Surgical correction of coxa vara: Evaluation of neck shaft angle,Hilgenreiner-epiphyseal angle for indication of recurrence

BackgroundCoxa vara is a hip deformity in which the femoral neck-shaft angle decreases below its normal value. Standard surgical treatment for this condition is corrective valgus osteotomy. Appropriate correction of the Hilgenreiner-epiphyseal angle is important to prevent recurrence. The purpose of this study is to: 1) evaluate the recurrence of the deformity at the latest follow up; and 2) find the appropriate angle of correction associated with the lowest recurrence.Methods34 hips in 31 patients who underwent surgery for treatment of coxa vara from 2005 to 2014 were included. Patient-reported outcomes, Hilgenreiner-epiphyseal angle, and neck-shaft angle were assessed preoperatively, postoperatively, and at latest follow-up.ResultsThe mean age at surgery was 10.99, with a range of 5–30, years. Preoperative neck-shaft angle ranged from 60 to 100 degrees, and Hilgenreiner-epiphyseal angle ranged from 60 to 90 degrees. At the latest follow up, the neck-shaft angle ranged from 120 to 135 degrees and the Hilgenreiner-epiphyseal angle ranged from 22 to 35 degrees (p < 0.001). The Harris hip score improved from 47.20 (34–66) to 79.68 (60–100) (p < 0.001). There was no recurrence of deformities at the mean follow up of 37.87 months.ConclusionSurgical correction of coxa vara in various pathologies can be done successfully with the Hilgenreiner-epiphyseal angle corrected to ≤ 35 degrees or the neck shaft angle corrected to > 120 degrees in order to prevent recurrence of the deformity. Majority of the patients were reported improvement of hip function. However, a longer-term follow up is required to determine further outcomes regarding to recurrence of the deformity.     

股骨转子间杵臼状外展截骨术治疗儿童髋内翻

本文报告采用股骨转子间杵臼状外展截骨术治疗儿童髋内翻１０例（１４髋）。年龄为６～１２岁。截骨处均在８周愈合。８例（１２髋）随访３～１０年（平均４年２月），均取得满意疗效。作者认为，本术式方法简单，截骨处接触面大，截骨后稳定，愈合快，畸形矫正满意，疗效好。对股骨颈干角小于１１０°者均可采用本法矫正，较大儿童颈干角应矫正至１３５°～１４５°。截骨后应以钢板螺丝钉内固定，并用髋人字石膏固定６～８周。     

Wagner multiple K-wire osteosynthesis to correct coxa vara in the young child: experience with a versatile 'tailor-made' high angle blade plate equivalent

In 1978, Wagner described a technique using multiple Kirschner wires (K-wires) to stabilize an intertrochanteric osteotomy performed for the correction of coxa vara in small children. Multiple K-wires are used to create a custom high-angle blade plate for valgus osteotomy. The authors have evaluated a retrospective series of 17 Wagner intertrochanteric osteotomies that were performed in 10 children with coxa vara between the ages of 1 year and 8 years. The neck-shaft angle was corrected from 93.5 degrees to 129.5 degrees at long-term follow-up, and the Hilgenreiner epiphyseal angle was corrected from 71 degrees to 37.6 degrees at long-term follow-up. Revision surgery was performed on five hips with inadequate initial surgical correction. Complications included a single broken K-wire, a femur fracture after hardware removal, and one hip developed avascular necrosis postoperatively.     

Late femoral osteotomy in congenital dislocation of the hip

We describe 95 patients with previously treated congenital dislocation of the hip who underwent femoral osteotomy after the age of five years. The commonest indication for surgery was progressive uncovering and subluxation of the femoral head; other reasons were coxa vara, long leg dysplasia and persistent anteversion. Femoral osteotomy for uncovering of the femoral head (Severin Grade III) in this age group gave good results at maturity only when the acetabular angle was less than 25 degrees before operation. Femoral osteotomy alone was inadequate for true subluxation of the hip (Severin Grade IV).     

