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blounts disease.pptx
- 1.
- 2. HISTORICAL BACKGROUND • ERLACHER(1922) –first description of tibia vara and internal rotation • Walter BLOUNT(1937)-described tibia vara
- 3. Blount: • An osteochondrosissimilar to coxa plana and madelung deformity but located at the medial side of proximal tibial epiphysis
- 4. • Anders Langenskloid(1952) • -radiographic changes and stages of disease in scandinavian population
- 5. synonyms • Infantile tibiavara • Erlachers disease • Blount-barber disease • Subepiphyseal osteochondropathy • Non rachitic bow legs • Osteitis deformans tibia
- 7. • Secondary effects •-internal torsion of tibia • -insufficient ossification of the medial portion of medial tibial condyle • Streched LCL
- 8. ANATOMY • Genu varumis a normal physiologic process in children • 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(<15) at ~ 7 years of age
- 11. Types • 2 types •1-Infantile-begins before 8 years of age • 2-Adolescent- begins after 10 years of age but before skeletal maturity • A) b/w 10 and 13 years -partial closure of epiphysis - trauma/infection • B) b/w 10 and 13 years –black and obese children-no distinct cause
- 12. INFANTILE BLOUNTS DISEASE •progressive pathologic genu varum centered at the tibia in children 2 to 5 years of age. • Diagnosis- presence of a genu varum/flexion/internal rotation deformity and confirmed radiographically with an increased metaphyseal-diaphyseal angle. • Treatment - bracing to surgery (patient age, severity of deformity, and presence of a physeal bar.)
- 13. ETIOLOGY Idiopathic more common male >female bilateral in 50% Altered enchondral ossification Risk factors overweight children early walkers (< 1 year) Hispanic and African American
- 14. Pathophysiology • multifactorial -butrelated to mechanical overload in genetically susceptible individuals • excessive medial pressure produces an osteochondrosis of the medial proximal tibial physis and epiphysis • (osteochondrosis can progress to a physeal bar)
- 15. • Intra articularpathology • Enlargement and hypermobility of medial meniscus • Depression of anterior aspect of medial femoral condyle • Depression of posteromedial plateau of tibia
- 17. type I toIV consist of increasing medial metaphyseal beaking and sloping type V and VI have an epiphyseal-metaphyseal bony bridge (congenital bar across physis) At stage 6 – medial portion of epiphysis fuses at 90 degree downward angle
- 18. PRESENTATION • Physical examination •genu varum/flexion/internal rotation deformity • usually b/l in infants • lateral thrust on walking • Waddling gait • may exhibit positive 'cover-up test' • often associated with internal tibial torsion • leg length discrepancy
- 20. • usually NOtenderness, restriction of motion, effusion • Bony hard non tender prominence –palpable at the medial epiphysiometaaphyseal junction • SIFFERT KATZ sign-as the extended knee is slightly flexed---medial femoral condyle engages tibial medial plateau depression and sublaxates posteromedially (varus instability at 15 degree knee flexion)
- 21. • Long standingneglected cases’ • -slight flexion deformity added • Unstable joint-lax ligaments • Medial compartment OA knee
- 22. IMAGING Radiographs • standing long-cassetteAP radiograph of both lower extremities • ensure that patella are facing forwards for evaluation (commonly associated with internal tibial torsion) – findings suggestive of Blounts disease • medial and posterior sloping of proximal tibial epiphysis(short ,thin,wedged,irregular) • varus focused at proximal tibia • severe deformity(asymmetric bowing) • sharp angular deformity(progressive)
- 23. metaphyseal breaking different than physiologic bowingwhich shows a symmetric flaring of the tibia and femur Often palpable Not diagnostic Pathognomic-progressive disease
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- 28. Other investigations • Ctscan to r/o physeal bar • Double contrast arthrography and arthroscopy –intra articular pathology(articular surface defects,medial meniscus) • Histological findings’ • -delayed ossification of medial epiphysis and proximal tibia • -cell hypertrophy • Dense cellularity • Fibrocartilage islands • Abnormally large group of capilaries
- 30. DIFFERENTIAL DIAGNOSIS • Persistentphysiological varus • Rickets • osteogenesis imperfecta • Multiple Episphyseal Dysplasia(fairbanks d/s) • Spondyloepiphyseal dysplasia • metaphyseal dysostosis (Schmidt, Jansen) • focal fibrocartilaginous defect • thrombocytopenia absent radius • proximal tibia physeal injury (radiation, infection, trauma)
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- 32. TREATMENT • Nonoperative • BRACETREATMENT WITH KneeAnkleFootOrthosis indications • Stage I and II in children < 3 years • technique • bracing - approximately 2 years for resolution of bony changes outcomes • improved outcomes if unilateral • poor results -obesity and bilaterality • if successful, improvement - within 1 year
- 33. KAFO Prefered by Railey Valgusforce at 3 points 23 hrs/day Full weight bearinng
