Deformity around knee joint

Deformity around knee
Varus
Valgus
Reccurvatum

1. Deformity around knee joint Dr Anshul Sethi PG ORTHOPAEDICS

2. NORMAL EVOLUTION OF LOWER LIMB ALIGNMENT New born and infants have bow legs with medial tibial torsion due to fetal position Become straight by 18-24 months By 2- 3 years of age genu valgus develop of approx. 12 degree By 7 year of age spontaneous correction happen.

3. DEFORMITIES GENU VARUM GENU VALGUM GENU RECURVATUM

4. Genu varum

5. INTRODUCTION It is an angular deformity of the proximal tibia in which child appear to have BOW LEGGED . It is OUTWARD angulation of the knee joint in which longitudinal axis of femur and tibia deviating medially It is simply seen on OBSERVATION

6. Bilateral bow leg can be documented by measuring the distance between the knee with child standing and the heels touching that would be recorded as LESS THAN 6 cm Internal torsion of distal shaft of tibia is an associated abnormality

7. Causes IT CAN BE UNILATERAL OR BILATERAL Physiological Blount’s disease (infantile tibia vara ) Rickets Lateral ligament laxity Trauma or infection

8. Growth abnormalities of upper tibial epiphysis. Tumors affecting lower end of femur or upper end of tibia Tibial hemimilea

9. Physiological genu varum 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

10. Suspicion of being pathological : Present after 2 year of age Unilateral Associated with shortening Obese child Severe deformity

11. Tibia Vara Growth retardation at medial aspect of proximal tibia epiphysis and physis resulting in persisting and persistant BOW LEGS IT IS OF 2 TYES INFANTILE TIBIA VARA : SEEN IN LESS THAN 3 YEAR ADOLOSCENT TIBIA VARA :SEEN IN 8 YEAR AND OLDER

12. Infantile tibia vara It is also known as blount’s disease It is abrupt angulation just below the proximal physis showing Irregular physeal line Wedge shaped epiphysis with beak at medial epiphysis With lateral subluxation of proximal end of tibia

13. Physiology The general findings have included (1) islands of densely packed cartilage cells displaying greater hypertrophy than expected from their position in the physis (2) islands of nearly acellular fibrocartilage (3) exceptionally large clusters of capillary vessels . The physeal cell columns become irregular and disordered in arrangement and normal endochondral ossification is disrupted, both in the medial aspect of the metaphysis and in the corresponding part of the physis . The varus deformity progresses as long as ossification is defective and growth continues laterally.

14. Blount’s disease It’s severity depends on degree of deformity at the time of presentation It involve proximal metaphysis With presence of thurst at knee while walking It has depressed medial tibial condyle giving s tilted pitched roof like appearance on radiograph MRI & ARTHROGRAPHY will show true joint line

15. Clinical features Patients with tibia vara are often obese. Presence of thurst of the knee during stance phase.(This sudden lateral knee movement with weight bearing is caused by varus instability at the joint line in concert with the angulation) Pain during walking & standing. Limping. Difficulty in routine activities.

16. Radiographic findings Sharp varus angulation in metaphysis Widened and irregular physeal line medially Medially slopped and irregular ossified epiphysis Beaking of medial metaphysis Lateral subluxation of proximal tibia

17. metaphyseal–diaphyseal angle (MDA), the angle created by the intersection of a line connecting the most prominent medial portion of the proximal tibial metaphysis (the “beak”) and the most prominent lateral point of the metaphysis with a line drawn perpendicular to the long axis of the tibial diaphysis

18. The tibial epiphyseal–metaphyseal angle has been proposed as an adjunctive measurement to aid early diagnosis of infantile tibia vara. An angle greater than 20 degrees in combination with an MDA greater than 10 degrees indicates a toddler at risk

19. MRI MRI characterizes the extent of the ossified and cartilaginous epiphysis, along with any physeal anatomic disruption .and is useful preoperative tools to evaluate location and size of the physeal bridge, as well as the presence or absence of “true” intraarticular deformity

20. Classification : In 1952, Langenskiöld classified infantile tibia vara according to the degree of metaphyseal-epiphyseal changes seen on radiographs.

