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A Classic Approach in the Evaluation and Resolving Pediatric Lower Limb Angular Deformity: Educational Corner

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A Classic Approach in the Evaluation and Resolving Pediatric Lower Limb Angular Deformity: Educational Corner J Orthop Spine Trauma. 2019 December; 5(4): 92-8. DOI: http://dx.doi.org/10.18502/jost.v5i4.4378 Educational Corner A Classic Approach in the Evaluation and Resolving Pediatric Lower Limb Angular Deformity: Educational Corner Philippe Violas 1, Amir Heydari2, Alireza Moharrami2, Mohammad Hossein Nabian 3,* 1 Professor, Pediatric Orthopedic Service, Central Hospital University of Rennes, 35000 Rennes, France 2 Resident, Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran 3 Assistant Professor, Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran *Corresponding author: Mohammad Hossein Nabian; Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran. Tel: +98-2161192767, Email: [email protected] Received: 02 September 2019; Revised: 23 November 2019; Accepted: 10 December 2019 Keywords: Genu Varum; Genu Varus; Pediatric; Growth Plate Citation: Violas P, Heydari A, Moharrami A, Nabian MH. A Classic Approach in the Evaluation and Resolving Pediatric Lower Limb Angular Deformity: Educational Corner. J Orthop Spine Trauma 2019; 5(4): 92-8. Background Case Presentation A 12 years-old girl presented with bilateral idiopathic Most pediatric knee angular deformities are genuvalgum who denied any comorbidities and past physiologic which are resolved spontaneously without medical history was examined in this study. We considered surgical intervention (1). However, these deformities are a her knee deformity as a pathologic genu valgus because of common finding and, in some cases, need to be addressed 9° valgus and her age was more than 7 years. In additional with some interventions such as bracing, growth assessments, it was confirmed that there was no metabolic modulation, and corrective osteotomy. There are some disorder and dysplasia. On a full standing alignment view reasons why we should address angular deformities, radiography, MAD was on zone +2 (0-25 percent) and the including unacceptable appearance, altered knee deformity was considered as a moderate genu valgus. Based biomechanics, gait disturbance, knee pain, and induced on the age, healthy physes and bilaterality of deformity, early osteoarthritis (2). hemiepiphyseodesis was performed and was followed with The goal of the surgical interventions is to restore 3 month intervals. After 18 months, the patient was normal lower limb mechanical axis and alignment as well examined with a 3-joint x-ray and all the lower limb as equal limb lengths and horizontal knees by skeletal deformities were resolved and MAD was in -1 zone maturity. Based on the age and skeletal maturity of the (50-75 percent) as a normal position. patients, there are different techniques for the correction Step one: Physiologic or Pathologic? of pathological angular deformities, such as growth A newborn or infant normally has varus knee or modulation and corrective osteotomy (3). Corrective bowlegs, and at months 6 to 12, the knee is in the highest osteotomies are often considered as the treatment choice grade of varus. At the 18 to 24 months of age, the knee has a in skeletally mature patients or in the older ages of neutral tibiofemoral angle (TFA) near zero (when the children when there is not enough time for growth infant begins to stand and walk). With growth, genu modulation. Another option is the growth modulation valgum (knock-knee) appears, and maximal valgus technique by manipulating normal bone growth patterns. deformity is around the age of 3-4 years with a mean TFA of Growth modulation by hemiepiphyseodesis was 12°. Continuously, the degree of genu valgum is decreased performed for pediatrics with a considerable amount of spontaneously by aging until seven years, and normal angular deformity in lower limbs (4-6). There are several degrees are 7 and 8 in the female and male gender, techniques and implants for lower limb respectively (1, 14) (Figure 1). hemiepiphysiodesis, including tension-band plate method (TBP), percutaneous transphyseal screw (PETS), 20 stapling, 8-plate, and 3-hole 3.5 mm reconstruction plate 15 (7-11). Previous studies revealed that growth modulation s had effective results in restoring lower limb normal Varu 10 5 alignment by all the implants with different complication rates which were favorable in terms of safety, cost, use of 0 Angle 1 2 3 4 5 6 7 8 9 10 11 12 13 hospital resources, speed of correction, and most -5 importantly, patient acceptance (3, 12, 13). -10 Therefore, in this educational corner, the aim is to -15 Valgus address the angular knee deformity in the coronal plane -20 in the pediatric population. To achieve this goal, the Age year) treatment methods and recent literature on lower limb angular deformity were reviewed step by step to achieve Figure 1. Normal development of the knee angular deformity the best decision. Copyright© 2019, Journal of Orthopedic and Spine Trauma. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited. http://jost.tums.ac.ir Violas et al.: Pediatric Knee Angular Deformity Treatment It is so important to be careful about the evaluation and diagnosis of angular deformity in pediatrics because there are different treatment methods based on the etiology and degree of deformity. The physiologic angular deformities often need no treatment except for observation and reassurance of the parents (3). A physiologic genu valgum has some features including, lack of symptoms, normal structure, symmetric deformities, and prevalence in ages between 2 and 5 years. Age at onset, stage of disease, condition of epiphyseal femoral head and extent of involvement, and the extrusion of the femoral head are the most important criteria considered to determine the prognosis of the disease and outcomes. The disease onset after the age of six, female gender, obesity, and hip joint stiffness, especially limited abduction, are associated with poor results (8, 9). The pathologic genu valgum is defined as a condition Figure 2. Mechanical axis deviation in the knee presented in the ages out of physiologic valgus (ages > 7 or < 2 years) in association with some conditions including As seen in figure 2, Tercier et al. divided the knee based on posttraumatic, systemic, and metabolic conditions, the Paley classification to zones from 0 to 100% laterally dysplasia, and neoplasms as seen in table 1 (15-17). relative to the medial knee (21). The zone between 50 and 75% However, some conditions can induce pathologic varus (negative side) is considered as the normal zone for the deformities such as metabolic disorders, dysplasia, mechanical axis. The aim of growth modulation is to deviate neoplasm, and previous trauma (Table 1). the mechanical axis to 50% or near zero zones of MAD. The A pathologic knee deformity needs further evaluation knee is in valgus deformity when MAD is in the positive zones such as history, radiological, and bone metabolic (0 to 50%); in these cases, a medial hemiepiphyseodesis is assessments. A full history examination should be performed performed and in varus deformities (MAD more than 75%) for the patients, including assessment of growth and patients undergoe a lateral hemiepiphyseodesis (22). development, progression, associated complaints (pain, The indication for intervention in this situation is limping), traumatic history, family history, onset, and deformities that are asymmetrical and associated with pain, previous treatments (18). All the patients with pathologic joint stiffness, systemic disorders, or syndromes that may knee deformities should undergoe a full standing lower limb indicate a serious underlying cause requiring treatment (3). radiography (3-joint or alignment view), anteroposterior (AP) Concerning idiopathic genu valgum after the age of eight and lateral knee x-ray, and mechanical angles must also be years old, correction of excessive physiologic (idiopathic) measured. The metabolic evaluations (19) such as calcium, genu valgum may be indicated when there is gait phosphorus, magnesium, vitamin D 25 OH, parathyroid disturbance, difficulty running, knee discomfort, patellar hormone (PTH), and thyroid hormones should be assessed in malalignment, evidence of ligamentous instability, or all patients with pathologic knee deformity. excessive cosmetic concern (23). Step Three: Location of Deformity Table 1. Skeletal affection presented as bowlegs and knocked-knee Evaluating the location of knee deformity needs a full Genu varum or bowlegs standing lower limb AP x-ray (3-joint) in order find the 1 Apparent genu varum 2 Physiologic genu varum mechanical axis of limb and measure the lateral distal 3 Congenital familial tibia vara femoral angle (LDFA) and mechanical femorotibial angle 4 Tibia vara (Blount’s disease) Asymmetric growth arrest of the medial part of the distal femur and (mFTA) (Figure 3). 5 proximal tibia due to infection, fracture, or tumor 6 Rickets-vitamin D deficiency or refractory (hypophosphatemia) 7 Bone dysplasia, such as achondroplasia and metaphyseal dysplasia 8 Fibrocartilaginous dysplasia (FCD) Congenital longitudinal deficiency of the tibia with relative overgrowth of 9 the fibula 10 Lead or fluoride intoxication Genu valgum ir knock-knee (15-17) 1 Physiologic valgus (most common) Posttraumatic (e.g., Cozen fracture, distal femoral physeal fracture,
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