Successfully reported this slideshow.

Blounts disease

69

Share

Upcoming SlideShare
Blounts disease
Blounts disease
Loading in …3
×
1 of 45
1 of 45

More Related Content

Related Books

Free with a 14 day trial from Scribd

See all

Blounts disease

  1. 1. Blounts Disease By Dr Harsimranjeet Singh Sidhu Chairperson- Dr Rupa Kumar C.S
  2. 2. History • Erlacher was the first to describe tibia vara and internal tibial torsion- 1922. • Blount- 1937- His Article prompted the diagnosis of this disorder • Langenskiold in 1952 came up with classification for this disorder
  3. 3. Dr Blount Description • “an osteocondrosis similar to Coxa Plana and Madelung deformity but located at the medial side of the proximal tibial epiphysis”
  4. 4. Introduction • It is a developmental condition characterised by a disturbance of orderly sequence of enchondral ossification at the upper end of the tibia, affecting the medial portion of growth plate, mainly in its posteromedial aspect and medial portion of the epiphyseal ossification centre. • Resulting in abrupt varus angulation at proximal portion oF tibial metaphysis , while diaphysis remains straight.
  5. 5. Etiology- What Causes It. • Current concept – tibia vara is an acquired disease of proximal tibial metaphysis of unknown cause. • Enchondral ossification is most likely altered.
  6. 6. Suggested causative factors • Infection • Trauma • Osteonecrosis • Latent form of rickets ALTHOUGH NONE HAVE BEEN PROVED Combination of developmental and hereditary factors is most likely the cause
  7. 7. • The Relationship of early walking and obesity with Blount disease has been clearly documented. • Rarely seen in non ambulatory children.
  8. 8. ETIOLOGY contd • Familial occurance reported by several authors…..but as noted by Langenskiold and Riska, because radiographic features of infantile tibia vara have never been seen in patients younger than 1 year and rarely before 2 years..this condition should be consider congenital one.
  9. 9. PATHOLOGY Histologic evaluation of affected growth plates and corresponding part of metaphysis shows :- 1. Islands of densely packed cartilage cells displaying greater hypertrophy than expected from their position in growth plate. 2. Island of nearly acellular cartilage. 3. exceptionally large clusters of capillary vessels.
  10. 10. Pathophysiology • The physeal cell collumns become irregular and disordered in arrangement and normal endochondral ossification is disrupted , both in the medial aspect of metaphysis and in corresponding part of physis. • Varus deformity progresses as long as ossification is defective and growth continues laterally on lateral part of physis.
  11. 11. • In later stages , an actual bony bridge may tether the medial growth , and the medial tibial plateau may apear deficient posteromedialy. • Ligamentous laxity on lateral side of knee frequently develops in a neglected or recurrent deformity .
  12. 12. Classification • Blount distinguished it as :- Infantile- Less than 8 years of age bilateral in 60 % Adolescent :- more than 8 years to skeletal fusion. with a cause- black, obese.
  13. 13. Langenskoild classification (1952) Depending on degree of metaphysial epiphysial changes- 6 progressive stages with increasing age • Stage I- Irregular metaphyseal ossification combined with medial and distal protrusion of the metaphysis. • Stage II,III, IV - evolves from mild depression of the medial metaphysis to a step- off of the medial metaphysis.
  14. 14. Langenskoild classification (1952) Stage V- Increased slope of medial articular surface and a cleft separating the medial and lateral epicondyle. • Stage VI- Bony Bridge across the physis.
  15. 15. • Bowleg deformity first becomes apparent when infant starts to stand and walk. • Obese child. • DEFORMITY  Sharp medial angulation of tibia at metaphysis. Deformity more evident in weight bearing position Internal tibial torsion
  16. 16. Clinical Picture
  17. 17. • To compensate for the tibial varus , the medial femoral condyle hypertrophies. • Over the medial aspect of epiphyseometaphyseal junction , a bony , hard , non tender prominence is palpable( reffered as BEAK on xrays ) • In long standing neglected cases –  slight flexion deformity is added to varus deformity.  collateral ligaments become lax- joint unstable.  medial tibial condyle becomes severely depressed and OA develops within medial compartment of knee.
  18. 18. Radiological examination • Standing AP view from hip to ankle. FEATURES :-  Varus angulation at the epiphyseal metaphyseal junction.  Widened and irregular physeal line medially.  Medially sloped and irregular ossified epiphysis, sometimes triangular.  Prominent beaking of the medial metaphysis with lucent cartilage islands within the beak.  Lateral subluxaton of the proximal end of tibia.