21. Adoloscent tibia vara It is less common It occur due to partial premature closure of physis as a result of trauma or infection in a patient of age 6to 13 years of age IT IS DEFINED GENERALLY AS Increasing tibia vara after 8 year of age in a patient who is male , morbid obese with no history of any kind oh physeal insult RADIOGRAPH LACK OF BEAKING NORMAL SHAPE OF EPIPHYSIS WIDENING OF PROXIMAL MEDIAL PHYSEAL PLATE Widening of distal lateral femoral physis.

22. Aim of treatment Restoration of limb alignment Arrest of deformity progression Prevention of reoccurrence post correction.

23. Treatment Non operative PHYSIOLOGICAL Get spontaneously correct itself as child grows . Usually by 3-4 yr of age. BLOUNT’S DISEASE Type 1 : If diagnosed early need just bracing and observation.if presentation between 2-5 year of age and deformity is not severe.

24. Type 2 lesion : Surgical overcorrection of the mechanical axis to at least 5 degrees of valgus by 4 years of age, along with lateral translation of the distal osteotomy fragment , proximal tibial osteotomy (e.g., dome, closing wedge, or opening wedge) in young children is not important as long as the appropriate valgus and lateral translation are obtained. The level of osteotomy should be just distal to the patellar tendon insertion to avoid the proximal physis and its most distal extent. Internal tibial torsion should be addressed by external rotation of the distal fragment. Fibular osteotomy in the proximal third of diaphysis.

25. The concept of “guided growth” using extraperiosteal nonlocking plates may prove to be an attractive alternative to conventional acute corrective osteotomy in young patients (younger than age 4) with Stage I and II disease. The technique relies upon the tension band principle as opposed to physeal compression, and observed rates of correction are equivalent and possibly more rapid than stapling with compar able effectiveness in desired normalization of mechanical axis

26. Type 3 : Corrective osteotomy in patients older than 4 years Deformity more than 10 degree of femorotibial varus Type 4 and 5 : Lateral epiphysiodesis (permanent/transient) Realignment combined with medial epiphysiolysis and the use of interposition material to prevent rebridging is the treatment of choice . Epiphysiolysis can restore symmetric growth of the proximal end of the tibia and prevent retethering medially, thereby reducing the likelihood of recurrent deformity or disruption of the articular surface.

27. Type 6 : Treatment of stage VI lesions with established bony bridges must also be individualized. Factors to be considered are patient age, the amount of skeletal growth remaining, and the degree of deformity of the joint surface. If the patient has less than 2 years of growth remaining and a relatively normal joint surface, corrective osteotomy with complete physeal closure. Treatment options in patients greater than 7 yrs with more than 2 years growth remaining include completion of the lateral tibial epiphysiodesis, angular correction, and lengthening,limb length equalization correction by external fixation and distraction osteogenesis

28. Surgical management: GROWTH MODULATION USING HEMIPHYSEAL ARREST ACUTE CORRECTION BY OSTEOTOMY GRADUAL CORRECTION BY OSTEOTOMY

29. GROWTH MODULATION It is a reversible method It halt growth of normal side of physis giving time to abnormal side to catch up the growth It is done using Staples Oblique screws Tension-band plates Success depend on preserving the periosteum overlying the perichondrial ring during insertion and removal of implant.

30. DISADVANTAGES Cannot be used if child is about to approach skeletal maturity It correct deformity about 1 degree per month taking 2-3 years to correct severe deformity Cannot be used of deformity is because of abnormality of growth plates ( physeal bars, juxtaphyseal enchondroma ) If opposite side physis is not growing

31. OSTEOTOMY Depending upon age and size of the patient osteotomy of the patient can be fixed with the crossed k-wire or fixation with long leg cast with internal or external fixation Gradual correction by external fixation using ilizarov , specially if it associated with shortening So proximal site of osteotomy serve as a point of deformity correction and lengthing .

