Range of variation of genu valgum and association with anthropometric characteristics and physical activity: comparison between children aged 3-9 years

Normal Development of Tibiofemoral Angle in Healthy South-Eastern Nigerian Children: A Clinical Study on 3147 Children

Background

Angular deformities of the lower extremities are common in children and are a frequent reason for orthopaedic referral. These deformities, which are usually encountered when children start to walk are typically measured using the tibiofemoral angle (TFA), which represents the angle formed by the intersection of the anatomical axis of the femur with the anatomical axis of the tibia.

Objectives

This study aimed to determine the TFA in healthy South-Eastern Nigerian children, and to determine the effect of gender and age on this angle.

Materials and Methods

This cross-sectional study was done in Enugu metropolis with 3147 school children and adolescents aged 3-17 years.

Results

It was found that the majority of the subjects (97.6%) had valgus TFA. The maximum knee valgus angle from the study was 6.8° ± 0.80° at 4 years. Thereafter, the knee valgus angle declined to a mean of 2° at 17 years.

Conclusion

There were physiological changes in TFAs noted, which vary with regards to both age and gender of the subject.

Coronal plane deformity around the knee in the skeletally immature population: A review of principles of evaluation and treatment

Coronal plane deformity around the knee, also known as genu varum or genu valgum, is a common finding in clinical practice for pediatricians and orthopedists. These deformities can be physiological or pathological. If untreated, pathological deformities can lead to abnormal joint loading and a consequent risk of premature osteoarthritis. The aim of this review is to provide a framework for the diagnosis and management of genu varum and genu valgum in skeletally immature patients.

Prevalence of lower limb deformities among primary school students

Background

Lower limb deformities could affect child's quality of life and may worsen with time. This work aims to study the prevalence of lower limb deformities among primary school students in our governorate.

Methods

This cross-sectional descriptive study was carried out on 4689 students attending 12 public primary schools during the academic year 2019–2020.Complete clinical examination was done for picking of cases of genu varum, genu valgum, genu recurvatum, flat foot, pes cavus, hallux valgus, in-toeing, and lower limb discrepancy, and x-ray on both feet, pelvis, and full-length lower limb was requested.

Results

This cross-sectional descriptive study included 4689 students. The prevalence of lower limb (LL) deformities was 16.61%. One hundred twenty-three (2.62%) children had a positive history of musculoskeletal pain, 0.09% had genu varum, 0.11% had genu valgum, 0.75% had Genu recurvatum, 0.03% had LL discrepancy, 13.86% had flexible flat foot, 1.22% had rigid flat foot, 0.23% had pes cavus, 1.04 % had in-toeing, 0.06% had hallux varus, and 0.11% had hallux valgus.

Conclusions

Lower limb deformities are a considerable problem in primary school students that need early diagnosis because it could affect child’s future, health, and career. Further studies are needed to investigate spinal deformity, vit D level, calcium level, foot wear, and school bag weight as hidden factors.

Balance control and lower limb joint work in children with bilateral genu valgum during level walking

BACKGROUND

Genu valgum results in lower limb malalignment and altered joint mechanics. The study aimed to identify the effects of genu valgum on balance control and muscular work at the joints during gait in children.

RESEARCH QUESTION

Would bilateral genu valgum affect balance control and muscular work at the joints during gait in children?

METHODS

Thirteen children with genu valgum and thirteen healthy peers walked at their preferred speed while the body's motions and ground reaction forces were measured to calculate the inclination angles (IA) and the rates of change of IA (RCIA) of the body's center of mass (COM) relative to the center of pressure (COP), as well as the muscular work done at the joints. An independent t-test was used to compare the variables between groups (α = 0.05).

RESULTS

Compared to the controls, the patients showed significantly increased step width with altered frontal IA and RCIA variables (p < 0.05), including increased average IA over single-limb support and increased peak RCIA during double-limb support (p < 0.05). The patients significantly increased posterior RCIA at heel-strike but decreased anterior RCIA at toe-off (p < 0.05). The patients showed increased muscular work at both the hip and knee during single-limb support (p < 0.05).

