Congenital deformities of the musculoskeletal system. Causes, types and treatment of congenital curvature of the hip Symptoms and signs

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Difficult cases of primary hip arthroplasty: Proximal femoral deformity

The normal anatomy of the proximal femur is quite variable, and in the vast majority of cases it is possible to manage with standard endoprostheses while following the usual surgical technique. From a practical point of view, a hip may be considered deformed if its shape and size are so unusual that compensation for 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 healed 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 anatomical location, which includes the greater trochanter, femoral neck, metaphysis, and diaphysis. In turn, deformities in each of the listed anatomical zones can be divided according to the nature of the displacement: angular (varus, valgus, flexion, extension), 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 these signs are possible. The greatest difficulties for treatment are deformations of the femur at two levels and in several planes.

General principles of treatment.

In the presence of femoral deformity, careful preoperative planning is necessary to determine the feasibility of standard approaches and designs. With some deformities, significant difficulties arise in preparing the medullary canal. For example, a displacement of the diaphysis in width in the sagittal plane can lead to perforation of the anterior cortical wall when inserting an endoprosthetic leg. Intraoperative fluoroscopy or radiography allows you to monitor the progress of canal preparation and significantly reduce the risk of perforation of the femoral wall. The surgeon must decide whether he can install the stem by deviating it from the standard position, or whether this is not possible and a femoral osteotomy must be resorted to. The presence of deformation influences the choice of leg geometry and method of its fixation. There are types of deformities that require specially designed femoral components and, in some cases, custom-made femoral components. With severe deformities, there is often a need for an osteotomy of the femur, and in some cases, a two-stage operation.

Thus, unfavorable factors that create difficulties during the operation and influence the choice of prosthetic leg are the following: osteoporosis, deformation of the bone marrow canal in the sagittal and frontal planes, medialization and rotation of the femur, the presence of unremoved metal structures. Before the operation, the surgeon must carefully plan and have at his disposal several designs of endoprosthetic legs of various types of fixation. The surgeon faces the following questions:

the possibility of immediate or staged elimination of deformity and 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:

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

Selection 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, which complicate the performance of arthroplasty: overhang of the greater trochanter with blocking of the entrance to the medullary canal and its high location. When the greater trochanter overhangs, the preparation of the canal becomes significantly more difficult, creating a real threat of its breaking off and varus installation of the endoprosthetic leg. The problem of endoprosthetics with a high location of the greater trochanter is the potential for the trochanter to rest on the pelvis (“impingement” syndrome) with the development of posterior instability of the joint during flexion and internal rotation of the hip, and the appearance of lameness due to insufficiency of the abductor muscles of the hip. To prevent these complications, it is advisable to initially perform an osteotomy of the greater trochanter during the approach, which facilitates the preparation of the canal and makes it possible to compensate for the strength of the abductor muscles by lowering 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 for varus deformity depends on the presence of bilateral or unilateral lesions, as well as the need to change the length of the leg. With a unilateral deformity, as a rule, the affected leg is shorter, and standard structures can be used. If the surgeon wants to maintain the length of the leg with bilateral deformity, it is necessary to consider using a leg with a smaller neck-shaft angle (for example, the Alloclassic leg 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 is usually associated with a narrow metaepiphysis and requires the use of stems with a narrow proximal part. In addition, it is advisable to use implants with a neck-shaft angle of 135° or more.

Small torsional deformations of the femoral neck can be compensated by the appropriate position of the endoprosthesis stem. Problems arise when the anteversion angle is greater than 30°.

If the leg is placed in this position, it will lead to limited external rotation and may be accompanied by hip dislocation. You can install the leg in the correct position by installing it on bone cement, or by using conical prostheses (Wagner type). Another way out of this situation may be to use legs of a modular design (such as S-ROM, ZMR). In case of severe rotational deformities, when other surgical methods cannot be used, derotational osteotomy of the femur is performed.

Deformations of the trochanteric region of the femur are extremely variable and have multiple etiologies. In principle, it is possible to use both types of legs. In the preoperative period, careful planning is necessary to determine the optimal position of the stem and the size of the cement mantle. Cemented stems are most often used in elderly patients with signs of osteoporosis. In addition, this option of endoprosthetics is used when there are difficulties with installing a cementless fixation stem.

