Genu recurvatum: A complication of prolonged femoral skeletal traction

Summary Genu recurvatum is a rare complication of prolonged skeletal traction. The literature reports very few cases, the majority secondary to wire traction applied to the tibia in the treatment of femoral shaft fractures. A case of genu recurvatum in a 12-year-old girl as a complication of prolonged femoral skeletal traction was treated at the Kobe University Hospital. A proximal open wedge tibial osteotomy using iliac bone grafts was the surgical treatment initiated at the time of diagnosis. Follow-up after 1 year showed recurrence of the genu recurvatum. Early surgical intervention, prolonged casting and application of knee orthosis were all contributory factors in the recurrence of genu recurvatum in our patient. It should be emphasized that extreme care should be taken in treating femoral shaft fractures in children, especially those requiring wire traction in the tibia or femur, in order to prevent genu recurvatum.Zusammenfassung Genu recurvatum ist eine seltene Komplikation langdauernder Skelettextension. In der Literatur sind nur sehr wenige derartiger Fälle berichtet; die Mehrzahl ist sekundär entstanden nach der Behandlung von Femurschaftfrakturen mit Drahtextension an der Tibia. Hier wird bei einem 12jährigen Mädchen über ein Genu recurvatum berichtet, welches als Komplikation einer langdauernden Skelettextension am Femur entstand. Die Behandlung bestand in einer proximalen Schienbeinosteotomie, die keilförmig geöffnet und mit Knochentransplantaten aus dem Beckenkamm aufgeffült wurde. Bereits 1 Jahr später hatte sich schon wieder ein Rezidiv des Genu recurvatum ausgebildet. Zu frühe chirurgische Intervention, lange Gipsruhigstellung und die Applikation einer Knie-Orthese haben das Wiederauftreten des Genu recurvatum bei unserer Patientin offenbar begünstigt. Es wird darauf hingewiesen, daß bei der Behandlung kindlichen Femurschaftfrakturen größte Sorgfalt darauf zu verwenden ist, die Entwicklung eines Genu recurvatum zu verhindern; dies gilt besonders dann, wenn eine Drahtextension an Tibia oder Femur erforderlich ist.     

Osteotomia prossimale di tibia nel trattamento del ginocchio recurvato. Tecnica chirurgica

Genu recurvatum is a debilitating deformity characterised by hyperextension of the knee over 15 degrees resulting in an abnormal distribution of the load that can progress during growth and lead to significant deformity and arthrosis if left underestimated. Recurvatum can be osseous, ligamentous, or mixed. Osseous genu recurvatum is usually caused by asymmetrical growth arrest of the proximal tibial physis affecting primarily the tibial tubercle. Here is reported a technique of osteotomy in addition for the treatment of primary and secondary genu recurvatum.     

Posterior-Stabilized TKA in Patients With Severe Genu Recurvatum Achieves Good Clinical and Radiological Results at 5-year Minimum Follow-Up: A Case-Controlled Study

BackgroundGenu recurvatum is a rare knee deformity. Total knee arthroplasty (TKA) in severe preoperative recurvatum requires surgical adjustments. Few studies have assessed the clinical and radiological results of TKA in recurvatum. The aim was to compare the clinical and radiological outcomes, complications, and revision rates after posterior-stabilized TKA in severe recurvatum with those without recurvatum.MethodsBetween 1987 and 2015, 32 primary posterior-stabilized TKA were performed with a preoperative genu recurvatum greater than 10° and minimum follow-up of 60 months. In severe genu recurvatum, the extension gap needs to be decreased compared with flexion gap. To achieve this, the distal femoral cut is distalized, whereas the posterior femoral and tibial cuts are performed as usual. They were compared with 64 matched posterior-stabilized TKAs without recurvatum. The demographic data were similar between groups. The clinical and radiological outcomes, complications, and revision rates were assessed at the last follow-up.ResultsAt a mean follow-up of 7.4 years ± 1.9, there was no significant difference in International Knee Score functional score (77.5 vs. 73.4; P = .50) and knee score (86.6 vs. 89.5; P = .37) between the recurvatum group and the control group, respectively. 6 patients had a postoperative recurvatum equal or superior to 10° in the recurvatum group (18.8%). There was no difference between both groups in radiological outcomes, complication, or revision rates. No instability was found in the recurvatum group.ConclusionPosterior-stabilized TKA with controlled distalization of the femoral component in the setting of severe preoperative genu recurvatum achieves good clinical and radiological outcomes at a minimum follow-up of 5 years and similar to TKA without preoperative recurvatum.Level of EvidenceIII.     

