Tibia Vara
A Critical Review”
ANDERSLANGENSKI~M.D.,
LD, H0n.F.R.C.S.
Downloaded from https://journals.lww.com/clinorthop by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3JvjgSxPcaSI2J7OsPDdQ38zHtxiiWRHpkZOEfRko3LU= on 08/29/2019
Since Blount’s classic article was published in
1937, many authors have contributed to t h e
knowledge of tibia vara. Tibia vara is character-
ized by an abrupt angulation of the tibia into varus
in the proximal end. The term does not reveal the
etiology of the anatomic deformity, which may be
developmental, posttraumatic, or postinfectious.
There a r e four types: (1) Infantile tibia vara
(Blount’s disease) is a developmental condition
that manifests itself between the ages of one and
four years. Roentgenographic findings are typical.
(2) Adolescent tibia vara is caused by partial clo-
sure of the growth plate after trauma or infection
between the ages of six and 13 years. (3) Late-
onset tibia vara appears in obese black children
between the ages of six and 15 years. The roent-
genographic findings differ from those of the other
types, but the histopathology is similar to infantile
tibia vara. (4) Tibia vara may also be caused by
focal fibrocartilaginous dysplasia. Eight cases in
which there was an area of fibrocartilaginous dys-
plasia in the medial aspect of the tibia have been
reported in the literature. Several problems have
been encountered in the treatment of infantile
tibia vara.
Since E r l a ~ h e r reported
’~ the first case of
infantile tibia vara in 1922 and Blount’ gave
a description of this condition in 1937, many
authors have contributed to the knowledge
about tibia vara. There have, however, been
controversies in this field. Since Blount’s re-
port in 1937,’ the term “tibia vara” has been
* By invitation.
From T h e Orthopaedic Hospital of T h e Invalid
Foundation. Helsinki. Finland.
Reprint requests t o Anders Langenskiold. M.D.,
Sikgranden 7 D. 02 170 ESBO. Finland,
Received: October 17. 1988.
195
associated with an anatomic condition char-
acterized by a n abrupt angulation of the tibia
into varus deformity in the proximal end of
the bone. As Blount6 pointed out in 1966,
the term does not tell anything about the eti-
ology of the anatomic deformity. Like coxa
vara, tibia vara may be developmental, post-
traumatic, or postinfectious in origin. When
writing about tibia vara, the first task is to
differentiate between the cases in which the
anatomic deformity has been produced by
completely different causes. Especially when
the deformity has been successfully treated,
the cause can usually not be determined
from roentgenograms taken after the growth
period, a fact that may cause confusion.
Blount’ described two types of the condi-
tion, including an infantile type that appears
when the child begins to walk and an adoles-
cent type that develops between the ages of
six and 13 years. The latter is a completely
separate entity in which the changes are sec-
ondary to trauma or infection. Two addi-
tional types of the deformity have been re-
ported recently. These are late-onset tibia
Vara10.5Y.6 I
and tibia vara caused by focal fi-
brocartilaginous dy~plasia.~,’.~’
Blount’ called the infantile type “osteo-
chondrosis deformans tibiae” but, because
osteonecrosis has never been found in this
condition, the term has been considered un-
satisfactory.8 Instead, the following condi-
tions causing a n abrupt angulation in the
upper end of the tibia in growing individuals
may be defined: ( I ) Infantile tibia vara
(Blount’s disease) is a developmental condi-

