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Congenital Genu Varum

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Brittany Mott

on 18 August 2014

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Transcript of Congenital Genu Varum

Blount's Disease-
Orthotic Treatment
General idea: Apply valgus force couple
CHECKPOINT!
Congenital Genu Varum- Diagnostic Technique
Observation
One or both lower legs may bow outward

X-Ray
Of the knee and lower legs confirms the diagnosis
(Usually this is the only required test)

Tests
If an underlying syndrome or disease is suspected by physical findings and history, tests may be ordered:
Blood tests
Bone biopsy
Genetic tests
Bone density tests
Urine tests

Congenital Genu Varum- Etiology
Congenital Genu Varum
Blount's Disease
Rickets

Congenital Genu Varum- Non-Orthotic
First 6 months- observe
(will probably correct through growth)
Blount's Disease- Etiology
Developmental disorder which results in progressive lower limb deformity with irreversible pathologic changes
Disordered medial growth of proximal tibial physis
Multiplanar deformity includes: varus, procurvatum, & internal rotation of tibia
2 forms of the disease:
1. Early Onset/Infantile Blount's Disease (1-3 years of age)
2. Late Onset
-Juvenile Blount's Disease (4-10 years)
-Adolescent Blount's Disease (>10 years)
What type of force couple should be used when designing a KAFO for infantile Blount's Disease?
Tess Burford
Allison Cerutti
Brittany Mott
Drew Nutter
Andrea Sherwood
Katie Toth

Genu Varum = Bow legged
Infants -> adults
Variety of causes
Physiologic Genu Varum in infants -> 2 year
Often symmetrical and painless
May have toe-in and often struggle with tripping
Resolves spontaneously without treatment

Pathologic Genu Varum
Blount’s Disease/Tibia Vara
Rickets
Skeletal Dysplasias
Celiac Sprue and other digestive disorders
Padget’s Disease
Lead poisoning & Fluoride poisoning
Bone fractures
Congenital Genu Varum- Clinical Presentation
When standing with feet together and flat on the floor, the legs “bow outward.”

In gait:
-note the foot progression angle may deviate from normal
-there may be lateral thrust
Pathologic or severe physiologic genu varum
Possible indications for treatment:
Asymmetry
Stature below 5th percentile
Other musculoskeletal abnormalities
Trosclair 1959
“Conventional-style” KAFO
Single medial or bilateral sidebars
3 point pressure system:
-Thigh + medial condyles
-Lateral calf
-Ankle
Congenital Genu Varum- Orthotic Treatment
Takatori & Iwaya 1984
N = 3
Case studies
Age @ initiation: 1y 7mos; 1y 10mos; 2y 1mo
100% correction
-Angles decreased to “normal” appearance for
age at treatment termination
Free motion knee vs. “conventional” locked knee

Note: above is a genu valgum brace;
strap placement is the same for genu varum
but with medial sidebar
Congenital Genu Varum- Orthotic Treatment
Surgery:
Tibial Osteotomy
-For skeletally mature patients
Hemiepiphysiodesis of femur and tibial physis
-Stapling or fusing medial growth plates
Gradual correction with external fixator
Congenital Genu Varum-
Orthotic Treatment
Post-operative knee immobilizer:
Proximal tibial hemiepiphyseal stapling
Proximal tibial hemiepiphysiodesis
Blount's Disease-
Etiology
-Cause is controversial & multifactorial (hereditary or developmental factors)
-Current theories:
Likely differs for different forms of the disease
Likely secondary to a combination of hereditary and/or developmental factors
Increased risk in overweight children
Increased risk with early walkers
Race
Genetics
-What came first...the chicken or the egg?
-Is it abnormal bone formation that is exacerbated by compressive forces OR compressive forces that cause abnormal bone formation?
Mechanical and biological factors influence the disease: weight, age at walking, deformity
Heuter-Volkmann Principle
Less than 1% in US
Increased incidence in African Americans
BLOUNT'S
DISEASE
Blount's Disease-
Clinical Presentation
Often associated with...
limb length discrepancy
deformity of distal femur
Early/Infantile Blount's Disease (1-3 years of age)
Usually discovered when child begins to ambulate
Usually bilateral
Often are early walkers
Varus deformity of tibia & internal torsion of tibia
Difficult to distinguish from normal bowing (normal in children under 2)
Usually does not have pain

