Varus deformity of the femur in children. Varus deformity of the lower extremities in children: causes, photos, treatment

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Complicated cases of primary hip arthroplasty: Deformity of the proximal femur

The normal anatomy of the proximal femur is quite variable, and in the vast majority of cases it is possible to get by with standard endoprostheses, while observing the usual surgical technique. From a practical point of view, the hip can be considered deformed if its shape and dimensions are so unusual that compensation of anatomical abnormalities is required through the use of special surgical techniques or non-standard implants.

Deformities of the proximal femur can be congenital (dysplasia), post-traumatic (improperly fused fractures of the trochanteric region), iatrogenic (therapeutic corrective intertrochanteric or subtrochanteric osteotomies), and also develop as a result of metabolic disorders in bone tissue(Paget's disease).

Hip deformities are classified according to their anatomical location, which includes the greater trochanter, femoral neck, metaphysis, and diaphysis. In turn, deformities in each of the listed anatomical zones can be subdivided according to the nature of the displacement: angular (varus, valgus, flexion, extensor), transverse, rotational (with an increase or decrease in anteversion of the femoral neck). In addition, changes in the normal size of the bone and a combination of the above signs are possible. The greatest difficulties for treatment are deformities of the femur at two levels and in several planes.

General principles treatment.

In the presence of femoral deformity, careful preoperative planning should be carried out in order to determine the possibility of using standard approaches and designs. With some deformities, significant difficulties arise in the preparation of the bone marrow canal. For example, displacement of the diaphysis along the width in the sagittal plane can lead to perforation of the anterior cortical wall when the endoprosthesis stem is inserted. Intraoperative fluoroscopy or radiography allows monitoring the progress of canal preparation and significantly reduces the risk of perforation of the femoral wall. The surgeon must decide whether he can place the stem by deviating from the standard position, or if this is not possible and a femoral osteotomy should be resorted to. The presence of deformation affects the choice of stem geometry and the method of its fixation. There are varieties of deformities that require the use of specially designed femoral components, and in some cases, their customization. In severe deformities, there is often a need for an osteotomy of the femur, and in some cases, a two-stage operation.

Thus, the unfavorable factors that create difficulties during the operation and influence the choice of the prosthesis stem are the following: osteoporosis, deformation of the medullary canal in the sagittal and frontal planes, medialization and rotation of the femur, the presence of non-removed metal structures. Before the operation, the surgeon must carefully plan and have at his disposal several designs of endoprosthesis stems of various types of fixation. The surgeon is faced with the following questions:

  • the possibility of simultaneous or staged elimination of the deformity and the installation of an endoprosthesis;
  • limb length correction;
  • restoration of muscle tone;
  • choice of endoprosthesis design;
  • removal of metal structures installed during previous operations.

We use the following working classification of deformations:

  1. According to the level of deformation: the neck of the femur; trochanteric region; subtrochanteric region (upper third of the thigh); two-level.
  2. By type of displacement: single-plane; two-plane; multiplanar.

The choice of surgical treatment method depending on the level of femoral deformity

Greater trochanter deformity.

There are two main types of deformation of the greater trochanter that make it difficult to perform arthroplasty: the overhang of the greater trochanter with the overlap of the entrance to the medullary canal and its high location. When the greater trochanter overhangs, the preparation of the canal becomes much more difficult, and there is a real threat of its chipping and varus installation of the endoprosthesis stem. The problem of arthroplasty with a high location of the greater trochanter lies in the potential for the trochanter to rest in the pelvis (“impingement” syndrome) with the development of posterior joint instability during flexion and internal rotation of the hip, the appearance of lameness due to insufficiency of the hip abductors. To prevent these complications, it is advisable to initially perform an osteotomy of the greater trochanter during the access, which facilitates the preparation of the canal and makes it possible to compensate for the strength of the abductor muscles by bringing down the greater trochanter.

Femoral neck deformity.

There are three types of deformity: valgus (excessive neck-shaft angle), varus (reduced neck-shaft angle) and torsion (excessive anteversion or retroversion). Often these types of deformation are combined with each other. The choice of treatment method for varus deformity depends on the presence of bilateral or unilateral lesions, as well as on the need to change the length of the leg. With unilateral deformity, the affected leg is usually shorter and standard designs can be used. If the surgeon wishes to preserve the length of the leg with bilateral deformity, it is necessary to consider the use of a stem with a lower cervical-diaphyseal angle (for example, the Alloclassic stem has an angle of 131°) or with an increased “offset” and a head with an elongated neck. In this case, it will be possible to restore the anatomy of the joint without lengthening the leg.

Valgus deformity of the femoral neck, as a rule, is combined with a narrow metaepiphysis and involves the use of legs with a narrow proximal part. In addition, it is desirable to use implants with a neck-diaphyseal angle of 135° or more.

Small torsional deformities of the femoral neck can be compensated for by the appropriate position of the endoprosthesis stem. Problems arise at an anteversion angle of more than 30°.

If the stem is placed in this position, it will restrict external rotation and may be accompanied by hip dislocation. You can set the stem in the correct position by placing it on bone cement, or using prostheses of a conical shape (such as Wagner). Another way out of this situation can be the use of legs of a modular design (type S-ROM, ZMR). In severe rotational deformities, when other methods of operations cannot be applied, derotational osteotomy of the femur is performed.

Deformities of the trochanteric region of the femur are extremely variable and polyetiological. In principle, both types of legs can be used. In the preoperative period, it is necessary to carry out careful planning in order to determine the optimal position of the stem, the size of the cement mantle. Cemented legs are most often used in elderly patients with signs of osteoporosis. In addition, this variant of arthroplasty is used in case of difficulties with the installation of a cementless fixation stem.

X-rays of the pelvic bones of patient V., aged 53, with left-sided dysplastic coxarthrosis: a — 6 years after therapeutic intertrochanteric osteotomy, progression of coxarthrosis is observed; b - endoprosthesis replacement of the left hip joint with a standard hybrid endoprosthesis (Trilogy cup, Zimmer, Lubinus Classic Plus stem, W.Link with 126° NSA). The choice of the stem was due to its best correspondence to the geometry of the medullary canal of the femur.