SIGNIFICANCE

The children with genu valgum showed a specific balance control strategy during gait. In the frontal plane, greater hip and knee muscular work was needed to maintain balance under an increased IA, likely owing to increased step width associated with the valgus alignment. In the sagittal plane, less smooth and less stable COM-COP control with increased RCIA at the key gait events indicates faster weight transfer between double-limb and single-limb support. It is suggested that patients with genu valgum, especially in more severe cases, should be monitored for signs of decreased ability and/or muscular strength in maintaining balance during gait.

Development of Garments with Elastic Straps and Pressure Applicator (GESPA) and "GVcorrect" App to Follow the Changes in Lower-Extremity Alignment (Genu Valgum)-A Pilot Study

BACKGROUND

There are non-invasive methods of correcting genu valgum (GV), but to date, there is no method to evaluate mechanotherapeutic intervention that does not restrict child's natural movements while the process is on-going so that timely decisions could be made on effectiveness of intervention. The aim of study was to develop and assess the comfortability of garments with elastic straps and pressure applicator (GESPA) and the reliability and user-friendliness of "GVcorrect" app, which aims to catch the elastic straps' pressure level (mN).

METHODS

6 children (5-7 y) with intermalleolar distance ≥5 cm wore GESPA daily for 3 months. Anthropometrical and goniometrical measurements were done according to standard technique; tone and biomechanical parameters of skeletal muscles determined with MyotonPRO; feedback about GESPA and "GVcorrect" collected via questionnaire.

RESULTS

Based on feedback from children and parents, new, more comfortable and user-friendly GESPA were designed; several updates were made to "GVcorrect" app; new goals were set for the next phase of the study.

CONCLUSIONS

GESPA and the "GVcorrect" app serve their purpose, but there are still a number of important limitations that need to be removed before the product can be marketed. The study continues with product development until a medical device certificate is obtained.

The Profile and Development of the Lower Limb in Setswana-Speaking Children between the Ages of 2 and 9 Years

Profile data on normal lower limb development and specifically tibiofemoral angle development in black, Setswana-speaking South African children are lacking. This study aimed to provide profiles on the development of the tibiofemoral angle, hip anteversion angle and tibial torsion angles in two- to nine-year-old children. Measurements of the tibiofemoral angle, intercondylar distances or intermalleolar distances, quadriceps-angle, hip anteversion- and tibial torsion angle were clinically obtained from 691 healthy two- to nine-year-old children. Two-year-old children presented with closest to genu varum at −3.4° (±3.4°). At three years, a peak of −5.7° (±2.3°) genu valgum was seen, which plateaued at −4.5° (±2.1°) at age nine years. Intermalleolar distance results support tibiofemoral angle observations. Small quadricep-angles were observed in the two-year-old group, (−3.81° ± 3.77°), which increased to a mean peak of −9.2° (±4.4°) in nine-year-olds. From the age of four years old, children presented with neutral tibial torsion angles, whilst two- and three-year-olds presented with internal tibial torsion angles. Anteversion angles were the greatest in three-year-olds at 77.6° ± 13.8° and decreased to a mean angle of 70.8° ± 6.9° in nine-year-olds. The tibiofemoral angle developed similarly to those tested in European, Asian and Nigerian children, but anteversion- and internal tibial torsion angles were greater in the Setswana population than angles reported in European children. Our findings indicate that lower limb development differs in different environments and traditions of back-carrying may influence the development, which requires further investigation.

Idiopathic Genu Valgum and Its Association With Obesity in Children and Adolescents

BACKGROUND

Obesity as a cause of lower extremity deformity in children has been well established. This deformity is most often seen as tibia vara, however, at our institution we have observed more obese children and adolescents over age 7 years with excessive or progressive idiopathic genu valgum. Our hypothesis is that children with idiopathic genu valgum have high rates of obesity which impact the severity of their disease.