Progressive coxa vara by eccentric growth tethering in immature pigs

The present study tested progressive coxa vara by eccentric growth tethering that might be used to correct coxa valga in cerebral palsy. Eight young pigs received screw fixation at inferior portion of right femoral head at age 4 months and were killed at age 7.25 months for bilateral femurs for comparison. The neck-shaft angle at the tethered side was significantly less than that at the control side (129.8 vs. 138.3 degrees , P<0.05). Histological study showed bony bar formation. Eccentric growth tethering by one screw resulted in a reduction of neck-shaft angle by 8.5 degrees and shortening of femoral length by 4%.     

High prevalence of coxa vara in patients with severe osteogenesis imperfecta

The purpose of this study was to determine the incidence and clinical presentation of coxa vara in 283 patients with osteogenesis imperfecta (OI). The charts and X-rays of 150 girls and 133 boys with OI were reviewed. The patients were classified according to the Sillence classification modified by Glorieux: 94 type I, 90 type IV, 67 type III, 18 type V, 10 type VI, and 4 type VII. The mean age was 9.4 years (range 0.3-23.3). Twenty-nine patients (10.2%) had coxa vara (23 left and 20 right). Fifty-five percent of them were type III, 24% type IV, 13.8% type VI, and 3.4% each of types V and VII. The incidence of coxa vara was 6% in type V, 8% in type IV, 24% in type III, 25% in type VII, and 40% in type VI (P < 0.001 for difference between types I, III, and IV). The mean neck-shaft angle was 99 degrees (range 80-110 degrees), the average head-shaft angle was 104 degrees (range 90-120 degrees), and the mean Hilgenreiner-epiphyseal angle was 68 degrees (range 40-90 degrees). Twenty-five patients (36 hips) had previous femoral rodding before diagnosis and seven hips (all type III) had no history of rodding. Abduction and internal rotation of the hip joints were restricted in all patients with this deformity. All children with coxa vara had a Trendelenburg gait. In conclusion, coxa vara in OI is not rare, especially in severe forms of the disease. Regular clinical and radiologic follow-up is indicated in children with previous femoral rodding and in severely affected children, particularly those with OI type III.     

Transfixing Kirshner wires for fixation of intertrochanteric valgus osteotomies in management of pediatric coxa vara

Background

Coxa vara is a radiological term describing a decrease in the neck–shaft angle to 120° or less. Coxa vara is associated with pathomechanical changes that can manifest clinically. If left untreated, coxa vara can affect the normal development of the pediatric hip. Valgus osteotomy is the standard surgical treatment for coxa vara, but there is no consensus regarding the optimal osteotomy technique and fixation method. The work reported here aimed to highlight transfixing wires as a fixation method for valgus osteotomy applied as treatment for various types of pediatric coxa vara.

Materials and methods

This study included 16 cases of pediatric coxa vara with different etiologies in 9 patients with a mean age of 39.9 ± 15.2 months. Radiological and clinical evaluations and scoring of the condition of each patient according to the Iowa Hip Score were performed pre- and postoperatively. Transfixing wires and a protective spica were used for the fixation of a V-shaped, laterally based, closing-wedge valgus osteotomy in all cases. The postoperative follow-up period ranged from 14 to 102 months, with a mean duration of 33.3 ± 27.7 months.

Results

The mean Hilgenreiner epiphyseal angle (HEA) was corrected from 81.7 ± 2.2° to 24.3 ± 3.5° and the mean femoral neck–shaft angle (FNSA) was improved from 86.9 ± 4.2° to 138.6 ± 3.5°. No recurrence of the deformity was observed during the follow-up periods considered here. The osteotomy site united after an average of 11.7 ± 2.2 weeks with no secondary displacement, and in cases of developmental coxa vara there was progressive ossification of the neck defect with no surgery-related complications. Clinical results were markedly improved by the osteotomy, with a mean postoperative Iowa Hip Score at last follow-up of 95.06 ± 2.6, compared to a mean preoperative score of 57.4 ± 3.6.

