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Blount's disease is a skeletal disorder that causes bowing of the legs. It is classified into infantile and adolescent types based on age of onset. Infantile Blount's disease is the more common type and is often bilateral. Treatment options include bracing, guided growth, osteotomy, and hemiplateau elevation depending on the stage and severity of deformity. Recurrence rates remain high, so long-term follow up is important. New techniques like percutaneous osteotomy and combined procedures aim to address more advanced or recurrent cases.
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Blount.pptx
- 1. Blount’s Disease Overall review and recent updates Abdelrahman Haroun, MSc NINMS-Pediatric fellowship Cairo, Feb, 2021
- 2. Learning objectives • What is Blount’s disease and how it happens? • Diagnosis and investigations needed. • Types and stages of the disease. • Treatment options. • Reviewing what is new on the subject.
- 3. Historical overview Phillipp Erlacher, 1922 Tibia vara Walter Blount 1937
- 4. 1966 Classification into infantile and adolescent Andres Langenskiöld Well accepted classification of infantile Blount’s
- 5. Types ONSET Early onset - Infantile • More common • bilateral • Onset before 4 years of age Late onset • Juvenile 4 ~ 10 – Bilateral – High recurrence • Adolescent > 10 – unilateral
- 6. Infantile blount Etiology • Multifactorial • Varus stress growth suppression of the upper medial tibial epiphysis in a susceptible individual • Obesity • Vit. D def. • Early walkers • Racial • Geographical Bathfield CA, Beighton PH: Blount disease. A review of etiological factors in 110 patients, Clin Orthop Relat Res 135:29, 1978
- 7. Pathogenesis • Primarly mechanical Excessive compression on the medial tibial physis leads to growth inhibition (Hueter- volkman law ) • Secondary biological Delayed enchondral growth on the upper medial tibial physis exaggerates varus drift
- 8. Clinical features Deformity – Complex deformity • 1ry deformities – Varus with Lateral thrust – Procarvatum – Internal tibial tortion • 2ry deformities – Distal femoral varus or valgus – Ankel valgus deformity – L.L.D. – Commonly bilateral Patient often obese, exceeding the 95th percentile for weight Femoral Deformity in Tibia Vara , Gordon, J JBJS: February 2006 - Volume 88 - Issue 2 - p 380-386
- 9. Radiographic findings X-rays Standing A-P view of the lower extremities from hip to ankle (1) A widened and irregular physeal line medially (2) Varus angulation in the metaphysis (3) A medially sloped and irregularly ossified epiphysis (4) prominent beaking of the medial metaphysis (5) Lateral sublaxation of the proximal tibia Angles and Measurements • MAD ( a ) – LDFA ( b ) – MPTA ( c ) • TFA ( d ) • MDA ( e ) • Medial plateau depression angle ( f ) • PPTA ( g )
- 10. • CT • MRI • Arthrogram
- 11. Classification Langenskiöld for infantile type I. Irregular physeal line II. Beaking III. Blunting IV. Epiphyseal depression V. Physeal bar VI. Separation of depressed epiphyseal fragment
- 12. Treatment Bracing • < 36 months old • Mild deformity ( I / II ) The concept is simple while reality is complicated 1. Physiologic versus Blount’s 2. No control group 3. Multiple variable
- 13. Guided growth • proceeds at approximately 1° per month • No cast • I or II • Cannulated screws versus conventional • Recurrence 33% • I.T.T • Limited LLD • BMI Guided growth for the Treatment of Infantile Blount's disease: Is it a viable option? B. Gage Griswold 2020 Tension Band Plate (TBP)-guided Hemiepiphysiodesis in Blount Disease: 10-Year Single-center Experience With a Systematic Review of Literature Mohit J. Jain 2019
- 14. Sleeper plate The “Sleeper” plate: A technical note Muayad Kadhim 2019 • Elevate plate • Bone wax Removal of Metaphyseal Screw Only after Hemiepiphysiodesis Correction of Coronal Plane Deformities Around the Knee Joint: Is This a Safe and Advisable Strategy? Keshet, Doron MD • 9 out of 12 cases needed changing of plate or plate position • Bony bar under plate causing growth arrest
- 15. Osteotomy • Just distal to patellar tendon • I.T.T • Fibular osteotomy • Osteotomy rule II • K-wires • Fasciotomy • Overcorrection Mycoskie PJ: Complications of osteotomies about the knee in children, Orthopedics 4:1005, 1981
- 16. Percutenous Osteotomy Osteoclasis POO • Minimally invasive • Simple and quick • Inherently stable • Cast should be molded • Don’t need fixation • No secondary procedures to remove implants Case courtesy of Dr. Mohamed Abdelwahed Associate Lecturer Tanta university
- 17. Recurrence after osteotomy • Correction into physiological valgus alignment • Medial epiphysiolysis • Lateral epiphysiodesis • MPS ≥ 60 degrees • Knee instability increased varus alignment on weight-bearing as measured by the tibio-femoral angle • Langenskiöld stage Decreasing risk of recurrence Predictive Factors for Recurrence in Infantile Blount Disease Treated With Tibial Osteotomy Pieter H. 2021 Medial Metaphyseal Slope as a Predictor of Recurrence in Blount Disease Laoharojanaphand. T 2019
- 18. Late presenting and recurrent cases Problems to consider Current • Advanced stage • Severe medial joint line depression • shortening Future • Relative lateral tibial plateau overgrowth • Relative proximal fibular overgrowth causing laxity of the fibular collateral ligament • Anticipated increased leg length discrepancy Case courtesy of Dr. Abdullah Nada Associate lecturer Tanta university
- 19. Adequate planning • MAD, LDFA, MPTA, Medial plateau depression angle..etc • Hemiplateau elevation • Metaphyseal osteotomy • Both Addressing secondary deformities • Femoral • Ankle • LLD
- 20. Acute correction • Mild to moderate • Plate or Ex.Fix • LLD usually in second stage • Fasciotomy • Risk for peroneal n. injury • May need grafting • No fine tuning post op.
- 21. Gradual correction • Severe cases TFA > 25 • Ex.Fix – Ilizarov – TSF • LLD addressed • No need for fasciotomy • No risk for neurological affection • No need for graft
- 22. Frame application Case courtsy of Prof.Mahmoud Elrosasy and Dr. Hossam Ghaly Tanta university
- 25. Hemiplateau elevation • Langenskold V or VI • Above 6 years of age • Medial plateau depression with physeal bar • Different techniques • Combined with lateral hemiepiphyseiodesis • Proximal fibula epiphyseodesis ? • LLD not addressed Is Proximal Fibula Epiphysiodesis Necessary When Performing a Proximal Tibial Epiphysiodesis? Jonathan Boyle , 2020 Severe infantile blount's disease: Hemiplateau elevation and metaphyseal correction with use of the taylor spatial frame Jonathan Wright, 2019
- 28. Single-stage medial plateau elevation and metaphyseal osteotomies in advanced-stage Blount’s disease: a new technique Mostafa M. Baraka 2020
- 29. Azhar dome physioclasis: A new surgical technique of treating patients with late presenting blount's disease , Y Elbatrawy 2020
- 30. Take home message • Early diagnosis can make huge difference • Know when to ask for CT, MRI • Get familiar with different techniques • Family counseling for recurrence and secondary procedures • Follow up till skeletal maturity