Physiologic Genu Varum Research Articles

Managing Genu Varum in Adolescents to Reduce Risks of Progression to Knee Osteoarthrosis

Introduction: Genu varum is not uncommon in adolescents. Managing the condition to reduce its progression may decrease the prevalence of incident knee osteoarthrosis in adulthood. The present review examines studies on risk factors contributing to the progression of genu varum and associated with the degeneration of the medial tibiofemoral joint. We proposed approaches to decrease the magnitude of genu varum and external knee adduction moment, to reduce the incidence of knee osteoarthrosis in the aged population. Methods and Materials: Literature searches were conducted in Pubmed, Embase, and Cochrane Systematic Reviews, using keywords individually and in combinations. We excluded papers on pathological genu varum, tibia vara, Blount disease, nutritional rickets, imaging, and surgery and included only articles on genu varum involving children and young adults. Reference lists of the included papers were also screened manually for additional references. Results and Discussion: Search results showed that many children with physiologic genu varum are deficient or insufficient in vitamin D. High-impact exercises in late children and adolescents promote genu varum. In contrast, therapeutic exercises reduce the magnitude of genu varum in young adults with postural bowlegs. Lateral wedge insoles decrease the external knee adduction moment. We proposed to check the serum vitamin D level of children and adolescents with genu varum. Growing children with genu varum should be advised to reduce the frequency of performing high-impact exercises. Adolescents with genu varum should strengthen the external hip rotators and use lateral wedged insoles.

EPIDEMIOLOGY OF GENU VARUM IN PEDIATRIC PATIENTS IN DR. SOETOMO GENERAL ACADEMIC HOSPITAL SURABAYA 2010-2018: A RETROSPECTIVE STUDY

Background: Genu varum is the condition of the legs that bend inward, leading to walking disruptions. However, data on genu varum are still lacking to prevent the disease. This study aimed to identify the epidemiology of patients with genu varum in preventing, managing and determining the prognosis and as a source for future research.Methods: This research is a descriptive study using a retrospective research design. The sampling technique used is a total sampling of genu varum patients gained from the Department of Orthopedics and Traumatology database, medical records from Dr. Soetomo General Academic Hospital Surabaya, and patients' home visits. The target population is all genu varum patients from 2010-2018.Results: The total sample was 31 patients, 21 patients were male (67%), and 10 patients were female (32%). The average age of patients was 4.3 years. The first complaint of the disease was, on average, realized at 1.8 years. The birth weight data obtained an average of 3.49 kg. The average body mass index is 26.3. Langenskiold stage I,II,III,IV,V,VI type; 2 (3%), 43 (70%), 2 (3%), 5 (8%), 2 (3%), 8 (13%). Eighteen patients (58%) had bilateral Blount disease and 7 patients (22%) had unilateral Blount disease, and only six patients (20%) had physiologic genu varum. Eighteen patients were carried out conservative methods, and 13 underwent operative methods.Conclusion: Blount disease is the commonest cause of genu varum in Dr. Soetomo General Academic Hospital, specifically infantile. The highest number of patients are male and those who underwent operative treatment.

Outcome of Dome-Shaped Proximal Tibial Osteotomy in Infantile Genu Varum

Background: The goals of the proximal tibial osteotomy are correcting the deformity, Hip-knee-ankle angle, and preventing the progress of the destruction of the medial compartment of the knee joint. Objectives: The aim of the work was to evaluate the outcome of children with genu varum after proximal tibial dome shaped osteotomy. Patients and Methods: These randomized clinical trials study included a total of 10 patients with 12 affected knees confirmed with persistent physiologic genu varum, attending at Orthopedic Department, Zagazig University Hospitals, Zagazig, Egypt. All cases were evaluated pre and post-operatively according to Modified Hospital for Special Surgery Knee Scoring System (HSSKS) as shown in appendix I. cases were assessed for functional improvement after surgery at 2, 4 months and detection of malunion or delayed union after 3 months. Results: The mean (±SD) pre-operative tibio-femoral angle was 21.7 (±5.6) versus 3.18 (±1.97) post-operatively, pre-operative femoral condyle-tibial shaft angle (FTA) was 16.3 (± 2.8) versus 3.2 (±1.1) post-operatively and pre-operative metaphyseal diaphyseal angle was 15.8 (±2.6) versus 3.6 (±1.2) post-operatively with a statistically significant difference in between (p < 0.05). The mean pre-operative HSSKS scores were 70.16±11.3 while the mean post-operative HSSKS scores were 91.4±2.1. Conclusion: It could be concluded thatproximal tibial osteotomy using dome-shaped procedure to correct Infantile Genu varum deformity, has favorable treatment outcomes, does not involve any dangerous complications, and can be used as a safe and effective treatment method for the correction of infantile genu varum deformity. In the current study, angles significantly improved, most of legs got full correction and little complications occurred.

