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PubMedDate not supplied

Vitamin d deficiency in breast-fed toddlers.

SUMMARY: The evaluation of genu varum and intoeing in young toddlers is a frequent problem seen by the primary care physician and the orthopaedic surgeon. This report describes six nonwhite breast-fed toddlers with extreme genu varum. Clinical and radiographic findings were consistent with vitamin D-deficiency rickets. Within 3 to 6 months of the initiation of ergocalciferol treatment, reparative processes were evident on both radiographic and clinical examinations. Laboratory studies also showed underlying correction. With the current emphasis on the benefits of breast-feeding and the limitation of sunlight, this diagnosis must remain on the differential in the evaluation of genu varum.

Black or African American↗
PubMed1989

X-linked hypophosphatemia: a clinical, biochemical, and histopathologic assessment of morbidity in adults.

Research and management of XLH have concentrated on the disease in childhood, and the natural history and morbidity of XLH in adult life are thus poorly understood. We have studied 22 adults (6 men) with XLH to clarify these aspects of this most common inherited form of rickets and osteomalacia. Most study participants had presented with rickets in early childhood and had undergone tibial osteotomies on at least 1 occasion. Seventeen individuals had genu varum, 1 had genu valgum, and 4 had straight legs, attributable to successful osteotomies in 2. Five subjects reported increasing lower limb deformity in the late teens or subsequently. Eight subjects complained of bone pain, 6 of whom had radiologic evidence of pseudofractures; pseudofractures were found in 4 additional asymptomatic individuals. None of 16 subjects who underwent transiliac bone biopsy had normal double tetracycline labeling; accordingly, all were considered to have osteomalacia. Bone pain was associated with a relative osteoid volume in excess of 25%. Relative osteoid volume was inversely related to serum 1,25(OH)2D concentration (r = -0.74, p less than 0.02), but unrelated to serum concentrations of calcium and phosphate or their product. Eighteen participants complained of joint pain, predominantly in the knees and ankles. The severity of joint pain correlated with the degree of lower limb deformity (p = 0.011) which, in turn, was related to fasting serum phosphate concentration (r = -0.56, p less than 0.025) and TmP/GFR (r = -0.70, p less than 0.005). Enthesopathy affected 33% of those younger than 30 years, and all those above this age. Nineteen individuals had experienced significant dental problems, most commonly abscess formation. Eight had required complete dental clearance. Twelve women from the group had a total of 22 live births. Fifteen of these were by cesarean section, although radiologic evidence of pelvic narrowing was not found in any subject. Serum ALP was elevated in all but 3 of the 18 untreated subjects. Levels correlated with those of other indices of bone turnover (BGP r = 0.82, p less than 0.005; urine total HP r = 0.60, p less than 0.025; urine free HPr = 0.78, p less than 0.005), but were not related to the degree of osteomalacia found on bone biopsy. Serum levels of iPTH, 25(OH)D, 1,25(OH)2D, and thyroid hormones were generally normal in the untreated patients. We conclude that adults with untreated XLH have osteomalacia that is frequently symptomatic. Even greater morbidity is caused by degenerative joint disease arising from lower limb deformities.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMedDate not supplied

Focal fibrocartilaginous dysplasia of long bones: report of eight additional cases and literature review.

We report eight additional cases of focal fibrocartilaginous dysplasia (FFCD) in the proximal tibia (five), distal ulna (one), and distal femur (two). Spontaneous, complete resolution of the lesion was observed in two tibiae and one ulna. Three tibial lesions with genu varum deformity were managed with osteotomy. Two femoral FFCDs caused persistent or progressive deformity: one genu valgum with patellar dislocation, and one genu varum. These patients underwent concomitant deformity correction and lengthening by the Ilizarov method. The final results were satisfactory in all patients except one, who underwent valgus tibial osteotomy and developed mild postoperative genu valgum. The analysis of a total of 46 cases in the literature and our experience suggests that (a) FFCD has a wide histopathologic spectrum, ranging from purely dense, fibrous tendon-like tissue to benign fibrocartilaginous tissue; (b) at least 45% of tibial FFCD demonstrates progressive, spontaneous resolution; (c) in contrast, femoral and humeral FFCDs appear to have a slim possibility of spontaneous regression of the deformity; and (d) corrective osteotomy is indicated when the deformity is increasing or persistent, or when the existing deformity is severe enough to jeopardize adjacent joint mechanics and alignment.