196 Lanaenskiold
tion usually not difficult to diagnose from
roentgenograms during the growth period
after infancy. (2) Adolescent tibia vara is
caused by partial premature closure of the
medial part of the proximal growth plate of
the tibia after trauma or infection. ( 3 ) Late-
onset tibia vara is a condition appearing
mainly in obese black children between the
ages of six and IS years without a history of
trauma or infection. The roentgenographic
findings differ from those of the other types,
but the histopathology is similar to that of
infantile tibia vara. (4) Tibia vara caused by
focal fibrocartilaginous dysplasia was first re-
ported in 198S.4 The deformity is associated
with an area of fibrocartilaginous dysplasia
in the medial aspect of the proximal part of
the tibia.
DIFFERENTIAL DIAGNOSIS
During the growth period, it is usually pos-
sible to differentiate the types of tibia vara
listed above on the basis of the roentgeno-
graphic findings and the history.
A matter of practical importance is the
early differentiation between infantile tibia
vara and physiologic bowlegs before the ap-
pearance of the typical roentgenographic
changes of inhntile tibia vara. In 1982, Le-
vine and D ~ e n n a ndefined
~~ the metaphy-
seal-diaphyseal angle (the proximal tibial
metaphyseal deformity). On the basis of a
study of 88 extremities, those authors stated
that the metaphyseal-diaphyseal angle
allows accurate early diagnosis of bowleg de-
formity, as well as accurate assessment of its
progression into infantile tibia vara. Fore-
man and Robertson17 confirmed that mea-
surement of the metaphyseal-diaphyseal
angle may allow early diagnosis and treat-
ment of tibia vara. O’Neill and MacEwen4’
also found that a more acute proxinial tibial
angulation than distal femoral angulation is
a possible prognostic sign that bowing is
likely to persist. Salenius and VankkasOmea-
sured the tibiofemoral angle in I279 children
in Finland and defined the development of
Clinical Olthopaeclics
and Related Research
physiologic bowleg of the newborn into
marked physiologic valgus during the first
three years of life of the normal child.
Vitamin-D-resistant rickets is easily dif-
ferentiated from all the types of tibia vara
listed above by the presence of changes in the
femora and other bones.
INFANTILE TIBIA V A K A
(BLOUNT’S DISEASE)
EPIDEMIOLOGY
Judging from the number of large series
published on black children with infantile
tibia vara,?.l I .20.24.46
white children seem to be
less commonly affected than black children.
The series of 61 cases reported by Lan-
genskiiild and Riska” was seen between the
years 1946 and I963 in a hospital where al-
most all cases of this kind in Finland were
treated. In Sweden, pediatric orthopedics has
been less centralized for decades than in Fin-
land. When Hansson and Zayer’” reported
all cases of infantile tibia vara seen in all or-
thopedic, pediatric, and roentgenologic de-
partments throughout Sweden, 8.5 cases were
diagnosed as Blount’s disease. Articles deal-
ing with this condition in the 1980s indicate
that it was not uncommon in the white pop-
ulation in North America.’6.’y~41.53
ETIOLOGY
Occasional familial occurrence of the con-
dition has been reported by several au-
thors.? I i 1 5 ( 4 Schoenecker 01 a/.” reported 32
patients. of which 14 had a family history of
the disease. Sibert and Bray” studied the oc-
currence of the condition in a family and
suggested that it may be inherited as an au-
tosomal dominant condition with variable
penetrance. Considering that roentgeno-
graphic changes typical for infantile tibia
vara have never been seen before the age of
one year and seldom before the age of two.
the condition is developmental rather than
congenital. Children in whom infantile tibia
vara is seen are often overweight. Although
Number 246
September, 1989
this has been pointed out by many authors, it
could not be shown to be the main etiologic
factor. However, the fact that early correc-
tion even for severe deformity usually leads
to a permanent cure, whereas neglect of such
deformity is usually followed by progression,
is a strong argument that abnormal pressure
on the medial part of the proximal tibia1
growth plate plays a role in the pathogenesis
of infantiIe tibia vara. The histopathoiogic
finding^^.''.'^ also speak in favor of this idea.
There are reasons to agree with Bathfield and
Beighton,’ who stated that it is possible that
Blount’s disease is multifactorial in etiology.
ROENTGENOGRAPHIC
CHANGES
In 1937, Blount” defined the infantile type
of tibia vara as a deformity with an abrupt
angulation just below the proximal epiphy-
sis, an irregular epiphyseal line, a wedge-
shaped epiphysis, and a prominent, beaklike
recurving medial metaphysis. In 1952, Lan-
genskiold2‘ observed in 17 cases that the
roentgenographic appearance of the infantile
type undergoes changes with increasing mat-
uration of the skeleton. The changes in the
proximal end of the tibia during the growth
period may be classified in six stages (Fig. 1).
Studies of numerous roentgenograms
taken of 80 legs in 6 I cases of infantile tibia
vara seen between the years 1946 and 1963
gave Langenskiold and Riska” no reason in
1964 to change the description of the stages
given in 1952. Although intermediate stages
may be seen, many authors have confirmed
the appearance of the six stages of infantile
tibia vara.
It must be stressed that the development
from Stage I1 to Stage IV in Blount’s disease
is a typical sequel of partial and often tempo-
rary blockage of ossification in the proximal
end of the tibia. This is proven by the histo-
pathologic finding^'.'^.'' and by the appear-
ance of corresponding roentgenographic
phenomena in cases of healed osteomyelitis
or bone tuberculosis.2x In 1964,35the use of
the word progression for the development
from Stage I or I1 to Stage IV gave a wrong
Tibia Vara 197
FIG. I . Diagram of the roentgenographic
changes seen in infantile tibia vara and their de-
velopment with increasing age.
idea of what is happening in the growing
bone. The description of Stages I-IV as the
development of roentgenographic changes
with increasing age has nothing directly to do
with prognosis and possible results of treat-
ment. Many legs osteotomized in Stage I1
have passed Stages 111 and IV and reached
maturity without recurrence of deformity as
was illustrated in 1964? The phenomenon
that the bony epiphysis gradually develops
an extension into the step in the metaphysis
(Stage I1 developing into Stage 111 and Stage
IV) is not a sign of progression of disease as
some authors have recently believed.3xThus,
Stages I-IV do not depict the aspects of in-
fantile tibia vara from mild to moderate to
severe as suggested in 1982.’’
Mitchell cf aL4’correctly pointed out that
the six roentgenographic stages are not re-
lated to the degree of deformity. On the other
hand, those authors regarded as Stage VI a
reproduced roentgenogram showing a Stage
I11 tibia. Mitchell et ~ 1 . ~defined
‘. the epiphy-
seal-metaphyseal angle as a quantitative
measurement that can be used to grade the
seventy of Blount’s disease. The values for
this angle depend on the distance of the me-
taphyseal beak from the epiphyseal nucleus.
Judging from that series, estimation of that
angle seems to be of value for grading sever-
ity in Stages 1-111. Development into Stages
V and VI as a rule is followed by increasing
varus deformity and indicates progression of
disease.
Figures 2A-2C show how the phenome-
non corresponding to the development of
Stage 111 into Stage IV in infantile tibia vara
was seen in a tibia as a sequel of neonatal

