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Re: Congenital coxa vara
послал Djoldas Kuldjanov, M.D. 05 Июль 2005, 01:39
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Dr. V. M. Iyer and All,
Regarding the case by Dr Mohd Amin Chinoy I am not so sure with just one-osteotomy with distal tranfer of the trochanter nor with intra-articular cortison injection, can be resolve treatment of this patient's problem.
It appears that this patient has bilateral congenital hip displasia, as presented on the radiographs. As shown, the problem involves both sides of the hip joint: the acetabulum and proximal femur.
This patient is noted to have a very vertical joint surface orientation, as well, with retroversion of the acetabulum.
In a hip with normal version, (on discussion list) Hip Pain (Dr.Kullerkann) the lines connecting the anterior and posterior acetabular wall as seen on an AP radiograph usually intersect at one point near the superior and lateral portion of the acetabulum. As an example of an abnormal hip, a patient with a retroverted acetabulum will show the figure 8 pattern, with the two shadows crossing over the femoral head. In this particular patient, again it appears that there is a significant amount of retroversion of the acetabular wall, as the anterior wall appears to be more anteriorly displaced than in a normal hip.
Typically, patients begin to have hip pain after adolescense depending upon the level of activity and weight of the patient. If untreated, this problem ultimately results in the need for total hip arthroplasty, which can often be difficult in a dysplastic hip. Reconstructive surgery, if performed early, can lead to many years of functional improvement and, potentially, a delay in the need for arthroplasty.
In this patient, it appears that addressing either the femur or the acetabulum will be insufficient to help correct this patient’s problem. It would be necessary to approach both sides of the hip joint to correct the hip dysplasia.
Depending upon surgeon preference, as well as availability of adequate operating room equipment and staff, this reconstruction can be done in two stages: periacetabular osteotomy with correction of acetabular retroversion would be the first stage. The second stage would involve a proximal femoral valgus osteotomy with neck lengthening.
In this second stage, a 120 degree blade plate can be used for correction proximal femur varus deformity. These procedures are both technically difficult, and require a great amount of pre-operative planning, both by the surgeons involved as well as the operating room staff.
The pre-operative planning would need to be done with the use of more radiographs for assessment of the hip dysplasia. These x-rays include a repeat AP pelvis, separate AP and lateral of the hips, long-standing femoral axis views of both legs, false profile view, as well as abduction and adduction films.
Pic. 1-5 preop plan; 6-8 similar case
Djoldas Kuldjanov, M.D.
Djoldas Kuldjanov, MD
Department of Orthopedic Surgery
St. Louis University Medical Center
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