EC Paediatrics

Objective: Coxa magna (CM) is defined as a condition in which the transverse (transverse) diameter of the femoral head is larger on the affected side than on the intact side. CM can occur as a manifestation of avascular necrosis (AVN) after treatment for developmental dysplasia of the hip (DDH).

Methods: This study is a retrospective study on 158 cases of DDH after zigzag osteotomy combined with fibular allograft (ZOFA) and CM from October 2009 to December 2012. The patients were divided 3 Variations: Variation 1 (ZOFA), variation 2 (ZOFA with limbusectomy) and variation 3 (ZOFA with femoral shortening osteotomy).

Results: One hundred fifty-eight patients with unilateral side. There were 133 girls (84.2%) and 25 boys (15.2%). Mean age at surgery was 21.5 months (12 to 36) and mean age at last follow-up was 10 years 4 months (9 years 7 months - 13 years 4 months). Median follow-up was 11 years 6 months (10 years 8 months to 14 years 2 months). Surgery was performed on 72 patients in V1, 53 patients in V2, and 33 patients in V3. Having CM: 48 (30.4%); AVN: 55 (34.8%). Overall, excellent 65.2%, good 2: 20.3%, fair: 11.4%, poor: 3.1%. Coxa magna 48 (30.4%) and AVN: 55 (34.8%).

Conclusion: One of the most important causes of coxa magna is overexpansion of the acetabular capacity by limbus resection. Another cause is avascular necrosis of the hip after surgery. Coxa magna worsens long-term results. To prevent coxa magna, it is important to retain the limbus.

 Keywords: Coxa Magna; Legg-Calvé-Perthes Disease; Asymmetry; Femoral Head Enlargement; Avascular Necrosis

1. Howorth BA. “Lifetime experience with congenital displacement of the hip”. Orthop Rei· 11 (1982): 33-45.
2. Buchanan JR., et al. “Management strategy for prevention of avascular necrosis during treatment of congenital dislocation of the hip”. Journal of Bone and Joint Surgery American Volume 63-A.1 (1981): 140-146.
3. Westin GW., et al. “Total avascular necrosis of the capital femoral epiphysis in congenital dislocated hips”. Clinical Orthopaedics and Related Research 119 (1976): 93-97.
4. Coleman SS. “Treatment of congenital dislocation of the hip in the infant”. Journal of Bone and Joint Surgery American Volume 47-A.3 (1965): 590-601.
5. Chung SM. “The arterial supply of the developing proximal end of the human femur”. Journal of Bone and Joint Surgery American Volume 58-A.7 (1976): 961-970.
6. Trueta J. “The normal vascular anatomy of the human femoral head during growth”. Journal of Bone and Joint Surgery British Volume 39-B.2 (1957): 358-394.
7. Ogden JA. “Changing patterns of proximal femoral vascularity”. Journal of Bone and Joint Surgery 56-A.5 (1974): 941-950.
8. Trueta J and Amato VP. “The vascular contribution to osteogenesis. III. Changes in the growth cartilage caused by experimentally induced ischaemia”. Journal of Bone and Joint Surgery 42-B (1960): 571-587.
9. Guille JT., et al. “Development dysplasia of the hip from birth to six months”. Journal of the American Academy of Orthopaedic Surgeons 4 (2000): 232-242.
10. Tönnis D., et al. “Congenital dysplasia and dislocation of the hip in children and adults”. Berlin, Germany, and New York, NY: Springer-Verlag (1987): 6,14.
11. Leveuf J and Bertrand P. “Luxations et subluxations congenitales de la hanche”. Leur traitement base sur l’arthrographie. Paris, France: Doin (1946).
12. Milgram JW and Tachdjian MO. “Pathology of the limbus in untreated teratologic congenital dislocation of the hip. A case report of a ten-month-old infant”. Clinical Orthopaedics and Related Research 119 (1976): 107-111.
13. Hung NN. Chapter 4. Zigzag Osteotomy combined Fibular Allograft (Hung Zigzag Pelvic osteotomy). Editor Nguyen Ngoc Hung. Overview and Hung Zigzag Pelvic Osteotomy. Developmental Dysplasia of the Hip in Children. LAP LAMBERT Academic Publishing. Germany. 2018.
14. Tönnis D. “Review of the literature on open reduction of the hip in congenital dysplasia and dislocation of the hip in children and adults”. Springer, Berlin Heidelberg New York (1987): 332.
15. Kleinberg S and Lieberman HS. “The acetabular index in infants in relation to congenital dislocation of the hip”. Archives of Surgery6 (1936): 1049-1054.
