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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 94-96

A neglected case of congenital dislocation of knee: Case report


1 Department of Orthopaedics, Kannur Medical College Hospital, Kannur, Kerala, Karnataka, India
2 Department of Orthopaedics, Vijayanagara Institute of Medical Sciences, Bellary, Karnataka, India

Date of Web Publication6-Jun-2014

Correspondence Address:
Prabhakar Venkataramana
#55, Rajyotsav Nagar, Rajivgandhi Road, Jayprakash Nagar 6th Phase, Jaraganahalli,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.134033

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  Abstract 

In this case report, we describe a 1 and ½-year-old girl who presented with the full clinical and radiographic features of congenital dislocation of knee (CDK). The knee deformity in our patient was compatible with a complete grade 3 anterior dislocation of the tibia on the femur. The classic surgical approach to true CDK has been a V-Y quadricepsplasty combined with medial and lateral arthrotomies of the knee, which allow mobilization of the ligamentous structures that are anteriorly displaced is performed. CDK is a rare congenital disorder. The results of treatment are favorable if started before age 3 months, or sometimes before age 1 year, but there is no effective treatment for older, neglected cases; therefore, we believe this case report demonstrates a novel surgical approach.

Keywords: Arthrotomies, congenital dislocation of knee, V-Y quadricepsplasty


How to cite this article:
Venkataramana P, Naik S. A neglected case of congenital dislocation of knee: Case report. J Orthop Traumatol Rehabil 2014;7:94-6

How to cite this URL:
Venkataramana P, Naik S. A neglected case of congenital dislocation of knee: Case report. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 Sep 21];7:94-6. Available from: http://www.jotr.in/text.asp?2014/7/1/94/134033


  Introduction Top


Congenital dislocation of the knee CDK is a relatively rare condition, with an incidence estimated to be 1% of developmental dislocation of the hip. [1] It ranges from hyperextension of the knee to translation of the femur on the tibia. [2],[3] This disorder is apparent at birth and is often described by parents as a knee placed backward. [4] Congenital hyperextension deformities of the knee comprise a spectrum of lesions, including simple hyperextension, subluxation, and complete dislocation. At least half of the babies presenting with these deformities will have some passive flexion at birth. [5] The disorder is usually associated with other skeletal anomalies, [2],[3] especially when it is bilateral and associated with ligamentous laxity syndromes such as Ehlers-Danlos and Larsen syndromes, or syndromes involving multiple joint contractures such as Beals syndrome or arthrogryposis multiplex congenita. [4]

A spectrum of pathological findings exists, but the anterior capsule and the quadriceps muscle are consistently contractured. In more severe cases, intraarticular adhesions and lack of formation of the suprapatellar pouch together with displacement of the collateral ligaments, hamstring tendons, iliotibial tract, and other posterolateral/medial structures can be seen. [3],[6] Treatments include bracing, splinting, manipulation and casting, and surgical options such as quadricepsplasty, intraarticular release, and femoral shortening osteotomy. [4]

A review of the literature uncovered no reports describing successful treatment of a neglected case of CDK at an older age.


  Case report Top


A 1 and ΍-year-old boy presented with history of inability to flex the left knee since birth. Mother [Primi] taken regular ante natal care (ANC). Full-term normal vaginal delivery at hospital. Child cried immediately after birth. No history of consanguineous marriage. No history of similar child birth in the family. Deformity detected at birth and advised orthopedic specialist consultation but patient relatives deferred. On examination, child had grade 3 congenital dislocation of left knee [Figure 1]. Femoral condyles palpable in popliteal fossa. Suprapatellar region transverse skin crease present. Knee can be flexed to near neutral position. Distal neurovascular status normal. Child had low set ears, depressed nasal bridge, flat faces, and delayed developmental milestones [Figure 2]. Preoperative X-ray showed grade 3 congenital dislocation of left knee [Figure 3]a and b. Child investigated for other bony and joint abnormalities. Spine examination was normal. The patient had only congenital knee dislocation with no other joint involvement. The biochemical and hematological investigations are within normal limits. Conservative management deferred as patient was presented late. The classic surgical approach to true CDK has been a V-Y quadricepsplasty combined with medial and lateral arthrotomies of the knee, which allow mobilization of the ligamentous structures that are anteriorly displaced is performed [Figure 4]. Postoperative period was uneventful. Child discharged with above knee cast with knee in 15° of flexion. Sutures removed at end of 2 weeks and cast changed with knee in 30° of flexion. postoperative X-ray shows normal joint spaces. Articular surfaces are in alignment with each other with absent patella [Figure 5]. Child was followed-up for 20 months and had full range of knee flexion with 20° of extension lag [Figure 6].
Figure 1: Figure showing child with grade 3 congenital dislocation of left knee

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Figure 2: Figure showing child with features of Larsen syndrome, low set ears,depressed nasal bridge, flat faces and delayed developmental milestones

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Figure 3: (a) Pre-op X ray showed grade 3 congenital dislocation of left knee AP View (b) Pre-op X ray showed grade 3 congenital dislocation of left knee lateral view