198 Langenskiold
FIGS.2A-2C. Roentgenograms of a tibia show-
ing sequels of neonatal osteomyelitis in the proxi-
mal end. (A) At the age of three years, there was a
defect in the metaphysis. The shape of the epi-
physeal bony nucleus was normal. The phenome-
non corresponds to Stage 111 in infantile tibia vara.
(B) At the age of six years, a pluglike extension of
the bony nucleus was filling out the defect in the
metaphysis. The development of this state corre-
sponded to the development from Stage 111 to
Stage IV in infantile tibia vara. (C) At the age of 12
years, the bone had grown normally although the
presence of the step could be seen in the growth
zone. Formation of a bone bridge was expected
but did not occur.
osteomyelitis. This tibia grew normally in
spite of the presence of the step in the growth
plate. The same phenomenon has been dem-
onstrated experimentally in the rabbit tibia
after blockage of ossification in the medial
part of the proximal growth plate.” A similar
Clinical Onhopaedics
and Related Research
development can sometimes be seen in the
proximal end of the femur in Perthes’ dis-
ease. Phenomena corresponding to Stages V
and VI have also been seen after osteomye-
litis.”
HISTOPATHOLOGY
The histopathologic changes in the medial
part of the affected growth plate and the cor-
responding part of the metaphysis in infan-
tile tibia vara were studied in one case by
Blount,5 in nine cases by Langenskiold,’h
and in six cases by Golding and McNeil-
Smith.” They found the following changes:
( 1 ) islands of densely packed cartilage cells
showing a greater degree of hypertrophy than
that corresponding to their position in the
growth plate; (2) islands of almost acellular
fibrous cartilage; and ( 3 ) abnormally large
groups of capillary vessels. The changes
imply a delayed ossification of cartilage, both
in the medial part of the metaphysis and the
corresponding part of the epiphysis. This
causes progression of varus deformity for as
long as blockage of ossification is present and
the bone continues to grow in the lateral part
of the growth zone. It is known that cartilage
tissue reacts to abnormal pressure with ne-
crosis,” and many types of experiments have
indicated that dead or damaged cartilage is
far more slowly ossified than cartilage col-
umns calcifying in the normal way. ‘K’’,’’A~
The irregularity of the medial part of the
growth zone with isolated islands of bone in
Stage I11 is not a consequence of fragmenta-
tion but of irregular advance of ossification.
Necrosis of bone has not been seen in speci-
mens from cases of Blount’s disease. Brad-
way rf u1.’ stated that, surprisingly, micro-
scopic studies of articular cartilage in
Blount’s disease are not available in the liter-
ature. Biopsy of the pathologic part of the
growth plate and the metaphysis does not
mean damage affecting further growth when
the bony epiphysis i s not touched. However.
biopsy of the articular cartilage is dubious as
far as damage to the patient is concerned.
Number 246
September, 1989
TABLE 1. Methods Used in the Treatment of Infantile Tibia Vara and Their Indications
Met h(1d.s
I. Brace
2. Osteotomy of the tibia and the fibula with
correction of varus and inward rotation
deformity
3 . Osteotomy of the tibia and the fibula and
epiph ysiodesis
4. Resection of an epiphysiometaphysial bone
bridge
5 . Osteotomy and elevation of the medical tibial
condyle and epiphysiodesis of the lateral
condyle and the proximal end of the fibula
TREATMENT
Table I shows the different methods used
in the treatment of infantile tibia vara.
The therapeutic effect of braces in roent-
genographically definite Blount's disease has
not been convincingly shown. However,
Blount' stated in 1966 that recovery from
infantile tibia vara without treatment has
been recorded by several authors, and the
number of successful cases justifies the use of
the brace before the age of two years. Schoe-
necker PI reported a good result from
brace treatment in five of six extremities.
However, the average patient age at presenta-
tion was one year and ten months.
Osteotomy of the tibia and the fibula with
correction of varus and inward rotation de-
formity has been commonly used. Judging
from the material reported by Langenskiold
and Riska,3s the chance for a cure after one
osteotomy is small when a patient is seen for
the first time after the age of eight years.
However, roentgenographically marked in-
fantile tibia vara with a deformity more than
10" should be corrected by osteotomy with-
out delay in any child older than two years
of age.
There have been different opinions re-
garding the technique of performing tibial
osteotomies in children. Some authors have
Tibia Vara 199
Indications
Before age 2 years
Without delay in children older than 2 years with
marked roentgenographic changes. When
performed after 8 years of age, recurrence
commonly requires additional measures.
In children aged 9 to 14 years with partial closure
of the growth plate but not marked ligamentous
laxity.
In selected patients aged 9 to 1 1 years with small
bone bridges
Indicated when excessive ligamentous laxity in the
knee caused by extreme sloping of the medial
condyle is present. Final correction of varus by
osteotomy of the tibia and the fibula is usually
necessary in a separate operation.
reported a high incidence of complications
after subcondylar osteotomies. Steel ef d s 8
reported that 20% of the patients developed
neurologic complications in 46 tibial osteot-
omies in children. Of these, 75% were closing
wedge osteotomies. Mycoskie4' reported one
or several complications in 20 of 32 children
(63%)who had osteotomies around the knee.
Open wedge osteotomy was the most com-
mon procedure. Van Olm and Gillespie" re-
corded 76 complications in 37 of 63 children
who had proximal tibial osteotomies. Those
authors found the complication rate unac-
ceptable. Hensinger" referred to a 76% com-
plication rate in 66 tibial osteotomies in chil-
dren, and Ferriter and Shapiro16 had ten
complications in 77 osteotomies in cases of
infantile tibia vara.
Schoenecker et treated 27 cases of
Blount's disease by osteotomy. In those
cases, various techniques of tibial osteotomy
were used, and none seemed to have a partic-
ular advantage. However, Roy and Robin-
reported a low incidence of complica-
tions in a series of children treated by dome
osteotomies of the tibia. Those authors con-
cluded that the technique of osteotomy was
important for avoiding complications, and
this is in agreement with the experience of
the present author. In 118 tibial dome oste-