Radiographs of the pelvic bones of patient V., 53 years old, with left-sided dysplastic coxarthrosis: a — 6 years after therapeutic intertrochanteric osteotomy, progression of coxarthrosis is observed; b - endoprosthetics of the left hip joint with a standard hybrid endoprosthesis (Trilogy cup, Zimmer, Lubinus Classic Plus leg, W.Link with a 126° wide angle). The choice of the stem is determined by its closest correspondence to the geometry of the medullary canal of the femur.

It must be borne in mind that when removing the plate simultaneously (after MWO) with installing a cement fixation stem, difficulties arise with good compression of the cement. To prevent cement from escaping from the holes in which the screws were located, they must be tightly closed using 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 stem with cement fixation (CPT, Zimmer) after removal of the plate.

The use of standard cementless fixation stems is possible after varus and varus intertrochanteric osteotomies, but with a slight change in the neck-diaphyseal angle and medialization of the distal femur. In these cases, it is advisable to use fully covered legs. Sometimes valgus placement of the endoprosthetic stem is justified, but it is advisable to use implants with a 126" neck angle to prevent instability.

Radiographs of patient S., 54 years old, with left-sided dysplastic coxarthrosis: a - deformation of the metaepiphysis of the femur after derotational-valgusizing intertrochanteric osteotomy (8 years after surgery); b - slight medialization allowed the use of a standard AML cementless fixation stem (DePuy); the choice of a stem with a sufficiently extended coating of balls (5/8 of the length) is due to the need for distal fixation of the endoprosthesis due to pronounced compaction of bone tissue at the site of MVO; c, d - 6 years after surgery.

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

Excessive medialization of the distal part of the femur and rotational flexion-valgus deformity of the intertrochanteric region significantly complicate the choice of implant. In these cases, it is determined by the shape of the channel below the deformation level. With a tapered 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 rotational installation.

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

If the bone canal has a round shape, preference is given to revision designs with a round shape of the leg, one of the options of which can be a leg with a “kapkar”. A distinctive feature of 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 a complete porous coating of the stem, providing distal fixation of the prosthesis.

Radiographs of the right hip joint of patient B., 53 years old: a - pseudarthrosis of the neck of the right femur, healed fracture of the femur after mednalizing therapeutic intertrochanteric osteotomy; b,c - taking into account the excessive medialization of the femoral diaphysis, a stem with a “calcar” (Solution, DoPuy) was chosen for endoprosthetics, which has a porous coating along its entire length, which ensures distal fixation of the endoprosthesis.

A distinctive feature of the surgical intervention 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 about the localization of the canal, and flexion-extension deformation creates a false idea about its direction. Therefore, one of the common mistakes is perforation of the femoral wall at the osteotomy site. Previous derotation of the proximal part (usually outward) can lead to installation 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, healed 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 surgery).

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 canal, it is advisable to use a round, fully covered stem of cementless fixation; with a wedge-shaped canal, it is advisable to use a conical stem.

Radiographs of patient K., 53 years old, with hip deformity in the subtrochanteric region, congenital hip dislocation (grade C): a - before surgery; b - the Trilogy cup (Zimmer) is installed in an anatomical position, taking into account the deformation 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 autogenous bone graft.

In case of severe deformation of the subtrochanteric region, the following is required:

osteotomy at the level of deformity; installation of the acetabular component in an anatomical position;
correction of leg length by the position of the endoprosthesis leg;
restoration of muscle “leverage” 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 osteotomy of the femur.

Radiographs of patient T., 62 years old: a, b - congenital dislocation of the hip (grade D), deformation of the subtrochanteric region after osteotomy with the aim of creating a supporting hip; c - the Trilogy (Zimmer) acetabular component is installed in the anatomical position, wedge-shaped osteotomy of the femur at the height of the deformity with implantation of a conical revision Wagner stem (Zimmer), refixation of the greater trochanter with screws; d - position of the implant and greater trochanter 15 months after surgery.

Deformation at the level of the femoral shaft creates complex problems when selecting an implant. Moderate or minor deformities can be compensated by using a cemented stem placed 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. Various osteotomy options are possible. Transverse intersection of the bone is a fairly simple manipulation, but it must be borne in mind that this requires strong fixation of the prosthetic leg in both the distal and proximal fragments to prevent rotational instability. Step osteotomy presents great technical challenges, but provides good stability of the bone fragments. After performing an osteotomy, it is possible to use both cemented and cementless fixation stems. However, given that it is difficult to prevent bone cement from getting into the osteotomy area, as a rule, preference is given to round stems of cementless fixation with a full porous coating (for a round canal) or conical Wagner 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 allobone cortical grafts and fixed cerclage sutures.

