Dr. Rami Abo Ali

1. ORTHOPEDIC SURGERY
Dr. Rami Abo Ali
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
1

2. PEDIATRIC ORTHOPEDIC ( 2 )
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
2

3.  Genu Valgum (knocked knees)
 Blount's Disease
 Infantile Blount's Disease (tibia vara)
 Adolescent Blount's Disease
 Clubfoot (congenital talipes equinovarus)
 Flat foot
 Flexible Pes Planovalgus (Flexible Flatfoot)
 Rigid flatfoot
 Tarsal coalition
 Congenital vertical talus
 Sever's disease
 Kohler's Disease
 Adolescent Knee Pain:
 Osgood Schlatter's Disease
 Sinding-Larsen-Johansson syndrome
 Patellar Tendinitis
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Orthopedic
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Dr.
Rami
Abo
Ali

4. GENU VALGUM (KNOCKED KNEES)
 Genu valgum is a normal physiologic process in children
 therefore it is critical to differentiate between a physiologic and pathologic
process
 distal femur is the most common location of primary pathologic genu valgum
but can arise from tibia
 Normal physiologic process of genu valgum
 between 3-4 years of age children have up to 20 degrees of genu valgum
 Children’s legs usually become aligned by the time they are about 7 years
old
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Orthopedic
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Dr.
Rami
Abo
Ali

5. GENU VALGUM (KNOCKED KNEES)
 Etiologies
 bilateral genu valgum
 physiologic
 renal osteodystrophy (renal rickets)
 skeletal dysplasia
 unilateral genu valgum
 physeal injury from trauma, infection, or vascular insult
 proximal metaphyseal tibia fracture
 benign bone tumors
 Symptoms
 symmetric inward angulation of the knees
 ankles remain apart ( >10cm ) while the knees are touching
 unusual walking pattern
 outward rotated feet
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Orthopedic
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Dr.
Rami
Abo
Ali

6. GENU VALGUM (KNOCKED KNEES)
 Treatment
 Nonoperative
 Observation : first line of treatment
 genu valgum <15 degrees in a child <6 years of age
 Bracing :rarely used
 Operative (osteotomy )
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

7. GENU VARUM
 Genu varum is a normal physiologic process in children
 physiologic genu varum :
 genu varum (bowed legs) is normal in children less than 2 years
 genu varum migrates to a neutral at 14 months
 continues on to a peak genu valgum (knocked knees) at 3-4 years of age
 genu valgum then migrates back to normal physiologic valgus at 7 years
of age
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Orthopedic
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Dr.
Rami
Abo
Ali

8. BLOUNT'S DISEASE
 Blount's disease is progressive pathologic genu varum
centered at the tibia
 Best divided into two distinct disease entities
 Infantile Blount's
 pathologic genu varum in children 2 to 5 years of age
 male > female
 more common
 bilateral in 50%
 Adolescent Blount's
 pathologic genu varum in children > 10 years of age
 less common
 less severe
 more likely to be unilateral 8
Orthopedic
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Dr.
Rami
Abo
Ali

9. BLOUNT'S DISEASE
 Etiology
 likely multifactorial but related to mechanical overload in genetically
susceptible individuals including
 excessive medial pressure produces an osteochondrosis of the medial
proximal tibial physis and epiphysis
 osteochondrosis can progress to a physeal bar
 Risk factors
 overweight children
 early walkers (< 1 year)
 African American
 Clinically, the child often presents with leg bowing (tibia vara) with little
or no associated pain
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Orthopedic
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Dr.
Rami
Abo
Ali

10. BLOUNT'S DISEASE
 metaphyseal-diaphyseal angle (Drennan)
 angle between line is drawn along the slope of the metaphysis,and
a line perpendicular to the longitudinal axis of the tibia
 >11 degrees is considered abnormal
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Orthopedic
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Dr.
Rami
Abo
Ali