200 Langenskiold
FIGS.3A A N D 3 8 . ( A ) Correction of varus de-
formity by d o m e osteotomy of the tibia and
oblique osteotomy of the fibula in a child aged 3
years. (B) The same bone 1.5 years after osteot-
omy. The arrows show the osteotomy site and the
growth arrest line formed aftcr the operation.
(Roentgenograms corresponding to Figures 3A
and 3B were published in 1952.")
otomies in a series of 7 1 cases of tibia vara,3i
the only kind of complication was insuffi-
cient correction of varus deformity. Later ex-
perience from many cases of infantile tibia
vara has confirmed the safety of dome oste-
otomy as it was performed in the reported
series.' The method was modified by F.
Langenskiold3" after his description of
curved osteotomy for this condition in 1928.
The following technique lir tibia1 and tib-
ular osteotomy in cases ofinfantile tibia vara
is rcconimended (Figs. 3 A a nd 3 B ) . A n
oblique osteotomy of the fibula is performed
through a small incision a little above the
middle one-third of the diaphysis. The prox-
imal part of the tibia is widely exposed an-
teromedially through a longitudinal incision
through the skin, subcutaneous fat. and peri-
osteuni up to the site of the abrupt angula-
tion deformity. The periosteum is detached
from the bone by blunt preparation, and re-
tractors are inserted between the bone and
' epiphysiodesis in the other leg.
the periosteum from both sides. The osteot-
o m y of the tibia is then performed subperi-
osteally within a sheath of periosteum that is
Clinical Oiihopaedlcs
and Related Research
protecting other soft tissues. With an osteo-
tome, the dome-shaped osteotomy is per-
formed with the convexity at the diaphyseal
fragment. It can be carried out with a spoon-
shaped osteotome or with a narrow straight
one. The lateral part of the osteotomy should
be a little more proximal than the medial
part. This allows locking of the osteotomy
surfaces without internal fixation. The dome
shape of the surfaces allows simultaneous
correction of varus and the deformity of in-
ternal rotation that is regularly present. The
sliding of the diaphyseal fragment medially
prevents bayonet deformity of the knee. The
varus should be corrected to a valgus posi-
tion corresponding to the normal position
for the age of the child.50 The tourniquet is
released. and the wounds are closed when
bleeding has subsided. A padded plaster cast
is applied from the toes to the groin, and the
cast is split to the last thread anteriorly. To
determine that correction of deformity is
maintained in the cast, roentgenograms are
taken on the operating table. Immobilization
is maintained for at least two months. In pa-
tients aged tive to 14 years with more than
10" varus. an open growth plate, and no liga-
mentous laxity. a simple osteotomy is indi-
cated but later additional procedures may be
necessary.
Dietz and Weinstein" used spike osteot-
omy with a low rate of complications in
Blount's disease. I t was performed with cir-
cumferential periosteal stripping and with-
out internal fixation. The present author has
used spike osteotomy in the femur with good
results in other conditions.
Osteotomy of the tibia and the fibula and
epiphysiodesis gives good results if there i s a
bone bridge (Stage VI) but no definite liga-
mentous laxity. Patients suitable for these
procedures are usually in the age group of
nine to 14 years. At this age, moderate loss of
length of the tibia can be compensated by
The first case of successful resection of an
epiphysiometaphysial bone bridge was re-
ported by the author in 1967.'" This type of
Number 246
September, 1989 Tibia Vara 201

FIGS.4A-4D. Roentgenograms of an infantile tibia vara

first treated by osteotomy and later by bone bridge resection
and implantation of fat after recurrence of the deformity. (A)
The tibia in Stage IV-V at age nine years before osteotomy.
Compare with postinfectious adolescent tibia vara seen in
Figure 5A. (B) Recurrence of varus with bone bridge in Stage
VI at age 1 1 years. Arrows show the bone bridge and growth
arrest line formed after osteotomy. (C) Eighteen days after
bridge resection at age I I . Arrows show metal markers im-
planted at surgery in the epiphysis and metaphysis. (D) Be-
fore the end of the growth period at 17 years of age, the tibia
grew 3.5 cm at the proximal end. Note the position of the
metal markers (arrows).The varus deformity was corrected
by growth. Compare with Figure 5C.

operation is also suitable for some cases of
infantile tibia vara in Stage V l . A detailed
description of the operation was given in
1983.’’ The author has used this procedure
in some cases of Blount’s disease, and it has
also been used by others for this condition
with varying results.’ ?’ ” 4 4 ’’ When fat is
used as an interposition material, a thick
layer of compact bone is formed around the
implant.74Several authors have used silastic
for this purpose, but this material is not
always available.‘ When six different inter-
position materials for this operation were
tested in 123 rabbits,’ fat was the most suit-
able and methylmethacrylate the least suit-
able. Kumar and Pizzutillo’5 alleged that
physeal bridge resection remains at the ex-
perimental stage in this disease. It must be
pointed out that resection of a large periph-
eral bone bridge often gives a poor result. In
Stage VI of infantile tibia vara, the bridge is
always peripheral and in most cases so large
that osteotomy and epiphysiodesis would
give a better guarantee for a good result. The
case illustrated in Figures 4A-4D is an exam-
ple of an unusually favorable indication for
 Clinical Orthopaedics
202 Langenskiold and Related Research

