Guide To Valgus Knee Prevention
What is Valgus Deformity?
Valgus knee is a lower leg deformity that exists when the bone at the knee joint is angled out and away from the body’s midline. This causes the inability for a person to touch his or her ankles while the knees touch together. When the legs are not aligned properly, there is additional stress and pressure placed on the knee joint that can result in pain and discomfort as well as secondary issues as the person ages.
Causes of Valgus Deformity
While there are multiple reasons for Valgus deformity, the primary cause is genetics. When genetics are the reason for the deformity, both legs are affected with an angle. If you have Valgus deformity, chances are that someone in your family has the same condition. Valgus deformity is common in young children, and while about 75 percent of children ages three to five have knock knees, Boston Children’s Hospital reports that about 99% of these conditions self-correct by age seven to eight.
- Outside of genetics, there are other causes of Valgus deformity, including the following:
- Tibial plateau fracture or an injury to the growth plate in childhood
- Vitamin D deficiency, also known as rickets when the deficiency is extreme
- Obesity, which can also make the condition more severe according to the Journal of Pediatric Orthopedics
- Arthritis in the knee
Effects of Valgus Deformity
Treatment for Valgus Deformity
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What Is Knee Valgus
Knee valgus occurs when the femur rotates inward, whether due to structural deformity or weakness in the muscles and ligaments that support the knee.
When it occurs both knees point towards one another in a standing position, rather than being pointed forward.
Typically, someone with knee valgus will have their femurs pointed inwards with their hips being in constant internal rotation.
These two factors work together to rotate the knees inwards.
Furthermore, flat feet or collapsed arches normally accompanies knee valgus.
Some people may also have tibia external rotation to compensate for the knock knees.
Mechanical Alignment And Bone Resection
In mechanically aligned TKAs, there should be a neutral coronal plane alignment and bone cut should be orthogonal to the mechanical axis. In a valgus knee, both femoral and tibial pathology should be addressed with respective bone cuts to achieve this goal. The normal knee typically has 6° of valgus angle however, in some cases, after surgical correction and despite achieving this desired 6° of femoro-tibial valgus angle, there may be a residual valgus malalignment . Hence, distal femoral resection should be performed with 2° of over-correction to maximize restoration of the mechanical axis. Therefore 3° of valgus is used to prevent under-correction of the underlying deformity as opposed to the typical 5° to 7° of valgus used for a varus knee .
Some authors have reported that under-corrected knees do not behave differently from well-aligned knees, while over-corrected knees with varus deformity showed a statistically higher rate of complications and lower Knee Society Score . In case of a fixed severe valgus knee, an over-correction of the HipKneeAnkle angle should be avoided, especially regarding the tibial mechanical angle. However, a residual valgus angle of more than 6° can induce patellar maltracking .
For distal femoral resection, the medial femoral condyle represents a reference point. A minimal amount of bone should be removed from the lateral femoral condyle because of wear and atrophy of this condyle. This will allow restoration of the joint line .
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How To Evaluate Varus And Valgus Deformity Of The Knee
Instability accounts for 25% of revision total knee arthroplasty procedures, making it one of the most common reasons for early and late revision procedures.
Thats why its so important for surgeons to address varus or valgus deformity during the index surgery, Matthew P. Abdel, MD, told attendees at ICJRs inaugural course for senior residents and fellows, Advanced Techniques in Total Hip & Knee Arthroplasty, whether they use cruciate retaining or posterior stabilized implants. Otherwise, the patient has a strong chance of requiring revision TKA.
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During his presentation, Dr. Abdel, from Mayo Clinic in Rochester, Minnesota, reviewed how he categorizes the amount of varus or valgus deformity and described how he alters his surgical technique to accommodate the deformity.
It all starts with standing long leg radiographs, which provide a good view of the overall alignment of the of the hip/knee/ankle complex, the contribution of the femur and tibia to the deformity, and the mechanical and anatomic axes. These radiographs are then used to determine the amount of varus or valgus deformity, which Dr. Abdel categorizes as mild, moderate, and severe:
- Mild deformity: 0° to 5° use standard technique
- Moderate deformity: 5° to 10° use a modified technique
- Severe deformity: More than 10° use advanced techniques
In summary, he noted that:
Disclosures: Dr. Abdel has disclosed that he receives royalties from Stryker.
What Are The Causes
Did you know that genetics is the leading cause of valgus deformity? But, at the same time, there can be other reasons too. So, if you have inherited this condition, both your legs will be titled with angle. Besides genetics, an injury, deficiency, obesity, or arthritis can also cause this leg deformity.
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Fixing Knee Valgus Is Not Simple But Form Counts
The exercises here are a great place to start and something you can do in isolation. But as you go about your day keep in mind what you are doing with your knees.
Look to correct the muscle imbalances from the hip all the way down to your knees because knee valgus isnt just about the knees.
If caught in its early stages, mild cases of knee valgus can be prevented from worsening and contributing to the development of more serious conditions like arthritis of the knee and osteoarthritis.
