Fixation of Intertrochanteric Valgus Osteotomy with T Plate in Treatment of Developmental Coxa Vara

BACKGROUND: Although the valgus subtrochanteric osteotomy is considered as a standard surgical treatment for coxa vara, there is no consensus on the optimal method of fixation and osteotomy technique. Fixation of the osteotomy has been achieved by various methods including external fixation and internal fixation with pins and cerclage and a variety of plates. The aim of this study is the evaluation of the results of developmental coxa treated by Y intertrochanteric valgus osteotomy fixed with a T-buttress plate compared with other methods of fixation in the literature. METHODS: Eighteen corrective valgus intertrochanteric femoral osteotomies were performed in 18 patients (18 hips) for treatment of unilateral developmental coxa vara deformity and fixed with a T plate. There were 12 males and 6 females. The right hip was affected in 10 patients and the left hip in 8 patients. Clinically, patients were evaluated by Larson hip score. Radiographically, anteroposterior view of the pelvis and frog leg lateral views of the affected hip were taken preoperatively and compared with the findings at the final follow-up. RESULTS: The average follow-up was 29 months (range, 24 to 36 months). Clinical results showed improvement of the mean Larson hip score from 57.8 to 97.0 (p < 0.001). Radiological results showed that all osteotomies were completely united in 2.4 months (range, 2 to 3 months) with the achievement of the planned correction angle. The average correction of Hilgenreiner's epiphyseal angle improved from 78.2° to 27.8° (p < 0.001) at the final follow-up. The femoral neck shaft angle was improved from 93.7° to 129.9° (p < 0.001) at the final follow-up. Shortening of the affected limb was corrected from 2.8 cm to 1.3 cm (p < 0.001) at the last follow-up. No major serious complications were recorded in the present study. CONCLUSIONS: Intertrochanteric valgus osteotomy of the proximal femur fixed with a T plate may be efficient for treatment of developmental coxa vara. With careful planning, it can result in a low complication rate and insignificant or minimal recurrence rate.

Coxa vara in conjunction with metaphyseal dysostosis

We describe a rare case of unilateral development of coxa vara secondary to metaphyseal dysostosis encountered in a 6-year-old boy. Family history and radiographic documentation revealed a 31-year-old father with a typical clinical history. Proximal femoral intertrochanteric valgus osteotomy and a revision cup [Allofit] have been performed for the child and his father respectively

Ángulo de Inclinación del Fémur en el Hombre y su Relación con la Coxa Vara y la Coxa Valga / Angle of Inclination of Femur in Man and its Relationship with Coxa Vara and Coxa Valga

Los autores realizan mediciones en fémures aislados, realizando comparación de los datos obtenidos con los resultados encontrados en la literatura investigada, con el objeto de determinar de forma porcentual los valores limítrofes para clasificar la coxa como vara o valga. Fueron analizados 56 fémures de cadáveres adultos, siendo determinado el ángulo de inclinación del fémur, que fue medido a través de un Goniómetro. Utilizamos el patrón poblacional normal de 66 por ciento (o test Z) para determinar cuál es el intervalo donde se encuentra el alineamiento ideal. En las mediciones de los ángulos de inclinación de los 56 fémures, los valores se encontraban entre 117,67 grados y 136,67 grados. Utilizando el patrón poblacional normal de 66 por ciento (o test Z), verificamos que el intervalo ideal (o normal) se encuentra entre 117 grados y 136 grados, siendo éste el intervalo donde se encuentra el alineamiento ideal. En este intervalo encontramos 47 fémures (84 por ciento). La determinación normal del ángulo entre 117 grados y 136 grados, posibilita clasificar de coxa valga cuando el ángulo de inclinación está debajo de 177 grados y coxa vara encima de 136 grados.