It should be borne in mind that with the simultaneous removal of the plate (after MTO) with the installation of the cement fixation stem, difficulties arise with good cement pressurization. To prevent the release of cement from the holes in which the screws were located, it is necessary to close them tightly with bone grafts made in the form of wedges.

Radiographs of the right hip joint of patient M., 70 years old, with varus deformity of the femoral neck: a - 12 years after therapeutic intertrochanteric osteotomy; b - osteoporosis of the femur, a wide medullary canal predetermined the installation of a wedge-shaped cemented stem (CPT, Zimmer) after removal of the plate.


The use of standard stems without cement fixation is possible after varus and vagal intertrochanteric osteotomies, but with a slight change in the cervical-diaphyseal angle and medialization of the distal femur. In these cases, it is advisable to use full-covered legs. Sometimes a valgus placement of the endoprosthesis stem is justified, but it is desirable to use implants with a neck angle of 126" to prevent instability.

Radiographs of the patient S., 54 years old, with left-sided dysplastic coxarthrosis: a - deformity of the femoral metaepiphysis after derotation-valgus intertrochanteric osteotomy (8 years after surgery); b - slight medialization made it possible to use the standard stem of cementless fixation AML (DePuy); the choice of a stem with a sufficiently extended ball coverage (5/8 of the length) is due to the need for distal fixation of the endoprosthesis due to pronounced compaction of the bone tissue at the site of MTO; c, d - 6 years after the operation.

Radiographs of the right hip joint of patient F., 51 years old: a - aseptic necrosis of the femoral head, fused fracture of the femur after valgus VIBO performed 11 years ago; b, c - VerSys ET (Zimmer) cementless fixation stem is installed with a valgus inclination in accordance with the geometry of the femoral metaepiphysis, the beak channel of the plate is filled with cancellous autologous bone.



Excessive medialization of the distal part of the femur, rotational flexion-valgus deformity of the intertrochanteric region significantly complicates the choice of an implant. In these cases, it is determined by the shape of the channel below the deformation level. With a conical shape, usually in combination with a small diameter, the implant of choice is the Wagner stem, which provides good primary fixation and does not create problems with the choice of a rotational installation.

One-plane deformity of the trochanteric region with a large medialization of the distal fragment and a conical shape of the femoral canal: a - before surgery; b - 2 years after the installation of the Wagner (Zimmer) conical leg.


With a round shape of the bone canal, preference is given to revision structures with round shape legs, one of the variants of which can be a leg with a "capcar". Distinctive feature This design is the absence of proximal expansion, the presence of special flanges of the proximal part of the stem in the sagittal plane (to create rotational stability of the prosthesis) and the full porous covering of the stem, which provides distal fixation of the prosthesis.

X-rays of the right hip joint of patient B., 53 years old: a - a false joint of the neck of the right femur, a fused fracture of the femur after a copper-plating therapeutic intertrochanteric osteotomy; b, c - taking into account the excessive medialization of the femoral shaft, a stem with a "calcar" (Solution, DoPuy) was chosen for arthroplasty, which has a porous coating throughout its length, which ensures distal fixation of the endoprosthesis.


A distinctive feature of the surgical technique is the need for careful verification of the medullary canal and the entire trochanteric region. Lateralization of the greater trochanter creates a false idea of ​​the localization of the canal, and flexion-extensor deformation - of its direction. Therefore, one of the most common mistakes is perforation of the femoral wall at the site of the osteotomy. Previous derotation of the proximal region (usually outwards) may result in the placement of the prosthesis in a position of excessive anteversion.

Radiographs of the right hip joint of patient G., 52 years old: a - aseptic necrosis of the femoral head, fused fracture after medializing MBO; b - perforation of the outer wall of the femur with the leg of the endoprosthesis at the site of osteotomy (intraoperative radiograph); c - reinstallation of the leg into the correct position with fixation of the greater trochanter with cerclages (1 year after the operation).


Deformation of the subtrochanteric region without pronounced deformation of the medullary canal. With this type of deformation, the greatest preference is given to fixing the implant below the level of deformation, with a round channel it is advisable to use a round full-covered stem without cement fixation, with a wedge-shaped channel - a conical stem.

Radiographs of patient K., 53 years old, with deformity of the hip in the subtrochanteric region, congenital dislocation of the hip (grade C): a - before surgery; b - the Trilogy cup (Zimmer) is installed in an anatomical position, taking into account the deformity of the femur in the middle third, a short conical Wagner stem (Zimmer) is implanted, plastic surgery of the inner thigh at the level of the neck of the prosthesis with an autologous bone graft.


With a pronounced deformation of the subtrochanteric region, it is required:
  • osteotomy at the level of deformity; installation of the acetabular component in the anatomical position;
  • leg length correction by the position of the endoprosthesis stem;
  • restoration of the muscle “lever” due to tension and fixation of the greater trochanter or proximal femur;
  • ensuring stable fixation of bone fragments after osteotomy.

In case of severe deformities, a fundamentally different surgical technique is required, including performing an osteotomy of the femur.

X-rays of patient T., 62 years old: a, b - congenital dislocation of the hip (degree D), deformity of the subtrochanteric region after osteotomy in order to create a supporting hip; c - the Trilogy (Zimmer) acetabular component is placed in an anatomical position, wedge osteotomy of the femur at the height of the deformity with implantation of a Wagner (Zimmer) conical revision stem, refixation of the greater trochanter with screws; d - the position of the implant and the greater trochanter 15 months after the operation.



