Lower Limb Development-Ganger

09.04.
2011
Lower Limb Development
Normal and Abnormal
R. Ganger, MD, PhD

Orthopaedic Hospital Vienna – Speising (www.oss.at)
Department of Pediatric Orthopaedic Surgery (F. Grill)
Frontal plane alignment:
• Physiologic variations: the range of normal knee angles

changes with age
• Account for the greatest number of referrals

(including torsional problems) of children to orthopaedists
- Genu varum: bow legs
- Genu valgum: knock knees
• Genu varum: bow legs
• Genu valgum: knock knees
1
09.04.2011
• Genu varum: bow legs

• Genu valgum: knock knees
Newborn 6 months 18 months
30 months 4-6 years
Frontal plane deformities:
• Genu varum or Genu valgum outside normal range (+/- 2 SD)
• Normal or abnormal?
- History: family, trauma, infection
- Body height and body proportion

- Other present deformities
- Unilateral or bilateral
- Leg length difference
- Laboratory examination: metabolic?
Frontal plane deformities:
• Genu varum or Genu valgum outside normal range (+/- 2SD)
• Warnings:
- Asymmetrical defromity
- Progression
- Pain
- Leg length difference
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09.04.2011
• Standard imaging: AP-long leg standing radiogram,

patella pointing straight forward
incorrect correct
• The majority of children with bow legs befors age of 2 yrs. and
knock knees presenting before 6 yrs. will resolve spontaneously
Natural history:
• benign
• selfcorrecting deformity
Correction devices (twister cables, night splints, shoe wedges)

are unnecessary.
Anual clinical checks are recommended.
• The minority of children with unilateral deformity, progression,

leg length discrepancy and pain need further investigation.
Pathological genu varum / valgum:
• M. Blount
• Rickets, Vit.D - resistent rickets,
• Deformities after infection, trauma,
tumor.
3
09.04.2011
Goal:
• Physiological deformities are best observed
• Pathological deformities are treated surgically to achieve

straight legs at same length
Torsional problems:
Intoing:
• usually not abnormal
• developmental variation
• resolves spontaneously
If the deformity is severe: TORSIONAL DEFORMITY
Torsion problems:
What conditions cause intoing:
• medial femoral torsion
• medial tibial torsion
• forefoot adduction
Each is contributing to the degree of intoeing
4
09.04.2011
Forefoot adduction:
Adduction of the forefoot in respect to the hindfoot can cause intoing
Femoral torsion:
Definition: angular difference between the axis

of the upper femur and that of the knee
Natural history:
• at birth the femoral torsion is 30°,
• it decreases with growth and averages at 15° for adults
From HEFTI
Kinderorthopädie
Springer-Verlag
Increased femoral antetorsion:
• intoing gait pattern with kneeing in (patella pointing medially)

• increased medial hip rotation, decreased lateral hip rotation
Medial (internal) hip rotation Lateral (external) hip rotation
5
09.04.2011
Tibial torsion:
Definition: deformity in which the horizontal plane

of the tibia is rotated medially or laterally
Natural history:
• at birth the tibial torsion is 0°,
• with growth it averages at 15° - 20° external rotation
From HEFTI
Kinderorthopädie
Springer-Verlag
Increased medial tibial torsion:
• resolve spontaneously in 95% over time
• often in combination with genua vara
Torsional deformity:
Age at presentation is important:
• early infancy: usually due to metatarsus adductus
• toddler age: medial tibial torsion
• early childhood: medial femoral torsion
6
09.04.2011
Torsional deformity:
Pitfalls of diagnosis: avoid overlooking underlying diseases
• intoeing: hip dysplasia, mild diplegia or hemiplegia
• out-toeing: SCFE
Femoral and tibial torsion:
Imaging:
• Sonography
• Rotational CT-scan:
helpful when operative

correction is planned
Femoral and tibial torsional deformities:
Treatment:
• the majority will resolve spontaneously over time
• devices like twister cables, night splints, shoe wedges

and inserts are not effective
• convince the family that observation is the best.
7
09.04.2011
Tibial torsional deformities:
Medial tibial torsion:

• mostly improves
• if persistant: supramalleolar derotation osteotomy
Lateral tibial torsion:

• increases with growth
• more often requires operative treatment
Femoral torsional deformities:
Medial femoral torsion:
• normally improves
• no risk of osteoarthritis
• if persistant and severe: rotational femoral osteotomy at the
proximal level in adolescence
Lateral femoral torsion (retrotorsion):
• risk of osteoarthritis
• requires operative treatment
Femoral torsional deformities:
Rotational femoral osteotomy,

plate fixation
8
09.04.2011
Torsional Malalignment Syndrom:
Combination of medial femoral torsion and lateral tibial torsion
• foot progression angle is normal, but the knee

is rotated medially
• patients complain of patellofemoral knee pain
• double osteotomy may be required in severe cases
9
09.04.2011
Leg Length Difference – LLD:
Structural LLD:
• may occur at any site in the limb or pelvis,

the height of the foot and pelvis should be included
in calculating the total discrepancy
Functional LLD:
• shorter:
- adduction contracture of the hip
- flexion contracture of the knee
• longer:
- abduction contracture of the hip
- foot equinus
Idiopathic LLD < 1cm:
• can be found up to 30 %
LLD > 2 cm:
• after trauma
• congenital (CFD, FH, TH)
• metabolic (rickets, Vit.-D-resitent rickets)
• after infection or radiation
• neurological (polio, cerebral palsy,…)
• osteodysplastic disorders, syndromas
(M. Ollier, Klippel-Trenaunay,..)
LLD > 2 cm:
• effect on gait depends on the magnitude,

compensation by flexing the knee on the long side,
standing in ankle equinus on the shortened side
• functional scoliosis because of

pelvis inequality
• sometimes back-pain
• causal relationship between LLD and

osteoarthritis has not been shown
10
09.04.2011
Clinical examination:
• LLD is best assessed

by progressively elevating
the short side with plates
until the pelvis is at
the same level
• measuring tape:
not accurate enough
• note a difference
in femoral or tibial length
11
09.04.2011
Imaging methods:
• AP-view standing radiograph

of the pelvis
Imaging methods:
• AP-view standing radiograph

of the pelvis
• the short side should be

supported on a lift
to eliminate compensatory
mechanisms that could
affect measurement
Imaging methods:
• Orthoradiogram:
12
09.04.2011
Imaging methods:
• Orthoradiogram:
- for calculation
of femoral and tibial length
- does not adress

foot height or
pelvic inequality
Imaging methods:
• Teleradiogram:
- film-focus distance:
305cm
- metal ball,
diameter 25mm,
at the level
of the bone
for calibration
Imaging methods:
• Teleradiogram:
13
09.04.2011
Prediction of LLD:
Calculation discrepancy at maturity:
• LLD at the end of growth ??
• Strategy of correction ??
- lift, lengthening, shortening, epiphysiodesis
• Timing of epiphysiodesis ??
Prediction of LLD:
Calculation discrepancy at maturity
• Problems:
- different methods, based on the bone age
- not accurate enough during period of puberty
- different formulas are based on the same patients data
Determination of the bone age:
• according to Greulich and Pyle:

- details from AP-hand radiogram
- specific for boys and girls
- data from children
born between 1917 and 1942
• according to Tanner and Whitehouse:

