Updated: 6/14/2021

Congenital Dislocation of the Knee

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  • summary
    • Congenital Dislocation of the Knee is a congenital knee condition that is primarily seen in patients with myelomingocele, arthrogryposis, or Larsen's syndrome.
    • Diagnosis is made clinically with a hyperextended knee at birth.
    • Treatment is a trial of reduction with manual manipulation and casting until the age of 3 months. Surgical management is indicated in cases of failure to gain 30° of flexion after 3 months of casting.
  • Etiology
    • 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 
      • graded by passive range of flexion and radiologic appearance
      • can guide treatment
    • Tarek Classification

      Radiology
      Range of passive flexion
      Grade I
      Simple recurvatum
      > 90°
      Grade II
      Subluxation/dislocation
      30° - 90°
      Grade III
      Dislocation
      30°
  • 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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(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?

QID: 4749
FIGURES:
1

Serial above-knee casting in extension for 4 weeks.

8%

(280/3606)

2

Serial above-knee casting in flexion for 4 weeks.

22%

(801/3606)

3

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

1%

(48/3606)

4

Percutaneous quadriceps recession, followed by above-knee casting

29%

(1037/3606)

5

Open VY quadriceps plasty, followed by above-knee casting

39%

(1424/3606)

L 5 C

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Evidence (6)
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