BLOUNT DISEASE

• What is your differential diagnosis?

- physiologic genu varum

- metaphyseal chondrodysplasia
- spondylo epiphyseal dysplasia
- multiple epiphyseal dysplasia
- achondroplasia
- renal osteodystrophy
- vitamin D–resistant rickets
- post-traumatic deformity
- postinfectious sequelae
- proximal focal fibrocartilaginous dysplasia (tachdjian 4 th ed)

• Do you need any further studies?

- The diagnosis is based on familiar radiographic changes in the proximal end of the tibia:
(1) a sharp varus angulation in the metaphysis, (2) a widened and irregular physeal line
medially, (3) a medially sloped and irregularly ossifi ed epiphysis, and (4) prominent
beaking of the medial metaphysis with lucent cartilage islands within the beak (tachdjian
4th ed)

• Describe the x ray (Anteroposterior View)

- Varus angulation at the epiphyseal–metaphyseal junction

- Widened and irregular physeal line medially
- Medially sloped and irregularly ossified epiphysis, sometimes triangular
- Prominent beaking of the medial metaphysis with lucent cartilage islands within the
beak
- Lateral subluxation of the proximal end of thetibia (tachdjian 4 th ed)

• What is your complete diagnosis for this patient?

- Infantile tibia vara (tachdjian 4th ed)

• What treatment you will choose for this patient?

- If the child is younger than 3 years of age and the lesion is no greater than Langenskiöld
stage II, orthotic treatment is recommended because 50% or more of these patients can
be successfully treated with braces, especially if they have only unilateral involvement
- Treatment of Langenskiöld Stage II Lesions. Surgical treatment in the early stages of the
disease (stage II) is crucial to achieve permanent and lasting correction and to avoid the
sequelae of joint incongruity, limb shortening, and persistent angulation.
- Treatment of Langenskiöld Stages IV/V Lesions. Lesions greater than stage III cannot be
definitively corrected by simple mechanical realignment because physiologic physeal arrest has
already occurred by stage IV
- Treatment of Langenskiöld Stage VI Lesions. Treatment of stage VI lesions with established
bony bridges must also be individualized (tachdjian 4th ed)

• Mention your preoperative preparation for this patient

 - Preoperative assessment by CT or MRI is essential to determine the amount of abnormal physis in
three dimensions (tachdjian 4th ed)

• How do you give your informed consent to the parents/ patients

- Untreated infantile tibia vara generally results in a nonresolving and sometimes

progressive varus deformity that produces joint deformity and growth retardation,
which can then be corrected only with complex surgical procedures.
- Unexpected recurrence of varus deformity after surgery
- Risk of growth arrest (tachdjian 4th ed)

• How to prepare the patient position?

- Fluoroscopic visualization of the proximal end of the tibia is essential to perform the osteotomy
without intra-articular displacement of the medial plateau. A straight anterior incision is made to
expose the medial plateau proximal to the tibial tubercle. The osteotomy begins distal to the
insertion of the medial collateral ligaments. A series of holes tracing the curve of the osteotomy
and stopping just short of the subchondral bone, just lateral to the tibial spine, are drilled in an
anterior-to-posterior direction (with the popliteal structures protected) Mention surgical
approach for cruris region (tachdjian 4th ed)

• How many tipe of osteotomy in general?

- dome, closing wedge, or opening wedge (tachdjian 4th ed)

• What kind of complication possibly occur in this surgery

- Complications of proximal tibial osteotomy in a growing child can be numerous. The osteotomy
must be performed distal to the tibial tubercle to avoid growth arrest. Injury to the proximal tibial
physis at the level of the tibial tubercle produces proximal tibial recurvatum, with resulting
hyperextension instability of the knee. The optimal site of the osteotomy, distal to the tubercle, is
near the level of the trifurcation of the popliteal artery. The anterior tibial artery, which passes
through the interosseous membrane and enters the anterior compartment, can be injured in as many
as 29% of osteotomy procedures. (tachdjian 4th ed)

• Mention the compartment in the leg

• How do you do the profilaxis osteotomy?

- Prophylactic fasciotomy of the anterior, lateral, and posterior compartments is

recommended because of the not insignificant incidence of compartment syndrome
(tachdjian 4th ed)

• How do you give your post operative instruction?

- Postoperatively, the extremity is immobilized in a non weight-bearing, long-leg, bent-

knee cast. Alternatively, a spica cast is used for the child with relatively short, fat
extremities. On occasion, a KAFO is used following cast removal if the pre operative
deformity was severe and associated with ligamentous laxity (lovell 7eth ed)