Angular Deformity Of Knee Surgical Program (Bowlegs)

 

Angular Deformity of Knee/ Genu Varum (Bowlegs)  

Genu varum, commonly known as bowlegs, is a type of angular deformity that is characterized by the outward curvature of the legs, causing the knees to remain apart while the ankles touch when standing, creating a noticeable gap between the knees. This condition can affect both children and adults. While it is often a normal part of development in infants and toddlers, persistent or severe cases may require medical attention.  

Treatment options in Cuba for genu varum is based on the underlying condition and can include bracing, physical therapy and surgery. If left untreated, people who are bowlegged may experience pain, increased deformity, knee instability and progressive knee degeneration (arthritis). Correction of the deformity leads:  

• Improved knee mechanics 

• Improved gait and coordinated movement of limbs 

• Reduced pain 

• Prevention of rapid progression of knee damage  

Types and Causes  

Genu Varum, or bowlegs, can be categorized into different types based on the underlying causes and characteristics of the condition.  

• Physiological Bowing: This is normal in infants and toddlers as part of their natural development. Most children outgrow this condition by the age of three.  

• Blount’s Disease: A growth disorder of the shinbone (tibia) that causes the bone to grow abnormally and bow outward.  

• Rickets: A condition caused by a deficiency in vitamin D, calcium, or phosphate, leading to the softening and weakening of bones.  

• Genetic Factors: A family history of bowlegs can increase the likelihood of developing the condition.  

• Bone Dysplasia: This refers to a group of disorders that affect bone growth, leading to abnormal bone development and bowing of the legs.  

Symptoms:  

The primary symptom of bowlegs is the visible outward curve of the legs with a noticeable gap between the knees when the ankles are together. Other symptoms may include:  

• Walking Difficulties: Individuals with bowlegs might walk with their feet turned inward or outward to compensate for the misalignment, leading to an uneven or waddling gait.  

• Knee Pain: The abnormal alignment can cause strain on the knees, leading to pain and discomfort, especially after physical activities.  

• Hip and Ankle Pain: The uneven distribution of body weight can increase stress on other the hip and ankle joints causing pain and discomfort.  

• Muscle Fatigue and Weakness: the misalignment in the legs cause the muscles, particularly in the thighs and calves, to work harder to maintain balance.  

• Balance Issues: The uneven leg alignment may increase difficulties with balance, increasing the risk of falls and injuries.  

• Postural Changes: The abnormal curvature can cause the pelvis to tilt and the lower back to arch excessively which can lead to back pain and postural problems. 

• Uneven Wear on Shoes: The abnormal gait can cause uneven wear on the soles of shoes, with more wear on one side of the shoe. This can be a noticeable indicator of the condition.  

• Developmental Delays in Children: In children, bowlegs can sometimes be associated with delays in reaching motor milestones such as walking, running, and jumping.  

Diagnosis  

Diagnosing bowlegs (Genu Varum) involves a multifaceted approach to accurately identify the underlying causes and assess the severity of the condition. Included in the diagnosis stage are the following:  

• Medical History:  

• Patient History: A detailed medical history, including questions about the onset of symptoms, duration, and any family history of similar conditions.  

• Developmental Milestones (for children): Assessment of the child’s developmental milestones, walking age, and any previous medical issues or nutritional deficiencies.  

• Medical Conditions and Lifestyle Factors (for adults): Evaluation of any existing medical conditions, such as metabolic bone diseases, arthritis, or previous surgeries. Occupational activities, physical activities, and nutritional habits that might contribute to the condition will also be assessed.  

• Physical Examination:  

• Visual Assessment: Inspecting the legs for outward curvature, identifying the degree of bowing, asymmetry, and any visible deformities.  

• Gait Analysis: Observing the patient’s walking pattern to assess any abnormalities in gait to assess the impact on mobility and identify any compensatory mechanisms.  

• Joint Examination: Assessing the range of motion in the hips, knees, and ankles to check for stiffness, instability, or pain.  

• Symmetry Check: Determining if the bowing is symmetrical or if one leg is more affected than the other.  

• Imaging Studies:  

• X-Rays: X-ray imaging is the primary in assessing the degree of bowing and identifying any underlying bone abnormalities, such as growth plate issues or bone deformities.  

• AP (Anteroposterior) View: Provides a front view of the legs measure the degree of bowing  

• Lateral View: Side view to assess bone structure and any additional abnormalities in bone structure.  

• MRI (Magnetic Resonance Imaging): Provides detailed images of soft tissues, cartilage, and bone marrow, useful for identifying underlying causes like meniscal or ligament injuries, or bone infections.   

• CT Scan (Computed Tomography): Used more for complex cases where precise anatomical details are necessary.  

• Bone Density Scan (for adults): To assess bone mineral density and evaluate for osteoporosis or other metabolic bone diseases.  

• Laboratory Tests  

• Blood Tests: To check for nutritional deficiencies (e.g., vitamin D, calcium, and phosphate levels) or markers of bone metabolism.  

Treatment Options  

Treatment options for genu varum is based on the patient’s:  

• Specific condition 

• Degree of curvature and severity of symptoms 

• Underlying causes 

• Age and overall health 

• Skeletal age   

Treatment options include:  

• Bracing and Orthotics: Bracing and orthotics are effective treatment options for both adults and children.   

• For children: Custom braces and orthotic devices are often used to direct leg growth into a more straight position, helping to correct alignment over time and prevent further progression of the condition.   

• For adults: Custom orthotic devices such as shoe inserts or custom orthotics are used to spread weight more evenly across the legs, reduce pain, and improve gait by providing additional support and stability.  

• Nutritional Supplements: Nutritional supplements are particularly important when the condition is related to deficiencies such as rickets for both adults and children, ensuring adequate intake of vitamin D, calcium, and phosphate which are essential for bone health and development.  

• Physical Therapy: Physical therapy is a vital component in the treatment of bowlegs for both adults and children, focusing on improving strength, flexibility, balance and coordination, gait and alignment.   

• Surgical Intervention: Surgical treatment for bowlegs in both children and adults is typically considered when conservative treatments like bracing, physical therapy, and orthotic devices are ineffective or if the condition is severe.  Surgical intervention involves various procedures based on the severity of the condition, patient’s age and the patient’s overall health.  

• Guided Growth Surgery (for children): This is a minimally invasive surgery used primarily in growing children with moderate to severe bowing. The procedure involves placing small plates or screws on one side of the growth plate in the knee. This technique slows down growth on one side while allowing the other side to continue growing, gradually correcting the leg alignment.  

• Osteotomy: This procedure is used for skeletally mature adolescents and adults and involves cutting and realigning the bones to improve leg alignment, typically the tibia (shinbone) is treated, but there are situations when the femur or both femur and tibia are treated. This procedure involves creating a controlled break in the bone and repositioning it to achieve a straighter configuration, which is then stabilized using plates, screws, or external fixators. 

In children, this procedure leverages their ongoing growth to facilitate correction, while in adults, it helps redistribute weight more evenly across the knee joint, alleviating pain and improving function.   

• Post-Surgical Rehabilitation: Physical therapy and pain management is an essential part of recovery after surgery with a focus on regaining strength, flexibility, and function.