Angular and Torsional Deformities of the Lower Limbs in Children THOoMas F. KLING, J Angular and torsional malalignments of the lower extremity in children are common problems for which parents seek orthopedic advice. Caleaneal valgus of the foot, internal tibial torsion, genu varus, genu valgus, and femoral anteversion are normally observed in infants and usually are cor- rected with growth. The majority of angular de- formities are physiologic; however, it is important to distinguish those requiring further evaluation and treatment. Accurate examination and know!- edge of the natural history of rotational and an- ‘gular deformities allow accurate assessment of the child and sound advice to the parents. There is a trend away from the use of shoe modification Denis-Browne-type bars, and twister cables treating these deformities. Surgical treatment is ‘occasionally required, but the prerequisites in each case should be carefully observed. Rotational and angular malalignments are common conditions that affect the lower ex- tremities in growing children, The most ob- vious manifestation of rotational deformity is the position of the feet, and it is common to refer to the condition as “toeing in” or “toeing out.” Toeing in may be due to fem- oral anteversion, internal tibial torsion, or ‘metatarsus adductus.'°2” Toeing out may re- sult from external rotation contracture of the hip, external rotation of the tibia, or calea- * Assistant Professor, Department of Surgery, Section ‘of Orthopaedic Surgery, University of Michigan, Ann ‘Arbor, Michigan. ** Professor, Department of Surgery, Section of Or- thopaedic Surgery, University of Michigan, Ann Arbor, Michigan, Reprint requests to Thomas F. Kling, Jr M.D., 1405. E. Ann St,, Ann Arbor, MI 48109. Received: August 24, 1982. M.D.,* AND ROBERT N. HENSINGER, M.D.** neal valgus of the foot.'®232? To manage the problem effectively, it is essential to deter- mine the level of the deformity, as it may occur anywhere between the foot and the hij management for each location is different. Two or more deformities may compensate for each other, as in the case of increased femoral anteversion and external tibial tor- sion, Other conditions may be additive; for example, a combination of mild metatarsus adductus and internal tibial torsion, together with increased femoral anteversion, may pro- duce severe in-toeing, Angular malalignments, or bow legs and knock knees, are common, particularly in the first years of life. The majority of these prob- lems represent normal physiologic develop- ments and will correct themselves in time without treatment,’22* Thus, itis important to differentiate between physiologic align- ments and those that are pathologic, as the latter may require treatment. To evaluate torsional and angular mal- alignment, familiarity with the natural his- tory and normal variation of each condition in children of various ages is necessary. Dis- tinction should be made not only between normal variation and pathologic deformity, but also between cosmetic and functional deformities. The current trend is away from the use of shoe wedges, bracing, and twister cables, ce these devices have not been effective in studies of children with angular and torsional malalignments.'**" In many instances treat- (0009-921X/83/0600/136 $01.40 © J. B. Lippincott Co. 136Lower Limb Deformities in Children 137 ment has been prescribed for the parent rather than the child; it is perhaps wiser to educate the family than to subject the child to ineffective and presently expensive treat- ment methods. It appears that in many cases improvement occurs spontaneously, consis- tent with the natural history of the disease. However, some patients may require con- servative treatment, ¢.g., stretching and splints, Rarely does a patient require surgical intervention. EVALUATION The evaluation should include the medical history of pregnancy, labor, and delivery; type of deformity; its apparent onset, pro- gression, and prior treatment; and the family history of the deformity. Also important is the parents’ perception of their child’s prob- lem, particularly in relation to future gait and appearance of the lower extremities. To determine the level of the deformity, examination should proceed in a sequential fashion: the child should first be observed walking, following which the foot, tibia, knee, and femur should be isolated. Most deformities in children are structural and, therefore, present at rest, Rarely are defor- mities dynamic, The most common dynamic deformity is the so-called searching, or atav- istic, toe.” During the stance phase the ad- ductors of the great toe contract, pulling the toe toward the midline with each step. Chil- dren with cerebral palsy, conversely, will first present with dynamic deformities. Examination of the parents often reveals a deformity similar to that of the child, al- lowing the physician to foresee the character of the deformity in adult life. For example, increased femoral anteversion frequently is found in the mother of an affected child. The sleeping posture in young children should be determined also. Metatarsus ad- ductus and internal tibial torsion, a result of position in wero,'%?!