Genu varum, Genu valgum, Genu recurvatum

SEMINAR

1. GENU VARUM GENU VALGUM GENU RECURVATM PRESENTER: DR. MURUGESH M KURANI Dept. of Orthopaedics, J N Medical College, BELAGAVI.

2. NATURAL HISTORY OF NORMAL EVOLUTION OF THE ALIGNMENT OF THE LOWER LIMBS 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°♂)

3. GENU VARUM

4. INTRODUCTION Angular deformity of the proximal tibia in which the child appears “bowlegged ”

5. 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. CAUSES 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. Contnd … 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. Physiological… 06/08/2017 12 Physiological… Pathological… AYODELE A.E

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

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

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

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

15. 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 .

16. 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…

17. TREATMENT: 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. METAPHYSEAL OSTEOTOMY FOR TIBIA VARA

24. GENU VALGUM Commonly called “ knock-knee” Knees are deviated towards midline of the body and touch one another when the legs are straightened.

25. Mild genu valgum can be seen in children from ages 2 to 5 where children have genu valgum angle up to 20 degrees . Genu valgum rarely worsens after age 7years & valgus should not be worse than 12 degrees. Intermalleolar distance should be <8 cm.

26. The deformity often get corrected naturally as children grow. However, the condition may continue or worsen with age, particularly when it is the result of a disease , such as rickets or metabolic origin.

27. Idiopathic genu valgum is the commonest form that is either because of congenital or has no known cause. Distal femur is the most common location of primary pathologic genu valgum but can arise from tibia.

28. ETIOLOGIES Bilateral Genu Valgum Physiologic Renal osteodystrophy (renal rickets) Skeletal dysplasia Morquio syndrome Spondyloepiphyseal dysplasia Chondroctodermal dysplasia

29. Unilateral genu valgum Physeal injury from trauma, infection, or vascular insult. Proximal metaphyseal tibia fracture. Benign tumors : Fibrous dysplasia Osteochondromas Ollier's disease

30. DIAGNOSIS: The degree of genu valgum can be estimated by the Q angle.

31. 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.

32. For persistent genu valgum , treatment recommendations have included a wide array of options, ranging from lifestyle restriction , bracing, exercise programs, and physical therapy.

33. In recalcitrant cases, if valgus malalignment of the extremity is significant , corrective osteotomy or, in the skeletally immature patient, hemiepiphysiodesis may be indicated.

34. NONOPERATIVE Observation of deformity & parent counselling Considered as first line of management for physiological genu valgum in children of <6years age with valgus angle <15 degrees .

35. Bracing Mostly used in progressive physiological genu valgum for parental satisfaction but limited use in pathological genu valgum . Common splints used are- mermaid splint, lateral single bar knee ankle foot orthosis , shoe modification with elevating inner border of shoe.

36. OPERATIVE Hemiepiphysiodesis or Physeal tethering: If the patient is still growing , hemiepiphysiodesis can be done to promote more normal growth and straightning the leg. At appropriate time, months before completing growth , bone clamps or stapples are put into the bone around the growth plate.

37. Over the next 1-2 years this will result in redirected growth that can lead to straightening of the legs. Bone stapples can be left in permanently once the goal is achieved and the legs are straight.

38. Osteotomy : Mostly indicated for genu valgum pateints around the age of growth plate fusion and patients with severe valgus deformity. Osteotomy is done at the apex of the deformity at femur and/or tibia depending on the site of deformity.

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

40. 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.

41. GENU RECURVATUM

42. 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.

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

44. 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

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

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

47. 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).

48. 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.

49. Surgery is indicated early in habitual dislocation of the patella and in established contractures to prevent late changes in the femoral condyles and patella.

50. 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.

51. 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.

52. contd 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.

53. contd 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