The deformity at the level of the femoral shaft creates complex problems when choosing an implant. Moderate or minor deformities can be corrected with a cemented stem in the femoral axis correction position. It is important to obtain a sufficient cement mantle around the stem. For large deformities, it is necessary to perform an osteotomy of the femur. Possible various options osteotomy. Cross-section of the bone is a fairly simple manipulation, but it must be borne in mind that this requires a strong fixation of the prosthesis stem both in the distal and proximal fragments to prevent rotational instability. The step osteotomy presents great technical difficulties, but provides good stability of the bone fragments. After performing an osteotomy, it is possible to use legs with both cemented and cementless fixation. However, given that it is difficult to prevent the penetration of bone cement into the osteotomy zone, as a rule, preference is given to round stems of cementless fixation with a full porous coating (for a round channel) or Wagner conical stems for a wedge-shaped canal. As a rule, there is no need for additional fixation of the fragments, however, in doubtful cases, it is advisable to strengthen the osteotomy line with allosteal cortical grafts fixed with cerclage sutures.

Given the above, when combining corrective osteotomy with simultaneous arthroplasty, we have identified the following requirements for surgical tactics:
  • sufficient tension of soft tissues at the level of osteotomy with possible free reduction of the endoprosthesis head;
  • rotational stability of the distal fragment and its correct orientation;
  • tight “fitting” of the endoprosthesis stem both in the distal and proximal fragments;
  • sufficient contact of the leg with the distal fragment (at least 6-8 cm);
  • creation of stable fixation of fragments due to their fixation according to the type of "Russian castle".

As an illustration, we present an extract from the medical history of a patient with a defect in the bone tissue of the acetabulum and deformity of the femoral shaft.

Patient X., 23 years old, was admitted to the clinic in January 2001 because of left-sided dysplastic coxarthrosis, supraacetabular acetabuloplasty with a titanium endoprosthesis, a fused fracture after flexion-derotation subtrochanteric osteotomy, a defect in the femoral head, posterior subluxation in the hip joint, and leg shortening, on 7 cm. In one of the medical institutions, the patient has consistently, since 1999, the following operations have been performed: supra-acetabular acetabuloplasty, subtrochanteric flexion-derotation osteotomy of the femur. As a result of contact of the femoral head with a metal endoprosthesis of the acetabular roof, the femoral head was destroyed, and its posterior subluxation developed. On January 15, 2001, the clinic performed the following operation: the left hip joint was exposed by external transgluteal access, the endoprosthesis of the acetabular roof was removed, and the femoral head was resected. During the revision, it was revealed that the acetabulum was flattened, the posterior wall was smoothed, there was a through defect at the location of the metal plate. The femur is internally rotated (at the site of the osteotomy) and has an angular deformity (the angle is open posteriorly and equals 35°). Bone grafting of the acetabular defect was performed, implanted and fixed with 4 spongy screws, a Muller support ring, a polyethylene liner, was installed in the usual anatomical position on bone cement with gentamicin. Produced wedge-shaped osteotomy of the femur at the height of the deformity, reposition of the femur (extension, derotation). After treatment of the medullary canal with drills and rasps, a fully covered leg of cementless fixation (AML, DePuy) was installed. The osteotomy line is covered with cortical allo-bone grafts, which are fixed with serrated sutures. In the postoperative period, the patient walked with the help of crutches with a dosed load on the leg for 4 months, followed by the transition to a cane. Leg length deficit was 2 cm and was compensated by shoes.

X-rays of the left hip joint and computed tomography of patient X., 28 years old(explanations in the text).


The disadvantages of using round massive stems are atrophy of the bone tissue of the proximal femur, stress-shielding syndrome, the clinical manifestation of which is the appearance of pain in the middle third of the thigh, at the level of the “tip” of the endoprosthesis stem, during exercise. In the case of a cone-shaped bone canal, it is preferable to use Wagner revision stems, however, it should be borne in mind that these implants do not have a bend, so careful selection of the implant length is required.

Radiographs of patient T., 56 years old: a - left-sided disylastic coxarthrosis with dislocation of the femoral head (grade D), deformity of the femur in the upper third and after corrective osteotomy; b - an attempt to get into the canal without osteotomy at the height of the deformity was unsuccessful (intraoperative radiographs); c - AML stem (DePyu) was installed after Z-shaped femoral osteotomy at the height of the deformity, additional fixation of the osteotomy line with a bone autograft from the femoral head; d, e - radiographs after 18 months: consolidation in the area of ​​osteotomy, good osseointegration of both components, the tip of the prosthesis rests against the anterior wall of the femur (indicated by the arrow), which causes pain during heavy physical exertion

Radiographs of patient K., 42 years old, with right-sided dysplastic coxarthrosis (grade D), double deformity of the proximal femur: a - before surgery; b - Trilogy cup (Zimmer) installed in the anatomical position, Z-shaped osteotomy of the femur at the height of the deformity with fixation of fragments according to the "Russian lock" type, revision stem Wagner (Zimmer); c - stable fixation of both components of the endoprosthesis, consolidation in the osteotomy zone after 9 months.


Acetabular fractures are a severe injury, in most cases they are combined in nature and, regardless of the method of treatment, have an unfavorable prognosis. Over time, degenerative-dystrophic changes in the hip joint occur in 12 - 57% of the victims. In 20% of patients, deforming osteoarthritis of the II-III degree develops, in 10% - aseptic necrosis of the femoral head.

The results of hip arthroplasty after acetabular fractures are inferior to the outcomes of this operation performed for deforming arthrosis of the hip joint. The frequency of aseptic loosening of the acetabular component of cement fixation in the long term (10 years after surgery) in post-traumatic coxarthrosis is 38.5%, while in ordinary forms of hip joint arthrosis it is 4.8%. The mechanical instability of endoprostheses with cementless fixation in the considered group of patients is also high and reaches 19% for the acetabular and up to 29% for the femoral components. Among the reasons for the observed differences are the violation of anatomical relationships, post-traumatic defect of the bone tissue of the acetabulum, chronic dislocation of the hip, the presence of scars and metal structures after previous operations. The younger age of patients and, accordingly, their increased physical activity may contribute to the earlier appearance of aseptic loosening.

