Introduction Blount's disease is progressive pathologic genu varum centered at the tibia Best divided into two distinct disease entities Infantile Blount's (this topic) pathologic genu varum in children 2 to 5 years of age male > female more common bilateral in 50% Adolescent Blount's pathologic genu varum in children > 10 years of age less common less severe more likely to be unilateral Etiology likely multifactorial but related to mechanical overload in genetically susceptible individuals including excessive medial pressure produces an osteochondrosis of the medial proximal tibial physis and epiphysis osteochondrosis can progress to a physeal bar Risk factors overweight children early walkers (< 1 year) Hispanic and black Prognosis best outcomes with early diagnosis and unloading of the medial joint with either bracing or an osteotomy young children with stage II and stage IV can have spontaneous correction Differential diagnosis the following conditions can also lead to pathologic genu varum persistent physiological varus rickets osteogenesis imperfecta MED, SED metaphyseal dysostosis (Schmidt, Jansen) focal fibrocartilaginous defect thrombocytopenia absent radius proximal tibia physeal injury (radiation, infection, trauma) Anatomy Genu varum is a normal physiologic process in children physiologic genu varum genu varum (bowed legs) is normal in children less than 2 years genu varum migrates to a neutral at ~ 14 months continues on to a peak genu valgum (knocked knees) at ~ 3 years of age genu valgum then migrates back to normal physiologic valgus at ~ 7 years of age Classification Langenskiold Classification type I thru IV consist of increasing medial metaphyseal beaking and sloping type V and VI have an epiphyseal-metaphyseal bony bridge (congenital bar across physis) provides prognostic guidelines Infantile Blounts Adolescent Blounts Age 2-5yrs >10yrs Bilaterality 50% bilateral Usually unilateral Risks Early walking, large stature, obesity Obesity Classification Langenskiold No radiographic classification Severity More severe physeal/epiphyseal disturbance Less severe physeal/epiphyseal disturbance Bone Involvement Proximal medial tibia physis, producing genu varus, flexion, internal rotation, AND may have compensatory distal femoral VALGUS Proximal tibia physis, AND may have distal femoral VARUS and distal tibia valgus Natural History Self-limited - stage II and IV can exhibit spontaneous resolution Progressive, never resolves spontaneously (thus bracing unlikely to work) Treatment Options Bracing and surgery Surgery only Presentation Physical exam genu varum/flexion/internal rotation deformity usually bilateral in infants may exhibit positive 'cover-up test' often associated with internal tibial torsion leg length discrepancy usually NO tenderness, restriction of motion, effusion lateral thrust on walking Imaging Radiographs views ensure that patella are facing forwards for evaluation (commonly associated with internal tibial torsion) findings suggestive of Blounts disease varus focused at proximal tibia severe deformity asymmetric bowing medial and posterior sloping of proximal tibial epiphysis progressing deformity sharp angular deformity lateral thrust during gait metaphyseal beaking different than physiologic bowing which shows a symmetric flaring of the tibia and femur measurements metaphyseal-diaphyseal angle (Drennan) angle between line connecting metaphyseal beaks and a line perpendicular to the longitudinal axis of the tibia >16 ° is considered abnormal and has a 95% chance of progression <10 ° has a 95% chance of natural resolution of the bowing tibiofemoral angle angle between the longitudinal axis of the femur and tibia Treatment Nonoperative brace treatment with KAFO indications Stage I and II in children < 3 years technique bracing must continue for approximately 2 years for resolution of bony changes outcomes improved outcomes if unilateral poor results associated with obesity and bilaterality if successful, improvement should occur within 1 year Operative proximal tibia/fibula valgus osteotomy overcome the varus/flexion/internal rotation deformity indications Stage I and II in children > 3 years Stage III, IV, V, VI age ≥ 4y (all stages) failure of brace treatment progressive deformity metaphyseal-diaphyseal angles > 20 degrees technique perform osteotomy below tibial tubercle staged procedures may be required for Stage IV, V, VI epiphysiolysis required in stage V and VI outcomes risk of recurrence is significantly lessened if performed before 4 years of age growth modulation technique tension band plate and screws physeal bar resection indication at least 4y of growth remaining technique perform together with osteotomy interpositional material is usually fat or PMMA hemiplateau elevation technique may be performed together with osteotomy Surgical Techniques Proximal tibia/fibula valgus osteotomy goals of correction overcorrect into 10-15° of valgus because medial physeal growth abnormalities persist distal segment is fixed in valgus, external rotation and lateral translation technique staples and plates function by increasing compression forces across the physis which slows longitudinal growth (Heuter-Volkmann principle) temporary lateral physeal growth arrest with staples or plates can be used increasing use for correction in younger patients include a bar resection (epiphysiolysis) when a physeal bar is present (Langenskiold V and VI) consider hemiepiphysiodesis if bar > 50% medial tibial plateau elevation is required at time of osteotomy if significant depression is present consider prophylactic anterior compartment fasciotomy Complications Compartment syndrome (with high tibial/fibular osteotomy) prophylactic release of anterior compartment
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Take This Question Anyway (OBQ08.124) A 32-month-old male with severe infantile Blounts disease has been treated with full time bracing for the past year. At most recent follow-up, the varus deformity of his bilateral legs has worsened despite compliance with bracing. What treatment is now recommended? Review Topic QID: 510 Type & Select Correct Answer Type in at least one full word to see suggestions list 1 Observation, discontinuation of bracing 4% (95/2152) 2 Observation, continuation of full-time bracing 15% (314/2152) 3 Bilateral proximal tibial osteotomies 68% (1458/2152) 4 Bilateral distal femur osteotomies 3% (67/2152) 5 Bilateral proximal tibial medial hemiepiphysiodesis 10% (214/2152) L 3 Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ08.183) Lateral tibial physeal stapling is a treatment option for adolescent Blount’s disease. How is the staple an example of the Hueter-Volkmann principle? Review Topic QID: 569 Type & Select Correct Answer Type in at least one full word to see suggestions list 1 Increased compression along the growth plate slows longitudinal growth 85% (1443/1694) 2 Decreased compression along the growth plate slows longitudinal growth 2% (39/1694) 3 Increased tension along the growth plate slows longitudinal growth 8% (133/1694) 4 Decreased tension along the growth plate slows longitudinal growth 3% (53/1694) 5 Increased compression along the plate increases longitudinal growth 1% (19/1694) L 2 Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07PE.69) Figure 29 shows the AP radiograph of a 14-year-old boy. The radiographic findings are most consistent with what pathologic process? Review Topic QID: 6129 FIGURES: A Type & Select Correct Answer Type in at least one full word to see suggestions list 1 Septic arthritis 0% (0/61) 2 Hemophilia 0% (0/61) 3 Juvenile rheumatoid arthritis (JRA) 0% (0/61) 4 Adolescent Blount’s disease 44% (27/61) 5 Infantile Blount’s disease 54% (33/61) L 3 Select Answer to see Preferred Response SUBMIT RESPONSE 5 You have 100% on this question. Just skip this one for now. Take This Question Anyway This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07PE.20) Examination of an obese 3-year-old girl reveals 30 degrees of unilateral genu varum. A radiograph of the involved leg with the patella forward is shown in Figure 10. Management should consist of Review Topic QID: 6080 FIGURES: A Type & Select Correct Answer Type in at least one full word to see suggestions list 1 continued observation until skeletal maturity. 6% (2/34) 2 fitting for a valgus-producing hinged knee-ankle-foot orthosis. 29% (10/34) 3 lateral proximal tibial hemiepiphysiodesis. 12% (4/34) 4 proximal tibiofibular osteotomy and acute correction. 50% (17/34) 5 proximal tibiofibular epiphysiodesis and osteotomy with lengthening. 3% (1/34) N/A Select Answer to see Preferred Response SUBMIT RESPONSE 4 You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ05.23) A 30-month-old boy has worsening bilateral bowleg deformities, and radiographs depicting Langenskiold stage II are shown in Figure A. The most appropriate initial management should consist of which of the following? Review Topic QID: 60 FIGURES: A Type & Select Correct Answer Type in at least one full word to see suggestions list 1 Observation 22% (307/1404) 2 Bracing with knee-ankle-foot orthoses 63% (887/1404) 3 Bracing with ankle-foot orthoses 2% (31/1404) 4 Proximal tibia/fibula valgus osteotomy with bar resection 5% (71/1404) 5 Proximal tibia/fibula valgus osteotomy with hemiepiphysiodesis 7% (97/1404) L 3 Select Answer to see Preferred Response SUBMIT RESPONSE 2 You have 100% on this question. Just skip this one for now. Take This Question Anyway (SBQ04PE.3) A valgus producing proximal tibial osteotomy with 10 degrees of overcorrection is the most appropriate treatment for which of the following patients with tibia vara? Review Topic QID: 2188 Type & Select Correct Answer Type in at least one full word to see suggestions list 1 A 4-year-old obese child with Blount's disease, Langenskiöld stage IV 70% (349/502) 2 An 18-month-old child with a proximal tibia metaphyseal-diaphyseal angle of 11 degrees 1% (7/502) 3 A 2-year-old obese child with Blount's disease, Langenskiöld stage II disease 6% (30/502) 4 A 5-year-old child with untreated renal osteodystrophy and a proximal tibia metaphyseal-diaphyseal angle of 16 degrees 9% (47/502) 5 A 8-year-old child with distal femoral varus and a lateral distal femoral angle of 95 degrees 13% (63/502) L 2 Select Answer to see Preferred Response SUBMIT RESPONSE 1
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