What are bow legs or genu varum?
‘Genu’ means knee, and ‘varum’ refers the deviation away from the midline, in simple terms to understand easily. It is commonly seen in childhood. However, it is also seen in adolescents and adults as a consequence of some injury or disease.
In toddlers it is normal until the age of three and is referred to as benign genu varum of toddlers. Any genu varus, above the age of two years, needs attention and active correction. In such cases and in adults, supracondylar osteotomy of the femur or upper end of the tibia may be required.
In all the cases nutritional deficiency like rickets or osteomalacia needs to be excluded.There is defective growth in the medial side of the joint in order to cause a varus deformity.
Bow leg surgeries are cosmetic surgeries, which help in correcting the deformity by surgeries commonly referred to as osteotomies. This means that a portion or a wedge of the bone is removed, or sometimes reinforced by adding bone grafts, in order to increase the length on the medial end, thereby correcting the varus.
What causes genu varum?
In most of the cases, there is no obvious reason for the disease, and especially in children it gets corrected as the child grows. This is known as physiological genu varum.
Tibia vara on the other hand,is a growth retardation on the medialaspect of the proximal tibial epiphysis, causing bow legs. Two forms of deformity are identified:
- Blount’s disease (Infantile tibia vara): It occurs before 3 years of age and causes an abrupt V shaped angulation. It often presents with a triad of tibia vara, genu recurvatum (hyperextension) and internal tibial torsion
- Late onset tibia vara: The juvenile form occurs between 4 to 10 years of age, and the adolescent form above 10 years.
Hoever, in case of adults the commonest causes are as follows;
- Fracture of the lower end of the femur or the upper end of the tibia (which forms the knee joint), resulting in a malunion
- Degenerative and inflammatory diseases like rheumatoid arthritis and osteoarthritis
- Diseases causing rarefaction of the bone, as seen in rickets and osteomalacia (vitamin d deficiency diseases).
- Bone softening diseases like Paget’s disease (osteitis deformans)
- Unequal growth of the epiphyseal plates in children, may occur in cases of injury,skeletal dysplasia or dyschondroplasia, or even an infection of the bone like osteomyelitis
What are the presentations of bow legs?
It is worth noting that bow legs may present in two ways:
- Unilateral genu varum: only one knee joint is affected and deformed. This is often seen in cases where only single joint involvement may occur as in trauma or fracture, and sometimes in some types of arthritis or joint inflammations
- Bilateral genu varum: This is more often seen in a systemic disorder, like rheumatoid arthritis or Paget’s disease of the bone, and also in vitamin deficiency disorders, which may affect both the knees in the same way.
Apart from these presentations, the other common presentations include:
- The patient may present with pain, swelling and redness with warmth in cases of active joint inflammations
- V- shaped angulations (sharp and unlike the usual U- shaped angulations) are seen in Blount’s disease
- Unequal length of the bone in cases of physeal plate injuries, where the normal bone growth is altered
- Psychological disturbances from the unappealing looks of the joint and sarcasms among social circles is often a common problem for people to undertake the surgery.
What are the types of surgeries and treatment options available for genu varum?
Bow legs are often treated by osteotomy surgeries. The most common of these is the High TibialOteotomy (HTO) surgery.
In the management of any case of genu varum, any organic pathology contributing to the disease must be excluded prior to considering any form of surgery.
This is ensured by a full clinical examination and history, and if necessary supportive radiography and blood investigations as well, before considering the genuvarum to be the benign genu varum seen in toddlers and childhood.
The treatment procedures available are:
- For children between 3 to 4 years of age: Hip – knee – ankle – foot orthosis (HKAFOs), medial upright elastic Blount’s brace may help especially in unilateral disease. Traditionally, a full time orthotic treatment was used.
- Surgical correction by corrective osteotomy by 4 years is imperative in order to achieve permanent reversal of inhibition of the proximal medial epiphyseal plate.
In adults, corrective surgery involving high tibial osteotomy with or without fibular osteotomy may be performed.
How is High TibialOstetomy performed?
High tibial osteotomy (HTO) as the name suggests is an osteotomy surgery performed on the proximal end of the tibia, and is one of the commonest surgeries done for genu varum.
