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Congenital Coxa Vara: Treatment
Updated: Jan 27, 2009
Treatment
Medical Therapy
Many forms of nonoperative treatment have been proposed, including spica cast immobilization and skeletal pin traction with bed rest, with generally unsatisfactory results. It is generally accepted that no place remains for conservative nonoperative measures for individuals requiring treatment for either symptomatic or progressive CCV.
Surgical Therapy
As surgical intervention is required in a large percentage of those with congenital coxa vara (CCV), remembering the indications for surgery and clearly defining the goals of treatment are important to ensure the best possible outcome and to minimize the number of surgical procedures for the patient.
The goals of surgical intervention are as follows:
- Correction of the neck shaft angle to a more physiologic angle and HEA to less than 35-40°
- Correction of femoral anteversion (or retroversion) to more normal values
- Ossification and healing of the defective inferomedial femoral neck fragment
- Reconstitution of the abductor mechanism through replacement of its normal length-tension relationship
The treatment of choice for CCV has followed the recommendations of early work by Amstutz, Freiberger, and Wilson in use of either subtrochanteric or intertrochanteric osteotomies.15,16 Among the intertrochanteric osteotomies (see Image 5), the Pauwels Y-shaped and Langenskiöld valgus-producing osteotomies have been shown to provide good results. Note, however, that these osteotomies have a somewhat limited ability to correct the associated femoral neck retroversion. The subtrochanteric valgus-producing osteotomies used by many authors also have provided good and lasting clinical results (see Image 6). More important, perhaps, is not the actual type of osteotomy performed but, rather, that the goals of surgical correction, as outlined above, are achieved.
Congenital coxa vara. Surgical methods of valgus-producing proximal femoral osteotomies. (A) Pauwels Y-shaped osteotomy. (B) Langenskiöld intertrochanteric osteotomy. (C) Borden subtrochanteric osteotomy.
Many issues have been raised surrounding surgical intervention, including the amount of correction needed, associated procedures at the time of surgery to aid in the osteotomy and decrease hip joint forces, and the optimum age for operation. Postoperatively, good results have been achieved consistently when the HEA has been corrected to less than 35-40°. Although some have suggested the need to correct the neck shaft angle to more than 130-135°, Carroll et al found no strong correlation between the postoperative neck shaft angle and lasting good clinical outcomes.17 They suggested that the most consistent and reliable predictor of outcome was the HEA.
Weighill emphasized the use of an adductor tenotomy in association with osteotomy, with adductor release removing the deforming force during reduction of the femoral bone fragments and aiding in postoperative stability of the osteotomy.18 If required, a segment of proximal femur may be removed to facilitate reduction and reduce joint reactive forces at the hip joint. Unfortunately, this may further shorten an already short limb.
Surgical treatment of congenital coxa vara. Progression from preoperative radiographs at ages 2 and 5 years, with characteristic bony changes. Postoperative radiographs at ages 6 and 12 years, with early and late follow-up results.
Many investigators have also considered the optimal age for surgical intervention. Weighill has suggested the best time for correction to be in patients as young as 18 months. Weinstein et al found that patients treated when older than, rather than younger than, 5 years maintained correction better.14 Serafin and Szulc suggest that correction in children younger than 9 years maximizes the remodeling potential of both the proximal femur and the acetabulum.19 It is generally accepted that more important than the age at correction is the ability to correct the hip to meet the goals of surgery. Once the diagnosis is clear and progression is evident, few reasons remain to delay surgery beyond an age at which stable fixation can be achieved reliably.
Preoperative Details
As with many surgical procedures, preoperative planning is essential to achieve a favorable outcome. Up-to-date imaging is necessary to determine the amount of bone to be resected and the size of implants to be used. Templating the operative plan is often invaluable to ensure that the proposed result will meet the surgical goals. Having hardware of various angles available is helpful if intraoperative measurements lead to alteration in the amount of bone resected.
Intraoperative Details
Position the patient supine on a radiolucent table and ensure that adequate quality images are available before beginning surgery. Rotate the affected hip under fluoroscopy to compensate for hip (femoral head) version, defining the maximal varus deformity. From this view, determine the size of the bone wedge to be resected. Use clinical rotation of the hip to decide whether derotation will be combined with wedge resection. Free draping of the hip allows for better intraoperative control. The proximal-lateral femur is routinely exposed. Image intensification is used in implant insertion and bone resection. Confirm correct positioning once provisional fixation is achieved.
Postoperative Details
After skin closure in the usual fashion, with the use of wound suction as required, apply a 1.5 hip spica cast. Obtain postoperative radiographs through the spica cast for later comparison. Maintain a non-weightbearing status for the patient until early bone healing is demonstrated radiographically, at approximately 6-10 weeks after surgery.
Follow-up
Perform an initial postoperative check 1 week after surgery, with radiographs to ensure maintenance of position and integrity of fixation. The patient should be seen every 2 weeks until early healing is present (approximately 6-8 wk after surgery). At that time, the spica cast is removed and physiotherapy is begun for mobilization and range-of-motion instruction. Close follow-up every 3-6 months is required to ensure that the deformity is resolving. Assess for greater trochanteric overgrowth and commonly encountered proximal femoral physeal closure. Carry out trochanteric apophysiodesis if indicated (see Complications). Perform a careful serial examination for a relative limb-length discrepancy and treat as appropriate.
Complications
Premature closure of the proximal femoral physis has been noted very consistently, and occurs along with or shortly after healing of the inferomedial fragment of metaphyseal bone. Carroll et al reported that all of their patients had premature closure of the proximal femoral physis, as did Desai and Johnson.17,20 This closure occurred their series at an average of 3 years after surgical correction. Pylkkanen reported a 90% rate of premature closure.10 This, along with any residual shortening due to the osteotomy, requires follow-up with an aim of a contralateral physeal arrest or ipsilateral lengthening at the appropriate time, should a clinically significant limb-length discrepancy exist near maturity.
Greater trochanteric overgrowth in treated congenital coxa vara.
Associated with the premature closure of the proximal femoral physis is the often-encountered overgrowth of the greater trochanter (see Image 7). Desai and Johnson reported that this occurred in 60% of their series, with just under half of these patients having abductor weakness at final follow-up. They noted no overgrowth in the cases in which successful greater trochanteric apophysiodesis was achieved. All of these patents had a good clinical outcome. Undertake surgical epiphysiodesis or distal transfer if overgrowth of the greater trochanter is noted both radiographically and clinically on follow-up.
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References
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Further Reading
Keywords
coxa vara, congenital coxa vara, CCV, developmental coxa vara, infantile coxa vara, cervical coxa vara, childhood coxa vara, proximal femoral varus, proximal femoral focal deficiency, PFFD, congenital short femur, congenital bowed femur
