Skip to main content
SpringerLink
Log in

Postinfectious Deformities of the Lower Limb

  • Chapter
Pediatric Lower Limb Deformities

Abstract

There is a diverse range of residual deformities following septic arthritis and osteomyelitis of the pediatric lower limb. Most of the postinfectious juxta-articular and articular deformities of the lower limb arise from complex pathology, often related to delayed treatment and suboptimal surgical intervention. These deformities are usually associated with loss of physeal growth or physeal growth disturbance following septic arthritis of the hip, knee, and ankle, and osteomyelitis of the femur or tibia. Affected children often present with clinical problems such as pain, limp, joint instability or contracture, restriction of motion, and even emotional disturbances. Functional disabilities are enormous, especially in children with severe, multifocal residual angular and/or rotational deformities, often associated with limb length discrepancy (LLD).

The ultimate surgical goals in the management of postinfectious deformities of the lower limb are to relieve current symptoms, and to prevent premature osteoarthritis secondary to the deformity by restoring the weight-bearing mechanical axis and by optimizing the joint mechanics by skeletal maturity. Deformity analysis via a thorough musculoskeletal physical and radiological assessment is of paramount importance for achieving successful results of lower limb reconstruction. The decision to perform either a reconstructive procedure or a salvage procedure must be made on an individual basis after having considered multiple variables, including age, type of sequelae, joint stability and motion, presence of a lurch, history of failed previous reconstructive surgery, and LLD. Acute correction of the deformity is preferable, but cannot always be achieved. In such cases, gradual correction using distraction osteogenesis is a viable option.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Choi IH, Pizzutillo PD, Bowen JR, Dragann R, Malhis T. Sequelae and reconstruction after septic arthritis of the hip in infants. J Bone Joint Surg Am. 1990;72:1150–65.

    CAS  PubMed  Google Scholar 

  2. Choi IH, Yoo WJ, Cho TJ, Chung CY. Operative reconstruction for septic arthritis of the hip. Orthop Clin N Am. 2006;37:173–83.

    Article  Google Scholar 

  3. Betz RR, Cooperman DR, Wopperer JM, Sutherland RD, White Jr JJ, Schaaf HW, et al. Late sequelae of septic arthritis of the hip in infancy and childhood. J Pediatr Orthop. 1990;10:365–72.

    Article  CAS  PubMed  Google Scholar 

  4. Shaw BA, Kasser JR. Acute septic arthritis in infancy and childhood. Clin Orthop. 1990;257:212–25.

    PubMed  Google Scholar 

  5. Gillespie R. Septic arthritis of childhood. Clin Orthop. 1973;96:152–60.

    Article  PubMed  Google Scholar 

  6. Strong M, Lejman T, Michno P, Hayman M. Sequelae from septic arthritis of the knee during the first 2 years of life. J Pediatr Orthop. 1994;14:745–51.

    Article  CAS  PubMed  Google Scholar 

  7. Fabry G, Meire E. Septic arthritis of the hip in children: poor results after late and inadequate treatment. J Pediatr Orthop. 1983;3:461–6.

    Article  CAS  PubMed  Google Scholar 

  8. Hallel T, Salvati EA. Septic arthritis of the hip in infancy: end result study. Clin Orthop. 1978;132:115–28.

    PubMed  Google Scholar 

  9. Shapiro F. Pediatric orthopedic deformities. Basic science, diagnosis, and treatment. London: Academic Press; 2001. p. 897–909.

    Google Scholar 

  10. Paley D. Principles of deformity correction. Berlin: Springer; 2002.

    Book  Google Scholar 

  11. Hunka L, Said SE, MacKenzie DA, Rogala EJ, Cruess RL. Classification and surgical management of the severe sequelae of septic hips in children. Clin Orthop. 1982;171:30–6.

    PubMed  Google Scholar 

  12. Johari AN. Residual problems in septic arthritis of the hips in childhood. Thesis submitted for the M.Ch Ortho, University of Liverpool 1988. In: Varghese M, editor. Current concept: septic arthritis in childhood. Trends in paediatric orthopaedics. London: Macmillan (I) Ltd.; 2002. p. 25–32.

    Google Scholar 

  13. Johari AN, Dhawale AA, Johari RA. Management of post septic hip dislocations when the capital femoral epiphysis is present. J Pediatr Orthop B. 2011;20:413–21.

    Article  PubMed  Google Scholar 

  14. Forlin E, Milani C. Sequelae of septic arthritis of the hip in children: a new classification and a review of 41 hips. J Pediatr Orthop. 2008;28:524–8.

