Instructional Course Lecture 2011 Yoon Hae Kwak Dept. of Orthopaedic Surgery Hallym University Sacred Heart Hospital Hallym University Medical Center
Rotational and Angular variations of the lower extremities are the most common parent s concerns. Most of these variations resolve spontaneously through the course of normal growth and development Accurate causative approach! And no unnecessary treatment Normal changes of rotational and angular alignment with age should be known.
Malalignment in the Lower Extremities Rotational variations Angular variations Flatfeet In-toeing Bowing Knock knees Flatfeet
Version ( 전향 ) : rotation of the long bones within normal range - anteversion / retroversion Torsion ( 염전 ) : rotation of the long bones range over 2 standard deviation - medial / lateral torsion - antetorsion / retrotorsion In appearance, Improved by different deformity as malalignment syndrome Aggrevated by over two level deformity
Femoral version Angle between transcervical axis & transcondylar axis Usually anteverted Davids JR(2003) Sugato N (1998)
Tibial version Angle between coronal axis of the knee joint & transmalleolar axis Usually external rotated SH Lee, CORR (2009)
Physical examination Rotational profile Rotation of the hip joint (A, B) Gr.troch. palpation method Thigh-foot angle (C) Transmalleolar angle (D) Foot progression angle (E) Evaluation of the foot
Foot progression angle Staheli LT(2006)
Greater trochanter palpation method
Thigh-foot angle Transmalleolar angle The second toe test SH Lee, CORR (2009)
Femoral anteversion at birth : 30 decrease as the child grows Femoral anteversion of the adults : 10 Tibial version at birth : 5 ext. rotation external rotation as the child grows Tibial version of the adults : 15 ext. rotated Rotational change as well as growth of length! Femoral & Tibial rotational variations gradually normalize as the child grows
Theoretically impossible to apply corrective forces to torsional deformity Most of braces apply torsional force to adjacent joint not to bony deformity itself Physiologically improved vs. effect of braces? Staheli LT(2006)
Age > 8 ~ 10 y-o Femoral antetorsion > 50 Hip joint : medial rotation > 85 lateral rotation < 10 Ext tibial torsion > 35 When severe(?) functional and cosmetic problem
Femoral anteversion Femoral derotational osteotomy Courtesy to Prof. HW Kim
Tibial external torsion Tibial derotational osteotomy
Courtesy to Prof. HW Kim Increased femoral anteversion Medial femoral torsion Increased Thigh-foot angle Lateral tibial torsion
Coronal plane Varus : distal portion of the limb closer to the center of the body - genu varum / coxa vara Valgus : distal portion of the limb away from the center of the body - genu valgam / coxa valga Sagittal plane Recurvatum : distal portion of the limb hyperextended - genu recurvatum
Genu varum Genu valgum Genu recurvatum
Tibio-femoral Angle in standing teleradiograph of the lower extremities including hip, knee, and ankle joints Angle(α) between the axis of the femur & tibia Assessment Intercondylar distance distance between the knees Intermalleolar distance distance between the medial malleoli
Correct Patella forward position Patella inward position Standing teleradiograph of the lower extremities
Chronological change of tibiofemoral angle in Korean children ( Yoo and Choi et al. 2008, JKMS ) : Provides data with the analysis of 452 Korean children Genu varum before 1 year of age Neutral at 1.5 years of age Genu valgum after 3 years of age Maximum valgus 7.8 at 3.5 years of age Adult pattern genu valgum(5 ~6 ) at 7 ~ 8 years of age
M/14mons M/26mons
F/5 F/7
Decreased medial longitudinal arch Usually physiologic and resolves spontaneously No functional limitation even when it persists in adults Be cautious when heel-cord tightness accompanied Mostly, treatment is not required
A prospective study to determine whether flexible flatfoot in children can be influenced by the treatment 129 children with the radiographic findings of flatfoot Group I : controls Group II : treatment with corrective orthopaedic shoes Group III : treatment with a Helfet heel-cup Group IV : treatment with a custom-molded plastic insert Minimum of three years of treatment No significant difference between the controls and the treated patients (p > 0.4) Wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children - Wenger, 1990, JBJS [Am], A study conducted by POSNA
Many kinds of untested braces are widespread and frequently misused. Braces have no effect of alignment correction. Most of torsional and angular alignment variations of the lower extremities in children are physiologic, and corrected spontaneouly with growth. Proper management of malalignment of the lower extremities in children just Wait & See
Thank you for your kind attention!