A CASE OF GENUA VALGA, WITH 
REMARKS ON OSTEOTOMY 
CHARLES GREENE CUMSTON, M.D. 
BY 
Boston. 
From 
PEDIATRICS, 
Vol. VII. No. 11, 1899. A CASE OF GENUA VALGA, WITH REMARKS ON 
OSTEOTOMY.* 
Charles Greene Cumston, M.D., 
Assistant Professor of Surgical Pathology, in the Faculty of Medicine of 
Tufts College, Boston. 
THIS young girl is seventeen years old, and has been 
employed in a rubber factory for the past two years, her 
occupation obliging her to be on her feet the greater 
part of the time. She is anemic, and not well nourished, 
as you see. Her family and personal history give us no par- 
ticular indications as to the affection for which she comes to 
obtain relief. 
The patient says that for about two years her knees have 
given her trouble, from the fact that they bend inwardly, and 
that after walking considerable pain is felt. Inspection of the 
limbs immediately reveals a typical genua valga, but the same 
pathological condition does not exist in each limb, for by closer 
examination you will observe that on the right the deformity 
is due to an hypertrophy of the internal condyle of the femur, 
while on the left there is an hypertrophy of the internal con- 
dyle of the tibia. 
This afternoon I shall operate on this girl, in order to 
restore the normal shape, and consequently the proper func- 
tions of the limbs. On the femur, an osteotomy by McEwen’s 
method will be done, while a wedge-shaped osteotomy will 
be done on the tibia of the left leg. Now, in order that 
*A Clinical Lecture delivered on February 14, 1899. 2 
PEDIATRICS. 
you may understand the steps and indications for osteotomy, I 
beg to say a few words regarding this operation, and those 
affections calling for this treatment. 
Osteotomy was not often undertaken by the older sur- 
geons, on account of the disastrous results following infection 
of their wounds, although the operation was performed as 
early as 1826 by Rhea Barton. Finally after the introduction 
of aseptic surgery, the operation again came into favor, and in 
ißß4McEwen, of Glasgow, published statistics of eighteen hun- 
dred cases of osteotomy, with only five deaths, all being due to 
specific disease, such as diphtheria, pneumonia and phthisis. 
The operation of osteotomy, as performed to-day, offers 
but little danger, the only untoward complication that can 
arise being fat embolus and infection of the wound. When the 
bone is separated by the incision, tiny drops of bone marrow 
sometimes enter the lumen of the veins divided in the opera- 
tion, and are carried along in the circulation to the right heart, 
and from there they enter the lungs by the arterial circulation, 
and block up the capillaries. If the amount of fat globules be 
in any quantity, the lungs will be pretty well filled, and death 
takes place from paralysis of the respiration. The use of 
Esmarch’s band, I believe to be responsible for fat embolus in 
many instances, and I always endeavor to do without artificial 
anemia in bone operations, for this reason. 
With all the recent progress made in surgery, the technic 
of osteotomy has been improved and considerably simplified. 
In the older operations, the bone was exposed by a lengthy 
longitudinal incision, or by a flap, and was then sawed. 
Another technic, advocated by von Langenbeck, was a 
small, cutaneous incision, the bone being cut without being 
exposed. This is called sub-cutaneous osteotomy. 
In sub-cutaneous osteotomy, a small incision is made in 
the integuments, and with a drill a passage is made through 
the middle of the bone. A chain saw is next passed through 
the drill hole, and the bone is sawn, first on one side and then 
on the other, to a certain extent. The saw is then removed, 
the skin incision closed by sutures, and the bone is then broken 
by manual force. 
Osteotomy is either linear or cuneiform, that is to say a 
wedge-shaped piece is excised from the bone; in the linear 
form the bone is chiseled directly through. McEwen’s opera- PEDIATRICS. 
3 
tion may be considered as an intermediary. In the operation 
devised by the noted surgeon of Glasgow, a set of different- 
sized wedge-formed chisels are used. 
Osteotomy may be either partial or total. In the first 
instance a small amount of bone tissue is left uniting the frag- 
ments, while in total osteotomy the bone is chiseled completely 
through. The principles of Langenbeck’s sub-cutaneous oste- 
otomy are now universally adopted for linear osteotomy, but 
this method cannot be applied in the case of cuneiform section of 
the bone, where we must use the mallet and the chisel instead 
of the chain saw. All types of osteotomy may have to be com- 
bined in certain instances, according to the deformity present 
in a given case. 
