Joint Deformities

It can often be tricky to treat joint deformities, as they could be acquired following an injury, or simply congenital. Deformities brought on through injury may become more severe during residual growth
 

Lesions of ligaments and joints necessitate a total clinical evaluation, as well as occasionally an evaluation through an arthro-CT scan or arthrography
 

Deformities in joints can include the entire joint, inducing poor positioning of the joints, or some of the surfaces of the joints
 

Soft Tissue Lesions

Tendons and muscles are sometimes abnormal, and can also show signs of lesions. It is essential  to have natural remodelling of soft tissue and tendinous retractions evaluated in order to assess how well your body can adapt to ligaments, joints or bones being surgically corrected
 

This evaluation can be done clinically, but can also be performed on muscles using isokinetic testing machines, and on ligaments with a KTM or MRI scan
 

It is also important to evaluate nerves. In some conditions, such as attached spinal cord or dwarfism, nerves react strongly to mild stretching and are relatively flexible during the lengthening process, and cases of irritation, transitory or total paralysis (complete or incomplete) can occur. EMG evaluation is available if necessary
 

Occasionally, some vessels may be missing. This lowers vascular supply, and increases risks when correcting deformities.

Hip

The right hip (left image) is in varus over 90° with a 90° retroversion, which is a very large deformity. Please note the other hip which is normal.

The right hip is varus over 90° with a 90° retroversion, which is a very large deformity.

A lesion in the socket part of the hip joint (cotyle) is considered a deformity because of to decreased bone formation (dysplasia). The cotyle is rectangular, rather than spherically shaped, and generally displays a double cavity pattern.At the femoral level, a backwards tilt (retroversion), a varus hip, congenital short femur or other associated lesions are possible. Deformities of the femoral head can manifest itself as a double contour, such as in the case of Legg-Perthes disease

 

Growth plate orientation at the hip constitutes a key part of normal bone formation and growth of the femoral neck. In the above diagram, see that the growth plate (transparent line across the neck) is practically horizontal at the top part of the left femoral neck (at the right of the image). By comparison, the growth plate at the right hip (seen on the left of the image) is over 90° off normal orientation.The growth plate is organized with columnar cells, which are loaded from top to bottom. On the patient’s right side (see above), the cells and columns are loaded at right ankles from their normal position. This causes the growth plate to undergo shear stress.

Blade plate correction resulted in a better hip orientation. The femoral retroversion is fully corrected, but full bone fusion, even obtained at the mid-neck, was not possibl at mid-shaft. This correction allowed growth plate stimulation, resulting in a decreased discrepancy between both femora.

Blade plate correction resulted in a better hip orientation. The femoral retroversion is fully corrected, but full bone fusion, even obtained at the mid-neck, was not possibl at mid-shaft. This correction allowed growth plate stimulation, resulting in a decreased discrepancy between both femora.

 
Surgery is essential in order to reorient the femoral neck, let it heal and let the growth plate work. In the middle of the right femoral neck, calcium deposit (ossification) has not progressed correctly because the two vascular supplies have failed to join. At the base of the neck (close to the shaft), a dark line is visible. This is actually a rupture of the bone between the neck and the shaft (pseudoarthrosis). Abnormal shear stress in varus of the femoral neck causes the bone to rupture, where healing has not occurred as it should
 

Treatment involves reorienting the growth plate in order to let it grow normally and be encouraged to regain some of its original discrepancy
 

Knee

Bone/joint support

Genu varum with femoral torsion (quadruple torsion syndrome) of 40° and lateral condyles without hypoplasia, or even with hyperplasia (angle between the 2 joint surfaces at 110°, for a normal angle close to 140°).

Genu varum with femoral torsion (quadruple torsion syndrome) of 40° and lateral condyles without hypoplasia, or even with hyperplasia (angle between the 2 joint surfaces at 110°, for a normal angle close to 140°).

