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Congenital coxa vara
Ортопедия и травматология Отправлено Muhammad Amin Chinoy 18 Июнь 2005, 09:44
Dear All,This 27 year old presented to a colleague, about 2 years back, with complaints of bilateral hip pain. He was treated symptomatically, but now has increasing pain, and walking distance is being limited.
On examination, he has got a lordotic gait, Trendelenberg negative, bilaterally, hip movements fairly good, with no FFD.X-rays are attached.Kindly give your opinions regarding management and future prognosis.Thanks and regardsMuhammad Amin Chinoy FRCS

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    Re: Congenital coxa vara
    T. Derek V. Cooke 18 Июнь 2005, 09:49
    Hello Mohamed:

    I took the liberty of 'marking up' your image with software tools we have been developing. Please note the measurements in millimeters are 'unscalled' because the image is not calibrated.









    Derek Cooke
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    • Re: Congenital coxa vara
      Отправитель: Angel Peirу Gonzбlez 18 Июнь 2005, 09:52
      Hello Derek
      can we know about the software tools?.
      Thanks in advance.
      Regards

      --
      Angel Peiró M.D.
      Valencia, Spain

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    Re: Congenital coxa vara
    V. M. Iyer 18 Июнь 2005, 09:53
    A typical case for which Pauvel's V Y osteotomy has been described with distal transfer of the greater trochanter. Have done one case ages ago. No further experience

    V M Iyer

    . Iyer Orthopaedic Centre,
    103,Railway lines Solapur India
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    Re: Congenital coxa vara
    V. M. Iyer 18 Июнь 2005, 10:00
    Dear All,
    There has been no reply regarding the present management of this case put up by Dr Mohd Amin
    ChinoyI had replied that this could be treated now by a Pauvel's V Y osteotomy with distal
    tranfer of the trochanter.
    No comments on that too!

    V M Iyer
    . Iyer Orthopaedic Centre,
    103,Railway lines Solapur India
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    Re: Congenital coxa vara
    Myles Clough 18 Июнь 2005, 10:02
    The best I could do with a MeSH search on the subject is "coxa vara" osteotomy which yields over 100 papers. Much of this is paediatric orthopaedic literature. A much more restricted collection (4 papers) came from "coxa vara" osteotomy Pauwels Note spelling difference. It never used to matter but mis-spelled terms now are a trap for over-eager orthogeeks!
    Clinically, I wonder about the source of the pain. If the patient has arthrosis of such severity that symptomatic treatment in not enough I would be concerned that altering the mechanics by doing an osteotomy would have limited effect and make eventual THR more difficult. I would suggest injecting some local anaesthetic into one hip. If there is full relief of pain I would consider holding out for a THR when the symptoms become that dominant.
    When THR is inevitable but I would like to defer it as long as possible, I consider intra-articular cortisone.

    Myles Clough
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    Re: Congenital coxa vara
    V. M. Iyer 19 Июнь 2005, 15:27
    Dear All,
    There has been no reply regarding the present management of this case put up by Dr Mohd Amin
    Chinoy. I had replied that this could be treated now by a Pauvel's V Y osteotomy with distal tranfer of the trochanter.
    No comments on that too!
    V M Iyer
    [ Ответить ]

    Re: Congenital coxa vara
    Djoldas Kuldjanov, M.D. 05 Июль 2005, 01:39
    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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