Taking into account the above, when combining corrective osteotomy with simultaneous endoprosthetics, we have determined the following requirements for surgical tactics:

sufficient tension of soft tissues at the level of osteotomy with possible free reduction of the head of the endoprosthesis;
rotational stability of the distal fragment and its correct orientation;
tight “fit” of the endoprosthesis leg in both 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 “Russian castle” type.

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 deformation of the femoral diaphysis.

Patient X., 23 years old, was admitted to the clinic in January 2001 with left-sided dysplastic coxarthrosis, supraacetabular acetabuloplasty with a titanium endoprosthesis, a healed fracture after flexion-derotational subtrochanteric osteotomy, a defect of the femoral head, posterior subluxation in the hip joint and shortening of the leg, on 7 cm. In one of the patient's medical institutions, starting in 1999, the following operations were performed successively: supraacetabular acetabuloplasty, subtrochanteric flexion-derotational osteotomy of the femur. As a result of contact of the femoral head with the metal endoprosthesis of the roof of the acetabulum, destruction of the femoral head occurred and its posterior subluxation developed. At the clinic on January 15, 2001, the following operation was performed: the left hip joint was exposed using an external transgluteal approach, the endoprosthesis of the acetabulum roof was removed, and the head of the femur was resected. During the inspection, it was revealed that the acetabulum was flattened, the posterior wall was smoothed, and there was a through defect at the location of the metal plate. The femur is internally rotated (at the osteotomy site) and has an angular deformity (the angle is open posteriorly and is equal to 35°). Bone grafting of the acetabulum defect was performed, a Muller support ring was implanted and fixed with 4 cancellous screws, and a polyethylene liner was installed in the usual anatomical position on bone cement with gentamicin. A wedge-shaped osteotomy of the femur was performed at the height of the deformity, and the femur was repositioned (extension, derotation). After preparation of the medullary canal with drills and rasps, a fully covered, cementless-fixed stem (AML, DePuy) was installed. The osteotomy line is covered with cortical allografts, which are fixed with cervical 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 a transition to a cane. The leg length deficit was 2 cm and was compensated by wearing shoes.

Radiographs of the left hip joint and computed tomograms of patient X., 28 years old(explanations in the text).

The disadvantages of using round massive legs 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 leg, during physical activity. If the bone canal is cone-shaped, it is preferable to use Wagner revision stems, but it must 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 disilastic coxarthrosis with dislocation of the femoral head (grade D), deformation of the femur in the upper third and after corrective osteotomy; b - an attempt to enter the canal without osteotomy at the height of the deformity was unsuccessful (intraoperative radiographs); c - an AML stem (DePyu) was installed after a Z-shaped osteotomy of the femur 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 osteotomy area, good osseointegration of both components, the tip of the prosthesis rests on 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 an anatomical position, Z-shaped osteotomy of the femur at the height of deformation with fixation of fragments according to the “Russian castle” type, revision Wagner stem (Zimmer); c - stable fixation of both components of the endoprosthesis, consolidation in the osteotomy area after 9 months.

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

The results of hip replacement after fractures of the acetabulum are inferior to the results 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%, whereas in conventional forms of arthrosis of the hip joint it is 4.8%. Mechanical instability of cementless fixation endoprostheses in the patient population under consideration 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 a violation of anatomical relationships, a post-traumatic defect in the bone tissue of the acetabulum, chronic hip dislocation, and the presence of scars and metal structures after previous operations. The earlier appearance of aseptic loosening may be facilitated by the young age of patients and, accordingly, their increased physical activity.

Depending on the anatomical changes after a 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 cavitary defect of the acetabulum with dislocation/subluxation of the femoral head;
III - consequences of a complex fracture with complete disruption of the anatomy of the acetabulum and a combined defect (segmental and cavitary) of bone tissue with complete dislocation of the femoral head.

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

And also the occurrence of hip deformities in general has various reasons. Some deformities occur from changes in the area of the hip joint and femoral neck. Deformities in the area of the metaphysis and diaphysis of the femur can be congenital, rachitic, inflammatory, and can be associated with trauma and various tumors.

Symptoms of femoral neck deformity.