Infantile Blount’s Disease: A case report of 3 years old female of Zhob, Pakistan

Background; Blount’s disease is a rare developmental disorder of children which causes progressive bowing of lower limbs. The term “Blount” was named after American orthopedic surgeon “Walter Putnam Blount” who first described this condition. The etiology of Blount’s disease is unknown but believed to be multifactorial. Various predisposing factors have been attributed including obesity, early walking, race, pre-existing varus, increased pressure on growth plate and nutrition. Blount’s disease has been suggested to be more frequent in African, Afro-american populations. Blount’s disease has to be differentiated from physiological bowing (physiologic genu varum) and rickets. Early diagnosis and treatment of Blount’s disease is essential as the disease process is reversible in early stage. Case; A three years old female child was brought by her mother with complaint of progressive bowing of both lower limbs for last one year. She achieved her milestones at appropriate age and started walking at 11 months of age without support. On examination, her height was 90 cms (at 10th centile) and weight was 17 kgs (at 90th centile). BMI (body mass index) was 20.9 (obese). There were no clinical signs or symptoms of rickets i.e frontal bossing, wide wrist, rachitic rosary, carpopedal spasm, fits or muscle weakness etc. Roentgenogram showed tibia in varus with a peculiar beak at metaphysic and raised metaphyseal-diaphyseal angle (&gt;16 degrees). Serum calcium and serum vitamin D (25-hydroxy vitamin D) were normal. Serum alkaline phosphatase level was raised. Keeping in view typical history, examination findings and radiological epiphyseal beaking along with raised metaphyseal-diaphyseal angle, diagnosis of Infantile Blount’s disease was made. Conclusion; The clinicians should have a high suspicion of infantile blount’s disease when a child, more than 3 year’s age presents with severe varus deformity at proximal tibia with typical radiological findings. Characteristic radiologic findings along with history and examination help to distinguish it from physiologic bowing (physiologic genu varum) and rickets. Keywords; Blount’s disease, Physiologic genu varum, Rickets, Tibia vara, Osteochondrosis deformans tibiae

Physiologic Leg Bowing is not a Physiologic Condition but Instead is Associated with Vitamin D Disorders in Toddlers.

When children around 2-year-old show leg bowing without lower-limb radiographic abnormalities for rickets, the leg bowing is classified as "physiologic" genu varum without conducting a blood test. However, it has recently been suggested that toddlers who are diagnosed with physiologic genu varum may in fact have some form of bone metabolic disorder. In this 1:2 case-control study, blood samples were obtained from 33 toddlers with genu varum without radiographic abnormalities for rickets and 66 age- and gender-matched healthy children. Serum alkaline phosphatase (sALP), intact parathyroid hormone (siPTH), 25-hydroxy vitamin D [s25(OH)D], calcium (sCa), and inorganic phosphate (sP) were measured. s25(OH)D of the subjects with genu varum (24.8 ng/ml) were significantly lower than those of the control (33.6 ng/ml) (p < 0.001). The frequency of vitamin D insufficiency/deficiency (< 20ng/ml) of the subjects with genu varum (39%) was significantly higher than that in the control (14%) (p = 0.004) (odds ratio by vitamin D insufficiency/deficiency: 4.1 [1.5-11.1, p = 0.004]). sCa in subjects with genu varum (10.2ng/ml) were significantly higher than in control (9.8ng/ml) (p < 0.001), as were sALP (1057IU/l) and siPTH (28.4pg/ml) (740IU/l and 8.8pg/ml in control, respectively; p < 0.001). siPTH levels were associated with s25(OH)D levels in subjects with genu varum (r = - 0.57, p < 0.001), while no association was observed in the control (r = 0.11, p = 0.36). Genu varum without radiographic abnormalities of rickets was associated with both vitamin D and bone-metabolic disorders in toddlers, indicating that physiologic genu varum is not a physiologic condition in toddlers.

Blount's disease: The importance of early diagnosis and early treatment.