Correlation of fetal posture and congenital dislocation of the hip

A statistical study was carried out on the incidence of CDH associated with mechanical factors in the uterus, including congenital genu recurvatum. There were 72 cases of CDH among 6559 infants (1.1 per cent). The incidence of CDH was 0.7 per cent in cephalic presentation, 2 per cent in footling presentation and 20 per cent in single-breech presentation. In another series, CDH was found in six of seven infants with congenital genu recurvatum. These findings suggest that a fetal posture with the hip flexed and the knee extended predisposes to the development of CDH.     

Opening-wedge osteotomy, allografting with dual buttress plate fixation for severe genu recurvatum caused by partial growth arrest of the proximal tibial physis: a case report

Injuries to the proximal tibial physis are among the least common epiphyseal injuries. We present a case of severe genu recurvatum deformity (45 degrees) with leg length discrepancy (4 cm) following a neglected proximal tibial physeal injury incurred 6 years previously. The 16-year-old patient was successfully treated by open-wedge osteotomy, allograft reconstruction, and dual buttress plate fixation. At 3 years' follow-up, the patient was asymptomatic, fully active with a full range of motion (0 - 140 degrees) of the leg, and equal leg lengths. There were no signs of genu recurvatum clinically.     

Genu recurvatum in an adolescent girl: hypothetical etiology and treatment considerations. A case report

Genu recurvatum may be the result of various bony or soft tissue deformities around the knee. We present a case of genu recurvatum with radiological features similar to those seen in infantile fibrocartilagenous dysplasia. The options for surgical treatment are described and discussed.     

Correction of genu recurvatum by the Ilizarov method.

The Ilizarov apparatus was used to carry out opening-wedge callotasis of the proximal tibia in ten patients who had suffered premature asymmetrical closure of the proximal tibial physis and subsequent genu recurvatum. In four knees, the genu recurvatum was entirely due to osseous deformity, whereas in six it was associated with capsuloligamentous abnormality. Preoperatively, the angle of recurvatum averaged 19.6 degrees (15 to 26), the angle of tilt of the tibial plateau, 76.6 degrees (62 to 90), and the ipsilateral limb shortening, 2.7 cm (0.5 to 8.7). The average time for correction was 49 days (23 to 85). The average duration of external fixation was 150 days (88 to 210). Three patients suffered complications including patella infera, pin-track infection and transient peroneal nerve palsy. At a mean follow-up of 4.4 years, all patients, except one, had achieved an excellent or good radiological and functional outcome.     

A new model of plastic ankle foot orthosis (FAFO (II)) against spastic foot and genu recurvatum.

A plastic ankle foot orthosis (AFO) was developed, referred to as functional ankle foot orthosis Type 2 (FAFO (II)), which can deal with genu recurvatum and the severe spastic foot in walking. Clinical trials were successful for all varus and drop feet, and for most cases of genu recurvatum. Electromyogram studies showed that the FAFO (II) reduced the spasticity of gastrocnemius and hamstring muscles and activated the quadricep muscles. Gait analysis revealed a reduction of the knee angles in the stance phase on the affected side when using the FAFO (II). Mechanical stress tests showed excellent durability of the orthosis and demonstrated its effectiveness for controlling spasticity in comparison with other types of plastic AFOs.     

Flexion osteotomy of the femur for genu recurvatum after poliomyelitis

We report the results of 21 femoral osteotomies performed in 18 patients for genu recurvatum and flattening of the femoral condyles after poliomyelitis. Before operation the average angle of recurvatum was 31 degrees and all the limbs required bracing. After a mean follow-up of four years there has been partial recurrence in only one case. Nine patients (10 limbs) needed no orthosis and the others had less discomfort and an improved gait. Complete remodelling of the femoral and tibial epiphyses was noted in two of the younger patients.     

