Coxa Valga Research Articles

An anatomical exploration of femoral angle of inclination in multi‐regional populations: clinical implications

The angle of inclination (AOI) is clinically relevant because of a predisposition for congenital femoral dysplasia. While AOI of the femur varies with age, gender, and ontogenetic growth patterns, abnormal AOI conditions increase stress at the hip joint and significantly affect gait. This study examined AOI in three ethnic/racial populations from European, African, and Asian ancestry. An Inuit group dated 500 BCE ‐ 500 CE was sampled from archaeological remains of Ipiutak populations from the osteological collections of the American Museum of Natural History. To measure AOI, a line was drawn from the midpoint of the intercondylar fossa to the greater trochanter projecting proximally through the shaft of the femur, and a second line was drawn from the femoral head to the femoral shaft through the center of the femoral neck; the AOI was defined by the intersection of these two lines. Preliminary results showed significant AOI differences (p < 0.01) found only between the Inuit and European populations. Developmentally, the AOI is widest at infancy and gradually narrows, ending its decline in adulthood. Inuit femurs presented with the greatest AOI of 139 degrees, demonstrating the orthopaedic condition of coxa valga. The fact that these findings suggest a possible increased prevalence of congenital femoral dysplasia in these populations has considerable clinical implications and will require further study.Grant Funding SourceN/A

The prevalence of canine patellar luxation in three centres

The medical records of 155 dogs with patellar luxation (PL) from three different centres were analysed. Each case was classified according to the nature of its luxation and any concurrent orthopaedic conditions plus the age at diagnosis were also noted. Measurements relating to angle of inclination (AOI) of the femoral neck and medio-lateral bowing of the femur and tibia at the stifle were also recorded. The femoral and tibial data were compared to dogs with another orthopaedic condition in a case-control assessment. Labradors were most commonly affected (21%). Most luxations were medial (92%) and 54% of affected dogs were female. The mean AOI of the hip was 148.95 degrees . There was a statistically significant difference between the stifles of dogs with PL compared to a control population. This study concluded that PL in large breeds is increasing. Lateral luxation was uncommon and was not associated exclusively with large breeds. Females were more likely to have PL than males and being female was a risk factor associated with coxa valga. There are significant differences in medio-lateral stifle conformation between dogs with PL and control dogs.

Incidence and characteristics of femoral deformities in the dysplastic hip.

Reorientation acetabular osteotomies can correct dysplastic deformities and provide marked improvement in hip function. Deformities of the proximal femur can produce suboptimal articulation or secondary impingement after acetabular reorientation, yet the incidence and characteristics of such deformities have not been well described. To describe the proximal femoral anatomy in patients with symptomatic acetabular dysplasia, we retrospectively analyzed the radiographs of 108 hips treated with periacetabular osteotomy. The radiographic findings were compared with those in 22 control hips. In the dysplastic group, 80 hips were in women and 28 in men, and the average age was 24.8 years. Of the 108 abnormal radiographs, 44% had coxa valga and 4% coxa vara. Seventy-two percent had an aspheric or deformed femoral head and the head-neck offset was insufficient in 75% of the hips. When compared with the control hips, dysplastic hips had differences in parameters of proximal femoral anatomy that we measured. These data demonstrate a high incidence of proximal femoral abnormalities associated with acetabular dysplasia. Identifying and treating these abnormalities may optimize joint congruency and minimize secondary impingement after acetabular reorientation. Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Too old, too soon: Hutchinson–Gilford progeria syndrome

Hutchinson–Gilford progeria syndrome (HGPS) is a rare genetic disease that is characterized by precocious aging in infants and always leads to early death from heart attacks or strokes at a mean age of around 13–14 years. The premature aging is manifest through cutaneous changes resembling normal aged skin, alopecia (hair loss), lipodystrophy, skeletal changes (coxa valga and low bone mineral density, although this may not be due to osteoporosis as in normal aging, but rather a failure to properly develop bone throughout infancy) and intense atherosclerosis. Other changes commonly associated with aging are absent, such as cataracts and diabetes mellitus, and there are no reported problems with cognition or CNS neurology1. Thus HGPS belongs to the small group of genetic disorders called the segmental progeroid syndromes (Figure 1).

