بسم الله الرحمن الرحيم

PERCUTANEAOUS DRILLING TIBIAL

OSTEOTOMY FOR THE TREATMENT OF BOW

LEGS AND GENU VARUM IN CHILDREN AND

ADOLESCENTSPresented by

Ahmed Abd El Razek

INTRODUCTION

• Genu varum, or bow legs, is a very common childhood angular deformity.

• Parents are mostly concerned with the cosmetic appearance of their children.

• There are many treatment options determined according to the cause of genu varum and its progression.

INTRODUCTION

• The surgical correction ranges from manipulation of physeal growth by hemiepiphysiodesis up to mechanical axis correction via an osteotomy.

• The valgus corrective osteotomy could be performed acutely or gradually.

Malalignment Test (MAT)• Malalignment test is designed to identify the sources of

mechanical axis deviation.

TYPES OF HIGH TIBIAL OSTEOTOMY:

1) Opening wedge osteotomy2) Closing wedge osteotomy3) Oblique osteotomy4) Serrated osteotomy (W/M osteotomy)5) Focal dome osteotomy6) Anterior posterior inverted-‘U’ osteotomy

Ultrasound was previously used to asses fracture healing by following new vessel formation at the fracture site during development of the fracture callus.

ULTRASOUND IN HEALING BONES

AIM OF THE WORK

AIM OF THE WORK

Evaluating the results of surgical correction of bow legs /

genu varum in children and adolescents using

percutaneous drilling tibial osteotomy and the effect of

the osteotomy on the intactness of the periosteoum at the

osteotomy site.

PATIENTS

1)AgeRange (4 to 16 years) mean age 6 ±4.3 years.

2)Gender7 boys (58.3%) 12 limbs 5 girls (41.7%) 9 limbs.

3)Side affected9 (75%) bilaterally 3 (25%) unilaterally.

PATIENTS Prospective study from July 2014 to August 2016. 21 limbs in 12 patients. Presented to El – Hadra Orthopedic and

Traumatology University Hospital.

4) Gait4 (33.3%) normal gait 8 (66.7%) intoeing gait bilaterally

5) Thigh foot angleRange 0◦ to -15◦ mean of -6.67◦ ±5.08.

6) Knee laxity3 (14.3%) +ve lateral ligamentous laxity 18 (85.7%) –ve knee laxity.

7) Tibio-femoral angle (TFA)Range -30◦ to -10◦ mean of -18.76◦ ±5.72◦

8) Medial proximal tibial angle (MPTA)Range 60◦ to 83◦ mean of 71◦± 5.97

PRE-OPERATIVE FINDINGS

Follow-up period of at least 6 months.

METHODS

1. Personal data.2. Complaints.3. History taking.4. Examination:

• General examination.• Local examination.

5. Laboratory study:• Serum calcium level.• Serum phosphorus level.• Serum alkaline phosphatase level.

I. METHODS OF CLINICAL ASSESSMENT

mLDFA

MPTA

mLDTA

TFA

1. The mechanical axis of the lower limb .

2. Measuremnet of : The tibio-femoral angle

(TFA) . The Metaphyseal- Diaphyseal

angle (MDA). The medial proximal tibial

angle (MPTA). The mechanical lateral distal

femoral angle (mLDFA)

II. METHODS OF RADIOLOGICAL EVALUATION:

• Surgical treatment using percutaneous drilling tibial osteotomy.

• A sharp 3.2 mm drill bit was used to make multiple bicortical perforations.

• Osteoclasis was performed with manual correction of the varus and rotational deformity.

• A well moulded above knee plaster cast was applied.

III. METHODS OF TREATMENT

• 1st post-operative day monitoring of distal circulation and neurological status

• 10th post-operative day periosteum was examined for its intactness using the ultrasound.

• 6th post-operative week check radiographs to assess union.

• 8th post-operative week cast removed - knee and ankle exercises were encouraged.

• 6th post-operative month to assess the final correction.