Conclusions

Transfixing wires protected in a hip spica cast represent a simple, easy, and reliable fixation method for valgus osteotomies performed to correct pediatic coxa vara. It assures stable fixation and rapid healing of the osteotomy without loss of the achieved correction, it completely avoids the femoral neck affording marked protection to the growth plate.

Level of evidence

IV.

     

Congenital coxa vara: computed tomographic analysis of femoral retroversion and the triangular metaphyseal fragment

Three patients with congenital coxa vara studied with two- and three-dimensional computed tomographic (2DCT and 3DCT) methods are reported. In all cases, the femoral retroversion was documented and subsequently corrected by proximal femoral osteotomy. In two patients with isolated coxa vara, the physeal-femoral neck angle was decreased as seen in slipped capital femoral epiphysis in adolescents. Our studies suggest that the triangular metaphyseal fragment reflects a Salter-Harris type II separation pattern through the defective femoral neck. The epiphysis and attached triangular fragment slip from the normal superoanterior portion of the neck in an inferior-posterior direction. The treating surgeon should be aware of the often marked femoral retroversion component present in severe congenital coxa vara. This knowledge allows surgical planning for corrective osteotomies that will better normalize hip mechanics. A combination of marked valgus and flexion with internal rotation of the distal fragment are required to fully correct the deformity.     

截骨矫形钢板固定治疗股骨近段纤维结构不良伴髋内翻畸形

目的 探讨股骨转子下截骨矫形、动力髋或髁螺钉系统固定治疗股骨近段纤维结构不良(fibrous dysplasia,FD)伴髋内翻畸形的临床疗效.方法 回顾性分析2001年4月至2010年5月收治的26例股骨FD伴髋内翻畸形患者的临床资料,男9例,女17例;年龄10～53岁,中位年龄19岁.单骨型14例,多骨型12例.病灶长度为多骨型9～36 cm(平均19 cm),单骨型7～15 cm(平均9 cm);17例合并病理性骨折;术前颈干角65°～110°(平均92°),患肢短缩1.5～4.5cm(平均2.8 cm).21例病灶累及股骨颈者采用髋螺钉固定,5例未累及股骨颈者采用髁螺钉固定.结果 手术时间80～170 min(平均120min),出血量280～1650ml(平均960ml).术后颈干角为119°～140°(平均127°);患肢平均延长2.3 cm(1.5～3.6 cm).随访9～118个月(平均39个月),截骨面均愈合.除1例颈干角从术后126°减小到术后56个月的115°,其余患者无髋内翻畸形复发,无内固定断裂或松动.1例股骨颈变短、髋螺钉沿滑槽滑动,但螺钉未切割股骨头;1例术后7年外伤后钢板远端处股骨干骨折.根据Guille的功能评价标准,24例满意、2例不满意.结论 转子下截骨矫形、动力髋或髁螺钉系统内固定能有效地纠正股骨上段FD伴髋内翻畸形,改善患肢功能.

Abstract：

Objective To investigate the clinical effect of subtrochanteric osteotomy plus dynamic hip/condyle screw (DHS/DCS)fixation to treat the fibrous dysplasia of the proximal femur with coxa vara.Methods Twenty-six clinical cases of femoral fibrous dysplasia with coxa vara were retrospectively analysed from April 2001 to May 2010.There were 9 males and 17 females,with a median age of 19(10 to 53).Forteen patients presented with monostotic disease,and 12 with polyostotic disease.The length of the lesion for polyostotic disease was from 9 cm to 36 cm,while for monostotic disease was from 7 cm to 15 cm.Seventeen cases were merged with pathologic fracture.The neck shaft angles were from 65 to 110 degree preoperation.The shortage of limbs was from 1.5 cm to 4.5 cm.Twenty-one patients involved in femoral neck were fixed with DHS and the other 5 cases with DCS.Results The duration of operation was from 80 to 170 min.The amout of bleeding was from 280 to 1650 ml with the average of 960 ml.The average postoperative neck shaft angles were 127 degree(119 to 140).The shortened limbs were extended 2.3 cm for average (1.5 to 3.6 cm).The follow-up time was from 9 to 118 months with the average of 39 months.All patients with osteotomy were healed.The neck shaft angle of 1 case decreased from post-operative 126°to 115°56months post-operatively,no coxa adducta recurrented and all internal fixations were in position.Hip screw backed out through the barrel in one case with the shortage of femoral neck.One case had femoral fracture after an injury.According to Guille function standard,24 cases were regarded as satisfied and 2 cases as unsatisfied.Conclusion Subtroehanteric osteotomy plus DHS/DCS fixation can effectively correct the fibrous dysplasia of the proximal femur with coxa vara,and significantly improve the function.     

