of exact cause of coxa vara… we should exclude the existance of the etiological risk before intervention.
  53. 53. Thank you

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