Pediatric Genu Varum

Pediatric Genu Varum

No Results

No Results

processing….

Genu varum is a Latin term used to describe bow legs. This condition may present from infancy through adulthood and has a wide variety of causes. As it becomes more severe, the patient may exhibit lateral knee thrust and a waddling gait. There may be associated in-toeing and secondary effects on the hip and ankle. The problem may be unilateral, with a functional limb-length discrepancy, or bilateral. The family and medical history may reveal clues to the likelihood of persistence or progression.

It is widely recognized that up to age 2 years, infants may have physiologic bowing of the lower extremities. The hallmark of this condition is symmetrical and painless bowing, usually associated with in-toeing and often with a propensity for tripping. This problem will resolve spontaneously without treatment, as a result of normal growth. [1, 2, 3]  All that is required is parental education and periodic follow-up to verify resolution. During the wait for the predicted spontaneous correction, reversing the shoes may reduce the frequency of tripping.

The prevalence of this condition is not known, but it is frequent enough to be considered a variation of normal in toddlers. Nevertheless, it is a relatively common cause of parents’ seeking medical attention from their primary care providers, who should be knowledgeable in the triage of these conditions. Only in the most persistent or worrisome cases is orthopedic consultation warranted. Radiographs, though optional as a rule, may be needed to differentiate physiologic varus from pathologic conditions that call for treatment. [4]

In normal alignment, the lower-extremity lengths are equal, and the mechanical axis (center of gravity) bisects the knee when the patient is standing erect with the patellae facing forward (see the image below). This position places relatively balanced forces on the medial and lateral compartments of the knee and on the collateral ligaments, while the patella remains stable and centered in the femoral sulcus.

In children younger than 2 years, physiologic genu varum is common but is self-limiting and innocuous. In older children with pathologic genu varum, as the knee drifts laterally, the mechanical axis falls in the inner quadrant of the knee; in severe cases, it does not even cross the knee (see the image below).

As a result, the medial femoral condyle and the medial plateau of the tibia are subjected to pathologic loading. The Heuter-Volkmann effect will compress the physis and the cartilaginous anlage of these structures and inhibit the normal ossification of the epiphysis. The lateral collateral ligaments are stretched, sometimes beyond their compliance, permitting the characteristic lateral thrust of the knees during gait.

When the mechanical axis deviates into or beyond the medial quadrant of the knee, regardless of the etiology, a number of clinical problems may ensue. Lateral ligamentous strain may be associated with recurrent knee pain, lateral thrust, in toeing, and the evolution of a waddling gait.

The natural history of untreated genu varum is not benign. During the adult years, premature and eccentric stress on the knee may result in medial meniscal tears, tibiofemoral subluxation, articular cartilage attrition, and arthrosis of the medial compartment of the knee. Nonoperative management that relies on shoe modification, physical therapy, and so-called Forrest Gump bracing is of no proven value.

The recognized etiologies for genu varum include the following:

An association between soccer playing and genu varum has been suggested. [5, 6]

Regardless of the etiology of pathologic genu varum and regardless of the patient’s age, surgical correction of significant and symptomatic malalignment is warranted.

Physiologic genu varum, defined as occurring in children younger than 2 years, is exceedingly common but is self-correcting. In contrast, pathologic genu varum, which is due to a variety of conditions, is much less prevalent, especially with increasing age. Among the known causes are tibia vara (Blount disease), rickets, and skeletal dysplasias. The collective frequency of these conditions is not specifically known, but they are common triggers for pediatric orthopedic referral.

In countries where malnutrition is widespread and access to medical care is limited, the overall incidence of genu varum is undoubtedly higher. Whereas polio has been largely eradicated, other infectious diseases and mistreated (or untreated) traumatic injuries make physeal damage a frequent cause of progressive and disabling clinical deformity.

Likewise, untreated congenital anomalies, genetic disorders, metabolic conditions, and rheumatologic diseases may all cause progressive genu varum. Finally, in any country, one may encounter iatrogenic postoperative genu varum.

The outcome of guided growth for genu varum is dependent on patient selection and timing. As noted earlier, this technique is contraindicated for physiologic genu varum and will be of no benefit after skeletal maturity has been attained. At least 6 (and preferably 12) months of predicted growth is needed to derive any benefit.