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

Curvature of the femoral neck is characterized by a decrease in the angle between the diaphysis and the femoral neck (to straight or even acute) and is called coxa vara. Based on anatomical changes, functional disorders arise, manifested by swaying of the body when walking, limited hip abduction, and lameness as a result of shortening the leg.

The swaying of the body when walking when the load is placed on the sore leg depends on the functional insufficiency of the gluteus medius and minimus muscles due to the upward displacement of the hip. 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. There are often complaints of increasing weakness of the lower limb, fatigue, pain when walking and standing.

A deformation that is related to the previous one is 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 open outward at the knee joint.

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. When trying to bring the feet closer together, the knee joints come in one after another. Such deformation of the knee joints is often accompanied by valgus position of the feet (outward deviation of the heel bones). Due to the progressive development of flat feet, this deformity can lead to pain.

Another deformity of the legs and knee joints, the O-shaped curvature of the legs, is most often based on rickets. An arched curvature of the leg bones with a convexity outward develops during vertical loading under the influence of muscle traction when the bones are softened by a rachitic process. The curvature of the lower leg increases under the influence of the traction of the triceps surae muscle, acting in the direction of the chord of the forming arch.

The vicious position of the bones is fixed in the process of their asymmetrical growth. The disease is manifested by a duck's gait, a positive Trendelenburg sign, limitation of abduction and rotation in the hip joint, however, unlike congenital dislocation of the hip, the head of its valgus deformity can be felt in Scarp's triangle.

Causes of femoral neck deformity.

The causes of valgus deformity of the femoral neck are varied. There are congenital, childhood or dystrophic, juvenile, traumatic and rachitic deformities. In addition, valgus curvature of the femoral neck is observed in systemic diseases: fibrous osteodysplasia, pathological fragility of bones, dyschondroplasia. The deformity may be a consequence of surgical interventions in 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 often bilateral, and then the disease is detected when the child begins to walk in a characteristic duck gait, which often suggests a congenital dislocation of the hip. In addition, upon examination, limited leg extension and high standing of the greater trochanters are noted. X-ray examination makes it possible to diagnose the disease. Often, deformity of the femoral neck is combined with other congenital defects: shortening of the limb, disruption of the shape of other joints.

Children's viral deformity of the femoral neck is often one-sided and is associated with degenerative processes as a result of trophic disorders and is accompanied by the restructuring of bone tissue according to the type of aseptic necrosis. The disease begins at the age of 3-5 years; under the influence of load, the deformation of the femoral neck progresses. Clinically, the disease manifests itself as lameness and pain, especially after long walking or running. The affected limb may be shorter and thinner, and hip abduction may be limited. The greater trochanter is located above the Roser-Nelaton line, and a positive Trendelenburg sign is noted.

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

Diagnosis of femoral neck deformity.

Making a 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 possible 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 joint in question is performed.

Treatment of femoral neck deformity.

Correction of such deformities is effective at the beginning of their formation (at 1-2 years of life). The principle of complex therapy, common to most orthopedic deformities, is also valid for this group of lower extremity deformities. Application and combined with orthopedic treatment (prescribing special splints, wearing special devices).

Treatment is surgical.

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

Before starting the operation, you need to plan the upcoming operation. Find out what methods and designs can be applied in this case. Thus, the surgeon faces the following questions:

Simultaneous or staged elimination of femoral neck deformity.
Limb length adjustment.
Removing old processes if operations of this type were carried out.
Design and installation of an endoprosthesis.

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

Exostectomy (removal of part of the bone head);
Ligament restoration;
Replacement with an implant;

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

Prevention of femoral neck deformity.

In order to prevent hip dislocation, it is recommended to carefully monitor safety in everyday life and while playing sports.

This creates a need for:

training various muscle groups, rational exercise;
using exclusively comfortable clothing and shoes to prevent falls;
use of professional protective equipment throughout sports activities. We are talking, at a minimum, about knee pads and thigh braces;
refusing any trips in icy conditions, paying attention to slippery and wet surfaces.

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

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

After this, 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. Their regularity will be the key to recovery. In addition, it is necessary to treat the damaged hip area as carefully as possible, because now it is one of the weakest points of the body.

Remembering 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.