Depending on the anatomical changes after the fracture of the acetabulum and the position of the femoral head, the following working classification was formed:
  • I - the anatomy of the acetabulum is not significantly disturbed, the sphericity is preserved, the femoral head is in its normal position;
  • II - the presence of a segmental or cavity defect of the acetabulum with dislocation / subluxation of the femoral head;
  • III - the consequences of a complex fracture with a complete violation of the anatomy of the acetabulum and a combined defect (segmental and abdominal) of the bone tissue with a complete dislocation of the femoral head.

R.M. Tikhilov, V.M. Shapovalov
RNIITO them. R.R. Vredena, St. Petersburg

In most patients, the deformity of the femur is associated with changes in the structure of its neck. Only 10% of patients have deformity of the femoral head. Basically, this group includes patients after a fracture of the femoral neck with improper fusion of bone tissue.

Primary changes begin with a shortening of the neck and thickening of its section in the region of the diaphyseal node of the articulation with the acetabulum pelvic bone. the axis of the neck and the central diaphysis are subjected to insignificant deformation, further aggravated by the contraction of certain femoral muscles. With varus deformity, shortening occurs along the inner surface. At hallux valgus the curvature passes with damage to the external muscles.

In about 70% of cases for such a disease of the musculoskeletal system, the prerequisites are formed at the stage of intrauterine development of the baby. And only in 25% of patients, the deformity of the femur is associated with degenerative lesions of cartilage and bone tissue. Usually the first signs in this case appear in old age, in menopause against the backdrop of osteoporosis. The traumatic nature of hip curvature is present in only 5% of patients with clinically diagnosed cases. This is due to the fact that recently, surgical methods for restoring the integrity of tissues have been actively used for fractures of the femoral neck. This allows for complete recovery without the formation of various kinds of degenerative deformities.

In the proposed material, you can learn more about the potential causes of the development of deformity of the femur in children and adults. It also tells about what methods of manual therapy can be effectively and safely treated in order to fully restore the physiological state of the femur.

Why does hip deformity occur?

Primary hip deformity occurs only as a congenital pathology, which may not manifest itself until adulthood. The gradual deformation of the femoral necks is a consequence of the influence of negative factors, such as:

  1. maintaining a sedentary lifestyle;
  2. excess body weight;
  3. smoking and drinking alcoholic beverages;
  4. incorrect positioning of the feet when walking and running;
  5. heavy physical labor with a maximum load on the hip joints;
  6. hip fractures;
  7. wearing high heel shoes.

Secondary deformity of the femoral necks always develops against the background of other diseases of the lower extremities. Among the most likely pathologies are:

  • deforming osteoarthritis of the hip joints (cosarthrosis);
  • deforming osteoarthritis of the knee joints (gonarthrosis);
  • curvature of the spine in the lumbosacral region;
  • symphysitis and divergence of the pubic bones during pregnancy in women;
  • incorrect setting of the foot in the form of flat feet or clubfoot;
  • tendonitis, tendovaginitis, bursitis, cicatricial deformities of the soft tissues of the lower limb.

It is also worth considering risk factors. These include intrauterine pathologies of the development of the bone skeleton, rickets in early childhood, osteoporosis in middle and old age, vitamin D and calcium deficiency, endocrine diseases (hyperthyroidism, diabetes mellitus, adrenal hyperfunction, etc.).

Successful treatment of hip deformity requires elimination of all possible causes and negative risk factors. Only in this case it is possible to get a positive effect.

Varus deformity of the femoral neck (thigh)

Pathology is divided into two types: valgus and varus deformity of the femur, in the first case, the curvature occurs according to the X-shaped type, in the second - according to the O-shaped. Both types are associated with a change in the angle located between the head and the shaft of the femur. Normally, its parameter ranges from 125 to 140 degrees. Increasing this value to 145 - 160 degrees leads to the development of an O-shaped curvature. A decrease in the angle entails a varus deformity of the femoral neck, in which the rotation of the lower limb will be sharply limited.

Abduction of the leg away from the body with varus deformity of the thigh is difficult and causes severe pain in the hip joint. Therefore, the initial diagnosis is often incorrect. The doctor suspects destruction and deformity of the femoral head and acetabulum. To confirm the diagnosis of deforming osteoarthritis, an x-ray image of the hip joint in several projections is prescribed. And during this laboratory examination, a varus deformity of the femoral neck is detected, which is clearly visible on radiographic images in frontal and lateral projections.

In the development of the curvature of the hip, several stages can be identified:

  1. slight deformation with a change in the angle of inclination by 2-5 degrees does not cause discomfort and does not give visible clinical signs;
  2. average degree it is already characterized by a significant curvature and leads to the fact that the patient has problems with the implementation of certain movements in the hip joint;
  3. severe deformity leads to shortening of the limb, complete blocking of rotational and rotational movements in the projection of the hip joint.

In adults, varus deformity often results in aseptic necrosis of the femoral head. Also, this pathology accompanies mucopolysaccharidosis, rickets, bone tuberculosis, chondroplasia and some other serious diseases.

Valgus deformity of the femoral necks (hips)

Juvenile and congenital valgus deformity of the femur is often diagnosed, which is characterized by a rapid progressive course. When looking at a patient with such a deviation, it seems that he brings his legs together at the knees and is afraid to unclench them. X-shaped valgus deformity of the femoral necks can be the result of hip dysplasia. In this case, the first signs of hip curvature appear at about the age of 3-5 years. Subsequently, the angle of deviation will only increase due to ongoing pathogenic processes in the cavity of the hip joint. Shortening of the ligaments and contraction of the muscle fibers will increase the curvature and deformity.

Congenital deformity of the femoral neck in a child may be due to the following teratogenic factors:

  • pressure on the growing uterus from the internal organs of the abdominal cavity or when wearing tight, squeezing clothing;
  • insufficient blood supply to the uterus and the growing fetus;
  • severe anemia in a pregnant woman;
  • violation of the process of ossification in the fetus;
  • breech presentation;
  • transmitted viral and bacterial infections in later dates carrying a pregnancy;
  • taking antibiotics, antiviral and some other drugs without medical supervision.

