Blount Disease

-Morteza-
Introduction

A progressive bowleg deformity associated with abnormal growth of the

posteromedial part of the proximal tibial physis
 Erlacher is credited with the first description of progressive tibial varus
deformity in otherwise healthy children.
 1937  Blount was the first to identify two forms of this disorder : infantile and
adolescent (or late onset) - and coined the term “osteochondrosis deformans
tibiae.”  Blount’s Disease
 Langenskiöld made significant early contributions to the identification and
management of infantile Blount disease.  Classification
 Thompson et al, described a variant form known as Juvenile Blount disease.
Epidemiology

 Noted between ages of 2 – 5 y.o.(Infantile), > 10 y.o.

(Adolescent)
 Boys are affected more often than girls.
 Approximately 50% of cases are bilateral, but not
necessarily symmetric.
 Commonest in African descent, Hispanics and Scandinavian.
Etiology and Pathophysiology

 The etiology of infantile Blount disease remains unknown.

 Spontaneous deceleration of growth occurs at the posteromedial proximal
tibial physis, resulting in varus/flexion/internal rotational deformity, medial
and posterior “sloping” of the proximal tibial epiphysis.
 Limited histologic evaluation of the affected physis has demonstrated
disruption of the normal columnar architecture of the physis, replacement of
physeal cartilage by fibrous tissue.
 Most severe form  osseous bridging (physeal arrest) between the epiphysis
and metaphysis.
 Predisposing factors : early walking age, large stature, obesity, dietary
vitamin D deficiency, Hispanic and Black race, or a combination of these
factors.
Type
Infantile blount’s Adolescent blount’s
Age 2-5yrs >10yrs
Prevalence Commoner Less common
Bilaterality 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

Location Physeal/epiphyseal
Metaphyseal

Bone involvement Proximal medial tibia physis, producing genu

Proximal tibia physis, AND may have distal femoral
varus, flexion, internal rotation, AND may have
VARUS and distal tibia valgus
compensatory distal femoral VALGUS
Natural history Self-limited - stage II and IV can exhibit Progressive, never resolves spontaneously (thus
spontaneous resolution bracing unlikely to work)
Treatment options Bracing and surgery Surgery only
Clinical Features

 Variable amount of varus deformity of the

proximal tibia.
 Increased internal tibial torsion.
 Palpable prominence or “beaking” of the proximal
medial tibial epiphysis and metaphysis.
 In unilateral cases, leg length inequality.
Radiographic Classification

 Langenskiöld
described the
radiographic
hallmark of infantile
Blount disease
Differential Diagnosis and Natural History

 The presumptive short-term natural history of

infantile Blount disease that does not resolve
spontaneously :
 Progressive varus deformity,
 Epiphyseal distortion,
 Leg length inequality in unilateral cases.
 In the long term, patients are at substantial risk
of developing meniscal tears and early
degenerative arthritis
Investigation

• Xrays
• medial epiphysis is short, thin and wedged
• Physeal contour is irregular, slopes medially
• Medial metaphyseal projection
(beaking), often palpable
• Angulation just distal to beak
• Asymmetric bowing in bilateral cases
Investigation

Illustration of the metaphysealdiaphyseal angle described by Levine and

Drennan.

They found that angles 11° indicated progression to infantile Blount

disease;
However, others have found that metaphyseal-diaphyseal angles 9° are
physiologic,
Whereas angles 16° strongly suggest infantile Blount disease,
And angles measuring between 9° and 16° are equivocal
Nonsurgical Management

 Long leg bracing has been recommended by some for

management of infantile Blount disease in select patients.
 The efficacy of bracing has not been established in a
controlled trial.
 Difficulty confirming compliance with brace wear make it
challenging to conduct a conclusive study on the efficacy of
bracing.
 Richards et al, found that long leg antivarus bracing during
the day was probably effective in patients aged ≤3 years
with unilateral involvement at Langenskiöld stage I-II.
Surgical Management

High Tibial and Fibular Osteotomy

 Treatment choice for patient with
progressive deformity and/or those whose
condition exceeds the guideline for bracing.
 Performed below the tibial tubercle.
 Goal :
 full to overcorrection of varus, flexion, and
internal rotational deformities of the tibia
Surgical Management

Growth modulation (Hemiepiphyseodesis)

 Growth modulation using internal fixation with a
tension band plate and screws is an alternative
option to high tibial osteotomy.
 Scott, reported a nearly 90% correction rate after
growth modulation but also noted instances of
implant failure.
 Growth modulation should not be expected to
correct the associated internal tibial rotational
deformity
Surgical Management

Physeal Arrest Resection

 Langenskiöld initially described the use of partial physeal arrest resection for partial closure of
the growth plate.
 Preference is to perform resection in the patient with at least 4 years of growth
remaining.
 Physeal arrest resection is typically combined with high tibial osteotomy using
interpositional material (fat or methylmethacrylate).
 Andrade and Johnston, examined the efficacy of physeal arrest resection for
patients with earlier stage disease (Langenskiöld stage IV and V) before development
of frank bony arrest  no varus recurrence in >80% of patients younger than age 7
years
Surgical Management

Hemiplateau Elevation
 Performed to correct the depression through a
crescent-shaped metaphyseal osteotomy that
extends into the intercondylar area, with grafting of
the space beneath the articular fragment and either
internal or external fixation of the tibia.
 The procedure may be performed with or without
secondary osteotomy below the tibial tubercle to
correct the associated metaphyseal-diaphyseal varus
deformity.
 Treatment

• Following osteotomy, immobilization is achieved by:

• Cast
• Pins
• External fixation – linear or ring
• Internal fixation – screws, plate and screws
Postoperative care/rehabilitation
• NWB for 4 weeks
• Cast changed at 4 weeks if callus present on xray, and weight-bearing
begun. Pins also removed at this stage if present
• Cast remains for 8-10 weeks before removal. Premature removal
results in re-fracture
 Prognosis Prognosis

• Best outcomes with early diagnosis and unloading of the medial joint
with either bracing or an osteotomy
• Young children with stage II & stage IV can have spontaneous
correction
 Complications
Complications
• Recurrence
• Older child
• Physeal bar
• Non-operative management
• Chronic joint pain
• Vascular occlusion
• Peroneal palsy
• Refracture
• Compartment syndrome
 Conclusions Conclusion

• Accurate diagnose and treatment is the important thing in Blount disease

• There is need for greater investment in the diagnosis and evidence-
based treatment of this condition.
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