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Principle of Deformity Correction in lower Limb
- 1. Principles of Deformity Correction- Lower Limb Presenter Kaushal Raj Kafle Moderator Dr Sharad Adhikari
- 2. Contents • Introduction • Etiology • Clinical assessment • Radiological assessment • Preoperative planning • Management • Principles of osteotomy • Methods of fixation and complications
- 3. Deformity Departure from normal bone or joint anatomy A structural deviation from the normal shape, size or alignment resulting in disfigurement Significant when it compromises the patients function
- 4. Axes of Deformity • X Y Z plane • 6 degree of freedom • Angulation, translation and rotation • Length – axial translation
- 5. Consequences • Primary – Change in mechanical axis of limb on weight bearing – Affects individual joint orientation • Secondary – Compensation by other joint by changing their motion of arc – Joint contact pressure affected > Unphysiological load > Degeneration – Muscle fatigue and pain in attempt to maintain unphysiological joint position
- 6. Compensation at adjacent bones – Active Physes – Anatomic correction unmasks the secondary deformity – Correction till limb aligns clinically puts joint in obliquity to mechanical axis – Anatomic normal state requires two osteotomies at two bones – Significant Morbidity
- 7. Difference in Upper limb and Lower Limb • Affects the arc of motion • Disturbs forearm functional unit • Length asymmetry well tolerated • Cosmetically better tolerated • Degeneration not much of problem
- 8. Etiology • Paediatric – Congenital • Adolescent – Developmental – Physeal arrest • Adult – Trauma • Elderly – Metabolic – Long term sequalae of malalignment
- 9. Causes • Congenital – Fibular hemimelia – Proximal Femoral focal deficiency • Post Traumatic – Malunion – AVN – Non union with malalignment – Physeal arrest • Developmental – Blounts disease – Diaphyseal aclasia • Metabolic – Rickets – Paget’s disease • Infection – Meningococcal septicemia with physeal arrest – Osteomyelitis • Tumor • Degenerative – Genu Varum
- 10. Approach to Deformity 1. Determine if it is abnormal? 2. Define its characteristics. 3. Determine if it needs treatment ? 4. Generate treatment plan.
- 12. Clinical Assessment • History – Need for consultation : cosmetic VS functional – Functional limitation and effect on activity of daily living – Pain and its characters – Other Conditions: Dysplasias, Metabolic, Non skeletal condition – More than one deformity – Progression of deformity
- 13. Examination • Bony deformity – Angular, rotational, translational and axial • Associated condition – Joint contracture – Soft tissue condition – Skin condition – Complete neurovascular assessment
- 14. Examination • Inspection – Coronal (varus or valgus) – Sagittal (apex anterior or posterior) • Compensation for a leg length discrepancy • Length assessment – Wooden Block – Length measurement – Galeazzi test
- 15. Examination • Rotational Deformity – Craig test – Thigh Foot angle – Transmalleolar Axis – Heel bissector line – Foot progression angle
- 16. Radiographic Assessment • Aim – Plane (Frontal/Sagittal/Coronal) – Direction (Varus/Valgus; Anterior/Posterior) – Bone and Joint (Tibia/Femur; Hip/Knee/Ankle) – Segment of Bone (Epiphysis/Metaphysis/Diaphysis) – Apex – Magnitude
- 17. • Standardized X Ray – AP and lateral views – 100% magnification – Including hip knee and ankle – Standing – Patella facing forward (Between Femoral condyles) – LLD corrected with blocks • Contralateral Limb as Reference
- 18. Scanograms CT Topograms Measures overall leg length and tibial and femoral lengths. • CT – Torsional abnormalities with axial CT scans. – 3D templating and printing – Accurate planning
- 19. Axis of long bone Mechanical Axis (MA) • Line Joining the centre of joints proximal and distal to the the bone Anatomical Axis (AA) • Line joining the multiple centre points of transverse diameter along the length • Tibia : MA = AA • Femur MA not equal AA
- 20. Mechanical axis • Always straight whether frontal or sagittal plane. • Measures varus and valgus alignment
- 21. Anatomical Axis • Normal bone-single straight line. • Deformed bone with angulation each bony segment has its own anatomic axis.
- 22. MAD / Malalignment • Loss of colinearity between hip, knee and ankle • Distance between MA and centre of knee – Medial : Varus – Lateral : valgus • Deformity around Joints with large ROM are well tolerated.