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

Primary changes begin with shortening of the neck and thickening of its section in the area of the diaphyseal joint with the acetabulum of the pelvic bone. The cervical axis and central diaphysis are subject to minor deformation, which is further aggravated by the contraction of certain femoral muscles. With varus deformity, shortening occurs along the inner surface. With hallux valgus, the curvature occurs with damage to the external muscles.

In approximately 70% of cases, the prerequisites for such a disease of the musculoskeletal system are formed at the stage of intrauterine development of the baby. And only in 25% of patients, deformity of the femur is associated with dystrophic lesions of cartilage and bone tissue. Typically, the first signs in this case appear in old age, during menopause, against the background of the development 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 tissue integrity have been actively used for hip fractures. This allows for complete recovery without the formation of various types of degenerative deformities.

In this material you can learn more about the potential causes of femoral deformity in children and adults. It also describes what methods of manual therapy can effectively and safely carry out treatment in order to completely restore the physiological state of the femur.

Why does femoral neck deformity occur?

Primary hip deformity occurs only as a congenital pathology, which may not appear until adulthood. Gradual deformation of the femoral neck is a consequence of the influence of negative factors, such as:

maintaining a sedentary lifestyle;
excess body weight;
smoking and drinking alcoholic beverages;
incorrect placement of feet when walking and running;
heavy physical labor with maximum load on the hip joints;
femoral neck fractures;
wearing high-heeled shoes.

Secondary deformity of the femoral neck 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 placement of the foot in the form of flat feet or club feet;
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 skeletal development, rickets in early childhood, osteoporosis in middle and old age, vitamin D and calcium deficiency, endocrine diseases (hyperthyroidism, diabetes mellitus, adrenal hyperfunction, etc.).

To successfully treat hip deformity, it is necessary to eliminate all possible causes and negative risk factors. Only in this case is it possible to get a positive effect.

Varus deformity of the femoral neck (thigh)

The pathology is divided into two types: valgus and varus deformation of the femur; in the first case, the curvature occurs in an X-shaped manner, in the second - in an O-shaped manner. Both types are associated with changes in the angle located between the head and diaphysis 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 varus deformation of the femoral neck, in which the rotation of the lower limb will be sharply limited.

With hip varus, moving the leg away from the body is difficult and causes severe pain in the hip joint. Therefore, the primary diagnosis is often made incorrectly. The doctor suspects destruction and deformation of the femoral head and acetabulum. To confirm the diagnosis of deforming osteoarthritis, an X-ray of the hip joint in several projections is prescribed. And during this laboratory examination, varus deformity of the femoral neck is revealed, which is clearly visible on radiographic photographs in direct and lateral projections.

Several stages can be identified in the development of hip curvature:

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;
the average degree is characterized by significant curvature and leads to the patient having problems performing certain movements in the hip joint;
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 from aseptic necrosis of the femoral head. This pathology also accompanies mucopolysaccharidosis, rickets, bone tuberculosis, chondroplasia and some other serious diseases.

Valgus deformity of the necks of the femurs (hips)

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

Congenital deformity of the femoral neck in a child may be caused by the following teratogenic factors:

pressure on the growing uterus from the internal organs of the abdominal cavity or when wearing tight, constricting clothing;
insufficient blood supply to the uterus and growing fetus;
severe anemia in a pregnant woman;
disruption of the ossification process in the fetus;
breech presentation;
previous viral and bacterial infections in the late stages of pregnancy;
taking antibiotics, antivirals and some other drugs without medical supervision.

Congenital valgus deformity of the femur is characterized by severe flattening of the articular surface of the acetabulum and total shortening of the diaphyseal portion of the femur. An X-ray examination shows an anterior and upward displacement of the femoral head with curvature of the neck and shortening of the bone section. Fragmentation of the epiphysis may appear at a later age.

The first clinical symptoms of valgus deformity of the femoral neck in children appear when they begin to walk independently. The baby may have shortened one leg, lameness, and a peculiar gait.

The juvenile type of pathology is that valgus deformity of the hip begins to actively develop in adolescence. At the age of 13 - 15 years, hormonal changes in the body occur. With an excessive amount of produced sex hormones, the pathological mechanism of epiphysiolysis (destruction of the head of the femur and its neck) can be triggered. When bone tissue softens under the influence of the growing body weight of a teenager, valgus deformation begins with deviation of the distal end of the femur.

