Surgical correction of valgus deformity of the knee joint in adults introduction

Hallux valgus (valgus) is an orthopedic pathology in which, due to the incorrect position of the bones in the heel area, the feet seem to “fall” inward.
The placement of the legs with valgus corresponds to an X-shape. If flattening of the arches is simultaneously observed, then the child’s foot deformity is called flat valgus. Girls suffer from this disorder more often than boys. This is due to a different anatomical structure of the pelvis. The wider it is, the more pronounced the curvature of the legs. If the alignment of your child's legs reminds you of the letter "X," this does not necessarily mean a deformity at the level of bones and joints that requires serious treatment. More often we are talking simply about a physiological feature, when the muscles are not yet sufficiently developed and cannot maintain the correct position of the foot.

What causes?

The disease can be congenital or acquired. In the first situation, valgus is caused by malformations of connective tissue, genetic, chromosomal abnormalities of the fetus, and disorders of the nervous system. The pathology begins during the period of intrauterine development; the newborn is born with it.

Such violations include:

• innervation disorders;
• incorrect position of the femurs and pelvis, hip dysplasia;
• congenital hip dislocation;
• disorders in the lumbosacral spine;
• cerebral paralysis;
• spina bifida (incomplete closure of the neural tube in the spinal cord);
• adhesions in the pelvis;
• congenital weakness of the muscular-ligamentous apparatus.

Parents often think that some of the congenital abnormalities have nothing to do with foot pathology. However, all musculoskeletal structures in the body are interconnected, so the causes of hallux valgus can be quite unexpected. For example, valgus can be caused by a birth injury such as a displacement of the bases of the skull bones, namely a change in the position of the occipital bone. Such trauma causes a chain reaction. The vertebrae of the cervical, thoracic, and lumbar spines become abnormal, the sacrum, pelvic bones, hips, and lower legs rotate. And so the deformation reaches the feet. In the same way, sometimes valgus can be a consequence of a diagnosis such as torticollis.

Acquired valgus foot placement in a child is caused by errors in the development and functioning of the musculoskeletal system, injuries, and excessive stress on a weakened muscular-ligamentous system.

It is facilitated by early standing in a vertical position and early walking. The risks are especially high if the baby is chubby or overweight. There is no need to rush to teach him to walk, to be equal to other children. It is much more beneficial for the musculoskeletal system to encourage the baby to actively crawl. The child’s body is ready to stand on its feet and begin walking only at 10–12 months. Some babies take their first steps at 9 months, while others at 15–18 months. And these are all variants of the norm. Remember that different walkers, jumpers, and reins can do harm, not good. Before using them, consult your pediatrician.

Unformed, fragile ligaments, tendons, and muscles with weakened tone are not able to hold the legs in the correct position, so the feet become deformed under the weight of the body. The situation is worsened by poor coordination and the baby's rocking gait, when he spreads his legs wide apart for stability.

A common cause of hallux valgus is rickets suffered in infancy. Oddly enough, this pathology occurs in mild severity in almost 30% of children under 3 years of age. The cause of rickets is a deficiency of vitamin D, which leads to impaired absorption of calcium, insufficient mineralization and bone strength.

Another common reason is unsuitable, tight or, conversely, too loose shoes. It leads to improper distribution of the load on the foot while walking, the formation of a gait that causes the appearance of curvature of the legs. Choose high-quality and good shoes for your child with an elastic hard back, a small heel, an orthopedic insole, and made from natural materials. It is strictly not recommended to give the shoes of older brothers, sisters, nephews, etc. to your child.

Favorable conditions for the development of pathology are created by:

• prematurity;
• excessive joint mobility;
• flat feet;
• calcium and vitamin D deficiency;
• frequent infectious diseases;
• weakened immune system;
• obesity;
• disorders in the nervous system;
• leg and foot injuries (fractures, dislocations, sprains);
• kidney diseases;
• genetic predisposition, the presence of valgus in parents, grandparents;
• endocrine disorders leading to disturbances in calcium metabolism.

How to detect?

