Acute correction of severe complex adolescent late-onset tibia vara by minimally invasive osteotomy and simple circular fixation: a case series with 2-year minimum follow-up

Severe complex neglected infantile Blount disease acute correction by Ilizarov frame: A case report

INTRODUCTION

Blount disease is a disorder causing three proportions of deformity, including varus deformity, procurvatum deformity, and internal tibial rotational deformity. The standardized treatment remains controversial despite extensive reviews. The application of Ilizarov external fixators for circumspect corrections is established. The SCARE 2023 criteria have been followed in reporting the case report.

CASE PRESENTATION

We present the case of a nine-year-old girl who's complaining about bowing on both of her knees. From the examination, we found that the metaphyseodiaphyseal angle of both knees was 50 degrees. On the right knee, there is 125 degrees of procurvatum deformity and 115 degrees of deformity on the left knee. After performing deformity correction with the Ilizarov application, there's clinical improvement in the patient.

CLINICAL DISCUSSION

Some experts advise using physeal distraction to manage the deformity in order to achieve correction. The limited popularity of physeal distraction technique may be attributed to the risks of premature closure of the growth plate that we manage to avoid. The Ilizarov frame provides maximum adjustability for aligning all planes, making it suitable for treating severe deformities. Secure fixation, improved patient mobility, being able to assess patient alignment in a functional standing position, and precision.

CONCLUSION

Acute correction and fixation using circular frames as a treatment option for Blount disease show positive outcomes without any significant complications.

Opening-Wedge High Tibial Osteotomy with a Cancellous Strut Bone Allograft Is Inadequate for Achieving Satisfactory and Lasting Correction in Neglected Infantile Tibia Vara: Results from a Cohort of 29 Patients

Background: Infantile tibia vara (ITV) is a rare proximal tibia deformity in infancy, leading to progressive knee varus. High tibial osteotomy is commonly practiced but has high recurrence rates. This study analyzed factors affecting treatment failure and recurrence in children undergoing opening-wedge high tibial osteotomy (OWHTO) for ITV. Methods: We retrospectively studied children with ITV who had OWHTO with a press-fit cancellous bone allograft between 2000 and 2020, with ≥2-year follow-up. Outcomes included recurrence (knee varus with tibiofemoral angle > 10°), complications, and reintervention. Results: We analyzed 39 knees in 29 patients (mean age: 4.8 ± 1.9 years; median follow-up: 7.4 years). Recurrence occurred in 22 cases (56%). Age at surgery significantly influenced recurrence, with rates of 16% before age 5 versus 95% later (hazard ratio: 12.0, p = 0.001). Langenskiöld stage also affected recurrence (β-coefficient: 2.7, 95% C.I. 1.0-4.5, p = 0.002; pseudo-R-squared: 0.50, p = 0.001), with recurrence in all stage IV or higher cases. Conclusions: Early diagnosis and treatment before age 5, ideally with Langenskiöld stage III or lower, are crucial for stable correction with OWHTO alone. Late, high-grade ITV may require combined, acute or gradual, and/or staged correction. Further evidence is needed for optimal management.

The Outcome of Corrective Transverse Osteotomy in Paediatric Tibia Vara

Background

Tibia vara is a three-dimensional deformity of the proximal tibia, varus, internal tibial torsion and procurvatum. It is an uncommon deformity with the surgical management varied. This study describes the outcomes of tibia vara management using a corrective transverse osteotomy in one centre.

Materials and methods

A retrospective cohort study was conducted involving eight patients with tibia vara (ten tibias). Consent was obtained for treatment using an acute corrective osteotomy. Measurements of Drennan's angle, the tibiofemoral angle (TFA) and the procurvatum angle were measured preoperatively and postoperatively both just after surgery and at 1 year. A validated questionnaire-the Knee Outcome Survey of Activity Daily Living (KOS-ADL)-was utilised to assess clinical function and outcome. Also recorded were the intraoperative and postoperative complications, the radiological lower limb alignments, the union rate and the recurrence of deformity.