16. Napoli MMM., et al. “Anteversão dos colos femorais: estudo radiológico”. Rev Imagem 7 (1985): 111-116.
17. Ryder CT and Crane L. “Measuring femoral anteversion: the problem and a method”. Journal of Bone and Joint Surgery American Volume2 (1953): 321-328.
18. Mootha AK., et al. “MRI Evaluation of femoral and acetabular anteversion in developmental dysplasia of the hip: a study in an early walking age group”. Acta Orthopaedica Belgica2 (2010): 174-180.
19. McKibbin B. “Anatomical factors in the stability of the hip joint in the newborn”. The Journal of Bone and Joint Surgery British Volume 52-B.1 (1970): 148-159.
20. Kalamchi A and MacEwen GD. “Avascular necrosis following treatment of congenital dislocation of the hip”. Journal of Bone and Joint Surgery American Volume6 (1980): 876-888.
21. Farrell BP., et al. “Congenital dislocation of the hip. A report of three hundred and ten cases treated at the network orthopaedic dispensary and hospital”. Journal of Bone and Joint Surgery 24 (1926): 551-561.
22. Mose K. “Legg-Calve-Perthes disease [Thesis]”. Aarhus, Denmark: University of Aarhus (1964).
23. Harris NH. “Acetabular growth potential in congenital dislocation of the hip and some factors upon which it may depend”. Clinical Orthopaedics and Related Research 119 (1976): 99-106.
24. Salter RB., et al. “Avascular necrosis of the femoral head as a complication of treatment for congenital dislocation of the hip in young children: a clinical and experimental investigation”. Canadian Journal of Surgery1 (1969): 44-61.
25. Barrett WP., et al. “The effectiveness of the Salter innominate osteotomy in the treatment of congenital dislocation of the hip”. Journal of Bone and Joint Surgery American Volume1 (1986): 79-87.
26. Trevor DLJ and Fixen JA. “Acetabuloplasty in the treatment of congenital dislocation of the hip”. Journal Bone and Joint2 (1975): 167-174.
27. Kessler JK., et al. “Use of allografts in Pemberton osteotomies”. Journal of Pediatric Orthopaedics4 (2001): 468-473.
28. Grudziak JS and Ward WT. “Dega osteotomy for the treatment of congenital dysplasia of the hip”. Journal of Bone and Joint Surgery6 (2001): 845-854.
29. Wade WJ., et al. “Contoured iliac crest allograft interposition for pericapsular acetabuloplasty in developmental dislocation of the hip: technique and short-term results”. Journal of Children’s Orthopaedics5 (2010): 429-438.
30. Bohm P and Brzuske A. “Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of followup”. Journal of Bone and Joint Surgery2 (2002): 178-186.
31. Ito H., et al. “Middle-term results of salter innominate osteotomy”. Clinical Orthopaedics and Related Research 387 (2001): 156-164.
32. Rab GT. “Biomechanical aspects of salter osteotomy”. Clinical Orthopaedics and Related Research 132 (1978): 82-87.
33. Ferguson AB. “Howorth M B: Coxa magna”. Journal of the American Medical Association10 (1935): 808-812.
34. Weinstein SL. “Developmental hip dysplasia and dislocation”. In: Weinstein SL, Flynn JJ, eds. Lovell and Winter’s Pediatric Orthopaedics. Volume 2. Seventh edition. Philadelphia: Lippincott Williams & Wilkins (2014): 983-1111.
35. Pearson JR. “Idiopathic coxa magna”. Lancet7295 (1963): 1350-1351.
36. Neuhauser EB and Wittenborg MH. “Synovitis of the hips in infancy and childhood”. Radiologic Clinics of North America 1 (1963): 13-16.
37. McMurrav B. “A report or six cases or co-xa magna following synovitis of the hip joint”. British Journal of Radiology 239 (1947): 477-481.
38. Edgren W. “Coxa plana”. Acta Orthopaedica Scandinavica 84 (1965): 1-129.
39. Schiller Axer A. “Hypertrophy of the femoral head in Legg-Calve Perches syndrome”. Acta Orthopaedica Scandinavica 1 (1972): 45-55.
40. Rigal WM. “As quoted by Iructa J: Studies of the development and decay of the human fracture”. Philadelphia, W. B. Saunders Co (1968): 85.
41. Trueta J. “Studies of the development and decay of the human frame”. Philadelphia. W.B. Saunders Co., (1968).
42. Tachdjian MO. “Congenital dysplasia of the hip”. Pediatric Orthopedics. 2^nd Philadelphia, PA: WB Saunders (1990): 297-312.
