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This study analyzes mathematically the orientation of the superior tibial epiphysis in frontal and sagittal planes for knees with genu varum arthrosis. The assessment of the opening is determined mathematically for the osteotomies; this leads to the establishment of tables which can be used in practise during upper tibial osteotomies.
The authors describe a modification of the original technique of Blaimont and Maquet. Cylindrical osteotomy allows correction of deformity in the frontal plane (genu varum or valgum) with forward displacement of the tibial tuberosity. The technique and instruments are described. The osteotomy is fixed by screws and joint mobilisation is begun after two weeks. Thirty patients have been operated on. The results are described as satisfactory.
Thirteen tibiae and seven femora suffering from bowing due to Paget's disease have been streightened operatively. In the tibiae, the deformities were of metaphysial genu varum with bowing in the sagittal plane of an average of 30 degrees combined with some medial rotation. In the femora, the main curve was anterolateral with some medial rotation and coxa vara. Seventeen cases united uneventfully after osteotomy. In three cases, there were septic complications, union occurred after removal of the internal fixation. Bowing recurred in three cases. The recurrence appeared to be related to incomplete correction leading to persistent mechanical strain on bones affected by rapid bone turnover. Inadequate internal fixation may also be a factor. All other cases were functionally improved by correction. Oblique osteotomy is indicated for the correction of tibial deformity when there is moderate medial rotation. Transverse osteotomy with fixation by intramedullary nailing is indicated for correction of femoral deformities.
In this report we describe different forms of clinical presentation of an autosomal dominant hypophosphatemic rickets (ADHR) in 4 members of the same family as well as the treatment used in these patients and their response to it. Patient No 1: a 60 year old female who consulted for bone pain: Bone densitometry showed osteoporosis. Laboratory assays showed hypophosphatemia with low renal phosphate threshold, high total alkaline phosphatase, normal intact PTH and normal serum calcium. With neutral phosphate and calcitriol, the biochemical parameters normalized and bone densitometry improved significantly in less than a year. Patient No 2 her grand daughter consulted at 1 year and 8 months of age for growth retardation (height at percentile 3) and genu varum. Laboratory assays showed low serum phosphate and high total alkaline phosphatase; thickening and irregular epiphyseal borders of the wrists were observed radiologically. She began treatment with calcitriol and phosphorus with normalization of laboratory parameters and increase in growth (height increasing to percentile 50 after 20 months of therapy). Patient No 3: mother of patient No 2, she had no clinical manifestations and normal densitometry but presented low serum phosphate (1.9 mg/dl) that normalized with neutral phosphate therapy. Patient No 4: he was the youngest son of Patient No 1, who had had hypophosphatemic rickets, by age 5; his serum phosphate normalized without treatment At age 29, he presented normal serum phosphate and bone densitometry. Genomic DNA analysis performed in patient No 3, showed missense mutation with substitution of arginine at position 179 for glutamine. The family was catalogued as having autosomal dominant hypophosphatemic rickets/osteomalacia.
Three cases are reported of spontaneous fracture of the tibia complicating osteoarthritis of the knee with genu varum. These fractures, which are very rare, with only eight cases published in the literature, seem to be associated with severe osteoarthritis in small, obese women. They usually progress to union with simple relief from weight-bearing but non-union may develop which makes the treatment of the causative osteoarthritis more difficult. A review of the published cases helped the indications for treatment to be defined.
Infantile tibia vara is a developmental condition producing progressive varus deformity of the knee in young children. It appears to have a worse prognosis in the predominantly nonwhite population seen with this condition in the United States than previous studies from Scandinavia would suggest. Early roentgenographic diagnosis is critical, since toddlers can have infantile tibia vara at an early stage instead of physiologic genu varum. Aggressive bracing is appropriate treatment until age three years. Correction to valgus alignment with upper tibial osteotomy predictably can produce complete resolution of the condition if performed by age four years. After that age, the procedure becomes less effective. Prognosis for Langenskiold Grade IV disease is guarded at best, regardless of age, because the physis behaves as if effective growth arrest has already occurred. Young patients with Grade IV or greater lesions should have corrective osteotomy combined with a physeal procedure to attempt restoration of growth in the medial physis. Early effective treatment can prevent permanent intraarticular incongruity.
A 73-year-old woman with genu varum developed sequential stress fractures of the proximal tibia over a period of 8 months. On presentation, the patient was walking unaided; this highlights the importance of radiological review of patients with degenerative arthritis who complain of inappropriate symptoms.