* usually improve spontaneously unless correction is delayed by the child sleeping in the prone position on the feet with the legs internally rotated, wl can perpetuate the deformity.”!27 All children with rotational abnormalities should be examined to rule out the possibility of such pathologic conditions as cerebral palsy, myelodysplasia, and diastematomye- . oF the subtle beginnings of a neurologic problem, ¢.g., hydrocephalus or Charcot- Marie-Tooth disease." The child who has asymmetric findings or a history of rapid progression is particularly suspect, since these are not the usual characteristics of rotational problems. In addition, knock knees or bow legs may be the first indication of rickets or renal disease, ROTATIONAL ALIGNMENT Knowledge of the natural history of rota- tional alignment in children is important if children are to be properly assessed and par- ents soundly advised. The limb bud of the Jower extremity appears during the third week of embryonic life. The great toe is ini- tially preaxial, or on the lateral side of the limb. Subsequently, it internally rotates, bringing the great toe into the medial side of the leg. External rotation of the extremity occurs at both the femoral and tibial levels during postnatal life.” Most children and adults walk with their feet externally rotated, Studies of normal children and adults show that the angle of gait, or the angle made by the foot with the line of progression, is approximately 10° ex- ternally rotated, Consistent in-toeing or ex- ternal rotation in excess of 30° is considered abnormal,”*? Foor Metatarsus adductus is the most common congenital foot deformity and cause of in- toeing.”” Several terms have been suggested to describe the deformity, including “meta- tarsus varus,” “metatarsus adductus,” “pes varus,” “hooked forefoot,” and “metatarsus adductovarus.” Currently, the term ‘meta- tarsus adductus” is used to describe the de-138 Kling and Hensinger Cinzal Omonaedee sa Rated Resoares formity in which the forefoot is adducted at the tarsal-metatarsal joint in the transverse plane. The hindfoot is usually normal, or in some cases the heel may be in slight varus.*** Metatarsus adductus can be observed in the newborn child but may be overlooked until the child is three to four months old. It occurs in both sexes, with a slight male predominance, and is bilateral in about two- thirds of cases.™ It is considered to be due to intrauterine position and may be accen- tuated if the infant sleeps with his feet tucked beneath him. The diagnosis can be determined best by examining the sole of the foot in the neutral position, with the child prone. The lateral border of the normal foot is straight. In meta- tarsus adductus, the lateral border is convex, and the medial border is concave at the tar- sal-metatarsal joint. Looking at the foot from the front, there is a dorsal and lateral prominence at the base of the fifth metatar- sal. In addition, approximately 75% of chi dren with metatarsus adductus also have in- ternal tibial torsion.6* The severity of the deformity is variable. Bleck? measured severity by constructing a reference line that bisects the center of the plantar surface of the hindfoot, the “heel bi- sector.” Normally, this line crosses between the second and third toes. The deformity is considered mild if the line crosses through the third toe; moderate, if it crosses between the third and fourth toes or through the fourth toe; and severe, if it crosses between the fourth and fifth toes. The flexibility of the foot, which is also variable, can be determined by holding the heel firmly in neutral alignment and pushing the forefoot laterally.*'6#* Flexibility can be classified by the extent of passive abduction of the forefoot with reference to the heel bi- sector. In flexible deformity the second and third toes abduct beyond the heel bisector; a partially flexible foot corrects to the heel bisector; and an inflexible foot does not cor- rect to the heel bisector line. Bleck? found no correlation between the severity and flexi- bility of the deformity and the end results of treatment. Roentgenographic analysis is usually un- necessary unless congenital abnormalities of the foot are suspected, An anteroposterior roentgenogram will show sharp medial an- gulation at the tarsal~metatarsal joint, with the first metatarsal more severely adducted than the fifth. Older children with persistent untreated metatarsus adductus walk with an in-tocing gait and wear out their shoes quickly. Older children and adults rarely complain of foot pain or disability, but they also complain about the appearance of their feet and wear out their shoes early.2#3 The natural course of metatarsus adductus is usually spontaneous resolution. Rush- forth?’ reported a series of 83 children (130 feet) with metatarsus adductus who were fol- lowed up for seven years without treatment. At follow-up examination, only 14% of the 130 feet had severe (4%) or moderate (10%) deformities. Ponsetti and Becker™ studied 379 children with metatarsus adductus; only 11.6% of infants with “severe” metatarsus adductus required treatment. Unfortunately, neither study reveals how to determine pro- spectively which feet will resolve sponta- neously and which will not. ‘The problem with metatarsus adductus is the lack of objective methods to determine which feet will improve spontaneously and which feet should be treated.'