1、BRITISH STANDARD BS 6324-5: 1990 ISO TR 9586: 1988 Terms relating to surgicalimplants Part 5: Guidance on the usage of the terms“valgus” and “varus” in orthopaedic surgeryBS6324-5:1990 This British Standard, having been prepared under the directionof the Health Care Standards Policy Committee, waspu
2、blished under the authorityof the Board of BSI andcomes into effect on 31July1990 BSI 12-1999 The following BSI references relate to the work on this standard: Committee reference HCC/17 Draft for comment 87/50944 DC ISBN 0 580 18155 3 Committees responsible for this BritishStandard The preparation
3、of this British Standard was entrusted by the Health Care Standards Policy Committee (HCC/-) to Technical Committee HCC/17, upon which the following bodies were represented: British Orthopaedic Association British Surgical Trades Association Ministry of Defence Royal College of Surgeons of England S
4、cottish Office Coopted Members Amendments issued since publication Amd. No. Date CommentsBS6324-5:1990 BSI 12-1999 i Contents Page Committees responsible Inside front cover National foreword ii 0 Introduction 1 1 Scope and field of application 1 2 Present usage 1 3 Anomalies of usage 1 4 Discussion
5、and conclusions 3 National appendix A Definitions of the terms “valgus” and “varus” 9 Figure 1 Illustration of varus and valgus deformities 4 Figure 2 Illustration of hallux valgus deformity showing the associated varus deformity of the first metatarsal 5 Figure 3 Illustration of the different usage
6、s of the terms “valgus” and “varus” in relation to the hip joint 6 Figure 4 Illustration of the terms “valgus” and “varus” as used in relation to osteotomies of the upper end of the femur 7 Figure 5 Illustration of the use of “valgus” and “varus” in relation to surface replacement of the femoral hea
7、d 8 Figure 6 Illustration of the use of “valgus” and “varus” when the head and neck of the femur has been replaced 8 Publications referred to Inside back coverBS6324-5:1990 ii BSI 12-1999 National foreword This Part of BS6324 has been prepared under the direction of the Health Care Standards Policy
8、Committee and is identical with ISOTR9586:1988 “Implants for surgery Usage of the terms “valgus” and “varus” in orthopaedic surgery”, prepared by Technical Committee150, Implants for surgery, of the International Organization for Standardization (ISO). This Part of BS6324has been prepared as a resul
9、t of international discussions in which the UK took an active part. The list of Parts of BS6324currently published is as follows. Part 1: Glossary of general medical terms; Part 2: Glossary of terms relating to mechanics; Part 3: Glossary of terms relating to materials; Part 4: Glossary of orthopaed
10、ic surgical terms. The intention of this Part of BS6324is to expand upon the explanatory material in Part4, particularly with regard to the anatomical regions where the usage of “valgus” and “varus” is, or has been, anomalous. The terms “valgus” and “varus” are defined, and brief explanatory notes a
11、re given in BS6324-4and, for the convenience of the reader of this Part of BS6324, relevant extracts are given in National appendix A. Textual errors. When adopting the text of the ISO Technical Report, the textual errors listed below were discovered. They have been marked in the text and have been
12、reported to ISO in a proposal to amend the text of the technical report. In Figure 3(a), in the caption to the second example of preferred usage, the word “varus” in the last line should read “valgus”. In Figure 5(a), in the caption, insert “- varus” after “alternative interpretation”. In Figure 5(b
13、), in the caption, insert “- valgus” after “alternative interpretation”. A British Standard does not purport to include all the necessary provisions of a contract. Users of British Standards are responsible for their correct application. Compliance with a British Standard does not of itself confer i
14、mmunity from legal obligations. Summary of pages This document comprises a front cover, an inside front cover, pages i and ii, pages1 to 10, an inside back cover and a back cover. This standard has been updated (see copyright date) and may have had amendments incorporated. This will be indicated in
15、the amendment table on the inside front cover.BS6324-5:1990 BSI 12-1999 1 0 Introduction This Type 3 Technical Report has been prepared in order to state the differences in usage of the terms “valgus” and “varus” so that anomalies of usage, especially in relation to the hip joint, may be clearly und
16、erstood and confusion minimized. The Terminology Working Group (WG1) of Technical Committee150 (Implants for Surgery) of the International Organization for Standardization (ISO) has for some years been discussing the terms “valgus” and “varus” in an attempt to reach agreed definitions. The terms hav
17、e been in use for centuries but their meaning seems to have varied from time to time. The present usage has developed in a haphazard manner, such that consistent definition of the terms seems to be impossible. A discussion paper (document ISO/TC150/WG1N59) was prepared by ISO/TC150/WG1and circulated