Cartilage Diseases↗
PubMed2005

[Proximal tibial valgus osteotomy with callus distraction].

OBJECTIVE: Correction of genu varum and unloading of the medial compartment using a proximal osteotomy, callus distraction. INDICATIONS: Symptomatic genu varum due to post-medial-meniscectomy syndrome, medial compartment osteoarthritis, articular cartilage lesions of medial compartment, avascular necrosis of medial femoral condyle, osteoarthritis dissecans of medial femoral condyle, posterolateral and/or anteromedial rotatory instability. CONTRAINDICATIONS: Advanced articular cartilage lesions of lateral compartment. Advanced osteoarthritis of patellofemoral compartment. Extension lag > 10 degrees. Patients > 60 years with low physical demands. SURGICAL TECHNIQUE: Installation of an external fixator under image intensification as close to the joint as possible. Skin incision medial to the tibial tuberosity. Osteotomy between proximal fixator screw and tibial tuberosity leaving the lateral cortex intact. Control of desired distraction under image intensification. Closure of distraction gap. POSTOPERATIVE MANAGEMENT: Start of distraction (1 mm/day) on day 5. Radiographs on day 5-7, after 6 weeks, and after 8-10 weeks. Removal of only the fixator rods once desired correction has been reached and sufficient callus has formed. If correction is maintained after full weight bearing, removal of screws. RESULTS: Between 1998 and 2000, 34 callus distractions were done in 24 patients (six women, 18 men, age 24-64 years). Follow-up of 21 patients after an average of 23 months (6-36 months). Exclusion of one patient after total knee replacement. Pre- and postoperative femorotibial angle 179 degrees (172-183 degrees) and 185 degrees (179-191 degrees), respectively. Median correction was 6 degrees (3-12 degrees). 20 patients would accept the procedure again. Using the score developed by the authors, improvement from 15 points preoperatively to 10 points postoperatively. Complications in 15 corrections, eight of these needing a surgical revision.

Adult↗
PubMed2004

Control of frontal plane knee laxity during gait in patients with medial compartment knee osteoarthritis.

OBJECTIVE: Patients with medial compartment knee osteoarthritis (OA) adopt an abnormal gait pattern, and often develop frontal plane laxity at the knee. The purpose of this study was to quantify the extent of frontal plane knee joint laxity in patients with medial knee OA and genu varum and to assess the effect of joint laxity on knee joint kinetics, kinematics and muscle activity during gait. DESIGN: Twelve subjects with genu varum and medial compartment knee osteoarthritis (OA group) and 12 age-matched uninjured subjects underwent stress radiography to determine the presence and magnitude of frontal plane laxity. All subjects also went through gait analysis with surface electromyography of the medial and lateral quadriceps, hamstrings, and gastrocnemius to calculate knee joint kinematics and kinetics and co-contraction levels during gait. RESULTS: The OA group showed significantly greater knee instability (P = 0.002), medial joint laxity (P = 0.001), greater medial quadriceps-medial gastrocnemius (VMMG) co-contraction (P = 0.043), and greater knee adduction moments (P = 0.019) than the control group. Medial joint laxity contributed significantly to the variance in both VMMG and the knee adduction moment during early stance. CONCLUSION: The presence of medial laxity in patients with knee OA is likely contributing to the altered gait patterns observed in those with medial knee OA. Greater medial co-contraction and knee adduction moments bodes poorly for the long-term integrity of the articular cartilage, suggesting that medial joint laxity should be a focus of interventions aimed at slowing the progression of disease in individuals with medial compartment knee OA.

Adult↗
PubMed2004

Drop foot after high tibial osteotomy: a prospective study of aetiological factors.