32. Genu valgum

33. Introduction It consist of medial angulation of the knee and outward deviation of longitudinal axis of both tibia and femur In advanced cases distal end of femur are rotated externally and by pull of bicep femoris and tensor fascia lata Proximal tibia develop compensatory internal torsion. It is normal physiological process in children

34. NORMAL PHYSIOLOGICAL VALGUS   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

35. CAUSES Most common cause is idiopathic . Fracture dislocation of epiphysis or a fracture through outer portion of epiphyseal plate Rickets (bilateral deformity) Fibrous dysplasia Olliers disease

36. evaluation History Nutritional deficiency Associated disease Stature Features of rickets

37. Intermalleolar distance : 8-10 cm distance is measured valgus deformity

38. Plumb line test : Normally a line drawn from ASIS to middle of the patella , if extended down strikes the medial malleolus But in case of genu valgum medial malleolus will be outside this line

39. Knee flexion test : This helps us in identifying the cause of deformity: If deformity disappear on knee flexion Then the cause lies in lower end of femur If deformity persist cause lies in proximal end of tibia

40. Q angle It is the angle formed by a line drawn from ASIS to centeral patella and 2 nd line drawn from centeral patella to tibial tubercle Normally it is 14 degrees in male and 17 degrees in female Increased Q ANGLE increase is a risk factor for patellar subluxation

41. Aim of treatment Restoration of limb alignment Prevention of reoccurrence post correction

42. TREATMENT Non Operative : It is done for child less than 6 year old with valgus deformity of less than 15 degrees Bracing can be used but it is rarely indicated in pathologicaL VALGUs Common splint used are : mermaid spint ; single bar ankle foor arthrosis

43. Guided growth with hemiepiphyseiodesis : INDICATIONS: More than 15 degree in a patient less than 10 yr of age it is reversible method done with the help of same staples , oblique screws .

44. osteotomy INDICATIONS : Child approaching skeletal maturity Associated peroneal nerve injury Knock knee deformity more than 10 cm at the age of 10 year In case of limb lenghtning : medial close wedge osteotomy is done. In case of limb shortening : lateral open wedge osteotomy is done.

45. Genu recurvatum

46. INTRODUCTION : Hyperextension in the knee is prevented by Integrity of the strong posterior capsule and ligament of knee Orientation of the articular surface of the femur and tibia GENU RECURVATUM occur wen both or either of the above mention 2 mechanism is ineffective or abnormal .

47. CAUSES Abnormal intra- utriene position of fetus Lower limb length disperancy Congential Polio Osteomylities Trauma Muscular dystrophy Quadricep contracture

48. Popliteus muscle weakness Hypermobile joint syndrome Marfan syndrome Ehlers danlos syndrome Benign hypermobile joint syndrome Osteogenesis imperfect

49. Presentation Limitation of knee flexion Pain in knee Mostly involve bilateral joints More common in females

50. Aim of treatment Relieve pain if present Correction of deformity Prevent reoccurence

51. TREATMENT : BRACING : It immobilize the knee and prevent It to undergo hyperextension and result in stiffness leading to stiff knee gait. It can be used with early recognition and passive exercises in between OSTEOTOMY : Open wedge or close wedge osteotomy help in correction of deformity and prevent its reoccurrence. Flexion supracondylar osteotomy Epiphyseodesis

52. EPIPHYSIODESIS PHEMISTER described epiphysiodesis in 1933 it is widely used for LIMB LENGTH EQUALIZATION. It can be done via various approaches : Percutaneous epiphysiodesis . Percutaneous transepiphyseal screw epiphysiodesis . Tension plate epiphysiodesis It is not recommended for shortening more than 5 cm.

53. PERCUTANEOUS EPIPHYSIODESIS Administration of general anesthesia, place the patient supine on the operating table. locate the lateral portion of the distal femoral physis . After it has been located with image intensification, make small medial and lateral stab wounds approximately 1.5 cm long. Place a smooth Steinmann pin or Kirschner wire into the physis and drill it into the side of the distal femoral physis Confirm correct positioning of the pin on anteroposterior and lateral image intensification views

54. Place a cannulated reamer over the guide pin and drill into the physis approximately halfway across; verify this with image intensification. After removal of the reamer, introduce a high-speed pneumatic drill with a dental burr. Use angled and straight curets to remove the physis . Ream the physis proximally and distally, anteriorly and posteriorly, especially at the periphery, to create a “bull’s eye” effect in the center of the physis at the lateral periphery. A lucent area or blackout effect is noted on image intensification where the physis and surrounding bone have been removed Thoroughly irrigate to remove all loose pieces of cartilage and cancellous bone. Close the wounds with subcutaneous sutures and apply a sterile dressing.