Congenital valgus deformity of the femur is characterized by a strong flattening of the articular surface of the acetabulum and a total shortening of the diaphyseal portion of the femur. An x-ray examination shows the displacement of the femoral head anteriorly and upwards with curvature of the neck and shortening of the bone area. Pineal fragmentation may appear later in life.

The first clinical symptoms of valgus deformity of the femoral neck in children appear at the beginning of independent walking. The baby may have a shortened one leg, lameness, a peculiar gait.

The juvenile type of pathology lies in the fact that valgus deformity of the hip begins to actively develop in adolescence. At the age of 13-15 there is a hormonal restructuring of the body. With an excess amount of produced sex hormones, the pathological mechanism of epiphyseolysis (destruction of the femoral head and its neck) can be launched. With the softening of the bone tissue under the influence of the growing body weight of a teenager, valgus deformity begins with a deviation of the distal end of the femur.

At risk are obese and overweight children who are sedentary, sedentary image lives addicted to carbohydrate foods. It is necessary to periodically show such adolescents to an orthopedic doctor for the timely detection of the disease at an early stage of its development.

Symptoms, signs and diagnosis

Clinical symptoms of valgus and varus deformity of the femur are hard to miss. Characteristic deviation of the upper leg, lameness, specific positioning of the legs are objective signs. there are also subjective sensations that can signal such trouble:

  • pulling, dull pain in the hip joints, occur after any physical exertion;
  • lameness, dragging of the leg and other changes in gait;
  • feeling that one leg is shorter than the other;
  • dystrophy of the thigh muscles on the side of the lesion;
  • the rapid appearance of a feeling of fatigue in the muscles of the leg when walking.

Diagnosis always begins with an examination by an orthopedic doctor. An experienced doctor will be able to make the correct preliminary diagnosis already during the examination. Then, to confirm or exclude the diagnosis, an x-ray image of the hip joint is prescribed. In the presence of characteristic features the diagnosis is confirmed.

How to treat hip deformity?

Valgus deformity of the femur in a child lends itself perfectly to conservative methods of correction. But only in the early stages can the physiological state of the head and neck of the femur be fully restored. Therefore, when the first signs of trouble appear, you should seek medical help.

The following manual therapy methods can be used to treat deformity of the femoral head:

  1. kinesiotherapy and physiotherapy aimed at strengthening the muscles of the lower extremities and, by increasing their tone, to correct the position of the head of the bone in the acetabulum;
  2. massage and osteopathy allow, due to physical external influence, to carry out the necessary correction;
  3. reflexology starts the recovery process by using the hidden reserves of the body;
  4. physiotherapy, laser treatment, electromyostimulation are additional methods of therapy.

Any course of correction is developed individually. before treating a deformity of the femur, it is necessary to consult with an experienced orthopedist.

In our clinic of manual therapy, each patient has the opportunity to receive professional advice from an experienced orthopedist absolutely free of charge. To do this, it is enough to sign up for the first appointment.

The invention relates to medicine, namely to orthopedics, traumatology in the treatment of varus deformity of the femoral neck. Essence: the spokes are passed through the iliac wing, the greater trochanter, the middle and lower thirds of the thigh, the ends of the spokes are fixed on the supports of the compression-distraction apparatus, the support on the wing of the ilium and the proximal support on the thigh are connected, and the middle support is connected to the distal one on the thigh, perform intertrochanteric osteotomy of the femur in the direction from the bottom up, from the outside - inside, the deformity of the proximal femur is corrected, a transverse osteotomy is performed in the lower third of the femur, the intermediate fragment of the femur is shifted medially, fixed in the achieved position, cantilevered wires are passed through the greater trochanter and the femoral neck, pins are passed through the supraacetabular region, they are bent in an arcuate manner, fixed and pulled to the arc of the apparatus, on the 5th-6th day after the operation, distraction between the middle and distal supports is carried out at a faster rate along the outer rods of the apparatus, which makes it possible to form the roof of the acetabulum, to equalize the length of the limb, but rmalize the biomechanical axis. 5 ill.