Signs of hallux valgus in a child appear by the age of 1 year, when the baby learns to walk and tries to take his first steps. To check for deformity, measure the distance between your ankles while standing with your feet tightly pressed together. If it is more than 5 cm before the age of 4 years, it means the child has hallux valgus.

In addition, the following symptoms are characteristic:

• complaints of fatigue and pain in the legs;
• lack of interest in walking, the child chooses to move in a stroller or in the arms of his parents;
• support on the inside of the foot in a standing position;
• X-shaped position of the legs (knees closely touching each other, ankles widely spaced);
• trampling of shoes from the inside.

What a hallux valgus looks like in a child, look at the photo below:

As a rule, hallux valgus is easy to notice visually by the feet turning outward. The main load or body weight falls on the inner edge of the foot, and the gait changes. The child may shuffle their feet a lot when walking or running.

If the deformity is congenital, it is noticeable almost immediately. At the first examination at 1 month, a pediatric surgeon or orthopedist will see this deviation. With a mild congenital abnormality, the pathology can be detected after the first year of life, when the baby begins to walk.

With planovalgus deformity, the child complains of dull, aching, throbbing pain, cramps in the foot, fatigue in the legs, and pain in the lower back. He will avoid stress, active games, and feel more comfortable in larger shoes.

Valgus is not only an aesthetic problem, but also a medical one. The child quickly gets tired when moving, sometimes even experiences pain while walking or after it.

Causes

Deformation of the knee joints can be caused by the following conditions:

• high load on the legs during a period of rapid growth, when muscles and ligaments are still poorly developed;
• rickets, lack of vitamin D and calcium;
• Erlacher-Blount disease (deforming osteochondrosis of the tibia);
• paralysis of limbs;
• damage to the pelvic bones;
• overweight;
• wearing uncomfortable shoes - too narrow or, conversely, wide;
• joint injuries and inflammation;
• environmental factor.

Walking test: the load on the legs during the child’s first steps increases many times over; during this period, parents should be especially careful.
The main and most common cause of leg deformation is overload of the limbs when the child begins to take the first steps. During the process of growth, the shape and relative position of the bones that form the knee joint changes. Very young children tend to only bend their knees, and when walking, the joints are fully extended. Instinctively, the baby places his legs wide, as the muscles are weak. Because of this, the varus (O-shaped) alignment of the legs gradually, over several years, changes to valgus. At the age of 5, 6 or 7 years everything returns to normal, and in the case of remaining deformation they speak of pathology.

Hallux valgus or alignment?

If parents notice that their child’s legs resemble the letter X in a standing position, then they immediately go to the Internet and, after browsing several sites, choose a diagnosis – hallux valgus. Is this always true? No not always. Moreover, it is very rare.

The fact is that in medicine there are two concepts: hallux valgus and hallux valgus or foot placement. The second option is also called installation or staged valgus. What are the differences?

Hallux valgus is a pathology that affects bones, joints, large tendons, and arches of the foot. It requires correction and comprehensive treatment.

Valgus alignment is a physiological phenomenon caused by weakness of muscles and ligaments that cannot yet hold the bones in the correct position. Most children under 4 years of age have more or less pronounced valgus alignment. But this is not a disease, these are physiological features. With age, as muscles and ligaments develop and strengthen, and bone strength increases due to changes in the mineral composition, they often go away on their own. Valgus alignment of the feet rarely leads to the formation of hallux valgus. This can happen against the background of infections, diseases, or weakening of the body. To prevent this from happening, we need preventive measures that will be aimed at strengthening muscle tissue and improving the trophism of the ligamentous and skeletal system.

To figure out whether your child has hallux valgus or a deformity, you need to evaluate the position of the feet not only under load, namely in a standing position, but also at rest or in a lying position. During deformation, changes will be visible both under load and at rest. When installed at rest, the legs will be almost straight, and will only take on an X-shape when standing. In practice, hallux valgus rather than deformity is more common in children.

Checking what exactly your child has is quite simple. In a lying position, bring the baby's straightened legs together so that they are pressed against each other at the knees. If the heels and ankles touch, then we are talking about valgus alignment of the legs. If the distance between the ankles is at least 4 - 5 cm, then this is a deformity. Another indicator is the position of the Achilles tendon. If at rest in a lying position it is straight, then there is most likely no deformation. And if it has the shape of an arc, then hallux valgus deformity can be suspected. In any case, to clarify the diagnosis, a consultation with an orthopedist or orthopedic traumatologist will be necessary.