Late/Adolescent Blount's Disease
Juvenile (4-10 years of age) / Adolescent (>10 years)
Often report pain
Usually overweight
(Scott, Kelly, Sullivan, 2007)
BMI >22 -> metaphyseal-diaphyseal angle >10 deg
Usually unilateral
Often have abnormalities of distal femur
Blount's Disease- Diagnostic Techniques
Observation
One or both lower legs may bow outward
Knee pain not uncommon
Measurements of leg(s) to determine severity

X-Ray
Of knee and lower leg(s) confirms diagnosis
Older the child, more evident the diagnosis
Blount's Disease-
Non-Orthotic Treatment
Surgery, Surgery, Surgery
Medial hemiplateau elevation osteotomy, asymmetrical physeal distraction, physeal bar restrictions, etc.
Tibial Osteotomy:
Removing a "wedge" to create realignment
Acute - pins, screws, wires
Gradual - external fixation
More accurate for multiplanar
Opening wedge, closing wedge, serrated, domed, and inclined
Often overcorrected
Blount's Disease-
Non-Orthotic Treatment
Guided Growth:
Fails to address sagittal plane
Can guide distal femur
Internal fixation using plating
Bottom Line:
Surgery is successful
Kawu(2012)-Recurrence rate of 15.1% in 86 knees
Scott(2012)-Growth manipulation success rate of 89% in 18 limbs
Jones (2009)-93% of patients were satisfied with correction
Most surgeries can't correct every plane and deformity
Recurrence is possible
Proximal
Medial
Distal
Medial
Lateral
Blount's Disease- Orthotic Treatment
Clinical Guidelines:
Age - when is the latest we can treat?
Full-time vs. night only
Locked vs. unlocked knee
Which design variation to choose?
Blount's Disease-
Orthotic Treatment
Raney et al., 1998:
N=60 involved limbs (38 patients)
90% correction
Literature has reported the following rates of resolution without any treatment: 72%, 50%, and 68%
Age at initiation: 18 months-3 years
Orthotic success=2.18 y.o. (average)
Surgery=3 y.o. (average)
Does this confirm that treatment must begin <3 y.o.?
Full-time vs. night only - no statistically significant difference in success
Blount's Disease-
Orthotic Treatment
Marshall (2010)
Orthotic design based on Raney et al.
Full-time but can be modified to night only
Blount's Disease-
Orthotic Treatment
Whiteside, 2011
N=2
Age at initiation: 3 years, 4 months; 1 year, 11 months
Improvement to normal developmental alignment in both cases
Does this indicate children >3 y.o. for orthotic treatment?
Is it due to the unique design?
Anatomical Concepts Inc. - more "dynamic"
Posterior Opening
Tamarack
(free DF/PF)
Blount's Disease- Orthotic Treatment
Type 1:
"Conventional"
Slowest
Type 2:
Discus pad
Fastest
Type 3:
Polymer with AFO
In between
Blount's Disease- Orthotic Treatment
JMMR, Inc. (2007)
Study in progress
"Positive track
telescoping
joints"
Thigh
Strap
Valgus Force=
Elastic Strap
+
Posterior
Pivot Joint
Calf Strap
A. Valgus
Proximal medial
Distal medial
Lateral at knee
B. Varus
Proximal lateral
Distal lateral
Medial at knee
Rickets - Etiology
A disease of growing bone, thus it is found in children from 6-24 months
Leads to bone softening/weakening due to Vitamin D, calcium, or phosphate deficiency
Failure of the osteoid to calcify (adults= osteomalacia)
Commonly seen in developing countries
Hereditary form of the disease: due to kidney problems
Risk Factors
(Krieter et al, 2000)
Infants who are only breastfed
People who have dark pigmented skin
Those who do not get enough ultraviolet (sunlight) light
If left untreated, may lead to
delayed skeletal development
skeletal deformity
pelvic distortion (issues with future childbirth)


