Angular deformities around the knee seminar

genu valgum,varus,recurvatum,procurvatum

1. Angular deformities around the knee Dr.PRASHANTH KUMAR Sec.DNB ORTHO HINDU RAO HOSPITAL

2. ANGULAR DEFORMITIES OF KNEE GENU VARUM GENU VALGUS GENU REURVATUM GENU PROCURVATUM

3. Bowlegs in new born and infant With medial tibial torsion = fetal position Becomes straight by 18/24 MONTHS By 2 or 3 YEARS genu valgus develop (avg. 12°) By 7 YEARS spontaneous correction To the normal of adult valgus ( 8° ♀ and 7° ♂ )

4. EVO L UT I O N O F A L I G NME N T I N TH E LOWER LIMBS Torsion Fetus MM behind LM Birth same level 1 YEAR LM behind MM Adult 20 degrees External torsion

5. GENU VARUM Angular deformity of the proximal tibia in which the child appears “bowlegged” Physiologic genu varum is a deformity with a tibiofemoral angle of at least 10 degrees of varus , a radiographically normal physis , and apex lateral bowing of the proximal end of the tibia and often the distal end of the femur.

6. Deformity is usually gauged from simple observation. Bilateral bow leg can be recorded by measuring the distance between the knees with the child standing and the heels touching; it should be less than 6 cm.

7. C A US E S May be seen in one knee or both knees Physiological Blount’s disease/ Mau- Nilsonne Syndrome Rickets Lateral ligament laxity Congenital pseudoarthrosis of tibia Coxa vara

8. Due to growth abnormalities of upper tibial epiphysis. Infections like osteomyelitis , etc. Trauma near the growth epiphysis of femur. Tumors affecting the lower end of femur and upper end of tibia.

9. CAUSES IN ADULTS may be sequel to childhood deformity and if so usually cause no problems. However, if the deformity is associated with joint instability, this can lead to osteoarthritis of the medial compartment. Other causes include: Fracture of the lower part of the femur or the upper part of the tibia with malunion . Osteoarthritis . Rarefying diseases of the bone such as rickets or osteomalacia . Other bone-softening diseases such as Paget’s disease.

10. In ligamentous laxity note lat.Widening Of knee joints In Blount angulation at med.tib metaphysis

11. In coxa vara , angulation at the neck shaft level In cong. Pseudarthrosis of tibia,the angulation is in the distal ⅓

12. PERSISTENT GENU VARUM Worried parents About 3 years old + bow legs + mild lateral thrust at the knees + in-toeing

13. CLINICAL FEATURES Patients with tibia vara are often obese, exceeding the 95th percentile for weight

14. Second, patients with infantile tibia vara often have a clinically apparent lateral thrust of the knee during the stance phase of gait that resembles a limp. This sudden lateral knee movement with weight bearing is caused by varus instability at the joint line in concert with the angulation .

15. PRESENTATION In response to this, secondary deformities develop in the tibia and the foot . Patient complains of pain during walking, standing etc. Limp may be present. Difficulty in carrying activities of daily living . Difficulty in using the Indian toilets. Difficulty in squatting on the ground etc…

16. Symmetric prox &middle third Bowed medially Absent < 11 Normal Normal Normal Gentle curve Gentle curve Often assymetrical Proximal metphysis Normal except late Often present Greater than 11 Irregular rarifaction Sloping Narrowed medially Straight Sharp angulation Physiological genu varum Blounts disease Site of angulation Femur Lateral thrust Meta Dia angle Upper tib Metaphysis Upper tib Epiphysis Upper tib Physis Lateral Tib Cortex Med Tib Cortex Invovement

17. TR E A TMEN T : NON OPERATIVE: Physiologic genu varum nearly always spontaneously corrects itself as the child grows. This usually occurs by the age of 3 to 4 years

18. Blount’s disease does not require treatment to improve. If the disease is caught early , treatment with brace may be all that is needed. Bracing is not effective however with adolescents with Blount’s disease. Untreated infantile Blount’s disease or untreated rickets results in progressive worsening of the bowing in later childhood and adolescence.

19. The treatment of Blount disease depends on the age of the child and the severity of the varus deformity. Generally, observation or a trial of bracing is indicated for children between ages 2 and 5 years , but progressive deformity usually requires osteotomy .

20. SURGICAL TREATMENT Physiologic genu varum , In rare instances , physiologic genu varum in the toddler will not completely resolve and during adolescence, the bowing may cause the child and family to have cosmetic concerns. If the deformity is severe enough , then surgery to correct the remaining bowing may be needed.

