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.     

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.     

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.     

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.     

远端半针Ilizarov外固定器结合微创截骨术治疗膝内翻畸形

 目的 探讨远端半针Ilizarov外固定器结合微创截骨术矫治膝内翻畸形的临床疗效。方法 回顾性分析2002年2月至2010年5月收治的31例膝内翻畸形患者的病例,男8例,女23例;年龄18~69岁,平均35.6岁;单侧6例,双侧25例,共56膝。术前膝内翻角度为7.7°~38.2°,平均17.0°±8.8°。根据美国膝关节关节协会评分（knee society score, KSS）为34~100分,平均（86.2±18.5）分。确定成角旋转中心与截骨矫形的位置,在胫骨畸形交点处用微创截骨器截骨,腓骨在头下截骨。安装术前已组装好的Ilizarov外固定器,通过调整伸缩内、外侧支架螺杆的长度渐进矫正内翻畸形。采用X线检查及膝关节KSS临床评分,结合行走时自我感觉及有无并发症等4项内容综合评价临床疗效。结果 患者佩戴Ilizarov外固定器的时间为9~20周,平均12周;随访时间14~50.4个月,平均30.5个月。末次随访时膝内翻角度为-3°~2.4°,平均1.7°±0.9°;膝关节KSS评分为75~100分,平均（96.1±7.7）分,其中优49例,良6例,可1例,优良率为98.2%（55/56）。11例患者术后早期发生轻度针道感染,经常规换药后感染控制;3例术后发生针道松动,经更换针道后恢复固定强度。结论 远端半针Ilizarov外固定器结合微创截骨术矫治膝内翻畸形具有微创、安全、动态矫形及符合美学要求的特点,临床效果满意。     

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.     

Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study

The results in ninety-three knees that had been treated by proximal tibial opening-wedge osteotomy for varus deformity and osteoarthritis of the medial compartment were evaluated after a mean length of follow-up of 11.5 years (range, ten to thirteen years). After ten years, only forty-two (45 per cent) of the ninety-three knees had an excellent or good result, and in fifty-one knees there was recurrent pain for which seventeen had another operation. At five years, on the other hand, 90 per cent of the knees had a good result. Deterioration occurred at an average of seven years after the osteotomy and was always associated with recurrence of pain. Although the results deteriorated with time, time was not the only determinant of the result. Alignment, measured as the hip-knee-ankle angle on radiographs of the whole limb that were made with the patient bearing weight, was also a determinant of long-term results. The best results were obtained in the twenty knees that had a hip-knee-ankle angle of 183 to 186 degrees. In these knees, there was no pain and no progression of the arthrosis in either the medial or the lateral tibiofemoral compartment. Of the five knees that had an angle of more than 186 degrees, all five had progressive degenerative changes in the lateral compartment. In the sixty-eight undercorrected knees (an angle of less than 183 degrees), the results were less satisfactory, and there was a tendency toward recurrence of the varus deformity and progression of the arthritis of the medial compartment. However, when the correction was insufficient the deterioration was slow (average, seven years), and it was not associated with lateral laxity and deterioration of the lateral compartment, which are the changes that characterize the natural course of gonarthrosis as described by Hernborg and Nilsson. Therefore, proximal tibial osteotomy is a very suitable operation for patients who have gonarthrosis of the medial compartment, but a rigidly standardized and precise operative technique is required as well as accurate radiographic measurements of the mechanical axis of the limb, because exact postoperative alignment is the prerequisite for the longest possible period of relief of symptoms after osteotomy.     

Anterior opening wedge osteotomy of the proximal tibia for anterior knee pain in idiopathic hyperextension knees

We analysed 20 patients with 24 knees affected by idiopathic genu recurvatum who were treated with an anterior opening wedge osteotomy of the proximal tibia because of anterior knee pain. We managed to attain full satisfaction in 83% of the patients with a mean follow-up of 7.4 years. The mean Hospital for Special Surgery score was 90.3 (range 70.5-99.5), and the mean Knee Society score score was 94.6 (70-100) for function and 87.7 (47-100) for pain. The mean Western Ontario and McMaster University Osteoarthritis Index score for knee function was 87.5 (42-100), for stiffness 82.8 (25-100) and for pain 87.3 (55-100). Radiographs showed a significant increase in posterior tibial slope of 9.4 deg and a significant decrease of patellar height according to the Blackburne-Peel method of 0.16 postoperatively. No cases of non-union, deep infection or compartment syndrome were seen. No osteoarthritic changes in the lateral or medial knee compartment were found with more than 5 years' follow-up in 16 patients with 19 affected knees. Three out of the four dissatisfied patients had a patella infera which led to patellofemoral complaints. One patient in the study underwent a secondary superior displacement of the patella with excellent results. We conclude that in a selected group of patients with idiopathic genu recurvatum and anterior knee pain an opening wedge osteotomy of the proximal tibia can be beneficial.     

Adolescent tibia vara: alternatives for operative treatment.