FIGS.5A-5C. Roentgenograms o f a n adolescent tibia vara caused by osteomyelitis in the medial part of
the proximal end of the bone at age seven years. (A) Before bridge resection at age eight years. Arrows
show the bone bridge and growth arrest lines formed in the tibia and in the femur at the acute stage of
osteomyelitis. Compare with infantile tibia vara in Figure 4A. (B) A tomograph taken seven days after
bridge resection and implantation of fat. Arrows show metal markers implanted at surgery and the
growth arrest line. (C) At 16 years of age, at the end of the growth period, the tibia had grown 7 cm at the
proximal end after surgery. The arrows show the metal markers and the growth arrest line formed at
acute osteomyelitis. After successful treatment, the type of the original growth disturbance cannot be
defined in the adult (compare with Fig. 4D). The varus deformity was corrected by growth.

this procedure in infantile tibia vara. An ex-
ample of the same operation in adolescent
tibia vara is seen in Figure 5 .
Osteotomy and elevation of the medial
condyle and epiphysiodesis of the lateral
condyle of the tibia and the proximal end of
the fibula are indicated when there is exces-
sive ligamentous laxity in the knee caused by
extreme sloping of the medial condyle (Figs.
6 and 7A). This condition is seen only in
neglected cases in Stages V or VI. Sloping of
the medial condyle in the roentgenogram is
no indication for this procedure when a thick
articular cartilage and a large medial menis-
cus still prevent marked ligamentous laxity.
This is clearly demonstrated by the course
seen in the case illustrated in Figures 4A-4D.
The value of arthrography showing the state
of the joint has been demonstrated.' 2 . ' 5 . 2 h . 3 5
The technique of this procedurc was de-
scribed in detail in 1964.35Usually final cor-
rection of varus deformity by ostcotomy of
the tibia and the fibula in a separate opera-
tion is indicated. The author and his col-
leagues have performed this procedure in
only five legs within a period of30 years. The
results at long-term follow-up examination
are shown in Figures 7B and 7C. It must be
pointed out that reefing of collateral liga-
ments was not carried out in these cases. In
the patient illustrated in Figures 6 and 7, the
knecs were completely stable and their mo-
bility was normal at the age of 4 I years.
Elevation of the medial condyle has been
Number 246
September. 1989 Tibia Vara 203

carried out in cases of infantile tibia vara in

late stages by several authors with encourag-
ing I I .38.47.49.5?.59
Siffert” performed
intraepiphyseal osteotomy in a child aged six
years. The present author has not found indi-
cations for this procedure.

PROGNOSIS
The prognosis for avoidance of later os-
teoarthritis of the knee should be excellent
for every child seen before Stage V or VI,
provided that regular follow-up examina-
tions and indicated additional procedures are
carried out. In a previous series.” osteoto-
mies were performed before the age of eight
years in 51 legs. Of these, 44 remained
straight after the first osteotomy. However,
in the seven legs requiring two or more os-
teotomies, the first correction was considered
insufficient. Schoenecker et ul.” treated 23 FIG. 6. Photograph showing a girl with ne-
extremities surgically before five years of age glected bilateral infantile tibia vara in Stages V-VI
at age nine years.
and 21 extremities after five years. Of the
patients treated with surgery before five
years, 83% had a good result after one correc- was partial premature closure of the proxi-
tive osteotomy. In the black population of mal growth plate between the ages of six and
North America, a more malignant course of 13 years. The partial closure of the plate ap-
the condition and poorer results have been re- peared without the preceding changes of the
corded” than in European population^."'^^^^^" shape of the epiphysis or the metaphysis. The
Treating 47 tibiae in a predominantly non- only factor this condition has in common
white population, Loder and Johnston’9 found with infantile tibia vara is the abrupt angula-
Stages I-VI at an earlier age than in the series tion into varus at the proximal end of the
reported by Langenskiold and R i ~ k aIt. ~must
~ bone. The condition is usually unilateral.
be stressed that the development from Stages I Spontaneous regression has been seen but is
and 11 into Stage IV may take place without rare. In contrast to Stage VI in infantile tibia
recurrence of varus after corrective osteotomy. vara, the bony bridge is usually not very
At Stage VI, simple osteotomy does not cure large. Thus, the treatment of choice should
the condition irrespective of age. be resection of the bridge and implantation
Figures 6 and 7 show that the prognosis for of interposition material, preferably adipose
a knee with infantile tibia vara may be good tissue. Figures 5A-5C show an example of
even when treatment is begun in a severely adolescent tibia vara caused by osteomyelitis
neglected patient. treated in this way.

ADOLESCENT TIBIA VARA LATE-ONSET TIBIA VARA

In the cases called adolescent tibia vara by
Blount,s Langenskiold,’6.’0 and Langen-
skiold and R i ~ k a the
, ~ ~etiology has been
trauma or infection. In those tibiae, there
The term “late-onset tibia vara” was first
used by Thompson et (11. in 1984.h0The con-
dition had not been reported before. Those
authors reviewed the clinical and roentgeno-
 Clinical Orthopaedics
204 Langenskiold and Related Research

FIGS.7A-7C. Roentgenograms of the same patient seen in Figure 6 . ( A ) The right tibia in Stage V at
age nine years. On both tibiae. three operations. including elevation of the medial tibia1 condyle, were
performed before age 15 years. The case was reported in 1964.j5 ( B ) Roentgenogram showing the right
knee at age 41 years. A n ostcophyte is seen in the distal end of the right femur. There were no clinical
symptoms of ostcoarthritis. (C) Roentgenogram ofthe left knee at age 41. There are no osteophytes or
other signs ofosteoarthritis. At age nine, this knee was similar to the right knee, as seen in Figure 7A.