21. different procedures; two main types. Guided growth . This surgery of the growth plate stops the growth on the healthy side of the shinbone which gives the abnormal side a chance to catch up , straightening the leg with the child’s natural growth. Tibial osteotomy . In this procedure, the shinbone is cut just below the knee and reshaped to correct the alignment.

22. After surgery, a cast may be applied to protect the bone while it heals. Crutches may be necessary for a few weeks , and exercises to restore strength and range of motion.

23. Genu Valgum (knocked knees) Introduction Genu valgum is a normal physiologic process in children therefore it is critical to differentiate between a physiologic and pathologic process distal femur is the most common location of primary pathologic genu valgum but can arise from tibia

24. • Medial angulation of the knee • Seventy-five percent is physiological up to 4 years of age. • Idiopathic is the most common type. • Deformity is the only complaint.

25. Anatomy Normal physiologic process of genu valgum between 3-4 years of age children have up to 20 degrees of genu valgum genu valgum rarely worsens after age 7 after age 7 valgus should not be worse than 12 degrees of genu valgum after age 7 the intermalleolar distance should be <8 cm

26. Etiologies bilateral genu valgum physiologic renal osteodystrophy (renal rickets) skeletal dysplasia Morquio syndrome spondyloepiphyseal dysplasia chondroctodermal dysplasia

27. unilateral genu valgum physeal injury from trauma, infection, or vascular insult proximal metaphyseal tibia fracture benign tumors fibrous dysplasia osteochondromas Ollier's disease

28. the threshold of deformity that leads to future degenerative changes is unknown deformity after a proximal metaphyseal tibia fracture (Cozen) should be observed, as it almost always remodels

29. Assesment of valgus / varus deformity History: nutritional deficiency renal disease muscle weakness gi problems family h/o trauma infections

30. EXAMINATION: stature, upper segment lower segment ratio, facies,teeth , metaphyseal thickening, hands,nails , features of rickets, proximal muscle weakness

31. A)INTER MALLEOLAR DISTANCE :8-10cm acceptable.measured in valgus deformity B)INTERCONDYLAR DISTANCE :measures varus deformity.if its >3 cms and it is unilateral it should be investigated

32. C)Plumb line test: Normally, a line drawn from anterosuperior iliac spine (ASIS) to middle of the patella, if extended down strikes the medial malleolus . In genu valgum , the medial malleolus will be outside this line.

33. D)Knee flexion test: This is to detect the cause of genu valgum whether it lies in the femur or tibia. If the deformity disappears with flexion of the knee, the cause lies in the lower end of femur and if it persists on flexion, the cause lies in the upper end of the tibia.

34. E)LATERAL TIBIOFEMORAL ANGLE F )Q ANGLE G)PATELLAR STABILITY H)TIBIAL TORSION I)FLAT FOOT

35. Q ANGLE  Q angle is the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle;     - an increased Q angle is a risk factor for  patellar subluxation ;     - normally Q angle is 14 deg for males and 17 deg for females;

36. In women , the Q angle should be less than 22 degrees with the knee in extension and less than 9 degrees with the knee in 90 degrees of flexion. In men , the Q angle should be less than 18 degrees with the knee in extension and less than 8 degrees with the knee in 90 degrees of flexion.

37. For persistent genu valgum , treatment recommendations have included a wide array of options, ranging from lifestyle restriction , bracing, exercise programs, and physical therapy. In recalcitrant cases, if valgus malalignment of the extremity is significant , corrective osteotomy or, in the skeletally immature patient, hemiepiphysiodesis may be indicated

38. W O L F F L A W Every change in the form and function of the bones or function alone is followed b y c e r t a i n d e f i n i t e c h a ng e s i n t h e e x t e r n a l configurations in accordance with mathematical laws .

39. GENU VALGUM COMPLEX Primary and secondary deformities together Primary deformity is medial angulation of knee Secondary deformities are A)external rotation deformity of distal end of femur and tibia because of pull of tensor fasia lata and biceps, B)internal rotation of tibia,lateral subluxation of patella,shortening of lateral structures and elongation of medial structures

40. Treatment Nonoperative observation indications first line of treatment genu valgum <15 degrees in a child <6 years of age bracing indications rarely used ineffective in pathologic genu valgum and unnecessary in physiologic genu valgum

41. HEUTER VOLKMANN LAW Pressure inhibit growth and decreased p r e ss u r e a cc e l e r a t e t h e g r o w t h o f t h e ph ysi s

42. Operative hemiepiphysiodesis or physeal tethering (staples, screws, or plate/screws) of medial side indications > 15-20° of valgus in a patient <10 years of age if line drawn from center of femoral head to center of ankle falls in lateral quadrant of tibial plateau in patient > 10 yrs of age

43. If lateral portion of epiphyseal plate is intact as seen in the radiographs, it contributes to the longitudinal growth at a reduced rate . This situation is suitable for stapling of the medial epiphysis, which arrests the growth on the medial side, allows the growth on the lateral side, and thus helps to correct the deformity to avoid physeal injury place them extraperiosteally to avoid overcorrection follow patients often growth begins within 24 months after removal of the tether

44. distal femoral varus osteotomy indications insufficient remaining growth for hemiepiphysiodesis complications peroneal nerve injury perform a peroneal nerve release prior to surgery gradually correct the deformity utilize a closing wedge technique

45. After skeletal maturity, an osteotomy must be performed at the site of maximum deformity of tibia or femur. If limb is long, medial close wedge osteotomy is done. If limb is short, lateral open wedge osteotomy is done. Knock-knee deformity more than 10 cm at the age of 10 years is an indication for surgery

46. It can done as medial close wedge osteotomy or lateral open wedge osteotomy .

47. Gross deformities can be corrected in a single sitting. However, this is a very invasive method fraught with potential complications, including malunion , delayed healing, infection, neurovascular compromise, and compartment syndrome.

48. Treatment facts of genu valgum < 4 yrs— No treatment. Only observation. 4-10 yrs—Heel raise, knock-knee brace. 10-14 yrs— Epiphyseal stapling. 14-16 yrs—wait until skeletal maturity, as it is too late for stapling and too early for osteotomy , as it may recur. > 16 yrs— Osteotomy .

49. GENU RECURVATUM This may be due to abnormal intra-uterine posture it usually recovers spontaneously. Rarely, gross hyperextension is the precursor of true congenital dislocation of the knee.

50. CAUSES Lower limb length discrepancy Congenital genu recurvatum Cerebral palsy polio Multiple sclerosis Muscular dystrophy Quadriceps Contracture Limited dorsiflexion ( plantar flexion contracture)

51. Popliteus muscle weakness Connective tissue disorders. In these disorders, there are excessive joint mobility (joint hypermobility ) problems. These disorders include: Marfan syndrome Ehlers- Danlos syndrome Beningn Hypermobile joint syndrome Osteogenesis imperfecta disease

52. Other causes of recurvatum are, Growth plate injuries and malunited fractures. These can be safely corrected by osteotomy .

53. F E A TUR E S Limitation of knee flexion from mild to severe . Effusion and other evidence of knee abnormality are absent . Sometimes a dense band that becomes tense during flexion of the knee could be palpated in the proximal part of the patella . Patella is always located more upwards and sometimes outwards.

54. Other features include; it is usually bilateral , common in identical twins , more common in females , and extremely resistant to conservative treatment .

55. POST-INJECTION CONTRACTURES IN INFANCY: Repeated injections and infusions into the thigh muscles soon after birth. Dimples present in the skin at the sites of injections. Common in twins and prematurity (because they often make injections necessary and in infants anterior thigh is commonly the preferred site).

56. TREATMENT Surgery is the treatment of choice and is usually indicated in established contractures , as conservative treatment is not beneficial. Early recognition and prevention through passive exercises while the child is receiving injections is the best preventive measure. Surgery is indicated early in habitual dislocation of the patella and in established contractures to prevent late changes in the femoral condyles and patella.

57. FOR QUADRICEPS PARALYSIS, Tendons usually are transferred around the knee joint to reinforce a weak or paralyzed quadriceps muscle; transfers are unnecessary for paralysis of the hamstring muscles because, in walking, gravity flexes the knee as the hip is flexed.

58. PRINCIPLES FOR SUCCESSFUL OPERATIONS ON THE SOFT TISSUES FOR GENU RECURVATUM 1. The fibrous tissue mass used for tenodesis must be sufficient to withstand the stretching forces generated by walking; all available tendons must be used. 2. Healing tissues must be protected until they are fully mature . The operation should not be undertaken unless the surgeon is sure that the patient will conscientiously use a brace that limits extension to 15 degrees of flexion for 1 year.

59. 3. The alignment and stability of the ankle must meet the basic requirements of gait . Any equinus deformity must be corrected to at least neutral . If the strength of the soleus is less than good on the standing test, this defect must be corrected by tendon transfer, tenodesis , or arthrodesis of the ankle in the neutral position