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Figure 4: (a) The classic surgical approach to true CDK has been a V-Y quadricepsplasty combined with medial and lateral arthrotomies of the knee, which allow mobilization of the ligamentous structures
that are anteriorly displaced is performed (b) Figure showing V-Y quadricepaplasty


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Figure 5: Post-op X-ray shows normal joint spaces. Articular surfaces are in alignment with each other with absent patella

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Figure 6: Child was followed up for 20 months and had full range of knee flexion with 20degree of extension lag

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  Discussion Top


CDK is a rare disorder. It is usually associated with other skeletal disorders and syndromes; [2],[3] therefore, patients need to be thoroughly examined, especially when the dislocation is bilateral. However, it may also be an isolated deformity. [4] CDK is classified in three grades. In grade I, the knee will flex and reduce with gentle stretching of the quadriceps. In grade II, the knee will not flex beyond neutral, but the femoral and tibial epiphyses are in contact and do not subluxate when flexion is attempted. In grade III, knee flexion is not possible and the tibia, which is anteriorly translated in the resting position, displaces laterally on the femur when more vigorous flexion is attempted. [4]

The theory that some mechanical factor is paramount in producing this deformity has had many adherents. The mechanical factors have been considered to be trauma to the mother, lack of amniotic fluid, lack of intrauterine space, or malposition of the fetus. It has been suggested by others that in utero the feet may become locked beneath the mandible or that one foot may become locked in the axilla, hyperextending the knee, and producing subluxation or dislocation. [7]

According to Ferris and Aichroth, [8] the results of treatment are favorable if started before age 3 months. In cases presenting after age 6 months, surgery is usually considered before age 1 year although good results have been achieved even in patients operated on before age 2 years. [8] It also seems quite logical to treat grade I CDK with serial casting. In grade II CDK in neonates, it is worth trying serial casting. If the range of flexion exceeds 90°, serial casting is continued; if it remains <90° it is necessary to proceed to percutaneous quadriceps recession (PQR). [6]

The recommended surgical procedure is a V-Y quadricepsplasty, with medial/lateral arthrotomy to mobilize the anteriorly displaced ligaments. Anterior cruciate ligament ACL deficiency and posterior capsule redundancy are considered less important at this stage. [4]

The same surgical procedures are recommended for older patients. [9]

Herring [4] recommends femoral shortening, ACL reconstruction, and posterior capsulorrhaphy for patients with CDK and ligament laxity, citing complications of quadricepsplasty including weakness of the quadriceps, followed by extension lag and fibrosis resulting in lack of flexion, and also the presence of posterior capsular redundancy and lack of ACL, which may result in recurrent anterior knee dislocation. Along with the osteotomy, it is possible to correct the accompanying developmental dysplasia of the hip.

Considering that in our patient no intraarticular ligament release was performed, the reason for instability must be sought in geometric differences in the shape of femoral and tibial condyles. According to Ferris and Aichroth, [8] anteroposterior instability may be investigated by arthroscopy and evaluation of the cruciate ligaments. CDK is a rare disorder with no effective treatment for neglected cases.

 
  References Top

1.Jacobsen K, Vopalecky F. Congenital dislocation of the knee. Acta Orthop Scand 1985;56:1-7.  Back to cited text no. 1
[PUBMED]    
2.Katz MP, Grogono BJ, Soper KC. The etiology and treatment of congenital dislocation of the knee. J Bone Joint Surg Br 1967;49: 112-20.  Back to cited text no. 2
[PUBMED]    
3.Johnson E, Audell R, Oppenheim WL. Congenital dislocation of the knee. J Pediatr Orthop 1987;7:194-200.  Back to cited text no. 3
[PUBMED]    
4.Herring JA. Disorders of the knee. In: Herring JA, editor. Tachdjian's Pediatric Orthopaedics, 4 th ed. Philadelphia: Saunders Elsevier; 2008. p. 919-26.  Back to cited text no. 4
    
5.Bell MJ, Atkins RM, Sharrard WJ. Irreducible congenital dislocation of the knee. Aetiology and management. J Bone Joint Surg Br 1987;69:403-6.  Back to cited text no. 5
    
6.Bensahel H, Dal Monte A, Hjelmstedt A, Bjerkreim I, Wientroub S, Matasovic T, et al. Congenital dislocation of the knee. J Pediatr Orthop 1989;9:174-7.  Back to cited text no. 6
    
7.Chapple CC, Davidson DT. A study of the relationship between fetal position and certain congenital deformities. J Pediatr 1941;18:483-93.  Back to cited text no. 7
    
8.Ferris B, Aichroth P. The treatment of congenital knee dislocation. A review of nineteen knees. Clin Orthop Relat Res 1987;216:135-40.  Back to cited text no. 8
    
9.Ooishi T, Sugioka Y, Matsumoto S, Fujii T. Congenital dislocation of the knee. Its pathologic features and treatment. Clin Orthop Relat Res 1993;287:187-92.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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