° Nontreatment can not be prescribed for an obvious foot deformity in a child, which has a 14% chance of being a persistent deformity later in life and which can be corrected only by a surgical procedure.':!624 Most authors have recommended treat- ment in infancy.'"6%2" For mild deformi ties passive stretching by the parents pro- motes spontaneous correction. 16224 If the foot is moderately or severely de- formed, serial plaster casts are applied with progressive passive abduction of the forefoot ist the stabilized heel, as described by Kite'® and by Ponsetti and Becker. Gen-ore Lower Limb Deformities in Children 139 erally, a series of three to four casts will suf- fice in the growing patient eight months of age or younger. Plaster treatment is not as effective after this age.* When the foot can be overcorrected, it is recommended that it be held in that position for several weeks to prevent recurrence. If at the end of this treat- ment the forefoot can be passively corrected but dynamically returns to the adducted po- sition, a reversed-last shoe can be used to maintain corre The experience of most authors is that the deformity will not recur once it has been well corrected.'©?!24 McCauley ef al?! found that the most common deformity following treat- ment of metatarsus adductus is a pronated foot. They concluded that this could be avoided by supination of the heel and ab- duction of the forefoot while the plaster hardens. Ifthe deformity recurs afier the use of plas- ter casts, it can be treated by repeated casting if the foot is more than mildly deformed. If this is unsuccessful in a child younger than three years of age, tenotomy of the abductor hallucis tendon at the neck of the first meta- tarsal has been suggested, with corrective plaster casts applied for six weeks.” This sur- gical procedure should be performed only if the metatarsals demonstrate flexibility, with correction to the midline on an anteropos- terior radiograph of the foot with the forefoot passively abducted. If metatarsus adductus is a continuing problem in the older child and the parents desire correction, surgical correction by tar- sal-metatarsal release (in a child younger than 7 years) or metatarsal osteotomy will result in a satisfactory appearance of the foot. CALCANEAL VALGUS Caleaneal valgus, a common postnatal finding, may present as out-toeing. The ankle is unusually lax, and the foot can be dorsi flexed nearly to the shin, Plantar flexion is restricted, and in severe cases the peroneal tendons may sublux anterior to the lateral malleolus. This condition may be confused with congenital vertical talus, or rocker-bot- tom foot; a lateral roentgenogram of the dor- siflexed foot will differentiate the two con- ditions. Calcaneal valgus generally responds quickly to passive plantar flexion stretching exercises. In a more resistant foot, taping or casting the foot in inversion and plantar flex- ion is effective.” TIBIAL TORSION Internal tibial torsion is a common cause of an in-toeing gait in childhood. It usually is brought to the physician’s attention when the child begins to walk between six and 18 months of age. The natural course of internal tibial tor sion is to improve with growth. In a study of 160 normal children and 20 adults, Staheli and Engel" found that the transmalleolar axis of the tibia was externally rotated from birth and that it increased with age. They measured the transmalleolar axis of the tibia with the knee flexed to 90° and found that it averages 5° of external rotation during the first year of life; 10° during midchildhood; and 14° in older children and adults. Pre- vious workers” measured the transmalleolar axis with the knee straight and found that the mean value of the transmalleolar axis was 20° in adults. From Staheli’s study, the au- thors conclude that the natural course of tib- ial torsion is to rotate externally with time. For tibial torsion the child is examined seated, the thighs directly in front of the hip joint, the heels against a flat surface (the ex- amining table), and the feet held at right an- gles to the back wall in both the sagittal and horizontal planes. The relationship of the medial to the lateral malleolus is used to de- termine the transmalleolar axis and its rela- tionship to the long axis of the tibia. An alternate method is to measure the thigh-foot angle,2” with the child placed prone, the knees together and flexed to 90°, and the foot at a right angle to the tibia. The angle between the thigh and the long axis of140 Kling and Hensinger Cingal Otmoneedce ra Rated Research the foot indicates the degree of tibial torsion. Internal tibial rotation as measured by the thigh-foot axis parallels that measured by the transmalleolar axis but exceeds it by about 5°.” Radiographic measurement of tibial tor- sion is theoretically more accurate but of lim- ited value in children since ossification is in- complete. Additional disadvantages include the cost and radiation exposure. There is controversy regarding the need for treatment, Internal tibial torsion has a sig nificant capacity for spontaneous improve- ‘ment in most children and seldom represents a significant handicap.'