2.4. Quality of life assessment

A decrease in the quality of life during the formation of long-term pathological conditions consists of many factors. At the same time, physical suffering is not always the leading one, but persistent psychological disorders come to the fore. Therefore, to assess the quality of life, the SF-36 questionnaire (scale) was used in accordance with the “Instructions for processing data obtained using the SF-36 questionnaire” [1].

“The SF-36 questionnaire (scale) is formed based on the analysis of answers to 36 questions, divided into two large groups - the physical component and the mental component” [2] (see Table 6).

“The 36 questionnaire items are grouped into eight scales: physical functioning, role functioning, bodily pain, general health, vitality, social functioning, emotional state and mental health (see Tables 8 and 9). The scores on each scale range between 0 and 100, with 100 representing full health. The results are presented in the form of scores on 8 scales, compiled in such a way that a higher score indicates a higher level of quality of life.”

The data that was obtained using questionnaires was then grouped into tables to compare the main indicators of treatment effectiveness before and after adjustment.

Types of hallux valgus

The severity of valgus is determined by the angle of deviation of the heel to the axis of the leg. In case of planovalgus deformity, the angle of the longitudinal arch of the foot is also taken into account.

When installing the heel to the shin axis, the following stages are distinguished:

• Stage I, slight deviation 10 – 15°;
• Stage II, heel deviation angle 15 – 20°;
• Stage III, curvature 20 – 30°;
• Stage IV, severe degree, deviation from the norm of 30° or more.

In the first and second degrees, treatment has a favorable prognosis; the deviation can be dealt with quite quickly, mainly using conservative methods. In the third and fourth stages, longer and more serious therapy will be required.

In case of planovalgus deformity, the degree of flattening of the longitudinal arch is additionally assessed by the angle of the arch of the foot.

There are several degrees of severity of the pathology:

• I degree – longitudinal arch angle 130 – 140 °, valgus angle of the calcaneus 5 – 10 °;
• II degree – longitudinal arch angle 141 – 160 °, valgus angle of the calcaneus 10 – 15 °;
• III degree – longitudinal arch angle 161 – 180 °, valgus angle of the calcaneus more than 15 °.

Due to the occurrence of planovalgus foot deformity, it can be congenital, acquired and neurogenic. In this case, mild deformities are mobile or movable. With them, it is possible to change the shape of the foot under the influence of lateral loads. And such deformities are acquired. Severe degrees occur more often against the background of neurogenic disorders or congenital malformations. Such deformations are rigid.

Recovery period

Patients are allowed to get out of bed the very next day after surgery. At first they are allowed to walk only in Baruk's shoes.

Baruk's shoes.

In the first days after surgery, patients are under the supervision of the attending physician. They are discharged from the hospital within 2-3 days. If a person was given non-absorbable sutures during the operation, they are removed after 10-14 days.

Regarding footwear, patients are required to wear orthotics for at least 3 months. You can wear heels only six months after surgery. However, their height should not exceed 6 cm.

Why is hallux valgus dangerous for a child?

The problem of hallux valgus in the absence of correction and treatment of the foot can lead to various problems in the entire musculoskeletal system.

If we talk about complications concerning the feet, then valgus contributes to the development of the following deviations:

• curvature of toes;
• neuroma;
• permanent calluses and corns on the plantar and lateral surfaces of the foot;
• formation of heel spurs;
• ingrown nails;
• inflammation of the Achilles tendon;
• foot drop;
• development of clubfoot.

Further complications are possible: degenerative and inflammatory processes in the area of ​​the knee and hip joints, inflammation of the knee menisci, synovial bursae, and disproportionate development of the muscles of the lower extremities. Inflammatory processes in the joints will be accompanied by redness, swelling, pain, which intensifies with certain movements. Valgus also negatively affects the spine, causing curvature of posture, misalignment, and displacement of intervertebral discs.