The invention relates to medicine, in particular to orthopedics and traumatology, and in particular is used in the treatment of varus deformity of the femoral neck using a transosseous fixation apparatus A known method for the reconstruction of the hip joint, providing for the simultaneous restoration of the cervical-diaphyseal angle (NDA) and an increase in the coverage of the femoral head by supraacetabular osteotomy of the ilium and tilting the distal fragment of the pelvis outward (AS 757155, USSR. A method for correcting the cervical-diaphyseal angle and the acetabular roof cavities in varus deformity of the femoral neck, published April 28, 1980, Bull. 31). However, this method involves performing subtrochanteric wedge-shaped or intertrochanteric angled osteotomy, supraacetabular osteotomy, followed by fixation with a plaster cast, which does not allow to gently form the roof of the acetabulum, eliminate pathological restructuring of the femoral neck, completely equalize the length of the limb and normalize its biomechanical axis. The objective of the present invention is to develop a method for the treatment of varus deformity of the femoral neck, which allows to increase the coverage of the femoral head without osteotomy of the ilium, eliminate the pathological restructuring of the femoral neck, completely equalize the length of the limb and normalize its biomechanical axis. The problem is solved by the fact that in a method for treating varus deformity of the femoral neck, including performing intertrochanteric osteotomy and fixing fragments of the femur and ilium in the supports of the transosseous apparatus, additionally introduced through the region of the greater trochanter, the femoral neck, at least four cantilevered spokes, and through the supraacetabular region - at least two wires, the ends of which are bent outward, fixed in the support of the device and pulled, while in the lower third, transverse osteotomy of the femur is performed, and intertrochanteric osteotomy is performed in the direction from bottom to top from the outside inward, after which the intermediate fragment is moved under the zone of pathological restructuring of the neck hips. The present invention is explained detailed description , clinical example, scheme and photographs in which: Fig. 1 depicts a diagram of osteotomy of the femur with fixation of its fragments and the hip joint in the supports of the transosseous apparatus; figure 2 is a photo of the patient E. before treatment; figure 3 shows a copy of the R-gram of the patient E. before treatment; figure 4 illustrates a photo of the patient E. after treatment; figure 5 is a copy of the R-gram of the patient E. after treatment. The method is carried out as follows. In the operating room after anesthesia treatment of the surgical field with an antiseptic solution, the needles are carried out at four levels (figure 1): through the wing of the ilium, the region of the greater trochanter, the middle and lower third of the thigh. The ends of the wires passed through the bone are fixed in pairs on the supports of the compression-distraction apparatus. The support on the wing of the ilium and the proximal support on the thigh are connected to each other by means of hinges; the middle support and the distal one on the thigh are connected to each other using threaded rods. The connected supports are movable relative to each other. Then, an intertrochanteric osteotomy of the femur is performed in the direction from the bottom up from the outside - inside. The deformity of the proximal femur is corrected. In the lower third of the thigh, its transverse osteotomy is performed and the medial shift of the intermediate fragment of the femur is performed. After that, the fragments of the femur are fixed with the help of supports in the achieved position. Cantilever wires are passed through the greater trochanter and femoral neck, and wires are passed through the supraacetabular region, which are arcuately bent, fixed and pulled to the arc of the transosseous fixation apparatus, which contributes to the stimulation of reparative processes in the femoral neck and acetabular roof. On the 5th-6th day after the operation, distraction is carried out between the middle and distal femoral supports at a faster pace along the outer rods of the apparatus, while forming a trapezoidal regenerate until the length of the limbs is equalized with the restoration of its biomechanical axis. After achieving complete consolidation in the areas of osteotomy, the apparatus is dismantled. An example of the implementation of the method. Patient E. (case history 30556) was admitted for treatment with the following diagnosis: Consequences of hematogenous osteomyelitis, varus deformity of the neck of the right femur - 90 o , shortening of the right lower limb 4 cm, combined contracture of the right hip joint (extension - 160 o , abduction - 100 o), valgus deformity of the knee joint - 165 o . The duration of the disease is 5 years (figure 2). Upon admission, he complained of fatigue, recurrent pain in the right hip joint, lameness, shortening of the right lower limb, limitation of movement in the right hip joint, and deformity of the right lower limb. Trendelenburg's symptom is sharply positive. On the radiograph of the pelvis - deformation of the proximal femur, SDA - 90 o . Destruction of the femoral neck with its fragmentation throughout is noted. The acetabulum is dysplastic: the acetabular index (AI) is 32 o , the thickness index of the bottom of the acetabulum (ITDV) is 1.75, the depth index is 0.3. In the operating room, after anesthesia, the treatment of the surgical field with an antiseptic solution, wires were inserted at four levels: through the wing of the ilium, the region of the greater trochanter, the middle and lower thirds of the thigh. The ends of the wires passed through the bone are fixed on the supports of the compression-distraction apparatus. The support on the wing of the ilium and the proximal support on the thigh are connected to each other by means of hinges; the middle support and the distal one on the thigh are connected to each other by means of threaded rods. Then intertrochanteric osteotomy of the femur was performed in the direction from the outside - inside from the bottom up and transverse osteotomy in the lower third of the thigh. The deformity of the proximal femur was corrected and the intermediate fragment of the femur was shifted medially. After that, the fragments of the femur are fixed with the help of supports in the achieved position. Cantilever wires are passed through the greater trochanter and femoral neck, and through the supraacetabular region - wires that are arcuately curved, fixed and stretched to the arc of the transosseous fixation apparatus. On the 5th-6th day after the operation, distraction was carried out between the middle and distal femoral supports at a faster pace along the outer rods of the apparatus until the length of the limbs was equalized and its biomechanical axis was restored, while a trapezoidal regenerate was formed. The distraction was 27 days. The apparatus was removed after 76 days. After treatment, there are no complaints, the gait is correct, the length of the legs is the same, the Trendelenburg symptom is negative, the range of motion in the hip and knee joints is complete (figure 4). On the radiograph of the pelvis, the centering of the femoral head in the acetabulum is satisfactory, SDU - 125 o , AI-21 o , ITDI - 2.3, the index of the depth of the acetabulum - 0.4 (figure 5). The proposed method of treatment is used in the clinic of the RRC "VTO" them. Academician G.A. Ilizarov in the treatment of patients with varus deformity of the femoral neck. The implementation of this method allows to achieve good anatomical and functional results by eliminating the deformation of the proximal femur, restoring the integrity of the femoral neck, gentle formation of the roof of the acetabulum by stimulating reparative processes with additional wires inserted into the femoral neck and the roof of the acetabulum, restoring the biomechanical axis of the limb when simultaneous unloading of the hip joint with a transosseous fixation device. The proposed method involves the use of well-known tools produced by the medical industry, does not require additional accessories, devices, expensive materials and is relatively low-impact. Allows functional load on the operated limb and exercise therapy in the early postoperative period, which prevents the development of persistent contractures of adjacent joints.

Claim

A method for treating varus deformity of the femoral neck, including performing an intertrochanteric osteotomy and fixing the fragments, characterized in that the spokes are passed through the iliac wing, the greater trochanter, the middle and lower thirds of the thigh, the ends of the spokes are fixed on the supports of the compression-distraction apparatus, the support is connected to the wing iliac bone and proximal femoral support, middle femoral support with the distal one, intertrochanteric osteotomy of the femur is performed in the direction from the bottom up, from the outside - inwards, the deformity of the proximal femur is corrected, transverse osteotomy is performed in the lower third of the femur, the intermediate fragment of the femur is shifted medially, fixed in the reached position, cantilever wires are passed through the greater trochanter and femoral neck, the needles are passed through the supraacetabular region, they are bent in an arcuate manner, fixed and pulled to the apparatus arc, on the 5-6th day after the operation, distraction is carried out between the middle and distal supports with advanced m pace along the outer rods of the apparatus.

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An analysis of the treatment of 47 children withcongenital varus deformity of the femoral neck(VVDShBK), who were treated at the RNIDOI them. G.I. Turner and RSDKONRTS from 1975 to 2005. The age of the patients ranged from 1 month to 19 years, there were 14 boys, 33 girls.

The pathological symptom complex included shortening of the limb from 3 to 25 cm, external rotational, adduction or flexion contracture in the hip joint. X-ray manifestations of congenital varus deformity of the femoral neck were characterized by a violation of the spatial position and the pathological state of the structure of the bone tissue of the proximal end of the femur. Varus deformity of the femoral neck (VBC) ranged from PO to 30°. The state of the bone tissue structure consisted in a delay in the ossification of the neck and head of the femur, neck dystrophy varying degrees against the background of its dysplasia, intertrochanteric false joint, as well asfemoral neck defect. On the basis of the conducted studies, a classification of congenital varus deformity of the femoral neck was developed, taking into account the size of the NVA, the state of the structure of the bone tissue and the amount of shortening: 1st degree of severity: NVA 90-110°, delayed ossification or dystrophy of the femoral neck of 1-2 degrees, shortening hips up to 30%; 2nd degree of severity: NSA less than 90°, degeneration of the femoral neck of 2-3 degrees or a false joint in the intertrochanteric region, shortening of the hip by 35-45%; Grade 3: NSA less than 70°, defect of the femoral neck, shortening of the femur by more than 45%.

The above classification of congenital varus deformity of the femoral neck served as the basis for the development of indications, firstly, for the treatment method (conservative or surgical), and secondly, for the choice of a specific surgical technique.

The indication for conservative treatment was grade I congenital varus deformity of the femoral neck in children under 3 years of age. Conservative treatment consisted of creating a favorable position of the femoral head in the hip joint using a Freik pillow, Mirzoeva splint, and in children older than a year, wearing an orthopedic device with landing on the ischial tubercle (Thomas type). Conducted massage and physiotherapy, aimed at improving blood circulation in the hip joint. The indication for the surgical method of treatment was II and III severity of congenital varus deformity of the femoral neck, as well as I degree in children over the age of 2-3 years with a NSA value of less than 110°.

I degree of congenital varus deformity of the femoral neck with signs of dystrophy of the femoral neck and NSA less than 110° was an indication for surgery according to the technique we developed. The basis of the operation was the transposition of a trapezoid-shaped fragment of the femur with a lesser trochanter under the zone of degeneration of the femoral neck and simultaneous correction of the SDA. II-III severity of congenital varus deformity of the femoral neck was an indication for early surgical treatment, which was aimed at eliminating the vicious position of the hip and consisted of operations on the soft tissues surrounding the hip joint. II degree of severity of congenital varus deformity of the femoral neck in children older than 2-3 years old was an indication for correction of the spatial position of the proximal femur according to the method developed by us (patent for invention No. 2183103). The basis of the operation was intertrochanteric detorsion-valgus osteotomy of the femur, accompanied by myotomy of the adductor, lumboiliac, rectus and sartorius muscles, cutting off the fibrous cord of the anterior portion of the gluteus medius muscle, and dissection of the fascia lata of the thigh in the transverse direction. III degree of severity of the lesion (defect of the femoral neck) in children older than 6 years was an indication for osteosynthesis of the head and proximal end of the femur using (for neck plasty) a musculoskeletal complex of tissues on a feeding vascular-muscular pedicle with fixation of the fragments with pins or screws.

The absence of the head, a pronounced adductor contracture in the hip joint in children older than 12 years of age and adolescents was the basis for reconstructive surgery on the proximal femur with the formation of an additional femoral support point in the pelvis.

According to the proposed surgical techniques, 39 children were operated on, 8 patients received only conservative treatment. When using the tactics developed by us for the treatment of children with congenital varus deformity of the femoral neck, good and satisfactory functional results were obtained in 93.6%.


Vorobyov S.M., Pozdeev A.P., Tikhomirov S.L.
Republican Specialized Children's Clinical Orthopedic and Neurological rehabilitation center, Vladimir, RNIDOI them. G. I. Turner, St. Petersburg

As well as the occurrence of hip deformities in general, it is based on various reasons. Part of the deformities comes from changes in the hip joint and femoral neck. Deformities in the area of ​​the metaphysis and diaphysis of the thigh can be congenital, rachitic, inflammatory, can be associated with trauma and various tumors.

Symptoms of deformity of the femoral neck.

Deformation of the femoral neck often develops in early childhood, is often the result of rickets, may depend on congenital and dysplastic changes in the skeletal system, and is less often associated with trauma.

The curvature of the femoral neck is characterized by a decrease in the angle between the diaphysis and the femoral neck (to a straight or even sharp one) and is called coxa vara. On the basis of anatomical changes, functional disorders occur, manifested by rocking of the body when walking, limitation of hip abduction, lameness as a result of shortening of the leg.

Swinging of the body when walking at the moment of loading on the sore leg depends on the functional insufficiency of the middle and small gluteal muscles due to the displacement of the thigh upwards. To keep the pelvis in a horizontal position, the patient is forced to tilt the body towards the affected leg. Thus, the so-called duck gait is formed. Often there are complaints of increasing weakness of the lower limb, fatigue, pain when walking and standing.

Deformation related to the previous one are X-shaped legs. The development of this deformity is associated with an uneven load on the femoral condyles and their uneven growth: the growth of the internal condyle gradually leads to the formation of a valgus curvature of the knee joint. Clinically, this deformity is manifested by the fact that the thigh and lower leg form an angle in the knee joint that is open to the outside.

