Genu Varum Research Articles

Rickets manifestations in a child with metaphyseal anadysplasia, report of a spontaneously resolving case

IntroductionRickets is not an unusual diagnosis for pediatricians even currently in developed countries. Children typically present with leg bowing, enlargement of wrists, rachitic rosary (swelling of costochondral junctions) and/or waddling gait. But not every child with growth delay and enlarged metaphyses is diagnosed with rickets. Metaphyseal anadysplasia (MAD) is a disorder of variable severity with metaphyseal flaring and irregularities, without vertebral abnormalities. MAD is characterized by an early onset and a regressive course in late childhood without treatment, despite persistent short stature. Autosomal dominant or recessive variants in the matrix metalloproteinase 13 gene (MMP13) are responsible for these transient metaphyseal changes.Case presentationWe report a new pathogenic heterozygous variant in MMP13 (NM_002427.4: c.216G>C, p.Gln72His) in a toddler, initially thought to have rickets, and his father, with MAD phenotypes. Additionally, we review the seven reported MMP13 variants.ConclusionOne should keep a wide differential diagnosis in cases of suspected rickets, including skeletal dysplasias which might have a regressive course.

Femur originated genu varum in a patient with symptomatic ACL deficiency: a case report and review of literature

BackgroundAnterior cruciate ligament (ACL) injury may be associated with genu varum. There are a few indications in which the varus deformity can be corrected at the time of ACL reconstruction. However, as the genu varum originates mostly from the tibia and the simultaneous presence of ACL deficiency and femur originated genu varum is uncommon, only a few papers have described their management for ACL deficient patients with femur originated genu varum.Case presentationA young patient visited our clinic with a complaint of right knee pain and giving way. Further work up revealed a full mid substance ACL tear, mild medial knee osteoarthritis and femur originated genu varum of his right knee. He was managed with simultaneous ACL reconstruction and distal femoral valgus osteotomy.ConclusionsAny corrective osteotomy for genu varum should be performed at center of rotation angle. Isolated ACL reconstruction in patients with simultaneous ACL deficiency and genu varum may hasten the knee degeneration.Level of evidenceIV

Medial Opening Wedge Proximal Tibial Osteotomy: Lessons Learned from a Series of 175 Consecutive Cases.

High tibial osteotomy (HTO) is a surgical procedure aimed at inhibiting the progression of osteoarthritis of the knee joint. The aim of this study was to identify factors influencing the functional outcome after opening wedge valgus HTO. A total of 175 cases (155 patients) of varus-correcting high tibial open-wedge osteotomies using the Tomofix plate were reviewed retrospectively. Patients answered the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire and 4 survey follow-up questions. A total of 76 of the 155 patients studied (84 of the 175 knees) completed the KOOS questionnaire, on average 3.1 years (SD 1.8 years) after the surgery. The median scores (with median absolute deviations [MAD]) for the KOOS pain, symptoms, daily activities, sports, and quality of life sections were, respectively, 76.4 (MAD 12.5), 75.0 (MAD 14.3), 85.3 (MAD 11.8), 50.0 (MAD 25.0), and 59.4 (MAD 21.9). No cases of nonunion were observed throughout the length of the study. Identified predictors of worse outcomes were higher weight and body mass index, limited knee flexion, genu varum and tibial varus of small magnitude, active smoking status at the time of surgery, further surgery for plate removal, and some grades of chondropathy in the patellofemoral, medial tibial, and femoral compartments. Patient gender, joint obliquity and over- or undercorrection were not associated with any of the outcomes. This study shows good results following valgus HTO that are comparable to outcomes following total knee arthroplasty, reinforcing the option of HTO as a valid alternative for total knee arthroplasty.

Effect of sports shoe mileage on running mechanics and lower limb muscular activities in male individuals with and without genu varus

