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COXA VARAShould it be corrected?
&
How?
Thamer Alhussainan, MD.Consultant pediatric orthopedic surgery
King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD1
THE 2ND MEPOS
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD2
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Introduction
• Coxa vara is a deformity of the proximal femur that
results in a reduction of the normal neck-shaft angle
( <110 deg ).
• It includes a wide spectrum of types with varying
pathologies and differing sites of deformity.
• Determining the site and type of coxa vara, is
important to plan the treatment.
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD3
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Types
Type of coxa vara Pathology Site of deformity Natural history
Congenital Dysgenesis Subtrochateric Progression
Developmental Growth abnormality
physisProgression/static/ regression
Dysplastic
Metabolic: rickets physis May progress
Dysplasia: fibrous dysplasia
metaphysis Progression
Acquired
AVN: Perthes or infection
Physis and epiphysis
Progression
Trauma, malunionof fracture
Physis:: SCFEMetaphysis: # NFSubtrichanteric : #
May partially resolve
Benjamin Joseph, Selvadurai Nayagam, randall loder, Ian Torode. 2009, Pediatric Orthopaedics: a system of decision-making , Hodder Arnold, UK09-Sep-15
Coxa Vara 2nd MEPOS Thamer Alhussainan, MD
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Congenital coxa vara
• Part of congenital short femur or PFFD.
• Usually unilateral.
• The deformity is subtrochanteric and related to
sclerotic segment or true pseudosrthrosis
• Associated with significant LLD, retroversion, and
later genovalgum.
• Fibular hemimelia is associated in some cases
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD5
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD6
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Developmental Coxa Vara
• Usually present after the child starts to walk, and it
is progressive in nature.
• Bilateral in 1/3 of cases.
• The pathognomic radiological feature is the
metaphyseal triangular defect.
• Natural history is strongly correlated to HE angle.
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD7
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Fairbank H. Coxa vara due to congenital defect in the
neck of the femur. J Anat. 1928 Jan;62(Pt 2):232-7
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NS angle <110
09-Sep-15 Coxa Vara 2nd MEPOS Thamer Alhussainan, MD
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HE angle > 60
09-Sep-15 Coxa Vara 2nd MEPOS Thamer Alhussainan, MD
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Weinstein JN, Kuo KN, Miller EA. Congenital coxa vara. A retrospective review. J PediatrOrthop. 1984 Jan;4(1):70-7
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Dysplastic Coxa Vara
• Coxa vara is secondary to a primary bony disease
such as fibrous dysplasia, rickets, or skeletal
dysplasia.
• Usually bilateral.
• Progression is disease related.
• Skeletal dysplasias are associated with significant
hip deformities. (FFD and retroversion).
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD11
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD12
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD13
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Acquired Coxa Vara
• The deformity is secondary to traumatic or vascular
insult to the hip joint .
• Mal-united fracture NOF, overcorrected varus
osteotomies, Perthes disease, SCFE, iatrogenic AVN
in DDH, or AVN secondary to septic arthritis.
• If the deformity is originated in the metaphysis,
remodeling is a possibility, but is it is generated in
the physis it is usually progressive.
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD14
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD15
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD16
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Should coxa vara be corrected?
• Affects the normal biomechanics of the hip.
• Center of hip rotation is lower than the level greater
trochanter.
• Association with :
– Femoral retroversion (future hip OA) .
– LLD.
– Genovalgum.
– Acetabular underdevelopment.
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD17
Schmidt TL, Kalamchi A. the fate of the capital femoral physis and acetabular developmentin developmental coxa vara. J pediatr
Orthop. 1982;2(5):534-8
Kim HT, Chambers HG, Mubarak SJ, Wenger DR. congenital coxavara:computed tomographic analysis of femoral retroversion. J
Pediatr orthop.2000; 20(5): 551-6
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How Coxa Vara can be
corrected?
• Objectives of surgical correction of coxa vara :
– Restoration of hip biomechanics.
– Correction of associated deformities.
– Prevent recurrence (HE angle < 38 deg, and GT
epiphysiodesis)
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD18
Carroll K, Coleman S, Stevens P. Coxa vara : surgical outcomes of valgus osteotomies.
J Pediatr Orthop. 1997:17(2);220-224
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How Coxa Vara can be
corrected?
• The surgical planning depends mainly on:
– Type of deformity.
– Site and severity of the deformity.
– Associated deformities.
– Age of the child .
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Thamer Alhussainan, MD19
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How Coxa Vara can be
corrected?
• Different types of
osteotomies were
described, selection is
based on:
– Age of the child.
– Site and severity of
deformity.
– Surgeon experience.
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD20
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Surgical Correction Of
Developmental Coxa Vara
• Intertrochanteric valgus producing osteotomy is
commonly used procedure for developmental coxa
vara.
• Angled blade plate is a trusted device of fixation.
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD21
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
• Pre-operatively, the
following should be
determined to assure
availability:
– Blade length.
– Blade plate angle.
– Blade plate offset (for
valgus osteotomy no offset).
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD22
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD23
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD24
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD25
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
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Thamer Alhussainan, MD26
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD27
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
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Thamer Alhussainan, MD28
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
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Thamer Alhussainan, MD29
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD30
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
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Thamer Alhussainan, MD31
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD32
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Surgical Correction Of Developmental
Coxa Vara: planning and technique
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD33
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Surgical Correction Of
Developmental Coxa Vara
• Positioning:
– Supine with a gel pad under the ipsilateral hemipelvis on
radiolucent table.
– Fracture table with access to the leg rotation key.
– Assess for adductors contracture, and consider the
release accordingly.
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Thamer Alhussainan, MD34
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Surgical Correction Of
Developmental Coxa Vara
• Approach :
– Lateral approach to the proximal femur.
– Make sure that the medial periosteum is elevated at the
desired level of the osteotomy.
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD51
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD52
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Surgical Correction Of
Developmental Coxa Vara
• Post operative care:
– Spica cast can be considered if fixation is not optimum.
– Patient can be mobilized NWB for 6 weeks.
– Healing is expected 2-3- months.
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD53
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Surgical Correction Of
Developmental Coxa Vara
• Outcomes:
– If the deformity is corrected, the metaphyseal defect will
heal within 3-6 months.
– 50-89% of cases the proximal femoral physis will close 1-2
yrs after surgery.
– Recurrence of deformity reported in30-70 %, but if HE
angle is less than 38 deg, success is 95 %.
– Recurrence of deformity and LLD discrepancy should be
monitored.
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD54
Schmidt TL, Kalamchi A. the fate of the capital femoral physis and acetabular developmentin developmental coxa vara. J pediatr
Orthop. 1982;2(5):534-8
Carroll K, Coleman S, Stevens P. Coxa vara : surgical
outcomes of valgus osteotomies. J Pediatr Orthop.
1997:17(2);220-224
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD55
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD56
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD57
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD58
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD59
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD60
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD61
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD62
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD63
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD64
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD65
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD66
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09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD67
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Discussion
09-Sep-15Coxa Vara 2nd MEPOS
Thamer Alhussainan, MD68