Defects in the growth of joint surfaces and the bones which supports them can result in anomalies. For example, decreased development (hypoplasia) of a condyle can lead to valgus or varus
 

Hypoplasia of a single condyle can be fixed by some surgeries, such as lowering the lateral condyle by intercondylar femoral osteotomy.The anterior component of the femur condyle can be hypoplastic, such as at the lateral condyle. This brings on a defect in the femoral trochlea which may “open”, and leads to dislocation of the knee cap (patella), causing it to slide outside of the leg once the knee is extended.Longitudinal bone development is linked to bone torsion. When assessing altered alignment, each parameter must be taken into account. A large knee varum with too high a femoral torsion can be associated with a hyperplastic inward rolling of the lateral condyle. This leads to the angle between the patella’s surface and the condyle grove’s two joint surfaces closing.In femoral retroversion (and sometimes femoral hypertorsion), as well as in genu varum, the lateral condyle can undergo relative hypoplasia, which opens of the angle between the two surfaces of the joint. This leads to a risk of subluxation or dislocation of the kneecap; in cases such as this, the patella slides and moves around the condyle of the lateral femur.Alterations in the bone can occur from soft-tissue lesions, such as in hypoplasia of the quadriceps’ vastus medialis – the part of the muscle above and within the knee. Surgery can be tailored to correction of soft-tissue and bone by a complete assessment of the functional and anatomical abnormalities linked to axis misalignment
 

LIGAMENTS

The cruciate ligaments – anterior (ACL) and posterior (PCL) – of the knee may not be present from birth. This destabilises the knee, though does not preclude a person with this condition from playing sports. Rather, as the body grows, the knee will gradually degrade, limiting the range of motion and leading to a risk of degenerative arthritis in later life. An unstable knee could slide, leading to the interior part of the femoral condyles to become flat, and the tibial plateau to change shape to include a posterior neo-joint.

Patient presenting with a congenital deficiency of both cruciate ligaments (left) with respect ot the normal contralateral knee (right).

Patient presenting with a congenital deficiency of both cruciate ligaments (left) when compared to the normal contralateral knee (right).

Young children have cartilaginous joint surfaces, which can be remodeled or modified easily. However, without cruciate ligaments, the knee is unable to model itself around the hinges of the ligament. As adult bone replaces growing cartilage, it is not possible to remodel the surface of the joint or its supports
 

 

Lateral X-rays of a knee with no cruciate ligaments, without (left) and with (middle) traction on the tibia, and of the positioning of the ligament to implant (right).

Lateral X-rays of a knee with no cruciate ligaments, without (left) and with (middle) traction on the tibia, and of the positioning of the ligament to implant (right).

In the case of congenital deficiency in cruciate ligaments, a replacement ligament (ligamentoplasty) is recommended, particularly for young children. This can be performed without creating lesions of the growth plate (arthroscopically) or through direct surgery
 

 

Adult arthroscopic techniques can be used during knee ligament reconstructions; there can be a risk of disturbed growth in young patients, as ligaments cross growth plates. These risks are non-negotiable.Historical surgical techniques led to the joints being overloaded, causing degenerative diseases. Consequently, they are not recommended for children
 

Dr. Guichet has pioneered his own technique which eradicates any failures of other methods, by perfectly centering the ligaments within the joints’ rotary centres, passing through bone without crossing growth plates
 

 

Patient presenting with a congenital deficiency of both cruciate ligaments. Stability test in flexion and "drawer" of the knees. Note the lateral view of a knee with no ligament (ACL) without (left) and with (right) traction on the tibia, showing full knee instability.

Patient presenting with a congenital deficiency of both cruciate ligaments. Stability test in flexion and “drawer” of the knees. Note the lateral view of a knee with no ligament (ACL) without (left) and with (right) traction on the tibia, showing full knee instability. 

Result after 4 year,s with the lateral view of the knee without (left) and with (right) traction on the tibia, showing a perfect knee stability.

Result after 4 year,s with the lateral view of the knee without (left) and with (right) traction on the tibia, showing a perfect knee stability.

Ankles

Some diseases can destabilise the ankles. In the case of fibular longitudinal deficiency, the fibula is partially or entirely absent (hypoplastic), with an additional deficiency to the lateral malleolus. This leads to a deviation at the outside of the ankle. The joint surface at the interface between the tibia and the foot (tibial-talus) loses its linearity as it gets rounded in the frontal plane