Intraepiphyseal osteotomy for progressive tibia vara: case report and rationale of management

Outcomes of late-stages infantile Blount's disease managed by acute single stage: medial hemi-plateau elevation and metaphyseal osteotomy. Eight case series

This study aimed to evaluate the clinical and radiological outcomes of surgical intervention involving acute medial hemi-plateau elevation and metaphyseal osteotomy with internal fixation and growth modulation for late-stages Blount's disease. A retrospective analysis was conducted on consecutive patients with late-stages infantile tibia vara between 2014 and 2020. Inclusion criteria consisted of children aged 8 years and older with Blount's disease with Langenskiold stage IV, V or VI, tibia vara more than 30*, medial plateau depression angle (MPDA) exceeding 25* and knee instability with a minimum follow-up period of 3 years. Patients with Limb length discrepancy greater than 5 cm were excluded. Data collection included assessments of age, weight, disease stage, clinical tibiofemoral angle (TFA), mechanical medial proximal tibial angle (mMPTA), MPDA, tibial torsion and knee instability. Functional outcomes were evaluated using modified Pediatric Outcome Data Collection Instruments (PODCI) scores. The study included 5 children with 8 affected limbs. Among them, three children with five limbs had recurrent deformities after previous surgeries. All cases showed significant improvements in TFAs, mMPTA, tibial torsion, knee instability and modified PODCI scores. Complications included 4 cases of superficial infections, 1 intra-articular fracture, 2 minor screw breakage and 2 on-table under correction. Surgical intervention involving acute Single-stage medial hemi-plateau elevation and metaphyseal osteotomy leads to satisfactory outcomes in late-stages Blount's disease among older children. It is crucial to achieve proper correction of all deformity components during surgery, with epiphysiodesis on the lateral side to prevent further recurrence. Continuous follow-up until skeletal maturity is essential for optimal results.

Acute "three-in-one" surgery for the treatment of severe Blount's disease: Surgical technique and report of two cases

The treatment of Blount's disease has historically remained controversial. All the described techniques for its treatment have their own advantages and disadvantages, and no consensus has been reached on a single surgical approach. The aim of this report is to share the early results of a combination technique in which we have collated three well-known surgical steps in one procedure. This combined procedure is indicated for severe and recurrent cases. Our ‘three-in-one’ technique combines an intra-epiphyseal plateau elevating osteotomy with a tibial metaphyseal osteotomy and a lateral tibial temporary hemi-epiphysiodesis. We also report initial results of three limbs in two patients who were treated using this technique. The first case was that of an adolescent with severe left Blount's disease (Langenskiold stage IV) and a lateral thrust. The second case was that of bilateral severe infantile Blount's disease (Langenskiold stage V) and the infant had a lateral thrust. All measurements remarkably improved in both patients during the post-surgical assessment. The limb length discrepancy was 0.6 cm in the first case and 0.5 cm in the second. The preoperative internal tibial rotation and lateral thrust were corrected spontaneously. No complications were recorded in either patient. The three-in-one technique is a safe and versatile surgical approach that can be used in severe, refractory, and recurrent cases of open physis. Furthermore, it can potentially solve the problems of lateral thrust and internal tibial rotation. More cases should be studied before we can endorse the safety and effectiveness of this technique.

Inverted V-shaped high tibial osteotomy for severe tibia vara associated with Turner syndrome: A case report and review of literature

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Severe cases of genu varum represent a major challenge in obtaining normal alignment.

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We performed inverted V-shaped HTO in a patient with Turner syndrome.

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Inverted V-shaped HTO can be a useful surgical method to treat severe tibia vara.

Introduction

Severe cases of genu varum represent a major challenge in obtaining normal configuration of the proximal tibia and overall limb alignment.