As to conditions necessitating osteotomy, we have angular 
deformities of the limbs, badly united fractures, ankyloses of 
various varieties, and contractures of the joints. Genu valgum 
and pes valgus and varus are usually, if not always, due to 
rachitic changes in the osseous system. 
Genu valgum, which is one of the most frequent mani- 
festations of rachitis, develops partly during the first years of 
life, and partly during or after the age of puberty, especially in 
subjects whose work obliges them to be much of the time on 
their feet, either standing or walking. 
This fact has been explained by some, by the hypothesis of 
a tardy rachitis; in other words it is to be admitted that rachitis 
can attack the bones, not only during childhood, but after the 
age of puberty has passed. 
The adversaries of this theory suggest an over amount of 
weight being placed upon the knee joint, as the etiological fac- 
tor of genu valgum in adolescents, and deny the possibility of 
rachitis in young adults. 
Now, in point of fact, the occurrence of tardy rachitis has, 
as yet, not been proven scientifically, but what is very evident 
is that genu valgum does frequently occur in the class of pa- 
tients above mentioned, and it is of daily observation to meet 
with young patients who are working all day standing up, 
whose bones are not sufficiently hard to bear their burden, and 
where the exact pathologic change is as yet not clearly defined 
which can account for the soft condition of the bone. We 
cannot make a definite distinction between a genu valgum due 4 
PEDIATRICS. 
rachitis, and the static variety of the affection as has been 
attempted by many authorities. 
The rachitic type of genu valgum is also a static one, inas- 
much as the inward curve of the bones in little rachitic chil- 
dren will only occur in consequence of the pressure of the 
weight of the body; and again in those cases where the over 
use of the limbs is the supposed etiological factor, it is natur- 
ally assumed that there is an abnormal lack of resistance in 
in the bone substance, and it is a question whether or not it is 
due to a true rachitic process. 
Genu valgum may be produced from the fact that the 
internal condyl of the rachitic femur undergoes hypertrophy, 
while the external condyl becomes atrophied. From this con- 
dition, the angle formed by the femur and the tibia, which is 
open outwardly and under normal conditions is about 170°, 
will be decreased several degrees on account of the greater 
abduction of the tibia, which is due to the hypertrophy of the 
internal condyle. An inward bending of the tibia may also 
produce a genu valgum, and often both conditions will be met 
with in the same patient, and this was well illustrated in the 
case just shown you. It might also be assumed that a genu 
valgum could be produced by an inward direction of the tibia 
and fibula, similar to the condition known as genu varum, 
which may be due to both an outward curve of the femur or 
tibia. And lastly, as I have shown you in our patient, an 
hypertrophy of the internal condyl of the tibia may cause a 
genu valgum. 
Such conditions will be readily understood if we make the 
following considerations: When a rachitic child makes its first 
attempt at walking, the weight of the body will produce an in- 
ward bending of the femur, if this particular bone is the one 
exclusively attacked by the pathological process, or at least 
more so than the others. The bending would naturally occur 
near to the point of support, consequently in this case it would 
be in the neighborhood of the knee joint. The irritation pro- 
duced by the pressure exercised on the internal condyle would 
explain the hypertrophy. 
Now, if the tibia and not the femur is the principal site of 
rachitic lesions, the weight of the body will, in this case, pro- 
duce a combination of deformities, and if the disease is more 
manifest in the lower third of the tibia, we will then have a PEDIATRICS. 
5 
pes valgus as well. It is ©f the utmost importance that you 
should be acquainted with these various conditions, because 
the treatment can then be rationally carried out. Conse- 
quently, the operative treatment of genu valgum will be an 
osteotomy of either the femur, tibia or fibula, according to the 
conditions presented in a given case. In 1894 I published the 
case of a little girl of ten years on whom an osteotomy of the 
tibia and fibula in both legs in their lower third, and an oste- 
otomy of the femur on the right was done for rachitic deform- 
ity, so you see how complicated cases may be. 
The operations devised for the correction of genu valgum 
are very numerous indeed, some cases requiring an osteotomy 
of the femur alone, while others demand an osteotomy of the 
tibia for their cure. Ogston’s osteotomy of the femur is not 
any longer performed, and was simply a linear section through 
the internal condyl of the femur. The knee joint was first 
opened, and then a chain saw was introduced at the inner edge 
of the femur, and the internal condyle was sawn off; after this 
had been done, the shape of the limb was corrected. 