°”” In a few instances the deformity may persist throughout child- hood, producing cosmetic and occasional functional disabilities. In addition, because results of studies documenting the deformity or its improvement have not been fully re~ producible, it is difficult to assess the efficacy of treatment methods. If the condition is discovered when the child starts to walk, the severity should be documented and the patient checked in three to four months. Lateral bowing of the tibia can accentuate internal tibial torsion. Gen- eral treatment measures include encouraging patients to sit cross-legged (Indian fashion) or on a chair and discouraging them from sitting on their feet. The sleeping position should be assessed. By sleeping prone with the legs internally rotated, the child may pre- vent spontaneous derotation. If the child is younger than 18 months of age, a simple Denis-Browne brace for night wear to change sleeping habits may correct the condition. The side requiring correction is adjusted to a moderate degree of external rotation, from 10° to 20°. Forceful rotation to any degree should be avoided. If the deformity is uni- lateral, the normal side should be adjusted to 7°=10° of external rotation. The length of the bar should be the width of the pelvis, usually 6-8 inches. However, ifthe child also hhas bow legs, a longer bar, from 10 to 12 inches, may be used. If the child has femoral anteversion and internal tibial torsion, a Denis-Browne splint may be contraindi- cated, as it may cause excessive external ro- tation of the tibia and a knock-kneed ap- pearance." The child usually is treated by applying the brace at night and during naps and left free during the day for crawling, sit- ting, and walking. The child is examined at three-month intervals. The end-point of treatment is a satisfactory gait and a normal transmalleolar axis. Treatment should be completed by the age of three years, after which correction is discouragingly slow and results usually are unsatisfactory. ‘The parents should be warned that many children and adults toe in when they are tired or when they wear heavy shoes or boots. Continuation of treatment to eradicate this type of in-toeing is unnecessary. External rotation of the tibia is less com- mon than internal rotation and seldom pre- sents as a clinical problem in the first few years of life. It is observed in older children, the majority of whom have been found to have femoral anteversion*'® (Fig. 1C). Ex- ternal rotation also can develop as a conse- quence of overtreatment of internal tibial torsion using a Denis-Browne bar in the child who has fixed anteversion of the hip.!? Ad- ditionally, it may be observed in such neu- romuscular conditions as polio or myelodys- plasia. To treat this condition, a Denis- Browne or Fillauer splint can be used at night, with the feet set in neutral or slight internal rotation. FEMORAL ROTATION Femoral anteversion is the most common cause of in-toeing in children three to 12 years of age. It is usually bilateral and sym- metric and is more often observed in girls.”' Usually, these children also have a slightly increased lordosis and ligamentous laxity. Femoral anteversion often is referred to as a problem of hip rotation, but, in fact, the entire femur is involved. Thus, it is impor- tant to emphasize to the parents that the etiology lies in the orientation of the femur,Figs. 1A-1C. A 5-year-old girl with marked femoral anteversion. (A) The hips internally rotate 85° bilaterally when tested in the prone position using the tibia as a dial. (B) Examination for ex- ternal rotation in the prone position shows 10° of external rotation of the sight hip. The left hip also externally ro- tates only 10°, (C) Seven years later, at the age of 13 years, she walks with the fect straight and has no complaints regarding the hips or position of the feet. Examination shows that the hips internally rotate 80° and externally rotate 15° bilaterally, indic: ig that femoral anteversion has not changed signifi- cantly. Note the marked external rotation of the tibia, which now compensates for the femoral ante~ version. and not in the child’s hip joint. In severe forms the femur can be internally rotated as much as 90°, and external rotation may be limited to 5°-10°. The natural course of femoral anteversion has been well documented by Fabray et al.* in a 20-year follow-up study of 1148 hips. Using the Dunlap-Shands method of deter- mining femoral torsion,“* they found that the newborn infant has a maximum femoral anteversion of approximately 40°. This de- creases to an average of 32° at the age of one year and further decreases to 16° by the age of 16 years. These investigators and others found that anteversion decreases rapidly, pla- teauing at the age of eight years and then decreasing slowly, to an average of 16° in the adult.”