The purpose of this image is to raise awareness of the early diagnosis and treatment of Blount's disease. Failure to distinguish between physiologic genu varum and early onset of Blount's disease can lead to irreversible outcomes, including progressive deformity with gait deviations, limb‐length discrepancy, and premature arthritis of the knee.

Association between leg bowing and serum alkaline phosphatase level regardless of the presence of a radiographic growth plate abnormality in pediatric patients with genu varum

When children around 2years of age show leg bowing and diseases are ruled out based on radiographic findings without conducting blood tests, they are classified as "physiologic" genu varum. Since whether or not physiologic genu varum is associated with bone metabolism is unclear, this study was conducted to clarify the association between genu varum and bone metabolism in children. Thirty-five pediatric patients with genu varm who visited our out-patient clinic were enrolled. While two of the 35 children had nutritional rickets, showing abnormalities on both blood test (ALP, ≥1000IU/L; iPTH, >65pg/mL and 25(OH)D, ≤20ng/mL) and radiographs (such as cupping, fraying or splaying), five of 35 children showed abnormalities on blood tests but not radiographs. While metaphyseal-diaphyseal angle (MDA) correlated with serum 25-hydroxy vitamin D (r=-0.35, p=0.04) and magnesium (r=-0.36, p=0.04), MDA and femorotibial angle (FTA) correlated with alkaline phosphatase (r=0.43, p=0.01 and r=0.51, p=0.006, respectively). A ridge regression analysis adjusted for age and body mass index indicated that ALP was associated with MDA and FTA. A logistic regression analysis adjusted for age and BMI indicated that higher ALP influenced an MDA >11°, which indicates the risk for the progression of genu varum (odds ratio 1.002, 95% confidence interval 1.0003-1.003, p=0.021). The higher ALP (+100IU), the higher risk of an MDA >11° (odds ratio 1.22). In conclusion, genu varum is associated with the alkaline phosphatase level regardless of the presence of radiographic abnormalities in the growth plate in children.

Bow legs and knock knees: is it physiological or pathological?

Knock knees and bow legs are commonly seen pediatric orthopedic problem, as the child grows the knee undergoes sequential changes in the axial development from varus to valgus. Differences in appearance of foot and position of foot while the child is walking as noticed by parents most often reflect variations of normal physiological development. As parents are not aware of normal growth and development of lower-extremity, and desire for normal alignment in their children, they are very much concern and motivated to seek medical advice. Many children are referred unnecessary to orthopedician for treatment of physiological genu varum and genu valgus which is unnecessary and may turn out to be sometimes harmful also. Most parents are happy to be reassured that this children deformity is with normal limits and will disappear. For this the physician should be aware of when to consider as physiological and pathological for which he has to take a detailed history of the problem, perform a detailed examination to rule out pathological causes. So, this article helps us to know when to consider physiological and rule out pathological so as to avoid unnecessary interventions for the child.

Obesity and Increasing Rate of Infantile Blount Disease

The incidence of infantile Blount disease is rising in parallel to the increasing obesity in children. Seven children (3 female) between the ages of 17 and 30 months (21.8 ± 4.3 months) were included in the study. All patients had complaints of inward bowing of the legs and excess weight gain. The biochemical and hormonal assessments of all patients yielded normal results. Patients were diagnosed with infantile Blount disease based on clinical, laboratory, and radiological findings. This disease should be differentiated from physiological genu varum, and the potential psychosocial and physical complications are prevented with early diagnosis and treatment.

Estimation of the Recovery of Physiological Genu Varum With Linear Mixed Model

Although previous studies have provided reference values for the lower limb alignment in children with physiological genu varum, those often have methodologic flaws, including problems with assumptions of statistical independence. In this study we intend to use appropriate statistical methods to determine reference values of the recovery of physiological genu varum by using a linear mixed model (LMM). The database of our institution was searched and teleroentgenograms of patients up to 5 years of age with clinical diagnosis of physiological genu varum were selected. The mechanical tibiofemoral angle (mTFA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured from each radiograph. These measures were then incorporated in LMM. The reference values for mTFA, mLDFA, and mMPTA were calculated by LMMs with age, sex, and side of the limbs, as the fixed effects with each subject as random effects. A total of 425 teleroentgenograms were evaluated from 161 patients with physiological genu varum. Age, sex, and limb side terms were found to be significant contributing factors to the measures. In the LMM, with the age as quadratic, mTFA was equal to -0.3-degree varus [95% confidence interval (CI), -5.9 to 5.3 degrees] at the age of 3 years. The mLDFA was equal to 87.8 degrees (95% CI, 82.8-92.8 degrees) at the age of 4.5 years. The mMPTA was equal to 88.8 degrees (95% CI, 80.4-97.2 degrees) at the age of 2.5 years. An LMM fitted well to estimate the natural recovery of physiological genu varum. Age, sex, and side of the limbs were found to be significant factors in the estimation of mTFA, and age and side of limbs were significant in estimation of mLDFA and mMPTA. Level III-diagnostic study.