Presentation of case

We performed inverted V-shaped high tibial osteotomy (HTO) by using a locking plate for recurrent severe bilateral tibia vara in a 15-year-old female patient with Turner syndrome. Preoperative medial proximal tibial angle (MPTA) and standing femorotibial angle (FTA) of the right/left legs were 67°/69° and 197°/203°, respectively. In order to obtain overall neutral alignment, the correction angle in the right/left knees was required to be 23°/32°. Preoperative planning demonstrated that inverted V-shaped HTO could provide sufficient correction angle with large bone stock and wide bony contact. A postoperative full-standing radiograph showed that the mechanical axes passed through the center of right/left knees with 87°/88° of MPTA.

Discussion

Inverted V-shaped HTO has advantages, as it requires a smaller amount of bone resection and smaller opening gap compared to the closing-wedge and opening-wedge osteotomies.

Conclusion

Inverted V-shaped HTO can be a useful surgical method to treat severe tibia vara in order to obtain adequate configuration of the proximal tibia and overall limb alignment.

Management of neglected Blount disease using double corrective tibia osteotomy and medial plateau elevation

PURPOSE

A double osteotomy for correcting tibial deformity in combination with medial plateau elevation is recommended for the management of neglected Blount disease cases. We report our clinical experience with the application of this surgical technique and describe the long-term follow-up of the patients who were operated on.

METHODS

During a 10-year period, eight children (8 boys) with mean age of 12 years (range 9-14 years) underwent surgery (9 operations) due to neglected infantile tibia vara. All patients suffered from stage V or VI Blount disease according to the Langenskiold and Riska classification. Two simultaneous combined osteotomies were performed for medial plateau elevation and for correction of the tibial deformity. The correction was immediate using K-wires for stabilization and a long-leg cast for immobilization. The mean duration of follow-up was 10 years (range 5-15 years), and the evaluations were based on clinical and radiological criteria.

RESULTS

At the latest follow-up, there was no observable knee flexion or extension restriction and no signs of instability or lateral thrust. All patients had returned to a higher activity level. Leg-lengthening surgery was performed in one child, but the length discrepancy was already present before the double osteotomy was performed. No other complications were noticed. All the angles measured on X-rays had been corrected, and this correction was retained until the latest follow-up.

CONCLUSIONS

This method results in very good outcomes in patients who suffer from Blount disease of stage V or greater. With this technique, the tibial deformity is corrected, the articular surface is restored, and future recurrence is prevented.

Intra-articular morphology of the knee joint in children with Blount disease: a case-control study using MRI

BACKGROUND

The clinical and radiographic abnormalities of the lower limb in children with Blount disease are well known. However, there is controversy regarding the intra-articular morphologic changes in the involved knee joint. The purpose of our study was to evaluate the meniscal and articular surface morphology in children with Blount disease with use of magnetic resonance imaging and to compare these findings with similar measurements in a control group.

METHODS

Preoperative magnetic resonance imaging scans of the knee of children with Blount disease were compared with those of a control group. Coronal and sagittal morphometric parameters including the height and width of the menisci, thickness of the unossified proximal tibial epiphysis, tibial condylar and meniscal inclination, and presence of signal changes and/or tears of the menisci were documented.

RESULTS

Twenty-six children (thirty-three) knees with Blount disease (mean age, 10.5 years) and twenty children without Blount disease (mean age, 9.6 years) were identified. The midcoronal medial meniscal height and width were greater in the Blount disease group (p < 0.0001). Abnormal signal changes were noted in the medial meniscus in twelve limbs (39%) in the Blount group and one limb (5%) in the control group (p = 0.008). The mean thickness of the unossified cartilage of the proximal medial tibial epiphysis was also greater in the Blount disease group (p = 0.0005). The morphology of the menisci and unossified cartilage in the lateral compartment did not differ between the two groups. The mean tibial condylar and bimeniscal inclinations in the coronal and sagittal planes were also similar in both groups. In a multivariate regression analysis, only body mass index correlated with the height of the medial meniscus in the coronal plane (p = 0.0035) and of the posterior horn of the medial meniscus in the sagittal plane (p = 0.0037) in children with Blount disease.