Proximal femoral geometry in cerebral palsy

There is much debate about the nature and extent of deformities in the proximal femur in children with cerebral palsy. Most authorities accept that increased femoral anteversion is common, but its incidence, severity and clinical significance are less clear. Coxa valga is more controversial and many authorities state that it is a radiological artefact rather than a true deformity. We measured femoral anteversion clinically and the neck-shaft angle radiologically in 292 children with cerebral palsy. This represented 78% of a large, population-based cohort of children with cerebral palsy which included all motor types, topographical distributions and functional levels as determined by the gross motor function classification system. The mean femoral neck anteversion was 36.5 degrees (11 degrees to 67.5 degrees) and the mean neck-shaft angle 147.5 degrees (130 degrees to 178 degrees). These were both increased compared with values in normally developing children. The mean femoral neck anteversion was 30.4 degrees (11 degrees to 50 degrees) at gross motor function classification system level I, 35.5 degrees (8 degrees to 65 degrees ) at level II and then plateaued at approximately 40.0 degrees (25 degrees to 67.5 degrees) at levels III, IV and V. The mean neck-shaft angle increased in a step-wise manner from 135.9 degrees (130 degrees to 145 degrees) at gross motor function classification system level I to 163.0 degrees (151 degrees to 178 degrees) at level V. The migration percentage increased in a similar pattern and was closely related to femoral deformity. Based on these findings we believe that displacement of the hip in patients with cerebral palsy can be explained mainly by the abnormal shape of the proximal femur, as a result of delayed walking, limited walking or inability to walk. This has clinical implications for the management of hip displacement in children with cerebral palsy.

Cenani–Lenz syndactyly with facial dysmorphism, hypothyroidism, and renal hypoplasia: a case report

Clinical summary and investigations A female child with Cenani–Lenz syndactyly (CLS) is described. The proband showed bilateral malformations of the hands and feet. The patient also had a prominent forehead, deep-set eyes, low-set ears, retrognathia, higharched narrow palate, a short-beaked nose, and high nasal bridge, (Fig. 1). The hands showed a complex syndactyly and disorganization of the fingers, which could not be identified individually (Figs 2, 3). The feet showed partial disorganization of the toes and partial syndactyly (Fig. 4). The karyotype was 46, XX. The proband had normal developmental milestones and cognitive abilities. Laryngomalacia was diagnosed in infancy. Although there were no clinical criteria of hypothyroidism, thyroid functions testing at 8 months of age showed a higher than normal thyroid-stimulating hormone level of 6.2, and a repeat at 9 months of 7.89 mU/l (N = 0.47–5.01), T4 of 12.55 pmol/l (N = 9.1–23.6), and T3 of 4.36 pmol/l (N = 2.58–5.44). Taking her young age into consideration, no further investigations were carried out at the endocrine clinic; she was diagnosed as having primary hypothyroidism and started on thyroxin with regular follow-up. Abdominal ultrasonography showed that the right kidney was hypoplastic and ectopic. Radiography of pelvis showed bilateral coxa valga and dysgenesis of the hip joints. The right hand showed fusion of all metacarpal bones into one mass, with broad, fused, disorganized phalanges and reduction of digital rays. The phalanges of the dorsiflexed little finger were seen overlying the phalanges of the adjacent fused digit. The left hand showed three separate metacarpals with fusion and disorganization of the phalanges and reduction of the digital rays (Fig. 5). Fig. 1

Subluxation de la hanche et coxa valga secondaires à un ostéome ostéoïde

We report on the case of a 2-year-old child with extra-articular osteoïd osteoma of the proximal femur leading to subluxation and coxa valga deformity of the hip joint at 10 year follow-up. The osteoïd osteoma reccured twice after surgical excision and percutaneous drilling. Patient's clinical history also reported a prolonged use of medications as treatment for these two recurrences. Second recurrence was combined with migration of the femoral head and retraction of the adductors: surgical treatment consisted in varus osteotomy to facilitate excision of the lesion, combined with a tenotomy of the hip adductors. Functional outcomes were satisfactory after 4-year follow-up. Reviews of the literature report two cases of hip subluxation secondary to intra-articular osteoïd osteoma. From our experience, it seems that hip subluxation in the present case could have been avoided with early surgical management.