The authors carried out isolated mensuration in femurs to compare data with the results found in literature. The objective was to determine in percentile form, bordering values to classify the thigh as pole or valgum. Fifty six femurs of adult corpses were analyzed, determining the angle of inclination in the femur, which was measured through a Goniometry. We used the normal population standard of 66 percent (or tested Z): to determine in which interval the ideal alignment is found. In the mensuration of inclination angles in 56 femurs., the values were between 117.67 and 136.67 degrees. Using the normal population standard of 66 percent (or tested Z), we verified the ideal interval (or normal) with findings between 117 and 136 degrees, the ideal alignment. In this interval we found 47 femurs (84 percent). The normal determination of the angle between 117 and 135 degrees allows classifying thigh valgum, when the angle of inclination is below 117 degrees and coxa vara is above 136 degrees.

Coxa Vara with Spondylometaphyseal Dysplasia / 대한정형외과학회잡지

Developmental coxa vara is a rare disease and the symptoms do not appear at birth, but rather, they appear at the age of walking. Clinically, the symptoms include a waddling gait, limb length discrepancy and frequent weariness. Developmental coxa vara is sometimes associated with skeletal dysplasia. Especially, it is associated with spondylometaphyseal dysplsia and the vertebral bodies and long bones are affected. The authors report here on diagnosing and treating this rare disease and we review the relevant literatures.

Successful general anesthesia for cervical spine fusion in a patient with spondyloepiphyseal dysplasia congenita: A case report

Spondyloepiphyseal dysplasia congenita (SEDC) is a kind of skeletal dysplasia, inheritable condition. The clinical features of SEDC are dwarfism, myopia with or without retinal detachment, coxa vara, thoracic dysplasia with respiratory failure and laryngotracheal stenosis. A point of particular concern to anesthetists is odontoid hypoplasia which, combined with ligamentous laxity, leads to atlantoaxial instability. We report successful general anesthesia for cervical spine fusion of a patient with SEDC.

Treatment of Reverse Oblique Trochanteric Fracture with Compression Hip Screw

PURPOSE: To investigate the results of treatment of reverse oblique trochanteric fractures with compression hip screw. METHODS: We reviewed the results of 12 cases of reverse oblique trochanteric fracture treated with compression hip screw from January 2000 to December 2006 which could be followed up for more than 1 year. The mean follow up period was 26 months (15~40). The mean age was 48 years old. Injury mechanism was composed of 6 cases of traffic accident and 6 cases of fall down. 8 persons were man. We investigated the union time, degree of neck-shaft angle change, amount of sliding of compression hip screw, complications, functional and clinical results. RESULTS: 10 cases were united and the mean union time were 5 months (3~8). The mean neck-shaft angle change was 3.5 degrees (0~12). The amount of sliding of compression hip screw was 8.9 mm (2~24). There were six coxa vara, six leg due to coxa vara shortening, two nonunion, and one superficial infection. Unsatisfactory results of Jensen's social function score and Parker and Palmer's mobility score were studied. CONCLUSION: The results of treatment of reverse oblique trochanteric fractures with compression hip screw were relatively unsatisfied.

The Results after Surgically Managing Patients with Fibrous Dysplasia of the Proximal Femur

PURPOSE: Single or multiple fibrous dysplasia of the proximal femur can cause coxa vara, Shepherd's crook deformity and a leg length discrepancy for those patients who require surgical treatment. We wanted to evaluate the efficiency of surgical treating fibrous dysplasia of the proximal femur. MATERIALS AND METHODS: Among the patients who underwent surgical treatment at our hospital during the period of June, 2001 to October, 2007, we selected 18 patients who underwent curettage and bone graft or valgus osteotomy and internal fixation due to proximal femur involvement. The clinical results were analyzed based on the patients' clinical records and radiologic findings. RESULTS: The group of patients with a normal neck-shaft angle (Group 1) could achieve satisfactory results by undergoing curettage, bone graft and internal fixation. The other group of patients who progressed to Shepherd's crook deformity (Group 2) could have satisfactory results when they underwent valgus osteotomy and soft tissue release or both proximal femur shortening osteotomy and valgus osteotomy, but not with undergoing valgus osteotomy only. CONCLUSION: Varus deformity in patients with fibrous dysplasia may progress even though they undergo valgus osteotomy. It is important to consider the preoperative biomechanical condition of the proximal femur before performing surgery.