  19. 19. Metaphyseal Beak
  20. 20. Tibia Femoral Angle • Normally progresses from pronounced varus before age of 1 year to valgus between the ages 1.5 to 3 years… • any deviation from normal tibiofemoral angle development indicates Blounts disease.
  21. 21. Metaphysio diaphyseal Angle • Levin And Drennan • If angle > 11 degree- mostly blount lesions • If angle < or = 11 degree….mostly resolves.
  22. 22. Further Work Up • No specific blood markers. • TESTS to rule out Rickets, ViTamin D deficiency • Ct scan is indicated to detect physeal bar in children above 5 years of age.
  23. 23. Diffrential Diagnosis • Physiologic Genu Varum • Skeletal dysplasias • Metabolic diseases ( renal osteodystrophy, vit d resistant rickets ) • post traumatic deformity • Post infective sequelae
  24. 24. Developmental (physiological) bowing: Developmental bowing Blount disease Disappear after 2 years. Progressive. Bilateral and symmetric. Unilateral or bilateral asymmetric. Metaphyseal diaphyseal angle < 11 Metaphyseal diaphyseal angle > 11
  25. 25. TREATMENT • Treatment choices and prognosis greatly depends upon on the age of the patient and radiographic stage of the disease
  26. 26. ORTHOTICS • INDICATIONS Child younger than 3 years of age Lesions not greater than langenskiold stage 1 and 2. Especially if unilateral involvement.
  27. 27. KNEE ANKLE FOOT ORTHOSIS(KAFO) • Rainley.et all Prefferred LOCKED KAFO that produced valgus force by 3 points pressure. • Recommended 23 hrs /day. • Full weight bearing. RISKS of failure:-  Ligamentous laxity. Patient weight above 90 percentile. Late initiation of bracing.
  28. 28. ELASTIC BLOUNT BRACE • 1987 • A medial upright design that uses a wide elastic band just distal to the knee joint. • Excusively used  ease of fabrication Smaller profile
  29. 29. Corrective Osteotomy Options  METAPHYSEAL  EPIPHYSEAL- METAPHYSEAL INTRA EPIPHYSEAL
  30. 30. Rx – CORRECTIVE OSTEOTOMY • In children older than 9 years with more severe involvement , osteotomy alone , with bony bar resection , or with epiphysiodesis of lateral tibial and fibular physis is indicated. • For older Children in whom bracing and tibial osteotomy have failed to prevent progressive deformity , Ingram , Siffert and others have suggested an intraepiphyseal osteotomy to correct severe joint instability and a valgus metaphyseal osteotomy to correct the varus angulation
  31. 31. CORRECTIVE OSTEOTOMY Rx • Schoenecker et al- elevation of medial tibial plateau along with metaphyseaal wedge osteotomy • Gregosiewics – Double elevating osteotomies; intraepiphyseal and metaphyseal. • Zeyer – hemicondylar tibial osteotomy through the epiphysis into the tibial intercondylar notch. • Bell, Coogan- Recommended illizarov technique.
  32. 32. Metaphyseal oblique osteotomy • George .T.Rab • Advantage- • single plane oblique cut allows simultaneous correction of varus and internal rotation . • permits postoperative cast wedging if necessary to obtain appropriate position.
  33. 33. • Post-operatively Cast is changed at 4 weeks Weight bearing allowed if callus evident over radiographs Cast worn till 8 weeks/ till union is evident radiologically
  34. 34. CHEVERON OSTEOTOMY • GREENE • MODIFICATION OF DOME OSTEOTOMY • Advantages  Greater Stability  Mininmal changes in leg length.
  35. 35. TECHNIQUE  Fibular osteotomy. • Tibial osteotomy. • Osteotomy fixation with pin. • Long leg bent knee cast . • Postoperative
  36. 36. DISADVANTAGES Loss of fixation/ correction  longer period of cast immobilisation
  37. 37. HEMICONDYLAR OSTEOTOMY • ZAYER INDICATED – LIGAMENTOUS LAXITY EXTREME DEPRESSION AND SLOPING OF MEDIAL TIBIAL CONDYLE.
  38. 38. INTRA EPIPHYSEAL OSTEOTOMY • Stiffert , Johnson ET AL. • Indication severe joint instability To correct intrarticular components of Blount disease • in addition valgus osteotomy to correct genu vara.
  39. 39. ILIZAROV TECHNIQUE • Effective in correction of deformity and lengthening if indicated in adolescent patient. • Allows – adjustment of limb alignment postoperatively. • Fixation to tibia is achieved by 4 proximal and 4 distal wires that are affixed to rings and tensioned.
  40. 40. COMPLICATIONS • Common peroneal nerve palsy. • Compartment Syndrome • Anterior Tibial Artery Occlusion • Recurrence
  41. 41. Treatment in breif AGE LANGENSKOILD STAGE TREATMENT < 2 YEARS STAGE 1 AND 2 OBSERVATTION 2-3 YEARS STAGE 1 AND 2 MODIFIED LOCKED KAFO 3-8 YEARS STAGE 2 TO STAGE 3 OBLIQUE / CHEVERON OSTEOTOMY 9+ YEARS STAGE 4 AND ABOVE RESECTION OF BONY/ PHYSEAL BAR + OSTEOTOMY + EPIPHYSEAL ELEVATION +/- LATERAL EPIPHYSEAL EPIPHYSEODESIS
  42. 42. REFERENCES 1. Campbells operative orthopaedics volume 2; 12th edition 2. Tachdijian’s pediatric orthopedics volume 2; 4th edition 3. Turek orthopaedic principle and application volume 2 ;4th edition.
  43. 43. THANK YOU!!!!!!!