    Article  PubMed  Google Scholar 

  15. Kim HT, Eisenhauer E, Wenger DR. The “sagging rope sign” in avascular necrosis in children’s hip disease – confirmation by 3D CT studies. Iowa Orthop J. 1995;15:101–11.

    CAS  PubMed  PubMed Central  Google Scholar 

  16. El-Tayeby HM. Osteochondroplasty of the femoral head in hip reconstruction for type II late sequelae of septic arthritis: a preliminary report. J Child Orthop. 2008;2:431–41.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Shin SJ, Choi IH, Cho TJ, Yoo WJ, Chung CY, Park MS. Unusual osteocartilaginous prominence or bump causing femoroacetabular impingement after septic arthritis of the hip: a report of 2 cases in preadolescence. J Pediatr Orthop. 2009;29:459–62.

    Article  PubMed  Google Scholar 

  18. Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias: technique and preliminary results. Clin Orthop. 2004;418:3–8.

    Article  PubMed  Google Scholar 

  19. Wenger DR, Pring ME. Triple innominate osteotomy. In: Flynn JM, Wiesel SW, editors. Operative techniques in pediatric orthopaedics. Philadelphia, PA: Lippincott Williams and Wilkins; 2011. p. 515–26.

    Google Scholar 

  20. Ganz R, Huff TW, Leunig M. Extended retinacular release soft-tissue flap for intra-articular hip surgery: surgical technique, indications, and results of application. Instr Course Lect. 2009;58:241–55.

    PubMed  Google Scholar 

  21. Leunig M, Ganz R. Relative neck lengthening and intracapital osteotomy for severe Perthes and Perthes-like deformities. Bull NYU Hosp Jt Dis. 2011;69 suppl 1:S62–7.

    PubMed  Google Scholar 

  22. Hasler CC, Morscher EW. Femoral neck lengthening osteotomy after growth disturbance of the proximal femur. J Pediatr Orthop B. 1999;8:271–5.

    CAS  PubMed  Google Scholar 

  23. Standard SC. Treatment of coxa brevis. Orthop Clin N Am. 2011;42:373–87.

    Article  Google Scholar 

  24. Paley D. The treatment of femoral head deformity and coxa magna by the Ganz femoral head reduction osteotomy. Orthop Clin N Am. 2011;42:389–99.

    Article  Google Scholar 

  25. Dobbs MB, Sheridan JJ, Gordon JE, Corley CL, Szymanski DA, Schoenecker PL. Septic arthritis of the hip in infancy: long-term follow-up. J Pediatr Orthop. 2003;23:162–8.

    PubMed  Google Scholar 

  26. Freeland AE, Sullivan DJ, Westin GW. Greater trochanteric hip arthroplasty in children with loss of the femoral head. J Bone Joint Surg Am. 1980;62:1351–61.

    CAS  PubMed  Google Scholar 

  27. Wopperer JM, White JJ, Gillespie R, Obletz BE. Long-term follow-up of infantile hip sepsis. J Pediatr Orthop. 1988;8:322–5.

    Article  CAS  PubMed  Google Scholar 

  28. Choi IH, Shin YW, Chung CY, Cho TJ, Yoo WJ, Lee DY. Surgical treatment of the severe sequelae of infantile septic arthritis of the hip. Clin Orthop. 2005;434:102–9.

    Article  PubMed  Google Scholar 

  29. Wada A, Fujii T, Takamura K, Yanagida H, Urano N, Surijamorn P. Operative reconstruction of the severe sequelae of infantile septic arthritis of the hip. J Pediatr Orthop. 2007;27:910–4.

    Article  PubMed  Google Scholar 

  30. L’Episcopo J. Stabilization of pathological dislocation of the hip in children. J Bone Joint Surg. 1936;18:737–42.

    Google Scholar 

  31. Harmon PH. Surgical treatment of the residual deformity from suppurative arthritis of the hip occurring in young children. J Bone Joint Surg. 1942;24:576–85.

    Google Scholar 

  32. Li XD, Chen B, Fan J, Zheng CY, Liu DX, Wang H, et al. Evaluation of the modified Albee arthroplasty for femoral head loss secondary to septic arthritis in young children. J Bone Joint Surg Am. 2010;92:1370–80.

    Article  PubMed  Google Scholar 

  33. Cheng JC, Aguilar J, Leung PC. Hip reconstruction for femoral head loss from septic arthritis in children. A preliminary report. Clin Orthop. 1995;314:214–24.

    PubMed  Google Scholar 

  34. Colonna PC. A new type of reconstruction operation for old ununited fractures of the neck of the femur. J Bone Joint Surg. 1935;17:110–22.