Children with obesity and overweight who lead a sedentary, sedentary lifestyle and are addicted to carbohydrate foods are at risk. It is necessary for such adolescents to be periodically shown to an orthopedist for 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 difficult to miss. A characteristic deviation of the upper leg, lameness, and specific positioning of the legs are objective signs. There are also subjective sensations that can signal such trouble:

nagging, dull pain in the hip joints that occurs after any physical activity;
lameness, dragging of the leg and other gait changes;
feeling that one leg has become shorter than the other;
dystrophy of the thigh muscles on the affected side;
the rapid appearance of a feeling of fatigue in the leg muscles when walking.

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

How to treat hip bone deformity?

Valgus deformity of the femur in a child is perfectly amenable to conservative methods of correction. But only in the early stages can the physiological state of the head and neck of the femur be completely 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:

kinesiotherapy and therapeutic exercises are aimed at strengthening the muscles of the lower extremities and, by increasing their tone, correct the position of the head of the bone in the acetabulum;
massage and osteopathy allow, through physical external influence, to carry out the necessary correction;
reflexology starts the recovery process by using the body’s hidden reserves;
physiotherapy, laser treatment, electrical myostimulation are additional methods of therapy.

Any correction course is developed individually. Before treating a femur deformity, you should consult an experienced orthopedist.

In our manual therapy clinic, each patient has the opportunity to receive professional advice from an experienced orthopedist completely free of charge. To do this, just make an appointment for the first time.

Varus deformity of the femoral neck- the basis is a shortening of the neck and a decrease in the neck-diaphyseal angle. It manifests itself as limited abduction and rotation of the femur in the hip joint, lumbar lordosis and duck gait. Radiologically, the following deformities are distinguished: congenital isolated, childhood, juvenile and symptomatic. Congenital varus deformity is rare.

U newborn shortening of the limb is determined, the greater trochanter of the femur is located high. In the absence of ossification nuclei, it is difficult to make a diagnosis. When ossification occurs, a bent neck and shortening of the femoral diaphysis are detected. The distal end of the femur is adducted. The epiphyseal growth zone is located vertically, the femoral head moves downward and posteriorly, the acetabulum is flattened, the greater trochanter is rebuilt in a beak-like manner and stands high.

For pediatric varus deformation, which develops up to the age of 3-5 years, a triangular bone fragment is formed in the inferomedial section of the femoral neck lateral to the zone of the growth cartilage, forming a picture similar to an inverted letter “U” with the upper vertical zone of enlightenment in the area of the head and neck. The course of the fissure is usually tortuous, the bone edges are jagged, uneven, and slightly sclerotic.

In the future the gap expanding up to 10-12 mm, the neck is shortened, the head lags behind in development, moves caudally and approaches the femoral diaphysis, the greater trochanter is located 4-5 cm above the upper edge of the acetabulum.

Juvenile varus deformation is characterized by changes in the growth zone, and not in the bony part of the neck, as in the children's form. In the early stage, the enchondral growth zone expands and loosens due to the resorption of bone tissue. Subsequently, the femoral head begins to slowly and gradually slide down, inward and posteriorly, i.e., epiphysiolysis of the femoral head develops.
Symptomatic varus deformity is caused by a pathological process of the femoral neck or its upper metadiaphysis.

Valgus deformity of the proximal end of the femur- deformation opposite to varus. It can be congenital or acquired. If normally the neck-diaphyseal angle ranges from 115-140°, then with valgus deformity it can approach 180°, then the axis of the femoral diaphysis serves as a direct continuation of the axis of the neck.

Congenital hip dislocation- population frequency 0.2-0.5%. Accounts for 3% of orthopedic diseases. The incidence of hip dysplasia is 16 cases per 1000 births. The dislocation is unilateral and in 20-25% of cases bilateral. The basis for the occurrence of dislocation is dysplasia of the hip joint, affecting all its components: the acetabulum (hypoplasia, flattening), the femoral head (hypoplasia, delayed ossification), and the neuromuscular system (developmental anomalies).

At congenital subluxation of the acetabulum underdeveloped, the head occupies an eccentric position. Then a congenital dislocation develops. The main clinical signs: the symptom of slipping - Marx's symptom (symptom of instability, clicking), limitation of hip abduction, asymmetry of the gluteal folds, shortening of the lower limb, and with the beginning of the child's walking - gait disturbance.