graphic characteristics of I 1 children, t h e pathogenesis similar to those of the infantilc

majority black, with a clinical onset o f
marked deformity at six to 14 years of age.
There was obesity a n d slowly progressive
genu varum deformity. Roentgenographi-
cally the epiphyses were wedge shaped owing
to medial flattening, a n d the growth plates
were irregular in thickness. T h e histopatho-
logic similarities in one late-onset case de-
scribed by Thompson ct u / . . ~ "two cases de-
scribed by Wenger 6'1 ~il.."'a n d three cases
reported by Carter Cf u/.'" t o those found in
infantile tibia vara5.".'" suggest that late-
onset tibia vara may have a n etiology and
type.
Wenger ('1 ul." pointed o u t that six of
seven patients had significant symmetrical
physiologic varus in early childhood that
corrected spontaneously although not com-
pletely o n the side that subsequently devel-
o p e d late-onset tibia vara i n adolescence
(Fig. 8). This figure shows the widening of
the medial part of the growth plate, which is
different in shape from that seen in the in-
fantile type and quite different from the par-
tial closure of the plate seen in adolescent
tibia vara. T h e treatment is osteotomy o f t h e
Number 246
September. 1989 Tibia Vara 205

tibia and the fibula. When this is performed

during the growth period, there is a risk of
recurrence.'"

TIBIA VARA CAUSED BY FOCAL

FIBROCARTILAGINOUS DYSPLASIA
Three cases of this rare type of tibia vara
were first reported from Australia by Bell ct
in 1985. In 1988, Bradish cf a/.' reported
five cases from Great Britain. The only factor
these cases have in common with the other
types of tibia vara is the abrupt angulation
into varus in the proximal end of the tibia.
The age at presentation has varied between
nine and 18 months. There seems to be a
tendency for spontaneous correction. The
histopathologic finding has been an area of
fibrocartilaginous dysplasia in the medial
aspect of the tibia.4.7
The author has seen roentgenograms of
one case of this kind in 1983.'' The roent-
genographic findings differ markedly from FIG.8. Drawing from a roentgenogram showing
infantile tibia vara. late-onset tibia vara published by Wenger C/ a/."
The roentgenographic finding is quite different
from postinfectious adolescent tibia vara seen in
D1SCU SSION Figure 5A.
The relationship of infantile tibia vara to
physiologic bowlegs is not clear. The obvious
genetic background of infantile tibia vara vara and the type of tibia vara caused by
may be related to an exaggerated inherited focal fibrocartilaginous dysplasia. However,
degree of physiologic bowleg leading to tibia the relationship of infantile tibia vara to late-
vara by increased pressure on the medial part onset tibia vara is uncertain. Perhaps the
of the growth plate. However, it may also be late-onset type is etiologically identical to the
an inherited sensitivity of the cartilage to infantile type. At present it seems logical to
pressure. The etiology and pathogenesis of keep them apart.
infantile tibia vara remain obscure. The indications for brace treatment of
The value of estimating the metaphyseal- children younger than two years of age may
diaphyseal angle37and the epiphyseal-meta- depend on the attitude of the orthopedist and
physeal angle4' in order to grade tibia1 defor- that of the patient's family. No real harm can
mity should be further tested. The histopa- result from brace treatment, although its re-
thology of manifest infantile tibia vara is sult is dubious. The prognosis for recurrence
well-known. It suggests that necrosis of carti- of deformity after osteotomy of the tibia and
lage is a factor causing delayed ossification in the fibula cannot be exactly defined. Fre-
the medial part of the metaphysis. That the quent follow-up evaluations are important
cause of this necrosis is pathologic pressure during the growth period. The type of oste-
has not been proved. otomy used seems to be important to the
The definition of infantile tibia vara is result in infantile tibia vara. The indications
clear, as is the definition of adolescent tibia for bridge resection in Stage VI in cases of

