Angular Deformity
- 1. ANGULAR DERFORMITY Prepared By:DR Abbas Hameed AL-khafaji Resident of orthopedic surgery Nacr city hospital For Health Insurance
- 2. NATURAL HISTORYOF NORMAL EVOLUTION OF THEALIGNMENT 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°♂)
- 5. GENU VARUM
- 6. INTRODUCTION Angular deformity of the proximal tibiain which the child appears“bowlegged” Physiologic genuvarum isadeformity with a tibiofemoral angle of at least 10degreesof varus,a radiographically normal physis, and apexlateral bowing of the proximal end of the tibia and often the distal end of the femur.
- 7. Deformity is usually gauged from simple observation. Bilateral bow leg canbe recorded by measuring the distance between theknees with the child standing and the heels touching ; it should be lessthan 6cm.
- 8. CAUSES May beseenin onekneeor both knees • Physiological • Blount’s disease/ Mau-NilsonneSyndrome • Rickets • Lateral ligament laxity • Congenital pseudoarthrosis of tibia • Coxavara
- 9. Contnd… • Dueto growth abnormalities ofupper tibial epiphysis. • Infections like osteomyelitis,etc. • Traumanear the growth epiphysis of femur. • Tumors affecting the lower end of femur and upper end of tibia.
- 10. CAUSES IN ADULTS • may be sequel to childhood deformity and if sousually causeno problems. However, if the deformity is associated with joint instability, this can lead to osteoarthritis of the medial compartment. Other causesinclude: • Fracture of the lower part of the femur or the upper part of the tibia with malunion. • Osteoarthritis. • Rarefying diseasesof the bone such asrickets or osteomalacia. • Other bone-softening diseasessuch asPaget’sdisease.
- 12. In ligamentous laxity notelat.Widening Of knee joints In Blount angulation at med.tib metaphysis
- 13. In coxavara ,angulation at the neck shaft level In cong. Pseudarthrosis of tibia,the angulation is in the distal⅓
- 14. PERSISTENT GENU VARUM Worried parents About 3 yearsold +bow legs +mild lateral thrust at the knees+in-toeing
- 15. CLINICALFEATURES Patients with tibia vara are often obese
- 16. Second,patients with infantile tibia varaoften haveaclinically apparent lateral thrust of the knee during the stance phase of gait that resembles alimp. This sudden lateral knee movement with weight bearing is causedby varus instability at the joint line in concert with the angulation.
- 17. PRESENTATION • In response to this, secondarydeformities develop in the tibia and thefoot. • Patient complains of pain duringwalking, standing etc. • Limp may be present. • Difficulty in carrying activities of dailyliving. • Difficulty in using the toilets. • Difficulty in squatting on the groundetc…
- 22. TREATMENT: NONOPERATIVE: Physiologic genu varum nearly always spontaneously corrects itself asthe child grows. This usually occurs by the ageof 3 to 4years.
- 23. Blount’s diseasedoes not require treatment to improve. If the diseaseis caught early,treatment with brace may be all that isneeded. Bracing is not effective however withadolescents with Blount’sdisease. Untreated infantile Blount’s diseaseoruntreated rickets results in progressive worsening of the bowing in later childhood andadolescence.
- 24. Thetreatment of Blount diseasedependson the ageof the child and the severity of the varus deformity. Generally, observation or atrial of bracingis indicated for children between ages2 and5 years, but progressive deformity usually requires osteotomy.
- 25. SURGICALTREATMENT Physiologic genu varum, • In rare instances, physiologic genu varumin the toddler will not completely resolve and during adolescence, the bowing may cause the child and family to havecosmetic concerns. • If the deformity is severeenough, then surgery to correct theremaining bowing may be needed.
- 26. different procedures; two maintypes. • Guided growth. Thissurgery of the growth plate stops the growth on the healthy side of the shinbone which givesthe abnormal side achance to catch up, straightening the leg with the child’s natural growth. • Tibial osteotomy. In this procedure, theshinbone is cut just below the knee and reshaped to correct the alignment.
- 27. • After surgery, acast may be applied to protect the bone while it heals. • Crutches may be necessaryfor afew weeks, and exercisesto restore strength and rangeof motion.
- 29. METAPHYSEAL OSTEOTOMY FOR TIBIA VARA
- 31. GENUVALGUM Commonly called “knock-knee” Kneesare deviated towards midline of the body and touch one another when thelegs are straightened.
- 32. Mild genu valgum canbe seenin children from ages2 to 5 where children have genu valgum angle up to 20degrees. Genuvalgum rarely worsens after age7years & valgus should not be worse than 12 degrees. Intermalleolar distance should be <8cm.
- 33. Thedeformity often get corrected naturallyas children grow. However, the condition may continue or worsen with age,particularly when itis the result of adisease, suchasrickets or metabolic origin.
- 34. Idiopathic genu valgum is the commonest form that is either becauseofcongenital or hasno known cause. Distal femur is the most common location of primary pathologic genu valgum but canarise from tibia.
- 35. ETIOLOGIES Bilateral GenuValgum Physiologic Renalosteodystrophy (renal rickets) Skeletal dysplasia Morquio syndrome Spondyloepiphyseal dysplasia Chondroctodermal dysplasia
- 36. Unilateral genuvalgum Physealinjury from trauma, infection, orvascular insult. Proximal metaphyseal tibia fracture. Benign tumors: Fibrous dysplasia Osteochondromas Ollier's disease
- 37. DIAGNOSIS: Thedegree of genu valgum canbeestimated by the Qangle.
- 38. In women, the Qangle should be lessthan 22 degreeswith the knee in extension and less than 9 degrees with the knee in90 degreesof flexion. In men, the Qangle should be lessthan 18 degreeswith the knee in extension and less than 8 degrees with the knee in90 degrees of flexion.
- 39. Forpersistent genu valgum, treatment recommendations have included awide verity of options, ranging from lifestyle restriction , bracing, exerciseprograms, and physical therapy.
- 40. In sever cases,if valgus malalignment of the extremity is significant, corrective osteotomy or, in the skeletally immature patient, hemiepiphysiodesis may beindicated.
- 41. NONOPERATIVE Observationof deformity & parentcounselling Considered asfirst line of managementfor physiological genu valgum in childrenof <6yearsagewith valgus angle <15degrees.
- 42. Bracing Mostly used in progressive physiological genu valgum for parental satisfaction but limiteduse in pathological genuvalgum. Common splints usedare- mermaid splint, lateral single bar knee ankle foot orthosis, shoe modificationwith elevating inner border ofshoe.
- 43. OPERATIVE Hemiepiphysiodesisor Physealtethering: If the patient is still growing, hemiepiphysiodesis canbe done to promote more normal growth and straightning theleg. At appropriate time, months before completing growth, bone clamps orstapples are put into the bone around the growth plate.
- 44. Over the next 1-2 yearsthis will result in redirected growththat canlead to straightening of the legs. Bonestapples canbe left in permanently once the goal is achieved and the legs are straight.
- 46. Osteotomy: Mostly indicated for genu valgum pateints around the age of growth plate fusion and patients with severe valgusdeformity. Osteotomy is done at the apex of the deformity at femur and/or tibiadepending on the site of deformity.
- 47. It can done asmedial close wedgeosteotomy or lateral open wedgeosteotomy.
- 48. Grossdeformities canbe corrected in asingle sitting. However, this is avery invasive method fraught with potential complications,including > malunion, >delayed healing, >infection, >neurovascular compromise, and >compartment syndrome.