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

Abstract

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 longterm 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.

Blount's disease: The importance of early diagnosis and early treatment

“…If this is not the case, then surgical treatment of neglected Blount's disease can be a real challenge for orthopedic surgeons and may require elevation of medial plateau, combined osteotomies, use of Taylor Spatial Frame or Ilizarov ring external fixation, and progressive limb‐lengthening. However, with careful, individualized, preoperative planning most patients with Blount's disease can expect very good functional and cosmetic results …”

The role of PPARγ in childhood obesity-induced fractures

“…In addition to obesity, there appear to be differences between age, sex, and race [65] and minerals such as zinc and copper [70], and there are mixed results regarding association with vitamin D levels [71, 72]. In these early-onset cases, excess weight causes bowing of the tibia, leading to altered pressure on the epiphysis, improper ossification of the cartilage in the medial metaphysis, and insufficient growth of the medial physis [73]. The longitudinal growth of the tibia via the physis is disrupted by these compressive forces in a process called the Hueter-Volkmann’s law [74].…”

“…The initiation step is the recruitment of hematopoietic precursor cells through capillary blood vessels that supply the cortical bone or precursors that are already present in the marrow cavity for trabecular bone. Homing of these precursor cells is directed by endocrine and paracrine factors released from endothelial cells, such as nitric oxide, vascular endothelial growth factor (VEGF), macrophage colony-stimulating factor (M-CSF), and a receptor activator of nuclear factor-κB ligand (RANKL) [73]. The latter two factors are secreted from osteoblasts and their mesenchymal precursors to regulate osteoclast recruitment and therefore bone resorption.…”

Severe Infantile Blount’s Disease in Kumasi, Ghana: A Case Report

“…Operative treatment of blount's disease requires corrective osteotomy, proximal tibila physeal distraction, physeal bar resection and elevation of the medial tibial plateau; lateral hemiepiphyseodesis is recommended particularly in young patiennts [17].…”