* The range of internal and external rotation of the hip in these normal children is approximately equal. Femoral rotation is best assessed with the patient lying prone, the hips in extension and the knees flexed to 90° (Fig. 1). The position of the legs is observed and the degree of ro- tation measured with the hip in internal and external rotation. It is tempting to perform this type of examination with the patient sit- ting, but the hips must be extended to tighten. the anterior joint capsule. In flexion the hip capsule is relaxed, which allows a greater range of external rotation and, thus, an in- accurate measurement. Marked internal femoral rotation and limited external rota- tion constitute presumptive clinical evidence of femoral anteversion.* Excellent radiographic techniques are available to determine the degree of femoral anteversion. The method of Dunlap and Shands has the longest follow-up study and gives a reliable and reproducible result.® The CT scan also has been shown to be accurate and useful in determining anteversion, but cost and scheduling are disadvantages.” Hip rotation varies with the age of the child, Children younger than two years of age usually have an external rotation contracture of the hip’! due to an intrauterine position in which the hips usually are flexed and ex- ternally rotated. This intrauterine posture results in contracture of the external rotator muscles of the hip and the capsular struc- tures, which persists after birth. The use of diapers encourages the infant to continue to hold the hips externally rotated and ab-142 Kling and Hensinger Gini! Omnopacdies ‘end elted Research ducted. The infant therefore has no compel- ling reason to rotate the hips internally. Chil- dren frequently have bow legs and/or inter- nal tibial torsion at birth, which tends to balance the externally rotated posture of the thigh. Thus, although femoral anteversion is maximal in the infant, the examination de- picts increased external rotation secondary to external rotation contracture. The infant beginning to stand is most comfortable with the greater trochanter in the relatively mid- lateral position, where the hip abductors work most efficiently. Standing thus pro- vides stimulus for the infant to rotate the hips internally, to bring the greater trochanter into relatively midlateral position. Many children maintain the thigh in ex- ternal rotation during the first several months of walking and toe out excessively due to an external rotation contracture of the extended hip. Persistence of this external rotation con- tracture is the main cause of'a toeing-out gait in the early walker but usually is resolved by 18-24 months of age. In such cases simple internal rotation stretching exercises seem to suffice. Femoral neck retroversion has not been demonstrated radiographically in chi dren and, hence, appears to be quite rare.'?? In-toeing secondary to femoral antever- sion is most obvious in children from four to six years of age. It is of interest that many children returning as teenagers no longer toe in, although the degree of femoral antever- sion may not be changed, Fabray ef al.,* in a study of children with femoral anteversion, found no significant decrease in anteversion at a 5'4-year follow-up examination, More- over, there was no significant change in an- teversion in children older than eight years of age, suggesting that there is potential for change in other areas, most likely stretching the capsule and soft tissues about the hip joint. In addition, these children develop ex- ternal tibial torsion and may change the in- clination of the acetabulum, which combine to make the deformity Jess apparent”*'° (Figs. 1A-1C). Occasionally, a child with severe femoral anteversion and little or no external rotation finds walking or running troublesome or clumsy. On rare occasions these children complain of pain in the hips and buttocks, believed to be due to the hyperfunction of the external rotators of the hips as the cl dren try to walk properly. There is no satisfactory treatment device to modify femoral anteversion. Children with increased femoral anteversion tend to sit in reversed tailor position, which may ag- gravate the deformity by preventing spon- taneous correction. This sitting habit should be discouraged; the child should be taught to sit Indian fashion or in a chair with the knees flexed. Fabray ¢f al.