48x36 Poster Template

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In children under the age of five, is bracing as
effective as surgery at correcting Blount's
disease (tibial varum) and preventing future
musculoskeletal impairments? Kristin Hamrick
Brandy Hirsch Bellarmine University DPT Class of
2015
Classification
Non-operative Intervention
Background
Outcomes Conclusion

• Surgery
• Potential motor weakness and/or sensory deficits
  secondary to damaged fibular nerve 5
• Not recommended before age 2 5
• Definitive surgery for infantile Blount's
  disease is most successful before age 5 to
  prevent recurrence 2
• The use of external fixation has better outcomes
  than internal fixation 2
• Good prognosis if under age 3, normal weight,
  Langenskiold stage I or II, ADA angle lt 18 6
• MPS most significant MPS angle or lt 59
  degrees 6
• Bracing
• Bracing appears to be effective in stages I II
  infantile Blount's disease, specifically in cases
  with unilateral involvement 3
• Children with bilateral disease or age greater
  than 4 are more likely to require surgical
  intervention 3
• Research suggests that daytime, ambulatory
  bracing can correct tibial vara in patients lt 3
  years of age 7
• Overall, outcome depends on patients age and
  severity of deformity at the time of intervention
  3
• Ultimately, if implemented early, bracing is an
  effective and less invasive treatment for
  Blounts disease, especially infantile form
  stages I II 8

• Blounts Disease
• Uncommon growth disorder usually seen in
  children and adolescents as a result of internal
  rotation of the proximal tibia immediately below
  the knee
• Although Blounts disease is idiopathic,
  biomechanical factors are still considered to be
  a large contributor of the pathological cycle 7
• Presents as excessive varus angulation at the
  knee
• Progressive (gets worse, not better) 1
• 3 Categories 2
• 1. infantile tibia vara before 4 years of age
• Typically bilateral
• MD angle gt 16 degrees
• 5x more common than adolescent form
• 2. juvenile tibia vara between 4-10 years
• 3. adolescent tibia vara after 10 years
• Typically unilateral
• Associated clinical characteristics 1,3,6
• Early walkers
• Obese
• African Americans

• Langenskiold Classification six roentenographic
  stages depending on degree of skeletal maturation
  and upper end bone development 4
• I under 3 yrs., medial and distal beaking of
  metaphysis with irregularity of entire metaphysis
• II age 2.5-4 yrs., sharp anteromedial
  depression and ossification line of wedge-shaped
  medial metaphysis
• III age 4-6 yrs., deepening of metaphyseal beak
• IV 5-10 yrs., enlargement of epiphysis
• V 9-11 yrs., cleft in epiphysis, appearance of
  double epiphysis
• VI 10-13 yrs., closure of medial proximal
  tibial physis
• Catonne Classification six stages based on
  progressive radiographic change 4
• I 2-3 yrs., asymmetry of tibial epiphysis
• II 3-5 yrs., sloped epiphysis uneven
  metaphyseal shape
• III 5-8 yrs., vertical medial epiphysis and
  metaphysis, medial calcifications
• IV 8-11 yrs., small medial bony bridge
• V medial bony bridge
• VI adult aspect of physis

• Bracing with KAFO
• KAFO above knee, ambulatory orthotic that 7
• maintains full extension
• places isolated valgus force on proximal medial
  tibia to unload bone
• controls knee lateral shift
• allows DF but limits PF to 90
• prevents hyperextension of knee
• can be released at the knee for sitting

• Theory shifting the pressure from the medial
  surface of the tibia to the lateral surface will
  cause a pull on the medial aspect of the knee,
  increasing joint space and allowing the medial
  tibia to grow, resulting in correction. 7
• Indications 3,7
• Children lt 3 years (especially if unilateral)
• Stages I-II
• MD angles gt 16 degrees
• MD angles between 9-16 degrees with presence of
  ligamentous laxity or obesity
• If successful, improvement should occur in 1
  year
• Bracing must continue for approximately 2 years
  for resolution of bony changes
• Risk factors for failure of bracing 3,8
• Obesity
• Varus thrust
• gt 3 years at initial treatment
• Bilateral disease
• Stage III or greater deformity

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Clinical Relevance
The key to successful treatment of Blounts
disease in the clinic is early identification of
the type (i.e. infantile) and stage of the
disease. Understanding what treatment options are
indicated for each stage will help clinicians
make the most appropriate and conservative choice
for each patient. Recognizing the time frames
when bracing or surgery are most successful is
crucial in correcting Blounts disease and
preventing further musculoskeletal impairments.

4
Surgical Intervention
Literature Cited

• Gold standard Corrective Osteotomy
• Procedure cut tibia just below knee joint to
  correct alignment and use plate or external
  device to facilitate bone healing in a
  straightened position
• Goals relieve pain and correct limb alignment
• Not recommended under age 2
• Indications 1,2
• Severe cases (Langenskiöld stage III or IV)
• Bracing/orthotics fail
• Unresolved deformity by age 4
• Adolescent tibia vara
• In the infantile population, the osteotomy must
  be performed while sparing both the tibial physis
  and apophysis of the tibial tubercle 3
•  

• Boyce PT, EdD, OCS, ECS. Bellarmine University.
  (2009). Pediatric Orthopedics. PowerPoint.
  Retrieved by blackboard.bellermine.edu
• Davidson R.S., Shirley E.D. Surgical Management
  of Blount's Disease. Inc Wiesel S.W. Operative
  Techniques in Orthopaedic Surgery. Volume II.
  Lippincott Williams Wilkins 2012 Chapter 30.
• Doyle BS, Volk AG, Smith CF. Infantile Blount
  disease long-term follow-up of surgically
  treated patients at skeletal maturity. J Pediatr
  Orthop. Jul-Aug 199616(4)469-76. Medline.
• Ducou le Pointe H, Mousselard A, Rudelli A,
  Montagne J.P, Filipe G. Blount's disease
  magnetic resonance imaging. Pediatric radiology.
  19952512-14. http//link.springer.com/article/10
  .10072FBF02020831page-1 Accessed November 15,
  2013.
• Jahangiri FR. Multimodality neurophysiological
  monitoring during tibial/fibular osteotomies for
  preventing peripheral nerve injuries. The
  Neurodiagnostic journal. 201353(2)15368.
  Available at http//www.ncbi.nlm.nih.gov/pubmed/2
  3833842
• Kaewpornsawan K, Tangsataporn S, Jatunarapit R.
  Early proximal tibial valgus osteotomy as a very
  important prognostic factor in Thai children with
  infantile tibia vara . Journal of the Med
  Association of Thailand. 2005572-79.
• Marshall JG. Orthotic Treatment of the Toddler
  with Bowed Legs. Pediatric Portal. Nov 2010 4-6.
  OP Business News.
• Orthotic Treatment of Infantile Tibial Vara.
  Medscape Orthopedics. 1999 3(6)
  www.medscape.com

Importance of Intervention

• Some musculoskeletal impairments can be prevented
  by early identification treatment of Blounts
  disease, including
• arthritis joint degeneration
• foot deformities excessive pronation/medial
  collapse
• weakened ligaments knee instability
• medial knee pain
• gait abnormalities
•  

Bilateral 1
Unilateral 1