Coxa Vara / Coxa Valga: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==


<u>'''Coxa valga'''</u> is defined when the femoral neck shaft angle as greater than 139 °.&nbsp;&nbsp;<ref>John C. Clohisy, MD, Ryan M. Nunley, MD, Jack C. Carlisle, MD, and Perry L. Schoenecker, MD. Incidence and Characteristics of Femoral Deformities in the Dysplastic Hip. Clin Orthop Relat Res. 2009, 467(1): 128–134.</ref>
<u>'''Coxa valga'''</u> is defined when the femoral neck shaft angle as greater than 139 °.&nbsp;&nbsp;<ref>John C. Clohisy, MD, Ryan M. Nunley, MD, Jack C. Carlisle, MD, and Perry L. Schoenecker, MD. Incidence and Characteristics of Femoral Deformities in the Dysplastic Hip. Clin Orthop Relat Res. 2009, 467(1): 128–134.</ref>  


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<u>'''Coxa vara'''</u> is as a varus deformity of the femoral neck. It may be defined when the angle between the neck and shaft of the femur is less than 110 – 120 ° (which is normally between 135 ° - 145 °) in children. <ref>Lam F, Hussain S, Sinha J. Emerg Med J. An unusual cause of a limp in a child: developmental coxa vara. 2001,18(4):314.</ref>


<u>'''Coxa vara'''</u> is as a varus deformity of the femoral neck. It may be defined when the angle between the neck and shaft of the femur is less than 110 – 120 ° (which is normally between 135 ° - 145 °) in children. <ref>Lam F, Hussain S, Sinha J. Emerg Med J. An unusual cause of a limp in a child: developmental coxa vara. 2001,18(4):314.</ref>
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'''''Coxa vara''''' is classified into several subtypes




'''''Coxa vara''''' is classified into several subtypes <br> ''Congenital coxa vara'' is present at birth and is caused by an embryonic limb bud abnormality. <br> ''Developmental coxa vara ''occurs as an isolated deformity of the proximal femur. It tends to go unnoticed until walking age is reached, when the deformity results in a leg length difference or abnormal gait pattern.<br> ''Acquired coxa vara ''is caused by an underlying condition such as fibrous dysplasia, rickets, or traumatic proximal femoral epiphyseal plate closure. <ref>DiFazio R, Kocher M, Berven S, Kasser J. Coxa vara with proximal femoral growth arrest in patients who had neonatal extracorporeal membrane oxygenation. J Pediatr Orthop 2003, 23: 20 – 26</ref><br>
 
*''Congenital coxa vara'' is present at birth and is caused by an embryonic limb bud abnormality.  
*''Developmental coxa vara ''occurs as an isolated deformity of the proximal femur. It tends to go unnoticed until walking age is reached, when the deformity results in a leg length difference or abnormal gait pattern.
*''Acquired coxa vara ''is caused by an underlying condition such as fibrous dysplasia, rickets, or traumatic proximal femoral epiphyseal plate closure. <ref>DiFazio R, Kocher M, Berven S, Kasser J. Coxa vara with proximal femoral growth arrest in patients who had neonatal extracorporeal membrane oxygenation. J Pediatr Orthop 2003, 23: 20 – 26</ref><br>


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==

Revision as of 16:15, 24 May 2011

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Search Strategy[edit | edit source]

Searched databases: Pubmed, PEDRo, Web of Knowledge, Science Direct
It is to be noted that most of the information found are case studies.

Definition/Description[edit | edit source]

Coxa valga is defined when the femoral neck shaft angle as greater than 139 °.  [1]


Coxa vara is as a varus deformity of the femoral neck. It may be defined when the angle between the neck and shaft of the femur is less than 110 – 120 ° (which is normally between 135 ° - 145 °) in children. [2]


Coxa vara is classified into several subtypes


  • Congenital coxa vara is present at birth and is caused by an embryonic limb bud abnormality.
  • Developmental coxa vara occurs as an isolated deformity of the proximal femur. It tends to go unnoticed until walking age is reached, when the deformity results in a leg length difference or abnormal gait pattern.
  • Acquired coxa vara is caused by an underlying condition such as fibrous dysplasia, rickets, or traumatic proximal femoral epiphyseal plate closure. [3]

Clinically Relevant Anatomy[edit | edit source]

Congenital coxa vara results in a decrease in metaphyseal bone as a result of abnormal maturation and ossification of proximal femoral chondrocytes. As a result of congenital coxa vara, the inferior medial area of the femoral neck may be fragmented. A progressive increase in varus might also occur in congenital coxa vara as well as excessive growth of the trochanter and shortening of the femoral neck. [4]


A review on the development of coxa vara shows an association with spondylometaphyseal dysplasia, demonstrating that stimulated corner fractures were present in most instances. [5]


Another review of patients with congenital and development coxa vara shows that an dysplastic acetabulum can lead to hip subluxation.
This review shows also that the acetabulum is abnormal in coxa vara. Acetabular index (AI) and sourcil slope (SS) are significantly greater in hips with coxa vara than normal hips. This have a statistically significant inverse correlation with the degree of varus. It shows also the acetabular indices are different in congenital and development coxa vara. [6] 

Epidemiology /Etiology[edit | edit source]

Femoral neck fractures in children are associated with a high incidence of complications. The most serious ones with high and long–term morbidity being osteonecrosis and coxa vara. [7]


A case study also shows that the incidence of coxa vara can be decreased by use of internal fixation utilizing either pins or screws.
Premature epiphyseal closure is described as one of the ethiological factors of coxa vara, and is reported to occur in around 6% (of the total population/in those with coxa vara)
Another possible explanation for the high occurance of coxa vara is the loss of reduction after initial fracture reduction of implant failure in unstable fractures. [8]

