Review Question - QID 218231

The patient has infantile tibia vara and the next best step in treatment for her is a valgus producing knee-ankle-foot orthosis.

Tibia vara, or "Blount disease," is a pathologic bowing of the lower extremities due to inadequate growth at the proximal medial tibial physis. Infantile Blount disease occurs between the ages of 2 and 5. For mild disease (Langenskold I or II) in patients less than three years of age an anti-varus brace may be tried. Evidence for bracing is controversial, but a trial of bracing is generally recommended for this patient population. Further confounding studies is highly variable compliance. For patients age three years or older and with more severe disease surgery is typically required.

Birch presents a review of tibia vara and comments on the management of infantile Blount disease. He notes that one study found bracing led to an improvement in alignment for children under age 3 with Langenskold I or II disease (Richards et al., PMID: 9600567). Although other studies have not found bracing to be effective, the author still recommends a trial of bracing for this group of patients.

Shinohara et al. present their experience on the natural history of infantile tibia vara. They found that spontaneous resolution of the deformity is possible even in Langenskold stages III and above, and found no difference with early brace treatment. They recognize other literature that advocates bracing, but they recommend simple observation at 6 month intervals until at least age 4 years, and consider osteotomy if the deformity is progressive.

Figure A is an AP standing radiograph of a patient with mild (Langenskold II) infantile tibia vara. Illustration A is a diagram demonstrating the Langenskold classification. Illustration B is a diagram demonstrating how to calculate the metaphyseal-diaphyseal angle which can be used to distinguish Blount's versus physiologic bowing. Illustration C is a clinical photograph of a patient wearing valgus producing KAFOs.

Incorrect Answers:
Answer 1: While bracing treatment is controversial in the literature and some do recommend simple observation even for a patient such as this, the correct answer for testing purposes is still considered to be a trial of bracing.
Answers 3-5: Surgical management is reserved for more severe disease and older age groups. If this child's deformity persists or progresses until age 4 then osteotomy would be the correct answer.