Genu varus and valgus

Genu varus and valgus by Dr Bipul Borthakur

1. GENU VARUS GENU VALGUS DR. BIPUL BORTHAKUR Professor, Dept of Orthopaedics, SMCH

2. INTRODUCTION Q – angle: angle formed between the line joining the ASIS and centre of patella and the line joining the center of patella and the tibial tuberosity Normal Males – 10 to 12 deg Females – 15 to 18 deg

3. GENU VALGUM Commonly known as ” Knock-knee ” Limb is deviated towards midline of the body and both knees touch each other when knee is in full extension

4. GENU VALGUM Genu valgum is a normal physiological process in children U p to 4 years of age . Therefore it is critical to differentiate between a physiological and pathological process Distal femur is the most common location of primary pathologic genu valgum but can arise from tibia

5. ETIOLOGY Bilateral Genu Valgum Physiological Renal osteodystrophy (Renal rickets) Skeletal dysplasia Morquio syndrome Spondyloepiphyseal dysplasia Chondroctodermal dysplasia Unilateral Genu Valgum Physeal injury –Trauma, Infection and Vascular insult Proximal metaphyseal tibia fracture Secondary arthritis Benign tumour Fibrous dysplasia Osteochondromas Ollier’s disease Ligamentous injury Paget’s disease

6. GENU VALGUM – Presentation Deformity is the only complaint Knee joints touch each other while standing – Knock knees Increased Q angle Increased inter- malleolar distance Inter- malleolar distance up to 9cm with child lying down is acceptable

7. GENU VALGUM – Investigations Plain radiograph of knee joints AP and lateral view Calculate Q-angle Orthoscanogram

8. GENU VALGUM – Treatment Non – operative Observation of deformity and parent counselling C onsider as first line of management for physiological Genu v algum in children of < 6 years Treatment of primary cause

9. GENU VALGUM – Treatment Operative treatment Hemiepiphysiodesis or physeal tethering Bone stapling Done before completing growth Put into the bone around growth plate

10. GENU VALGUM – Treatment Corrective Osteotomy Done at the apex of the deformity at femur and /or tibia 10 years old with Inter- malleolar distance > 10cm Can be a lateral open wedge or medial close wedge osteotomy

11. GENU VALGUM – Treatment 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.

12. GENU VARUM Angular deformity of proximal tibia in which the child appear “ bowlegged ”. Maximum varus is present at 6-12 months of age Bowlegs after 2 years of age considered abnormal

13. GENU VARUM - Etiology Physiological Pathological Blount’s disease Hypophosphatemic or nutritional rickets Post-traumatic Post-infectious Congenital deformities Focal fibrocartilaginous dysplasia Metaphysealchondrodysplasia Fibrous dysplasia Osteogenesis imperfecta Renal osteodystrophy

14. GENU VARUM - Etiology CAUSES IN ADULTS May be sequel of childhood deformity a nd 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 osteomalacia Other bone-softening diseases such as Paget’s disease .

15. GENU VARUM - Assessment HISTORY: The stature and nutritional status of the child Developmental milestones Other nutritional or medical problems History of trauma or infections

16. GENU VARUM - Assessment EXAMINATION: Short stature : Suggests the possibility of vitamin D refractory (hypo- phosphatemic ) rickets or bone dysplasia ( achondroplasia or metaphyseal dysplasia). The inter-condylar distance: Performed with the medial malleoli in contact Done in stance and supine. Greater than 6 cm is abnormal. Ruling out the deformity of the feet : e.g . metatarsus varus or valgus which may represent torsional deformity of the limb

17. GENU VARUM - Investigations Plain radiograph of knee joints AP and lateral views Orthoscanogram Complete bone metabolic profile Serum Ca , Ph , ALP Serum Vitamin D level Complete blood count RFT, urine Ca level

18. GENU VARUM - Treatment Non-operative In the vast majority of cases, genu varum will correct with growth. In physiological genu varum , education and assurance of the parents is important and just follow its natural course by reassessing the child in 6 months. Treatment of underlying causes Brace application

19. GENU VARUM - Treatment Brace application: The effectiveness of the brace is related to the relief of weight bearing stresses on the medial physeal region of the proximal tibia. Brace treatment is reported to be successful in 50 % to 80% of the patients treated. The brace is worn until the deformity has been corrected which usually takes about 1 year. Thus , bracing is usually not a viable option for children over the age of 3.

20. GENU VARUM - Treatment Operative: Tibial osteotomy – The shinbone is cut just below the knee and reshaped to correct the alignment 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

21. THANK YOU