* found that chi dren with increased anteversion corrected 3.2° in 5% years without treatment, They compared this figure with the correction ob- tained in children treated by a Denis-Browne bar or twister cables and those treated by both, noting an average correction of 2°-3°, These devices were of no benefit in correcting femoral anteversion and may, in fact, be harmful, producing abnormal external rota- tion of the tibia and a knock-kneed gait. The only effective means of correcting in- creased anteversion is derotation femoral os- teotomy, a significant surgical procedure that is justified only if the deformity is severe?” Indications for surgical correction are con- troversial. The authors’ criteria include (1) presence of significant functional and cos- metic disability; (2) internal rotation of ap- proximately 90° and external rotation of less than 10°; (3) anteversion in excess of 45°, as measured radiographically; and (4) exter- nal tibial torsion that does not exceed 35°. Derotation osteotomy should not be accom- plished before the child is seven or eight years of age, since correction due to growth con- tinues to the age of eight years, However, an osteotomy should be done before the child begins to develop significant external tibial torsion, Before surgical correction is under- taken, it is desirable to observe a child for atNumer 176 Sina 4983. Lower Limb Deformities in Children 148 least one year to determine whether the de- formity is improving. In addition, the pro- cedure should only be undertaken after in- forming the parents that late disability is un- likely if the condition is untreated. The osteotomy can be done at the distal femoral metaphysis in children seven to nine years of age. In older children it should be accomplished in the subtrochanteric region. using internal fixation, There is no evidence that increased fem- oral anteversion leads to degenerative ar- thritis, nor that it leads to pain or functional disability in adult life.”* Therefore, a pro- phylatic operation to realign the knee is not indicated in children. ANGULAR MALALIGNMENT Bow legs and knock knees are common conditions that affect the lower extremities in growing children, While the great majority of these problems represent normal physio- logic development and are corrected in time without treatment, it is important to differ- entiate between physiologic angular defor- mities and the variety of pathologic condi- tions that cause genu varum or genu valgum, which require special evaluation and treat- ment, PrysioLoaic Bow Leas AND KNock KNEES The natural course of physiologic genu varum and genu valgum has been defined by Salenius and Vankka.”* They studied the de- velopment of the tibiofemoral angle, mea- sured clinically and roentgenographically in 1480 normal children, and found it similar in boys and girls. The tibiofemoral angle in newborns up to the age of one year is in pro- nounced varus (15°). At about the age of 1” years, the knees tend to straighten, During the second and third years, the tibiofemoral angle changes toward marked valgus angu- lation (12°), The valgus alignment is then corrected to that of the adult in the following years. Other authors have utilized the distance between the condyles to measure bowing and that between the ankles to measure knock knees.”?3 However, these measurements have not been followed longitudinally, nor are they as accurate as a measure of the ti- biofemoral angle. When obtaining a roent- genogram of the legs to measure the tibiofe- moral angle, the legs must be positioned properly, since external rotation will decrease valgus deformity and internal rotation will increase valgus angulation."* The normal infant usually stands with the legs apart, and the fat may mask early phys- iologic varus angulation, A mild degree of bow legs appears in children younger than 1% years. Internal tibial torsion often accom- panies physiologic genu varum, and its pres- ence will accentuate the bow-leg attitude in stance and with ambulation. Physiologic val- gus angulation usually is observed between the ages of 2 and three years. Pes planus and external tibial torsion may accompany genu valgum and will accentuate the ap- pearance of knock knees. Clinical evaluation of angular deformities should include family history and a descrip- tion of the deformity, its onset, and progres- sion, The child should be observed ambu- lating, with particular attention to the stance phase of gait to determine whether there is a lateral thrust (bow legs) or medial thrust (knock knees) at the onset of weight-bearing. Presence of a thrust indicates that the medial or lateral restraint of the knee is not com- petent to resist the deformity. Children with physiologic varus or valgus angulation will not exhibit a thrust. However, in most patho- logic conditions that cause varus or valgus angulation, there will be a thrust, indicating incompetence of the knee ligaments and probable continued progression of the defor- mity, similar to genu varus and osteoarthritis, of the knee in the adult. Treatment of physiologic genu varus and valgus should consist of reassurance and ob- servation. Sleeping splints, corrective shoes,144 Kling and Hensinger Cina! Onrepsaces ova'Rated Research and active and passive exercises have been advocated, but no change in the appearance of the extremities other than that expected through normal growth and development has been noted.” Knock knees in children younger than seven years of age may be safely ignored un- less the condition is excessive, as measured by a tibiofemoral angle of greater than 15° of valgus; asymmetric; or accompanied by shortened stature.””