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Developmental Coxa Vara

Developmental Coxa Vara. CHEO 10 Minute Rounds May 2013 Brad Meulenkamp. Overview. Coxa Vara : Abnormally low femoral neck-shaft angle (< 120°) Congenital, Developmental, Acquired. Overview. Congenital Present at birth Abnormal ossification of femoral head

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Developmental Coxa Vara

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  1. Developmental CoxaVara CHEO 10 Minute Rounds May 2013 Brad Meulenkamp

  2. Overview • CoxaVara: Abnormally low femoral neck-shaft angle (< 120°) • Congenital, Developmental, Acquired

  3. Overview • Congenital • Present at birth • Abnormal ossification of femoral head • Associated with skeletal dysplasias • Cleidocranial Dysplasia • Multiple Epiphyseal Dysplasia • Proximal Focal Femoral Deficiency • Spondyloepiphyseal Dysplasia

  4. Overview • Acquired (secondary coxavara) • Infection • LCP • Osteopetrosis • SCFE • Fibrous Dysplasia • Trauma

  5. Overview • Developmental • Occurs in later childhood • Characteristic radiographs • Isolated skeletal manifestation • Incidence 1:25 000 • 30-50% Bilateral • M = F, R = L

  6. Etiology • AD with incomplete penetrance • Current accepted theory • Primary defect in endochondral ossification in the medial part of the femoral neck • Eventual fatigue of fystrophicbone along the medial inferior  progressive varusdeformity • Vertical orientation of the proximal femoral physis • Shear rather than compression

  7. Clinical • Presentation after walking age (most < 6 yrs) • Painless limp  unilateral • Waddling gait  bilateral • Pain is uncommon • Physical • Prominent greater trochanter • LLD (usually < 3cm) • Increased lumbar lordosis if bilateral • Abductor weakness • Global decreased ROM

  8. Radiographs • Decreased neck shaft angle • Coxabreva • Decreased femoral anteversion • Vertically oriented physis • Higenreiner-epiphyseal angle • ** correlates with progression • ‘Inverted Y-sign’ • Pathognomic

  9. Treatment • Based on Hilgenreiner-Epiphyseal angle • Observe if < 45° • Operate if > 60° • Between 45° and 60° • Follow with serial radiographs if asymptomatic • Surgical Indications • Trendelenburg gait • Fatigue pain in abductors • Evidence of progression

  10. Surgery • Proximal Femoral Valgus Osteotomy • Goal is valgus overcorrection • Neck:Shaft angle 140° - 150° • Adductor tenotomy is often necessary • May need de-rotation • Subtroch or intertrochanteric osteotomy

  11. Complications • Recurrence: 50% • Reduced by post-op HEA < 38° • 95% success • Premature physeal closure: 89% • LLD • Trochanteric overgrowth

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