Modified Pauwels' intertrochanteric osteotomy in neglected femoral neck fractures in children: a report of 10 cases followed for a minimum of 5 years

OBJECTIVES: To evaluate the role of a modified Pauwels' intertrochanteric osteotomy (MPIO) in neglected femoral neck fractures in children. DESIGN: Prospective study with retrospective analysis. SETTING: Tertiary care Postgraduate Institute of Medical Sciences. PATIENTS: Ten children (8 males, 2 females) with an average age of 10.2 years with neglected femoral neck fractures were seen from 1990 to 1998. A femoral neck fracture was considered neglected when no proper medical treatment was instituted for at least 1 month following the fracture. Nonunion was accompanied by coxa vara and resorption of the femoral neck in 9 patients; a 10th patient had a neglected femoral neck fracture for 1 month without coxa vara. Three patients at time of presentation with Delbet Type II displaced fractures with associated nonunion and coxa vara (2 with Ratliff Type III and 1 with Type I) also had avascular necrosis using plain radiographic criteria of increased density. INTERVENTION: Modified Pauwels' intertrochanteric osteotomy. The children were immobilized in a hip spica for 6-10 weeks postoperatively and weightbearing was started after hip spica removal. MAIN OUTCOME MEASUREMENTS: Fracture healing, neck-shaft angle, avascular necrosis, and functional outcome. RESULTS: Patients were followed for an average of 8.2 years (range 5-12 years). All patients had union of their fracture within an average of 16.6 weeks (12-20 weeks) and of the osteotomy site within 8.2 weeks (7-9 weeks). Radiologic signs of avascular necrosis disappeared completely in the 3 patients who presented with avascular necrosis. In 1 patient with a preoperatively viable femoral head, radiologic signs of Ratliff Type I avascular necrosis appeared between 60 and 98 weeks. This radiologic finding became normal again, indicating viability of the femoral head somewhere between 98 to 205 weeks of follow-up. Postoperatively, an average of 135-degree neck-shaft angle was achieved (range 125-160 degrees). The average preoperative neck-shaft angle was 104.4 degrees (range 92-120 degrees) and on the normal hip side it was 127.7 degrees (range 124-132 degrees). Significant improvement in the neck-shaft angle was seen compared with the preoperative angle (P < 0.001) and normal hip angle (P < 0.05). Coxa vara and signs of chondrolysis were not observed in any of the patients. Premature proximal femoral epiphyseal closure resulting in a 1-cm and a 1.5-cm leg-length discrepancy was seen in 2 patients as compared with their normal side. A mild Trendelenburg gait was observed in 1 patient (10%). Using Ratliff's criteria, 9 patients (90%) were graded as a good result and 1 patient (10%) was graded as a fair result. The osteotomy plate was removed in 1 patient (10%). CONCLUSION: An MPIO creates a biomechanical environment conducive to healing of a neglected femoral neck nonunion in a child while simultaneously correcting an associated coxa vara. The procedure also seems to have a biological role in helping restore viability to a noncollapsed femoral head with avascular necrosis.     

Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children.

Seventeen transcervical/basal femoral neck fractures in children were treated by free fibular graft and cancellous lag screw. Two cases were failures of a previous surgery, and 15 had been untreated for 3 weeks or more. Four cases had radiological evidence of avascular necrosis of the head and one of the neck preoperatively; five cases had neck resorption. At an average of 48.1 months postsurgery all fractures had united and there was only one new case of avascular necrosis. Four cases had coxa vara, and four cases had premature epiphyseal closure. There were 13 good, three fair, and one poor result(s) using Ratliff's criteria. We recommend this procedure in cases with delayed initial appearance or failed previous surgery. Complications of the procedure such as long screw/graft and fibular fracture are preventable. The incidence of coxa vara in cases with neck resorption may be reduced by adding subtrochanteric osteotomy to the procedure.     