As for any surgery, assessment and anaesthetic fitness must be attained prior to conducting the surgery. This will involve a series of steps from anaesthetic fitness for surgery and admission, followed by pre-operative preparation and anaesthesia. After, the induction of anaesthesia, the surgery is performed by your orthopaedician.
The steps of surgery are as follows:
- The surgical site is cleaned and draped using antiseptic solutions and sterilised clothing material is used for draping in the operation theatre
- A medial approach is used for the surgery and an incision is placed on the medial side of the knee undergoing the surgery, precisely over the proximal part of the tibia.
- Once the skin is opened, soft tissues are dissected down to reach the bone.
- The bone is exposed and guide wires or pins are placed in order to ensure the orientation of the osteotomy.
- Using a surgical saw, osteotomy or cutting of the bone is performed on the medial side of the upper end of the tibia with the guide wires as reference points. The anterior part of the osteotomy is oblique in order to avoid the tibial tubercle of Gerdy.
- The lateral cortex is not cut when the osteotomy is performed, and this acts as a hinge for the proximal fragment of bone. An osteotome is then used to compete the osteotomy
- Once the osteotomy is complete, laminar spreaders are used to open the osteotomy and thereby correcting the varus deformity to the required amount of correction with great precision.
- The decision on the degree of correction is done by radiographic planning, prior to surgery and is confirmed intraoperatively with the surgery.
- As the laminar spreaders keep the bone segments apart on the medial end, a T shaped locking plate is used in order to fix the two fragments apart.
- Locking screws and drills are then used in order to fix the locking plate in place.Typically, the proximal part of the T which lies on the proximal segment of the tibia is fixed using four locking screws. The distal part of the T-shaped plate stabilises the distal tibialsegement, using three to four screws.
- This helps in stabilising the segments of the bone by maintaining the opening wedge correction
- The laminar spreaders are then removed once all the screws are in place. This ensures that the segments of the bone have been fixed adequately, as the segments of bones stay in position.
- The space or wedge which has been created is now filled with bone grafts and the wedge now hinges on the lateral cortex which was not cut during the surgery
- This completes the high tibial osteotomy surgery and the skin is closed and haemostasis is achieved
- Following the surgery, the anaesthetic team will recover you from anaesthesia and then shifted out into the post operative room and observed for a while following which you will be shifted out to the respective wards or rooms. They also take care of the necessary medications to ensure adequate post operative analgesia. We may add a short course of antibiotics to prevent any infection and also ensure less chances of a venous clot formation with added medicines.
- Once you are in the ward or room, your operating surgeon will review you every day to see your progress and also consider an early mobilisation and physiotherapy. This helps you with a speedy recovery and functional rehabilitation.
- As you improve with your mobility and free of any adverse events, you will be discharged sooner with a planned review in a week to ensure your progress.
Am I a Good Candidate for osteotomy surgery?
Do you ever feel less confident of yourself due to the bow legs that you suffer from?
You are the ideal candidate for the surgery.
If bow legs are being the limiting factor in any major advances in life, do get the surgery done and correct it to see the amazing results. We have seen candidates in their adolescent ages to middle ages coming to us requesting medical help for correcting these deformities.
The results show remarkable improvements in the quality of life and decreasing their disability adjusted life years, because the disability is no more. Call us today!!
What are the benefits of doing osteotomy surgeries for genu varum?
Osteotomy surgeries are a permanent cure to your bow legs and may help you in leading a normal life as your peers.
There is no more sarcasm or insecurity that you will have to suffer from, following the surgery, because the bow legs would have totally disappeared by then.
We will see you running and moving actively once the initial phase of the healing process is complete. It helps you to attend your day to day activities with confidence and with a smile, which we aim to achieve.
Why Choose MedcureIndia?
Our orthopaedic team is very well equipped with all sophisticated instruments and technological advancements. Our treatment packages are also available at an affordable price, without compromising on the quality of the setting.
We at MedcureIndia, make sure that the extensively trained personnel in orthopaedics will ensure you a cosmetically better appeal to your outlook and open you to a new world free of your knee defect.
Our success stories in this field are incomparable to any other organisations in India, making it unique in its setting, and quality assurance.