RICKETS
Rickets-
Diagnostic Techniques
Physical Exam
Reveals bone pain, rather than pain in the joints or muscles
Tests
Arterial blood gases
Blood tests
Serum calcium
Serum Alkaline phosphatase
Serum phosphorus
Parathyroid hormone (PTH)
Bone biopsy
X-rays
Alkaline Phosphatase isoenzyme
Urine Calcium

Rickets-
Non-Orthotic Treatment
Treating Nutritional Deficits
Single Dose - 15,000 mcg of Vitamin D
Oral or intramuscular
Gradual Treatment - 125-250 mcg/day for 2-3 months of Vitamin D
Diet
Liver, Fish, Processed Milk
Take in enough Vitamin D, Phosphate, and Calcium
Nutritional Rickets subside within 6-7 days
Severe cases require surgery

Rickets-
Non-Orthotic Treatment
Hypophosphatemic Rickets
Vitamin D Resistant
Oral Phosphate
Calcitriol
Lots of side effects:
Hyperparathyroidism and urinary phosphate wasting
Hypercalcemia, Hypercalurinia, neprocalcinosis

Rickets-
Orthotic Treatment
Guerre-Aguilar 2007:
Monodos hinge = one-way locking hinge
Monodos placed anteriorly
Coronal control
Posterior ROM hinge
Tibial and thigh cuffs
Night only


Remember this?
CHECKPOINT!
Rickets is a softening of the bone cause by a deficiency in which vitamin?

A. Vitamin A
B. Vitamin K
C. Vitamin D
D. Vitamin E
CHECKPOINT!
True or false?

Congenital Genu Varum can be caused by pathologic or physiologic factors.

Thank you! Any questions?
Rickets- Clinical Presentation
Bone Pain or Tenderness
Arms, Legs, Pelvis, Spine
Impaired growth
Dental deformities
Increased bone fractures
Muscle cramps
Short stature
Skeletal deformities
Asymmetrical or misshapen cranium
Bowlegs
Bumps in the ribcage
Pigeon chest (breast bone pushed forward)
Pelvic deformities
Spine deformities
Alsancak, Guner, & Kinik (2013)
N=31 (20 participants)
Age at initiation: 19-28 months (average 31.8 months)
Controlled trial
3 designs
"5-point" pressure system
100% correction
Is a 5-force design better than 3?
Treatment design varied between the different types
When would treatment duration matter?
Compliance?
Alsancak, S., Guner, S., & Kinik, H. (2013). Orthotic variations in the management of infantile tibia vara and the results of treatment. Prosthet Orthot Int, 37(5), 375-383. doi: 10.1177/0309364612471369

Birch, J. G. "Blount Disease." J Am Acad Orthop Surg 21.7 (2013): 408-18. Print.

Cheema, J., & Harche, T. H., (2013, November 1). Blount Disease Imaging. Blount Disease Imaging. Retrieved July 26, 2014, from http://emedicine.medscape.com/article/406458-overview#a01

Fitoussi, F., et al. "Fixator-Assisted Medial Tibial Plateau Elevation to Treat Severe Blount's Disease: Outcomes at Maturity." Orthop Traumatol Surg Res 97.2 (2011): 172-8. Print.

Gabriel, Keith. (2008). Congenital and acquired disorders. In J. D. Hsu, J. W. Michael & J. R. Fisk (Eds.), AAOS Atlas of Orthoses and Assistive Devices (4 ed., pp. 460-461). Philadelphia, PA: Elsevier.

Guerre-Aguilar, Britt-Mary, Davidson, Michael, & Bunnell, William. (2007). New Orthotic Method for Treatment of Angular Deformity of the Knee in Children. Journal of Proceedings. Loma Linda University.