We reviewed the cases of fifteen obese patients (twenty-one extremities) who had had adolescent tibia vara and had been followed for at least two years. Of the nine patients (eleven extremities) who had been initially managed with lateral tibial hemiepiphyseodesis, eight (ten extremities) were skeletally mature at the time of the review (mean duration of follow-up, five years). The mechanical alignment was judged to be excellent in three of these ten extremities, fair in three, and poor in four. Excellent mechanical alignment was defined as a value within the reported normal range of 5 degrees of varus to 2 degrees of valgus. A poor result was defined as alignment that was more than 5 degrees outside the normal range. After secondary operative procedures, three of the extremities for which the result had been poor and one for which it had been fair had excellent alignment. Five of the nine patients had bilateral involvement. Two of them were managed with bilateral tibial hemiepiphyseodesis; two, with contralateral proximal tibial osteotomy; and one had a mild deformity on the contralateral side that was not treated. Six extremities in six patients (two of whom had a contralateral hemiepiphyseodesis) were managed primarily with proximal tibial osteotomy and were evaluated an average of seven years postoperatively. Two additional patients were managed with proximal tibial osteotomy because of residual varus deformity after the hemiepiphyseodesis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Technical considerations of total knee arthroplasty after proximal tibial osteotomy

Forty-five total knee replacements in forty-one patients who had continued to have progressive osteoarthritis after a proximal tibial osteotomy were evaluated prospectively. There were 51 per cent excellent, 29 per cent good, 4 per cent fair, and 16 per cent poor results after a minimum follow-up of two years. The resection of tibial bone that was produced by the osteotomy could not be related causally to the fair or poor clinical results that were found after arthroplasty. Radiographic study, however, showed that 80 per cent of the knees had patella infera before the arthroplasty, which may contribute to altered biomechanics of the patellofemoral joint of the arthroplasty. The procedure for total knee replacement is made more difficult by the previous osteotomy, and a custom-made prosthesis may be required. The clinical results that were obtained in this series are similar to those for the revision total knee arthroplasties that have been done at this institution, but they were not as satisfactory as those that were obtained after primary total knee replacement. Our results should be considered when a surgeon compares the advantages and disadvantages of proximal tibial osteotomy with those of total knee arthroplasty for an older patient who has unicompartmental osteoarthritis of the knee.     

Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee

From 1960 through 1979, a closing-wedge varus osteotomy of the proximal part of the tibia was performed in thirty-one knees (twenty-eight patients) for painful osteoarthritis of the lateral compartment of the knee that was associated with a valgus deformity. The patients were followed for two to seventeen years (average, 9.4 years). Twenty-four knees (77 per cent) had either no pain or only occasional mild pain at the last evaluation. Six knees had moderate pain and one, severe pain. Six knees required a subsequent total knee arthroplasty at an average of 9.8 years after the osteotomy. No patient had an infection or non-union. Osteotomy of the proximal part of the tibia is a reasonable method of treating unicompartmental degenerative arthritis in a knee with a valgus deformity. Although some patients with as much as 20 degrees of anatomical valgus deformity obtained a good result in this series, osteotomy in the supracondylar region of the femur is probably preferable if the valgus angulation exceeds 12 degrees or if the tilt of the tibial articular surface that will result from the surgery will exceed 10 degrees. Correction beyond the normal 5 to 7 degrees of valgus angulation to zero degree of anatomical tibiofemoral alignment is recommended to prevent recurrence of the valgus deformity and to decrease the load on the lateral tibiofemoral compartment.     

Genu recurvatum caused by partial growth arrest of the proximal tibial physis: simultaneous correction and lengthening with physeal distraction. A report of two cases

Two cases of genu recurvatum deformity and leg length discrepancy after partial growth arrest of the proximal tibial physis are described. The patients are both boys thirteen and fifteen years old respectively. The etiology of the deformity is considered to be local pressure on the tibial tuberosity, in the first case after treatment with plaster cast after correction of an angular deformity in a tibial fracture and in the second case after prolonged treatment with patellar tendon bearing brace. The boys were treated with physeal distraction which corrected both the leg length discrepancy and the angular deformity. The technique is recommended because the correction is done at the site of the deformity and knee motion is possible during the entire treatment period.     

Proximal tibial extension medial rotation osteotomy to correct knee flexion contracture and lateral rotation deformity of tibia after polio

A proximal tibial extension medial rotation osteotomy was performed on 17 tibias in postpoliomyelitis patients to correct knee flexion contractures simultaneously with the correction of lateral rotation deformity of the tibia through the same osteotomy. Gait improved in 10 patients. Five patients developed recurrence of knee flexion contractures; five more developed greater than 20 degrees genu recurvatum. One patient developed a common peroneal nerve palsy. Because of the high incidence of complications, we recommend that this procedure be abandoned.     