The clinical manifestations and pathomechanics of contracture of the extensor mechanism of the knee.

Experience with thirty-eight Asian children and adolescents who presented with either stiffness of the knee, genu recurvatum, habitual dislocation of the patella or congenital lateral dislocation of the patella showed that all those disorders were manifestations of contracture of the extensor mechanism, which fell into two groups according to the components involved. In Group I the main components affected were in the midline of the limb, namely rectus femoris and vastus intermedius; these patients presented with varying degrees of stiffness of the knee, or worse, with genu recurvatum. In Group II the main components involved were lateral to the midline of the limb, namely vastus lateralis and the ilio-tibial band; these patients presented with habitual dislocation of the patella, or worse, congenital lateral dislocation of the patella. In both groups untreated patients developed secondary adaptive changes such as subluxation of the tibia or marked genu valgum which made operative procedures more formidable and less effective. Release of the contracture should therefore be performed as early as possible.     

Asymmetrical arrest of the proximal tibial physis and genu recurvatum deformity

We are reporting six cases of premature asymmetrical closure of the proximal tibial physis and associated genu recurvatum deformity and have reviewed the fourteen cases reported in the English-language literature. No single etiological factor could be implicated as the cause of the physeal arrest. Trauma, prolonged immobilization, tibial wire traction, and a surgical procedure involving the proximal tibial physis were observed risk factors among our patients. In our patients, established genu recurvatum due to deformity of the proximal end of the tibia and associated tibial length discrepancy were managed successfully by an opening-wedge osteotomy through the proximal one-third of the tibia and bone-grafting. Epiphyseodesis in the contralateral extremity may be required in patients with significant shortening of the tibia.     

Anterior open-wedge hepta-lateral osteotomy for severe post-traumatic genu recurvatum: a case report and review of the literature

European Journal of Orthopaedic Surgery & Traumatology - Severe post-traumatic genu recurvatum is an uncommon condition in orthopedics. The typical symptoms are pain, weakness, and instability....     

Genu recurvatum due to partial growth arrest of the proximal tibial physis: Correction by callus distraction

Summary The formation of a genu recurvatum after partial growth arrest of the proximal tibial physis is uncommon. This contribution deals with the case of a 16 years old male patient who after a direct injury to the proximal tibia four years ago showed a genu recurvatum of 18 degrees. An incomplete upper tibial corticotomy was performed and a hinge type de Bastiani fixator applied. The deformity was corrected at a distraction rate of one millimetre a day. The corticotomy gap filled with callus during the distraction process. The advantages of this concept are omision of iliac crest grafts, maintainance of a full range of knee motion with partial weight bearing during distraction and determination of the final degree of correction with the aid of proper radiographs.

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Zusammenfassung Das Genu recurvatum nach partiellem Verschluß der proximalen Tibiaepiphysenfuge ist selten. Es wird über einen 16jährigen Patienten berichtet, bei dem sich nach direktem Trauma der proximalen Tibiaregion im Verlauf von vier Jahren ein Genu recurvatum von 18 Grad ausgebildet hatte. Die Fehlstellung wurde nach Durchführung einer inkompletten proximalen Kortikotomie graduell mit einer Geschwindigkeit von einem Millimeter pro Tag durch einen Kippgelenkfixateur nach de Bastiani vollständig korrigiert. Der Kortikotomiespalt füllte sich unter der Distraktion mit Kallus auf. Vorteile dieses Verfahrens sind der Verzicht auf eine Spongiosaplastik, Beibehaltung der vollen Kniegelenksbeweglichkeit während der Korrektur mit Teilbelastung und die problemlose Überwachung und Festlegung des Korrekturausmaßes mit Standardröntgenaufnahmen.

     

Tibial physeal closure and genu recurvatum after femoral fracture: occurrence without a tibial traction pin

Two cases of premature closure of the anterior portion of the proximal tibial physis with associated genu recurvatum deformity in adolescent males who had sustained a closed femur fracture are reported. In both cases, physeal closure occurred without use of a proximal tibial traction pin. In one patient, treatment included distal femoral pin traction; the other patient was treated with skin traction followed by spica cast. We believe that development of recurvatum of the tibia after femoral fracture in children is not necessarily iatrogenic and related to a tibial traction pin, but instead may result from physeal injury incurred at the time of the original trauma.     

