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In Depth Tutorials and Information
approach, the procedure is done under image intensifier
control. The advantages of this method are less blood
loss, more rapid union of the osteotomies, easier post-
operative mobility and smaller scars. Both Li et al.
78
and
Abulsaad and Abdelrahman
77
observed that less atro-
phy of the bone occurred following this approach.
Chotigavanichaya and colleagues
93
noted that it was
difficult to accurately predict the canal diameter of OI
patients undergoing primary osteotomy with intramed-
ullary fixation on preoperative radiographs. They found
the radiographs often overestimated the narrowest
diameter because the cross-sectional shape of the long
bones was often elliptical. Accordingly, it is important to
have a wide variety of implant sizes available at the time
of surgery.
Aarabi and colleagues
94
observed a high incidence of
coxa vara in children with severe forms of OI, especially
type III. The clinical consequences of this deformity were
limited abduction and internal rotation of the hip, and
abductor insufficiency leading to a Trendelenburg gait.
These authors noted that an anterior curvature of the
proximal shaft of the femur may cause a radiographic
appearance of coxa vara in some patients even when the
neck-shaft angle is normal. They suggested that if this
deformity is suspected, a radiograph of the hip in exten-
sion should be obtained. In a later study from the same
institution
95
the authors described a surgical technique
involving a valgus intertrochanteric osteotomy and the
use of Kirshner wires and intramedullary rods to correct
this deformity (
Figures 46.9 and 46.10
).
FIGURE 46.9
Drawing of the steps of the technique to correct
coxa vara as described by Fassier et al. (A) Coxa vara is present. (B)
Two smooth Kirschner wires are placed along the femoral neck. (C) A
valgus osteotomy is performed and a hole is made in the lateral cor-
tex of the proximal metaphyseal fragment. (D) The cortex of the distal
fragment is contoured. (E) An intramedullary nail is inserted. (F) The
Kirschner wires are bent and secured to the shaft with cerclage wires.
(From: Fassier F et al. Results and compliations of a surgical technique for
correction of coxa vara in children with osteopenic bones. J Pediatr Orthop
2008; 28: 799-805, with permission.)
(A)
(B)
(C)
FIGURE 46.10
(A) Anteroposterior lower extremity radiograph of a 3-year-old patient with a hypertrophic proximal femoral non-union.
In addition, there is severe coxa vara, with a neck-shaft angle of less than 90 degrees. (B) Lateral femoral radiograph showing the apex anterior
deformity at the non-union site. (C) A 4-week postoperative anteroposterior femoral radiograph of the patient after undergoing proximal femo-
ral osteotomy with correction of the coxa vara, and take-down of the non-union with elongating intramedullary fixation. Autogenous bone graft
was used both at the osteotomy and non-union sites.