Developmental tendency of the femur head following femoral head necrosis due to conservative treatment of a dislocated hip (2nd report)

The development of the proximal femur was studied in a follow up of 64 patients--on average 24.4 years of age--with congenital hip dislocation and 101 subsequent aseptic necroses of the femoral head. For measurement of the angle of antetorsion and the femoral neck-shaft angle, biplanar radiographs were taken. A coxa valga with a true femoral neck-shaft of 137 to 164 degrees was present in one third of the cases with partial necrosis and in the group without necrosis. An increasing degree of necrosis led to coxa vara. Damage of the capital epiphysis caused development of coxa vara (average of 115.77 degrees), overgrowth of the greater trochanter and increase of femoral antetorsion (average of 30.23 degrees). Pre-existing damage of the capital epiphysis following non-operative treatment of congenital hip disease or Perthes disease cannot be recommended for intertrochanteric varisation osteotomy.

Pathogenesis and prevention of spastic hip dislocation

Based on retrospective analysis of 82 hips of 41 patients with cerebral palsy, a pathogenetic model of spastic paralytic dislocation of the hip is introduced including recent observations of the normal hip development. According to this model the reduced activity of the gluteus maximus, medius, minimus and quadriceps femoris muscles, which normally cause a decrease of valgus and anteversion, results in an increased subluxating coxa valga antetorta with a consecutive dislocation. In order to prevent a dislocation, these muscle groups have to undergo increased activation. Since walking has to be to undergo increased activation. Since walking has to be considered the strongest stimulus for the dislocation-preventing hip abductors, hip extensors, outward rotators and knee extensors, the erect gait should be encouraged with statomotorically favored children early as possible. This can be supported by muscle relaxing surgery of the antagonistically effective hip flexors, hip adductors and inward rotators as well as the knee flexors. These muscle release operations will counteract, although to a limited extent, a dislocation even with a severely handicapped child who is unable to walk.

Follow-up results of adduction-derotation osteotomies in hip dysplasia

The first part of the investigation was concerned with the evaluation of radiographs of 64 children in whom 97 intertrochanteric adduction-derotation osteotomies were performed when the patients were between two and ten years old. Prior to surgery, immediately thereafter and two and six years later, the CCD, AC, ACM and CE angles of all the patients were measured on plain pelvic radiographs. On the radiographs made after six years 70% of the CCD angles were normal, while pathologic coxa valga was found in 15% and coxa vara also in 15%. The AC angle was normal in 32% , the ACM angle in 31%; however, these normal groups were only 76% identical. The CE angle had normalized in 32% of the cases. The second part of the paper deals with clinical and radiological follow-up findings in 46 of these patients in whom 64 hips had been treated. The follow-up period varied between six and 13 years. On clinical examination the result was found to be satisfactory in 59% and unsatisfactory in 41%. A comparison with radiological-anatomical findings showed that in 32% of the radiologically satisfactory cases there were some considerable functional limitations and subjective complaints. The author's own results are compared with communications in the literature, in particular with the Swiss collective statistics published by Jani (1973) and Reichelt and Hansen's publication (1975). To provide the reader with a survey of the number of cases, age at operation and periods of observation quoted by different authors, these data are presented synoptically in tabular form. Another table lists the criteria investigated by the individual authors (AC, ACM, CE, CCD and AT angles). The discussion is completed with conclusions relevant to clinical practice.

Die Dreifach-Osteotomie des Beckens bei dysplastischen Hüftpfannen im Kindes- und Erwachsenenalter

We report on a post operative radiological and clinical follow-up (3-6.4 years) of 80 triple-osteotomies (29 operations according to the technique of Carlioz and 51 according to Tönnis). This study includes 32 osteotomies in children and 48 in adults. In 82% of the cases of low dysplastic hip joints and in 88% of the cases in severe dysplastic hip joints, the results came up to the expectations of the patients. The acetabular inclination angle and the acetabular angle improved about 10 degrees and the center edge angle about 25 degrees. In cases of neurological diseases, the radiological results of the hips were less satisfactory. The results is negatively influenced by pseudarthrosis and stress fractures in the ischium. These complications occur to a lower degree after Tönnis-osteotomy. From the age of 7, the triple-osteotomy represents an useful alternative to the operative correction of the hip joint dysplasia. The operation can be carried out in cases of congruity of head and acetabulum. Under certain circumstances, a transposition operation is additionally necessary, it is only indicated with a coxa valga. The triple-osteotomy can positively influence the biomechanical situation of the hip joint by means of an improved head roofing, by an ameliorated adjoining of the area of force reception to the pressure resultant and by medialisation of the acetabulum.