- AP-hand radiogram
- 20 different details
- time consuming
14
09.04.2011
Determination of percentile group:
• bone age
• body height
• Anderson charts
Prediction of LLD:
Growth remaining charts – Green & Anderson:
• determination
of bone age and
height percentile
• identification
of remaining growth
on the diagram
• specific for
boys and girls
Prediction of LLD:
Moseley straigth-line graph:
• graphic method based on

the Anderson data
• 3-4 evaluations of actual

LLD are necessary
to predict final LLD
at maturity
15
09.04.2011
Prediction of LLD:
Multiplier method according to Paley:
• biological age and

age-specific multipliers
are used
• specific
for boys and girls
Prediction of LLD:
Multiplier method according to Paley:
Height at maturity =
actual height x
multiplier
LLD at maturity:
actual LLD x
multiplier
LLD: conservative treatment
Insole:
• 0,5 – 1 cm
Shoe lift:
• 1 – 5 cm
• avoid instability
Orthopedic shoes:
• 5 – 10 cm
Orthoprothetic device:
• more than 10 cm
16
09.04.2011
LLD: conservative treatment
Insole:
• 0,5 – 1 cm
Shoe lift:
• 1 – 5 cm
• avoid instability
Orthopedic shoes:
• 5 – 10 cm
Orthoprothetic device:
• more than 10 cm
Algorithm for management of LLD:
From STAHELI: Fundamentals of Pediatric Orthopedics
Normal lower limb alignment:
Frontal plane:
• Mechanical axis
17
09.04.2011
Frontal plane:
• Anatomical axis
Frontal plane:
Femur:
• Mechanical axis
difference of 6°
versus
• Anatomical axis
Tibia:
same
Sagittal plane:
18
09.04.2011
Lower limb malalignment:
Deformity analysis:
Frontal plane:
• Varus, valgus, translation
Sagittal plane:
• Antecurvation, recurvation, translation
Axial plane:
• Rotation, lengthening or shortening
Malalignment test acc. to Paley and Herzenberg:
• Identify the source(s)

of the
mechanical axis
deviation
Femoral deformity
Malalignment test:

of the
mechanical axis
deviation
Tibial deformity
19
09.04.2011
Malalignment test:

of the
mechanical axis
deviation
Femoral and tibial

deformity
Tibial mechanical axis planning:
Frontal plane:
Frontal plane:
20
09.04.2011
Frontal plane:
• Digital planning
with
TraumaCad
program
Frontal plane:
with
TraumaCad
program
Frontal plane:
with
TraumaCad
program Deformity: 4°
Correction: 8.5°
With Auto Alignment:

MAD 7mm med
Individual Alignment:
MAD 1mm med
21
09.04.2011
Frontal plane:
with
TraumaCad
program
Frontal plane:
with
TraumaCad
program
22
09.04.2011
LLD: procedures for lengthening and axial correction
Different devices:
Different indications for different devices:
• Etiology of the disease (congenital, metabolic, posttraumatic,

postinfection,…)
• Type of deformity (unilevel, multilevel, leg length difference)
• Bony maturation (open / closed growth plates)
• Training and skill of the surgeon
• Availibility of the system (costs,…)
Unilateral fixators:
• Orthofix – fixator (Orthofix company)

• Dynafix – fixator (Biomet company)
• Fixation with screws

(diameter of 5 or 6 mm)
Best indications:
• Diaphyseal and distal femoral deformities

• Distal femoral lengthening procedures
23
09.04.2011
Unilateral fixator:
Posttraumatic LLD left femur – 3,6cm, no axial deformity, Dynafix 8.2000
Unilateral fixator:
10.2000 4.2001 4.2002, 1 y. after removal
Posttraumatic LLD left femur – 3,6cm, no axial deformity, Dynafix 8.2000
Traditional
Ilizarov fixator:
Gavril A. Ilizarov
Each frame is a special custom made construct

for a given deformity
24
09.04.2011
Traditional
Ilizarov fixator:
A.E., 10y., Vit.D-resistant rickets, multiapical and multidirectional deformity
Traditional
Ilizarov fixator:
Traditional
Ilizarov fixator:
25
09.04.2011
Taylor Spatial Frame:
Charles J. Taylor
• Circular external fixation system