206 Langenskiold
infantile tibia vara should be restricted for
children nine to I I years of age with unusu-
ally limited closure of the growth plate.
The terminology for the four different
types of tibia vara has evolved as this field
has developed. There seems to be no indica-
tion to change this terminology at this time.
REFERENCES
1. Raeta Giner. V.. and Olietc Sanr. V.: Prohlaxis de
10s ptlentes oseos del cartilago de crecimiento. Estu-
dio experimental. Rev. Ortop. Trauma. 24:305.
I9 x0.
2. Bathfield. C. A,. and Beighton. P. H.: Blount dis-
ease. A review of etiological factors in I 10 patients.
Clin. Orthop. 13529, 1978.
3 . Beck. C. I... Burke. S. W.. Roberts. J. M.. and John-
ston. C. E.: Physeal bridge resection in infantile
Blount disease. J. Pcdiatr. Orthop. 7:161. 1987.
4. Bell, S. N.. Campbell. P. E.. Cole. W. G,. and Men-
elaus. M. R.: Tibia vara caused b> focal fibrocartila-
ginousdysplasia. J. Bone Joint Surg. 678:780. 19x5.
5 . Blount. W . P.: Tibia vara. Osteochondrosis dcfor-
mans tibiae. J. Bone Joint Surg. 1911. 1937.
6. Blount, W. P.: Tibia vara. osteochondrosis tibiae.
Curr. Pract. Orthop. Surg. 3:141. 19b6.
7. Bradish. C. F.. Davies. S. J. M.. and Malone M.:
Tibia vara due to focal tibrocartilaginous dysplasia.
J. Bone Joint Surg. 70B:lOO. I Y X X .
8. Bradway. J. K.. Klassen. R. A,. and Peterson. H. A,:
Rlount disease. A re\iew ofthe English literature. J.
Pediatr. Orthop. 7:472. I Y X 7 .
9. Bueche. M. J.. Phillips. W. A.. Goldstein. S. A..
Gordon. J.. and Best. R.: The e t k t o f interposition
material on mechanical behavior in partial physeal
resection-a canine model. Pediatr. Orthop. Soc.
North Am. Annual Meeting. Colorado Springs.
Colorado. Ma! 5-8. I Y X X .
10. Carter. J . R.. Leeson. M . C.. 'l'honipson. G. H..
Kalamachi. A.. Kellk. C, M.. and Makley. J. T.:
Late-onset tibia vara: A histopathologic analysis, a
comparati\e e\aluation with intantile tibia kara and
slipped capital femoral epiphysis. J. Pediatr. Orthop.
8: I x7. 19x8.
I I . C'atonnc. Y.. Dintimilk. I I.. A r k S.. and Mouchet.
A,: La maladie de Blount aux Antilles. A propos de
76 observations. Re\. Chir. Orthop. 69: I3 I , 19x3.
17. Dalinka. M . K.. Coren. (3..Hensinger. R . . and Irani,
R . N.: Arthrography in Blount's disease. Radiology
I13:161. 1974.
13. Diet7, F. R . . and Weinstein. S. I..: Spihe ostcotomy
for angular dcforniities of the long bones i n chil-
dren. J. Bone Joint Surg. 70A:WX. 1988.
14. Erlacher, P.: Ileforniierende Prozessc der Epiphy-
sengegeiid hci Kindern. Arch. Orthop. Unfall-Chir.
2 O : X I . I???,
15. Ebensen. A.. and Stetfrnsen, J.: Tibia vara (osteo-
chondrosis defornians tibiae). Acta Orthop. Scand.
26:200. 1957.
16. Ferriter. P.. and Shapiro. F.: Inhntilc tibia vara.
Clinical Orthopaedlcs
and Related Research
Factors affecting outcome following proximal tibia1
osteotomy. J . Pediatr. Orthop. 7: I . 19x7.
17. Foreman. K. A,. and Robertson. W. W.. Jr.: Radio-
graphic measurement of inhntlle tibia Lard. J . Pe-
diatr. Orthop. 5:452. 1985.
18.'Call. E. A,. Lingley. J . R.. and Hilcken. J. A.: Com-
parative experimental studies of 200 kilovolt and
1000 kilovolt roentgen rays. Biological effects on
epiphysis ofalbino rat. Am. J. Pathol. 16:605. 1940.
19. Golding. J. S. R.. and McNeil-Smith, J. D. G . :Ob-
servations o n the etiology oftibia vara. J . Bone Joint
Surg. 45B:XO. 1963.
20. Hansson. L. 1.. and Zayer. M.: Physiological genu
varum. Acta Orthop. Scand. 46:221. 1975.
21. Heikel. H. V. A,: Experimental epiphyseal trans-
plantation. Part 11. Histological observations. Acta
Orthop. Scand. 30: 1. 1960.
27. Hensinger. R. N.: Meeting highlights. J . Pediatr.
Orthop. 7:610. 1987.
13. Herring, J . A,: Blount disease. J . Pediatr. Orthop.
7:601. 1987.
24. Hofmann, A,. Jones. R . E . . and Herring. J. A.:
Blount's disease after skeletal maturity. J . Bone
Joint Surg. 64A: 1004. 1982.
25. Kumar. S. J.. and Pizzutillo. P. D.: rreatment of
Blount's disease. I ~ Uhthoff,
I H. K., and Wiley. J. J.
(eds.): Behabior of the Growth Plate. New York.
Raben Press. 1988. p. 299.
26. Langenskiold. A,: Tibia vara (osteochondrosis de-
formans tibiae). A survey of 23 cases. Acta Chir.
Scand. 103:l. 1957.
27. Langenskiiild. A.: Aspects of the pathology of tibia
vara (osteochondrosisdeformans tibiae). Ann. C'hir.
Glnaecol. Fenniae. 44:58,1955.
28. Langcnskidd. A,: The shape of the epiphysis com-
pensating for metaphyseal defects. Change caused
bq osteomqelitis or tuberculosis. Ann. Chir. Gynae-
col. Fenniae. 44:X7. 1955.
2?. 1.angenskiold. A.: The possibilities of eliminating
premature partial closure o f an epiphyseal plate
caused by trauma or disease. Acta Orthop. Scand.
38:267. 1967.
30. Langenshiold, A.: Lbia vara: Osteochondrosis de-
formans tibiae. Blount's disease. Clin. Orthop.
l58:77. 19x1.
3 I . lmgenskiijld. A.: Growth disturbance after osteo-