Genu recurvatum in total knee replacement

Genu recurvatum deformities are unusual before total knee arthroplasty (TKA), occurring in less than 1% of patients. Because of its rarity, concern may exist regarding the recurrence of the deformity and the potential for instability after TKA. Recurvatum may be associated with a severe osseous deformity, including genu valgum, capsular or ligamentous laxity, and, rarely, neuromuscular disease. In the presence of the latter, a plantarflexion contracture of the ankle also may be present. Therefore, specific attention should be given preoperatively to evaluation of the quadriceps, hamstrings, and gastrocnemius complex. Because genu recurvatum is known to recur in patients with certain neuromuscular disorders, the etiology of the hyperextension deformity must be elucidated thoroughly before surgery. In the absence of neuromuscular disease, however, hyperextension deformities tend not to recur after TKA. Care should be taken to avoid even mild degrees of residual instability in the coronal plane at surgery because this is associated with increased extension in the postoperative period.     

A long-term retrospective study of proximal hamstring release for hamstring contracture in cerebral palsy

Proximal hamstring release was used exclusively for hamstring contracture in patients with spastic cerebral palsy. Average follow-up was 9 years 5 months. Thirty-two of 78 patients were examined retrospectively. Straight leg raising increased from 30 to 68 degrees. Knee flexion contracture decreased from 16 to 9 degrees. Knee flexion contractures of greater than 10 degrees were not permanently corrected. Only four of 64 knees were in mild (5-10 degrees) recurvatum at follow-up. Lumbar lordosis averaged 53 degrees at follow-up, and hip flexion contracture release apparently had little effect on lumbar lordosis. Proximal hamstring release can be used by this described technique without severe lumbar lordosis or devastating genu recurvatum.     

Treatment of genu recurvatum by proximal tibial closing-wedge/anterior displacement osteotomy

An operation is described for correction of the osseous form of genu recurvatum, which is secondary to premature closure of the anterior part of the proximal tibial physis with continued growth of the posterior part. At the Alfred I. duPont Institute 14 patients with 17 involved knees have been treated surgically for osseous genu recurvatum. All patients complained of cosmetic deformity, and nine of the 14 had pain. Etiologic factors included immobilization, trauma, and Osgood-Schlatter disease. The average age at surgery was 15 years six months, and the average follow-up period to date has been 20 months. Surgical procedures include the Irwin osteotomy (6 knees), the proximal opening-wedge osteotomy (2 knees), the distal closing-wedge osteotomy (1 knee), and the closing-wedge/anterior displacement osteotomy (8 knees). In all 17 of the knees in this series symptoms resolved following surgery, and 16 knees were stable at clinical examination. The closing-wedge/anterior displacement osteotomy has the advantages of rapid healing, good correction of the deformity, restoration of the depressed tibial tubercle, fewer complications, and resection of the remaining physis, which prevents recurrence.     

A simple treatment of genu recurvatum in ataxic and athetoid cerebral palsy

An inexpensive, simple treatment for ataxic- or athetoid-related genu recurvatum is presented with analysis of the relevant gait mechanics. An exaggerated posterior heel flair is used in combination with a functionally dorsiflexed, below-knee orthosis to overcome terminal swing phase recurvatum at heel strike, and to provide an effective forward knee thrust through the solid ankle link. This combination is very effective in some patients, even when more extensive treatments have failed. It is easily reversible. Computerized gait analysis, used in this report for illustration, is not essential for implementation, nor for patient selection. However, video examinations are useful for adjustment of the treatment geometry.     

Genu recurvatum: a late complication of tibial wire traction in fractures of the femur in children.

Seven cases of genu recurvatum following wire traction through the proximal end of the tibia in children treated for fractures of the femur are reported. A premature closure of the anterior part of the growth plate was most probably caused by too close a proximity of the wire to the tibial tuberosity. Where tibial wire traction is used in children it is advisable to insert the wire distal to the tuberosity.