When the condyle was cut through, it would slip upwards 
and would unite with the bone at a point higher up. The prin- 
cipal danger in this operation is the opening of the joint, which 
often will give rise to disturbances in the process of repair, for 
even if asepsis is perfect, the opening into the joint is fre- 
quently followed by suppuration, a fact that may be explained 
by the anatomical structure of a joint. A joint is lined with 
synovial membrane, which is serous in nature, and like all 
serous membranes, it is more prone to infection than any other 
tissues of the body, and if there are any pyogenic bacteria in 
the general circulation, and it is a well-known fact that they 
are sometimes accidentally present in the blood, they will 
accumulate in the joint, and grow in the excellent culture soil 
offered them after an osteotomy, namely, an effusion of blood. 
Another danger in Ogston’s osteotomy is due to the pres- 
ence of small particles of bone chipped off during section, 
which may accumulate in the joint, and set up inflamma- 
tory phenomena and ankylosis, or arthirtis may result. 
It is certain that Ogston’s operation has achieved many 
successful results, with excellent functional use of the limb, 
and a cosmetic result far beyond any other method, but for all 
that, I prefer other methods for the reasons already stated. 6 
PEDIATRICS. 
Condylotomy, which was devised by Swan, is a modifica- 
tion of Ogston’s osteotomy. An incision is made over the inner 
aspect of the femur, and a special kind of chisel is introduced, 
the proper oblique direction being given the instrument. No 
mallet is used. The operator seizes the handle of the chisel 
firmly, and pressing the instrument against the bone in the 
required direction, sawing motion is made, and the condyl is 
cut, and finally completely detached, by using the chisel as a 
lever. The limb is then forcibly corrected. 
Annandale and Chiene’s operations must also be recalled. 
The first-named is an osteotomy of both condyles, while the 
second is a cuneiform osteotomy of only one condyle. But all 
these technics have the same objection as Ogston’s opera- 
tion, namely, the opening of the knee joint. 
Mace wen was the first to devise an operation in which 
opening and resection of the joint were avoided, and he per- 
formed his first extra-articular cuneiform osteotomy of the 
femur in 1872. The operation is done as follows: An incision 
about five centimeters long is made about four fingers’ breadth 
above in the articular line on the inner aspect, and the knife is 
brought directly down on the bone through the muscle. The 
large vessels are out of the way, and any injury to them need 
not be feared. A chisel is then introduced into the wound 
along the blade of the knife, using the latter as a director, and 
a wedge-shaped piece of bone is excised. The incision is then 
closed and a drain inserted, and the limb is put up in plaster 
in a corrected position. 
Later on Macewen advised a linear instead of a cuneiform 
osteotomy,and obtained just as good results, and in fact, when 
a wedge-shaped piece is excised from the bone, the space left 
is immediately filled by blood, which would become organized 
and be included in the formation of the callus. 
Now, there is just one point on which I would insist, and 
that is stripping off the periosteum before making the cunei- 
form excision. It is fairly easy to do this if you use a perios- 
teum elevator, such as I show you here. The blade is narrow 
and forms with its long handle an angle of about 1600. By 
carrying the incision through the muscle and periosteum you 
can easily insert the elevator and strip off the bone covering 
sufficiently for the chisel to be passed between the periosteal 
flaps. PEDIATRICS, 
7 
The operation of osteotomy is applied to genu valgum, 
whether produced by an hypertrophy of the internal condyl 
or to a curve at the lower third of the femur. If now the 
course of knock-knee is due to a similar pathologic condition 
of the bones of the leg a subcutaneous incomplete osteotomy 
of the tibia and fibula may be done or an incomplete cuneiform 
osteotomy of the tibia alone can be performed. Cuneiform 
osteotomy of the tibia and linear osteotomy of the fibula is rec- 
ommended by Schede. 
Now, if it be recalled that genu varum is also produced by 
a pathologic curving of the femur, there being an hypertrophy 
of the external condyle of the tibia, it will readily be seen that 
osteotomy is indicated for the correction of this deformity as 
well. The tibia is the bone usually at fault in genu varum, 
and in most instances a wedge-shaped or linear osteotomy of 
this bone will be quite enough to correct this condition. 