A retrospective study show the following complications in children: [9]

1) avascular necrosis (14.5%)
2) limb shortening in seven (11.3%)
3) coxa vara (8%) and premature epiphysis fusion (8%)
4) coxa valga (3.2%), arthritic changes (3.2%).
5) non-union in one (1.6%)

Characteristics/Clinical Presentation[edit | edit source]

Clinically the condition presents itself as an abnormal but painless gait pattern. A Trendelenburg limp is sometimes associated with unilateral coxa vara and a waddling gait is often seen when bilateral coxa vara is present. Patients with coxa vara often show:
 Leg length discrepancy
 Prominent greater trochanter
 Limitation of abduction and internal rotation
Patients may also show femoral retroversion or decreased anteversion. [10]

Differential Diagnosis[edit | edit source]

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Diagnostic Procedures[edit | edit source]

 Radiography (AP view of the pelvis) can be utilized to determine the HEA (Hilgenreiner Epiphyseal Angle). Signs to look out for are as follows:
o The neck – shaft angle is less than 110 – 120°.
o The greater trochanter may be elevated above the femoral head.
o A growth plate with an overly vertical orientation. [11]

 Magnetic Resonance Imaging can be used to visualise the epiphyseal plate, which has been found to broaden during development of coxa vara. [12]


 Computed Tomography can be used to determine the amount/degree of femoral anteversion or retroversion. [13]

Outcome Measures[edit | edit source]

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Examination[edit | edit source]

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Medical Management
[edit | edit source]

According to a case study, the objective of medical interventions is to restore the neck-shaft angle and realigning the epiphysial plate to decrease shear forces and promote ossification of the femoral neck defect.
This is achieved by performing a valgus osteotomy, with the valgus position of the femoral neck improving the action of the gluteus musculatuur, normalising the femoral neck angle, increasing total limb length and improving the joint congruence.

The following are indications for surgical intervention:
 Neck – shaft angle less than 90 °.
 Progressive development of deformity.
 Vertical physis and a significant limb.

Other indications are based on the HE – angle.
 HE – hoek > 60 ° is an indicatie for surgery.
 HE – hoek 45 – 60 ° warrants close follow – up.
 HE – hoek < 45 ° warrants spontaneous resolution.


Except when the neck–shaft angle is less than 110°, progression of the varus angulation takes place, gait pattern abnormalties or degenerative changes take place. [14] 

Physical Therapy Management
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Key Research[edit | edit source]

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Resources
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Clinical Bottom Line[edit | edit source]

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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  1. John C. Clohisy, MD, Ryan M. Nunley, MD, Jack C. Carlisle, MD, and Perry L. Schoenecker, MD. Incidence and Characteristics of Femoral Deformities in the Dysplastic Hip. Clin Orthop Relat Res. 2009, 467(1): 128–134.
  2. Lam F, Hussain S, Sinha J. Emerg Med J. An unusual cause of a limp in a child: developmental coxa vara. 2001,18(4):314.
  3. DiFazio R, Kocher M, Berven S, Kasser J. Coxa vara with proximal femoral growth arrest in patients who had neonatal extracorporeal membrane oxygenation. J Pediatr Orthop 2003, 23: 20 – 26
  4. Javad Parvizi MD, FRCS, Gregory K. Kim MD, and Associate Editor. Coxa Vara. High Yield Orthopaedics, 2010, Page 125
  5. Currarino G, Birch JG, Herring JA. Developmental coxa vara associated with spondylometaphyseal dysplasia (DCV/SMD): “SMD – corner fracture type” (DCV/SMD – CF) demonstrated in most reported cases. Pediatr Radiol. 2000 Jan;30(1):14-24.
  6. Ashish Ranade MD, James J., McCarthy MD, Richard S. Davidson MD. Acetabular changes in Coxa Vara. Clin. Orthop. Relat. Res (2008) 466: 1688 - 1691
  7. Robert E., Georg S., Peter F., Annelie M W., and Michael E H. Post – traumatic coxa vara in children following screw fixation of the femoral neck. Acta Orthopaedica 2010; 81 (4): 442 - 445
  8. Robert E., Georg S., Peter F., Annelie M W., and Michael E H. Post – traumatic coxa vara in children following screw fixation of the femoral neck. Acta Orthopaedica 2010; 81 (4): 442 - 445
  9. Togrul E, Bayram H, Gulsen M, Kalaci A, Ozbarlas S. Fractures of the femoral neck in children: long – term follow – up in 62 hip fractures. Injury. 2005 Jan ;36(1):123-30.
  10. Javad Parvizi MD, FRCS, Gregory K. Kim MD, and Associate Editor. Coxa Vara. High Yield Orthopaedics, 2010, Page 125
  11. Juan Pretell Mazzini, Juan Rodriguez Martin and Rafael Marti Ciruelos. Coxa vara with proximal femoral growth arrest as a possible consequence of extracorporeal membrane oxygenation: a case report. Cases Journal. 2009, 2: 8130
  12. Javad Parvizi MD, FRCS, Gregory K. Kim MD, and Associate Editor. Coxa Vara. High Yield Orthopaedics, 2010, Page 125
  13. Javad Parvizi MD, FRCS, Gregory K. Kim MD, and Associate Editor. Coxa Vara. High Yield Orthopaedics, 2010, Page 125
  14. Juan Pretell Mazzini, Juan Rodriguez Martin and Rafael Marti Ciruelos. Coxa vara with proximal femoral growth arrest as a possible consequence of extracorporeal membrane oxygenation: a case report. Cases Journal. 2009, 2: 8130