Relations between degenerative changes in the femoral head and the radiologically determined biomechanical magnitude of effects

40 femoral heads taken at hip arthroplasty are examined. The position and expansion of cartilage loss are determined and related to the preoperative X-rays. Femoral "bald heads" appear most frequently at the lateral ventral aspect. The angle phi formed by the hip resultant (Pauwels) and the longitudinal axis of the body is related to the CE-angle (Wiberg) as follows: Small CE-angles are associated with large phi and vice versa. Coxa valga (projected CCD-angles greater than 141 degrees) is associated with predominantly lateral location of areas of bone exposure. Low CCD-angles (less than 120 degrees) and large CE-angles (greater than 30 degrees) go along with larger "bald heads". In cases with overweight the expansion of bone exposures does not exceed the amounts found in "normal body weight". Thus bone exposing destruction of cartilage is mainly situated near the point of penetration of the resultant force through the weight bearing surface of the joint. Larger "bald heads" occur favourable at the "deep" acetabula revealing high CE-angles and at low CCD-angles.

Femoral Angle of Inclination of the Femur: Polyethnic/Racial Differences for Orthopaedic Considerations

The angle of inclination (AOI) of the femur varies with age, sex, and ontogenetic growth pattern. The variation exhibited by ethnic/racial populations, however, has been focused only in recent studies. This study examines three polyethnic human populations that include African, European, and an archaeological sample representing pre‐European contact Ipiutak (500 BCE – 500 CE) Inuit populations from the osteological collections at the American Museum of Natural History. A line was drawn from the midpoint of the intercondylar fossa projecting through the middle shaft of the femur to the greater trochanter. A second line was drawn through the middle of the femoral neck. The intersection of the two lines forms the angle of inclination. The diaphyseal length was also measured between the two lowest points on the shaft. Results showed statistically significant differences in AOI and in diaphyseal length between the Inuit and contemporary European populations. There was no significant difference found in these two measures between Inuit and African and between European and African groups except in diaphyseal length in the latter comparison group. Developmentally, the AOI is greatest in newborns and markedly decreases during the aging process reaching between 115–140 degrees in the adult condition. The Inuit sample shows the greatest AOI of the study categorizing this group as coxa valga. This condition, biomechanically, increases total load across the hip and puts undue stress on lower limb joints. As the Inuit population presumably migrated from an Asian origin, future studies should focus on AOI of current Asian populations.

Fracture dislocation of sacroiliac joint associated with triradiate cartilage injury in a child: a case report

We report a very rare injury of a 8-year-old girl with sacroiliac fracture dislocation and triradiate cartilage separation. After the restoration of the sacroiliac joint by open means, reduction of the separated cartilage was seen. At 20 months follow-up, an osseous bridging at the triradiate cartilage and mild coxa valga deformity developed. We think that every child with serious sacroiliac joint injury should be evaluated for associated triradiate cartilage injury and followed to skeletal maturity for late complications such as acetabular dysplasia, hip subluxation and pelvic asymmetry.

