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.  EVOLUTION OF ALIGNMENT IN
THE LOWER LIMBS
 Torsion
 Fetus MMbehind LM
 Birth samelevel
 1YEAR LMbehind MM
 Adult 20degreesExternal torsion

6. 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.

9. 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.

11. 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

12. • 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.

13. 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.

14. IN LIGAMENTOUS LAXITY NOTE LAT.WIDENING
OF KNEE JOINTS
In Blount angulation at med.tib metaphysis

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

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

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

18. 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.

19. 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…

20. 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

21. 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

22. 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.

23. 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.

24. 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.

25.  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.

26. • 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.

27. 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

28. • 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.

29.  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

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

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

32.  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

33. ASSESMENT OF VALGUS/VARUS DEFORMITY
 History:
 nutritional deficiency
 renal disease
 muscle weakness
 gi problems
 family h/o
 trauma
 infections

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

35.  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

36. 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.

37.  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.

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

39. 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;

40. 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.

41.  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

42. WOLFF LAW
Every change in the form and function
of the bones or function alone is followed by
certain definite changes in the external
configurations in accordance with mathematical
laws.

43. 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

44. 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

45. HEUTERVOLKMANN LAW
 Pressure inhibit growth and decreased
pressure accelerate the growthof
the physis

46. 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

47.  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

49.  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

50.  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

51. IT CAN DONE AS MEDIAL CLOSE WEDGE
OSTEOTOMY OR LATERAL OPEN WEDGE
OSTEOTOMY.

52. 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.

53. 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.

54. 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.

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

56. • 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

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

58. 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.

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

60. 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).

61. 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.

63.  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.

64. 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.

65.  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