Congenital dislocation of the knee at birth - Part 2: Impact of a new classification on treatment strategies, results and prognostic factors

Prenatal diagnosis and postnatal outcome of fetal congenital knee dislocation: systematic review of literature

OBJECTIVES

Congenital knee dislocation (CKD) is a rare condition, affecting 1 in 100 000 newborns. Its prenatal diagnosis is challenging and not well described in the literature, especially when it appears isolated and not as part of a complex malformation or syndromic pattern. The purpose of this study was to provide a comprehensive review of the available literature on the prenatal diagnosis and postnatal outcome of CKD and to summarize the current evidence on this topic.

METHODS

A systematic review of the literature on the prenatal diagnosis of CKD was performed in PubMed, Scopus and EMBASE. A predefined combination of specific keywords was used, focusing on intrauterine manifestations, diagnostic methods, prenatal behavior, postnatal treatment and neonatal outcome as well as long-term outcome in terms of ambulation, motion and joint stability. The quality of studies was assessed using the National Institutes of Health tool for quality assessment of case series. A summary of results was carried out providing proportions and rates of diagnostic and prognostic features associated with this rare condition.

RESULTS

In total, 20 cases were retrieved for analysis, of which 19 were obtained from the identified eligible studies (n = 16) and one was an unpublished case from our center. The median gestational age at prenatal diagnosis, which was made using ultrasound in most cases, was 20 weeks (range, 14-38 weeks). Bilaterality was observed in 11/20 (55%) cases. The condition was isolated in 7/20 (35%) cases and associated with other anomalies in 13/20 (65%) cases. An association was observed with oligohydramnios (4/20 (20%)), and an invasive procedure was performed in 13/20 (65%) cases, including 11 cases with an invasive procedure performed for diagnostic purposes. Genetic testing was normal in all isolated cases for which information was available (4/7), while a genetic syndrome was present in 10/13 (77%) non-isolated cases (Larsen, Noonan, Grebe, Desbuquois or Escobar syndrome). There were seven terminations of pregnancy, of which six were performed in cases with associated anomalies and one in an isolated case, 11 cases of postnatal survival, one case of intrauterine death and one of neonatal death. The fetal and neonatal deaths occurred in cases with associated anomalies or abnormal genetic findings. Postnatal treatment was mostly conservative, with only two reports (18% of the 11 surviving neonates) of surgical intervention, both in cases with associated anomalies. Postnatal follow-up was up to 1 year in most cases, and motor outlook appeared normal in all isolated cases.

CONCLUSIONS

CKD is a rare fetal anomaly with a prenatal diagnosis achievable from the early second trimester, for which a favorable outcome can be expected when no associated anomalies are present. Prenatal diagnosis should include detailed ultrasound assessment and amniocentesis for extensive genetic studies, particularly in non-isolated cases. Early postnatal treatment achieves success in most cases without surgical intervention and leads to a normal motor outlook. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Congenital Knee Dislocation: Help for Neonatologists and Pediatricians

Congenital knee dislocation is relatively rare pathology of the musculoskeletal system. Timely diagnosis and treatment onset allow us to achieve full range of motion in the knee joint. However, low awareness of physicians in these topics and, as a result, diagnostic errors lead to pseudo-correction and motor deficit in the knee joint. This article describes correct examination of a child with congenital knee dislocation directly in the delivery room, management after discharge, and subsequent patient's routing with the assistance of orthopedic traumatologist.

Bilateral Congenital Knee Dislocation in Colombia: Case Report and Literature Review

Congenital knee dislocation (CKD) is a rare disease with an estimated incidence of 1 per 100,000 live births, characterized by a rare musculoskeletal malformation in genu recurvatum deformity present at birth, affecting one or both lower limbs. The diagnosis may be suspected during ultrasound when observing that the situation of the extremities is not correct, and is confirmed by physical examination at birth, with plain radiography being helpful to establish the degree of severity. At present there are controversies regarding treatment and there is no definitive protocol. We present a new case of CKD, observed in the city of Manizales, diagnosed immediately after birth.

Congenital Dislocation of the Knee: Idiopathic or Arthrogryposis?

Fetal akinesia associated with fixed joints is a common cause for suspicion of arthrogryposis multiplex congenita, a severe condition with heterogeneous etiology. We present the case of a rarer but more benign condition, congenital knee dislocation.

The authors report the case of a 27-year-old woman medicated with levetiracetam for epilepsy whose prenatal ultrasound at 22 weeks of gestational age revealed bilateral clubfoot, permanent extension of the inferior limbs with internal knee rotation, normal amniotic fluid quantity, and fetal echocardiography. The remaining ultrasounds revealed similar results. Prenatal genetic testing revealed no pathological findings. The pregnancy was otherwise uneventful. A female newborn was delivered at 39 weeks by cesarean section, with no need for resuscitation. She presented with bilateral knee hyperextension and clubfoot, spontaneous movements, and normal mobility in all other joints. The remaining physical examination and brain and hip ultrasound on the second day of life were normal. These findings were compatible with idiopathic congenital dislocation of the knee (CDK). The patient was undergoing treatment with favorable evolution and adequate neurodevelopment, at the time of this report. 

This case describes a diagnostic workup with the exclusion of severe syndromic pathologies, namely arthrogryposis. Despite the initial suspicion of arthrogryposis, a condition with a poor prognosis, this infant presented a more benign disease with favorable evolution.

Neglected intrauterine bilateral congenital knee dislocation

Bilateral congenital knee dislocation is a rare deformity which may present with other musculoskeletal abnormalities. In the early period, conservative treatment options have a high chance of success. However, in later stages, surgical treatment is indicated in neglected or unresponsive cases to manipulation in the early period. Herein, we present a rare case of bilateral congenital knee dislocation which was diagnosed after birth. Retrospective examination revealed that it occurred in the antenatal period and neglected.

Congenital knee dislocation: a rare and unexpected finding

Congenital knee dislocation is a rare condition of unknown aetiology. It could be associated with syndromes or may occur as an isolated entity. The severity of the deformity determines the method of treatment. Treatment options range from conservative casting to surgical correction. The case presented is of a newborn with an isolated grade II dislocation treated with serial casting. On follow-up at 2 years, the patient had a good outcome, with full range of motion and independent mobility.

Congenital knee dislocation. Therapeutic protocol and long-term functional results

BACKGROUND AND OBJECTIVE

Congenital knee dislocation is a very rare entity, characterised by deformity in knee recurvatum present at birth, and there is currently no consensus on the optimal treatment. The aim of the present study is to analyse the functional results and long-term complications after the application of a protocol of therapeutic action for the management of congenital knee dislocation (CKD) created in a reference centre for child orthopaedics.

MATERIALS AND METHODS

Retrospective descriptive study of patients with congenital dislocation of the knee who followed CRPL between January 1997 and December 2010. Demographic variables, type of treatment, functional outcomes at the end of the follow-up, complications and relapses were studied. The conservative treatment consisted of serial casts, leaving the surgical treatment for cases in which passive flexion was not achieved above 30° or the conservative treatment failed.

RESULTS

9 patients (11 knees) met the inclusion criteria. The 66.7% were girls and the average follow-up was 15 years (9-22). In all cases, conservative treatment was initiated. Of the 11 knees treated, less than half (36%) required surgery. The average Lysholm questionnaire was 90.3 points, the WOMAC pain 0.4 (0-1), WOMAC stiffness 1.8 (0-6) and WOMAC function 3.8 (1-12).

CONCLUSIONS

The existence and application of the PLCR protocol in a pathology as rare as congenital knee dislocation suggests good long-term functional results with few complications and no recurrences.

Congenital hyperextension deformity of the knees due to arthrogryposis multiplex congenita? Case report

Introduction: Arthrogryposis multiplex congenita is a disorder characterized by non-progressive joint contractures. It has an estimated prevalence of 1 in every 3 000-5 000 live births, with the same male-to-female ratio.Case presentation: This is the case of a male newborn with adequate prenatal care checkup appointments, who presented with a congenital deformity of the lower limbs. On physical examination, he had hyperextension of the knees (passive flexion of 20° in the left leg and 30° in the right leg), and painful active movement. On admission, peripheral pulses had good intensity, and adequate distal perfusion was found. Barlow and Ortolani maneuvers were negative, and no midline lesions were observed in the spine. The patient was diagnosed with arthrogryposis multiplex congenita and received multidisciplinary treatment to avoid early morbidity and mortality.Conclusion: To attain satisfactory clinical development in patients with arthrogryposis, it is essential to have a high level of antenatal suspicion, as well as appropriate prenatal checkups. All this allows for proper management, minimizing diagnostic errors, avoiding unnecessary procedures, and performing effective and timely treatment with outstanding results.

Congenital dislocation of the knee in a three-year-old-child with Larsen syndrome: Treatment with a hexapod-type external fixator

Congenital knee dislocation (CDK) is a rare condition, and its treatment is subject to debate. Here, we report on a new treatment for CDK (using a hexapod-type external fixator, HEF) in a three-year-old child with Larsen syndrome and grade III anterior dislocations of both knees. The left knee was treated with serial splints, whereas an HEF was used to treat an irreducible dislocation of the right knee. Two HEF aluminium rings were applied surgically. The procedure involved a distraction of the knee, then tibial posterior translation, and lastly progressive flexion. The clinical and radiological outcomes were good; after four years of follow-up, the right knee had stabilized and had a range of motion of 110°. We conclude that as an innovative, effective option for the management of CDK, the use of an HEF may constitute a relatively advantageous alternative to quadriceps tenotomy.