For the remainder of patients, regardless of age or diagnosis, guided growth holds promise for complete correction of the deformity and may reduce or eliminate the need for more invasive osteotomies. For specific endocrinologic conditions, concomitant medical management is required.

The parents must have a vested interest in the success of the procedure and must understand that although the incisions are small and the correction gradual, the onus is on them to return for follow-up appointments at the specified intervals (typically every 3 months while the implants are in place).

Heath CH, Staheli LT. Normal limits of knee angle in white children–genu varum and genu valgum. J Pediatr Orthop. 1993 Mar-Apr. 13(2):259-62. [Medline].

Salenius P, Vankka E. The development of the tibiofemoral angle in children. J Bone Joint Surg Am. 1975 Mar. 57(2):259-61. [Medline].

Kling TF Jr, Hensinger RN. Angular and torsional deformities of the lower limbs in children. Clin Orthop Relat Res. 1983 Jun. 136-47. [Medline].

Levine AM, Drennan JC. Physiological bowing and tibia vara. The metaphyseal-diaphyseal angle in the measurement of bowleg deformities. J Bone Joint Surg Am. 1982 Oct. 64(8):1158-63. [Medline].

Colyn W, Agricola R, Arnout N, Verhaar JA, Bellemans J. How does lower leg alignment differ between soccer players, other athletes, and non-athletic controls?. Knee Surg Sports Traumatol Arthrosc. 2016 Nov. 24 (11):3619-3626. [Medline].

Asadi K, Mirbolook A, Heidarzadeh A, Mardani Kivi M, Emami Meybodi MK, Rouhi Rad M. Association of Soccer and Genu Varum in Adolescents. Trauma Mon. 2015 May. 20 (2):e17184. [Medline]. [Full Text].

Machen MS, Stevens PM. Should full-length standing anteroposterior radiographs replace the scanogram for measurement of limb length discrepancy?. J Pediatr Orthop B. 2005 Jan. 14(1):30-7. [Medline].

Dietz FR, Merchant TC. Indications for osteotomy of the tibia in children. J Pediatr Orthop. 1990 Jul-Aug. 10(4):486-90. [Medline].

Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am. 1994 Jul. 25(3):425-65. [Medline].

Steel HH, Sandrow RE, Sullivan PD. Complications of tibial osteotomy in children for genu varum or valgum. Evidence that neurological changes are due to ischemia. J Bone Joint Surg Am. 1971 Dec. 53(8):1629-35. [Medline].

Mycoskie PJ. Complications of osteotomies about the knee in children. Orthopedics. 1981 Sep 1. 4 (9):1005-15. [Medline].

Phemister DB. Operative arrestment of longitudinal growth of bones in the treatment of deformities. J Bone Joint Surg. 1933. 15:1-15.

Stevens PM. Guided growth: 1933 to the present. Strategies Trauma Limb Reconstr. 2006. 1:29-35. [Full Text].

Canale ST, Russell TA, Holcomb RL. Percutaneous epiphysiodesis: experimental study and preliminary clinical results. J Pediatr Orthop. 1986 Mar-Apr. 6(2):150-6. [Medline].

Ogilvie JW. Epiphysiodesis: evaluation of a new technique. J Pediatr Orthop. 1986 Mar-Apr. 6(2):147-9. [Medline].

Bowen JR, Leahey JL, Zhang ZH, MacEwen GD. Partial epiphysiodesis at the knee to correct angular deformity. Clin Orthop Relat Res. 1985 Sep. (198):184-90. [Medline].

Blount WP, Clark GR. Control of bone growth by epiphyseal stapling. J Bone Joint Surg. 1949. 31A:464-71.

Blount WP. A mature look at epiphyseal stapling. Clin Orthop Relat Res. 1971. 77:158-63. [Medline].

Frantz CH. Epiphyseal stapling: a comprehensive review. Clin Orthop Relat Res. 1971. 77:149-57. [Medline].

Fraser RK, Dickens DR, Cole WG. Medial physeal stapling for primary and secondary genu valgum in late childhood and adolescence. J Bone Joint Surg Br. 1995 Sep. 77(5):733-5. [Medline].

