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.     

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 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.     

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.     

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.     

Genu recurvatum caused by partial growth arrest of the proximal tibial physis: Simultaneous correction and lengthening with physeal distraction

Summary 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.

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Zusammenfassung Es werden 2 Fälle von Genu recurvatum mit Beinverkürzung nach teilweisem Verschlufß der proximalen Wachstumsfuge der Tibia beschrieben. Die Patienten waren Jungen im Alter von 13 und 15 Jahren. Als Ätiologie der Deformität wird lokaler Druck auf die Wachstumsfuge der Tuberositas tibiae angenommen, im ersten Falle durch einen korrigierenden Gips nach einer Tibiafraktur, im zweiten durch langes Tragen eines entlastenden Unterschenkelapparates mit Abstützung am Ligamentum patellae. Die Behandlung der Deformitäten bestand in Distraktion der Wachstumsfuge, wodurch sowohl die Beinlängendifferenz als auch die Rekurvation korrigiert wurde. Diese Technik erscheint empfehlenswert, weil dabei die Korrektur an der Stelle der Deformität vorgenommen wird und die Beweglichkeit des Knies während der gesamten Behandlungsdauer erhalten bleibt.

     

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.

     

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.     

A fixed-ankle, below-the-knee orthosis for the management of genu recurvation in spastic cerebral palsy.

A fixed-ankle, below-the-knee molded plastic splint designed to maintain the ankle in 5 degrees of dorsiflexion and correct any foot deformity was used on eighteen extremities of twelve children with spastic cerebral palsy and genu recurvatum. After an average follow-up of twenty-six months, the genu recurvatum was well controlled and gait was improved.     

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.     

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 osteotomy of the tibia for the treatment of genu recurvatum in adults.

Twenty-seven opening-wedge osteotomies of the proximal part of the tibia were performed in twenty-five patients who had genu recurvatum. In sixteen knees, the genu recurvatum was due entirely to osseous deformity. In the remaining eleven knees, it was due to a combination of osseous and soft-tissue deformity; in five, the deformity was predominantly osseous and in six, primarily in the soft tissues (the ligaments and capsule). The average age of the patients was twenty-three years (range, fifteen to fifty-four years). The osteotomy was proximal to the tibial tuberosity in twenty-two knees. In eighteen of these knees, the tuberosity was detached with its patellar ligament and then reattached to the proximal part of the tibia over the block of bone in the opened wedge; in the remaining four knees, the tibial tuberosity was not detached. The osteotomy was distal to the tuberosity in five knees. The patients were followed for an average of 14.5 years (range, three to thirty years). Of the eighteen knees in which the osteotomy had been proximal to the tibial tuberosity and the tuberosity had been detached and then reattached, nine (50 per cent) had a result that was excellent; five (28 per cent), good; and four (22 per cent), fair. Of the four knees in which the operation had been proximal to but without detachment of the tuberosity, one had a result that was excellent; two, good; and one, fair. Of the five knees in which the osteotomy was distal to the tibial tuberosity, one had a result that was good; three, fair; and one, poor. Of the twenty-one knees in which the deformity was entirely or predominantly osseous, eighteen (86 per cent) had an excellent or good result. None of the six knees in which the deformity was predominantly in the soft tissues had an excellent or good result. Patients in whom the deformity was not primarily osseous, and those in whom the operation was distal to the tibial tubercle, were much more likely to have a fair or poor result.     

Case report. Post-traumatic tibial recurvatum: resolution with growth

The outcome of proximal tibial fractures in children is often complicated by the development of malalignment. Progressive valgus deformity is frequently seen, but is known to correct spontaneously in a high proportion of cases; however, recurvatum of the tibia usually requires surgical intervention. We present a child with a proximal tibial metaphyseal fracture who developed increasing tibial recurvatum which corrected spontaneously.     

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     

Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group

Expert opinion regarding experience with the management and complications of pediatric anterior cruciate ligament (ACL) injuries was studied by surveying members of The Herodicus Society and The ACL Study Group. There was large practice variation in initial management and ACL reconstruction technique. There were 15 reported cases of growth disturbance: 8 cases of distal femoral valgus deformity with arrest of the lateral distal femoral physis, 3 cases of tibial recurvatum with arrest of the tibial tubercle apophysis, 2 cases of genu valgum without arrest, and 2 cases of leg length discrepancy. Associated factors included fixation hardware across the lateral distal femoral physis in 3 cases, bone plugs of a patellar tendon graft across the distal femoral physis in 3 cases, large (12 mm) tunnels in 2 cases, fixation hardware across the tibial tubercle apophysis in 3 cases, lateral extra-articular tenodesis in 2 cases, and over-the-top femoral position in 1 case. Based on this experience, we recommend a guarded approach to ACL reconstruction in the skeletally immature patient with careful attention to technique and follow-up.     

Treatment of genu valgus deformity in congenital absence of the fibula

Twenty patients with Syme amputation for congenital absence of the fibula and genu valgus deformity were followed until skeletal maturity. Radiographs were analyzed for genu valgus, mechanical axis, tibial angulation, and the condylar height ratio. This ratio was determined by measuring the greatest perpendicular height from the physis to the joint line and dividing the lateral height by the medial height. A smaller value represented more marked lateral condylar hypoplasia. The presence of medial tibial angulation and the degree of lateral femoral condylar hypoplasia correlated with the degree of genu valgus. Two of three patients who had proximal tibial osteotomies required multiple procedures for recurrent deformity. Medial distal femoral physeal stapling corrected the deformity in five of six limbs. The procedure is simple, allows immediate weightbearing in the prosthesis postoperatively, and has low morbidity. Patients should be followed closely until skeletal maturity. Osteotomy performed before skeletal maturity can result in recurrence of genu valgus deformity.     

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.     

Combined distal tibial rotational osteotomy and proximal growth plate modulation for treatment of infantile Blount’s disease

Infantile Blount’s disease is a condition that causes genu varum and internal tibial torsion. Treatment options include observation, orthotics, corrective osteotomy, elevation of the medial tibial plateau, resection of a physeal bar, lateral hemi-epiphysiodesis, and guided growth of the proximal tibial physis. Each of these treatment options has its disadvantages. Treating the coronal deformity alone (genu varum) will result in persistence of the internal tibial torsion (the axial deformity). In this report, we describe the combination of lateral growth modulation and distal tibial external rotation osteotomy to correct all the elements of the disease. This has not been described before for treatment of Blount’s disease. Both coronal and axial deformities were corrected in this patient. We propose this combination (rather than the lateral growth modulation alone) as the method of treatment for early stages of Blount’s disease as it corrects both elements of the disease and in the same time avoids the complications of proximal tibial osteotomy.