Two clinical variants of spondylo-epiphysial dysplasia congenita

Seventeen patients with congenital spondylo-epiphysial dysplasia from six centres in Britain have been investigated and two variants delineated. There is wide clinical and radiological variability in each group with overlap between them, but 12 of the patients had very short stature and grossly disorganised hips with severe coxa vara, and the five remaining patients were less seriously affected with height only a little below the third percentile and only mild coxa vara. Both groups can be diagnosed at birth but the two cannot be differentiated on clinical and radiological grounds until after the age of three to four years when the developing severe coxa vara and difference in stature become apparent. All cases were sporadic with the exception of a concordant twin-pair.     

Y型截骨术治疗先天性髋内翻

[目的]探讨Y型截骨、鹅头钢板内固定治疗先天性髋内翻。[方法]对7例9髋先天性髋内翻采用股骨小粗隆下截骨、股骨大粗隆外侧截骨。截骨线呈Y型,股骨远侧断端与股骨大粗隆外侧截骨面相对合,以鹅头钢板内固定。[结果]本组随访1~5年(平均3.6年),按史颖奇评定标准,优4髋,良4髋,可1髋。[结论]Y型截骨、鹅头钢板内固定能够改善股骨上端异常结构,增加患肢真性长度,是治疗先天性髋内翻的有效方法。     

Stress fractures of the femoral neck and coxa vara

BACKGROUND: Theoretically, coxa vara substantially modifies the biomechanical conditions of the femoral neck, increasing the effect of direct muscle pull and leading to fatigue of opposing muscle groups; such modifications would appear to favour the appearance of stress fractures. METHODS: We studied 22 stress fractures of the femoral neck, 12 in patients with coxa vara (group A) and 10 in patients with a normal neck-shaft angle (group B), to assess the possible influence of the femoral angle in the production of stress fractures. RESULTS: Intergroup differences were found for age at the appearance of the fracture (younger patients in the coxa vara group) and symptom duration (longer in group A). CONCLUSIONS: It is suggested that coxa vara predisposes to femoral neck stress-fracture.     

PFNA及倒置 LISS钢板治疗股骨近端骨折的对比研究

 目的探讨股骨近端螺旋刀片抗旋髓内钉(proximal femoral nail antirotation blade,PFNA)和倒置股骨远端锁定接骨板(less invasive stabilization system,LISS)治疗股骨近端骨折合并髋内翻畸形患者的临床疗效并进行对比分析。方法回顾性分析 2007年 6月至 2010年 6月采用 PFNA和倒置 LISS钢板内固定治疗且随访时间超过 10个月的股骨近端骨折合并髋内翻畸形患者 46例的病例资料.采用 PFNA内固定治疗者 24例.采用倒置 LISS钢板内固定治疗者 22例。所有患者术后 6h开始不负重状态下功能锻炼。对比分析两组患者术前美国麻醉学会(American society of anesthesiologists,ASA)评分、手术时间和术中失血量、术后完全负重时间、骨折愈合时间、Parker-Palmer活动评分和颈干角角度丢失的情况。结果 所有患者获得 10~12个月随访.平均 11.2个月。两组术前 ASA评分、手术时间、术中失血量和末次随访 Parker-Palmer活动评分的差异均无统计学意义。倒置 LISS钢板组完全负重时间和骨折愈合时间较 PFNA组延长.颈干角角度丢失减少。结论 PFNA固定允许患者早期负重;但对于骨质疏松严重、内固定切割风险较高的患者.倒置 LISS钢板固定有助于降低术后髋内翻的发生率。     

Effect of finger ulnar deviation on gliding resistance of the flexor digitorum profundus tendon within the A1 and A2 pulley complex