The aim of the present study was to evaluate the long-term effects of shoes wearing on lower limb kinetics and electromyography activity of selected muscles of genu varus males compared with healthy age-matched controls during running. Equipment and methods Fifteen healthy males (age: 23.20 ± 1.78 years) and 14 males with genu varus (age: 21.57 ± 2.34 years) were eligible for inclusion in this study. Participants received new shoes before the baseline test and were measured with the same shoes (used shoes) after six months in the post-test. Ground reaction forces and muscle activities were recorded in both pre-test and post-test during running. Irrespective of the groups, pair-wise comparisons revealed that peak medial ground reaction force (p = 0.002; d = 0.316) values were higher at post-test. Furthermore, peak negative free moment (p = 0.008; d = 0.235) and peak positive free moment (p < 0.002; d = 0.298) were higher and lower respectively at the post-test. For electromyography activity at the loading phase, the tibialis anterior and vastus medialis muscle activities were higher in the post-test, while the vastus medialis, vastus lateralis, and rectus femoris muscles activities were higher at the mid-stance phase. The gluteus medius muscle activity was reduced at the push-off phase in the post-test. Shoe mileage appears to have an impact on ground reaction force and selected muscle activities in healthy male individuals with and without genu varus. Together with the observed findings on shoe stiffness, it seems appropriate to change running shoes after a great wearing time of approximately six months with walking and to run mileage about 17 km/week. Le but de la présente étude était d’évaluer les effets à long terme du port de chaussures sur la cinétique des membres inférieurs et l’activité électromyographique de certains muscles de genu varus mâles par rapport à des témoins sains en fonction de l’âge pendant la course. Quinze hommes en bonne santé (âge: 23,20 ± 1,78 ans) et 14 hommes atteints de genu varus (âge: 21,57 ± 2,34 ans) étaient éligibles à l’inclusion dans cette étude. Les participants ont reçu de nouvelles chaussures avant le test de base et ont été mesurés avec les mêmes chaussures (chaussures usagées) après six mois dans le post-test. Les forces de réaction au sol et les activités musculaires ont été enregistrées à la fois avant et après les tests pendant la course. Indépendamment des groupes, des comparaisons par paires ont révélé que les valeurs maximales de la force de réaction au sol médiane (p = 0,002; d = 0,316) étaient plus élevées au post-test. De plus, le moment libre négatif maximal (p = 0,008; d = 0,235) et le moment libre positif maximal (p <0,002; d = 0,298) étaient respectivement plus élevés et plus faibles au post-test. Pour l’activité d’électromyographie à la phase de chargement, les activités musculaires du tibial antérieur et du vaste médial étaient plus élevées dans le post-test, tandis que les activités des muscles du vaste médial, du vaste latéral et du rectus fémoral étaient plus élevées à la phase intermédiaire. L’activité musculaire du fessier moyen a été réduite lors de la phase de poussée dans le post-test. Le kilométrage des chaussures semble avoir un impact sur la force de réaction au sol et certaines activités musculaires chez les individus masculins en bonne santé avec et sans genu varus. Parallèlement aux résultats observés sur la rigidité des chaussures, il semble approprié de changer de chaussures de course après une grande durée de port d’environ six mois avec un kilométrage à pied et à pied d’environ 17 km/semaine.

Hemiepiphysiodesis via the Bowen Method for Genu Valgum in Adolescents

Surgical techniques using bone blocks, screws, plates and staples have been described to biologically manipulate the growth plate to correct leg length inequality, genu varum and genu valgum.

Prevalence of Flexible Flat Foot in Iranian Male School Children

Background: Flat foot is a deformity in which patients lack standard arches in the soles of the foot. Flat foot improves with age. This study was designed to determine the prevalence of flexible flat foot among male school children in Tehran, Iran. Methods: A total of 1539 male school children were included in this study. Students were examined for the flatness of the sole of the foot as well as its degree and type. Flat foot was diagnosed on inspecting a poor formation of the arch. The severity of flatness was classified according to Denis criteria. Results: Among 1512 children whose foot condition was recorded, 80.7% had normal/grade 1 sole, 16.7% had 2nd degree flat feet, and 2.6% had 3rd degree flat feet. Prevalence of genu varum was 16.1% and prevalence of genu valgum was 2.7% (P = 0.504). The prevalence of flat foot decreased significantly with age; in the group of 11-year-old boys and younger, 23.1% showed a grade 2 and grade 3 flat foot, whereas in the group of 12-year-old boys and older, only 13.6% hada grade 2 and grade 3 flat foot (P &lt; 0.001). Conclusion: In this study, a significant relationship was found between weight gain and body mass index (BMI) with flat feet. There is a significant association between passing the age of 12 years and a decrease in flat foot. Also, the association between flat foot with weight and height of children was examined separately, and it was found that weight could significantly be a poor predictor of flat feet.