With hallux valgus, the child may often experience painful sensations in the feet, knees, and hips. They become especially pronounced after prolonged physical activity or stress. With severe deformity, pain can reach the back.

How to treat?

If you suspect hallux valgus in children, contact a pediatric orthopedist or orthopedic traumatologist. Additional examinations may be needed to confirm the diagnosis and objectively assess the situation. Inspection, questioning, functional tests, X-rays, plantography (computer analysis of deformation), podometry (assessment of load distribution) are used. Tell the doctor your observations, concerns, and describe the child’s condition in detail. To exclude pathologies of the nervous system, a consultation with a neurologist is indicated.

Treatment of valgus and flat valgus feet in children is difficult and lengthy. Success depends on age, the severity of the changes, and the persistence, patience, and support of parents. The goal of therapy is to restore the normal shape and function of the legs, strengthening the muscular and ligamentous apparatus.

What to do to correct hallux valgus in a child?

Doctors prescribe:

• special shoes, orthopedic insoles, inserts;
• massotherapy;
• gymnastics, exercise therapy;
• physiotherapy (electrophoresis, magnetic therapy, electrical muscle stimulation).

In the early stages, insoles, massage, taping, and exercise therapy for children help well.

When choosing a treatment method, you always need to find out the causes and severity of the pathology. In the first and second degrees of severity, disorders are easily corrected with the help of conservative treatment. With the third degree, treatment will be long, but there is still a chance to do without surgery. In the most severe fourth degree, the deformity is eliminated surgically.

The most common reason for the development of hallux valgus in children is muscle hypertonicity, calcium deficiency in the bones and vitamin D deficiency in the body.

If we are talking about hallux valgus, then the treatment will be very simple: sun, air, water. Very often, trips to the sea, where the child will actively run, swim, and walk on the sand, help cope with the problem in children under 6–7 years old. Such rest will contribute to the proper development and strengthening of the bones, muscles, and ligaments of the foot. If there is no opportunity to go to the sea, then just walk more with your child in the fresh air on sunny days, play outdoor games. You can replenish calcium reserves necessary for the growth and strengthening of your child’s bones through nutrition. Make sure that your baby's diet always includes dairy products.

If you live in a region where sunlight is rare, discuss with your pediatrician how to prevent vitamin D deficiency. Perhaps in this case, the doctor will prescribe vitamin complexes to your child in a dosage form appropriate for his age (solution, gummy candies, tablets, capsules).

Massage

If a child has hallux valgus, massage is prescribed first. It must be performed by a certified pediatric massage therapist. Massage is done along the entire length of the legs, including the pelvis and lumbar area. It normalizes muscle tone, the condition of connective tissue, improves blood supply, and stabilizes the ankle joint. Usually the course consists of 10 - 15 sessions, repeated every two months. A massage therapist can teach parents a massage technique for a child with hallux valgus to do at home, and suggest a video of working on the feet. And check that parents perform the first massage sessions correctly.

It is important that the procedure does not cause discomfort or pain in the child. To do this, gradually increase the intensity of the massage techniques so that the body gets used to them, avoid sudden movements.

Massage is useful at all stages of hallux valgus, but the milder the degree of change in a child’s feet, the more noticeable its results will be.

Exercise therapy

Exercise therapy is prescribed in any case, both for hallux valgus and for hallux valgus, regardless of the severity. How to do exercise therapy and gymnastics can be found on YouTube via video. With hallux valgus in children, exercises that actively involve the muscles of the foot help. They need to be selected according to the age, wishes and characteristics of the child. Therapeutic exercises should not cause negative emotions, resistance, whims, or crying.

Unfortunately, it is difficult to attract children under four years of age to exercise. Therefore, parents will have to make movements with their hands while holding the leg. The most accessible exercise for this age is walking. If the child has a severe degree of deformity, and walking causes fatigue and pain, then you should not load the baby.

For positional valgus, the following exercises are recommended:

• going up and down stairs;
• squats;
• walking in single file, squatting;
• walking on uneven massage mats and special embossed playing surfaces;
• walking on the toes, heels, external and internal lateral surfaces of the feet;
• climbing up and down the stairs on your toes;
• rolling a tennis ball or massage ball with rubber spikes on the plantar surface of the foot;
• walking on uneven surfaces (pebbles, sand, special massage mats);
• lifting small toys or other objects from the floor with your toes;
• grasping and collecting a piece of fabric with your toes;
• walking along a narrow path 10–15 cm wide, without going beyond it;
• sitting in a Turkish position;
• full-foot squat with a ball pressed between the knees.