18、 widely throughout the world for comment. The results of the study of the comments reveal that the terms are now so ingrained in day-to-day use that it is most unlikely that they can be abandoned or replaced by alternative terms. This Technical Report has been prepared in order to point out the diff
19、erences in usage of the terms “valgus” and “varus” in orthopaedic surgery. 1 Scope and field of application This Technical Report gives the present usage of the terms “valgus” and “varus” in orthopaedic surgery, and describes anomalies of usage in order that they may be clearly understood and confus
20、ion minimized. 2 Present usage The terms “valgus” and “varus” are used to characterize certain deformities of limbs in the coronal plane of the body. The deformities may be centred on a joint or within the length of a long bone. The terms are mostly used in relation to deformities occurring in the l
21、ower limbs, and the only common use in the upper limbs is in relation to the elbow joint following supra-condylar fractures of the humerus, or abnormalities of the lower humeral epiphysis. The term “valgus” equates to a movement of abduction, such that the limb distal to the point of deformity is an
22、gled away from the median plane of the body in the coronal plane. Conversely, the term “varus” is used when the part of the limb distal to the deformity is angled towards the median plane and thus equates to the movement of adduction (Figure 1). Thus “genu valgum”, meaning a “valgus” deformity of th
23、e knee, results in the limb distal to the knee being angled away from the other limb. “Tibia vara” indicates that there is a “varus” deformity of the distal tibia in relation to the proximal tibia. It should be noted that distal deformity, particularly in a lower limb, tends to be balanced by an opp
24、osite deformity in the proximal part of the limb, and perhaps the commonest example of this is where “hallux valgus” is associated with a “varus” deformity of the first metatarsal (Figure 2). This concept is vital to the understanding of the reasons for the different usage of the terms “valgus” and
25、“varus” in relation to the hip joint. 3 Anomalies of usage There are four areas where the use of the terms is anomalous: 3.1 The foot Normally the foot is considered to be in the horizontal plane of the body and thus, strictly speaking, deformities of the toes should not be characterized by the term
26、s “valgus” and “varus”. However, traditional usage is such that it would be impossible to eradicate the terms in this context. “Hallux valgus” is probably the most common use for the term “valgus”. It should be noted that in the instance of the big toe, “hallux valgus” in fact equates to the movemen
27、t of adduction of the big toe although it conforms with the definition given above of the toe being angled away from the median plane of the body. The reason for this anomaly is obvious the terms adduction and abduction in the foot relate to the axis of the foot and not to the median plane of the bo
28、dy. Also, the terms “valgus” and “varus” are used to qualify some deformities of the hind foot. The “valgus” calcaneum relates to eversion of the subtalar joints and “varus” calcaneum to inversion, seen when the patient is standing. The deformity may just be postural but may also be caused by some d
29、eformity of the bone due to soft tissue imbalance during growth, as in club foot deformity.BS6324-5:1990 2 BSI 12-1999 3.2 The hip joint It is in relation to the hip joint and the upper end of the femur that major differences of usage of the terms “valgus” and “varus” occur. The anatomy of the upper
30、 end of the femur is rather complicated in that there is an angle between the neck and the shaft of the femur in the intercondylar region which is normally considered to be130 (Figure 3). However, in the anatomical position there is also anterior angulation of the neck in relation to the coronal pla
31、ne. During X-ray examination of hip joints, the femora are lying in the normal anatomical position, so that the neck is anteverted in relation to the shaft. Thus the neck/shaft angle is distorted when viewed in an ordinary antero-posterior X-ray picture and, if anteversion is greater than normal, th
32、e neck/shaft angle appears to be greater than130 , whereas with little or no anteversion the neck/shaft angle approaches130 , assuming that development of the head and the neck of the femur are normal. It should also be remembered that the hip joint is composed not just of the head of the femur and
33、the acetabulum but also includes most of the neck of the femur. Just as there is an angle between the shaft and the neck of the femur, there is also a “normal” angle between the neck of the femur and the acetabulum. This fact is important to remember when the anomalies of use of the terms “valgus” a