Proximal tibial osteotomy in patients who are fifty years old or less. A long-term follow-up study

Proximal tibial valgus osteotomy was performed for unicompartmental osteoarthritis in forty-five patients (fifty-one knees). The average age of the patients was forty-one years (range, twenty-three to fifty years), and the average length of follow-up was ten years. At follow-up, 70 per cent (thirty-six knees) were rated as good or excellent and 30 per cent (fifteen knees) were rated as fair or poor. There was no clear correlation between the quality of the result and the radiographic evidence of the severity of the arthritis preoperatively, the age of the patient at osteotomy, or the length of follow-up. There was a correlation between an improved result and an increased angle of correction after osteotomy, but the values were not statistically significant. The most important factor influencing the quality of results was the over-all level of disease in the knee as reflected in the preoperative knee score. Deficiency of the anterior cruciate ligament at the time of the osteotomy did not prevent a good result. We believe that proximal tibial osteotomy for unicompartmental arthritis of the knee is a good and effective procedure for patients who are less than fifty years old and who have an active life-style, and that lasting results can be achieved if the procedure is done early in the course of the disease.     

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: 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.     

Opening wedge tibial osteotomy for large varus deformity with CeraverTM resorbable beta tricalcium phosphate wedges

The results in 53 knees that had been treated by proximal tibial opening-wedge osteotomy for large varus deformity and osteoarthritis of the medial compartment were evaluated after a mean length of follow-up of ten years (range, 8–12 years). We used a porous beta-tricalcium phosphate (β-TCP) wedge because it is resorbable and osteoinductive. All osteotomies were completely consolidated and complete osseointegration of the remnant of the β-TCP wedge took place. However, after a mean maximum follow-up of ten years none of the cases showed complete resorption. After ten years, 40 (81%) of the 53 knees had an excellent or good result, and in 13 knees there was recurrent pain for which six had an arthroplasty. Although the results deteriorated with time, time was not the only determinant of the result. Alignment, measured as the hip-knee-ankle angle on radiographs of the whole limb that were made with the patient bearing weight, was also a determinant of long-term results. The best results were obtained in the knees that had a hip-knee-ankle angle of 183–186 degrees. In these knees, there was no pain and no progression of the arthrosis in either the medial or the lateral tibiofemoral compartment. Of the three knees that had an angle of more than 186 degrees, all five had progressive degenerative changes in the lateral compartment. In the undercorrected knees (an angle of less than 183 degrees), the results were less satisfactory, and there was a tendency toward recurrence of the varus deformity and progression of the arthritis of the medial compartment. However, when the correction was insufficient the deterioration was slow. Therefore, proximal tibial osteotomy is a very suitable operation even for patients who have gonarthrosis of the medial compartment and a large varus deformity. Although, a rigidly standardised and precise operative technique is required as well as accurate radiographic measurements of the mechanical axis of the limb because exact postoperative alignment is the prerequisite for the longest possible period of relief of symptoms after osteotomy, and this exact alignment is difficult to obtain for patients with large varus deformity.     

Single stage osteotomy and total knee arthroplasty for tibio-femoral malunion with osteoarthritis of the knee

Extraarticular tibiofemoral malunion causing malalignment and osteoarthritis of the knee can be managed by an extraarticular osteotomy, or by compensatory distal femoral or proximal tibial wedge resection along with total knee replacement, to achieve limb alignment and improve knee function. We operated on 6 knees with tibiofemoral malunion with osteoarthritis of the knee. All knees had an extraarticular osteotomy either at the site of malunion (3 knees) or away from the malunion site (3 knees). There were 4 femoral deformities and 2 tibial malunions. In one patient a femoral osteotomy was done as a part of revision knee replacement for loosening with supracondylar malunion. 5 of these patients had a press fit stemmed superstabiliser total knee replacement. In the remaining patient with tibial malunion, a conventional total condylar total knee replacement was done along with a high tibial osteotomy. At a mean follow-up of 45 months (range 24 to 84), one osteotomy had not healed inspite of bone grafting and one patient had an above knee amputation for infection. The HSS (Hospital for Special Surgery) scores revealed a good result in 4 knees, fair in 1 and poor in 1 patient. None of the surviving knee replacement has required a revision to date for clinical or radiological loosening. All patients had a good mechanical alignment of the lower limb, with no ligamentous imbalance following surgery. Single stage osteotomy and total knee arthroplasty is a technically demanding surgery associated with complications and should be reserved for large deformities. Minor deformities should be corrected by intraarticular distal femoral or proximal tibial wedge resection taking due care that ligament balance is not compromised and a satisfactory alignment is restored.      

Uptilting osteotomy of the lateral tibial plateau for a knee deformity. A case report.

A middle-aged woman had had anterior poliomyelitis at 11 years of age that had left her with residual weakness in both legs. She gradually developed a recurvatum and valgus deformity in both knees, which caused pain and instability. A technique to restore the top of the tibia by means of a rotational osteotomy of the lateral tibial plateau is presented. This operation resulted in painless, asymptomatic knees and improved function.     

Spontaneous or traumatic premature closure of the tibial tubercle

 A premature closure of the physis of the tibial tubercle in a young man has given rise to a shortening of the tibia, a patella alta and a reversed tibial slope of 20° with clinical genu recurvatum. After a proximal open wedge tibial osteotomy all three postural deformities could be restored. The etiology of this complex deformity is discussed.

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Résumé  Les auteurs rapportent un cas de traitement chirurgical de fermeture prématurée du cartilage de croissance de la tubérosité tibiale antérieure

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Accepted: 19 February 1998