Arthroscopic Treatment of Osseous Abnormalities as a Cause of Femoroacetabular Impingement : Preliminary Clinical Results / 대한정형외과학회잡지

PURPOSE: To report the preliminary clinical results for arthroscopic treatment of osseous abnormalities as a cause of femoroacetabular impingement (FAI). MATERIALS AND METHODS: We evaluated 26 patients diagnosed with FAI who were treated by arthroscopic debridement of the labrum, spur resection, and bump resection from March 2004 to March 2005. Osseous abnormalities of FAI were evaluated for the presence or absence of asphericity, pistol grip deformity, coxa vara, coxa valga, retroversion of the acetabulum, and protrusion of acetabulum were present or not. We evaluated the clinical manifestations based on patient satisfaction, sequential JOA pain scores and ranges of motion of the hips. RESULTS: 24 patients were satisfied postoperatively. The average JOA pain score preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months, were 0.85, 0.71, 1.50, 1.71, and 1.86, respectively. At 2 weeks preoperatively, the clinical symptoms were aggravated and 6 months postoperatively, the clinical symptoms were improved. 11 patients could not take a cross-legged position preoperatively: but 10 of the 11 patients could take a cross-legged position postoperatively. CONCLUSION: Preliminary clinical results for arthroscopic treatment of osseous abnormalities were satisfactory. We need to perform a follow-up study of the clinical results about the early detection of which findings and decompression of which osseous abnormalities will prevent or delay the progression of osteoarthritis through mid and long-term follow up.

Total Hip Arthroplasty with Use of Proximal Modular Femoral Stem in Secondary Coxarthrosis of Hip Associated with Deformed Femur

Purpose: The purpose of this study was to evaluate the clinical and radiological results of total hip arthroplasty using a proximal modular femoral stem in patients who had secondary coxarthrosis associated with a deformed femur. Materials and Methods: Forty-two patients (45 hips) with secondary coxarthrosis were evaluated after primary total hip arthroplasty using an S-ROM proximal modular femoral stem, between January 2001 and March 2004. The average follow-up was 44 months (range, 24 to 60 months). The mean age of the patients was 48.5 years old and there was a predominance of female patients (65.5%). The preoperative diagnoses included 26 cases of developmental dysplasia of the hip, 13 cases of sequalae of LCP, 2 cases of epiphyseal dysplasia, 3 cases of sequalae of pyogenic arthritis, and 1 case of congenital coxa vara. Results: The average Harris hip score improved from 52.2 points to 85.5 points. All the femoral stems demosntrated stable fixation, which included 37 cases by bony ingrowth and 8 cases by stable fibrous ingrowth. Neither osteolysis nor progressive radiolucent lines around the femoral stems were found at the latest follow-up. Postoperative complications included: 2 cases of hip dislocations, 1 case of periprosthetic fracture, 1 case of infected cup loosening, and 1 case of sciatic nerve palsy. Overall, forty-one hips (91.9%) exhibited excellent or good clinical results at the most recent follow-up. Conclusion: For advanced secondary coxarthrosis, total hip arthroplasty with use of a proximal modular femoral stem yielded good mid-term results based on clinical and radiological criteria.

Femoral Head Deformity in Legg-Calve-Perthes Disease / 대한정형외과학회잡지

PURPOSE: To determine the developmental patterns of 4 major deformities of femoral head commonly observed in Legg-Calve-Perthes disease (LCPD): coxa plana, coxa magna, coxa vara, subluxation. MATERIALS AND METHODS: We reviewed the clinical records and radiographs of 85 unilateral LCPD children who were followed up from the early stage of disease to full skeletal maturity. Four major deformities were measured and observed during 3 periods: the active disease stages of avascular necrosis and fragmentation, the healing stage, and skeletal maturity. RESULTS: All four deformities were first observed at early stages of the disease, avascular or fragmentation stage. Appearance rates were 79% in coxa plana, 28% in coxa magna, 35% in coxa vara, and 27% in subluxation. The gradual progression of deformities with time which was demonstrated at the healing stage and at skeletal maturity were observed in all except subluxation. And this gradual increase was supposed to be dependent on the normal bony growth with aging. CONCLUSION: We determined the developmental pattern of major deformities of the femoral head. And this determination will help to understand the natural course of deformity which is clinically important in terms of late osteoarthritis.