Main radiographic symptoms: in the absence of ossification nuclei, a vertical line passing through the superolateral protrusion of the acetabulum intersects the inner edge of the so-called beak of the femur, which is more distant from the ischium than on the healthy side; the acetabulum index (acetabular index) reaches 35-40°; the ledge-like Menard-Shenton line and the broken Calvet line are characteristic; the distance from the most prominent proximal surface of the femur to the Hilgenreiner line (the acetabular line connecting both Y-shaped cartilages) is less than 1 cm.

If there are nuclei ossification In addition to these symptoms, the following are detected: Hilgenreiner's line crosses the head or is located below it; ossification on the side of the dislocation is delayed, the ossification point of the head is smaller, the ischiopubic synchondrosis is more open, on the side of the dislocation there is bone atrophy, deformation of the head, shortening and thickening of the femoral neck, antetorsion of the neck. The horizontal line drawn along the lower edge of the femoral neck passes above the so-called teardrop, or Kohler’s comma, the Maykova-Stroganova symptom is characteristic - a “crescent figure” is superimposed on the medial contour of the femoral neck, etc.

One of the rare developmental anomalies of the femurs is their varus deformity. The disease occurs no more often than 0.3-0.8% of cases among newborns. Along with valgus curvature of the proximal end of the femur, congenital varus deformity of the femur is a skeletal defect. It can lead to serious dysfunction of the musculoskeletal system.

Description of femoral varus deformity

The varus curvature of the hip joints is based on shortening of the femoral neck and a decrease in the degree of the neck-shaft angle. Another name for the disease is juvenile epiphysiolysis, although in fact the latter is a form of hip deformation and occurs very rarely, only in adolescence. Changes in the hip joints with this pathology are significant - degeneration of spongy tissue of the neck, bone destruction, formation of cysts, fibrosis phenomena.

Varus hip deformity includes a whole range of symptoms from the lower extremities. This disease may combine the following symptoms:

change in the shape of the articular heads of the pelvic bones;
shortening of the leg;
contractures of the hip joint;
dysplasia, dystopia of leg muscles;
lumbar lordosis.

In a child with hip deformation, there is a serious violation of the rotation and abduction of the leg, so the gait becomes “duck-like.” When the anomaly occurs in a newborn, the leg is already shorter than the second leg from birth, and the trochanter of the femur is located higher than it should be. If the pathology is not treated for a long time, it continues to progress and ossification occurs. The femoral neck bends and the diaphysis shortens.

When varus type joint deformity occurs at 3-5 years of age, a triangular bone fragment appears in the femoral neck. Visually, the head and neck of the femur resemble an inverted letter U. The joint gap becomes tortuous, the edges of the bone are jagged, uneven, and foci of sclerosis appear in them. After this, the gap of the hip joint widens to 1-1.2 cm, the neck shortens, and the head stops developing normally.

If in the childhood form of varus curvature changes are observed in the bone zone, then in the juvenile form there are disturbances in the growth zone. The latter loosens, the bone dissolves, the head slowly slides down. Therefore, the pathology is called “epiphysiolysis of the femoral head.”

Causes of the disease

Typically, congenital varus deformity is a consequence of intrauterine damage to the cartilage of the femur or a disruption in the process of their compaction. In 2/3 of patients the defect is unilateral, in other cases it is bilateral. Thus, the disease occurs due to various problems in the embryonic period, which can happen for the following reasons:

severe maternal infections during pregnancy;
alcohol abuse, drug use, toxic medications;
poisoning, intoxication;
advanced maternal age;
endocrine diseases;
influence of radiation.

As for acquired forms, they can arise for various reasons. Thus, juvenile epiphysiolysis develops at 11-16 years of age - during puberty, or precedes puberty. The head of the femur begins to deform precisely against the background of a general restructuring of the body, when some parts of the skeleton are most vulnerable. It is believed that the cause of pathology in adolescents is hormonal disorders, so patients also often experience other phenomena:

absence of secondary sexual characteristics;
delay of menstruation in girls;
too tall;
obesity.

Also, varus deformity of the femur is associated with trauma and rickets, with a number of systemic diseases - pathological fragility of bones, fibrous osteodysplasia, dyschondroplasia. The pathology can also be caused by:

unsuccessful hip surgery;
osteomyelitis;
bone tuberculosis;
osteochondropathy.

Symptoms of the disease

The childhood form of the pathology usually begins to develop no later than 3-5 years, since during this period there is an increase in the load on the lower extremities. Parents may notice the following symptoms:

lameness after a long walk;
pain in the legs in the afternoon due to fatigue;
inability to run for a long time or play outdoor games;
discomfort in the hip and knee, in the popliteal region;
pain in the knee joint.