PURPOSE: To evaluate the effect of ulnar deviation of the finger on gliding resistance of the flexor digitorum profundus tendon within the A1 and A2 pulley complex. METHODS: Thirty-two human cadaveric fingers (index through small fingers) were used. The gliding resistance was measured at 5 different angles of ulnar deviation (0 degrees, 15 degrees, 30 degrees, 45 degrees, 60 degrees). RESULTS: There was a significant increase in gliding resistance with increased ulnar deviation. The gliding resistances at 0 degrees, 15 degrees, 30 degrees, 45 degrees, and 60 degrees of ulnar deviation were 0.40+/-0.13 N, 0.44+/-0.13 N, 0.55+/-0.17 N, 0.74+/-0.21 N, and 1.02+/-0.30 N, respectively. The gliding resistance at 60 degrees was significantly greater than at all other angles; 45 degrees ulnar deviation had significantly higher gliding resistance than 0 degrees, 15 degrees, and 30 degrees; and 30 degrees ulnar deviation had significantly higher gliding resistance than 0 degrees. CONCLUSIONS: A greater angle of ulnar deviation causes higher gliding resistance during motion of the flexor digitorum profundus tendon within the A1 and A2 pulley complex. The gliding resistance increases significantly at angles greater than 30 degrees of ulnar deviation. The increased tendon loading needed to overcome increased gliding resistance caused by ulnar deviation could result in a vicious cycle of progressive ulnar deviation. Although mild degrees of ulnar deviation may be well tolerated mechanically a reasonable therapeutic guideline might be to prevent deviation from exceeding 30 degrees.     

The Chiari osteotomy. A review of 58 cases

Fifty-eight Chiari osteotomies performed in 51 patients were reviewed retrospectively. The indications for surgery were painful subluxation, instability, or poor acetabular coverage. The average age at surgery was 16 years (range, 7-45), and the average follow-up period was 40 months. The majority of the patients had congenital hip dislocation, but also included were patients with cerebral palsy, Legg-Calvé-Perthes disease, polio, infection, coxa vara, and epiphyseal dysplasia. Supplemental bone grafts were applied as needed. The functional results were unrelated to age, with 26 excellent, 28 good, and four poorly functional hips. After operation, 39 out of 41 had total pain relief, 41 out of 58 had a normal acetabular index, and 54 out of 58 had a normal center-edge angle. Trendelenburg gaits were unchanged by the Chiari osteotomy, but trochanteric transfer improved the gait in few cases.     

Neglected neck femur fractures in adolescents and young adults: factors predicting the surgical outcome

Background

Neglected femoral neck fracture in young adults is an intriguing problem. This retrospective study tried to solve that challenge through open reduction, cannulated screw internal fixation, autogenous iliac bone and bone marrow grafting.

Methods

Thirty-six cases were studied; they were classified according to Sandhu et al.'s classification. Twenty cases were type I and 16 cases were type II fractures; the mean age was 26.8 years; fracture neglect averaged 44.6 days. Twenty cases had posterior comminution and 16 cases had anterior comminution. All cases had open reduction, cannulated screw internal fixation, autogenous iliac bone and bone marrow grafting. The Harris hip score and Matta et al. grading system were applied for functional and radiological evaluation, respectively.

Results

The average postoperative follow-up was 25.3 months; 94.4 % of the cases had solid union in a mean of 19.6 weeks. Functionally, the Harris hip score averaged 87.8 points. Nonunion, avascular necrosis and coxa vara complicated two, two and four cases, respectively. Fair and poor radiological results were related to coxa vara and avascular necrosis, respectively. Nonunion was significantly related to posterior comminution, type II neglected fracture, and a neglect of more than 45 days. Age groups more than 30 years old and postoperative neck-shaft angles <140° were significantly associated with late-onset radiological healing and nonunion.

Conclusions

Cannulated screw osteosynthesis augmented by autogenous bone and bone marrow grafting is a simple, easy-to-perform surgical procedure with encouraging clinical outcomes for selected patients complaining of that difficult problem.