IV. POST-OPERATIVE MANAGEMENT

Clinically: At the end of follow up all patients were clinically assessed according to modified Garcia-Cimberlo et al criteria:1. Bone consolidation2. Bone infection3. Neurovascular injury4. Residual deformity (using TF angle)5. Knee motion6. Ankle motion7. Limb-length discrepancy8. Scars9. Patient / parents' evaluation

RADILOLOGICALLY: long standing antero-posterior views of both lower extremities from hips to ankles.

V. METHODS OF ASSESSMENT OF THE RESULTS

RESULTS

I. The end results

• 17 limbs (81%) good (satisfactory) results

• 4 limbs (19%) poor (unsatisfactory) results

• No case had a fair results

Poor4

19.0%

Good1781.0%

II. Assessment of the clinical and radiological criteria

Full in all 1) Bone consolidation

NIL 2) Bone infection

NIL 3) Neurovascular injury

4) Residual deformity 17 cases <10% residual deformity (good cases) 4 cases >20% residual deformity (poor cases)

II. Assessment of the clinical and radiological criteria

FROM in all 5) Knee and ankle motion

NIL 6) Limb length discrepancy

All cosmetic 7) Scars

All good 8) Patients\parents' evaluation

The improvement in the mean thigh-foot angle value was highly significant

9) Correction of thigh-foot angle (clinical assessment of tibial torsion)

10) Radiological assessment of residual varus deformity

a) Correction of tibio-femoral angle (TFA)• Mean pre-operative TFA -18.76◦± 5.72• At the end of follow-up -2.24◦ ± 5.04• The improvement in the mean TFA value was highly significant

(p<0.001)

b) Correction of medial proximal tibial angle (MPTA)• Mean pre-operative MPTA 71◦ ± 5.97 4• At the end of follow-up 87◦ ± 4.79.• The improvement in the mean MPTA value was significant (p<0.001)

1) Relation between the final results and the age of the cases

• Patients ≤10 years had good results.• Patients >10 years had poor results.• It was found that, there was a significant

correlation between the final results and the age of the patients.

2) Relation between the end results and the sex of the cases

There was a statistically insignificant correlation between sex and the final end result.

STATISTICAL CORRELATIONS

3) Relation between the end results and pre- operative knee laxity

4) Relation between the end results and the thigh-foot angle

• There was a significant correlation between the pre-operative thigh-foot angle and the final results.

STATISTICAL CORRELATIONS

• In good cases all legs had negative laxity.

• In poor cases 3 legs (75%) had positive laxity.

• knee laxity was associated with poor results and this was statistically significant.

5) Relation between the end results and the Tibio-Femoral angle (TFA)

• In good cases was 0◦

• In poor cases ranged from -18◦ to -8◦ with a mean -11.75◦±4.5◦

• There was a significant relationship between the improvement

of the TFA and the end result.

6) Relation between the end results and the intercondylar distance (ICD) of the cases

STATISTICAL CORRELATIONS

• There was an insignificant correlation between the pre-operative intercondylar distance ICD and the final results.

`

7) Relation between end results and intactness of the periosteum on ultrasound (U\S)

• In good cases 2 cases disrupted periosteum 15 cases an intact periosteum

• In poor cases 2 disrupted periosteum 1 case intact periosteum

• There was insignificant relationship between the end results and intactness of the periosteum on U/S

8) Relation between the end results and radiological union

• There was a significant relationship between the end result and radiological union.

STATISTICAL CORRELATIONS

CASES

• A 4 -year- old girl with post-rachitic bilateral genu varum.

• Inter-condylar distance 13 cm .

• Thigh-foot angles -15° on the right side & -10° on the

left side.

• TFA -29° on the right side & -22°on the

left side.

• MDA 10° bilaterally.

• After six months of follow up the thigh-foot angle was 0°

bilaterally, and the TFA was 0°.

Patient 1

• An 11 -year- old female with bilateral genu varum • The inter-condylar distance 13 cm • Thigh-foot angle 0° bilaterally • knee laxity positive bilaterally• TFA -24° on the right & -19° on the left

side• During Osteoclasis of the tibia iatrogenic Salter Harris type II

injury of the proximal physis of the tibia occurred on the left side • After six months of follow up, TFA was -18° on the right side & -

11° on the left side.

Patient 2

CONCLUSIONS AND RECOMMENDATIONS

CONCLUSIONS AND RECOMMENDATIONS