Management of developmental coxa vara in cleidocranial dysostosis

Like Father, Like Son: Cleidocranial Dysplasia: A Case Report

CASE

We present the case of a six-year-old boy who was referred to the pediatric orthopaedics division of our academic medical center by his primary care physician for a concern regarding possible fractured clavicles. He was diagnosed with cleidocranial dysplasia, a genetic condition characterized by skeletal and dental anomalies, primarily delayed ossification of midline osseous structures. On radiographs, cleidocranial dysplasia has been linked to both coxa vara and a characteristic "chef's hat" appearance of the femoral head.

CONCLUSION

Cleidocranial dysplasia has multiple potential orthopaedic complications, and an awareness of this condition, its presentations, and its diagnosis is useful for all physicians.

Coxa vara with proximal femoral growth arrest as a possible consequence of extracorporeal membrane oxygenation: a case report

Coxa vara is an abnormality of the proximal femur with a decreased neck-shaft angle and resulting leg-length discrepancy, has been associated with conditions such as congenital coxa vara, traumatic injury, sepsis, rickets, vascular damage, or metabolic disorders; however its possible relationship with extracorporeal membrane oxygenation has been recently reported.

A full term girl was born with a total infradiaphragmatic anomalous pulmonary venous drainage, at the age of 12 days, an anastomosis of the pulmonary venous trunk with the left auricle and closure of the auricular septal defect was performed; during this procedure extracorporeal membrane oxygenation was used during 104 minutes, no neonatal sepsis was developed. She had no orthopedic issues until she was 3 years and 10 months old, when she presented with limp related to the right lower limb, with no pain. She had a leg-length discrepancy of 2 cm (right - left), limited right hip abduction to 25°, and internal rotation to 5°, also had a positive Trendelenburg test. No flexion/extension abnormalities. Anteroposterior radiographs and magnetic resonance revealed coxa vara with proximal femoral growth arrest. A valgus osteotomy with greater trochanteric epiphysiodesis was performed. At the eight month follow-up, she had no hip pain, better hip range of motion, no difficulties with recreational activities and the osteotomy healed.

Another four similar cases had been reported with similar outcome, we think that it will be recommendable to take images in patients with this background and limb leg-length discrepancy or abnormal range of motion.

Coxa vara in chondrodysplasia: prognosis study of 35 hips in 19 children

BACKGROUND

To better understand anatomical and functional outcomes of coxa vara in chondrodysplasia according to the initial presenting hip morphology, disease type, and impact of surgery.

METHODS

Clinical and radiographic records of 19 children (35 hips) diagnosed with coxa vara and with osteochondrodysplasia were reviewed. We classified the hip radiographic findings into 2 groups: (a) group I, coxa vara with a fragmented and/or nonossified head; and (b) group II, coxa vara with a regular femoral head. Surgical indications in coxa vara included decreased range of hip motion (usually diminished abduction, extension, and internal rotation), coxa vara with progression documented on regular follow-up hip radiographs, and/or severe coxa vara with a Hilgenreiner epiphyseal angle (HEA) of 60 degrees or more. Follow-up was until the completion of growth and, for some patients, into early adulthood. Mean follow-up was 8 years.

RESULTS

Twenty-five hips were operated on in 13 patients. In 23 hips, the procedure was a valgus osteotomy fixed by pins and wire. A pelvic extension osteotomy without valgus osteotomy was performed in one patient (2 hips). Coxa vara recurred in 7 hips. In 4 of these hips, repeat surgery with hypervalgus osteotomy was indicated to stop epiphyseal slipping (3 hips) or to improve the arc of motion (1 hip). Functional outcomes were poor in coxa vara associated with poor epiphyseal development (nonossified or fragmented epiphysis) as seen in spondyloepiphyseal dysplasia congenita, spondyloepimetaphyseal dysplasia, Kniest disease, and multiple epiphyseal dysplasia. Coxa vara with physeal instability as observed in spondylometaphyseal dysplasia resulted in deformity recurrence postoperatively during growth. In contrast, outcome was better in cases of coxa vara with nonphyseal/nonepiphyseal involvement, that is, good femoral head morphology, stable physis, and good articular cartilage, as seen in cases of metaphyseal dysplasia and cleidocranial dysplasia.

CONCLUSIONS

Coxa vara with physeal and epiphyseal involvement and severe impairment of the articular cartilage has a poor prognosis even after reconstructive surgery. In coxa vara with an abnormal physis, there were numerous postsurgical recurrences of the deformity during growth if the physis was not stabilized at the time of valgus osteotomy. In these cases, we should delay osteotomy until an HEA greater than 60 degrees. Coxa vara in which only the metaphysis of the femoral neck is involved, the deformity is milder and often requires no treatment. Indications for surgery in this group are increasing coxa vara, Trendelenburg gait, or an HEA greater than 60 degrees.

Coxa vara: surgical outcomes of valgus osteotomies

Since the 1950s, valgus-producing femoral osteotomy has been the preferred treatment for significant coxa vara. Despite well-performed surgeries, the literature cites recurrence rates of 30-70%. The present study reviews our past 15 years of surgical experience for coxa vara; 26 children with 37 affected hips were retrospectively evaluated for outcome following valgus osteotomy. Both congenital and acquired types of coxa vara were included. Overall recurrence rate following valgus osteotomy was 50%. Age at time of surgery, type of surgery, and type of implant and etiology were found to have no bearing on recurrence. However, if Hilgenreiner's epiphyseal angle was corrected to < 38 degrees, 95% of children had no recurrence of varus. In contrast, head-shaft angle was found not to be a reliable indicator of appropriate correction. Only six of 37 hips required pelvic osteotomy (five Pemberton, one Chiari) for dysplasia, and four of these had developmental dysplasia of the hip as the underlying etiology for their coxa vara. However, if the proximal femur was corrected and maintained before age 10, 83% of children had excellent acetabular depth, spherical congruency, relief from pain, and correction of Trendelenburg gait at latest follow-up.