• Gradual correction by use of 6 telescopic struts
(HEXAPOD – system)
• Combination with a webbased software – program
Angulation deformity Angulation-translation deformity
• Web-based
software:
Login-site
26
09.04.2011
• Web-based
software:
Define deformity
site
• Web-based
software:
Prescription
site
• multiapical planning
L.J., Achondroplasia: correction against varus and lengthening of 6 cm
27
09.04.2011
Taylor
Spatial Frame:
• multiapical
planning
Taylor
Spatial Frame:
• multiapical
planning
Taylor
Spatial Frame:
• multiapical
planning
28
09.04.2011
Taylor
Spatial Frame:
• multiapical
planning
Taylor
Spatial Frame:
• multiapical
planning
Bilateral bilevel correction, lengthening 6 cm
Taylor
Spatial Frame:
• multiapical
planning
Bilateral bilevel correction, lengthening 6 cm, final result
29
09.04.2011
Intramedullary lengthening nail – FITBONE®:
Power Supply
Fitbone®
Transmitter
Skin
Receiver Distraction-Nail
(Motor / Gear)
Subcutaneous Bone
Tissue
M.M., born 1979

LLD femur – 3 cm
6.2007
retrograde
femoral nail
FITBONE
Black: prä-OP
Green: post-OP
Red: post lengthening
M.M., born 1979

LLD femur – 3 cm
6.2007
retrograde
femoral nail
FITBONE
8.2007 11.2007
30
09.04.2011
S.M., born 1988

LLD tibia – 3,2 cm
6.2007
tibia nail
FITBONE
6.2007 7.2007
S.M., born 1988

LLD tibia – 3,2 cm
6.2007
tibia nail
FITBONE
11.2007
Indications:
• closed growth plates
• adequate intramedullary diameter

(FITBONE: minimum 12 mm)
• lengthening procedures with moderate deformities
• uniapical deformities
31
09.04.2011
Thank you for your attention!
32

Lower Limb Development-Ganger

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09.04.

Lower Limb Development

Normal and Abnormal

R. Ganger, MD, PhD

Lower Limb Development

Frontal plane alignment:

• Physiologic variations: the range of normal knee angles

• Account for the greatest number of referrals

- Genu varum: bow legs

- Genu valgum: knock knees

Lower Limb Development

Frontal plane alignment:

• Genu varum: bow legs

• Genu valgum: knock knees

Lower Limb Development

Frontal plane alignment:

• Genu varum: bow legs

Newborn 6 months 18 months

30 months 4-6 years

Lower Limb Development

Frontal plane deformities:

• Genu varum or Genu valgum outside normal range (+/- 2 SD)

- History: family, trauma, infection

- Body height and body proportion

- Laboratory examination: metabolic?

Lower Limb Development

Frontal plane deformities:

• Genu varum or Genu valgum outside normal range (+/- 2SD)

- Leg length difference

Lower Limb Development

Frontal plane alignment:

• Standard imaging: AP-long leg standing radiogram,

Lower Limb Development

Frontal plane alignment:

Correction devices (twister cables, night splints, shoe wedges)

Lower Limb Development

Frontal plane alignment:

• The minority of children with unilateral deformity, progression,

Pathological genu varum / valgum:

Lower Limb Development

Frontal plane alignment:

• Physiological deformities are best observed

• Pathological deformities are treated surgically to achieve

Lower Limb Development

• usually not abnormal

If the deformity is severe: TORSIONAL DEFORMITY

Lower Limb Development

What conditions cause intoing:

• medial femoral torsion

• medial tibial torsion

Each is contributing to the degree of intoeing

Lower Limb Development

Adduction of the forefoot in respect to the hindfoot can cause intoing

Lower Limb Development

Definition: angular difference between the axis

Lower Limb Development

Increased femoral antetorsion:

• intoing gait pattern with kneeing in (patella pointing medially)

Medial (internal) hip rotation Lateral (external) hip rotation

Lower Limb Development

Definition: deformity in which the horizontal plane

Lower Limb Development

Increased medial tibial torsion: