Femoral Angle of Inclination Angle within the frontal plane between the femoral neck

and the medial side of the femoral shaft

Average adult measurement of 125 degrees Newborns born with 140-150 degree angle which

reduces to approximately 125 degrees with onset of standing/walking

Determines :The effectiveness of hip ABD muscles The length of the limb The forces acting on the hip joint and femoral neck
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Angle of Inclination
Coxa Vara A of I markedly less than 125 degrees Coxa Valga A of I markedly greater than 125 degrees

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Coxa Vara

If the angle of inclination is less than 125 degrees it is termed coxa vara.

Click to edit Master subtitle style This: 1. shortens the limb;

2.

decreases the effectiveness of the abductors;

3. increases the load on the femoral neck;

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Coxa Valga

If the angle of inclination is greater than 125 degrees it is termed coxa valga.

This: 1. lengthens the limb; 2. mimics contracture of the hip abductors; 3. reduces the load on the femoral neck; 4. increases the load on the femoral head.
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Symptoms of Coxa Vara-:

stiffness, pain, difference in leg length(shortening) ,resulting in a limp and difficulty walking. Unilateral involvement with an associated relative limblength discrepancy and Trendelenburg limp may be noted. This discrepancy in limb lengths usually is mild, ranging from 1.5 to 4.0 cm Waddling gait in bilateral cases weak abductors, a prominent greater trochanter, decreased abduction A decrease in internal rotation also is often noted, caused by decreased femoral anteversion or true retroversion 4/23/12 associated with this condition.

Coxa Valga (L) v. Coxa Vara

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The Types of Coxa Vara

Coxa Vara typically falls into one of three categories: congenital, developmental, or acquired. Congenital Coxa Vara (CCV) is present at birth, and believed to be the result of either embryonic abnormalities or possibly the result of certain intrauterine conditions or mechanical stresses that could affect the way in which the hip forms. The developmental form of Coxa Vara presents itself during early childhood and seems to follow a progressive pattern that continues as the child develops. 4/23/12

Surgical Therapy:The goals of surgical intervention are as follows: Correction of the neck shaft angle to a more physiologic angle Correction of femoral anteversion (or retroversion) to more normal values Ossification and healing of the 4/23/12 defective inferomedial femoral

Femoral Torsion Angle(angle of

anteversion) Torsion angle
relative rotation (twist) that exists between the shaft and

neck of the femur. The angle of the femoral neck in the transverse plane is termed the angle of anteversion.

Normal Anteversion: Normally the femoral

neck is rotated anteriorly 12 to 14 degrees with respect to the femur. Increases the MA of the gluteus maximus making it a more effective hip external rotator

Excessive anteversion: beyond 14 degrees

causes the head of the femur become uncovered. tends to dislocate, unstable hip

Retroversion:If the angle of anteversion is 4/23/12

reversed so that it moves posteriorly, it is

 Normal Anteversion 10-15 degrees

allows optimal alignment and joint congruency

Normally the femoral neck is rotated

anteriorly 12 to 14 degrees with respect to the femur.

Average adult measurement of 10-

15 degrees of anterior rotation (Anteversion) of femoral head

Newborn TA typically 30 degrees of

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anteversion; which reduces to 10-15 degrees by 6 years of age

Femoral Torsion Angle (cont.) Excessive Anteversion :TA significantly greater than 15 degrees causes the head of the femur become uncovered. Often associated with congenital dislocation in the infant; marked joint incongruence; and increased degenerative wear In order to keep the head of the femur within the acetabulum a person must internally rotate the femur.

So ,Compensated excessive anteversion may result in toeing-in gait pattern (pigeon toed)

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Excessive Femoral Anteversion

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Femoral Torsion Angle (cont.) Retroversion :

If the angle of anteversion is reversed so that it moves posteriorly, it is termed retroversion. TA significantly less than 15 degrees (i.e. 5 degrees of anteversion This condition causes the person to externally rotate the femur and produces a toe out gait (duck feet). Less common than excessive anteversion

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DEVELOPMENTAL COXA VARA Eric Sandefur, D.O., Pediatric Orthopaedic Surgery William G. Mackenzie, M.D., Attending Pediatric Orthopaedic Surgeon August 2, 1995 CLINICAL CASE PRESENTATION ORTHOPAEDIC DEPARTMENT THE ALFRED I. DUPONT INSTITUTE WILMINGTON, DELAWARE DEFINITION : also known as cervical or infantile coxa vara represents coxa vara not present at birth but rather developing in early childhood coxa vara is defined as any decrease in the femoral neck-shaft angle less than 120 - 135 degrees
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ETIOLOGY :

currently remains unknown the most popular theory, proposed by Dylkkanes in 1960, states that the deformity is caused by a defect of enchondral ossification of the femoral neck. Weightbearing causes shearing stresses which result in fatigue of the dystrophic one and progressive varus deformity results other proposed theories include: metabolic abnormalities cause a deficiency or delay in the ossification process mechanical abnormalities may occur during development and early ambulation partial vascular insult to the inferior aspect of the femoral neck developmental abnormality which causes faulty cartilage formation and maturation histologic studies have shown that there are abnormalities in both cartilage production and metaphyseal bone formation. These findings are similar to those found in the proximal tibia in patients with Blount's disease. 4/23/12

CLINICAL PRESENTATION: most commonly seen between when the child begins to ambulate and age six most common complaint is a progressive gait abnormality in unilateral involvement this is due to both abductor muscle weakness and limb length inequality patients with bilateral involvement have a waddling gait and increased lumbar lordosis (similar to that seen in bilateral DDH)
PHYSICAL EXAM:

prominent and elevated greater trochanter positive Trendelenburg test limb-length inequality (usually less that 2.5 cm) decreased ROM with restrictions noted with abduction and internal rotation

RADIOGRAPHIC FINDINGS:

femoral-neck shaft angle below 90 degrees

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more vertical position of the

main objectives of surgical treatment include:

correction of varus angulation

changing of the loading characteristics from shear to compression of the femoral neck restoring proper length of abductors muscles resolution of limb-length inequalities current criteria for surgical

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proper surgical treatment also includes: adductor tenotomy which allows for less forceful correction and improved stability proximal femoral shortening osteotomy if necessary to help relieve excessive femoral head pressure when the valgus angle is restored stable internal fixation and hip spica cast if needed goal of surgical treatment is to produce an overcorrection of valgus angle to greater than 150 - 160 degrees, as well as, correction of epiphyseal angle to less than 30 degrees The timing of surgery remains controversial. Several authors recommend delay surgery until 5 6 years of age. Others state that surgery may be performed after 18 months if the above criteria are met.
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COMPLICATIONS: Recurrence of proximal femoral varus deformity-many feel that this is due to undercorrection at surgery while others feel that it is due to failure to place the osteocartilaginous defect into a compressive mode Premature physeal closure-the incidence may be as high as 89% and has not been found to be related to physeal injury at the time of surgery Greater trochanteric overgrowth-associated with premature capital femoral physeal closure and is commonly treated by greater trochanter transfer or epiphysiodesis Acetabular dysplasia-found to be increase in patients with premature physeal closure and inpatients who have had an undercorrection of the neck-shaft angle less than 140 degrees other complications have included pseudarthrosis, avascular necrosis, leg-length discrepancy, and degenerative arthritis

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