34、nd “varus” in relation to the hip joint are considered below. Anomalies of growth occur in the head and neck of the femur, usually giving rise to a reduction in the neck/shaft angle. If the head and neck of the femur are then placed in normal relationship to the acetabulum, the result would be to ca
35、rry the shaft of the femur into “varus” and hence such an anomaly is commonly known as “coxa vara”. Conversely, if the shaft of the femur is put into the normal anatomical position then it might be construed that the head and neck of the femur are “valgus” in relation to the acetabulum, and thus thi
36、s deformity is sometimes called “coxa valga” (Figure 3). Fractures occurring in the intercondylar region frequently give rise to deformity of the neck/shaft angle. A decrease in neck/shaft angle should be called “femora vara” but in fact in most countries this is commonly called “post-traumatic coxa
37、 vara”. However, this might be called “femora valga” or “coxa valga” for the reasons stated above. Thus, the conflict relates to whether the deformity in the region of the neck of the femur should be related to the leg otherwise lying in its normal position, or whether it should be related to the ef
38、fect on the leg if the hip joint, namely the acetabulum and femoral head and neck, is placed in a normal relationship. 3.3 Osteotomy of the upper end of the femur The use of the terms “valgus” and “varus” in relation to osteotomy of the upper end of the femur is as confused as it is with deformities
39、 of the head and neck of the femur. The confusion appears to relate to whether the osteotomy is named after the deformity that surgery is intended to produce, or after the deformity that the surgery is intended to correct. Logically, an osteotomy should be described by its effect upon the distal fem
40、ur if the terms are to be used within the accepted definition. Thus, osteotomy of the upper shaft of the femur, which results in the reduction of the neck/shaft angle, should be called a “varus” osteotomy and, vice versa, an osteotomy which apparently increases the neck/shaft angle should be called
41、a “valgus osteotomy” (Figure 4). Unfortunately, precisely the opposite interpretation is placed upon osteotomies in which the reduction of the neck/shaft angle is considered to cause a “valgus” hip. 3.4 Femoral prostheses “Valgus” and “varus” are being used in relation to the insertion of prostheses
42、 to replace the femoral head. With surface replacement of the femoral head, the replacement may be said to be “valgus” or “varus”, depending on its relationship to the angle of the neck of the femur. Thus “valgus” replacement of the femoral head cup usually relates to the cup being placed more super
43、iorly than the anatomical orientation of the head would suggest. (Figure 5). Conversely, if the cup is placed inferiorly, then “varus” siting is produced (Figure 5). The reasoning is that the neck/shaft angle of the femur should be measured from the centre of the prosthesis to the centre of the base
44、 of the neck, rather than from a line passing up through the centre of the neck of the femur.BS6324-5:1990 BSI 12-1999 3 When considering stemmed femoral prostheses, confusion arises because surgeons consider the relationship of the stem of the prosthesis to the shaft of the femur but not the deform
45、ity that the placing of the stem causes. Thus, if the tip of the stem touches the lateral cortex, this may be considered by some to be “valgus” in relation to the stem, but it causes a “varus” deformity of the shaft of the femur in relation to the head and thus should be termed a “varus” deformity (
46、Figure 6). Similarly, if the tip of the shaft of the prosthesis touches the medial cortex of the femoral shaft, it causes a “valgus” deformity of the shaft of the femur in relation to the neck and thus the placement of the prosthesis should be termed “valgus” (Figure 6). Once again, this placement o
47、f the prosthesis is sometimes termed “varus” in that the stem is in a “varus” position in relation to the shaft of the femur. 4 Discussion and conclusions As a result of the comments received after circulation of the discussion paper prepared by ISO/TC150/WG1, it is quite obvious that the terms “val
48、gus” and “varus” are unlikely to disappear. Unfortunately the terms have been used in a somewhat haphazard fashion, their usage having developed over the years without formal definition. The definitions noted in clause2 of this Technical Report cover most of the common and traditional uses of the te
49、rms. The anomaly of usage with respect to the foot has been pointed out but it must be accepted that such usage is so traditional that it is unlikely that this anomaly is of any significance. However there appears to be a fundamental difference of usage of the terms in relation to the hip joint and upper end of the femur. The alternatives have been explained and illustrated in this Technical Report. The differences of usage over recent years have been used to describe deformities produced deliberately by osteotomies of the upper femur and also to describ