In a child with a similar deformity, the knee joints are in close contact, while the feet are at a great distance from one another. In an effort to bring the feet together, the knee joints come one after the other. Such a deformity of the knee joints is often accompanied by a valgus installation of the feet (deflection of the calcaneal bones outwards). This deformity can lead to pain in connection with the progressive development of flat feet.

At the heart of another deformity of the legs and knee joints, the O-shaped curvature of the legs, most often lies rickets. An arcuate curvature of the bones of the lower leg with a bulge outward develops in the process of vertical load under the influence of muscle traction during softening of the bones by a rachitic process. The curvature of the lower leg is enhanced under the influence of the traction of the triceps muscle of the lower leg, acting in the direction of the chord forming the arc.

The vicious position of the bones is fixed in the process of their asymmetric growth. The disease is manifested by a duck gait, a positive Trendelenburg symptom, limited abduction and rotation in the hip joint, however, unlike congenital hip dislocation, the head of its valgus deformity is palpable in the Scarpov triangle.

Causes of deformity of the femoral neck.

The causes of valgus deformity of the femoral neck are varied. Allocate congenital, children's or dystrophic, youthful, traumatic and rachitic deformities. In addition, valgus curvature of the femoral neck is observed in systemic diseases: fibrous osteodysplasia, pathological bone fragility, dyschondroplasia. The deformity may be the result of surgical interventions in the area of ​​the femoral neck or any pathological conditions of the bone in this area (consequences of osteomyelitis, tuberculosis, subcapital osteochondropathy).

Congenital valgus deformity of the femoral neck is more often bilateral, and then the disease is detected with the beginning of the child's walking in a characteristic duck gait, which often suggests a congenital dislocation of the hip. In addition, on examination, there is a limitation in the spread of the legs and a high standing of the large skewers. X-ray examination makes it possible to diagnose the disease. Often, the deformity of the femoral neck is combined with other congenital defects: shortening of the limb, a violation of the shape of other joints.

Children's viral deformity of the femoral neck is more often unilateral and is associated with dystrophic processes as a result of trophic disorders and is accompanied by bone tissue restructuring by the type of aseptic necrosis. The disease begins at the age of 3-5 years, under the influence of the load, the deformity of the femoral neck progresses. Clinically, the disease is manifested by lameness, pain, especially after a long walk, run. The affected limb may be shorter and thinner, and hip abduction is limited. The greater trochanter is located above the Roser-Nelaton line, a positive Trendelenburg sign is noted.

In other words clinical manifestations largely identical congenital dislocation hips. However, there will be no symptoms characteristic of dislocation, such as displacement of the thigh along the longitudinal axis (Dupuytren's symptom), a symptom of a non-disappearing pulse with pressure on the femoral artery in the Scarpov triangle.

Diagnosis of deformity of the femoral neck.

Diagnosis in the vast majority of cases does not cause any difficulties for a traumatologist or any other specialist. In order to clarify the position of the end of the femur and exclude probable bone damage, it is necessary to conduct an x-ray study. Moreover, it must be in two projections.

In the same case, if the diagnosis is in doubt, an MRI of the entire described joint is performed.

Treatment of deformity of the femoral neck.

Correction of such a deformity is effective at the beginning of their formation (on the 1st-2nd year of life). The principle of complex therapy common to most orthopedic deformities is also valid for this group of deformities of the lower extremities. Application and combined with orthopedic treatment (appointment of special splints, wearing special devices).

Treatment is operative.

It is carried out in two directions: therapy of the causes of deformity and surgical (the deformity itself). Based on cases of detection of the disease, it is noted that valgus deformity of the femoral neck appears in a patient from birth. There are rare cases when the deformity occurs with a traumatic or paralytic etiology.

Before starting the operation, it is required to plan the upcoming operation. Find out what methods and constructions can be applied in this case. Thus, the following questions arise before the surgeon:

  • Simultaneous or staged elimination of hip deformity.
  • Limb length adjustment.
  • Removal of old processes in the event that operations of this type were carried out.
  • Design and installation of the endoprosthesis.

There are more than 100 methods of treating valgus deformity of the femoral neck:

  • Exostectomy (removal of part of the head of the bone);
  • Restoration of ligaments;
  • Replacement with an implant;

In the case when the femoral neck is replaced with an implant, local or general anesthesia is performed before the operation. The surgeon then makes a small incision. Next, the surgeon removes the femoral neck and installs an endoprosthesis that ideally repeats its shape. The prosthesis facilitates movement, helps to correct gait, improve the quality of life, get rid of pain. There are many types of prostheses, which are selected according to the specific case of the disease.

Prevention of hip deformity.

In order to prevent dislocation in the hip area, it is recommended to carefully monitor safety in Everyday life and during sports activities.

This raises the need for:

  • training of various muscle groups, rational physical activity;
  • the use of exceptionally comfortable clothing and footwear to prevent falls;
  • the use of professional protective equipment throughout sports activities. We are talking, at a minimum, about knee pads and hip braces;
  • avoiding any trips on ice, paying attention to slippery and wet surfaces.

In order to fully restore the hip joint after dislocation, it will take, if there are no complications, from 2 to 3 months. This period can only be lengthened if there are concomitant fractures. So, the doctor may insist that a non-long-term skeletal type traction be carried out with further sets of exercises. This is done with the help of a device of continuous inactive movement.

Independent movement using crutches is possible only in the absence of any pain. Until the moment when lameness disappears, it is recommended to resort to additional aids for moving, for example, a cane.

After that, it is recommended to use general strengthening drugs that will affect the structure of bone tissue. It is also important to carry out certain exercises, the list of which should be compiled by a specialist. The regularity of their implementation will be the key to recovery. In addition, it is necessary to treat the damaged area of ​​the thigh as carefully as possible, because now it is one of the weakest points in the body.

Keeping in mind all the rules of prevention and treatment, it is more than possible to quickly and permanently get rid of any consequences of hip dislocation while maintaining the optimal rhythm and tone of life.