Mielke CH, Stevens PM. Hemiepiphyseal stapling for knee deformities in children younger than 10 years: a preliminary report. J Pediatr Orthop. 1996 Jul-Aug. 16(4):423-9. [Medline].

Stevens PM, Maguire M, Dales MD, Robins AJ. Physeal stapling for idiopathic genu valgum. J Pediatr Orthop. 1999 Sep-Oct. 19(5):645-9. [Medline].

Zuege RC, Kempken TG, Blount WP. Epiphyseal stapling for angular deformity at the knee. J Bone Joint Surg Am. 1979 Apr. 61(3):320-9. [Medline].

Métaizeau JP, Wong-Chung J, Bertrand H, Pasquier P. Percutaneous epiphysiodesis using transphyseal screws (PETS). J Pediatr Orthop. 1998 May-Jun. 18(3):363-9. [Medline].

Stevens PM. Guided growth for angular correction: a preliminary series using a tension band plate. J Pediatr Orthop. 2007 Apr-May. 27(3):253-9. [Medline].

Jelinek EM, Bittersohl B, Martiny F, Scharfstädt A, Krauspe R, Westhoff B. The 8-plate versus physeal stapling for temporary hemiepiphyseodesis correcting genu valgum and genu varum: a retrospective analysis of thirty five patients. Int Orthop. 2012 Mar. 36 (3):599-605. [Medline].

Böhm S, Krieg AH, Hefti F, Brunner R, Hasler CC, Gaston M. Growth guidance of angular lower limb deformities using a one-third two-hole tubular plate. J Child Orthop. 2013 Oct. 7 (4):289-94. [Medline].

Aslani H, Panjavy B, Bashy RH, Tabrizi A, Nazari B. The efficacy and complications of 2-hole 3.5 mm reconstruction plates and 4 mm noncanulated cancellous screws for temporary hemiepiphysiodesis around the knee. J Pediatr Orthop. 2014 Jun. 34 (4):462-6. [Medline].

Novais E, Stevens PM. Hypophosphatemic rickets: the role of hemiepiphysiodesis. J Pediatr Orthop. 2006 Mar-Apr. 26(2):238-44. [Medline].

Ballal MS, Bruce CE, Nayagam S. Correcting genu varum and genu valgum in children by guided growth: temporary hemiepiphysiodesis using tension band plates. J Bone Joint Surg Br. 2010 Feb. 92(2):273-6. [Medline].

Kulkarni RM, Ilyas Rushnaiwala FM, Kulkarni GS, Negandhi R, Kulkarni MG, Kulkarni SG. Correction of coronal plane deformities around the knee using a tension band plate in children younger than 10 years. Indian J Orthop. 2015 Mar-Apr. 49 (2):208-18. [Medline]. [Full Text].

Peter M Stevens, MD Professor, Director of Pediatric Orthopedic Fellowship Program, Department of Orthopedics, University of Utah School of Medicine

Peter M Stevens, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Pediatric Orthopaedic Society of North America

Disclosure: Received royalty from Orthofix Inc for independent contractor; Received royalty from Orthopediatrics, Inc for independent contractor; Received honoraria from Orthopediatrics, Inc for speaking and teaching. for: Orthodox, Orthopediatrics.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Professor of Orthopedic Surgery, Baylor College of Medicine as Co-Director, Combined Baylor College of Medicine-The San Antonio Orthopaedic Group, Texas Sports Medicine Fellowship; Medical Director, Burkhart Research Institute for Orthopaedics (BRIO) of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Herodicus Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; MTF; Aesculap; The Foundry, Cotera; ABMT; Conmed; <br/>Received research grant from: Histogenics; Cotera; Arthrex.

Jeffrey D Thomson, MD Professor of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Connecticut Children’s Medical Center; Vice President of Medical Staff, Connecticut Children’s Medical Center

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pediatric Orthopaedic Society of North America, Scoliosis Research Society

Disclosure: Nothing to disclose.

Pediatric Genu Varum

Research & References of Pediatric Genu Varum|A&C Accounting And Tax Services
Source


Leave a Reply