Les ostéotomies fémorales et tibiales autour du genou chez l'enfant:Quand et pourquoi?

1. Osteotomy around the knee
in children: when and why?
F. Moungondo ,R. Elbaum
Service d’orthopédie
Hôpital Erasme

2. Introduction
• In young children or
adolescent,most of frontal
knee defformity can be
correct without osteotomy
only by simple epiphysiodesis
(staple,scews or growth plate).
• In some cases when the
deformity is too complex or
when the patient is too old ,
knee osteotomy is the only
solution to restaure anatomy.

3. Just a little remind
The variation of the normal pattern

4. Physiologic evolution in the frontal
plane

5.  ligament laxity
 weight-bearing
Variation of the measurements
10 cm 4 cm

6. VARIATIONS
Obese adolescents = False knock-knee
Abnormal fat distribution
10cm

7. Axe diaphysaire F et T en
charge
Use of the metaphyseal-diaphyseal angle in the evaluation
of bowed legs.
J Bone and Joint surg. 1993 Nov;75(11):1602-9.
Feldman MD1, Schoenecker PL.

8. - 5°
0°
+ 5°
2 Y 4 Y 12 Y 15
G. Varum
G. Valgum
M
EVOLUTION OF THE TF ANGLE IN THE FRONTAL PLANE
F

9. Normal femoral and tibial torsion
Torsion :
Is the turning of a
bone on its longitudinal axes.
As a result the upper and
the lower epiphysis are not
in the same plane

10. Femoral anteversion
angle :
Fabry (1973)
Tibial torsion angle :
Dupuis ( 1951)
Jend (1981)
ROTATIONAL NORMS IN HEALTHY CHILDREN
Rotational angles vary with age

11. 5 Y 1O Y 15 Y
30°
15°
10°
5°
40°
20°
10°
FA
Lat. T.T.
EVOLUTION
OF THE NORMAL FEMORAL AND TIBIAL TORSION / AGE

12. Consequences of constitutional
angular deformities
Do severe angular deformities induce
osteoarthritis of the knee ?
Modifications of TF angle
Alteration of distribution of loads on the
knee
Osteoarthritis

13. No prospective study on the long term
of angular deformities
However

14. Consequences of constitutional
rotational deformities
Do severe rotational deformities induce
osteoarthritis of the knee and hip ?
Exaggerated torsion
Alteration of the loads on hip or knee
osteoarthritis

15. No prospective and longitudinal study
on the long term of rotational deformities
However

16. Knee growth potential

17. Indication of osteotomy around the
knee in children and adolescent
FEMORAL OSTEOTOMY
• Post acquired epiphysiodesis
(septic,traumatic…)
• Posttraumatic deformity
• Idiopathic malalignement (Genu
Valgum,Genu Varum; Femoral
hyperantetorsion)
• Flexion contracture
arthrogryppotic,IMOC,Polio
• Congenital deformity
(PFFD,neurofibromatosis,OI…)
• Acquired deformity (Rickets,blount
disease…)
• ….
TIBIAL OSTEOTOMY
• Tibia vara (Blount disease)
• Postraumatic deformity
• Idiopathic Malalignement
(Excessive tibial torsion, genu
varum or valgum)
• Congenital (Tibial hypoplasia,
hemielia,OI, CPT…)
• Aquired Genu varum
(Rickets,Blont disease…)
• Postraumatic
• Focal chondrodyspalsia
• ….

18. Mechanical axis

19. But we know that mechanical axis is a little
bit medial to center of the knee
Normal : 9±7mm (Paley et al 2004)
4±4mm (Bhave et al)

20. Anatomical Axis (Paley 1994)

21. What about the frontal plane?

22. « Pathological » constitutional
frontal deformities
« Pathological » constitutional angular deformities :
Should be related to the natural history
Frequently found in other members of family
They can be corrected in late chilhood
They must be differentiated from secondary deformities
TF angle exceeding 2 SD around the mean for age and sex

23. Constitutional angular deformity
Patients < 3 years old
24 months
 Constitutional genu varum
ITT
Bow legs
Spontaneous correction

24. Boy 16 years old
Bilat genu varum
Girl 12 years old
Genu valgum I M D : 12 cm
Constitutional angular deformities in
preadolescents

25. Rickets :
Nutritional
Vitamin D resistant
Hypophosphatasia
Infantile tibia vara (Blount)
Metaphyseal chondrodysplasia
Focal fibrocartilaginous dysplasia
Secondary angular deformities in
patients less than 3 Y

26.  Focal Chondrofibrodysplasia

27.  Blount disease • Black ,carribean
• infantile bilat
• adolescent
unilat

29.  Rickets
Genu varum
X ray : widening of
the physis+++

30. 3 Y
Genu varum
ICd = 9cm
Metaphyseal chondrodysplasia

31.  Secondary to :
Trauma
Infection
M.. l. 15 Y
Femoral Epiphysiodesis
Unilateral genu valgum or varum
Secondary angular deformities in
patients more than 10 Y

32.  Secondary to
Carentiel
Neuro
Polyepiphyseal dysplasia
Bone Tumor…

34. Late onset tibia vara (12Y)
Courtesy PL Docquier

35. AND WHAT ABOUT THE ROTATIONNAL
PLANE??

36. Relationships between
rotational malalignment and the patella
Eckhoff (1997) : « the patellar tracking pattern is determined
by the femoral and tibial torsion ».
The patella is subjected to increased stress
due to malalignment syndrome.
Anterior knee pain is associated with triple deformity sd :
Delgado (1996)
Bruce (2004)
Patella instability is related to torsional problems :
Turner ( 1994)
Cameron (1996)

37. Treatment
Outward femoral osteotomy
+
Inward tibial osteotomy
(Delgado 1996)

38. AND WHAT ABOUT THE SAGITTAL
PLANE??

39. flessum defformity

41. Extension deformity (genu recurvatum)
 Iatrogenic (post épiphysiodèse TTA)
 Post trauma
 Post septic

42. Technique de l’ostéotomie tibiale de flexion
pour le recurvatum d’origine tibiale
LECUIRE F, LERAT JL et al.
Le genu recurvatum et son traitement par ostéotomie tibiale
Revue de Chirurgie Orthopédique, 198O

43. Complications of osteotomies about
the knee in children.
“On Sixty-five procedures were performed by a variety of
techniques with the majority being on the proximal tibia.
Postoperative complications were numerous with 63% of
the patients having one or more. These complications
included loss of alignment, vascular complications,
pathologic fractures, wound infection, anterior and
posterior angulation at the osteotomy site, tibial tubercle
prominence and patellofemoral malalignment.”
Myckosie J.P. Orthopedics 1981 Sep 1;4(9):1005-15.

44. CONCLUSION
• In children ,most of pathological knee deformity
can be corrected by simple procedure if some
principles are respect
• If a knee osteotomy is planned ,it has to be
decide after a good explanation to the child and
his parents.
• Type of procedure depends on the surgeon habits
• Be very carefull because complications rate are
not so rare.

45. THANK YOU