CONCLUSIONS

Children with Blount disease have increased thickness of the chondroepiphysis of the proximal medial aspect of the tibia, increased height and width of the medial meniscus, and greater frequency of abnormal signals in the posterior horn of the medial meniscus. These morphologic changes may compensate for the diminished height of the ossified portion of the medial proximal aspect of the tibia in patients with Blount disease.

Fixator-assisted medial tibial plateau elevation to treat severe Blount's disease: outcomes at maturity

INTRODUCTION

Severe forms of Blount's disease may be associated with medial tibial plateau (MTP) depression. Management should then take account of joint congruence, laxity, limb axis, torsional abnomality, leg length discrepancy (LLD) and eventual recurrence history.

PATIENTS AND METHODS

Eight knees (six patients) were managed in a single step comprising MTP elevation osteotomy, lateral epiphysiodesis and proximal tibia osteotomy to correct varus and rotational deformity. Fixation was achieved using an Ilizarov external fixator. Mean age was 10.5 years. Mean hip-knee-ankle (HKA) angle was 151°; distal femoral varus, 94°; metaphyseal-diaphyseal angle (MDA), 27°; and angle of depression of the medial tibial plateau (ADMTP), 42°. Predicted residual proximal tibial growth was 2.6 cm.

RESULTS

At a mean 48 months' follow-up, results were good in six cases, medium in one and poor (due to incomplete lateral epiphysiodesis) in one. Mean lateral tibial torsion was 9° and final LLD 11 mm. Weight-bearing was resumed at 2 months, and the fixator was removed at 5.5 months postoperatively. At end of follow-up, mean HKA angle was 179.6°, MDA 7.3° and ADMTP 5.4°.

DISCUSSION

This technically demanding procedure gave satisfactory results in terms of axes and congruence; longer term assessment remains needed.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

A safer technique for the double elevation osteotomy in severe infantile tibia vara

Infantile tibia vara is a deformity of abrupt angulation into varus due to an affection of the postromedial aspect of the proximal tibial physis. The deformity often includes internal tibial torsion and limb length discrepancy. Gradual correction of the deformity is currently the treatment of choice for these challenging cases as it requires less invasive surgery, allows progressive and adjustable correction, permits bone lengthening if needed and achieves a more accurate correction compared to acute correction. Elevation of the depressed medial tibial condyle allows restoration of the joint architecture. Different techniques described to elevate the depressed medial tibial plateau are all technically demanding and carry potential risks of unsalvageable intra-operative complications. The aim of this study is to report the results of a safer technique for the double elevation osteotomy combined with gradual correction using the Ilizarov frame, allowing it to be more reproducible, less technically demanding and avoid those potential complications. This study included 12 limbs in 8 patients (mean age 9 years), all were classified as stage V or VI according to the Langenskiold classification. All osteotomies healed completely in all patients. The mean time in the frame was 23 weeks. The mean preoperative femoral shaft-tibial shaft angle was 36° of varus. This improved to 5° of varus. The mean preoperative femoral condyle-tibial shaft angle was 58°. This improved to 84°. The mean preoperative angle of depressed medial tibial plateau was 63°. This improved to 8°. All patients were maintaining full extension of the knee at the final follow-up, and all patients noticed a significant improvement in their gait pattern. We believe that this technique is safer and less invasive compared to traditional and even newly described techniques for elevating the depressed medial tibial plateau and correcting the deformity in severe infantile tibia vara, which will allow it to be more reproducible.

