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ق�د�ير( صدق الله العظيمال

MANAGEMENT OF MANAGEMENT OF CONGENITAL COXA VARACONGENITAL COXA VARA

ByBy

Salah Mahmoud AbdelkaderSalah Mahmoud Abdelkader

M.B.B.ChM.B.B.Ch

SupervisorsSupervisors

Prof. Dr. Abdelfatah Kotb Ismail WaliProfessor of Orthopaedic Surgery

Faculty of MedicineZagazig University

Dr. Hossam Mohammed KhairyAssistant Professor of Orthopaedic Surgery

Faculty of MedicineZagazig University

Dr. Mohammed Elsadek AttiaLecturer of Orthopaedic Surgery

Faculty of MedicineZagazig 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 varaCoxa 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 varaConganital coxa varaDevelopmental abnormalityPrimary 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 HIPANATOMY 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 EpiphysisUpper 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 BIOMECHANICSHIP JOINT BIOMECHANICSA 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

EtiologyEtiology

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 VaraPathophysiology 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 The upper femoral epiphysis tends to tilt and become displaced medially, and the tensile become displaced medially, and the tensile

stresses increase.growth of the femoral neck is stresses increase.growth of the femoral neck is less on the medial side than on the lateral side. 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 PresentationClinical 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 CaseUnilateral 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

• 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

On ExaminationOn Examination

• 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 FindingsRadiographic Findings

CCV is differentiated radiographically from other forms of proximal femoral varus by

• The characteristic finding of an inverted Y-shaped 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 Y-

shaped 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.

TreatmentTreatment

1-Non surgical

2-Surgical

Non-surgicalNon-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 TreatmentSurgical Treatment

Indications of SurgeryIndications 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 Diagram of Hilgenreiner’s epiphyseal angle in CCV and normal hip angle in CCV and normal hip

Aims of treatmentAims 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 surgeryTiming 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 TreatmentMethods 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 PROCEDURESFEMORAL 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 osteotomiesIntertrochanteric 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 OsteosynthesisWagner multiple K-wire Osteosynthesis

Langenskiold’s OsteotomyLangenskiold’s Osteotomy

• Langenskiold’s osteotomy was used only when the neck shaft angle was lower than 80 degrees

Pauwels Y shaped osteotomyPauwels Y shaped osteotomy

SUBTROCHANTERIC VALGUS SUBTROCHANTERIC VALGUS OSTEOTOMIESOSTEOTOMIES

• 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 PlateFixation 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 Percutaneous Triplaner Femoral OsteotomyOsteotomy

AdvantagesAdvantages

• 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

DisadvantagesDisadvantages

• Despite well-performed the other osteotomy, the literature cites recurrence rates as high as 30% to 70%.

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:

• More important is not the actual type of osteotomy performed but the goals of surgical

correction are achieved or not

N.BN.B::

After TreatmentAfter Treatment

• Regular follow-up includes assessment of possible recurrence of the deformity and the

development of progressive limb-length discrepancy that requires additional treatment.

ComplicationsComplications

1.Recurrence

2.Development of coxa Valga

3.Premature epiphyseal plate closure

4.Avascular necrosis

5.Degenerative changes

ComplicationsComplications

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 coxa-

vara 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