- 34. ELASTIC BLOUNT BRACE 1987 Wide elasticband just distal to knee joint
- 35. OPERATIVE • PROXIMAL TIBIA/FIBULAVALGUS 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 outcomes • risk of recurrence is significantly lessened if performed before 4 years of age
- 36. 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
- 38. RAB OSTEOTOMY(meta physeal/oblique) A-transverse incision at tibialtubercle B-y shaped periosteal incision C-insertion of steinman pin D-mark saw and osteotomy(prevent overpenetration) E-oblique cut beneath pin F-rotation of osteotomy and fixation with lag screw
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- 45. • PHYSEAL BARRESECTION • indication • at least 4y of growth remaining • technique • perform together with osteotomy • interpositional material is usually fat or PMMA
- 46. COMPLICATIONS • 1.Compartment syndrome(with high tibial/fibular osteotomy)-prophylactic release of anterior compartment • 2.CPN palsy • 3.anterior tibia artery injury 4.Recurrence of tibial vara • severe cases-- physeal bar-- progressive varus after a well executed proximal tibial valgus osteotomy--- require a lateral tibial hemiepiphysiodesis or physeal bar resection
- 47. Physeal bar • MCcause of recurrence • Greene criteria(CT scan) • 1.age>5 • 2.medial physeal slope 50-70 degree • 3.langenskiold grade 4 or more’ • 4.body weight >95 th percentile • 5.black girls who meet previous criteria
- 48. PROGNOSIS • Best outcomes •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
- 49. •Infantile versus AdolescentBlount's •Infantile Blounts •Adolescent Blounts •Age •2-5yrs •>10yrs •Bilaterally •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
- 50. Adolescent Blount's Disease progressive, pathologic genuvarum centered at the tibia in children > 10 years of age. Treatment is generally surgical epiphysiodesis or osteotomy depending on severity of deformity and amount of growth left.
- 51. ETIOLOGY • Less common •less severe • more likely to be unilateral • more likely to have femoral deformity • obesity • African-American descent • Pathophysiology-dyschondrosis of medial physis of proximal tibia – multifactorial- mechanical overload in genetically susceptible individuals
- 52. PRESENTATION hallmark is genuvarum deformity obesity usually unilateral (compared to bilateral in infantile Blount's) limb-length discrepancy secondary to deformity mild to moderate laxity of medial collateral ligament May have femoral varus and distal tibia valgus
- 53. RADIOGRAPHIC findings s/o adolescentBlount's disease narrowing of the tibial epiphysis widening of the medial tibial growth plate occasional widening of the lateral distal femoral physis metaphyseal breaking less commonly seen with adolescent Blount's
- 54. Treatment • Surgical • 1.Lateral tibia and fibular epiphysiodesis • 2. Proximal tibia/fibula osteotomy • 3. distal femoral osteotomy or epiphysiodesis
- 55. Lateral tibia andfibular epiphysiodesis indications mild to moderate deformity with growth remaining outcomes up to 25% may require formal osteotomy due to residual deformity a. transient hemiepiphysiodesis tether physis with 8-plates or staple may remove implant once correction is achieved simple allows for gradual correction is children with adequate growth remaining b. permanent hemiepiphysiodesis obliteration of physis through small, lateral incision limited surgery overcorrection is uncommon cannot correct rotational deformity up to 25% may require formal corrective osteotomy
- 56. Proximal tibia/fibula osteotomy indications moresevere cases in the skeletally mature - valgus producing tibial osteotomy and plating -external fixation goals of correction overcorrection to valgus not indicated (as is the case in infantile Blount's) strive for neutral mechanical axi
- 57. High Tibial OsteotomyWith Rigid Internal Fixation variety of techniques, including closing wedge, opening wedge, dome, serrated and inclined osteotomies variety of fixation devices including cast, pins and wires, screws, plates and screws post-op limited weight bearing with use of crutches for 6-8 weeks immediate correction potential for neurologic injury due to acute lengthening potential for compartment syndrome
- 58. Osteotomy With External FixationAnd Gradual Correction perform osteotomy, and connect frame that allows for gradual correction Taylor Spatial Frame or Ilizarov ring external fixator post-op usually 12-18 weeks of treatment are needed gradual correction limits neurovascular compromise and risk for compartment syndrome allows for correction of deformity in all planes pin site infection duration of treatment bulk of construct
- 59. Distal Femoral OsteotomyOr Epiphysiodesis indications for distal femoral varus deformity of 8 degrees or greater
- 61. REFERENCES • Campbell’s OperativeOrthopaedics 14th edition (2021) • Apley's System of Orthopaedics and Fractures • TUREK orthopedic principles and application • https://pubmed.ncbi.nlm.nih.gov/ • https://www.orthobullets.com/