43. Leveuf J. “Results of open reduction of “true” congenital luxation of the hip”. Journal of Bone and Joint Surgery American Volume4 (1948): 875-882.
44. Ponseti IV. “Morphology of the acetabulum in congenital dislocation of the hip. Gross, histological and roentgenographic studies”. Journal of Bone and Joint Surgery American Volume5 (1978): 586-599.
45. Scaglietti O and Calandriello B. “Open reduction of congenital dislocation of the hip”. Journal of Bone and Joint Surgery British Volume 44 (1962): 257-283.
46. Milgram JW and Tachdjian MO. “Pathology of the limbus in untreated teratologic congenital dislocation of the hip. A case report of a ten-month-old infant”. Clinical Orthopaedics and Related Research 119 (1976): 107-111.
47. Angliss R., et al. “Surgical treatment of late developmental displacement of the hip: results after 33 years”. Journal of Bone and Joint Surgery British Volume 3 (2005): 384-394.
48. Kim YH. “Acetabular dysplasia and osteoarthritis developed by an eversion of the acetabular labrum”. Clinical Orthopaedics and Related Research 215 (1987): 289-295.
49. Tumer Y., et al. “Medial open reduction in the treatment of developmental dislocation of the hip”. Journal of Pediatric Orthopaedics 2 (1997): 176-180.
50. Berkeley ME., et al. “Surgical therapy for congenital dislocation of the hip in patients who are twelve to thirty-six months old”. Journal of Bone and Joint Surgery American Volume3 (1984): 412-420.
51. De Valderrama JA. “The “observation hip” syndrome and its late sequelae”. Journal of Bone and Joint Surgery British Volume 45 (1963): 462-470.
52. Nachemson A and Scheller S. “A clinical and radiological follow-study of transient synovitis of the hip”. Acta Orthopaedica Scandinavica 4 (1969): 479-500.
53. Stulberg SD., et al. “The natural history of Legg-Calve-Perthes disease”. Journal of Bone and Joint Surgery American Volume7 (1981): 1095-1108.
54. McAndrew MP and Weinstein SL. “A long-term follow-up of Legg-Calve-Perthes disease”. Journal of Bone and Joint Surgery American Volume6 (1984): 860-869.
55. Gamble JG., et al. “Coxa magna following surgical treatment of congenital hip dislocation”. Journal of Pediatric Orthopaedics5 (1985): 528-533.
56. Kallio PE. “Coxa magna following transient synovitis of the hip”. Clinical Orthopaedics and Related Research 228 (1988): 49-56.
57. Leitch JM., et al. “Growth disturbance in Legg-Calve-Perthes disease and the consequences of surgical treatment”. Clinical Orthopaedics and Related Research 262 (1991): 178-184.
58. Matani J., et al. “Coxa magna after open reduction for developmental dislocation of the hip”. Journal of Pediatric Orthopaedics3 (1995): 337-341.
59. Shigeno Y and Evans GA. “Quantitative correlation between the initial and final femoral head deformity in Perthes’ disease”. Journal of Pediatric Orthopaedics B1 (1996): 48-54.
60. Luhmann SJ., et al. “The prognostic importance of the ossific nucleus in the treatment of congenital dysplasia of the hip”. Journal of Bone and Joint Surgery American Volume12 (1998): 1719-1727.
61. Rowe SM., et al. “The correlation between coxa magna and final outcome in Legg-Calve-Perthes disease”. Journal of Pediatric Orthopaedics 1 (2005): 22-27.
62. Larson AN., et al. “A prospective multicenter study of Legg-Calve´-Perthes disease: functional and radiographic outcomes of nonoperative treatment at a mean follow-up of twenty years”. Journal of Bone and Joint Surgery American Volume7 (2012): 584-592.
63. Sakamaki T. “Clinical study on coxa magna during the treatment in congenital dislocation in the hip”. Nihon Seikeigeka Gakkai Zasshi5 (1979): 491-504.
64. Gamble JG., et al. “Coxa magna following surgical treatment of congenital hip dislocation”. Journal of Pediatric Orthopaedics5 (1985): 528-533.
65. Topak D., et al. “Coxa magna following treatment of developmental dysplasia of the hip: investigation for associated potential factors”. Journal of Pediatric Orthopaedics B1 (2023): 21-28.
66. Young EY., et al. “Femoral head asymmetry and coxa magna: anatomic study”. Journal of Pediatric Orthopaedics B4 (2014): 415-420.
67. Iwasaki K., et al. “Coxa magna occurs after open reduction for congenital hip dislocation [in Japanese]”. Rinsho Seikei Geka 13 (1978): 20-21.