Elevation of medial tibial condyle for severe tibia vara

Clinical and radiological evidence of knee instability was used as criteria for elevation of medial tibial condyle in severe tibia vara. Restoration of tension to the exposed medial collateral ligament was used as a guide for the required amount of elevation. A second-stage proximal tibial osteotomy was performed later for correction of the remaining varus deformity. External fixators were used in all instances. Elevation of the medial tibial condyle is indicated in severe tibia vara with arrest of the medial tibial physis, in which more than a 10 degrees difference exists between valgus and varus stress radiographs with the knee in extension as compared with an opposite normal knee.

A new double elevating osteotomy in management of severe neglected infantile tibia vara using the Ilizarov technique

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.

Femoral deformity in tibia vara

BACKGROUND

Previous studies have suggested that compensatory valgus deformity of the femur is common in patients with tibia vara, or Blount disease. The availability and routine use of standing long-cassette radiographs of the lower extremities to assess angular deformities has allowed quantitative evaluation of this hypothesis.

METHODS

The cases of all patients with tibia vara, two years of age or older, seen at our institution prior to treatment, over a thirteen-year period, were reviewed. Seventy-three patients with a total of 109 involved lower limbs were identified and were classified as having either infantile tibia vara (thirty-seven patients with fifty-six involved limbs) or late-onset tibia vara (thirty-six patients with fifty-three involved limbs). Standardized standing radiographs of the lower extremity were examined to assess the deformity at the distal part of the femur and the proximal part of the tibia by measuring the lateral distal femoral angle and the medial proximal tibial angle.

RESULTS

The distal part of the femur in the children with infantile tibia vara either was normal or had mild varus deformity, with a mean lateral distal femoral angle of 97 degrees (range, 82 degrees to 129 degrees). The mean medial proximal tibial angle in these children was 72 degrees (range, 32 degrees to 84 degrees). Older children with infantile tibia vara were noted to have little distal femoral deformity, with no more than 4 degrees of valgus compared with either normal values or the contralateral, normal limb. Children with late-onset tibia vara had a mean lateral distal femoral angle of 93 degrees (range, 82 degrees to 110 degrees) and a mean medial proximal tibial angle of 73 degrees (range, 52 degrees to 84 degrees). On the average, the varus deformity of the distal part of the femur constituted 30% (6 degrees of 20 degrees) of the genu varum deformity in these patients.

CONCLUSIONS

Patients with infantile tibia vara most commonly had normal alignment of the distal parts of the femora; substantial valgus deformity was not observed. Distal femoral varus constituted a substantial portion of the genu varum in children with late-onset disease. When correction of late-onset tibia vara is planned, the surgeon should be aware of the possibility that distal femoral varus is a substantial component of the deformity.

Focal dome osteotomy for the correction of tibial deformity in children

Tibial deformity in childhood often combines torsional and angular malalignment. A focal dome osteotomy was performed, proximally or distally, in 39 tibiae in 31 patients. In 33 limbs, the primary deformity was varus (with internal torsion). The osteotomy was held with K-wires and a plaster cast. The mean age at surgery was 10.25 years and the minimum follow-up 24 months. All osteotomies united and no compartment syndrome occurred. Postoperatively, two patients (5%) had temporary neurological deficits. Thirty of 31 patients had good clinical and radiological correction of alignment. Recurrent deformity was seen in one patient with hypophosphataemic rickets.

Double-elevating osteotomy for late-presenting infantile Blount’s disease

We reviewed 34 knees in 24 children after a double-elevating osteotomy for late-presenting infantile Blount’s disease. The mean age of patients was 9.1 years (7 to 13.5).

All knees were in Langenskiöld stages IV to VI. The operative technique corrected the depression of the medial joint line by an elevating osteotomy, and the remaining tibial varus and internal torsion by an osteotomy just below the apophysis. In the more recent patients (19 knees), a proximal lateral tibial epiphysiodesis was performed at the same time.