    Google Scholar 

  35. Westin GW. The stick femur. In: Proceedings and reports of university colleges, councils and associations. J Bone Joint Surg Br. 1970;52:778–9.

    Google Scholar 

  36. Axer A, Alan A. A new technique for greater trochanteric hip arthroplasty. J Bone Joint Surg Br. 1984;66:331–3.

    CAS  PubMed  Google Scholar 

  37. Weissman SL. Transplantation of the trochanteric epiphysis into the acetabulum after septic arthritis of the hip: report of a case. J Bone Joint Surg Am. 1967;49:1647–51.

    CAS  PubMed  Google Scholar 

  38. Ferrari D, Libri R, Donzelli O. Trochanteroplasty to treat sequelae of septic arthritis of the hip in infancy. Case series and review of the literature. Hip Int. 2011;21:653–6.

    Article  PubMed  Google Scholar 

  39. Abrishami S, Karami M, Karimi A, Soufali AP, Aslani HR, Badizadeh K. Greater trochanteric preserving hip arthroplasty in the treatment of infantile septic arthritis: long-term results. J Child Orthop. 2010;4:137–41.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Milch H. The pelvic support osteotomy. J Bone Joint Surg. 1941;23:581–95.

    Google Scholar 

  41. Milch H. The “pelvic support” osteotomy. Clin Orthop. 1989;249:4–11.

    PubMed  Google Scholar 

  42. Peltier LF. The classic. The “pelvic support” osteotomy. Clin Orthop. 1989;249:4–11.

    Google Scholar 

  43. Schiltenwolf M, Carstens C, Bernd L, Lukoschek M. Late results after subtrochanteric angulation osteotomy in young patients. J Pediatr Orthop B. 1996;5:259–67.

    Article  CAS  PubMed  Google Scholar 

  44. Choi IH, Cho TJ, Yoo WJ, Shin CH. Recurrent dislocations and complete necrosis: the role of pelvic support osteotomy. J Pediatr Orthop. 2013;33 Suppl 1:S45–55.

    Article  PubMed  Google Scholar 

  45. Ilizarov GA. Treatment of disorders of the hip. In: Green SA, editor. Transosseous osteosynthesis. Berlin: Springer; 1992. p. 668–96.

    Chapter  Google Scholar 

  46. Pafilas D, Nayagam S. The pelvic support osteotomy: indications and preoperative planning. Strategies Trauma Limb Reconstr. 2008;3:83–92.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Ilizarov GA, Samchukov ML, Kurtov VM. Ilizarov restorative reconstruction surgery in the treatment of hip osteoarthritis, congenital and pathological hip dislocation in children and adults. In: Materials of Second International Symposium. Experimental, theoretical, and clinical aspects of transosseous osteosynthesis developed in Kurgan Scientific Research Institute. Kurgan, USSR, 1986, pp. 100–2.

    Google Scholar 

  48. Ilizarov GA, Samchukov ML. Ilizarov reconstructive surgery in the treatment of hip osteoarthritis. Ortop Travmatol Protez. 1988;6:10–3.

    PubMed  Google Scholar 

  49. Kadykalo OA, Kuftyev LM. Some biomechanical principles of the hip reconstruction with defect on head and neck of the femur by Ilizarov method. In: The value of general biological patterns in regeneration tissue opened by G. A. Ilizarov. Scientific works collection 13th Edition, The Ministry of Health, The RSFSR (The Russian Soviet Federative Socialist Republic) Kurgan All-union scientific center. Rehabilitation Traumatology Orthopedics, 1988, pp. 124–9.

    Google Scholar 

  50. Samchukov ML, Ivanova IV, Dolganov DV. Analysis of pelvo-trochanteric muscles and weight-bearing after Ilizarov femoral reconstruction in patients with hip osteoarthritis. In: The congress of scientific and technical advances of the young scientists of the Urals. USSR, 1986, pp. 86–7.

    Google Scholar 

  51. Paley D. Hip joint considerations. In: Paley D, editor. Principles of deformity correction. Berlin: Springer; 2002. p. 647–94.

    Chapter  Google Scholar 

  52. Kocaoglu M, Eralp L, Sen C, Dincyurek H. The Ilizarov hip reconstruction osteotomy for hip dislocation. Outcome after 4-7 years in 14 young patients. Acta Orthop Scand. 2002;73:432–8.

    Article  PubMed  Google Scholar 

  53. Manzotti A, Rovetta L, Pullen C, Catagni MA. Treatment of the late septic arthritis of the hip. Clin Orthop. 2003;410:203–12.