Jones, J. K., et al. "Outcome Analysis of Surgery for Blount Disease." J Pediatr Orthop 29.7 (2009): 730-5. Print.

Kaneshiro, N., Zieve, D., Eltz, D., Slon, S., & Wang, N. (2012, November 12). Blount's disease: MedlinePlus Medical Encyclopedia. U.S National Library of Medicine. Retrieved July 14, 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/001584.htm

Kaneshiro, N., & Zieve, D. (2012, August 1). Rickets: MedlinePlus Medical Encyclopedia. U.S National Library of Medicine. Retrieved July 14, 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/000344.htm

Kreiter, S. R., Schwartz, R. P., Kirkman, H. N., Jr., Charlton, P. A., Calikoglu, A. S., & Davenport, M. L. (2000). Nutritional rickets in African American breast-fed infants. J Pediatr, 137(2), 153-157. doi: 10.1067/mpd.2000.109009

L., D. (2013, July 18). Physical Therapy Pht6381 > Bloyer > Flashcards > Peds- MS Orthopedic Assessment | StudyBlue. StudyBlue. Retrieved July 14, 2014, from http://www.studyblue.com/notes/note/n/peds-ms-orthopedic-assessment/deck/7009661

LaMont, L., Fragomen, A., Rozbruch, S. R., Talavera, F., DeBerardino, T., & Patel, D. (2013, November 12). Blount Disease . Blount Disease. Retrieved July 14, 2014, from http://emedicine.medscape.com/article/1250420-overview#a03

Marshall, Janet G. (2010). Orthotic Treatment of the Toddler with Bowed Legs. O&P Business News, (November). Retrieved from Healio website:

Molino, Joseph L. (2007). Blount's Disease A New Dynamic Bracing Technique. Presentation. JMMR Inc.

Raney, E. M., Topoleski, T. A., Yaghoubian, R., Guidera, K. J., & Marshall, J. G. (1998). Orthotic treatment of infantile tibia vara. J Pediatr Orthop, 18(5), 670-674.

Rijn, R. V., McHugh, K., Wood, B., Coombs, B., Stringe, D., Krasny, R., et al. (2013, September 16). Rickets Imaging . Rickets Imaging. Retrieved July 14, 2014, from http://emedicine.medscape.com/article/412862-overview

Schwarz, S., Greer, F., Finberg, L., Schwarz, S., Windle, M., & Bhatia, J. (2014, April 18). Rickets . Rickets. Retrieved July 14, 2014, from http://emedicine.medscape.com/article/985510-overview#showall

Scott, A. C. "Treatment of Infantile Blount Disease with Lateral Tension Band Plating." J Pediatr Orthop 32.1 (2012): 29-34. Print.

Stevens, P., Talavera, F., DeBerardino, T., & Grogan, D. (2013, August 29). Pediatric Genu Varum . Pediatric Genu Varum. Retrieved July 14, 2014, from http://emedicine.medscape.com/article/1355974-overview

Takatori, Y., & Iwaya, T. (1984). Orthotic management of severe genu varum and tibia vara. J Pediatr Orthop, 4(5), 633-635.

Thompson, George H. (2001). Angular Deformities of the Lower Extremities in Children. In M. W. Chapman (Ed.), Chapman's Orthopaedic Surgery (3 ed., pp. 4287-4335). Philadelphia: Lippincott Williams & Wilkins.

Trosclair, M.J. (1959). Corrective Braces for Genu Valgum and Genu Varum. Orthopedic & Prosthetic Appliance Journal, 52-53.

Whiteside, Joseph W. (2011). Preliminary Outcome Using a New Free Motion Offloading KAFO for Postoperative Management of Hemiepiphysiodesis in Adolescent Tibia Vara. ACPOC News, 17, 38. Retrieved from The Association of Children's Prosthetic-Orthotic Clinics website:

References
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