Drop foot is not uncommon after high tibial osteotomy for genu varum. The authors report their results of a prospective study of 16 patients operated on between May 1990 and May 1991. All patients had medial femoro-tibial osteoarthritis with a constitutional genu varum. They all had a subtraction valgus high tibial osteotomy fixed by a blade plate. The experimental protocol included clinical review, antero-lateral compartment pressure measurements, intra- and post-operative electromyography, assessment of the post-operative drainage, serum estimation of muscle enzymes and post-operative arteriography. From their own results and a literature review, the authors consider successively the different aetiological factors for post-operative drop foot. Certain deficits occur due to direct trauma on the nerve during high osteotomy of the fibula, by local high pressure due to poor haemostasis or ineffective drainage. In addition, there are several related phenomena. The pneumatic tourniquet sensitises the nerve to trauma, and stretching of the nerve during correction of the deformation depends on the local anatomical factors and their marked variation. In order to diminish the frequency of these post-operative complications, the authors suggest limiting the surgical approach, and limiting as far as possible the traumatic manoeuvres on the nerve by using a tibial resection jig, which allows correction without forced manoeuvres. Finally, the authors discuss the benefits of using a pneumatic tourniquet.

Action Potentials↗
PubMedDate not supplied

Orthotic treatment of infantile tibia vara.

Difficulty differentiating physiologic genu varum from early Blount's disease persists. Drennan's metaphyseal-diaphyseal (MD) angle remains the most consistently valuable radiographic parameter despite measurement error. Clinical risk factors also should be considered. All patients receiving orthoses for genu varum since 1985 were reviewed. The focus of the study was those patients with an MD angle of >16 degrees or between 9 and 16 degrees with a clinical risk factor for progression. Risk factors considered were ligamentous instability, obesity, asymmetry, and being female, black, or Hispanic. Thirty-eight patients with 60 tibiae were included. The success rate was 90%. Risk factors for failure (six cases) were instability, obesity, and delayed bracing. In cases with MD angles >16 degrees, the success rate was 86%. The results of orthotic treatment, restricted to patients meeting the stated parameters, represent improvement on the reported natural history.

Body Weight↗
PubMed2006

Femoral deformity in tibia vara.

BACKGROUND: Previous studies have suggested that compensatory valgus deformity of the femur is common in patients with tibia vara, or Blount disease. The availability and routine use of standing long-cassette radiographs of the lower extremities to assess angular deformities has allowed quantitative evaluation of this hypothesis. METHODS: The cases of all patients with tibia vara, two years of age or older, seen at our institution prior to treatment, over a thirteen-year period, were reviewed. Seventy-three patients with a total of 109 involved lower limbs were identified and were classified as having either infantile tibia vara (thirty-seven patients with fifty-six involved limbs) or late-onset tibia vara (thirty-six patients with fifty-three involved limbs). Standardized standing radiographs of the lower extremity were examined to assess the deformity at the distal part of the femur and the proximal part of the tibia by measuring the lateral distal femoral angle and the medial proximal tibial angle. RESULTS: The distal part of the femur in the children with infantile tibia vara either was normal or had mild varus deformity, with a mean lateral distal femoral angle of 97 degrees (range, 82 degrees to 129 degrees). The mean medial proximal tibial angle in these children was 72 degrees (range, 32 degrees to 84 degrees). Older children with infantile tibia vara were noted to have little distal femoral deformity, with no more than 4 degrees of valgus compared with either normal values or the contralateral, normal limb. Children with late-onset tibia vara had a mean lateral distal femoral angle of 93 degrees (range, 82 degrees to 110 degrees) and a mean medial proximal tibial angle of 73 degrees (range, 52 degrees to 84 degrees). On the average, the varus deformity of the distal part of the femur constituted 30% (6 degrees of 20 degrees) of the genu varum deformity in these patients. CONCLUSIONS: Patients with infantile tibia vara most commonly had normal alignment of the distal parts of the femora; substantial valgus deformity was not observed. Distal femoral varus constituted a substantial portion of the genu varum in children with late-onset disease. When correction of late-onset tibia vara is planned, the surgeon should be aware of the possibility that distal femoral varus is a substantial component of the deformity.