Clinical and radiographic evaluation of bowlegs.

Lower extremity bowing is a normal physiologic process that commonly occurs in walking children under the age of 2 years. After this age, any significant amount of residual bowing is abnormal and may be due to infections, traumatic physeal injuries, genetic predisposition, metabolic factors, or a combination of these. Of the pathologic conditions, infantile Blount's disease is the most common and is predominantly found in obese children with an early onset of walking. Because of its frequency in occurrence and general tendency for spontaneous resolution, physiologic genu varum must be clearly distinguished from other pathologic processes that result in bowleggedness. Treatment of the latter cases may consist of early bracing or surgery.

Long-term results after physiological genu varum.

All reports agree that the physiological genu varum is a normal condition in early childhood which does not require any treatment, but there is no documentation to correlate between the clinical and radiographic severity of the varus deformity in early childhood and the prognosis in later life. Seventy three cases (135 knees) were followed up from the onset of genu varum at age 11.5 months (range, 8-24 months) until the last follow-up, at age 36.5 years (range, 28-65 years). The angles, femorotibial and metaphyseal-diaphyseal of tibia at first examination were analysed on 107 radiographs (57 cases). The femorotibial angle measured 17 degrees (range, 0-40 degrees), and the metaphyseal-diaphyseal angle of the tibia was 8 degrees (range, 0-21 degrees). None of these knees developed Blount's disease. About two-thirds of the cases (50 cases, 89 knees) showed no symptoms at all and were satisfactory, whereas about one-third of the cases (17 cases, 34 knees) reported that sometimes, they have mild pain, stiffness or both, especially on exertion. One can not be sure whether these cases should be interpreted as a beginning of arthrosis or not. More research is needed to study the long-term results after physiological genu varum as unfortunately there appear to be no reports of work on this topic in the world literature.

Orthotic treatment of infantile tibia vara.

Difficulty differentiating physiologic genu varum from early Blount's disease persists. Drennan's metaphyseal-diaphyseal (MD) angle remains the most consistently valuable radiographic parameter despite measurement error. Clinical risk factors also should be considered. All patients receiving orthoses for genu varum since 1985 were reviewed. The focus of the study was those patients with an MD angle of >16 degrees or between 9 and 16 degrees with a clinical risk factor for progression. Risk factors considered were ligamentous instability, obesity, asymmetry, and being female, black, or Hispanic. Thirty-eight patients with 60 tibiae were included. The success rate was 90%. Risk factors for failure (six cases) were instability, obesity, and delayed bracing. In cases with MD angles >16 degrees, the success rate was 86%. The results of orthotic treatment, restricted to patients meeting the stated parameters, represent improvement on the reported natural history.

小児における生理的Ｏ脚の経時的Ｘ線検討

小児における生理的Ｏ脚の経時的Ｘ線検討

Physiological genu varum.

Physiological genu varum is a condition which, during the first years of life, usually does not require any treatment, but it can present differential diagnostic difficulties. The condition can be distinguished from Mb Blount, prenatal genu varum, hypophosphataemia, rachitis, and post-traumatic genu varum in its course, roentgenological picture, and laboratory examination. It is highly probable that physiological genu varum is the reversible initial stage at Mb Blount, because both physiological genu and Mb Blount can occur at the same time in the same patient.

Genu varum and genu valgum. Another look.

Eighty-eight patients with either physiological genu varum or genu valgum have been followed at the Florida Crippled Children's Clinic at Variety Children's Hospital. A critical assessment was conducted clinically and radiographically to evaluate their course. Approximately 32.5% of the patients seen with genu varum were found to undergo a transition to genu valgum. In this group, there were both treated and untreated patients. The peak incidence of genu varum was found to be between 1 and 2 years of age, while that of genu valgum was found to be between the ages of 3 and 4 years.