Treatment of Subtrochanteric Fracture with Rowe plate / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to report the clinical result of subtrochanteric fractures which were treated with Rowe plate. MATERIALS AND METHODS: 30 cases of subtrochanteric fracture, which were operatively treated with Rowe plate, were evaluated clinically and radiographically. All patients were followed for at least 1 year. RESULTS: Primary bony union was achieved in 28 cases (93%) . Bony union after secondary operative procedure was obtained in 2 cases (6.7%) . The fracture was united within 6 months except 3 cases. As complications, coxa vara deformity under 120. of neck-shaft angle was observed in 2 cases and one of them was associated with limb shortening more than 1 cm. CONCLUSION: We could obtain satisfactory clinical results with the use of Rowe plate in treating some selected cases of subtrochanteric fracture. The good indications for the use of Rowe plate seem to be some subtrochanteric fracture associated with intertrochanteric fracture, long spiral subtrochanteric fracture, comminuted subtrochanteric fracture with multiple large fragment, and subtrochanteric fracture in deformed proximal femur.

Complications after Hip Fracture in Children / 대한정형외과학회잡지

PURPOSE: To analyze complications and their effects on prognoses of children hip fractures. MATERIALS AND METHODS: 26 childhood hip fractures (6 type I, 7 type II, 10 type III, 3 type IV) were studied for 11 years (1986-1997) . We analyzed factors possibly related to complications and their effects on prognoses, especially avascular necrosis (AVN) of the femoral head. RESULTS: Of 26 patients, there were 7 AVN (27%) , 2 nonunions (8%) , 3 coxa vara (12%) , 9 premature epiphyseal closures (35%) , and 2 infections (8%) . Of 7 patients with AVN, 3 patients had type I fracture and 4 patients had type II fracture. No AVN developed in type III and IV fractures. Of 2 patients who had type I fracture with dislocation, all patients had AVN (100%) . Four of 14 patients who had displacement of the fracture site and one in 10 patients who had non-displacement fracture developed AVN. In our study of the incidence of AVN according to surgical reduction time after injury, 3 (60%) of 5 patients who were treated by surgical reduction within 6 hours and 4 (19%) out of 21 patients who were treated by surgical reduction after 6 hours developed AVN. CONCLUSION: In childhood hip fracture, surgical reduction time after trauma (10 years) were found to be an effective treatment of AVN. AVN concomitant with pyogenic infection had the worst prognosis.

The Asian-Pacfic Gamma Nail for Intertrochanteric Fracture of the Femur / 대한정형외과학회잡지

PURPOSE: To evaluate the treatment results of geriatric intertrochanteric fractures by using Asian-Pacific Gamma nails. MATERIALS AND METHODS: From June 1994 to June 1997, 58 cases of the intertrochanteric fractures were treated with Asian-Pacific Gamma nail, particularly compression hip screw fixation complications such as communited fracture involving lesser trochanter, transverse or reverse oblique intertrochanteric fracture. We evaluated the bone union time, neck-shaft angle, lag screw sliding by follow up radiographs, and studied complications and intraoperative cautions. RESULTS: The average age was 74.4 years old, the mean duration of follow-up was 17 months, the mean duration of bone union was 14.2 weeks, the average neck-shaft angle was postop. 133+/-2.78 degree and last follow-up was 129.5+/-3.37 degree, and the average lag screw sliding was 4.7+/-3.16 mm. Intraoperative complications were difficulty in distal drilling (posterior drilling) in 4 cases, fracture displacement by nail insertion in 3 cases, and postoperative complications were coxa vara in 13 cases, superior cutting out of lag screw with nonunion in 1 case and superficial infection in 1 case. The entry portal must be formed by awling. The fracture displacement when inserting nail could be prevented by proper reaming after inserting the C-shaped guide pin, and posterior drilling could be avoided by confirming the locking between target device and nail. CONCLUSIONS: We conclude that the Asian-Pacific Gamma nail could appropriately treat the osteoporotic, communited intertrochanteric fracture in elderly patients and we obtained satisfactory results.

