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PRESENTER: DR. MURUGESH M KURANI
Dept. of Orthopaedics, J N Medical College,
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°♂)
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.
Deformity is usually gauged from simple
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.
May be seen in one knee or both knees
• Blount’s disease/ Mau-Nilsonne Syndrome
• Lateral ligament laxity
• Congenital pseudoarthrosis of tibia
• Coxa vara
• Due to growth abnormalities of upper tibial
• Infections like osteomyelitis, etc.
• Trauma near the growth epiphysis of femur.
• Tumors affecting the lower end of femur and
upper end of tibia.
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
Other causes include:
• Fracture of the lower part of the femur or the upper part of
the tibia with malunion.
• Rarefying diseases of the bone such as rickets or
• Other bone-softening diseases such as Paget’s disease.
In ligamentous laxity note lat.Widening
Of knee joints
In Blount angulation at med.tib
In coxa vara ,angulation at the neck shaft
In cong. Pseudarthrosis of tibia,the
angulation is in the distal ⅓
PERSISTENT GENU VARUM
About 3 years old + bow legs + mild lateral
thrust at the knees + in-toeing
Patients with tibia vara are often obese,
exceeding the 95th percentile for weight.
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.
• In response to this, secondary deformities
develop in the tibia and the foot.
• Patient complains of pain during walking,
• Limp may be present.
• Difficulty in carrying activities of daily living.
• Difficulty in using the Indian toilets.
• Difficulty in squatting on the ground etc…
Physiologic genu varum nearly always
spontaneously corrects itself as the child
This usually occurs by the age of 3 to 4 years.
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.
The treatment of Blount disease depends on
the age of the child and the severity of the
Generally, observation or a trial of bracing is
indicated for children between ages 2 and 5
years, but progressive deformity usually
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
• If the deformity is severe enough, then
surgery to correct the remaining bowing may
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
• Tibial osteotomy. In this procedure, the shinbone
is cut just below the knee and reshaped to
correct the alignment.
• 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
Commonly called “knock-knee”
Knees are deviated towards midline of the
body and touch one another when the legs
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
Intermalleolar distance should be <8 cm.
The deformity often get corrected naturally as
However, the condition may continue or
worsen with age, particularly when it is the
result of a disease, such as rickets or
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
The degree of genu valgum can be estimated
by the Q angle.
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
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
For persistent genu valgum, treatment
recommendations have included a wide array
of options, ranging from lifestyle restriction ,
bracing, exercise programs, and physical
In recalcitrant cases, if valgus malalignment of
the extremity is significant, corrective
osteotomy or, in the skeletally immature
patient, hemiepiphysiodesis may be indicated.
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.
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.
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
Over the next 1-2
years this will result in
redirected growth that
can lead to
straightening of the
Bone stapples can be
left in permanently
once the goal is
achieved and the legs
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.
It can done as medial close wedge osteotomy
or lateral open wedge osteotomy.
Gross deformities can be corrected in a single
However, this is a very invasive method fraught
with potential complications, including
• delayed healing,
• neurovascular compromise, and
• compartment syndrome.
• Popliteus muscle weakness
• Connective tissue disorders. In these
disorders, there are excessive joint mobility
(joint hypermobility) problems. These
– Marfan syndrome
– Ehlers- Danlos syndrome
– Beningn Hypermobile joint syndrome
– Osteogenesis imperfecta disease
Other causes of recurvatum are,
Growth plate injuries and malunited fractures.
These can be safely corrected by osteotomy.
• Limitation of knee flexion from mild to severe.
• Effusion and other evidence of knee abnormality are
• 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
• Other features include; it is usually bilateral, common
in identical twins, more common in females, and
extremely resistant to conservative treatment.
POST-INJECTION CONTRACTURES IN
• Repeated injections and infusions into the
thigh muscles soon after birth.
• Dimples present in the skin at the sites of
• Common in twins and prematurity (because
they often make injections necessary and in
infants anterior thigh is commonly the
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.
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.
PRINCIPLES FOR SUCCESSFUL OPERATIONS
ON THE SOFT TISSUES FOR GENU
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
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