    Article  PubMed  Google Scholar 

  54. Samchukov ML, Birch JG. Pelvic support femoral reconstruction using the method of Ilizarov: a case report. Bull Hosp Joint Dis. 1992;52:7–11.

    CAS  Google Scholar 

  55. Rozbruch SR, Paley D, Bhave A, Herzenberg J. Ilizarov hip reconstruction for the late sequelae of infantile hip infection. J Bone Joint Surg Am. 2005;87:1007–18.

    Article  PubMed  Google Scholar 

  56. El-Mowafi H. Outcome of pelvic support osteotomy with the Ilizarov method in the treatment of the unstable hip joint. Acta Orthop Belg. 2005;71:686–91.

    PubMed  Google Scholar 

  57. Mahran MA, Elgebeily MA, Ghaly NA, Thakeb MF, Hefny HM. Pelvic support osteotomy by Ilizarov’s concept: is it a valuable option in managing neglected hip problems in adolescents and young adults? Strategies Trauma Limb Reconstr. 2011;6:13–20.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Inan M, Bomar JD, Kucukkaya M, Harma A. A comparison between the use of a monolateral external fixator and the Ilizarov technique for pelvic support osteotomies. Acta Orthop Traumatol Turc. 2004;38:252–60.

    PubMed  Google Scholar 

  59. Park DH, Bradish CF. The management of the orthopaedic sequelae of meningococcal septicemia; patients treated to skeletal maturity. J Bone Joint Surg Br. 2011;93:984–9.

    Article  CAS  PubMed  Google Scholar 

  60. Grogan DP, Love SM, Ogden JA, Millar EA, Johnson LO. Chondro-osseous growth abnormalities after meningococcemia. A clinical and histopathological study. J Bone Joint Surg Am. 1989;71:920–8.

    CAS  PubMed  Google Scholar 

  61. Nectoux E, Mezel A, Raux S, Fron D, Maillet M, Herbaux B. Meningococcal purpura fulminans in children: I. Initial orthopedic management. J Child Orthop. 2010;4:401–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Sakurakichi K, Tsuchiya H, Kabata T, Yamashiro T, Watanabe K, Tomita K. Correction of juxtaarticular deformities in children using the Ilizarov apparatus. J Orthop Sci. 2005;10:360–6.

    Article  PubMed  Google Scholar 

  63. Nakase T, Yasui N, Kawabata H, Shimizu N, Ohzono K, Hiroshima K, Yoshikawa H. Correction of deformity and shortening due to post traumatic epiphyseal arrest by distraction osteogenesis. Arch Orthop Trauma Surg. 2007;127:659–63.

    Article  PubMed  Google Scholar 

  64. Cooke TDV, Pichora D, Siu D, Scudmore RA, Bryant JT. Surgical implications of varus deformity of the knee with obliquity of joint surfaces. J Bone Joint Surg Br. 1989;71:560–5.

    CAS  PubMed  Google Scholar 

  65. Paley D. Gait considerations. In: Paley D, editor. Principles of deformity correction. Berlin: Springer; 2002. p. 717–58.

    Chapter  Google Scholar 

  66. Bar-On E, Becker T, Katz K, Velkes S, Salai M, Weigl DM. Corrective lower limb osteotomies in children using temporary external fixation and percutaneous locking plates. J Child Orthop. 2009;3:137–43.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Rozbruch SR. Fixator-assisted plating of limb deformities. Oper Tech Orthop. 2011;21:174–9.

    Article  Google Scholar 

  68. Gugenheim Jr JJ, Brinker MR. Bone realignment with use of temporary external fixation for distal femoral valgus and varus deformities. J Bone Joint Surg Am. 2003;85:1229–37.

    PubMed  Google Scholar 

  69. Kocaoglu M, Eralp L, Bilen FE, Balci HI. Fixator-assisted acute femoral deformity correction and consecutive lengthening over an intramedullary nail. J Bone Joint Surg Am. 2009;91:152–9.

    Article  PubMed  Google Scholar 

  70. Sabharwal S, Rozbruch SR. What’s new in limb lengthening and deformity correction. J Bone Joint Surg Am. 2011;93:2323–32.

    PubMed  Google Scholar 

  71. Simpson AH, Cole AS, Kenwright J. Leg lengthening over an intramedullary nail. J Bone Joint Surg Br. 1999;81:1041–5.

    Article  CAS  PubMed  Google Scholar 

  72. Song HR, Oh CW, Mattoo R, Park BC, Kim SJ, Park IH, et al. Femoral lengthening over an intramedullary nail using the external fixator: risk of infection and knee problems in 22 patients with a follow-up of 2 years or more. Acta Orthop. 2005;76:245–52.