- 23. Joint Orientation line • Relation of joint axis to the AA and MA • Both in frontal and sagittal plane. • Knee JOL 3o valgus • JCLA • Ankle JOL parallel to floor to 8o valgus
- 24. JOL in saggital plane • Posterior slope of the tibial plateau (normal 7–9o) • Anterior slope of the tibial plafond (normal 7–10o) • Tibia recurvatum / procurvatum
- 25. Joint Orientation Angle • Relation between anatomical or mechanical axis with the joint orientation lines • LDFA n – 2o Valgus with MA – 7o Valgus with AA • MPTA – 1-3o Varus with MA/AA • LDTA
- 26. Centre of Apex of Rotation (CORA) • Diaphysis : Intersection of the proximal axis and distal axis of a deformed bone • Metaphyseal or Juxtaarticular : Intersection of the Line perpendicular to JOL and middiaphyseal line of deformed bone • Surgeon has no control over CORA
- 27. CORA • Multiapical Deformity : More than one CORA • CORA and Apex of deformity do not coincide : Additional Translational deformity • CORA in both frontal and sagittal plane : Oblique deformity
- 28. Bisector Line • Line that passes through the CORA and bisects the angle between proximal and distal half of deformity • Angular correction around bissector realigns of anatomic and mechanical axes without introducing iatrogenic deformity
- 29. Angulation Correction Axis (ACA) • Axis of rotation around which correction takes place • Can be different from CORA or Osteotomy site • Surgeon has some control over ACA and osteotomy site
- 30. Preop Planning/Templating • Pencil and Scissors • Dedicated softwares – mediCAD AO Osteotomy software – TraumaCad Digital Orthopedic Templating – Bone Ninja
- 31. Steps in Planning Correction • Measuring all parameters in systematic manner to determine the site and amount of CORA
- 32. Final Outcome • Relative position of CORA, ACA and Osteotomy site decides the final position of bone segments.
- 33. Management • Goal – Improve the function of limb and patient • Surgical Aim – Accurate Correction – Early Union – Maintenance of Joint ROM – Early Weight bearing – Low incidence of post op complication
- 34. Corrective Surgery • Balancing anatomical ‘normality’ with the anticipated gain in function. • ‘Anatomical’ correction, desirable, is not always necessary.
- 35. Factors affecting Correction Acute Gradual Age Well established deformity Skeletally immature patient Amount Less than 15-20 degree Greater deformity Site Neurovascular structure on concave side Soft tissue Poor vascularity, poor elasticity Scarring and tethering of vessels Compromised healing, infection and necrosis Associated LLD Recommended General Medical Condition Diabetes, use of steriod and NSAIDs, smoker,
- 36. Correction : Acute • All deformity corrected at once : immediate satisfaction • Quicker return to activity • Accuracy of correction • No further adjustments • Soft tissue and NV under tension • Translation component may hinder fixation • Only limited amount of lengthening
- 37. Correction : Gradual Gradual • Allows adjustments • Allows certain amount of axial loading • Bone resections can be avoided • Simultaneous limb lengthening is possible along with correction of angular and rotational deformity • Cumbersome fixation devices • Frequent Clinic Visits • Prolonged rehabilitation
- 38. Growth Modulation • Hemiphyseal stappling /Percutaneous screw across physis – Symmetric Angular deformity • Advantage – Low surgical morbidity – Reversibilty of growth deceleration after staple removal • Disadvantage – Uncertain nature – Recurrence – Continued angular growth
- 39. Osteotomy 1. Angulation-only osteotomies • Opening wedge • Closing wedge 2. Angulation with translation osteotomies. • Circular cut (dome) • Oblique cut
- 40. Principles of osteotomy • Uniapical deformity with CORA, ACA and Osteotomy in same plane • Proximal and distal bone axis become collinear and are realigned with no translation
- 41. • ACA is through CORA, Osteotomy at different level • Axis will realign with angulation and translation
- 42. • Osteotomy and ACA is away from CORA • Secondary translational deformity will occur.
- 43. CORA and Apex of deformity at different level
- 44. • CORA lies outside the boundaries of the involved bone, a multi-apical deformity is present • Deformity more akin to a curve • Requires multiple osteotomies.
