Sherif Galal

Developmental coxa vara (DCV) develops during early childhood between the age of independent walking and 6 years. The deformity includes a decrease in the neck-shaft angle and femoral retroversion. Recently, good results have been reported using external fixator systems for the correction of proximal femoral deformities secondary to slipped capital femoral epiphysis, Perthes' disease in children, and percutaneous proximal femoral osteotomy for coxa vara. This preliminary study was performed to evaluate the results of percutaneous subtrochanteric osteotomy in restoring the normal alignment and orientation (radiographic outcome), thereby restoring the normal mechanics of the hip joint, overcoming shortening of the limb, and re-establishing the length-tension relationship of the abductor muscles (functional outcome). During the period between January 2009 and January 2012, a prospective study was conducted involving 30 (33 hips) patients with DCV and a preoperative Hilgenreiner's epiphyseal angle of 60° or greater on coronal radiographs. Clinical and radiological (anteroposterior radiograph of the pelvis) evaluation of patients was carried out preoperatively and postoperatively until union was achieved and fixator removal was carried out, and then at 6 months and at the final follow-up, with a minimum of 12 and a maximum of 33 months after surgery and an average of 20.8 months. We used the technique described by Sabharwal and colleagues (2005) to perform an acute, opened wedge subtrochanteric valgus-flexion-derotation femoral osteotomy using a percutaneous multiple drill hole technique. A low-profile Ilizarov external fixator was applied in each case. The average operative time (including anesthesia time) was 74 (range 60-130) min. The average time spent in the external fixator until union was 11 (range 7-15) weeks. The average intraoperative blood loss was 35 (range 10-150) ml, and no patient developed hemodynamic instability or required any postoperative blood transfusion. The hospital stay averaged 1.2 (range 1-2) days. Hilgenreiner's epiphyseal angle preoperatively averaged 70.6° (ranging from 55° to 90°). At 6 months it averaged 40.6° (ranging from 15° to 60°). At final follow-up it averaged 41.16° (ranging from 15° to 60°). Percutaneous subtrochanteric osteotomy with external fixation appears safe and effective in treating multiplanar proximal femoral deformities associated with DCV in children.

LEVEL OF EVIDENCE: Level IV.

UNLABELLED: Subtrochanteric femoral fractures in children are uncommon and have received limited attention in the literature. Its treatment is controversial, and different options are available: traction, spica casting, internal fixation and external fixation. The aim of this study is to present our results with external fixation of subtrochanteric femoral fractures in children using Ilizarov frame. Between January 2012 and January 2014, 14 patients with closed subtrochanteric femoral fractures were treated in Cairo University School of Medicine Teaching Hospital. The average age at the time of injury was 6.4 years (range 3.8-11.5 years). Pathological fractures and fractures associated with neuromuscular diseases were excluded from this study. Two patients were multiply injured with abdominal injuries (as ruptured spleen). In all cases, a low profile Ilizarov frame was inserted using two half pins inserted proximally from greater to lesser trochanters parallel to the hip joint orientation line (line between tip of greater trochanter and femoral head centre) and secured to an arch, and another three half pins were inserted distally perpendicular to the femoral shaft and secured to an arch that was connected by three rods to the proximal arch. No post-operative spica was used. Average follow-up was 18 months (range 12-36 months). All fractures united with anatomical alignment within an average of 8 weeks (range 6-12 weeks). There were no deep infections and no significant limb length discrepancies. At the latest follow-up, no patient had any restriction of activities. External fixation with a low profile Ilizarov frame appears as a good treatment option for subtrochanteric femoral fractures in children.

LEVEL OF EVIDENCE: Level IV.