Editor's Notes

  • Severel author have reported familail occurance of this disease, however acc to
  • Histologic evaulation has been reported by several authors.
  • By physeal cell collumns I mean all the layers of physis…..growth will cont on the lateral side of the physis ….but it wil be defective on the medial side…..soo the progression of varus deformity.
  • BONY BRIDGE FORMATION BETWEEN METAPHYSIS AND PHYSIS AND EPIPHYSIS….WICH WILL TETHER THE MEDIAL GROWTH
    Ligamentous laxity is due to depression of med
  • Stage 2 – complete restoration possible
    Stage 4 – restoration possible
  • Stage 2 – complete restoration possible
    Stage 4 – restoration possible
  • This is a case of blounts disease…..showing an obeses childe……bilateral tibia vara……..foot is internaly rotated and hence internal tibial rotation is also present….
  • Metaphyseal beak….wich would be shown after few slides on xrays.

    SLIGHT FLESION DEFORMITY …..AS POSTEROMEDIAL PART EPIPHYSIS BECOMES DEPRESSED.
    LIGAMENT LAXITY CAUSED BY EXTREME DEPRESION MEDIAL CONDUYE
  • Angle formed by line joining the longitudinal axis of tibia and femur.- …..normally this angle is 7 degree
  • The angle formed by the line connecting most prominent medial portion of the proximal tibial metaphysis and the most prominent lateral point of metaphysis with a line drawn perpendicular to the long axis of tibial diaphysis……..in a study, blount disease developed in 29 out of 30 patients, whose angle was more than 11 degree…..and only out of 58 patients only 3 developed this condition whoes angulation was 11 degree or less.
  • From tachidian page 976
    Mostly it is misdiagnosed with physiologic genu varum
  • Brace treatment not appropriate in children older than 3 years….because maximum trial of 1 year to correct the deformity with orthotic treatment is recommended…..if the correction is not achieved within this time frame the surgeon can stil perform definitive surgery till the time child is 4 years old….now if orthotic treatment begins after the child is 3 years old means that results wont be known till the time child is older than 4 years….this will delay the surgical osteotomy for 1 year…it may seem meldodramatic…but even few months delay in performing surgery after 4 years may lead to failure in achieving permanent reversal in inhibition of proximal medial physis.
  • Rainley and associates used kafo orthosis in 60 tibiae….out of wich 54 resiloved without surgery…out of 54 tibiae wich resolved 27 were treated with full time orthotic use…..23 by night time use only…..4 by day time use only....the 6 patients qwich required surgery …..3 patient ….full time orthotics……and 3 had only night time use of orthotics….according to this findings…..author recommended night time use only