    Article  PubMed  Google Scholar 

  73. Cherkashin AM, Samchukov ML, Birch JG, Stapleton JJ, Zgonis T. Stepwise approach to adult and pediatric foot and ankle malunions/nonunions and external fixation. In: Cooper PS, Polyzois VD, Zgonis T, editors. External fixators of the foot and ankle. Philadelphia, PA: Lippincott Williams and Wilkins; 2013. p. 318.

    Google Scholar 

  74. Jaramillo D, Shapiro F, Hoffer FA, Winalski CS, Koskinen MF, Frasso R, et al. Posttraumatic growth-plate abnormalities: MR imaging of bony-bridge formation in rabbits. Radiology. 1990;175:767–73.

    Article  CAS  PubMed  Google Scholar 

  75. Thawait SK, Thawait GK, Frassica FJ, Andreisek G, Carrino JA, Chhabra A. A systematic approach to magnetic resonance imaging evaluation of epiphyseal lesions. Magn Reson Imaging. 2013;31:418–31.

    Article  PubMed  Google Scholar 

  76. Rizzo P, Gould E, Lyden J, Asnis SE. Diagnosis of occult fractures about the hip: Magnetic resonance imaging compared with bone scanning. J Bone Joint Surg Am. 1993;75:395–401.

    CAS  PubMed  Google Scholar 

  77. Weber BG, Simpson LA. Corrective lengthening osteotomy of the fibula. Clin Orthop. 1985;199:61–7.

    PubMed  Google Scholar 

  78. Weber D, Friederich NF, Müller W. Lengthening osteotomy of the fibula for post-traumatic malunion. Indications, technique and results. Int Orthop. 1998;22:149–52.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. Lubicky JP, Altiok H. Transphyseal osteotomy of the distal tibia for correction of valgus/varus deformities of the ankle. J Pediatr Orthop. 2001;21:80–8.

    Article  CAS  PubMed  Google Scholar 

  80. Wiltse LL. Valgus deformity of the ankle: a sequel to acquired or congenital abnormalities of the fibula. J Bone Joint Surg Am. 1972;54:595–606.

    CAS  PubMed  Google Scholar 

  81. Keeler KA, Gordon JE. Distal tibial osteotomy. In: Wiesel SW, Flynn JM, editors. Operative techniques in pediatric orthopaedics. Philadelphia, PA: Lippincott Williams and Wilkins; 2011. p. 251–8.

    Google Scholar 

  82. Paley D. Intraarticular osteotomies of the hip, knee, and ankle. Oper Tech Orthop. 2011;21:184–96.

    Article  Google Scholar 

  83. Davids JR, Valadie AL, Ferguson RL, Bray 3rd EW, Allen Jr BL. Surgical management of ankle valgus in children: use of a transphyseal medial malleolar screw. J Pediatr Orthop. 1997;17:3–8.

    CAS  PubMed  Google Scholar 

  84. Sevens PM, Belle RM. Screw hemiepiphysiodesis for ankle valgus. J Pediatr Orthop. 1997;17:9–12.

    Google Scholar 

  85. Stevens PM, Kennedy JM, Hung M. Guided growth for ankle valgus. J Pediatr Orthop. 2011;31:878–83.

    Article  PubMed  PubMed Central  Google Scholar 

  86. Saran N, Rathjen KE. Guided growth for the correction of pediatric lower limb angular deformity. J Am Acad Orthop Surg. 2010;18:528–36.

    Article  PubMed  Google Scholar 

  87. Takakura Y, Takaoka T, Tanaka Y, Yajima H, Tamai S. Results of opening-wedge osteotomy for the treatment of a post-traumatic varus deformity of the ankle. J Bone Joint Surg Am. 1998;80:213–8.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Pediatric Orthopedics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea

    In Ho Choi MD, PhD

Authors
  1. In Ho Choi MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to In Ho Choi MD, PhD .

Editor information

Editors and Affiliations

  1. Professor, Department of Orthopedics; Chief, Division of Pediatric Orthopedics, Rutgers-New Jersey Medical School, Newark, New Jersey, USA

    Sanjeev Sabharwal

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Choi, I.H. (2016). Postinfectious Deformities of the Lower Limb. In: Sabharwal, S. (eds) Pediatric Lower Limb Deformities. Springer, Cham. https://doi.org/10.1007/978-3-319-17097-8_31

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-17097-8_31

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-17096-1

  • Online ISBN: 978-3-319-17097-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation