Updated: 8/9/2018

Congenital Dislocation of the Knee

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Introduction
  • Spectrum of disease including
    • positional contractures
    • rigid dislocation
  • Structural components include
    • quadricep tendon contracture
    • anterior subluxation of hamstring tendon
    • absent suprapatellar pouch
    • tight collateral ligament
  • Often occurs in children with
    • myelomeningocele
    • arthrogryposis
    • Larsen's syndrome
  • Associated conditions
    • developmental dysplasia of the hip
    •  
      • 50% will have hip dysplasia affect one or both hips
    • clubfoot, 
    • metatarsus adductus
Classification                                                                                                                                                                                                                   
  • Tarek CDK Classification 
    • Graded by passive range of flexion and radiologic appearance
    • Can guide treatment
Presentation
  • Presents with hyperextened knee at birth
Treatment
  • Nonoperative treatment
    • reduction with manual manipulation and casting
      • indications
        • Tarek GI, initial treatment for GII (up to 1 month of age)
        • most cases can be treated nonoperatively
        • if both knee and hip dislocated, then treat knee first 
          • can't get Pavlik harness on hip if knee dislocated
      • technique
        • long leg casting on weekly basis
  • Operative treatment 
    • surgical soft tissue release
      • indications
        • failure to gain 30° of flexion after 3 months of casting
        • Tarek GII (identified after 1 month of age), GIII, and in recurrent cases 
      • goal of surgery is to obtain 90° of flexion 
        • percutaneous quadriceps recession (PQR)
        • quadriceps tendon lengthening (V-Y quadricepsplasty or Z lengthening) 
        • anterior joint capsule release
        • hamstring tendon posterior transposition
        • collateral ligaments mobilization
      • postoperative
        • cast in 45 to 60° flexion for 3 to 4 weeks
 

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Questions (3)
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(OBQ13.114) A mother brings in her 6-month-old infant with a knee deformity. The child had previously been treated with serial casting in flexion for 3 month at an outside facility. Examination reveals passive hyperextension to 25° and passive flexion to 15° as shown in Figures A and B respectively. A lateral radiograph of the knee is shown in Figure C. What is the most appropriate next step in treatment? Tested Concept

QID: 4749
FIGURES:
1

Serial above-knee casting in extension for 4 weeks.

8%

(270/3411)

2

Serial above-knee casting in flexion for 4 weeks.

22%

(753/3411)

3

Arthroscopic anterior cruciate ligament division, followed by above-knee casting

1%

(44/3411)

4

Percutaneous quadriceps recession, followed by above-knee casting

29%

(985/3411)

5

Open VY quadriceps plasty, followed by above-knee casting

39%

(1343/3411)

L 5 B

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