A Case of Spondyloepiphyseal Dysplasia Congenita

Spondyloepiphyseal dysplasia congenita is one of the osteochondrodysplasia, used to be diagnosed by clinical symptoms and radiologic findings. Clinical findings are short-trunk dwarfism, oval face, hypertelorism, short neck, kyphosis, lordosis, joint instability, coxa vara, pectus excuvatum, cleft palate, severe myopia, retinal detachment, deafness, and radiologic findings are thoracic kyphosis, lumbar lordosis, platyspondyly, anterior flaring of ribs, delayed ossification of head of humerus and femur, delayed ossification of pubic bone, short femoral neck, often metaphyseal irregularity. The etiology was known as only family disorder, at now a gene mutation of COL2A1 at chromosome 12. So it is classified as the type II collagenopathy. Authors had experienced a case of spondyloepiphyseal dysplasia congenita with clinical and radiologic findings.

A Child with Familial Hypophosphatemic Ricket: A case report

Familial hypophosphatemic ricket (Vitamin D-resistant ricket), first described by Albright in 1937, has been known to be transmitted as an X-linked dominant trait in most families. Children with this disease would show growth retardation with characteristic clinical features such as congenital alopecia, genu varum or genu valgum, coxa vara and waddling gait. Although the physical features associated with this disease have been documented frequently, the potential involvement of auditory pathway due to abnormal bone formation in skull has not been explored frequently. We report a twenty six-month-old female child with familial hypophosphatemic ricket who presented abnormal findings of brainstem auditory evoked potential study. The impaired hearing function should be alerted as one of possible accompanying disabilities of the disease.

Coxa Vara with Spondylometaphyseal Dysplasia / 대한정형외과학회잡지

Spondylometaphyseal dysplasia(SMD) is very rare disease characterized with platyspondyly and metaphyseal changes in the long bone. Shrot status and later abnormal gait associated with coxa vara are common clinical feature. A 6 years 4 months old boy progressive bilateral coax vara were transferred with abduction limitation of the hip. With the skeletal survey, multiple dysplastic changes of the metaphysic of the long bone including knee, shoulder, ankle, and flatterning of the body of lower thoracic and upper lumbar spine(T11,12,L1) were noted. A corrective valgus osteotomy on the both hip were followed with improvement of the range of motion.

Treatment of Ipsilateral Fractures of the Femoral Neck and Shaft / 대한정형외과학회잡지

Ipsilateral fractures of the femoral neck and shaft represent many difficulties in diagnosis and treatment. The femoral neck fracture of this injury is commonly missed on initial evaluation. The overlooked femoral neck fracture may lead to higher risk of complications such as avascular necrosis of the femoral head, nonunion and coax vara. The authors reviewed nine cases of ipsilateral femoral neck and shaft fracture treated in our clinic from September 1989 to May 1995, and average follow-up period was 33 months(range, 12 to 101 months). The results obtained were as follows : 1. The most common cause of injury was traffic accident, and three femoral neck fractures were missed initially. 2. The most common site of femoral neck fractures was basicervical in 7 cases, and that of shaft fracture was middle 1/3 shaft in 5 cases. 3. The most common associated injury was ipsilateral knee injury(6 cases). 4. Five cases were treated with femoral reconstruction nail, two with multiple neck-pinning and retrograde interlocking IM nail, one with multiple screws for neck fracture and long dynamic compression plate for shaft fracture, and the other, multiple neck-pinning and antegrade interlocking IM nail. 5. The complications were a refracture of the shaft after removal of interlocking nail and a delayed union of shaft fracture which had been treated by reconstruction nailing. Coxa vara, delayed union and metal loosening were found in femoral neck fracture site, but all that were clinically acceptable. In conclusion, the fracture of femoral neck should be kept in mind not to be lost in case of high velocity-femoral shaft fracture, and if found, it should be treated with anatomical and rigid internal fixation in femoral neck fracture having first priority. Recently reconstruction nail for the treatment of these fractures was widely used, but that is technically difficult and might destroy the neck fracture during shaft fracture fixation. We recommend retrograde interlocking nail followed by multiple neckpinning might be safe and stable fixation for the ipsilateral neck and shaft fracture.