A case of transient hyperphosphatasemia presenting with mild degree of bow legs

Introduction: Transient Hyperphosphatasia (TH) is a benign condition in which serum Alkaline Phosphatase is elevated without any underlying pathology. This is mainly seen in children compared to adults and it is usually an incidental finding. The hallmark of the condition is that normalization of ALP level will with time. However, not knowing the entity would lead to unnecessary investigations and referrals. Here we report a child with TH who presents with a mild degree of bow legs. Case report: A 1year and 8 months old boy was brought by his mother with a concern of bow legs. He was the first child born to non-consanguineous healthy parents following normal antenatal and perinatal periods. His birth weight was 3.5kg and he was growing in his birth centile. He had age-appropriate development and parents had been having a concern about bow legs after he started walking. He is getting an average Sri Lankan diet with animal food and he gets adequate sun exposure as well. There was no history to suggest the liver of renal diseases. On examination, he had a mild degree of bow legs without any features to suggest rickets. His cardiovascular, respiratory, abdominal, and neurology exams were normal. His bone profile showed a high value of ALP (3782 U/L) with normal calcium, phosphate, and vitamin D levels. Due to high ALP levels, he underwent liver and renal functions and that was within the normal range. The diagnosis was made as TH and he was followed up monthly with ALP values. He had a downward trend of ALP levels and in 3 months the ALP value dropped to (580 U/L). Parents were reassured about the condition and the diagnosis was confirmed as TH. Conclusion: It is important to rule out, bone, kidney, or a liver pathology if a child has markedly elevated ALP levels. However, it is important to recognize this entity to avoid unnecessary procedures and concerns.

Tibial plateau inclination is associated with bone marrow lesions in early knee osteoarthritis

