genu varum osteotomy more biological safe and easy to apply with good results

1. ‫م‬‫ي‬‫ح‬‫الر‬‫من‬‫ح‬‫الر‬‫هللا‬‫م‬‫س‬‫ب‬

2. Ahmed Abd

3. INTRODUCTION
• Genu varum, or bow legs, is a very common childhood angular deformity.
• Parents are mostly concerned with the cosmetic appearance of their children.
• There are many treatment options determined according to the cause of genu
varum and its progression.

4. INTRODUCTION
• The surgical correction ranges from manipulation of physeal growth by
hemiepiphysiodesis up to mechanical axis correction via an osteotomy.
• The valgus corrective osteotomy could be performed acutely or gradually.

6. Malalignment Test (MAT)
• Malalignment test is designed to identify thesources of mechanical axis deviation.

7. 1) Opening wedge osteotomy
2) Closing wedge osteotomy
3) Oblique osteotomy
4) Serratedosteotomy(W/M osteotomy)
5) Focal dome osteotomy
6) Anteriorposteriorinverted-‘U’osteotomy

8. Ultrasound was previously used to asses fracture
healing by following new vessel formation at the
fracture site during development of the fracture
callus.

9. AIM OF THE WORK

10. AIM OF THE WORK
Evaluating the results of surgical correction of bow legs / genu varum in children and
adolescents using percutaneous drilling tibial osteotomy and the effect of the osteotomy on the
intactness of the periosteoum at the osteotomy site.

11. PATIENTS

12. 1) Age
Range (4 to 16 years) mean age 6 ±4.3 years.
2) Gender
7 boys (58.3%) 12 limbs
5 girls (41.7%) 9 limbs.
3) Side affected
9 (75%) bilaterally
3 (25%) unilaterally.
PATIENTS
 Prospective study from July 2014 to August 2016.
 21 limbs in 12 patients.
 Presented to El – Hadra Orthopedic and Traumatology University Hospital.

13. 4) Gait
4 (33.3%) normal gait
8 (66.7%) intoeing gait bilaterally
5) Thigh foot angle
Range 0◦ to -15◦ mean of -6.67◦ ±5.08.
6) Knee laxity
3 (14.3%) +ve lateral ligamentous laxity
18 (85.7%) –ve knee laxity.
7) Tibio-femoral angle (TFA)
Range -30◦ to -10◦ mean of -18.76◦ ±5.72◦
8) Medial proximal tibial angle (MPTA)
Range 60◦ to 83◦ mean of 71◦± 5.97
PRE-OPERATIVE FINDINGS
Follow-up period of at least 6 months.

14. METHODS

15. 1. Personal data.
2. Complaints.
3. History taking.
4. Examination:
• General examination.
• Local examination.
5. Laboratorystudy:
• Serumcalciumlevel.
• Serumphosphorus level.
• Serumalkalinephosphatase level.

16. mLDFA
MPTA
mLDTA
TFA
1. Themechanicalaxis of thelower limb .
2. Measuremnet of:
 Thetibio-femoralangle(TFA) .
 TheMetaphyseal-Diaphysealangle(MDA).
 Themedialproximal tibial angle(MPTA).
 Themechanicallateral distalfemoral angle
(mLDFA)

17. • Surgicaltreatmentusing percutaneousdrilling tibialosteotomy.
• A sharp3.2 mm drill bit wasusedtomakemultiple bicorticalperforations.
• Osteoclasiswasperformedwithmanualcorrectionofthevarusandrotationaldeformity.
• A well mouldedabovekneeplastercastwasapplied.

20. • 1st post-operative day monitoring of distal circulation and neurological
status
• 10th post-operative day periosteum was examined for its intactness
using the ultrasound.
• 6th post-operative week check radiographs to assess union.
• 8th post-operative week cast removed - knee and ankle exercises were
encouraged.
• 6th post-operative month to assess the final correction.