    KNEE ANLE FOOT BRACE….VALGUs CORRECTION SHOULD BE INCREASED BY BENDIONG THE MEDIAL UPRIGHT EVERY 2 months until standing radiographs shows that atleast a neutral mechanical axis is being correctedand the lesions should have nearly resolved by the time that the patient is no longer using orthotics.
  • In image note the medial upright that can be locked to increase the effectiveness of valgus pressure during weight bearing.
  • Principle of oblique osteotomy for tibia vara…..Rotation around the face of cut will produce valgus and external rotation. Which is done in case of tibia vara.
  • after preparing and draping patient….aaply and inflate tourniquet….
    A- make a transverse incision over the lower pole of tibial tubercle.
    b. The a y shaped incision over the periosteum ….
    c…..steimen pin at an angle of 45 degree is placed just 1 cm distal to tibial tubercle and is advanced till the time ir passes just into posterior cortex…..this is done under image intensifier to make sure that the steimen pin is distal to the physis……
    d…now this pin length is measured and the same length is markedd over or saw blades…….this will help to remind abt the saw depth
    e….now the oblique cut is just made distal to the steimen pin….
    F- now this osteotomy is rotated on its face by external rotaion and valgus rotationin blounts diseases…..and is fixed with corticalor cancellous lag screw …wich is kept loose….both limbs are checked for the correct alignment…..long knee ,bent knee cast is applied…..as the screw is kept loose …changes in the alignment can be made while applyind cast.

  • Patient is prepared in usual manner……sandbag is given under ipsilateral hip to improve exposure of fibula
    Fibular osteotomy - middle third of fibula is exposed through the interval between lateral and posterior compartments…..1 cm segment of fibula is removed with saw……fibula is cut obliquely from superolateral to inferomedial …so that when leg is brought from varus to valgus position …the distal part of fibula can slide past the proximal fragment
    Tibial osteotomy after hockey stick incision tibial tubercle and gerdy tubercle are exposed

    …apex of osteotomy is just distal to tibial tubercle…..a whole is drilled anterior to posterior at this point to mininmise the riskof extending osteotomy beyond this location…..now the osteotomy is completed using a saw …..and lateral wdge is removed………after osteotomy distal tibia is swinged in desired position of valgus and external rotation…..lateral wedge is inserted medialy given a position which maintains correction….depending on age and degree of obesity of child osteotomy is fixed with single or 2 crossed threaded pins are given.
    Postoperatively no weight bearing for 4 weeks after surgery ……cast removed after 4 weeks and f healing is satisfactory radiologically weight bearing is gegun after pins removal…….usually 8- 10 weeks of immobilisation is necessary.
  • IN THIS PROCEDURE ….OSTEOTOMY AND ELEVATION OF MEDIAL TIBIAL CONDYLE IS DONE…..
    EPIPHYSIDESIS OF LATERAL TIBIAL PHYSIS AND FIBULA PHYSIS IS DONE IF INDICATED.
  • Procedure – in this procedure curved osteotomy through the medial aspect of the epiphysis is done….the osteotomised tibial condyle is elevated to place in congruity with femur condyle…and bone graft is placed in between…

  • Anterior tibial artery- at interossoeus membrane- streching of artery occurs on varus correction …..and occlusion with valgus correction
  • ×