Knock Knee Responses

Knock Knee Responses

5/3/2006

Thanks for the plethora of input. Here are the responses.

It is obiously hard to diagnose long distance, but...here goes nothing. Does she also pronate excessively? In my practice (and in my daughter!) I find young girls frequently have accessory naviculars, causing hyperpronation, and sometimes present with genu valgum. While KAFOs for a young girl seem excessive, especially if she is assymptomatic, UCBs might help if the underlying cause is foot/ankle alignment. Good luck.

We do treat a fair number of kids here for Genu Valgum both idiopathic and those with underlying etiology like arthrogryposis. Is the laxity such that it does not impede flexion and extension?? Some times we'll come across a kid that at full knee extension has significant valgus due to a deformity of the shape of the distal femur. As you range the knee from flexion to full extension you can feel and see the point that the knee begins to go into valgus, usally about 15-20 deg. Short of full extension. If it's just a genu valgum issue at full extension here's what we do. A static KAFO. Plastic thigh and calf cuffs, free motion ankle (gaffney, tamarack ankle jts), and a 3/16X 5/8 aluminum bar on the lateral side using 6wide elastic gusset to wrap over the knee to pull (if you will) the kne towards the lateral bar. The knee position of the device should be at the maximum nuetrual position (for
varus/valgus) as can be tolerated in full extension. It's a static full knee extesion design so ambulating is like goose stepping. If you can't get full valgus correction at initial casting and fitting as time goes on you can just bend the static bar towards nuetrual for more correction.

Please look at her feet. She may be a symptomatic ie she may not have any pain but I will bet she has planus and valgus at the level of feet. Your Dr. may want to treat both of them. Like to hear if my guess is right. I am seeing horrendous amount of cases like this and when it is pointed out to the Dr. they appreciate your observation.

At 7yrs. old she is probably pretty short and here really lies the problem. If you put two of any type traditional braces on her the hinges will usually rub and the minimum length is usually shortest 14. It is really necessary to connect the hinges in order to add true stability. However if you want to try something www.hely-weber.com has a 5656 Knapp brace that has 3 different style of hinges maybe you can mix and match to put the thinner hinge in the medial area and the HH heavy hinge laterally. The reason you would do this is to minimize the space between each leg as to minimize the possibility of rubbing the hinges. I recommend these because the hinges are enclose in neoprene and the straps above and below are about 3 to 4 thick, they also do any customs for $30.00. Oh yeah you also have the ability to get them in a wrap around version.

Suggest a lateral single upright kafo with a valgus correction 5 strap pull knee pad. I would use a total contact thigh and tibial shells since you do not want to cause deformity of the long bones since she is still young and growing; ie: wolfs law. You can attach to a shoe or ucbl with a full lateral wall extending just behind sulcus.

You can do what we call a reverse Blounts brace, the name says it all and it's just as effective.

If she has M-L ligamentous laxity of the knees with foot and ankle involvement, I would recommend a Triplanar Control KAFO(s) with free motion at the knees. If the M-L of the knee is intact, a Triplanar Control AFO(s) may be a viable solution.

Depending on the reasons for the genu valgum. If the valgum is caused by Blount's disease then I suggest you use the new Blount's brace designed by Joe Molino and Michael Rebarber they can be reached at www.blountsdisease.com . The orthosis works very well for these kids. If the etiology is unknown but the valgus is significant then the use of custom unloader type knee orthoses do well, specifically the single upright with a counter force strap to keep her knees in neutral. Not doing anything is not the best option if the valgus is so significant. By using the orthoses now as the child gets older and the opportunity for therapy and muscle strengthening grows the valgus control becomes better and less pronounced. If the child does have form of Blount's Disease then the Blount's orthoses should worn as described by Joe and Mike.

I recommend you do a literature search for a great paper written by Terry Supan C.O. about 6-8 years ago. I believe it was published in the Almanac. The paper dealt with tibia vara (bow legs) some were true Blounts disease. The reverse design desreibed has worked will for valgus knees for us.

I developed a new double upright offloading custom K.O that I think would work very well known as the V-VAS (Varum -Valgum Adjustable Stress). Check out ACI's web site @ www.PRAFO.com to get an idea on how it functions. The nice part is that it is adjustable to what ever degree of correction you feel is optimal. ACI fabricates it and distributes it.

SINGLE UPRIGHT KAFO WITH PRE TIBAL SHELL AND A POSTERIOR STRAPING DESIGN ---FREE MOTION ANKLE ----IF CHILD IS COOPERATIVE ADD KNEE JOINTS FOR SITTING PURPOSES WITH DROP LOCKS

Using an elastic, neoprene or similar sleeve with uprights is sometimes very effective in these cases. Children are usually very light and easily within the pressure range and correction qualities of this type of orthosis.

Depending on the severity, we have done bracing for significant bil valgus. We have done night bracing and it has done well . The question is whether they would have corrected on their own anyway.

How about a single lateral upright KAFOs (long for leverage!). Use a large elastic band over the knee joint and medial knee to correct. molded plastic shells will also help correct.

Thanks Again!

Michael S. Johnson CPO

OrthoPro of Twin Falls, Inc.
762 North College Road
Suite A
Twin Falls, ID 83301

ph: 208-733-0505
fax: 208-734-0766