68. O'Brien T and Salter RB. “Femoral head size in congenital dislocation of the hip”. Journal of Pediatric Orthopaedics3 (1985): 299-301.
69. Sosna A and Rejholec M. “Ludloff's open reduction of the hip: long-term results”. Journal of Pediatric Orthopaedics5 (1992): 603-606.
70. Ando K. “Experimental study on hypertrophy of the femoral head—with special reference to the effects of the surgical procedure to the hip joint [in Japanese]”. Japanese Orthopaedic Association 4 (1985): 443-445.
71. Hatanaka T. “An experimental study on the influence of surgical procedures for hip joints in young rabbits [in Japanese]”. Japanese Orthopaedic Association 51 (1977): 42-49.
72. Papavasiliou VA and Piggott H. “Acetabular floor thickening and femoral head enlargement in congenital dislocation of the hip: lateral displacement of the femoral head”. Journal of Pediatric Orthopaedics1 (1983): 22-27.
73. Tönnis D and Heinecke A. “Acetabular and femoral anteversion: relationship with osteoarthritis of the hip”. Journal of Bone and Joint Surgery 81-A.12 (1999): 1747-1770.
74. Haidar RK., et al. “Simultaneous open reduction and Salter innominate osteotomy for developmental dysplasia of the hip”. Journal of Bone and Joint Surgery British Volume3 (1996): 471-476.
75. Ombredanne L. “Precis Clinique et Operatoire de Chirurgie Infantile”. Paris: Masson (1923).
76. Predrag K and Ljubisa J. “Combined procedure of open reduction and shortening of the femur in treatment of congenital dislocation of the hips in older children”. Clinical Orthopaedics and Related Research 119 (1976): 60-69.
77. Harris NH., et al. “Acetabular development in congenital dislocation of the hip: with special reference to the medications for acetabuloplasty and pelvic or femoral realignment osteotomy”. Journal of Bone and Joint Surgery 57-B.1 (1975): 46-52.
78. Klisic P and Jancovic L. “Combined procedure of open reduction and shortening of the femur in treatment of congenital dislocation of the hip in older children”. Clinical Orthopaedics and Related Research 119 (1976): 60-69.
79. Galpin RD., et al. “One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening”. Journal of Bone and Joint Surgery American Volume5 (1989): 734-741.
80. Wenger DR., et al. “Derotational femoral shortening for developmental dislocation of the hip: special indications and results in the child younger than 2 years”. Journal of Pediatric Orthopaedics6 (1995): 768-779.
81. Massie WK and Howorth MB. “Congenital dislocation of the hip. Part II. Results of open reduction as seen in early adult period”. Journal of Bone and Joint Surgery American Volume 33-A (1951): 171-190.
82. Durham HA. “Anteversion of the femoral neck in the normal femur and its relation to congenital dislocation of the hip”. Journal of the American Medical Association3 (1915): 223-224.
83. Sankar WN., et al. “Risk factors for failure after open reduction for DDH: A matched cohort analysis”. Journal of Pediatric Orthopaedics3 (2011): 232-239.
84. Warndorf R. “The pathology amid therapy of congenital dislocations of the hip”. American Journal of Orthopedic Surgery 10 (1912): 241-261.
85. Badgley CE. “Correlation of clinical and anatomical facts leading to a conception of etiology of congenital hip dysplasia”. Journal of Bone and Joint Surgery 3 (1943): 503-523.
86. Hibbs RA. “Anteversion of the neck of the femur in connection with congenital dislocation of the hip”. Journal of the American Medical Association21 (1915): 1801-1802.
87. Farrell BP., et al. “Congenital dislocation of the hip. A report of three hundred and ten cases treated at the nework orthopaedic dispensary and hospital”. Journal of Bone and Joint Surgery 24: 551-561.
88. Lorenz A. “Some remarks on the treatment and after-treatment of congenital dislocation of the hip”. American Journal of Orthopedic Surgery 2 (1926): 219-233.
89. Bradford EH. “The treatment of congenital dislocation of the hip”. Journal of Bone and Joint Surgery 5 (1923): 76-98.
90. Soutter R and Lovett RW. “Congenital dislocation of the hip. A study of two hundred and twenty-seven dislocations”. Journal of the American Medical Association 3 (1924): 171-177.
91. Fairbank HAT. “Congenital dislocation of the hip: with special reference to the anatomy”. British Journal of Surgery 67 (1930): 380-416.
92. Kumar S and Jain AK. “Open reduction of late unreduced traumatic posterior hip dislocation in children”. Acta Orthopaedica Scandinavica 6 (1999): 599-602.