*? Howorth'? believed that if knock-knee deformity is greater than 3 inches, as measured between the medial malleoli with the knees together at the age of ten years, the deformity is not likely to be corrected with time, He also believed that excessive genu valgum contributes to awk- wardness of gait, subluxing patella, easy fa- tigability, and joint pains. Thus, Howorth and others recommended surgical stapling of the medial tibial and femoral epiphyses."22 Stapling the distal femoral epiphysis works well for knock knees when the staples remain in place, but the amount of correction is un- predictable, since a rebound increased growth occurs when the staples are removed. Zuege et al. suggested allowing for 5° of rebound, of which 1°-2° will be corrected when the plate closes. They also recommended sta- pling as the patient approaches maturity, not before a skeletal age of 11 years in girls and 12 years in boys. In addition, the staples should not be left in place for more than one year; if they are left in place for longer than one year, longitudinal growth may not re- sume when the staples are removed. PATHOLOGIC BOWING AND KNOCK KNEES. Unilateral genu varus or valgus may be associated with tumors, congenital deformity of the knee, metaphyseal dysplasia, osteo- chondromatosis, hemihypertrophy, paraxial fibular hemimelia, multiple epiphyseal dys- plasia, osteochondrodystrophy, Blount’s dis- ease, rickets, and fibrous dysplasia. In addi- tion, nondisplaced fracture, surgery, or os- teomyelitis of the proximal tibia, as well as direct trauma and X-rays to the physis, can result in deformity. Blount’ disease is probably the most com- mon cause of pathologic bow legs. The epiph- yseal and metaphyseal regions of the poste- rior medial aspect of the proximal tibia are involved, resulting in bow legs. There are two types of Blount’s disease, predominantly af- fecting blacks"; (1) The infantile form is usually bilateral, progressive, and associated with significant internal tibial torsion. (2) The juvenile form is recognized in children six to 14 years of age, is usually unilateral, produces less deformity, and is not associated with internal tibial torsion. The juvenile type is much less common than the infantile type. Lagenskiéld and Riska'? described six stages of roentgenographically visible pro- gression, based-on the degree of epiphyseal depression and metaphyseal fragmentation of the proximomedial tibia."* It is difficult to distinguish between the initial stage of infan- tile Blount’s disease and extreme physiologic bow legs, and it may be the extreme variation of physiologic genu varum that represents the initial stages of Blount’s disease, Drennan? suggested the use of the metaphyseal-diaph- yseal angle to predict which children will progress from physiologic bow legs to Blount’s disease. He draws a line through the widest portion of the tibial metaphysis on an an- teroposterior roentgenogram and an inter- secting line parallel to the lateral border of the tibia, A third line is drawn perpendicular to the metaphyseal line, and the angle be- tween it and that on the lateral border of the tibia is measured. Angles less than 11° tend to resolve, while those greater than 11° prog- ress to Blount's disease. In addition, if a lat- eral thrust has developed with weight-bearing in a child with bow legs, the prognosis for improvement is poor. The clinical diagnosis is usually not made until the child begins to walk. ‘There is disagreement as to the etiology of the condition. Langenskidld and Riska!® and Blount‘ believed that it is caused by distur- bance in growth and ossification of the me-Number 175, ‘hire, 1983 Lower Limb Deformities in Children 145 Figs. 2A AND 2B. (A) Standing roentgenogram ofa 3-year-old black boy with Blount’s disease of the left leg. which has been treated in a brace for 1 year. The radio graph shows the left leg to be nicely aligned. However, note that the standing support used to place both legs on the film is pushing the knees into valgus. (B) Standing roentgenogram obtained the same day without the standing table, Note the persistent varus attitude of the leg and the lack of full correction. This so- called “squish film" will not show the true patho- logic condition and may lead to brace removal too early. dial part of the proximal tibial epiphysis and metaphysis. Others'*"5"” believed that the problem develops as a result of early walking, when physiologic genu varus is maximal and weight-bearing transmits its force across the medial tibiofemoral compartment, thereby slowing the growth of the medial tibial physis, None of these investigators has spe- cific data for their theories, but most cases are reported from the West Indies and West Africa, where physiologic varus is marked and black children walk early in infancy. Treatment of Blount's disease depends on the degree of deformity and the age of the patient. Infantile Blount’s disease usually progresses rapidly during the first four years and then more slowly during the remainder of growth. Patients younger than 18 months can be observed. If the varus deformity is not improving by 18 to 24 months of age, it may be treated with an orthosis, which is effective up to the age of three years* (Figs. 2A and 2B). Ifa child presents with a persistent varus deformity, a tibiofemoral angle measuring more than 15° of varus, and roentgenogram showing Langenskidld Stage III disease or more, bracing probably will not be successful and osteotomy will be required."