Adolescent↗
PubMed1997

Five additional cases of local fibrocartilaginous dysplasia.

Focal fibrocartilaginous dysplasia has previously been described as an etiology of genu varum deformity in children at about walking age. We have found 20 cases in the literature, and all of them were located in the medial proximal tibial metaphysis. We report five additional cases of this entity. The patients had a genu varum deformity, and the angulation was at the site of the bone lesion. Four cases were in the tibia, and one case was in the distal medial femoral metaphysis. Age at diagnosis ranged from 13 to 24 months. A cortical defect with surrounding sclerosis was observed on radiographs. The angulation usually progressed initially, and spontaneous resolution was observed in two cases at last follow-up. Open biopsy and tibial valgus osteotomy were performed in two cases. The unusual femoral case was also treated with open biopsy and medial hemicircumferential periosteal release. Spontaneous remodeling of varus angulation and resolution of bony defect may be expected in most cases, and osteotomy can be avoided.

Cartilage Diseases↗
PubMed1986

[Stapling using Blount's technic in idiopathic frontal deviations of the lower limbs in children].

Growth plate stapling using Blount's technique is still under discussion in its application to adolescent's lower limbs axial deformities. To establish its validity, we present a review of 18 stapling cases, 15 for valgus knees and 3 for genu varum. Mean follow up is 5 years 9 months. We analyse chronological age, bone age, clinical measurements, standing X-rays, as well as the site, time of insertion and removal of staples in these children all with symetrical involvement. Full correction of genu valgum is obtained in 30% of cases, partial correction in 30%, but varus deformity is never completely corrected. Undercorrection is as frequent as overcorrection, valgus being twice converted to significant varus. Immediate complications are few and benign, but long term sequellae of various consequence numerous. We think that this technique should be abandoned for genu varum. results when applied to valgus knees are unpredictable due to the inaccuracy of estimation of bone age and remaining growth potential, rendering impossible the exact timing of staples insertion and removal, need to avoid either definitive epiphysiodesis or deformity recurrence through rebound effect.

Child↗
PubMed1985

[Transplantation of the anterior tibial tubercle by the Elmslie-Trillat technic. Indications as a function of morphotype].

The authors note that medial transplantation of the tibial tubercle diminishes the control of lateral rotation of the tibia by the quadriceps and increases stresses on the knee in varus. They have reviewed a hundred knees operated on between 1973 and 1981. Before operation, the morphology of the patients compared with a normal population was characterised by a moderate medial torsion of the femur, a marked lateral torsion of the tibia and some genu varum. After the transplant the varus was identical but in about half of the cases, lateral laxity was noted. Passive rotation of the tibia was increased and this sign was even greater in cases of marked tibial torsion. The authors conclude that this procedure is not indicated in cases of genu varum, excessive lateral tibial torsion and lateral laxity. The best indications are cases of recurrent dislocation of the patella in knees with normal rotary alignment and painful patello-femoral syndromes. They emphasise the importance of an extensive release of the lateral patellar retinaculum, of distal transplantation of the tubercle in cases of patella alta but not too much and of some degree of anterior displacement of the tubercle.

Adolescent↗
PubMed1992

[Arthroscopic meniscectomy. Comparison of the functional results of meniscectomy in patients above and under 45 years of age. Apropos of 107 cases].

A comparative retrospective study of 107 cases of arthroscopic meniscectomies performed between December 1985 and December 1988 on 52 operated patients under 45 (P1 = 54 knees) and 52 operated patients over 45 (P2 = 53 knees). Those two populations have been selected among 292 isolated meniscal lesions files (without anterior cruciate ligament tear) operated for arthroscopic meniscectomy between 1985 and 1988. There were 81 medial meniscus lesions, 16 lateral meniscus lesions and 10 bi-meniscal lesions. The follow-up was for 1 to 5 years with a score of 70.3 per cent functional satisfactory results for the above 45 years (P2) and a score of 89.4 per cent below 45 (P1). Regarding the medial meniscus lesions only, we count 76 per cent (P2) satisfactory results versus 87.5 per cent (P1). This assessment can be easily explained by the variety of meniscal lesions (8 degenerative meniscal lesions among P2 namely 15 per cent), by associated cartilage lesions of the medial compartment of the knee (medial condyle: P2 = 37.75 per cent, medial tibial plateau: P2 = 41.5 per cent) and by genu varum deformity. However, in spite of this significant statistical difference (alpha < 0.05), we don't think we should condemn the arthroscopic meniscectomy over 45: the morbidity is very low and if some patients were not cured, the majority of them said that they improved after the operation. The cartilaginous degenerations of the medial compartment, discovered during arthroscopy, in a context of genu varum, don't need any tibial osteotomy at first, especially if they are asymptomatic and without tibia varum.

Adult↗
PubMed1977

Non-rachitic deformities of the knees in Nigerian children.

Non-rachitic lesions of the knee are a common condition found in Nigerian children, the aetiology of which is unknown. 67 patients were studied, 24 had genu valgum, 28 genu varum and 15 with varo-valgum. Possible aetiology has been discussed and the following hypotheses have been put forward. The early weight bearing of the immature bones of the lower limbs has uneven pressure effects on the growth plate and also the laxity of the knee ligaments produces abnormal posture. The abnormal posture during growth and pressure effect of a tight band around the knee when the child is carried on the back predisposes to genu varum and valgum. Dietetic abnormalities may also be one of the factors but these have not been elucidated. Lastly, the tendency of the condition to occur in the African race raises the possibility of genetic factors.

Adolescent↗
PubMed1992

Proximal tibial valgus osteotomy for hemophilic arthropathy of the knee.

Between 1975 and 1985, 14 hemophilic patients with symptomatic genu varum were treated with proximal valgus osteotomies of the proximal tibia; lateral closing wedge tibial osteotomies were carried out; associated fibular osteotomies were not performed, but the proximal tibiofibular syndesmosis was excised in all cases. The mean age of the patients was 32 years, and the average length of follow-up was 6.5 years. Clinical evaluation was undertaken using a modification of the Hospital for Special Surgery Knee Rating Score. Eleven patients (78.5%) had improvements in their postoperative scores, and three patients (21.5%) deteriorated. Postoperative pain decreased in patients who had successful results with no evidence of deterioration over time. There was one case of superficial wound infection, which cleared after the administration of intravenous antibiotics. We conclude that our simplified technique for proximal tibial valgus osteotomy is an effective and reliable treatment method for painful genu varum of the hemophilic knee.

Adult↗
PubMedDate not supplied

Hemiepiphyseal stapling for knee deformities in children younger than 10 years: a preliminary report.

Epiphyseal stapling, which is the only reversible method of growth alteration, has traditionally been reserved for teenagers. We are reporting the application of hemiepiphyseal stapling in a series of 25 children younger than 10 years. With a variety of underlying diagnoses, three children had genu varum and 22 had genu valgum. The technique involved fluoroscopic localization of all growth plates and careful preservation of the periosteum while inserting (and subsequently removing) one or two staples per physis. The mean age at stapling was 6 years + 4 months. Follow-up averaged 3 years + 3 months. The anatomic (tibiofemoral) angle and mechanical axis improved in all patients. One staple broke on removal; there were no other hardware failures. We conclude that hemiepiphyseal stapling is a safe and effective treatment for children younger than 10 years who have angular deformities of the knee. No growth-plate arrests have occurred. In the event of recurrent deformity, stapling may be repeated.

Bone Diseases, Developmental↗
PubMed2006

[Accuracy of total knee replacement bone cuts using a conventional ancillary system: 300 Innex total knee arthroplasties].