Arthrosis following rupture of the anterior cruciate ligament has been analysed in two series. The first series was derived from a review of 150 cases of reconstruction of the anterior cruciate ligament with a follow-up of 3 years or more. Arthrosis was seen to have developed in 13.3%. The second series was concerned with 64 cases of unilateral arthrosis treated by upper tibial valgus osteotomy in whom there had been a previous rupture of the anterior cruciate ligament. The "tolerance time"--that is the time between the original ligamentous injury and the time of osteotomy--for the development of arthrosis was very variable, ranging in cases with a "natural history" from 10 to 50 years with a mean of 35 years. It is important to recognise the radiological signs of the onset of arthrosis. These are osteophytosis of the intercondylar notch, osteophyte formation at the posterior part of the medial tibial plateau, and, in particular, narrowing of the medial joint line with posterior subluxation of the medial femoral condyle, well seen in lateral radiographs whilst standing on one lower limb. Early arthroses, appearing after 10 years, may occur as a "natural arthrosis", but it develops much more frequently after surgical treatment that had failed to correct anterior laxity and particularly when it had been performed on knees that were already pre-arthrotic. The main factor in arthrosis is anterior laxity measured radiologically by an "active Lachman" radiograph. Removal of the medial meniscus, which, in itself, is liable to produce arthrosis is even more harmful in anterior cruciate laxity since it doubles the degree of anterior subluxation of the tibia seen on unilateral weight-bearing. The development of varus deformity, which characterises progressive arthrosis, has its origin in wear of the posterior part of the medial tibial plateau caused by anterior cruciate laxity. Other factors play an important part such as associated lateral laxity, constitutional genu varum and weakness of the hamstring muscles which oppose the subluxating action of the quadriceps.
The authors carried out a study of contrast arthrography in 48 cases of primary genu varum, i.e. not secondary to trauma or to pathological conditions of the hip or foot. The patients all had symptoms and were classified according to the commonly used Trillat-Dejour method into four groups or stages depending on the degree of varus and the radiographic and arthrographic findings. Associated lesions secondary to the basic pathology were observed in all cases. These ranged from hypertrophic synovitis to torn medial or lateral menisci up to total compromise of the joint typical of stage 4 arthritic varus knee. In these patients, contrast arthrography is useful in planning surgery, particularly high tibial osteotomy. It also enables the surgeon to decide whether complementary intra-articular measures are indicated without having to resort to arthroscopy. This is always a more invasive method, necessitating general anaesthesia, as these knees are quite painful and the arthroscopic access is difficult.
In the C57 Black, STR/IN and MAGf strains of mice, which are prone to develop spontaneous osteo-arthritis of the knee, histomorphological examinations were made of the osseous parts of the joint. It was found that the number of animals with osteo-arthritis and with degenerative changes in the epiphyseal growth zone increases with age. There is nevertheless evidently no interrelation between the two phenomena. The same applies to the occurrence of osteoporosis and degenerative joint disease, since male C57 Black mice, for example, develop osteo-arthritis of the knee relatively often, but develop osteoporosis much more rarely, while the opposite is observed in the females. Moreover, among the juvenile joint degenerations in the STR/IN and MAGf strains, a high percentage of osteo-arthritis of the knee is found, but only a few instances of osteoporosis. The majority of the (relatively rare) idiopathic condylar necroses coincide with osteo-arthritis of the knee, but not vice versa. The development of osteosclerosis and degenerative cartilaginous defects is mostly (possibly always) a sequela and not the cause of osteo-arthritis of the knee. Malpositions are often associated with the development of osteo-arthritis of the knee. The C57 Black strain exhibits a certain tendency to develop genu valgum, and the STR/IN strain almost regularly shows genu varum; no distinct tendency is detectable in MAGf mice. Like the osteophytes, the enlarged menisci with obligatory ossification centres invariably seen in conjunction with osteoarthritis apparently help to compensate for the condylar incongruence caused by the degenerative process, prevent partial dislocations, and hence improve the stability of the joint.
The specific shape of the long bones is due to a more or less regular increase in length at the level of the epiphyseal plate (Pauwels 1958). This theory assumes, that the epiphyseal cartilage reacts to the local magnitude of stresses. The amount of bone formation is supposed to be proportional to the stress magnitudes. The bone grows straight in the direction of its axis, if the stresses are distributed evenly over the cross-section; but if the stresses increase toward one border of the epiphyseal plate, the bone formation will be stimulated more intensively at this side and consequently the axis of the bone will be bent to the opposite side. By this mechanism, the epiphyseal plate becomes oriented at a right angle to the direction of the stressing force. Pauwels (1958) explains the reorientation of the articular extremities in bones with fractures, consolidated in an angular position by the described reaction. The same reaction is responsible for the formation of the juvenile genu valgum. The genu varum and the so-called coxa vara congenita on the other hand are due to overloading of the epiphyseal cartilage. The described theory has been expressed by a mathematical function and the biological response of the bone has been simulated by means of a computer model. This model explains in a first approximation normal reactions of the growing bone even well as some pathological growth processes.