Over time, the leg on the affected side becomes somewhat thinner, abduction of the hip becomes more difficult, more so on the inside (on the outside it can, on the contrary, increase). In a number of children, symptoms begin with pain in the knee, and it is not always possible to immediately establish a connection with damage to the hip.

Juvenile forms of hip deformity often do not give clinical signs at all, only in advanced cases they begin to manifest themselves. There is slight lameness and increased fatigue when walking. Some teenagers have a protruding abdomen and a pathological lordosis of the spine. The strength and tone of the gluteal muscles decreases. With bilateral damage to the hips, the child begins to walk like a duck, waddling and swaying.

Classification of pathology

Due to the appearance and radiological signs, deformation of the femoral bones can exist in the following forms: childhood, juvenile, symptomatic, rachitic, tuberculous. The disease can also be isolated or affect other joints and feet of the child. Another classification involves dividing the disease into three stages (degrees).

First degree of severity

At the first stage, pathological changes begin in the growth region of the femur. It gradually loosens and expands, but the epiphysis does not shift.

Second degree of severity

At the second stage, progression of the processes of bone tissue restructuring and displacement of the epiphysis is observed. The image shows a thinning of the femoral neck and unclearness of its structure.

Third degree of severity

At the third stage, a complication of the pathology is already registered - deforming arthrosis. There is also muscle atrophy of the lower limb and pronounced changes in gait.

Diagnosis of varus deformity

The most popular and informative diagnostic method remains radiography of the hip joint. At the very beginning of hip deformation, heterogeneity of bone mass in the area of the femoral neck is revealed. Later, other structural changes appear, as well as disturbances in the anatomy of the hip joint.

When examined by an orthopedist, disturbances in the adduction and abduction of the limb on one or both sides are revealed. In parallel, kyphosis, scoliosis, lordosis, wedge-shaped deformation of the vertebrae, and other disorders in the knees, sacrum, and ankles can be diagnosed.

Treatment of pathology

In the early stages, conservative therapy helps well, later surgical treatment is used. Initially, as a rule, the patient is hospitalized for limb traction (skeletal traction), after which treatment is continued at home.

Conservative treatment

In the case of a congenital form of the pathology, conservative therapy is indicated for all babies up to 3 months of age. The goals are to normalize the blood supply to the hip joint and accelerate bone recovery, improve the tone of muscle tissue, and reduce the influence of muscles on the condition of the joint. For this purpose, the following treatment methods are performed:

wide swaddling for 14 days, then a Freika pillow for 2.5 months;
Sollux, paraffin applications;
from 6-8 weeks - electrophoresis on the joint area with calcium, phosphorus, with vasodilators - on the area of the sacral spine.

Other forms of varus deformity are treated by complete exclusion of any stress on the leg and strict bed rest. The patient is given a limb cast and traction with a load of up to 2 kg. Treatment can take several months, so it is often carried out in specialized sanatoriums.

Operation

If the processes of bone restructuring have already completed and there is a pronounced degree of varus deformity of the femur, surgical treatment should be planned. It will help lengthen the limb, restore the integrity of the articular surfaces and prevent the development of coxarthrosis.

In babies older than 3 months with contractures of the hip joint, surgery is also indicated. The goals are to create conditions for proper development of the bone head and prevent deformation of the neck-shaft angle.

During the operation, the adductor muscles of the thigh, fascia lata, and a number of tendons are cut. Fibrous cords in the gluteal muscle area are removed. In children from 3 years of age, an additional corrective osteotomy is performed if there is excessive ossification of the femoral neck. The operation includes cervicoplasty. It is performed in the second stage after the bone tissue has healed - several months after the first intervention.

Rehabilitation treatment

After the operation, the patient must be prescribed a complex of exercise therapy, physiotherapy, and general restorative drug treatment. Children use orthoses and other orthopedic devices. Thus, with hip curvature in adolescents, the use of orthoses can last for several years. Dispensary observation is carried out until the child reaches the age of 18 years.

If left untreated, the pathology will steadily progress, which causes the formation of a false joint of the femoral neck (in 50-70% of cases). Coxarthrosis then develops, which will ultimately require joint replacement. When treatment is started early, the outcome is often favorable.