°?? For fantile Blount’s disease a valgus external ro- tational osteotomy is required, whereas in the juvenile form external rotation usually is not necessary. Osteotomy done at an early age will usually completely correct the deformity permanently, with greater chances for recur- rence if the osteotomy is done in later years,!"? This is particularly true if the me- dial portion of the physis is closed in Lan- genskidld Stage IV disease. Rickets can also cause bow legs or knock knees. Interestingly, the various forms of rickets, including vitamin D deficiency, chronic renal insufficiency, hypophosphata- sia, and vitamin D resistant rickets, result in different deformities. Vitamin D deficient and vitamin D resistant rickets cause genu varum, which is associated with internal tib- ial torsion. Conversely, rickets caused by chronic renal insufficiency usually result in genu valgum, which usually is not associated ith internal tibial torsion, Chronic renal in- sufficiency has become a more frequent causeCina Ommopaedes 146 Kling and Hensinger end'hetted Research Fics, 3A-3C. (A) Radiograph of a 3-year-old girl who fell from a porch, fracturing the right proximal tibial metaphysis. The fracture is nondisplaced, and the fibula is intact. She was treated for 6 weeks in a long-leg cast. Her parents noticed that she had slightly increased valgus on the right compared with the left when the cast was removed. (B) Eight months after fracture. she has valgus deformity that ‘measures 20° using the tibiofemoral angle, as compared with 9° on the left side. (C) She was treated with a long-leg orthosis, with a medial pad exerting a varus force in the knee for | year. At follow-up examination at 5 years of age. the legs are nicely aligned, with 9° of valgus on the left and 12° on the right, The right leg is “4 inch longer than the left. of knock knees. The advent of improved medical management using renal dialysis and kidney transplantation has increased longevity. Therefore, correction of these de- formities by osteotomy is reasonable and should be undertaken if the deformity is se- vere. It should be recognized that proper med- ical management is necessary to ensure proper healing in children with rickets who undergo osteotomy. In cases of chronic renal insuf- ficiency, the children are likely to have ter- tiary hyperparathyroidism. In these cases healing may be delayed, and the dialysis may have to be adjusted. Isaacson"? suggested that removing the parathyroid glands before os- teotomy will ensure healing within a reason- able period. There is evidence that parathy- roid tissue can be frozen and a small amount reinserted subcutaneously in children who become hypoparathyroid.2? Another cause of unilateral valgus defor- mity is an undisplaced or minimally dis- placed fracture of the medial side of the prox- imal tibial metaphysis (Figs. 3A-3C). Jack- son and Cozen'* reported that genu valgum is a potential sequela of this fracture, occur- ring in children three to nine years of age, and is usually recognized shortly after the fracture heals, The valgus may be 15° or more as compared with the other side. The development of genu valgum has been at- tributed to a discrepancy in growth between the tibia and fibula, with the fibula exerting a tethering effect.” Treatment using a knock- knee brace worn for about one year is usually successful." Corrective osteotomy may be necessary if the remaining growth potential is too limited or if the genu valgum is severe, It should be noted that surgical trauma sec- ondary to osteotomy, or osteomyelitis of the proximal tibial metaphysis, may stimulatemoos 176 ‘hie. 083 Lower Limb Deformities in Children 147 overgrowth” and further valgus deformity. The problem with this fracture is that those treating it may not advise the parents of this complication from the onset, rendering fol- low-up care difficult if valgus deformity en- sues. Proximal tibial osteotomies are the treat- ment of choice for Blount's disease and for some valgus deformities of the tibia in chil- dren. Any child who undergoes a tibial os- teotomy presents a potential hazard and should be observed carefully for compromise of the neurovascular or motor status of the lower extremity in the postoperative period. Steel and coworkers” documented signifi- cant compromise of the neurovascular struc- tures of the lower extremities in up to 20% of children undergoing proximal tibial oste- otomy and suggested that the problem is due to entrapment of the anterior tibial artery following correction, not to injury of the pe- roneal nerve, They therefore recommended that if there is neurovascular compromise following proximal tibial osteotomy, the ap- propriate treatment would be to replace the limb in the uncorrected position. REFERENCES |. Bateson, E, M.: The relationship between Blount’s disease and bow legs. Br. J. Radiol. 41:107. 1968. 2, Bleck, E. E. Spastic abductor hallucis. Dev. Med. Child: Neurol, 9:802, 1967. 3. Bleck, E. 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