Remember, the advice provided in this article is not meant to replace the advice of a medical professional.
If your knee valgus is accompanied by swelling or buckling of the knee, you may have an underlying condition that is causing your knock knees.
Before attempting to correct knock knees, consult with your doctor about possible causes and treatment options for your knee valgus.
When To Get Medical Advice
Knock knees in children aren’t usually a cause for concern and should improve as your child gets older.
However, visit your GP if:
- the gap between the ankles is greater than 8cm while standing with the knees together
- there’s a big difference between the angle of the lower legs when standing compared with the upper legs
- the problem seems to be getting worse
- a child under the age of 2 or over the age of 7 has knock knees
- only one leg is affected
- there are other symptoms, such as knee pain or difficulty walking
- you have any other concerns about the way your child stands or walks
- you develop knock knees in adulthood
Your GP will examine your or your child’s legs, ask about any pain or walking difficulties, and may take some measurements.
They may refer you to an orthopaedic surgeon and arrange an X-ray of your legs and blood tests to check for underlying problems.
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What Are The Treatment Options For Knock Knees
In most cases, children with knock knees do not need medical treatment. The most common treatment for children between 2 and 5 years old is close observation. Up to 99 percent of children with knock knees grow out of the condition by the time they turn 7. Children do not need to avoid physical activity, wear braces or special shoes, or do any special exercises.
Possible Causes Of Knee Valgus
In this section, well look at the possible causes of Knee Valgus.
The causes of knee valgus are plentiful. Some of the cases of knee valgus are caused by bone deformities and complications such as Osteoarthritis, Rickets and Scurvy.
Genetics has also been known to play a part with some people developing it early and some people developing it later in life.
Knee valgus is common in young children, with more than 20 per cent of kids under the age of 3 having a gap of at least 0.4 inches between their ankles.
In most cases, however, the condition corrects itself as the body matures. Studies show that by the age of 7, only 1 per cent of children have a gap.
In some cases, knee valgus may continue into adolescence or develop in adulthood.
These cases are rare and usually the result of an underlying illness or condition, such as Blounts disease.
One other common cause of knee valgus is poor posture. This is what well explore in more detail in the next section.
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What Is The Anatomy
If you analyze the knee’s anatomy, the average physiologic procedure of knock misalignment starts at the age of 3 to 4 years in a child. The kid is likely to experience 20 degrees of knee deformity. However, this condition hardly deteriorates when the child crosses the age of 7 years. So, after seven years, the knee deformity should not be greater than 12 degrees. At the same time, the intermalleolar distance is likely to be less than 8 cm.
Knee Arthritis With Valgus Knee
Rheumatoid knee commonly presents as valgus knee. Osteoarthritis knee may also sometimes present with valgus deformity though varus deformity is common. Total knee arthroplasty to correct valgus deformity is surgically difficult and requires specialized implants called constrained condylar knees.
- Ankle:talipes valgus outward turning of the heel, resulting in a ‘flat foot’ presentation.
- Elbows:cubitus valgus forearm is angled away from the body
- Foot:pes valgus a medial deviation of the foot at subtalar joint.
- Hand:manus valgus
- Hip:coxa valga the shaft of the femur is bent outward in respect to the neck of the femur. Coxa valga > 125 degrees. Coxa vara < 125 degrees.
- Knee:genu valgum the tibia is turned outward in relation to the femur, resulting in a knock-kneed appearance.
- Toe:hallux valgus outward deviation of the big toe toward the second toe, resulting in bunion.
- Wrist:Madelung’s deformity deformity wherein the wrist bones are not formed properly due to a genetic disorder.
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Implications For Intraoperative Planning Of Valgus Correction Angle
Mullaji et al. studied the variation in femoral valgus correction angle between the two limbs in patients with windswept deformity undergoing TKA and found that VCA in varus knees was significantly higher compared to mean VCA in the valgus knees. Shi et al. , in their large study on the accuracy of using individualized valgus correction angle during TKA for varus and valgus deformities of the knee, concluded that individual correction angles improve the accuracy of postoperative limb alignment after TKA compared with using fixed valgus correction guides. Nam et al. , in a retrospective review of 320 consecutive patients, found that the use of a variable distal femur resection angle improves femoral component alignment after TKA. Similarly, Zhou K et al. , in a radiological study, showed that individual VCA for distal femoral resection could achieve better postoperative alignment accuracy and fewer outliers of limb and femoral component malalignment in the coronal plane.