Clinical and radiographic delineation of odontochondrodysplasia

The association of dentinogenesis imperfecta (DI) with a distinct form of chondrodysplasia in a boy was reported by Goldblatt et al. [1991; Am J Med Genet 39:170-172] and has been given the name of Goldblatt syndrome or odontochondrodysplasia (ODCD; OMIM#184260). Since the original description, only four further individuals have been reported (one sib pair and two unrelated cases). We report on an additional six individuals, including a second sib pair (brother and sister), with clinical and radiographic features that cluster and thus confirm the nosologic status of this entity. The main radiographic features are congenital platyspondyly with coronal clefts, severe metaphyseal changes particularly of the hands, wrists, and knees, mesomelic limb shortening, and coxa valga. The main physical signs are short stature, joint laxity, narrow chest, scoliosis, and DI. This combination of clinical and radiographic findings allows clear recognition of this syndrome in early childhood. Of note, the signs that are present in the newborn period are not entirely specific and the differential diagnosis includes spondylometaphyseal dysplasia (SMD) Sedaghatian type or platyspondylic lethal dysplasia (PSLD) Torrance type. The occurrence of two sib pairs in a group of only 11 patients suggests an autosomal recessive inheritance pattern. Overmodification of cartilage-extracted collagen 2 has been reported in two sibs, but mutation analysis of COL2A1 as well as of COMP, FGFR3, RMRP, and SBDS in one or more patients have given negative results, and the molecular etiology is as yet unknown.

Les luxations traumatiques de la hanche chez l’enfant

Traumatic hip dislocation is a rare event in children. Appropriate management remains a subject of debate. The purpose of this study was to investigate the epidemiological, therapeutic features of this situation and the long-term outcome after treatment. This was a retrospective analysis of 15 traumatic hip dislocations collected over a period of 20 years in pediatric patients with at least two years follow-up. We searched for predisposing factors and factors affecting prognosis. The series included 11 boys and three girls, mean age eight years. Dislocation was posterior in 13 hips and anterior in two. Time to reduction was less than 3h in eight cases, 3-6h in five and greater than 6h in two. After reduction, traction was performed in nine children, for 20 days on average, followed in five cases by immobilization for 40 days on average. Five hips were immobilized directly after reduction. We identified two groups by age: group 1 with dislocations in children aged less than six years (seven children) were characterized by low-energy trauma. Dislocation was not associated with other lesions. Predisposing factors (overt ligament hyperlaxity, insufficient superolateral head cover, coax valga) were noted in six children. Reduction was simple. Later treatment consisted in immobilization with a pelvispedious cast for 30-45 days. Group 2 were dislocations in children aged over six years (seven children) victims of high-energy trauma. Associated injuries were frequent. Predisposing factors were not present. At mean 11 years follow-up, all hips are considered normal clinically. The radiograph was normal for 14 hips. In one case, there was a slight coax magna. In three patients, defective femoral head cover persisted. Coxa valga persisted in two patients. Traumatic dislocation of the hip joint is rare in very young children, but results from a minimally traumatic event. This suggests the presence of predisposing factors in this category of patients, particularly capsuloligamentary hyperlaxity. After reduction, immobilization can be recommended. Traumatic hip dislocations in children are different from the adult variety due to their rarity, the general absence of associated fractures, easy reduction and better prognosis. The epidemiological and therapeutic features in children older than six years are however similar to those in adults.

22q11.2 Distal Deletion: A Recurrent Genomic Disorder Distinct from DiGeorge Syndrome and Velocardiofacial Syndrome

Microdeletions within chromosome 22q11.2 cause a variable phenotype, including DiGeorge syndrome (DGS) and velocardiofacial syndrome (VCFS). About 97% of patients with DGS/VCFS have either a common recurrent approximately 3 Mb deletion or a smaller, less common, approximately 1.5 Mb nested deletion. Both deletions apparently occur as a result of homologous recombination between nonallelic flanking low-copy repeat (LCR) sequences located in 22q11.2. Interestingly, although eight different LCRs are located in proximal 22q, only a few cases of atypical deletions utilizing alternative LCRs have been described. Using array-based comparative genomic hybridization (CGH) analysis, we have detected six unrelated cases of deletions that are within 22q11.2 and are located distal to the approximately 3 Mb common deletion region. Further analyses revealed that the rearrangements had clustered breakpoints and either a approximately 1.4 Mb or approximately 2.1 Mb recurrent deletion flanked proximally by LCR22-4 and distally by either LCR22-5 or LCR22-6, respectively. Parental fluorescence in situ hybridization (FISH) analyses revealed that none of the available parents (11 out of 12 were available) had the deletion, indicating de novo events. All patients presented with characteristic facial dysmorphic features. A history of prematurity, prenatal and postnatal growth delay, developmental delay, and mild skeletal abnormalities was prevalent among the patients. Two patients were found to have a cardiovascular malformation, one had truncus arteriosus, and another had a bicuspid aortic valve. A single patient had a cleft palate. We conclude that distal deletions of chromosome 22q11.2 between LCR22-4 and LCR22-6, although they share some characteristic features with DGS/VCFS, represent a novel genomic disorder distinct genomically and clinically from the well-known DGS/VCF deletion syndromes.