Developmental Coxa Vara / 대한정형외과학회잡지

Deveolopmental coax vara represents coax vara not present at birth but rather developing in early childhood, showing a progressive deterioration in the proximal femoral neck-shaft angle during growth. In order to determine the factors that could affect the results of corrective osteotomy, we evaluated the results of 15 developmental coax vara in 12 patients who had been treated with the femoral osteotomy at the Department of Pediatric Orthopedic Surgery, Seoul National University Children's Hospital, from February 1983 to March 1993. Of the 12 patients, there were 6 boys and 6 girls. Three patients had bilateral operations, 5 patients on the right, and the remaining 4 patients on the left. Average at the onset of symptoms was 4 years plus 5 months(range; from 1 year to 7 years plus 2 months), and average age at the tome of operation was 6 years plus 3 months(range; from 2 years plus 4 months to 10 years). We could obtain the following results: 1. Average post-operative loss of neck-shaft angle was 5% in the cases in which post-operative neck-shaft angle was converted more than 130 degrees, and was 8% in the cases in which post-operative neck-shaft angle was converted less than 130 degrees. 2. Loss of neck-shaft angle was higher during the first post-operative period, and was higher in cases in which the triangular osseous defect was persistent post-operatively. There was no correlation between the post-operative neck-shaft angle and disappearance of triangular osseous defect. 3. The femoral anteversion was converted 8.7 degrees to 27.2 postoperatively. 4. The premature arrest of the capital femoral physis was higher in cases in which the neck-shaft angle was less than 130 degrees postoperatively. 5. Leg length discrepancy, which was 2.1 cm preoperatively, did not change in cases in which the neck-shaft angle was more than 130 degrees postoperatively. However, it was converted to 3.3 cm in cases in which the neck-shaft angle was less than 130 postoperatively. 6. we could observe the femoral head deformity in 6 out of 7 cases in which the operation was performed after 7 years of age. We could draw the following conclusion based on our results: 1. We must correct the neck-shaft angle more than 130 degrees. 2. We could not equalize the leg length discrepancy by corrective osteotomy alone. 3. It may be reasonable to perform the corrective osteotomy before 7 years of age.

The Operative Treatment on the Fracture of the Displaced Femoral Neck in Children / 대한정형외과학회잡지

The femoral neck fracture in children are extremely rare and occur secondary to severe trauma. Many authors recommend early anatomical reduction and firm internal fixation because of many complications after treatment. Eleven displaced femoral neck fractures in children who were treated at the Keimyung University Dong San Medical Center from February, 1989 to February, 1993. Following results were obtained, after clinical and radiological evaluations. 1. Fractures of the femoral neck in children occurred from five to sixteen years, the highest inci dence was between ten and thirteen years of age. 2. The main causes of the fracture were traffic accident in 9 cases. 3. 10 cases were treated by arthrotomy, open reduction and internal fixation and one by closed reduction and internal fixation. 4. Operation were performed within 24 hrs after trauma in 5 cases, within 5 days in 4 cases, and 2 cases were performed within 10 days after trauma. 5. According to the classification of Delbet and Colonna(12), cervicotrochanteric fracture(type III) was the most common type(7 cases). 6. The degrees of displacement were 4 cases totally displaced, one case more than two third dis placed, 4 cases 1/3 to 2/3 displaced, and 2 cases less than one third displaced. 7. Complications were transient AVN confirmed by bone scan(1 case) and coxa vara due to nonunion(1 case). 8. According to the Ratliffs assessment(22) the results were good in 9 cases, fair in one, and poor in one.