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Introduction
  • Genu valgum is a normal physiologic process in children
    • therefore it is critical to differentiate between a physiologic and pathologic process
  • Epidemiology
    • distal femur is the most common location of primary pathologic genu valgum but can arise from tibia
  • Etiologies
    • bilateral genu valgum
      • physiologic
      • renal osteodystrophy (renal rickets)
      • skeletal dysplasia
        • Morquio syndrome
        • spondyloepiphyseal dysplasia
        • chondroctodermal dysplasia
    • unilateral genu valgum
      • physeal injury from trauma, infection, or vascular insult
      • proximal metaphyseal tibia fracture 
      • benign tumors
        • fibrous dysplasia
        • osteochondromas
        • Ollier's disease
  • Prognosis
    • the threshold of deformity that leads to future degenerative changes is unknown
    • deformity after a proximal metaphyseal tibia fracture (Cozen) should be observed, as it almost always remodels
Anatomy
  • Normal physiologic process of genu valgum
    • between 3-4 years of age children have up to 20 degrees of genu valgum
    • genu valgum rarely worsens after age 7
    • after age 7 valgus should not be worse than 12 degrees of genu valgum
    • after age 7 the intermalleolar distance should be <8 cm
Treatment
  • Nonoperative
    • observation
      • indications
        • first line of treatment
        • genu valgum <15 degrees in a child <6 years of age
    • bracing
      • indications
        • rarely used
          • ineffective in pathologic genu valgum and unnecessary in physiologic genu valgum
  • Operative
    • hemiepiphysiodesis or physeal tethering (staples, screws, or plate/screws) of medial side  
      • indications
        • > 15-20° of valgus in a patient <10 years of age
        • if line drawn from center of femoral head to center of ankle falls in lateral quadrant of tibial plateau in patient > 10 yrs of age  
      • technique
        • to avoid physeal injury place them extraperiosteally
        • to avoid overcorrection follow patients often
        • growth begins within 24 months after removal of the tether
    • distal femoral varus osteotomy  
      • indications
        • insufficient remaining growth for hemiepiphysiodesis 
      • complications
        • peroneal nerve injury
          • perform a peroneal nerve release prior to surgery
        • gradually correct the deformity
        • utilize a closing wedge technique
 

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Questions (3)
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(OBQ11.3) An 18-year-old girl presents with a deformity of the left leg that limits her ability to play basketball and volleyball. She reports pain along the lateral joint line with vigorous activity. A clinical image of the left leg in the supine position is shown in Figure A. A standing alignment radiograph is shown in Figure B with the mechanical lateral distal femoral angle measured at 73° (mLDFA 88°, range 85°-90°), an mechanical medial proximal tibial angle of 87° (mMPTA 87°, range 85°-90°), and a tibial femoral angle of 25°(range 5°-10°). Which of the following is the most appropriate surgical treatment? Review Topic

QID: 3426
FIGURES:
1

Lateral closing wedge proximal femoral osteotomy with medial opening wedge tibial osteotomy

5%

(108/2229)

2

Lateral closing wedge tibial osteotomy

2%

(51/2229)

3

Medial opening wedge femoral osteotomy

8%

(177/2229)

4

Medial closing wedge tibial osteotomy

6%

(140/2229)

5

Medial closing wedge femoral osteotomy

78%

(1733/2229)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ11.13) A 12-year-old skeletally immature female presents with a several year history of bilateral knee pain and lower extremity deformity with her knees rubbing together while she runs. Her medical history is positive for asthma and eczema. She denies constitutional symptoms. She is neurovascularly intact in the bilateral lower extremities. A standing alignment radiograph is shown in Figure A. Which of the following treatment options is most appropriate? Review Topic

QID: 3436
FIGURES:
1

Hip-knee-ankle-foot orthotic (HKAFO)

5%

(107/2237)

2

Distal femoral osteotomy with plate fixation of bilateral distal femurs

5%

(117/2237)

3

Temporary hemiepiphysiodesis across the bilateral medial distal femoral growth plates

75%

(1682/2237)

4

Temporary hemiepiphysiodesis across the right medial distal femoral growth plate

6%

(139/2237)

5

Temporary lateral hemiepiphysiodesis of the bilateral distal femoral growth plates

7%

(164/2237)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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