4/5/2020 Congenital Dislocation of the Knee – RP's Ortho Notes

RP's Ortho Notes

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Congenital Dislocation of the Knee

Definition

Congenital dislocation of the knee is a condition characterised by hyperextension deformity of knee

with varying degrees of pathological anterior displacement of the tibia present at birth.

History

First described by Chenssier in 1812.

Subsequently reported by Chatelaine in 1822 and by Bord in 1834.

Aetiology

Three theories have been proposed about the causation. (Elmadag 2013)
Mechanical theory – Due to abnormal intrauterine position
Primary embryologic theory – Due to embryonic defect
Mesenchymal theory – Due to quadriceps contracture
The primary cause can be extrinsic or intrinsic.
Intrinsic causes are genetic or developmental and extrinsic factors are mechanical factors.
Extrinsic causes can be oligohydramnios, multiple pregnancy, intrauterine fetal malposition,
quadriceps contracture and birth trauma.

Epidemiology

Majority of cases are sporadic.

Incidence is 1 in 100,000 live births. Seen in 1% of patients with DDH
Associations
Breech presentation – 30%
CTEV- 47%
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4/5/2020 Congenital Dislocation of the Knee – RP's Ortho Notes

DDH- 50%
Syndromes
Arthrogryposis multiplex
Larsen syndrome
Ehlers Danlos syndrome
Beals syndrome
Myelodysplasia

Classification

Leveuf and Pais Classification

Simple hyperextension – 15-200hyperextension, passive flexion up to 900.

Anterior subluxation – 25-400hyperextension and no flexion.

Anterior dislocation – No contact between distal femoral and proximal tibial articular surfaces.

Finder’s Classification (Finder 1964)

Type I– Physiological hyperextension up to 200is considered normal. Usually disappears by the age
of 8 years.

Type 2- Simple hyperextension that persist into adult life.

Type 3- Anterior subluxation with hyperextension up to 90 0. Flexion only to neutral position.

Type 4- Dislocation of knee with anterior and proximal migration of proximal tibia.

Type 5- Complex variants associated with syndromes and other congenital deformities.

Tarek CDK grading system (Tarek 2011)

G1- Simple recurvatum. Passive flexion >900. Manage by serial casting.

G2- Subluxation. Passive flexion 30-900. Manage by percutaneous quadriceps release

G3- Dislocation. Passive flexion <300. Manage by V-Y Quadricepsplasty.

Pathology

Quadriceps fibrosis and contracture.

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4/5/2020 Congenital Dislocation of the Knee – RP's Ortho Notes

Tight anterior capsule.

Hypoplastic or absent patella.
Hypoplastic suprapatellar bursa.
Anterior subluxation or dislocation of knee.
Transverse anterior skin crease.
Round condyles.
Increased tibial plateau.
Rotatory or valgus deformity of tibia.
Hamstrings may be displaced anteriorly and become extensors of knee.
Absent or elongated anterior cruciate ligaments (Ka 1967).
Lax or displaced cruciate ligaments.

Clinical features

Child born with varying degrees of hyperextension deformity of the knee.

Passive flexion of knee limited to varying degrees depending on the severity.
May be associated with other musculoskeletal anomalies like developmental dysplasia of hip or
congenital talipes equinovarus.
Varying degrees of anterior displacement of the tibia in relation to the femur present.

Diagnosis

Prenatal ultrasound may help in diagnosis.

X-ray shows deformity with angulation in hyperextension type, anterior translation with variable
amount of contact between femur and tibia in subluxation type and total loss of contact between
femur and tibia with hyperextension deformity in dislocation type.
Ultrasound shows obliteration of suprapatellar pouch.
Arthrogram may be necessary to identify intra-articular pathology.

Treatment

Treatment options
Closed manipulative reduction and serial casting
Percutaneous quadriceps recession
V-Y quadricepsplasty
Treatment should be started as early as possible, preferably within 24 hours.
Rumiantcev closed reduction method
Give longitudinal traction to the knee by holding the foot and ankle and by applying
counterpressure over the hip for about 20 minutes.
Flex the hip fully, so that the back of the knee is accessible to the surgeon.
Place the thumbs of the surgeon on the posterior aspect of femoral condyles
Place the index fingers on the anterior aspect of tibia.
Apply pressure to reduce the anterior displacement and flex the knee.
Immobilize in the position of maximum flexion achieved.
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