Purpose: While varus inclination of proximal tibia and bone marrow lesion (BML) are important factor for understanding knee osteoarthritis (OA) etiology, the relationship between these wo factors remain unclear. This study aimed to investigate the effect of proximal tibial inclination and serum bone metabolic markers on bone marrow lesion (BML) in the Japanese general population with early knee osteoarthritis (EKOA). Methods: A total of 441 female volunteers who participated in the Iwaki Health Promotion Project in 2017 were enrolled. Participants without radiographic abnormalities were divided into normal and EKOA groups according to Luyten’s classification criteria for EKOA (Figure 1). In this study, proximal tibial inclination was assessed with reference to growth plate (GP). The GP-tibial plateau (TP) angle was defined as the angle between the GP and TP lines (a), whereas the GP-medial tibial plateau (MTP) angle was defined as the angle between the GP and MTP lines (b) The medial proximal tibial angle (MPTA), GP-TP angle, and GP-MTP angle were measured on standing anteroposterior radiographs of the knees. BML severity on T2-weighted fat-suppressed magnetic resonance imaging (MRI) was scored using the Whole-Organ MRI Score method. Serum levels of N-telopeptide of type I collagen (NTx), tartrate-resistant acid phosphatase-5b (TRACP-5b), bone-specific alkaline phosphatase, procollagen type I N-terminal propeptide, pentosidine, and homocysteine were assessed. Serum concentrations of bone metabolic markers and radiographic measurements were compared using the Wilcoxon rank sum test. To investigate the relationship among BML, proximal tibial inclination, and serum bone metabolic markers, multiple linear regression analyses were conducted with the total BML score as the dependent variable and with age, body mass index, MPTA, GP-MTP angle, GP-TP angle, and serum bone metabolic markers as independent variables in patients with and without EKOA. To estimate the predictive cut-off level of proximal tibial inclination for detecting BML, receiver operating characteristic (ROC) analysis was performed for the EKOA group. Finally, in order to evaluate the cut-off values, the participants were divided into three groups according to the cut-off values estimated from the ROC analysis—the neutral group, tibia vara (extra-articular deformity) group, and genu varum (intra-articular deformity) group. Serum bone metabolic marker levels were compared among these three groups using one-way analysis of variance and Tukey’s test. Of these 309 participants, 48 participants (16%) had EKOA. With reference to the GP line, the GP-TP angle was inclined at 3.6±1.1° and the GP-MTP angle was 9.9±2.6°.Tabled 1Clinical characteristics of the participantsGP not observedGP observedp valueTotalNon-OAEKOASample number13130926148nsAge (years)52.7±14.154.5±9.554.4±9.755.0±8.8nsHeight (cm)156.1±6.0157.4±6.0157.5±6.0156.8±6.1nsBMI (kg/m2)22.4±3.622.0±3.121.9±3.122.3±3.2nsMPTA (°)86.6±1.286.1±5.986.4±1.586.6±1.4nsGP-TP (°)3.6±1.13.6±1.23.6±0.9nsGP-MTP (°)9.9±2.69.9±2.69.8±2.6nsNTx (nM)15.0±5.114.9±3.815.0±3.814.5±3.7nsTRACP-5b (mU/dL)415±190422.4±185431±14393.5±27nsBAP (μg/L)13.8±5.013.0±8.913.1±4.99.8±4.3nsPINP (μg/L)51.0±19.647.4±18.447.8±1.545.9±2.6nsPentosidine (pmol/mL)27.4±9.630.5±24.329.3±16.837.1±47.2nsHomocysteine (nmol/mL)9.0±3.18.5±2.78.5±0.28.3±0.4ns Open table in a new tab Serum bone metabolic marker levels did not significantly differ between the non-OA and EKOA groups. The MPTA was negatively correlated with the GP-TP and GP-MTP angles (r=−0.253, p<0.001 and r=−0.369, p<0.001, respectively). The BML was detected in 64 participants (31%) out of 205 participants who were performed MRI (). The MPTA was smaller in participants with EKOA who had BML than in those who did not (p=0.020), and the GP-MTP angle was larger in participants with BML than in those without BML (p=0.018).Tabled 1Radiographic measurements between participants with and without BMLNon-OAp valueEKOAp valueBML (-)BML (+)BML (-)BML (+)MPTA86.4±1.486.3±1.8ns86.8±1.386.0±1.20.020GP-TP3.5±1.33.5±1.1ns3.5±1.03.9±0.7nsGP-MTP10.0±2.59.9±2.9ns9.4±2.711.1±2.00.018 Open table in a new tab Linear regression analysis revealed that age was positively associated with BML severity in overall participants. In the non-OA group, serum TRACP-5b level was positively associated with BML (β=0.236, p=0.047). Proximal tibial inclination (MPTA and GP-MTP angle) was associated with BML only in the EKOA group (β=−0.281, p=0.011 and β=0.262, p=0.046, respectively).Tabled 1Relationship among bone marrow lesion, tibial inclination, and serum bone metabolic markersParameterNon-OApEKOApββAge0.1340.0090.503<0.0001BMI−0.014ns−0.072nsMPTA−0.056ns−0.2890.011GP-MTP−0.053ns0.2620.046GP-TP0.082ns0.137nsTotal PINP0.052ns0.060nsTRACP-5b0.2360.0470.076nsBAP−0.004ns−0.039nsNTx−0.032ns−0.074nsPentosidine0.024ns−0.136nsHomocysteine−0.011ns−0.136ns Open table in a new tab The ROC analysis indicated that the cutoff values for detecting BML were 86.7° for the MPTA (AUC: 0.703, p=0.030) and 9.7° for the GP-MTP angle (AUC: 0.706, p=0.028). Based on these cutoff values, tibial bone morphology was divided into the following three groups: neutral (MPTA ≥86.7°). (a), tibia vara (extra-articular deformity: MPTA <86.7° and GP-MTP angle <9.7°) (b), and genu varum (intra-articular deformity: MPTA <86.7° and GP-MTP angle ≥9.7°) groups (c). In the neutral group, 55 (46%) participants out of 120 participants had GP-MTP angle ≥9.7°. The serum NTx level was significantly lower in the genu varum group than in the tibia vara group (p=0.023). The serum TRACP-5b level was significantly lower in the genu varum group than in the neutral group (p=0.012).Tabled 1Serum bone metabolic marker levels among proximal tibial inclination typesNeutral (MPTA ≥86.7°)Inclined (MPTA <86.7°)p valueTibia vara (MTP-GP <9.7°)Genu varum (MTP-GP ≥9.7°)Sample number12075114MPTA87.6±0.785.5±0.985.1±1.2<0.001GP-MTP9.1±2.47.7±1.512.2±1.7<0.001NTx14.9±3.515.9±7.913.8±3.90.023BAP13.1±0.412.5±0.511.7±0.4nsTRACP-5b421±193409±202351±1680.012PINP46.8±18.249.4±27.245.1±19.7nsPentosidine32.6±2.230.5±28.228.2±2.2nsHomocysteine8.4±2.58.6±3.08.3±2.5ns Open table in a new tab Conclusions: The GP was a reasonable reference for assessing TP inclination. The presence of BML was associated with greater TP inclination and higher bone formation activity, even in participants without radiographic abnormalities. Residual medial tibial inclination may potentially result in knee pain and symptoms in EKOA.