niqelitis o f femoral condyles in infants. A c t a
Orthop. Scand. 55: 1. I 984.
3 2 . Langenskidd. A . . and F.dgren. W.: Imitation of
chondrodysplasia by localized roentgen ray injury
-an cxpcrimcntal study of bone growth. Acta Chir.
Scand. 99:353. 1950.
33. Langenskiold. A.. and Osterman. K.: Surgical elimi-
nation of post-traumatic partial fusion of the growth
plate. It! Houghton. G . R . . and Thompson, G. H.
(eds.): Problematic Musculmkeletal Injuries in
Children. London, Buttenvorths. 1Y83. p. 14.
34. Langenskiold. A.. Osterman. K.. and Valle. M.:
Growth of fat grafts after operation for partial bone
growth arrest. Demonstration by computed tomog-
raphy scanning. J. Pediatr. Orthop. 7389. 1987.
35. Langenskiiild. A . ?and Riska, E. B.: Tibia vara (os-
teochondrosis deformans tibiae). A survey of sev-
enty-one cases. J. Bone Joint Surg. 46A:1405, 1964.
Number 246
September. 1989
36. Langenskiold. F.: Demonstration eines mit Genu-
varum-Bildung einhergehenden dunklen Lcidens in
der oberen Tibiaepiphyse, sowie uber die Technik
der bogenforrnigen Osteotomie. I n Bentzon. P. G.
K. (ed.): Proceedings of the Scandinavian Ortho-
paedic Association. Acta Chir. Scand. 64: 193. 1928.
37. Levine. A. M.. and Drennan. J. C.: Physiological
bowing and tibia vara. J. Bone Joint Surg.
64A: I 158. 1982.
38. Lichtblau. P. 0..and Waxman. B. A,: Blount’s dis-
ease. Review of the literature and description of a
new surgical procedure. Contemp. Orthop. 3:526.
1981.
39. Loder. R. T.. and Johnston. C. E.: Infiantile tibia
vara. J. Pediatr. Orthop. 7:639. 1987.
40. Medbo. I.:Tibia vara (osteochondrosis deibrmans
tibiae or Blount’s disease). Acta Orthop. Scand.
34:323, 1964.
41. Mitchell. E. 1.. Chung, S. M. K.. Das. M. M.. and
Gregg, J. R.: A new radiographic grading of Blount’s
disease. Evaluating the epiphyseal metaphyseal
angle. Orthop. Rev. 9 2 7 . 1980.
42. Mycoskie. P. J.: Complications of osteotomies
about the knee in children. Orthopedics 4: 1005,
1981.
43. O’Neill. D. A.. and MacEwen, G. D.: Early roent-
genographic evaluation of bowlegged children. J.
Pediatr. Orthop. 2:547, 1982.
44. Osorio. F.. and Costa, E. B.: La dtstpiphysiodkse
associte a I’osttotomie tibiale dans Ie traitement de
la maladie de Blount. A propos de 2 observations.
Rev. Chir. Orthop. 71:167. 1985.
45. Osterman. K.: Operative elimination of partial pre-
mature epiphyseal closure. Acta Orthop. Scand.
147[Suppl.]:44, 1972.
46. Oyemade. G. A. A,: Advanced tibia vara (Blount
disease) in adolescent Nigerians. J. Natl. Med.
Assoc. 73:339. 1981.
47. Rigault. P., Alain. J. L.. and Guyon Varch. G.: Le
tibia varum. Deux cas chez I’enfant. Rev. Chir.
Orthop. 58:803. 1972.
48. Roy. D. R., and Robinson, W.: Proximal tibial os-
teotomies in children. Pediatr. Orthop. Soc. North
Am. Annual meeting, Colorado Springs, Colorado.
May 5-8. 1988.
Tibia Vara 207
49. Roy. L.. and Chaise, F.: Maladiede Blount. revue de
huit cas. Rev. Chi,. Orthop. 65: 187. 1979.
50. Salenius, P.. and Vankka. E.: The development of
the tibiofemoral angle in children. J. Bone Joint
Surg. 57A:259. 1975.
5 I . Salter. R. S . . and Field. P.: The effect of continuous
pressure on living articular cartilage. J. Bone Joint
Surg. 42A:3 I , 1960.
52. Sasdki. T.. Yagi. T.. Monji. J.. Yasuda, K., and
Kanno. Y.: Transepiphyseal plate osteotomy for se-
vere tibia vara in children. Follow-up study offour
cases. J. Pediatr. Orthop. 6 5 1 . 1986.
53. Schoenecker. P. L.. Meade. W. C., Pierron. R. L..
Sheridan. J. J., and Capelli, A. M.: Blount’sdisease.
A retrospective review and recommendations for
treatment. J. Pediatr. Orthop. 5:181. 1985.
54. Sevastikoglu, J. A.. and Eriksson. 1.: Familial osteo-
chondrosis deformans tibiae. Idiopathic tibia vara.
Acta Orthop. Scand. 3831. 1967.
55. Sibert. J. R.. and Bray. P. T.: Probable dominant
inheritance in Blount’sdisease. Clin. Genet. 1 1:394,
1977.
56. Sifert. R. S.: Intraepiphyseal osteotomy for progres-
sive tibia vara. Case report and rationale of manage-
ment. J. Pediatr. Orthop. 2:81. 1982.
57. Smith. C. F.: Current concepts review. Tibia vara
(Blount’s disease). J. Bone Joint Surg. 64A:630.
1982.
58. Steel. H. H.. Sandrow. R. E.. and Sullivan. P. D.:
Complications of tibia1 osteotomy in children for
genu varum or valgum. J. Bone J o i n t Surg.
53A:1629. 1971.
59. Stmen. H.: Operative elevation of the medial tibial
joint surface in Blount’s disease. Acta Orthop.
Scand. 40:788. 1970.
60. Thompson, G. H., Carter, J. R.. and Smith. C. W.:
Late-onset tibia vara. A comparative analysis. J. Pe-
diatr. Orthop. 4: 185. 1984.
61. Van Olm, J. M. J.. and Gillespie, R.: Proximal tibial
osteotomy for angular knee deformities in children.
J. Bone Joint Surg. 66B:301, 1984.
62. Wenger. D. R., Mickelson. M.. and Maynard. J. A.:
The evolution and histopathology of adolescent
tibia vara. J. Pediatr. Orthop. 4:78. 1984.
63. Zayer. M.: Personal communication. 1983.