21. Clinically: At the end of follow up all patients were clinically assessed according to modified
Garcia-Cimberloet al criteria:
1. Boneconsolidation
2. Boneinfection
3. Neurovascularinjury
4. Residualdeformity (using TFangle)
5. Kneemotion
6. Ankle motion
7. Limb-lengthdiscrepancy
8. Scars
9. Patient/ parents'evaluation
RADILOLOGICALLY: long standingantero-posteriorviews ofbothlower extremitiesfromhips to
ankles.

22. RESULTS

23. • 17 limbs (81%) good (satisfactory) results
• 4limbs (19%) poor (unsatisfactory)results
• No case had a fair results

24. Full in all1) Bone consolidation
NIL2) Bone infection
NIL3) Neurovascular injury
4) Residual deformity
17 cases <10% residual deformity (good cases)
4 cases >20% residual deformity (poor cases)

25. FROM in all5) Knee and ankle motion
NIL6) Limb length discrepancy
All cosmetic7) Scars
All good8) Patientsparents' evaluation
The improvement in themean thigh-
footangle value washighly significant
9) Correction of thigh-foot angle
(clinical assessment of tibial torsion)

26. 10) Radiological assessment of residual varusdeformity
a) Correctionof tibio-femoralangle (TFA)
• Meanpre-operative TFA -18.76◦±5.72
• At theend of follow-up -2.24◦ ±5.04
• Theimprovementinthe mean TFA valuewas highlysignificant (p<0.001)
b) Correctionof medialproximal tibial angle (MPTA)
• Meanpre-operative MPTA 71◦ ± 5.974
• At theend of follow-up 87◦ ± 4.79.
• Theimprovementinthe mean MPTAvalue was significant (p<0.001)

27. 1) Relationbetween
thefinalresults
andthe ageof the
cases
• Patients≤10 yearshadgoodresults.
• Patients>10 yearshadpoorresults.
• It was found that, there was a significant correlation between the final
resultsandtheageofthe patients.
2)Relation between
the end results
and the sexof the
cases
There was a statistically insignificant correlation
between sex and the final endresult.

28. 3) Relation between the
end results and pre-
operative knee laxity
4) Relation between the
end results and the
thigh-foot angle
• There was a significant correlation between the pre-
operativethigh-footangleandthefinal results.
• In goodcasesall legs hadnegativelaxity.
• In poorcases3 legs (75%) hadpositivelaxity.
• knee laxity was associated with poor results and this was
statisticallysignificant.

29. 5) Relation between the
end results and the
Tibio-Femoral angle
(TFA)
• In good cases was 0◦
• In poor cases ranged from -18◦ to -8◦ with a mean -11.75◦±4.5◦
• There was a significant relationship between the improvement
of the TFA and the end result.
6) Relation between the
end results and the
intercondylar distance
(ICD) of the cases
• There was an insignificant correlation between the
pre-operative intercondylar distance ICD and the final
results.

30. `
7) Relation between end
results and intactness
of the periosteum on
ultrasound (US)
• In good cases 2 cases disruptedperiosteum 15 casesanintactperiosteum
• In poor cases 2 disruptedperiosteum 1 caseintactperiosteum
• There was insignificant relationship between the end results and
intactnessof theperiosteum on U/S
8) Relation between the
end results and
radiological union
• Therewas a significant relationship between the
end result and radiological union.

31. CASES

32. • A 4 -year-oldgirl withpost-rachiticbilateralgenu varum.
• Inter-condylardistance 13cm .
• Thigh-footangles -15°on theright side & -10°onthe leftside.
• TFA -29°on theright side & -22°onthe leftside.
• MDA 10°bilaterally.
• Aftersix monthsof followupthe thigh-footanglewas 0°bilaterally,andtheTFA was0°.
Patient 1

33. • An 11-year-old femalewithbilateralgenu varum
• Theinter-condylardistance 13cm
• Thigh-footangle 0°bilaterally
• kneelaxity positivebilaterally
• TFA -24°ontheright& -19°ontheleftside
• During Osteoclasis of the tibia iatrogenic Salter Harris type II injury of the proximal physis of the tibia
occurredontheleftside
• Aftersix monthsof followup,TFA was-18°ontherightside &-11°ontheleftside.
Patient 2

34. CONCLUSIONS AND
RECOMMENDATIONS