- 45. Dome Osteotomy • More cylindrical than spherical • Osteotomy site does not pass through the mutual CORA correction axis • Obligatory translation • Principle of Wedge Osteotomy holds true for Dome osteotomy
- 46. • Axis of correction – Convex border: Opening Dome – Concave Border: Closing dome – At the axis : Neutral Dome
- 47. Internal Fixation • Plates and screws • Percutaenous pins • Acute correction • Rigid fixation • Versatile for peri-articular deformities • Direct visualisation • Extensive soft tissue dissection • Limitation of weight bearing • Inability to correct shortening
- 48. Internal Fixation • Intramedullary devices • Diaphyseal deformity • Metaphyseal diaphyseal deformity • Osteopenic bone
- 49. External Fixation • Minimal soft tissue dissection • Minimal infection • Post op adjustment • Axial translation, angular deformity correction • Longer healing time • Slower mobilization • Potentially complex surgery • Poor patient acceptance and compliance • Illizarov ring fixators • Garches clamp • Taylor spatial frames
- 51. Complications • General – Infection , thromboembolism • Undercorrection/ Overcorrection • Nerve tension – Acute correction avoid >20o • Compartment Syndrome • Non Union
- 52. Summary • Deformity and its correction is a fundamental part of orthopedic surgery. • A balanced and matured approach is needed as every deformity does not require correction. • Personality of Deformity must be well understood before planning any corrective surgery. • Relative position of CORA, ACA and Osteotomy site determines the final outcome. • Though exacting procedures, use of various planning tools, osteotomy techniques with various fixation methods has made deformity correction more straightforward .
- 53. References Apley and Solomon's System of Orthopaedics and Trauma, 10e Tachdjian's Pediatric Orthopaedics Principle of deformity correction, Butcher and Atkins (Current Orthopedics) Relevant online articles.
- 54. Thank you • Next presentation – Coxa Vara by Dr Aakash Prabhakar
Editor's Notes
- Deformity correction is a very much fundamental part of orthopedic surgery ORTHOPEDICS etymoloically means making a straightened child Focus on the angular deformity as LLD was discussed previously by Nitish sir in previous presentation
- Axis of deformity Rotational deformity along the long axis
- If compensations are not addressed we may inadverntly land up in secondary deformity
- Distal femoral valgus deformity Mild varus deformity ta proximal tibia which partially compensates What level of deformity is sufficient to warrant two bone, two level osteotomy, how much angular deformity can be left untreated and without significant morbidity is a matter of conjecture.
- Upper arm are more of the limb with function in space while lower limb are more of weight bearing and mobilization. Essentially non weight bearing joints Unlike in lower limb requirement of mobility aids and degenerative changes in the subsequent joints does not cause much of problem.
- Physeal arrest : fracture, infection, irradiation, surgical injuries, periphyseal fractures, Assymetrical physeal arrest : periphyseal fracture , enchondroma, osteochondroma
- Systemic causes : renal metabolic diseases, vit d resistant rickets, Generalised bone conditions: enchondromatosis, osteochondromatosis, Osteogenesis imperfecta Trauma : Cozens phenomenon
- Symmetrical physiological varus : 18-24 months Valgus deformity : maximum at 3 Mature lower limb alignment of 5-7 valgus by 6-8 years of age with leveled pelvis and medial femoral condyles and medial malleoli touching on either limbs. Minor variations are common and normal. Slightly higher in females. Foot progression angle : -5 to +20 degrees Thigh foot angle : 5 IR in infant which progress to 10 ER in 8 years ‘ Transmalleolar axis : 15 IR at birth and 15 ER during growth
- How long the defromity has been perceived, rate of evolution , antecedenat trauma or infection
- Standing alignment , Joint ROM and stability, LLD, Limb function during walking/ running Periarticulat deformity have compensatory fixed deformity at adjacent joint, correction without addressing compensatory joint deformity results in straight joint with maloriented joint Source of deformity can be Soft tissue contracture, muscle spasm or paralysis , joint dislocation or malformation,
- This method takes into consideration the heel height, but cannot be used in the presence of knee or hip contractures Tilting pelvis down towards affected side Ankle of short limb held in equinus, Long limb can be flexed at knee A
- The compensation of the lower limb to rotation is mostly guided by two parameters the FOOT PROGRESSION ANGLE while walking and the Orientation of KNEE JOINT AXIS while running and hence the pelvis hip and foot accommodate according to ease the two. Hip Internal Rotation to identify Femoral anteversion >15 retroversion <8 degree TFA : Tibial torsion normal infants (5 IR ) 8 yrs (10 ER) >10 ER is abnormal Transmalleolar axis > 15 IR abnormal Foot progression angle -5 to 20
- Eliminates compensation, reduces magnification error, Repeatable If patella is subluxed this may not be use ful then you have to do Flexion extension of knee joint If the contra-lateral limb is abnormal, then standard reference measurements and angles can be used.
- any contribution from the feet or angular deformity from the non-weight bearing joints will not be assessed and flexion deformity of hip or knee will result in measurement errors. Xray are 2D images while deformity exist in 3D
- Femur AA straight in AP curved in Lat Tibia AA anterior 1/5 of prox tibia and centre of ankle joint Limb Alignment is the mechanical axis of entire limb
- Falls just medial to the centre of knee (8mm
- Mechanical Axis Deviation Some author consider Normal:1-15 mm medial to joint center >15 mm varus deformity. <1mm valgus deformity Frontal plane MAD well defined and more deleterious than sagittal at knee Sagittal plane deformity are well tolerated as it is compensated over the ROM In Hip knee and ankle, however the coronal plane deformity around the knee is least tolerated. Joints with large ROM and the deformity adjacent to them are well tolerated.
- Joint Line Congruity Angle : angle bewteen the lines between two femoral condyles and two tibial plateaus are parallel (>2 abnormal) , ligamentous laxity
- PPFA ANSA PDFA PPTA ADTA Normative values for relations among various paramaters used to assess deformity
- Crucial parameter for surgical planning / site of osteotomy or hinge in any angular deformity Juxta articular deformities are difficult to characterize hence the use of JOL is used
- Oblique defromity complex and greater than what seems in AP and lateral Xray Apparent CORA Oblique deformity characterization can be done using trigonometric methods and specilaised formulations are there.
- All points on the bisector can be considered as the CORA because: angulation about these points will result in re-alignment of the deformed bone Transverse and horizontal bisector Moving ACA away from CORA in bisector line changes the length, on concave side decreases length and on convex side increases length
- Hinge along which the bone will be rotated
- A Distal femoral valgus deformity B Mechanical Axis of entire limb : Varus malalignment C Mechanical Axis of Femur and tibia D Joint Orinetation line E Joint Orientation angle F CORA by using line perpendicular to JOL two possible sites of osteotomy distal along CORA proximal Away from CORA G osteotomy and ACA at CORA : Opening Wedge Osteotomy H Osteotomy away from ACA and CORA : Translation but mechanical alignment is maintained .
- Improve the current and long term function Cosmesis alone is never an indication however when it is sufficient to cause cosmetic problem, it is often the case that the function is compromised. Patient generally present with symptoms and deformity , the management is simpler. But in asymptomatic patient with deformity, it is a challenge. Informed and shared decision should be made after discussing the effects of deformity, and consequences of treatment.
- Scaring tethering of neurovascular structures Overlying soft tissue for skin flaps and grafts
- Incomplete bone to bone contact, incongruences in the medullary canal and bony cortices may hinder stable fixation methods
- Asyymetrical Deceleration of growing bones by inserting screws Variation : percutaneous screw placement by stevens belle and metazeiu distal tibial valgus deformity by a percutaneously inserted medial malleolar screw
- Ideally angular deformity should be corrected at apex of deformity (Metaphysis and Diaphysis) Ape at epiphysis and physis this is not possible
- No secondary deformity and hence can be fixed Moving ACA away from CORA in bisector line changes the length, on concave side decreases length and on convex side increases length Neutral : correction distracts the concave site and compresses the convex side
- If the rotation axis is not placed on the bisector, a translation deformity will ensue despite satisfactory correction of angulation Though bone is collinear there will be slight zigzag deformity Useful in periarticular deformity where segment is small, osteotomy can be moved away such that it gives adequate space for application of fixation devices
- Usually a complication however can be used to advantage when there is preexisting translational deformity Further away the ACA from CORA more is the translation Moving ACA away from CORA in bisector line changes the length, on concave side decreases length and on convex side increases length
- Angulation with translateon The converse of which is
- Resolved CORA Osteotomy at resolved CORA may align the mechanical axis but the bone may look crooked and deformed.
- Congruent Convex and Concave surfaces Removal of bone is rearely required as the movement of one bone is rarely impeded by the shape of the osteotomy
- Simple steinman pin Added casts
- Both acute and delayed Delayed healing mostly with angular correction ‘
- Orthofix monolateral fixation devices 2 rings fixed to limb with wires and half pins and 6 adjustable struts Illizarov : Callotasis, Distraction Histeogenesis
- Rather than cosmesis, the deformity is significant when it compromises the patients function and activity of living. Deformity is much complex than seen in Xray. Exacting : making great demands on one's skill, attention, or other resources.
- Principle of maluniomn by Brinker and ‘connor 2014 Principle of deformity correction butcher 2003 (Current Orthopedics) Limb lengthening and Reconstrcution surgery atlas PODC Hamdy 2015 Paleys principle of Deformity correction Herzenberg