Exposure And Robot Registration
The patient was taken to the operating room electively, and a standard medial parapatellar approach to the knee was utilized. Exposure included a limited 2 cm soft tissue sleeve circumferential medial release, resection of the anterior cruciate ligament and posterior cruciate ligament and meniscal remnants, as well as removal of osteophytes from the femur, tibia, and patella. Two pins were placed in both the femur and tibia, respectively, and tracking arrays were securely fastened for the OMNIBot. Registration of the landmarks utilized by the OMNIBot was performed as previously described . A detailed video demonstrating the technique for using the OMNIBot system in conjunction with the BalanceBot device can be found online . Following landmark registration, the left lower extremity was taken through a range of motion from the fullest extension that could be achieved to approximately 110 degrees of flexion and repeated with varus and valgus stress applied to the knee. The OMNIBot recorded the knee alignment and medial and lateral gaps throughout the range of motion, yielding the graph in Figure 3. During this step, the patella was kept reduced to ensure that all structures providing lateral restraint were accounted for. Regarding this patient, the graph demonstrated a 5-degree flexion contracture and valgus alignment in extension that did not correct with application of a varus force with a gradual improvement to neutral alignment in flexion.
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Symptoms Of Valgus Knee
The angle at which load passes through the knee can be important. If theres excessive load placed on the outside of the knees, as happens in a valgus knee, theres an increased likelihood of degenerative changes in these parts of the knee. Excessive varus or valgus malalignment may be an independent risk factor for the development of knee arthritis.
The patella, or kneecap, functions as a fulcrum to increase the force of the quadriceps muscles. The patella sits in the trochlea, a groove between the two rounded ends of the femur. The tendon of the quadriceps muscles encases the patella and continues downward to attach at the top of the shin.
Knee valgus can cause problems with tracking of the patella, as the quadriceps pull the patella outward relative to the trochlear groove and patellar tendon attachment. Knee valgus and patellar tracking issues have often been associated with pain in or around the joint between the kneecap and the knee.
Dynamic valgus leading to patellar maltracking can be a significant factor in the development of patellofemoral pain syndrome , a condition that causes pain around the joint between the patella and trochlea. Theres strong evidence that knee arthritis is associated with both the shape of the trochlea and the alignment of the knee when viewed from the front.
Japanese researchers examining a group of 34 women with varus or valgus alignment found that subjects with valgus engaged their quadriceps more strongly when landing from a jump.
Symptoms Of Knock Knees
If someone with knock knees stands with their knees together, their lower legs will be spread out so their feet and ankles are further apart than normal.
A small distance between the ankles is normal, but in people with knock knees this gap can be up to 8cm or more.
Knock knees don’t usually cause any other problems, although a few severe cases may cause knee pain, a limp or difficulty walking.
Knock knees that don’t improve on their own can also place your knees under extra pressure, which may increase your risk of developing arthritis.
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Physical Therapy And Weight Management
The primary treatment for knock-knee comprises anti-inflammatories to manage pain. However, if your condition is not due to genetics, physiotherapy is ideal for improving your situation. Exercises may help you achieve right knee and leg alignment, which will result in gait improvement, knee stability, and muscle strengthening. Besides, if your condition is due to any deficiency or overweight, your doctor may prescribe you a vitamin D supplement or weight management plan to improve your primary condition.
Impact Of Knee Varus And Valgus Deformity On Alignment In Lower Extremities After Total Knee Arthroplasty
F. Tian, X.-H. Zang, Y.-S. Sun
Department of Orthopedics, First Peoples Hospital of Jingzhou, First Affiliated Hospital of Yangtze University, Jingzhou, China. 350729191@qq.com
OBJECTIVE: To investigate the impact of knee varus and valgus in varying degrees on the alignment in lower extremities of patients who received the total knee arthroplasty .
PATIENTS AND METHODS: We retrospectively analyzed the condition of varus and valgus deformity in full-length X-ray films of double lower extremities in weight-bearing position of 120 patients before and after they firstly received the TKA between March 2012 and May 2014 to discover the impact of knee varus and valgus in varying degrees on the alignment in lower extremities of patients who received the total knee arthroplasty . 120 patients were divided into three groups by the pre-operative hip-knee-ankle angle , the HKAs of three groups were compared after operation, and linear regression analysis was conducted to identify the correlation between pre- and post-operative HKAs. In addition, comparison between the pre- and post-operative lean of arms and legs was carried out to explore the variations before and after operation as well as the differences in the average variations among three groups.
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Treatments For Knock Knees
In most cases, knock knees don’t need to be treated because the problem tends to correct itself as a child grows.
Your child doesn’t need to avoid physical activity, wear supportive leg braces or shoes, or do any special exercises.
Mild knock knees that persist into adulthood don’t need to be treated unless they’re causing problems, such as knee pain.
Assessment Of The Reproducibility
To examine the inter-observer reproducibility of this classification system, two observers measured the deformities and did the classification for all the 105 knees independently. The intraclass correlation coefficient was calculated. For those cases with disagreement from the two observers, a senior doctor was assigned to bring an agreement on the classification. The final prevalence of each subtype we reported in this study was calculated after an agreement was achieved for every knee. To examine the intra-observer reproducibility of the system, one of the two observers was assigned to re-measure and re-classify all the 105 knees after blinded processing of the basic information on radiographs and waiting for an interval time of more than 2âweeks for every case. The ICC was also calculated to evaluate the intra-observer reproducibility. An ICC > â0.75 was considered to be with good consistency.
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