PURPOSE OF THE STUDY: Short-term functional results and long-term outcome in terms of stability and wear greatly depend on the precision of the bone cuts. We wanted to know whether conventional ancillaries are still competitive in terms of accuracy in comparison with computer-assisted navigation systems. A few comparative studies favor navigation, but have generally only included a small number of patients. We studied radiographically a prospective consecutive series of 300 total knee prostheses (Innex, Zimmer) implanted with the conventional technique by the same operator. MATERIAL AND METHODS: A telegonometric view in the upright position and a short lateral view were obtained in all patients. In the AP view, implants were measured in comparison with the mechanical axis of the femur (F) and the tibia (T). On the lateral view, the prosthesis-tibial shaft angle (PT) was measured from the proximal portion of the tibial shaft and the prosthesis-femoral shaft angle (PF) from the distal portion of the femur. The same operator made all measurements using the same optimal conditions. The series included 178 women and 122 men, mean age 72 +/- 8 years who presented genu varum (n = 248 knees) and genu valgum (n = 52 knees): degenerative disease (n = 238), polyarthritis (n = 4), hemophilic arthropathy (n = 3), necrosis (n = 3), revision of unicompartmental prosthesis (n = 8), and osteotomy (n = 44). RESULTS: The standard x-ray protocol was performed at two months in all patients. The mechanical axis (HKA) was 179.4 +/- 2.4 degrees (range 173-186 degrees) and was +/- 3 degrees in 87% of knees with no difference for varum and valgum. F was 90.1 +/- 1.4 degrees (87-95), with +/- 3 degrees for 98.7%. T was 89.3 +/- 1.5 degrees (85-94) with +/- 3 degrees for 95.6%. PF was 88.6 +/- 1.6 degrees (84-93) for 87%, PT was 87 +/- 2 degrees (81-93) with +/- 3 degrees for 94%. The four cuts were within +/- 3 degrees for 227 prostheses (77%), within +/- 2 degrees for 156 (52%) and within +/- 1 degrees for 56 (18%). Measurements made again one year after implantation for 203 knees gave the same results. Operative time for implantation was 68 +/- 23 minutes for implantation and 85 +/- 23 minutes including complete closure (less than 60 minutes for 68 knees). DISCUSSION: The accuracy of each cut was satisfactory on average with a small standard deviation. Recent data in the literature show that the accuracy in our series is comparable with that obtained currently with navigation systems. In light of this experience, it can be seen that better precision can be achieved for each of the cuts. CONCLUSION: The accuracy of conventional instrumentation systems is still comparable with that obtained with computer-assisted surgery. The purpose of this study was not to question the benefit of navigation, but to establish a basis upon which progress can be measured. The results enabled a more realistic comparison of the precision of navigation systems and also can be comforting for operators still using conventional ancillaries.

Adult↗
PubMed1990

[Arthroscopic findings of the rheumatoid knee mode of cartilage changes and synovial proliferation in contrast to plain X-ray findings].

To establish a more objective evaluation of the arthroscopic findings in knees affected by rheumatoid arthritis (RA), the degrees of synovial proliferation and cartilage change were classified semiquantitatively. In 73 knees out of 41 cases with RA, the joint surface was divided into 6 regions. The cartilage changes and synovial proliferation at each region was classified into 5 ranks. Plain X-ray findings were evaluated by Larsen's grading system. The cartilage changes found by arthroscopy were more advanced than expected from the radiographical findings. Also, plain radiographical films did not accurately show the degree of synovial proliferation. In cases with Larsen grade III or below, the lateral compartment of the knee, in particular, the lateral meniscus often demonstrated advanced cartilage changes. In cases with Larsen grade IV or above, cartilage loss was uniformly noted in all 6 regions. Advanced cartilage changes were found mostly medially in knees with genu varum and laterally in knees with genu valgum, and were related to the femoro-tibial angle. Advanced synovial proliferation was mostly seen in the lateral gutter regions and the periphery of the menisci regardless of alignment.

Adult↗
PubMed1992

[Lateral approach of the knee with tibial tubercle osteotomy for prosthetic surgery].

The authors describe a lateral approach to the knee associated with a tibial tubercle osteotomy and a plasty using the fat pad to provide a complete closure of the wound. This lateral approach has been performed successfully in 98 cases, with only 3 skin necrosis. It offers a large exposure of the joint, facilitates placement of tibial component trial fit, and allows the self centering of the quadriceps patellar-tendon mechanism at the end of the intervention. The lateral approach disputable in case of genu varum is recommended in all cases of genu valgum or important deformities.

Humans↗