11. BLOUNT'S DISEASE
Infantile Blounts Adolescent Blounts
Age 2-5yrs >10yrs
Bilaterality 50% bilateral Usually unilateral
Severity More severe physeal/epiphyseal
disturbance
Less severe physeal/epiphyseal
disturbance
Natural
History
Self-limited - stage II and IV can
exhibit spontaneous resolution
Progressive, never resolves
spontaneously
Treatment
Options
Bracing and surgery Surgery only
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

12. BLOUNT'S DISEASE
 Radiographic features
 The tibial shaft is in the varus position, and the epiphysis is wedge-shaped,
fragmented or can appear absent
 Treatment
 Treatment depends on the subtype and stage. As a general rule:
 infantile or early stage: often conservatively managed (brace treatment )
 adolescent or late stage: a proximal tibial osteotomy is often considered
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

13. CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
 Idiopathic deformity of the foot of unclear etiology
 Most common musculoskeletal birth defect
 overall incidence 1:1000 , though some populations
1:250
 Africans : 2-3 per 1000
 Male : female ratio approximately 2:1
 50% of cases are bilateral
 Genetic component is strongly suggested
 unaffected parents with affected child have 2.5% -
6.5% chance of having another child with a clubfoot
 Monozygotic twins 32.5% coincidence
 Dizygotic 2.9%
 Familial occurrence in 25% 13
Orthopedic
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Dr.
Rami
Abo
Ali

14. CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
 Muscle contractures contribute to the characteristic deformity that
includes (CAVE)
 Cavus of mid foot (tight intrinsics, FHL, FDL)
 Adductus of forefoot (tight tibialis posterior)
 Varus of hind foot (tight tendoachilles, tibialis posterior, tibialis
anterior)
 Equinus of hind foot (tight tendoachilles)
 Bony deformity consists of medial spin of the midfoot and forefoot
relative to the hindfoot
 talar neck is medially and plantarly deviated
 calcaneus is in varus and rotated medially around talus
 navicular and cuboid are displaced medially
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Orthopedic
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Dr.
Rami
Abo
Ali

15. Orthopedic
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Dr.
Rami
Abo
Ali
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Cavus of mid foot Adductus of forefoot
Equinus of hind foot
Varus of hind foot

16. Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
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17. CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
 Physical exam
 small foot and calf
 shortened tibia
 medial and posterior foot skin
creases
 foot deformities
 hindfoot in equinus and varus
 midfoot in cavus
 forefoot in adduction
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Orthopedic
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Dr.
Rami
Abo
Ali

18. CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
 Radiographs
 dorsiflexion lateral (normally
measure between 35° - 50°)
 shows hindfoot parallelism
between the talus and calcaneus
 will see talocalcaneal angle < 25°
 AP
 talocalcaneal angle is < 20°
(normal is 20-40°)
 talus-first metatarsal angle is
negative (normal is 0-20°) -- talus
points lateral to first metatarsl
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

19. CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
 Treatment
 Nonoperative
 Ponseti method of serial manipulation and casting
 Ponseti method is the gold standard in most of the world
 Ponseti method has a > 90% success rate in avoding comprehensive
surgical release
 children can be expected to walk, run and be fully active in the
absence of other comorbidities
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

20. CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
 Ponseti method of serial manipulation and casting
 goal is to rotate foot laterally around a fixed talus
 order of correction (CAVE)
1. Cavus
2. Adductus
3. Varus
4. Equinus
 Heel cord tenotomy needed in at least 80-90% of children in most
series
 Foot abduction orthosis (FAO)
 critical for long-term success
 FAO noncompliance is the biggest risk factor for deformity
recurrence
 FAO use is ~full-time for 3 months and then at night (+/- naps)
for 2-4 years
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Orthopedic
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Dr.
Rami
Abo
Ali

21. CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
 Operative
 posteromedial soft tissue release and tendon lengthening
 medial column lenthening or lateral column-shortening osteotomy
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Orthopedic
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Dr.
Rami
Abo
Ali

22. CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
 Complications
 deformity relapse
 rocker bottom deformity
 residual cavus
 pes planus
 undercorrection
 osteonecrosis of talus
 dorsal bunion
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Orthopedic
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Dr.
Rami
Abo
Ali

23. FLAT FOOT
 There are two general types of flatfoot:
 flexible flatfoot
 rigid flatfoot.
 In flexible flatfoot, the foot has a normal arch at rest (not
standing or walking), but it disappears once it comes in
contact with the ground. If there is no arch, whether sitting or
standing, they have a "rigid" or "true" flatfoot.
 Rigid flatfoot
 Conginital (Tarsal coalition ,Congenital vertical talus)
 Acquired flatfoot" or "posterior tibial tendon dysfunction
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Orthopedic
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Dr.
Rami
Abo
Ali

24. Flat foot
Flexible
flatfoot
Rigid flatfoot
Tarsal coalition
Congenital
vertical talus
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

25. FLEXIBLE PES PLANOVALGUS (FLEXIBLE FLATFOOT)
 Physiologic variant consisting of a decrease in the medial longitudinal arch
and a valgus hindfoot and forefoot abduction with weight bearing
 This condition is frequently familial and almost always bilateral.
 The medial longitudinal arch of children remained stable from 7 to 9 years
of age
 Epidemiology
 unknown in pediatric population
 20% to 25% in adults
 generalized ligamentous laxity is common
 25% are associated with gastrocnemius-soleus contracture
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Orthopedic
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Dr.
Rami
Abo
Ali

26. FLEXIBLE PES PLANOVALGUS (FLEXIBLE FLATFOOT)
 Anatomy
 The medial arch is formed by the calcaneus, talus, navicular,
three cuneiforms and first three metatarsal bones
 The lateral arch is formed by the calcaneus, cuboid and 4th
and 5th metatarsal bones
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Orthopedic
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Dr.
Rami
Abo
Ali

27. FLEXIBLE PES PLANOVALGUS (FLEXIBLE FLATFOOT)
 Symptoms and examination
 usually asymptomatic in children
 may have arch pain or pretibial pain
 foot is only flat with standing and reconstitutes with toe walking
 valgus hindfoot deformity
 forefoot abduction
 normal and painless subtalar motion
 hindfoot valgus corrects to a varus position with toe standing
 evaluate for decreased dorsiflexion and tight heel cord
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Orthopedic
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Dr.
Rami
Abo
Ali

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Dr.
Rami
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Ali

29. FLEXIBLE PES PLANOVALGUS (FLEXIBLE FLATFOOT)
 Radiographs
 indications
 painful flexible flatfoot to rule out other mimicking conditions
 tarsal coalition (sinus tarsi pain)
 congenital vertical talus (rocker bottom foot)
 accessory navicular (focal pain at navicular)
 rigid flatfoot
 recommended views
 weightbearing AP foot
 weightbearing lateral foot
 evaluate Meary's angle
 weightbearing oblique foot
 rule out tarsal coalition 29
Orthopedic
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Dr.
Rami
Abo
Ali

30. FLEXIBLE PES PLANOVALGUS (FLEXIBLE FLATFOOT)
 Meary's angle will be apex
plantar
 it is an angle subtended from
a line drawn through axis of
the talus and axis of 1st ray
 0 degrees – normal
 0 – 15 degrees – mild
 15 – 30 degrees – moderate
 > 30 degrees – severe
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

31. FLEXIBLE PES PLANOVALGUS (FLEXIBLE FLATFOOT)
 Treatment
 Nonoperative
 observation, stretching, shoewear modification, orthotics
 asymptomatic patients, as it almost always resolves
spontaneously
 counsel parents that arch will redevelop with age
 athletic heels with soft arch support or stiff soles may be helpful for
symptoms
 orthotics do not change natural history of disease
 stretching for symptomatic patients with a tight heel cord
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Orthopedic
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Dr.
Rami
Abo
Ali