Results

There were eight patients involved in this study with a total of ten tibias (six with unilateral tibias and two with bilateral tibias). The mean age of the patients was 11.3 years old (ranging from 8 to 15 years old) with most males (five males and three females). The affected tibias were 6 right sided and 4 left sided. Measurements of Drennan's angle, the TFA and the procurvatum angle were used to determine lower limb alignment preoperatively, postoperatively (immediate post-surgery) and at 1-year follow-up. Functional parameters were measured using the KOS-ADL. A descriptive analysis between the preoperative and postoperative variables was done. The mean for Drennan's angle was 21.6 (±5.2) preoperatively, 3.6 (± 2.3) postoperatively and 4.9 (±2.8) at 1-year follow-up. The TFA was improved from 22.6 (±6.1) preoperatively to 3.5 (±2.8) postoperatively and 4.4 (±2.0) at 1-year follow-up. The procurvatum angle was improved preoperatively from 8.20 (±7.5) to 2.40 (±2.5) postoperatively and 2.20 (±2.5) at 1-year follow-up. At the latest follow-up, the ADLS mean score was 98.5 (±2.6) while the SAS mean score was 97.5 (±3.3). The mean length follow-up period was 2 years (ranging from 1 year to 3 years). None of the patients developed postoperative complications with all achieving union without deformity recurrence in the period of observation.

Conclusion

This study revealed that acute correction via a corrective transverse osteotomy of the tibia is a safe and effective method in treating tibia vara.

How to cite this article

Irwan MA, WH Chan, Anuar Ramdhan MI, et al. The Outcome of Corrective Transverse Osteotomy in Paediatric Tibia Vara. Strategies Trauma Limb Reconstr 2024;19(2):111-117.

Recurrence and Complication Rates of Surgical Treatment for Blount's Disease in Children: A Systematic Review and Meta-Analysis

BACKGROUND

Blount's disease is a growth disorder of the proximal tibia that causes progressive genu varum in children. Surgical treatment is recommended if the deformity worsens, but which intervention is best remains controversial. This study aims to identify factors influencing outcomes and determine the most effective surgical approach.

METHODS

A systematic review was conducted of studies published before January 2022.

RESULTS

In total, 63 retrospective studies with CEBM IIIb/IV levels were included (1672 knees in 1234 patients). The most commonly reported treatment was acute correction via osteotomy (47%), followed by hemiepiphysiodesis (22%) and gradual correction (18%). Combined procedures were reported in 13% of cases. The overall recurrence rate was 18%, with a significant difference when comparing the recurrence rates after gradual correction with those after hemiepiphysiodesis (7% and 29%, respectively). Major complications beyond recurrence were observed in 5% of cases. A meta-analysis of the available raw data showed a significantly increased recurrence rate (39%) among treated children who were between 4.5 and 11.25 years of age and were followed for a minimum follow-up of 2.5 years.

CONCLUSIONS

Overall, poor evidence with which to establish an optimal treatment for Blount's disease was found. This study remarked on the need for early diagnosis, classification, and treatment of infantile tibia vara, since a significant rate of recurrence was found in neglected cases.

Osteotomy treatments and post-operative fixations for Blount disease: A systematic review

Background

Blount disease is a developmental abnormality characterized by abnormal ossification of proximal tibia, resulting in lower limb deformities with tibia vara. The condition worsens into knee deformity, gait abnormalities, and premature medial compartment osteoarthritis if left untreated. Managements of those deformities have also advanced in line with the understanding of the deformities. Without proper care management, they could lead into residual and translational deformities, increase of recurrence, and complicate the revision surgery.

Methods

This study aims to enrich our understanding about the recent advances of treatments for Blount disease by reviewing 15 articles published with osteotomy surgeries and fixation methods. We also highlight many aspects of pre-operative assessment and planning, post-operative complications and recurrence, patients' follow-up, and overall satisfaction from patients’ self-assessment.

Results

The scope of this review is considered small but still covers various efforts to manage Blount diseases, including single-stage double osteotomy, grafting fibular fragments into tibia, two comparison studies, two unique case study, and experimental techniques to manage special cases requiring novel procedures.

Conclusion

Careful surgical planning, acute or gradual correction options, and the use of fixator should be tailored to individual cases.

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Blount disease management is preferable before age four years old.

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Osteotomy surgeries and fixation methods is recommended for Blount disease.

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Mostly satisfactory outcome was reported using this methods.