By Dr Harsimranjeet Singh Sidhu
Chairperson- Dr Rupa Kumar C.S
• Erlacher was the first to describe tibia vara and
internal tibial torsion- 1922.
• Blount- 1937- His Article prompted the diagnosis of
• Langenskiold in 1952 came up with classification for
Dr Blount Description
• “an osteocondrosis similar to Coxa Plana
and Madelung deformity but located at
the medial side of the proximal tibial
• 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
• Resulting in abrupt varus
angulation at proximal portion oF
tibial metaphysis , while diaphysis
Etiology- What Causes It.
• Current concept – tibia vara is an acquired
disease of proximal tibial metaphysis of
• Enchondral ossification is most likely altered.
Suggested causative factors
• Latent form of rickets
ALTHOUGH NONE HAVE BEEN PROVED
Combination of developmental and hereditary
factors is most likely the cause
• The Relationship of early walking and obesity
with Blount disease has been clearly
• Rarely seen in non ambulatory children.
• 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
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
• 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.
• 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
• Blount distinguished it as :-
Less than 8 years of age
bilateral in 60 %
more than 8 years to skeletal fusion.
with a cause- black, obese.
Langenskoild classification (1952)
Depending on degree of
metaphysial epiphysial changes-
6 progressive stages with
• Stage I- Irregular metaphyseal
ossification combined with
medial and distal protrusion of
• Stage II,III, IV - evolves from
mild depression of the medial
metaphysis to a step- off of the
Langenskoild classification (1952)
Stage V- Increased slope of medial articular
surface and a cleft separating the medial and
• Stage VI- Bony Bridge across the physis.
• Bowleg deformity first
becomes apparent when
infant starts to stand and walk.
• Obese child.
Sharp medial angulation of
tibia at metaphysis.
Deformity more evident in
weight bearing position
Internal tibial torsion
• 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
• Standing AP view from hip to ankle.
Varus angulation at the epiphyseal
Widened and irregular physeal line
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.
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
development indicates Blounts
Metaphysio diaphyseal Angle
• Levin And Drennan
• If angle > 11 degree- mostly
• If angle < or = 11
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.
• Physiologic Genu Varum
• Skeletal dysplasias
• Metabolic diseases ( renal osteodystrophy, vit d
resistant rickets )
• post traumatic deformity
• Post infective sequelae
Developmental (physiological) bowing:
Developmental bowing Blount disease
Disappear after 2 years. Progressive.
Bilateral and symmetric. Unilateral or bilateral
angle < 11
angle > 11
• Treatment choices and prognosis greatly depends
upon on the age of the patient and radiographic
stage of the disease
Child younger than 3 years of age
Lesions not greater than langenskiold stage 1 and 2.
Especially if unilateral involvement.
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:-
Patient weight above 90
Late initiation of bracing.
ELASTIC BLOUNT BRACE
• A medial upright design
that uses a wide elastic
band just distal to the knee
• Excusively used
ease of fabrication
Corrective Osteotomy Options
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
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.
Metaphyseal oblique osteotomy
• George .T.Rab
• single plane oblique cut allows
simultaneous correction of varus and
internal rotation .
• permits postoperative cast wedging if
necessary to obtain appropriate position.
Cast is changed at 4 weeks
Weight bearing allowed if callus evident over
Cast worn till 8 weeks/ till union is evident
• MODIFICATION OF DOME OSTEOTOMY
Mininmal changes in leg length.
• Tibial osteotomy.
• Osteotomy fixation with
• Long leg bent knee cast .
Loss of fixation/ correction
longer period of cast
AND SLOPING OF
INTRA EPIPHYSEAL OSTEOTOMY
• Stiffert , Johnson ET AL.
severe joint instability
To correct intrarticular
components of Blount
• in addition valgus osteotomy
to correct genu vara.
• Effective in correction of deformity and
lengthening if indicated in adolescent patient.
• Allows – adjustment of limb alignment
• Fixation to tibia is achieved by 4 proximal and 4
distal wires that are affixed to rings and
• Common peroneal nerve palsy.
• Compartment Syndrome
• Anterior Tibial Artery Occlusion
Treatment in breif
< 2 YEARS STAGE 1 AND 2 OBSERVATTION
2-3 YEARS STAGE 1 AND 2 MODIFIED LOCKED KAFO
3-8 YEARS STAGE 2 TO
OBLIQUE / CHEVERON
9+ YEARS STAGE 4 AND
RESECTION OF BONY/ PHYSEAL
BAR + OSTEOTOMY + EPIPHYSEAL
ELEVATION +/- LATERAL
1. Campbells operative orthopaedics volume 2;
2. Tachdijian’s pediatric orthopedics volume 2;
3. Turek orthopaedic principle and application
volume 2 ;4th edition.
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