Pes valgus, varus, or varo-equinus also require osteotomy 
for their cure. When correcting these deformities the point is 
to give the foot a normal position, which is accomplished by 
wedge-shaped excisions or extirpation of certain bones of the 
foot or the malleoli. 
The bones mostly concerned are the talus, calcaneum, os 
cuboideum and naviculare, the internal malleolus of the tibia 
and external malleolus of the fibula. In flat-foot, for example 
a wedge-shaped excision comprising the head of the talus, the 
anterior articular surface of the calcaneum, a large portion of 
the os cuboideum and a smaller amount of os naviculare is 
sometimes indicated. 
After this excision the correction of the foot from plantar 
flexion, adduction, and supination into a nearly normal posi- 
tion can be obtained. In other cases a simple extirpation of 
the talus is enough, while if, for example, you are dealing 
with a badly united fracture of the malleolus, which has pro- 
duced a traumatic pes varus, a wedge shaped osteotomy of the 
external malleolus and dislocated talus will produce the desired 
rectification of the deformity. Some cases of varo-equinus are 
best treated by extirpation of the talus. 
Tarseotomy in infantile paralysis is sometimes indicated 
where the tensor muscles are so weakened that a total inversion 
of the foot results, but as each case requires separate considera- 
tion I cannot enter into the discussion of this subject today. 8 
PEDIATRICS. 
Another condition to be mentioned is hallux valgus, a 
deformity that is usually produced by improperly fitted foot- 
wear. The toes are pressed over one another and tightly 
together, and the integuments being easily excoriated, infec- 
tion takes place, often resulting in abscess formation. The 
head of the first metatarsal bone will usually be found greatly 
hypertrophied, and if by suitable shoes the deformity cannot 
be corrected we must resort to the excision of the hypertro- 
phied part of the bone. 
Badly united fractures that require osteotomy are not so 
often met with as rachitic conditions of the bones. In fractal es 
where union has taken place with the fragments in bad 
approximation, it is not so much the deformity as it is the 
shortening of the limb that calls for operation. The femur is 
the bone most frequently calling for osteotomy, while a vie- 
FIG'I. 
FIG. 11. 
FIG. 111. 
FIG.; IV. 3 
iously united fracture of the arm would not necessitate an 
operation, and a shortening of the humerus of as much as six 
or seven centimetres will not inconvenience the patient suffi- 
ciently to justify osteotomy, while if it were the femur this 
amount of shortening would practically incapacitate the 
patient. 
Practically we have four types of vicious healing after 
fracture, as follows: 
1. —Lateral union of the fractured ends. 
2. —Longitudinal displacement. 
3. —Angular displacement. 
4. —Peripheral dislocation where the displacement is pro- 
duced by the rotation of one or both fragments. (See Figs. 1, 
2, 3, and 4). 
Longitudinal and angular displacements are the only ones 
that would produce a shortening of the limb, while in lateral PEDIATRICS. 
9 
union and peripherial dislocation the length of the femur will 
remain practically the same as before fracture. 
In longitudinal displacement an oblique section of the 
callus is all that is required, while in angular displacement a 
wedge-shaped osteotomy should be performed, the size of the 
excised portion of bone varying with the degree of shortening 
present, which, in itself, is in direct relation to the amount of 
the angle formed by the fragments. Linear osteotomy may 
occasionally be indicated in lateral union or displacements by 
rotation of the fragments. 
One point more and I shall have finished. Inexperienced 
operators are most likely to be at loss as to how much bone 
should be cut out in the wedge in order to produce just enough 
correction of the limb. The solution of the problem is easy; 
1. Incision carried perpendicularly throng'll the long axis of femur. 
2. Incision carried perpendicularly through the long axis of tibia. 
FIG. V. 
all that you remember is to cut down on each bone with your 
chisel perpendicularly to the bone. For example, in osteotomy 
of the knee (see Fig. 5). The femur is first cut through at 
right angles with its long axis and then the tibia is likewise 
treated. You see that although a seemingly large amount of 
bone is thus removed, still, by following out the rule above 
given, you will not have taken out too much or too little for 
the proper correction of the deformity. 
871 Beacon Street. VOL 3 N9 i 
JANUARY tst 1897 
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