32. FLEXIBLE PES PLANOVALGUS (FLEXIBLE FLATFOOT)
 Operative
 Achilles tendon or gastrocnemius fascia lengthening
 flexible flatfoot with a tight heelcord with painful symptoms
refractory to stretching
 calcaneal lengthening osteotomy (with or without cuneiform
osteotomy) rarely indicated
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Orthopedic
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Dr.
Rami
Abo
Ali

33. TARSAL COALITION
 Tarsal coalition describes the complete or partial union between
two or more bones in the midfoot and hindfoot
 It occurs in about 5% of the population and although congenital,
patients typically present in adolescence.
 There is a significant male predilection (M:F 4:1).
 50% are bilateral (even if symptomatic only on one side).
 Pes planus (flat foot) is usually a feature.
 arch of foot does not reconstitute upon toe-standing
 Location
 calcaneonavicular (most common)
 talocalcaneus
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Orthopedic
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Dr.
Rami
Abo
Ali

34. TARSAL COALITION
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Dr.
Rami
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Ali

35. TARSAL COALITION
 Presentation :
 history of prior recurrent ankle sprains
 most coalitions are found incidentally
 75% of people are asymptomatic
 Pain
 Pes planus (flat foot)
 Radiology
 Plain films (AP + lateral + 45° internal oblique) are usually the first
investigation of choice
 CT or MRI is often needed in case of talocalcaneal coalition
 Treatment :
 Non operative observation, shoe inserts immobilization with
casting, analgesics
 Operative
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

36. CONGENITAL VERTICAL TALUS
 Congenital vertical talus is the result of dorsal dislocation of the
navicular on the talus.
 This typically presents as flat feet evident from birth.
 Half of all cases are bilateral and there is a male predominance (M:F;
2:1)
 rigid rockerbottom deformity
 Treatment :Serial manipulation and casting
 If casting fails then surgery at 6 to 12 months of age
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

37. SEVER'S DISEASE
 Common cause of heel pain
 thought to be an overuse injury of the calcaneal apophysis in a
growing child
 commonly seen in immature athletes participating in running &
jumping sports
 frequently seen just before or during peak growth
 exact etiology is unknown
 thought to be due to traction apophysitis and repetitive
microtrauma experienced during gait
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Orthopedic
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Dr.
Rami
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Ali

38. SEVER'S DISEASE
 Symptoms
 pain in the area of the calcaneal apophysis in an immature athlete
 pain increased with activity or impact
 can display warmth, erythema, & swelling
 tight Achilles tendon
 positive squeeze test (pain with medial-lateral compression over the
tuberosity of the calcaneus)
 pain over the calcaneal apophysis
 Radiographs
 diagnosis is clinical as there is no established diagnostic criteria
 sclerosis can be present in both patients with and without calcaneal
apophysitis
 fragmentation is more frequently seen in patients with Sever's
disease
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Orthopedic
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Dr.
Rami
Abo
Ali

39. SEVER'S DISEASE
 Treatment
 Nonoperative
 symptomatic treatment
 modalities include
 activity modification
 Achilles tendon stretches (can help decrease recurrence)
 ice application before and after athletic endeavors
 use of heel cups or heel pads
 NSAIDs
 short leg cast immobilization of persistent pain
 There is no role for operative treatment 39
Orthopedic
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Dr.
Rami
Abo
Ali

40. KOHLER'S DISEASE
 A rare avascular necrosis of the navicular bone of unclear etiology
that usually presents with pain on the dorsal and medial surface
of the foot
 occurs in young children (usually age 4-7 years)
 four times more common in boys than girls
 80% of cases in boys
 can be bilateral in up to 25% of cases
 the blood supply of the central one third of the navicular is a
watershed zone
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Orthopedic
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Dr.
Rami
Abo
Ali

41. KOHLER'S DISEASE
 History
 patient may not have complaints as disease can be asymptomatic
 characteristically described as midfoot pain with an associated
limp
 Symptoms
 pain in dorsomedial midfoot
 may have swelling, warmth, and redness
 point tenderness over the navicular
 Physical exam
 antalgic limp (may place weight on lateral side of foot)
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Orthopedic
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Dr.
Rami
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Ali