Amongst the 250 tibial valgisation osteotomies performed for medial femoro-tibial osteoarthrosis of the knee between 1970 and 1973, only 93 in 66 patients could be followed up for 10 years or more (10-13 years). The long term outcome of the operation is dominated by frontal angular correction. The radiological and clinical result was regularly satisfactory after ten years only when the valgus was between 3 and 6 degrees. With more than 6 degrees valgus, there was deterioration of the lateral femoro-tibial compartment in all cases. Clinical and radiological results were variable with more than 3 degrees varus and were all the worse when there was considerable persistent varus. However functional impairment of those knees in which correction was inadequate occurred only after a mean latent period of 7 years. It remained slow and moderate, offering the possibility of a new osteotomy in case of failure. This would confirm that tibial osteotomy has at least two actions: a trophic action which disappears at about 7 years and a mechanical action, the importance of which appears in the long term. It is therefore felt that tibial valgisation osteotomy is a sufficiently reliable operation to be proposed in all cases of symptomatic and progressive osteoarthrosis with genu varum. Correction and results are all the more satisfactory when the operation is carried out before flexion deformity or laxity interfere with the accuracy of the correction. A preference for the insertion of a prosthesis may be preferred only in the elderly (the authors preferring the medial unicompartmental type), the principal advantage being to decrease the relatively long period of postoperative immobilisation following osteotomy.
We studied the cases of twenty-one patients with the syndrome of thrombocytopenia and absent radius. Patients with this syndrome usually have associated intra-articular dysplasia of the knee joint bilaterally, causing genu varum and a flexion and torsional deformity that become manifest in the first or second year of life. Usually there is progression of the deformities during growth and therefore treatment with braces or operations, or both, will frequently be needed. Despite correctional osteotomy, the varus angulation and internal tibial rotation have a natural tendency to recur, possibly because of the intra-articular deformity that involves the femoral and tibial condyles. After skeletal maturity has been reached, minimum progression of the deformity has been observed.
The author presents 2 cases of genu varum due to Blount's disease, one in an infant and the other in an adolescent. Both were successfully corrected by monolateral medial epiphyseal distraction using Hoffmann's external fixator.
Medial compartment osteoarthritis remains a clinical challenge for the orthopedic surgeon. Accurate preoperative planning is an integral part of management. MCOA with genu varum is not a single condition but a family of related deformities. One single technique may not be appropriate for all the permutations. An individualized approach is necessary to address the many facets of this complex disorder. Treatment must begin with recognition of all of these facets through careful history and physical examination and radiographic evaluation and through preoperative planning of the location of the deformity (femur, tibia, or knee joint), level of angulation, magnitude of the deformity, and plane of the angulation. One can then formulate a treatment plan to address the problems identified. Surgeons should not become rigid in their choice of method or device, but also consider its appropriateness to address the problems to be corrected. Because the patient seeks to prolong the life of the knee before joint replacement, a comprehensive approach achieving as accurate a correction as possible should be associated with the best possible outcome. In total knee replacement, the important emphasis has been on achieving correct bony alignment and soft-tissue balance. With osteotomy, the emphasis has been on bony alignment. However, soft-tissue balance should also be considered an important element in preserving the knee in osteotomy surgery.
Pseudoachondroplasia is a heterogeneous inherited skeletal dysplasia in which dwarfism is a major feature. We report here a case of a 7 year old girl misdiagnosed as rickets, who presented with short stature, lordosis, genu varum and flexion deformities at both the elbows. Skeletal survey revealed epiphyseal and metaphyseal irregularities. A review of literature is also presented.
Spondyloepimetaphyseal dysplasias (SEMDs) are a heterogeneous group of skeletal disorders that can have a genetic basis, but their classification and prognostication suffer because few families have been extensively studied. We describe a large kindred affected by a unique type of SEMD that is transmitted as an autosomal dominant trait. The propositus and his affected brother and first cousin were evaluated as inpatients. Other kindred members were screened by telephone interviews and lateral thoraco-lumbar spine radiographs, and then, in most cases, investigated by additional x-ray studies. Of the 29 living members of the kindred, 22 were studied radiologically. Among the 22 subjects investigated, 15 were affected, and the status of 1 individual with minor changes on x-ray was indeterminate. The deceased patriarch was presumed to be affected. These 16 affected subjects could usually, but not invariably, be distinguished from their unaffected sex-matched siblings by their smaller heights. Nevertheless, it was only affected children who had short stature; the heights of all affected adults were normal. Often, affected individuals had rhizomelic shortening, especially of the lower extremities, and genu varum (not always evident clinically, but present on radiographs). Occasionally, they also manifested limited extension of their upper limbs. Radiologic study showed abnormal metaphyses, epiphyses, and vertebrae in affected children, but these 3 skeletal regions became less remarkable by late childhood and most affected adults had normal epiphyses. One obligate affected man had only spinal changes. Despite their normal heights, severely affected adults who had bowing deformity of their legs developed disabling degenerative joint disease limited to the knees in the 7th decade of life--disease severe enough to require knee replacement surgery.
Eight patients with an age ranging from 72 to 83 years, seen in an outpatient clinic over a one-year period for stress fractures of the proximal tibia responsible for acute knee pain and effusion were studied retrospectively. Plain roentgenograms were often normal at presentation but subsequently showed sclerosis of the proximal tibia. Radionuclide bone scanning was the most useful investigation for early diagnosis. Potential risk factors were advanced: age, genu varum or valgum, overweight and vitamin D deficiency. Stress fracture of the proximal tibia should be considered in elderly patients with knee pain, effusion and normal roentgenograms. Elimination of weight-bearing ensures healing of the fracture.