55. Post op care Immediate weight bearing in a soft knee immobilizer is allowed. The immobilizer is worn for approximately 2 to 3 weeks. If femoral and tibial epiphysiodeses have been done, a knee immobilizer is worn for 10 to 14 days, and then active range-of-motion exercises are begun. Crutches are used for guarded weight bearing for the first 4 weeks.

56. PERCUTANEOUS TRANSEPIPHYSEAL SCREW EPIPHYSEIODESIS Through a small stab incision over the lateral aspect of the distal femoral metaphysis, drill a hole directed obliquely downward and medially. slightly posterior to the midcoronal plane of the femur, advance the drill to cross the physis at the junction of its middle and inner thirds, and stop just short of the articular surface of the medial femoral condyle. Insert a cancellous screw with long threads Insert the second screw from the medial aspect, symmetrically to the first screw slightly anterior to the midcoronal plane to avoid the first screw

57. LATERAL CLOSING WEDGE OSTEOTOMY Coventry described a closing wedge osteotomy made proximal to the tibial tuberosity lateral approach to correct a varus deformity and a medial approach to correct a valgus deformity. The advantages of osteotomy are: it is made near the deformity, that is, the knee joint it is made through cancellous bone, which heals rapidly it permits the fragments to be held firmly in position by staples or a rigid fixation device, such as a plate-and-screw construct it permits exploration of the knee through the same incision.

58. patient supine, place a sandbag under the involved hip to allow easier access to the lateral aspect of the knee. Make an inverted-L–shaped incision for a lateral approach to the proximal tibia divide the proximal tibiofibular capsule with a sharp 3/4-inch curved osteotome Using small Kirschner wires to identify the joint line and insert the transverse osteotomy jig with the top portion touching the needles or wires. Flex and extend the osteotomy guide to match the patient’s posterior slope and to determine proper plate positioning. This can be confirmed by placing the plate over the smooth pin in the jig .

59. drill a second hole and fill it with a smooth pin. central hole in the transverse osteotomy guide, adjacent to the osteotomy slot, drill completely across the tibia, and use a depth gauge to measure the tibial width. Replace the transverse osteotomy jig with the slotted oblique jig; this jig is slotted in 2-mm increments to allow the desired degree of correction Make the oblique portion of the osteotomy and remove the oblique jig, leaving the pins in place Remove the wedge of bone and carefully inspect the osteotomy site to ensure no residual bone is left

60. Apply a buttress plate over the two smooth pins. Remove one pin and replace it with a 6.5-mm cancellous screw, using the second pin as a parallel alignment marker Remove the second pin and replace it with a cancellous screw Insert the curved pin at the end of the compression clamp into this hole, while placing the straight pin on the end of the clamp into the most distal hole of the L-plate, and apply slow compression When the osteotomy is closed, evaluate overall alignment with either a long alignment rod or an electrocautery cord. When aligned from the center of the hip to the center of the ankle, the plumb line should pass through the lateral compartment of the knee.

61. Confirm alignment and placement of the plate with anteroposterior and lateral radiographs or fluoroscopy. Remove the compression device and insert a cortical screw in the most distal hole in the plate. Tighten the proximal cancellous screws. POST OP CARE : Continuous passive motion is begun immediately after surgery in the recovery room, progressing 10 degrees each day. Ambulation is begun on the second day after surgery, and 50% weight bearing is allowed for the first 6 weeks with the use of crutches. Muscle strengthening and active range-of-motion exercises also are begun on postoperative day 2. Full weight bearing is allowed after 6 weeks.

62. Thank you…..