The doctor must determine which exercises are suitable for the child. They need to be done daily. First, under the supervision of an instructor, and then independently at home or in sports centers. The main thing to remember. The basis of recovery is not in the quantity and variety of exercises, but in the regularity of their implementation. This requires a comprehensive, systematic approach.

In addition to the given exercises for exercise therapy, the child should avoid prolonged standing, especially with legs wide apart. Any exercise aimed at maintaining balance will be beneficial. This includes roller skating, ice skating, and skateboarding. Outdoor games, trampolining, jumping rope, hopscotch, football, cycling, and walking will also help. They help strengthen and develop the entire musculoskeletal system. At home, install a wall bars with a rope, beams, and ladder.

The limitation for physical activity with hallux valgus is the child’s complaints of pain and leg fatigue. If the child does not experience any discomfort and feels good while running, jumping and other active games, then there will be no harm to health from them.

Taping

New methods of treating hallux valgus in children include taping. Correct installation is simulated by applying special adhesive tapes. This method is auxiliary. If you use only it and nothing else, there will be no result. However, in complex therapy it works very well and speeds up the correction of the position of the feet.

The adhesive tapes used for the procedure are made of cotton. They come in different widths from 2 to 10 cm. They have good stretchability, so they are practically not felt on the skin. When applied, tapes can stretch up to 70% of their original length. They do not require daily removal and can be worn for up to 5 days. You can swim and shower with them, since the tapes do not come off under the influence of water.

Tapes must be fixed by a specialist. Their independent use is permissible only after training, since errors during application reduce their effectiveness.

For problems in the feet, taping is carried out using the following method:

• the first 2 - 3 cm of tape are attached without tension in the area of ​​​​the instep of the foot;
• the middle part is stretched by about 25 - 30% and wrapped around the ankle in the shape of a figure eight;
• the remaining part is glued to the lower leg without tension.

The therapeutic effect of tapes for hallux valgus deformity is that they:

• eliminate pain caused by compression of the muscles of the nerve fibers;
• accelerate lymph outflow, improve blood microcirculation in the foot area;
• reduce the inflammatory process;
• correct the position of the joints, fixing them in the anatomically correct position;
• improve metabolic processes due to the micromassage effect.

Shoes

When treating hallux valgus in children, special attention is paid to shoes. It should be special with a hard insole, fixation on the side and back. You cannot buy orthopedic products of your choice, as there are many varieties of shoes and insoles. If your child has hallux valgus, it is important to consider their specific characteristics. The wrong choice will make the condition worse. To avoid mistakes, strictly follow your doctor's instructions.

The main task of shoes is to unload the foot, the correct distribution of support points. When a child puts on orthopedic shoes, it becomes easier for him to keep his feet straighter and in the correct position. Depending on the severity of the deformity, your doctor may prescribe wearing shoes all the time or for several hours a day. If the child does not have a deformity, but only has a valgus alignment, then wearing orthopedic shoes is, in principle, not necessary. With a valgus position, on the contrary, you need to train and not unload the muscles. Walking on rough terrain, sand, pebbles, and barefoot is good for this. This will help the bones and joints of the foot acquire a natural, correct shape.

Treatment

Treatment of valgus deformity of the knee joints in children is complex and is prescribed after diagnostic measures. To clarify the severity of the disease, an x-ray is taken. To exclude joint pathologies, biochemical blood test indicators are assessed: the presence of C-reactive protein, rheumatoid factor and uric acid. Micronutrient tests measure the levels of calcium and phosphorus in the body.

Modern methods of therapy make it possible to completely correct the shape of the legs and stop further progression of the deformity. Several effective methods are used:

• wearing orthopedic devices;
• physiotherapy;
• massage;
• Exercise therapy.

Comfortable shoes that support the foot play an important role in the complex treatment of valgus.