METHODS

Retrospective review of existing data was performed on 66 consecutive children/112 limbs over age 7 years with idiopathic genu valgum, seen from 2010 to 2013. Children with known metabolic or skeletal disease were excluded. Genu valgum was defined as mechanical axis in zone II or III and mechanical tibiofemoral angle ≥4 degrees on standing anteroposterior radiograph of the lower extremities. Body mass index (BMI) was calculated and classified by Center for Disease Control percentiles. Skeletal maturation was rated by closure of pelvic and peri-genu physes. Severity of genu valgum was also assessed by femoral and tibial mechanical axes and the mechanical axis deviation.

RESULTS

Mean patient age was 12.2±2.2 years. 47% of patients had BMI≥30 and 71% were categorized as obese (>95th percentile). No sex differences were identified. Skeletal maturation explained 25% of the variance in the mechanical axis deviation and 22% of the mechanical tibiofemoral angle. BMI predicted 9.8% of the tibial valgus. Because of its skewed distribution, BMI percentile was a less useful parameter for assessment.

CONCLUSIONS

The 71% obesity rate found in our children with idiopathic genu valgum is significantly higher than the normal population. Higher BMI is associated with more tibial valgum but skeletal maturation was the main predictor of overall valgus severity. This suggests that obesity may play a role in the etiology of idiopathic genu valgum which progresses with skeletal maturation, thereby increasing the risk of osteoarthritis in adulthood.

LEVEL OF EVIDENCE

Level III.

PREVALENCE OF GENU VALGUM IN PUBLIC ELEMENTARY SCHOOLS IN THE CITY OF SANTOS (SP), BRAZIL

OBJECTIVE

To evaluate the prevalence of genu valgum and associated factors in elementary school students.

METHODS

Cross-sectional study, carried out in 2015, with 1,050 children and adolescents enrolled in an elementary school in Santos, Southeast Brazil. Misalignment of the knee was assessed by intermalleolar distance, considering ≥8 cm or <8 cm. Inter-examiners reliability was measured by Kappa coefficient, resulting in 0.94. Nutritional status was evaluated according to the World Health Organization 2006 references. Logistic regression model was applied to analyze variables associated with genu valgum.

RESULTS

Among schoolchildren, 7.1% had genu valgum. The frequency was higher among overweight or obese schoolchildren. On average, students with genu valgum are older than those without it. There was no association with gender. Upon logistic regression model, only nutritional status was significantly associated with this condition. The chance of occurrence of valgus knee in overweight and obese schoolchildren was, respectively, 6.0 and 75.7 times greater than among thin or eutrophic subjects.

CONCLUSIONS

The prevalence of genu valgum in elementary school children and adolescents was 7.1%, being higher among overweight/obese students and presenting no association with gender or age.

Developmental pattern of tibiofemoral angle in healthy north-east Indian children

PURPOSE

Physiological range of tibiofemoral angle (TFA) is poorly defined and may lead to unnecessary therapeutic interventions. Studies on TFA developmental pattern suggest that racial and ethnic differences are present; children in north-east India who have not yet been studied need to be evaluated.

PATIENTS AND METHODS

Cross-sectional study of clinical TFA, intermalleolar distance and intercondylar distance in 1020 healthy north-east Indian children aged from 2 to 18 years was done. Height, weight and body mass index were also recorded.

RESULTS

At two years of age the mean TFA was valgus. The values reached a peak of 8.55° (standard deviation (SD) 1.01) valgus at seven years of age. The TFA then gradually stabilised to 3.18° (SD 1.18) valgus by 18 years of age. There was no significant difference in TFA between male and female patients.

DISCUSSION

The present study is the largest and only the third such study on Indian children and the first on healthy northeast Indian children. By the end of two years most children had valgus angulation. This, along with the peak angulation observed, was similar to most of the other studies. The age at peak angulation and subsequent stabilisation of valgus angulation varied greatly among children of different origins, especially non-Indian children.

CONCLUSIONS

Data can be used to identify children who require further follow-up/evaluation and can serve as guidelines during deformity correction and future studies. The development of TFA in this cohort is not different from other children of India but differs from children of other ethnic origins.