Investigation of ALPL variant states and clinical outcomes: An analysis of adults and adolescents with hypophosphatasia treated with asfotase alfa

BackgroundHypophosphatasia (HPP), a rare metabolic disease, can be inherited in an autosomal recessive (biallelic) or an autosomal dominant (monoallelic) manner. Most of the severe, early-onset, frequently lethal HPP in infants is acquired through recessive inheritance; less severe, later-onset, typically nonlethal HPP phenotypes are acquired through either dominant or recessive inheritance. HPP's variable clinical presentation arises from >400 identified ALPL pathogenic variants with likely variable penetrance, especially with autosomal dominant inheritance. This post hoc analysis investigated the relationship between ALPL variant state (biallelic and monoallelic) and clinical outcomes with asfotase alfa in HPP. MethodsData were pooled from two phase 2, randomized, open-label studies in adolescents and adults with HPP; one study evaluated the efficacy and safety of different doses of asfotase alfa (n = 25), and the other assessed the pharmacodynamics and safety of asfotase alfa (n = 19). Patients were grouped by ALPL variant state (biallelic or monoallelic). Available data from both studies included ALPL pathogenic variant state, Baseline characteristics, HPP-specific medical history, and Baseline TNSALP substrate levels (inorganic pyrophosphate [PPi] and pyridoxal 5′-phosphate [PLP]) concentrations). Clinical outcomes over 5 years of treatment were available from only the efficacy and safety study. ResultsIn total, 44 patients with known variant status were included in the pooled analysis (biallelic, n = 30; monoallelic, n = 14). The most common pathogenic variant was c.571G > A (p.Glu191Lys) in biallelic patients (allele frequency: 19/60) and c.1133A > T (p.Asp378Val) in monoallelic patients (allele frequency: 7/28). Median (min, max) Baseline PPi concentrations were significantly higher in patients with a biallelic vs monoallelic variant state (5.3 [2.2, 12.1] vs 4.3 [3.5, 7.4] μM; P = 0.0113), as were Baseline PLP concentrations (221.4 [62.4, 1590.0] vs 75.1 [28.8, 577.0] ng/mL; P= 0.0022). HPP-specific medical history was generally similar between biallelic and monoallelic patients in terms of incidence and type of manifestations; notable exceptions included fractures, which were more common among monoallelic patients, and delayed walking and bone deformities such as abnormally shaped chest and head and bowing of arms or legs, which were more common among biallelic patients. Data from the efficacy and safety study (n = 19) showed that median PPi and PLP concentrations were normalized over 5 years of treatment in patients with both variant states. Median % predicted distance walked on the 6-Minute Walk Test remained within the normal range for monoallelic patients over 4 years of treatment, and improved from below normal (<84%) to normal in biallelic patients. ConclusionsAlthough patients with biallelic variants had significantly higher Baseline PPi and PLP levels than monoallelic variants, both groups generally showed similar pretreatment Baseline clinical characteristics. Treatment with asfotase alfa for up to 5 years normalized TNSALP substrate concentrations and improved functional outcomes, with no clear differences between biallelic and monoallelic variant states. This study suggests that patients with HPP have significant disease burden, regardless of ALPL variant state.

Alfacalcidol improves the growth velocity in children with vitamin D deficiency/insufficiency: A single center retrospective cohort study.

ObjectivesTo investigate the growth velocity-improving effects of vitamin D replacement therapy in pediatric patients diagnosed with vitamin D deficiency and insufficiency.Study designA retrospective cohort study was conducted in 34 pediatric patients diagnosed with vitamin D deficiency/insufficiency. Based on the clinical findings, the subjects were divided into two groups: a bowed leg (BL) group and a non-bowed leg (non-BL) group. After the initiation of alfacalcidol, the standard deviation score (SDS) of their heights, weights and growth velocities in each group were monitored.ResultsThe median age at the first visit was significantly lesser in the BL group (1.58 years old [interquartile range (IQR): 1.33, 2.17]) than that in the non-BL group (3.00 years old [IQR: 2.33, 3.67]). On the contrary, the SDS for height was significantly lower in the non-BL group (-2.27 [IQR: -2.63, -1.94]) than that in the BL group (-1.37 [IQR: -1.91, -1.07]). One-year treatment with alfacalcidol showed significant improvements in both height SDSs and growth velocity SDSs not only in the BL group but also in the non-BL group.ConclusionsThe current study revealed that vitamin D replacement therapy improved the growth rate in children with vitamin D deficiency/insufficiency, regardless of the presence of BL. This study emphasizes the importance of assessing the vitamin D status in children with poor growth rates and suggests that alfacalcidol could be a valid option for the treatment of short stature.

Percutaneous high tibial closed-wedge corticotomy and casting for treating genu varum in adolescents

Diverse surgical modalities have been designated for the treatment of genu varum deformity. However, other studies have not constantly confirmed which technique to be better than the other. The use of hardware, bone graft or bone substitute have their own risks. In this study, simple technique of percutaneous high tibial closed-wedge corticotomy and casting for treating genu varum in average body-built adolescents without hardware fixation was reported. An overall 22 knees of 16 average-weight adolescents having genu varum with a mean age of 14.8 years (range, 12-18 years) underwent percutaneous high tibial closed-wedge corticotomy and casting. The study was conducted between May 2017 and January 2020. The typical follow-up duration was ten months (range, 8-22 months). Clinical and radiological evaluation for all patients was implemented. Mean postoperative Rasmussen clinical score was 27 (range, 24-30), with 16 excellent and six good results. The tibiofemoral angle improved from a mean of 18.2 degree varus (range, 14-25 degree varus) preoperatively to 1.3 degree valgus (range, 0-8 degree valgus) postoperatively, indicating a significant improvement (P < 0.05). Bone union was achieved at a mean of ten weeks (range, 8-14 weeks). None of the patients sustained nonunion, delayed union, infection, or knee stiffness. Percutaneous high tibial closed-wedge corticotomy and casting is a minimally invasive procedure for treating genu varum in adolescents. Good results are able to be attained with proper patient selection and meticulous surgical technique.

The Effect of a Course of Up-cholugi and Yup-chagi Exercises on the Kinematic Indices of the Knee and the Incidence of Bow-leggedness (Genu Varum) in Professional Taekwondo Practitioners

Objective: Knee brace is one of the lower limb abnormalities. This study aimed to investigate the effect of knee kinematical parameters on the development of knee Genu Varum. Methods: This study’s statistical sample was 32 taekwondo practitioners with red and black belts of sports clubs in the northeast of Tehran, determined using G-Power software and in two groups of 16 people in terms of gender, age, and membership in the field. The 8-week training intervention, which included 3session of 1-hour training sessions emphasizing performing the techniques of up-chulogi and yup-chaggy, was performed for the experimental group. The control group did not have any specific activity during this period. Knee kinematic indices include naval drop size tests, tibial torsion, Q angle, androgen enterogen, internal and external hip rotation, and knee hyperextension in the two groups of healthy and injured in pre and posttest was evaluated. The data were statistically analyzed using descriptive analysis using t-test and SPSS V. 23 software. Results: According to the study results, a significant positive relationship was observed between the variables of the selected technique of up-chology and the technique of up-chugi on the incidence of knee Genu Varum. Also, there was a significant difference between the indices of naval drop (P=0.003), torsion (P=0.006), Q angle (P=0.005) and knee hyperextension (P=0.001) in pre-test to post-test results. Conclusion: The selected exercises have increased the distance between the knees and functional disorders. Because the braced knee may play a role in influencing athletes’ negative performance and injury in training and competition, it is necessary to consider it in studies related to the prevention of potential injuries.

Relationship of Patellofemoral Angles and Tibiofemoral Rotational Angles With Jumper's Knee in Professional Dancers: An MRI Analysis.

