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Genu valgum is one of the reasons why an orthopaedic assessment is most frequently required in
children. “My son has X-shaped knees, is that normal? Can we do something?”
In most cases these are physiological conditions for which it is enough to reassure parents. Yet, in some
cases, more attention is required.
Typically the lower limbs of newborns show a slight varus axis, which is more evident when the infant
starts to stand, with consequent concern of the parents.
The axis then tends to improve spontaneously, reaching the neutral axis around 18-24 months and then
continuing towards valgus deviation, with a peak around 3.5 – 4 years.
Finally, valgus deviation decreases again and gradually returns to the mild physiological valgus of the
adult’s knee.
The physiological development of the knee axis (Salenius, J Bone Joint Surg Am, 1975)
This description obviously corresponds to an average of healthy subjects, so it is possible to find small
variations from the average. For example, it is common to find children with slight deviation (with respect
to the graph), without this falling into a pathological picture.
In this position one can evaluate the angle between the thigh and the leg (difficult to measure) or
alternatively measure the Inter-Malleolar Distance (IMD), that is the distance that separates the two
malleoli.
This is an empirical measure affected by many parameters (correct positioning of the child or the
presence of fat thighs, etc), but has the advantage of simplicity and can allow to monitor the progression
of axis over time.
In general, an IMD below 6-8 cm is considered physiological, always considering all the aspects (age,
trend, overweight, etc).
Some children, after the completion of the physiological development of the knee axis (then after about 8
years), continue to present, even in the absence of underlying pathologies, an excessive valgus knee.
This can lead to problems, in particular: obstacles in walking and running, patellar disturbances, stress on
the ligaments on the medial side of the knee and aesthetic disturbances.
If not corrected, over time can lead to excessive overload with wearing of the cartilage of the knee.
SECONDARY
a) Left genu valgum due to previous growth plate fracture; b) Multiple hereditary exostosis;
c) Skeletal dysplasia
Do the orthopaedic shoes and orthotics work? Effectiveness has never been proven.
Are the night braces working? No, and they are poorly tolerated by children.
In preparation for surgery, radiographs are performed to calculate the mechanical axes.
Radiograph of the lower limbs correctly performed
Asymmetrical epiphysiodesis
It’s a simple and very effective procedure if done properly. Metallic tools (the most frequent is the “eight-
plate”) are applied on the medial (=internal) side of the growth cartilage of the knee in order to slow the
growth in this area. The remaining cartilage in the lateral part continues to grow and leads progressively
to the correction.
a) scheme representing the longitudinal growth of cartilage ; b) radiographic aspect of
asymmetrical epiphysiodesis of the medial distal femur; c) diagram showing how the
intervention acts by slowing the growth of the internal part (X); the external part continues to
grow (bidirectional arrows) progressively leading to the correction (curved arrow)
The plates can be placed at the femur (more frequently) and/or tibia based on the site of deformity. The
correction of the axis does not occur directly in the operating room, but progressively with time: the speed
is proportional to the growth of the operated limb.
Patient undergoing medial epiphysiodesis of the distal femur for genu valgum in
hypochondroplasia before surgery (a) and after 2 years (b)
It’s a minimally invasive procedure, it doesn’t need immobilization or plaster, you can do it on both knees
at the same time. Patients quickly recover walking and return to sporting activity within a few weeks.
It is a temporary procedure: once the desired objective has been reached (that is, once the axis has been
corrected), plates are removed and the physis is supposed to start to grow again.
a. The risk of lesions of the growth cartilage produced by the plate itself: once the plates are
removed, the knee will still deviate in the direction of correction, leading to hyper-correction
b. The rebound effect: Once the plates are removed, cartilage starts to grow too much, leading to
a recurrence of the deformity.
For this reason, it is necessary to perform the procedures with the correct technique, timing and
indications.
It is a very effective surgery for the treatment of valgus knee, but more challenging than the
epiphysiodesis. Bones are corrected and fixed in the new position by metallic tools (Kirschner wires,
plates, screws, etc.).
Patient with left genu valgum and shorter limb. Correction with lenthening of the limb by
external fixator
Genu Varum
Blount Disease