42. KOHLER'S DISEASE
 Radiographs
 characteristic sclerosis, fragmentation, and flattening of tarsal
navicular
 most tarsal navicular bones reorganize after disease has run its course
 some continue to be deformed but almost all of those remain
asymptomatic
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Orthopedic
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Dr.
Rami
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Ali

43. KOHLER'S DISEASE
 Treatment
 Nonoperative
 NSAIDs : short course can be used to decrease symptoms
 immobilization with short leg walking cast when pain with activities
 studies have shown treatment in a short leg walking cast will
decrease the duration of symptoms
 radiographs improve at around 6-48 months from onset of
symptoms
 Operative
 not indicated for this disease
 Prognosis
 typically a self-limiting condition
 intermittent symptoms for 1-3 years after diagnosis typically
associated with activity
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Orthopedic
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Dr.
Rami
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Ali

44.  Adolescent Knee Pain
 Osgood Schlatter's Disease
 Sinding-Larsen-Johansson syndrome
 Patellar Tendinitis
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Orthopedic
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Dr.
Rami
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Ali

45. OSGOOD SCHLATTER'S DISEASE
 Also called Tibial Tubercle Apophysitis
 Occurs between ages 10 - 15 years and is usually unilateral.
 more common in boys
 Osgood-Schlatter disease is a common cause of knee pain in
growing adolescents
 Osteochondrosis or traction apophysitis of tibial tubercle
 Etiology of is thought to be trauma due to excessive traction
by the patellar tendon on its immature epiphyseal insertion,
leading to microavulsion fractures.
 risk factors : jumpers (basketball, volleyball) or sprinters
 Characteristic symptoms of Osgood-Schlatter disease are
pain, swelling, and tenderness over the tibial tubercle at the
patellar tendon insertion. There is no systemic disturbance. 45
Orthopedic
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Dr.
Rami
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Ali

46. OSGOOD SCHLATTER'S DISEASE
 Radiographs : irregularity and fragmentation of the tibial
tubercle
 Treatment
 Nonoperative (most cases )
 NSAIDS, rest, ice, activity modification, strapping/sleeves to decrease
tension on the apophysitis and quadriceps stretching
 Operative : ossicle excision
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Orthopedic
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Dr.
Rami
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Ali

47. SINDING-LARSEN-JOHANSSON SYNDROME
 Overuse injury causing anterior knee pain at the inferior
pole of patella at the proximal patella tendon
attachment
 Similar to Osgood-Schlatter's disease which is at the
distal attachment of the patella tendon
 Location : patellar tendon insertion at the inferior pole
of the patella
 insidious onset of pain on anterior aspect of knee after
or during activity
 Physical exam
 tenderness over inferior patella
 swelling
 usually a self limiting process
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Orthopedic
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Dr.
Rami
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Ali

48. SINDING-LARSEN-JOHANSSON SYNDROME
 Nonoperative (most cases )
 activity modifications, NSAIDS, physical therapy
 Operative
 debridement of damaged tissue/stimulation of healing
response
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Orthopedic
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Dr.
Rami
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Ali

49. PATELLAR TENDINITIS
 activity-related anterior knee pain associated
with focal patellar-tendon tenderness
 also known as "jumper's knee“
 Incidence : up to 20% of jumping athletes
 males > females
 insidious onset of anterior knee pain at inferior
border of patella
 more common in adolescents/young adults
 poor quadriceps and hamstring flexibility
 Radiographs usually normal
 Ultrasound findings : thickening of tendon and
hypoechoic areas
 MRI : tendon thickening and edema 49
Orthopedic
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Dr.
Rami
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Ali

50. PATELLAR TENDINITIS
 Treatment
 Nonoperative (most cases )
 ice, rest, activity modification, followed by physical therapy
 cortisone injections are contraindicated due to risk of patellar tendon
rupture
 Operative rarely indicated
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Orthopedic
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Dr.
Rami
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Ali

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Dr.
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Ali