Background:Jumper’s knee is a type of tendinopathy affecting the distal insertion of the quadriceps tendon (25% of cases) or the patellar tendon. It has been shown that frontal-plane measurements, such as genu valgum, genu varum, an increased quadriceps angle, a protuberant tibial tuberosity, patella alta, and short hamstring muscles, may be related to jumper’s knee.Purpose:To investigate the effects of tibiofemoral rotational angles and patellofemoral (PF) angles on the development of jumper’s knee in professional folk dancers.Study Design:Case-control study; Level of evidence, 3.Methods:We examined 26 dancers (16 male, 10 female) with knee pain using magnetic resonance imaging (MRI), for a total of 32 knees. Of the knees, 21 with quadriceps tendinopathy (QT) and 7 with patellar tendinopathy (PT) were detected. Using MRI scans, we measured PF angles (PF sulcus angle, lateral PF angle, patellar tilt angle, lateral trochlear inclination angle, lateral patellar tilt angle, and PF congruence angle) and tibiofemoral rotational angles (condylar twist angle, posterior condylar angle, femoral Insall angle, tibial Insall angle, posterior tibiofemoral angle, and angle between the Whiteside line and posterior femoral condylar line) and noted specifics such as patella alta, patella baja, and the Wiberg classification of the patellar shape between the patients with versus without QT and between patients with versus without PT to understand if there was any relationship with tendinopathy.Results:No statistically significant difference was observed in age, sex, patella alta, or the Wiberg classification between the QT groups (with vs without) and between the PT groups (with vs without) (P > .05). Having QT was found to be significantly associated with the PF sulcus angle (P = .009), and having PT was found to be significantly associated with the femoral Insall angle (P = .029).Conclusion:Jumper’s knee was found to be associated with anatomic variations of the PF sulcus angle and rotation of the patellar tendon in relation to the femur (femoral Insall angle) on axial MRI scans in professional dancers. Unlike those of other athletes, dancers’ knees are exposed more to external rotation forces because of turnout, and this can be the cause of jumper’s knee.

Prevalence of Gait Features in Healthy Adolescents and Adults

Forensic gait analysis is the identification of individuals by their gait style and walking characteristics. This study aimed to examine the prevalence of gait patterns in healthy adolescents and adults. Five hundred healthy participants (mean age, 36.9 years) were enrolled and divided into four age groups: 13-20, 21-35, 36-50, and ≥51 years. The gait of the participants was recorded in a gait analysis laboratory. Five specialists experienced in gait analysis selected several gait features. The prevalence of out-toe, in-toe, planovalgus, and turtleneck was 25.0%, 1.6%, 6.8%, and 4.2%, respectively. The prevalence of genu varum (10.4%) was higher than that of genu valgum (5.6%). Genu valgum and hindfoot valgus were more common in younger than in older subjects (P=0.018 and P=0.029, respectively). Genu varum was more prevalent in older subjects (P<0.001). The prevalence of out-toe was higher in males (P<0.001), whereas the in-toe and genu valgum were more common in females than in males (P=0.027 and P=0.038, respectively). We have documented the prevalence of several gait features in healthy adolescents and adults. These gait features can be used to enhance evidentiary competence in forensic gait analysis and thereby help improve the arrest rate of offenders. Key Words: Forensic gait analysis · Prevalence · Gait features · Out-toe · Ganu varum

Complex Primary Total Knee Arthroplasty in a Patient with Achondroplasia, Osteoarthritis, and Severe Coronal Instability.

Genu varum in patients with achondroplasia is common and is often exacerbated by the associated generalized ligamentous laxity. Despite this, development of knee osteoarthritis is rare. There are only a few previously published case reports of total knee arthroplasty in this population. We present 2-year follow-up of a patient with achondroplasia who underwent staged bilateral primary total knee arthroplasties using hinged components. Technical considerations and careful preoperative planning are required in patients with achondroplasia given their small skeletal stature, metaphyseal deformities, and ligamentous laxity.

Alkaline phosphatase in pediatric patients with genu varum caused by vitamin D-deficient rickets.

An elevated serum alkaline phosphatase (ALP) level is one of the markers for the presence of rickets in children, but it is also associated with bone formation. However, its role in diagnosing genu varum in pediatric patients with vitamin D-deficient rickets is still unknown. To clarify the role of the serum ALP level in assessing the severity of genu varum, we retrospectively investigated this issue statistically using data on rickets such as serum intact parathyroid hormone (iPTH), 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, ALP, the level of creatinine as the percentage of the median according to age (%Cr), and the metaphyseal diaphyseal angle (MDA) in the lower extremities as an index of the severity of genu varum. A multiple regression analysis revealed that log ALP and %Cr values were negatively associated with MDA values. The former association was also confirmed by a linear mixed model, while iPTH was positively associated with MDA by path model analysis. To elucidate the association of ALP with MDA in the presence of iPTH, we investigated three-dimensional figures by neural network analysis. This indicated the presence of a biphasic association of ALP with MDA: the first phase increases while the second decreases MDA. The latter phenomenon is considered to be associated with the increase in bone formation due to the mechanical stress loaded on the lower extremities. These findings are important and informative for pediatricians to understand the significance of the serum ALP level in pediatric patients with genu varum caused by vitamin D deficiency.

Bowing of legs is it always rickets? A case report.