The mean pre-operative angle of depression of the medial tibial plateau of 49° (40° to 60°) was corrected to a mean of 26° (20° to 30°), which was maintained at follow-up. The femoral deformity was too small to warrant femoral osteotomy in any of our patients. The mean pre-operative mechanical varus of 30.6° (14° to 66°) was corrected to 0° to 5° of mechanical valgus in 29 knees. In five knees, there was an undercorrection of 2° to 5° of mechanical varus. At follow-up a further eight knees, in which lateral epiphysiodesis was delayed beyond five months, developed recurrent tibial varus associated with fusion of the medial proximal tibial physis.

Three-dimensional tomography of relapsed infantile Blount's disease

Three-dimensional computed tomography reconstructions were done in the preoperative workup of five patients receiving Ilizarov correction for relapsed infantile Blount's disease. There were four girls and one boy with a mean age of 9 years 11 months. In all patients, the computed tomography reconstruction images made assessment of the deformity easier and revealed abnormalities not readily seen on plain radiographs. This information has particular relevance to medial plateau elevation using the Ilizarov frame because it is possible to correct a medial and posterior slope of the tibial plateau using this technique. Also, this imaging modality is safe, easy to do, and is a useful adjunct for planning before surgical correction of relapsed Blount's disease.

Recurrence of varus deformity after proximal tibial osteotomy in Blount disease: long-term follow-up

In a retrospective review of 74 tibial osteotomies performed for Blount disease, the patients were divided into three groups based on age and treatment. Group A (26 osteotomies), 4 years old or younger, and group B (34 osteotomies), older than 4 years, were treated the same with osteotomy and crossed pins. Group C (14 osteotomies), older than 4 years, was treated with osteotomy and external fixator. At 6 years of follow-up, the recurrence of varus deformity was 46%, 94%, and 72% in groups A, B, and C, respectively. There was no correlation between recurrence of varus deformity and preoperative deformity angle or degree of surgical correction. Fixation with crossed pins or external fixator was not a factor. Surgery at 4 years old or younger and correction of the postoperative deformity angle in valgus may obviate recurrence of varus deformity in Blount disease at long-term follow-up.

Use of Orthofix T-Garche fixator in late-onset tibia vara

The treatment of late-onset tibia vara has not been well described. High tibial corticotomies and use of the Orthofix T-Garche fixator were performed on 11 children (14 knees) with late-onset tibia vara. The average age at surgery was 12 years, and follow-up was 2 years. Minimum follow-up was until completion of growth. Angular deformities were measured by using the tibiofemoral angle, metaphyseal-diaphyseal angle, and the mechanical axis both preoperatively and on removal of the fixation device. Union was accomplished in 7-12 weeks, and the total time with the appliance averaged 9 weeks. Complications included superficial pin-tract infections (two) and a transient nerve palsy (one). High tibial corticotomy followed by corrective gradual distraction osteosynthesis by using the Orthofix T-Garche fixator is effective in correcting angular deformity and alleviating knee pain. Advantages of this technique include ease of application, immediate weight bearing, and minimal discomfort with hardware removal. Disadvantages include difficulty in obtaining adequate radiographs with the anteriorly based fixation device, pin-tract infections, and the high degree of patient compliance needed.

Genu Varum in Children: Diagnosis and Treatment

Genu varum is a relatively common finding in children. Physiologic bowing, which is seen most often, has a well-documented favorable natural history. Idiopathic tibia vara is the most common of the pathologic conditions that are associated with bowed legs; treatment strategies vary with the patient's age and the stage of disease and deformity. Genu varum may also accompany systemic conditions, such as achondroplasia, vitamin D-resistant rickets, renal osteodystrophy, and osteogenesis imperfecta-all of which can result in short stature. Indications for intervention are not always well defined. A rare disorder, focal fibrocartilaginous dysplasia, usually requires no treatment. Standing radiographs of the entire lower limbs are necessary for surgical planning, as the deformity can sometimes affect the distal femur rather than the proximal tibia. Restoration of the mechanical axis of the limb is the principal goal of treatment; the particular type of internal fixation is of secondary importance.