Disease Progression in Hutchinson-Gilford Progeria Syndrome: Impact on Growth and Development

Hutchinson-Gilford progeria syndrome is a rare and uniformly fatal segmental "premature aging" disease that affects a variety of organ systems. We sought to more clearly define the bone and weight abnormalities in patients with progeria as potential outcome parameters for prospective clinical trials. We collected and analyzed longitudinal medical information, both retrospectively and prospectively, from a total of 41 children with Hutchinson-Gilford progeria syndrome spanning 14 countries, from the Progeria Research Foundation Medical and Research Database at the Brown University Center for Gerontology. In addition to a number of previously well-defined phenotypic findings in children with progeria, this study identified abnormalities in the eruption of secondary incisors lingually and palatally in the mandible and maxilla, respectively. Although bony structures appeared normal in early infancy, clavicular resorption, coxa valga, avascular necrosis of the femoral head, modeling abnormalities of long bones with slender diaphyses, flared metaphyses, and overgrown epiphyses developed. Long bones showed normal cortical thickness centrally and progressive focal demineralization peripherally. The most striking finding identified in the retrospective data set of 35 children was an average weight increase of only 0.44 kg/year, beginning at approximately 24 months of age and persisting through life, with remarkable intrapatient linearity. This rate is >2 SD below normal weight gain for any corresponding age and sharply contrasts with the parabolic growth pattern for normal age- and gender-matched children. This finding was also confirmed prospectively. Our analysis shows evidence of a newly identified abnormal growth pattern for children with Hutchinson-Gilford progeria syndrome. The skeletal and dental findings are suggestive of a developmental dysplasia rather than a classical aging process. The presence of decreased and linear weight gain, maintained in all of the patients after the age of 2 years, provides the ideal parameter on which altered disease status can be assessed in clinical trials.

Navigation Reduces the Learning Curve in Resurfacing Total Hip Arthroplasty

Hip resurfacing is a novel technique with a substantial learning curve resulting in poor outcomes for many patients. We asked whether navigation would influence this learning curve and accuracy of implantation. Twenty medical students earning their degree in surgical technology participated in a randomized trial. We provided instruction about the surgical technique, including the use of conventional instrumentation, the use of a computed tomography-based planner for hip resurfacing, and a navigation system. The 20 students were then split into three groups undertaking these tasks in three different orders. Synthetic femurs replicated normal, osteoarthritis, slipped capital femoral epiphysis, and coxa valga. The mean error using the conventional method to insert a guidewire was 23 degrees; using the computed tomography plan method it was 22 degrees; and using navigation was 7 degrees. Students produced similar accuracy, even in their first attempt, on difficult anatomy when provided navigation. Motivated students rapidly achieved an expert level of accuracy when provided with navigation. Learning a conventional method first did not improve performance, even in difficult cases. Our data suggest navigation may play an important role in reducing the learning curve in hip resurfacing arthroplasty and other tasks in arthroplasty in which a high degree of accuracy is clinically important.

Mechanical Axis Cannot be Restored in Total Knee Arthroplasty With a Fixed Valgus Resection Angle: A Radiographic Study

Alignment radiographs of 174 extremities in patients undergoing total knee arthroplasty were measured to determine the variability in valgus cut angle (VCA) and the anatomical factors that affect the VCA necessary to restore the mechanical axis. The VCA averaged 5.6° ± 1.0° with a range of 2° to 9°. With the 3different methods of defining the anatomical axis of the femur, 30% to 51% of patients required a VCA of less than 5° or greater than 6°. The offset and neck-shaft angle of the ipsilateral hip exert a strong effect on the VCA necessary to restore the mechanical axis. Patients with coxa valga or reduced hip offset generally require a VCA less than 5°. Patients with coxa vara or increased hip offset generally require a VCA greater than 6°.