Perinatal Risk Factors and Genu Valgum Conducive to the Onset of Growing Pains in Early Childhood

The most prevalent musculoskeletal disorder of childhood with unclear aetiology is growing pains (GPs). Anatomic deformities and factors that change bone turnover are implicated in GP pathophysiology. Perinatal risk factors alter the bone metabolism affecting the bone mineral density and content. The aim of our study was to analyze the relationship between GPs, knock knees and perinatal factors. The examined population consisted of 276 children aged 3–7 years. Among them, ten pairs of dizygotic twins were evaluated. The data were collected by using a combination of semi-structured questionnaires, clinical examinations and medical charts of the children and the obstetric history of the mothers. A total of 78 children presenting GPs met Peterson’s criteria. Genu valgum severity was a significant factor for GP manifestation and for their increased frequency and intensity. Subsequently, perinatal factors regarding gestational age, Apgar score, head circumference (lower than 33 cm) and birth length or weight (smaller than 50 cm and 3000 g, respectively) made a remarkable contribution to the development of GPs. Conversely, antenatal corticosteroid treatment, increased maternal age and maternal smoking during pregnancy were not predictive of the disorder. Our data are potentially supportive for the “bone strength” theory and for the contribution of anatomical disturbances in GP appearance.

Physical Examination Findings Among Children and Adolescents With Obesity: An Evidence-Based Review

Overweight and obesity affects 1 in 3 US children and adolescents. Clinical recommendations have largely focused on screening guidelines and counseling strategies. However, the physical examination of the child or adolescent with obesity can provide the clinician with additional information to guide management decisions. This expert-based review focuses on physical examination findings specific to children and adolescents with obesity. For each physical examination element, the authors define the finding and its prevalence among pediatric patients with obesity, discuss the importance and relevance of the finding, describe known techniques to assess severity, and review evidence regarding the need for additional evaluation. The recommendations presented represent a comprehensive review of current evidence as well as expert opinion. The goal of this review is to highlight the importance of conducting a targeted physical examination during pediatric weight management visits.

Genu Valgum and Flat Feet in Children With Healthy and Excessive Body Weight

PURPOSE

To examine the relationship between obesity, genu valgum, and flat feet in children, and find practical implications for therapeutic interventions.

METHODS

A total of 1364 children aged 3-7 years took part in the research. Their body mass index was calculated and their weight status described. Participants' knee alignment was assessed by measuring the intermalleolar distance in the standing position with the knees in contact. The height of the longitudinal arch of each foot was measured using Clarke's angle.

RESULTS

The prevalence of overweight and obesity increased with age. Reduction of intermalleolar distance and increased longitudinal arch of the foot, characteristic of typical growth and development, were observed. Genu valgum was more common in children who were overweight. Significant correlations among body mass index, intermalleolar distance, and Clarke's angle (P < .05) were also discovered.

CONCLUSION

Children who are overweight or demonstrate obesity are more likely to develop genu valgum and flat feet.

Timely diagnosis of malalignment of the distal extremities is crucial in morbidly obese juveniles

BACKGROUND/AIMS

To determine i) whether obesity in childhood can be related to malalignment of the distal extremities, ii) the proportion of genu valgum malalignment and abduction setting, and iii) the respective deviation dominance in children who are morbidly obese.

METHODS

31 morbidly obese Caucasian children (16 males) recruited for the STYJOBS Study (ClinicalTrials.gov Identifier NCT00482924) with a mean age of 13.9 ± 0.5 years, a mean height of 162.3 ± 2.7 cm, a mean weight of 90.62 ± 5.0 kg, and a mean BMI of 33.8 ± 1.2 kg/m(2) were clinically examined using the Mikulicz line in order to assess load distribution on the knee joint. 21 participants received a whole-leg X-ray because of a clinically estimated malalignment.

RESULTS

8/31 participants examined were diagnosed with genu valgum, 1/31 with genu varum, and 22/31 did not have any malalignment of the femur or tibia. The majority of genu valgum presentation was due to femoral deviation. Of those without malalignment, 4/22 participants had an abduction setting, while 2/22 showed an adduction of the leg.

CONCLUSION

Genu valgum as a predominant malalignment of the distal extremities is frequent in youth with morbid obesity. Timely guided correction of angular deformity of the knee seems pivotal in order to avoid osteotomy or osteoarthritis later in life.