angulardeformitiesaroundthekneeseminar-190904023048.pptx

Deformities around knee

1. A NGUL A R DEFORMITIES AROUND THE KNEE

2. ANGULAR DEFORMITIES OF KNEE GENU VARUM GENU VALGUS

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. 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.

5. 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.

6. CAUSES May be seen in one knee or both knees Physiological Blount’s disease Rickets Lateral ligament laxity Congenital pseudoarthrosis of tibia Coxa vara

7. 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.

8. 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.

9. I N LIGAMENTOUS LAXITY NOTE LAT .W IDENING O F KNEE JOINTS In Blount angulation at med.tib metaphysis

10. I N COXA VARA , ANGULATION AT THE NECK SHAFT LEVEL In cong. Pseudarthrosis of tibia,the angulation is in the distal ⅓

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

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

13. 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.

14. PRESENTATION In response to this, secondary deformities develop in the tibia and the foot . P a ti e n t c o m pl a in s o f p ain durin g w alkin g , st a ndin g 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…

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

16. T R E A TME N T : NON OPERATIVE: Physiologic genu varum nearly always sp o nt ane o u sl y c o r r e ct s itself as the c h ild g r o w s . This usually occurs by the age of 3 to 4 years

17. Blount’s disease does not require treatment to improve. If the disease is caught early , treatment with brace may be all that is needed. B r ac in g is no t e f f ec ti v e h o w e v er with adolesce n ts with Blount’s disease. U n t r e at ed i n f a n til e B l o u n t ’ s dis e a s e o r u n t r e at e d ri c k e t s results in progressive worsening of the bowing in later childhood and adolescence.

18. 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.

19. 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.

20. different procedures; two main types. Gui de d g r o wt h . Thi s su r g ery o f the g r o wt h pl at e st o p s the growth on the healthy side of the tibia 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 tibia is cut just below the knee and reshaped to correct the alignment.

21. After surgery, a cast may be applied to protect the bone while it heals. Crutches may be necessary for a few weeks , and e x e r c i s e s t o r e s t o r e s t r e n g t h and r an g e o f moti o n.

22. G ENU V ALGUM ( 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

23. 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.

24. 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

25. Etiologies bilateral genu valgum physiologic renal osteodystrophy (renal rickets) skeletal dysplasia spondyloepiphyseal dysplasia

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

27. 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

28. A SSESMENT OF VALGUS / VARUS DEFORMITY History: nutritional deficiency renal disease muscle weakness gi problems family h/o trauma infections

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

30. 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

31. 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.

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

33. 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;

34. 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.

35. For persistent genu valgum , treatment recommendations have included a wide array of opti o ns, r a ng i n g f r o m li f e s t y l e r e s t r i c t i o n , bracin g , exercise programs, and physical therapy. I f valgus malalignment of the extremity is significant , corrective osteotomy or, in the skeletally immature patient , hemiepiphysiodesis may be indicated

36. T REATMENT 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

37. H E U TE R VO L K M AN N L A W inhibit growth and decreased accelerate the growth of Pressure pressure the physis

38. O PE R A TIVE 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

39. 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

40. 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

41. 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

42. I T CAN DONE AS MEDIAL CLOSE WEDGE OSTEOTOMY OR LATERAL OPEN WEDGE OSTEOTOMY .

43. Gross deformities can be corrected in a single sitting. H o w e v e r , this is a v ery i nv a s i v e meth o d f r a ug h t with potential complications, including malunion, delayed healing, infection, neurovascular compromise, and compartment syndrome.

44. Opening Wedge Osteotomy The opening wedge  osteotomy  has the advantage of avoiding leg shortening, but  delayed union  or  nonunion  may result. Although the leg length change may not seem significant if only 1 cm of shortening is performed with the  wedge resection  osteotomy, such change does become significant if an opening wedge osteotomy is performed with a 1-cm graft, when the height differential is almost 2 cm once the graft has healed.

45. Closing Wedge Osteotomy The closing wedge osteotomy has a major disadvantage of limb shortening but generally is easier than the opening wedge procedure, particularly if both the  fibula  and the  tibia  are included. With any skin-related problems (previous incisions with scar formation or previous infection) or the potential for vascular compromise, a closing wedge procedure must be performed

46. CORA Measuring the center of rotation of angulation (CORA) of the deformity is important. The CORA is located at the intersection of two lines representing the mechanical axes of the proximal and distal segments of the deformity. A closing or opening wedge osteotomy at the level of the CORA leads to complete realignment of the foot and ankle. If the osteotomy is made proximal or distal to the CORA, the center of the ankle translates relative to the mechanical axis of the tibia and creates an unnecessary shift of loads and a clinically obvious zigzag deformity