Objective: Familial Blount disease is a rare developmental disorder that results in acute varus angulation of the proximal tibia. In this case report, we present a young male child along with his mother and two of his siblings who presented with Blount disease, we reviewed the etiology, risk factors and the most common differentials and the common approach of this rare disease. This presentation of bilateral progressive leg bowing, turned out to be Blount disease after a thorough clinical/radiological workup. Methods: A single case of reviewed for this case study. The patient an 8 year old male who presented with progressive bilateral leg bowing was examined, investigated and managed accordingly. We also reviewed the etiology, risk factors, differentials and common approach to a patient with Blount disease. Results: The patient was referred to the orthopedic clinic and was scheduled for bilateral epiphysiodesis. Conclusion: When evaluating leg bowing in children, many causes should be ruled out before making a diagnosis. This case documents a rare cause behind leg bowing in children that pediatricians/general physicians should always keep in mind.

FROM GARRINCHA'S LEGS TO NEYMAR'S LEGS: THE GENU VARUM AND VALGUM IN SOCCER. HISTORICAL OVERVIEW AND UPDATE.

ABSTRACTThe presence of abnormalities in knee alignment (genu varum and genu valgum) is extremely common in soccer. It can occur in the junior league / youth academy and perpetuate itself throughout the professional career. The consequences of years of high-level sports practice in players with genu varum / genu valgum can be harmful to the knees. By observing football matches of the present and the past, the authors of the article noted that great Brazilian soccer players were, or are, affected by the malalignment of the knees: Garrincha (the most famous), Leandro, Dunga, Romário, Rivaldo and Neymar. This study aims to discuss the relationship between high-performance sport and the development of these orthopedic deformities, serving as a tool for updating the trauma-orthopedic knee subspecialty. Level of Evidence III, Retrospective comparative study.

A retrospective study of treatment of genu valgum/varum with guided growth: Risk factors for a lower rate of angular correction.

The rate of angular correction (ROAC) is very unpredictable and may be affected by various factors in the treatment of genu valgum and varum by means of guided growth. The purpose of this study was to assess the ROAC in cases from our institution and to identify risk factors associated with the occurrence of lower ROAC.We retrospectively reviewed the chart records of 68 patients undergoing guided growth with figure-eight plate for the correction of genu valgum and varum. Based on the data from these patients, the annual increment of physeal growth was calculated and compared with data from the Anderson chart. The associations between patient characteristics and ROAC were evaluated with the use of univariate logistic regression.The mean rate of femoral angular correction was 10.29 degrees/year, while the mean rate of tibial angular correction was 7.92 degrees/year. In a univariate logistic regression analysis, the variables associated with a higher risk of lower ROAC included non-idiopathic coronal deformity of the knee (odds ratio = 13.58, p < 0.001) and body weight at or above the 95th percentile for children (odds ratio = 2.69, p = 0.020).Obesity and non-idiopathic coronal deformity of the knee are risk factors for lower ROAC. It is still uncertain whether severity of deformity, race, and operative procedure have a substantial effect on the rate of correction.Level III evidence.

Infantile Blount disease: a developmental tibial growth defect.

A 2.5 years male child, who presented with Leg bowing. As per the parents, infant started walking early at 10th month and bowing of legs got worsened over time. Paediatric orthopedicians diagnosed him with endochondral disorder of the proximal end of medial tibial physis. He was referred to Physiotherapy department, for evaluation and rehabilitation. On examination, genu varum was seen (A), a positive ‘cover-up test´, internal tibial torsion, leg length difference, no tenderness, limitation of motion, and effusion, according to the review which lead to the diagnosis Blount's Disease. Lower extremity deformities in Rickets can closely mimic and osteochondro-dysplasia or genetic bone diseases which can cause lower extremity deformities similar to Blount's disease. The metaphyseal-diaphyseal angle of bones was determined and found to be 24°, which is considered abnormal. The child's lower leg was seen turned inward, causing the leg to appear bent below the knee (B). He had difficulties during walking and complained of pain in both the knees after 5-7 minutes of walk with lateral thrust on walking. According to Langenskiold Classification, the child is in stage 2 (2.5-4 yrs. old). As a result, parents were introduced to a home exercise program which included strengthening and stretching to correct gait and muscle imbalances, flexibility, as weak hip and core muscles contribute to knee deformities, and range of motion, which eases physical tasks and can benefit in the regression of secondary compensatory deformities, as well as Gait re-education through assistive devices (walker) improved the child's gait parameters.