Blount Disease (Tibia Vara) Treatment & Management

Updated: Sep 27, 2019
  • Author: Lauren LaMont, MD; Chief Editor: Thomas M DeBerardino, MD  more...
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Treatment

Approach Considerations

Nonoperative treatment is an option in a select group of infantile Blount disease patients. If they are diagnosed before age 4 years, knee-ankle-foot orthoses (KAFOs) have a role in Langenskiöld stage I or II disease, especially with unilateral involvement. [28] Patient characteristics that predispose to failure of conservative treatment include the following [8] :

  • Varus thrust
  • Age older than 3 years
  • Weight greater than 90th percentile
  • Bilateral disease
  • Langenskiöld grade higher than 3

In late-onset patients and early-onset patients in whom brace management fails, operative intervention is indicated for increasing severity of symptoms or progression of deformity.

Surgical intervention is contraindicated in children younger than 2 years because it is difficult at this age to differentiate between Blount disease and excessive physiologic bowing that may resolve spontaneously.

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Medical Therapy

Conservative treatment can be an option in early-onset Blount disease and consists of bracing. Brace therapy should be attempted in all children younger than 2.5 years with stage I or II disease. [29] Ambulatory bracing with an above-the-knee orthosis has been shown to prevent progression of disease. Bracing has been shown to correct both the varus deformity and the pathologic proximal-medial tibial growth disturbance. [28, 30] If the disease continues to progress to stage III with bracing, brace treatment will no longer be effective.

Other risk factors for failure of brace treatment include the following:

  • Obesity
  • Varus thrust
  • Age older than 3 years at initial treatment
  • Bilateral disease
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Surgical Therapy

The obesity associated with Blount disease leads to additional risk factors for surgery. Owing to their obesity, patients are at higher risk for obstructive sleep apnea (OSA) and should be screened during their preoperative workup so that they can be adequately treated postoperatively. [31]

Infantile Blount disease

Surgical intervention is indicated in early-onset patients who develop Blount disease changes consistent with Langenskiöld stage III or IV. Bracing has not been shown to be effective past these stages, and the disease will continue to progress. Surgical options include corrective proximal tibial osteotomies with various fixation methods used sometimes in concert with guided growth or hemiepiphysiodesis. (See the images below.)

Clinical picture of a child with infantile Blount Clinical picture of a child with infantile Blount disease prior to surgery. Courtesy of Austin T. Fragomen, MD.
Anteroposterior radiograph of tibia of a child wit Anteroposterior radiograph of tibia of a child with infantile Blount disease at the time of distal femoral 8 plate application tibial osteotomy and Taylor spatial frame. Courtesy of Austin T. Fragomen, MD.
Subsequent standing hip-to-ankle anteroposterior r Subsequent standing hip-to-ankle anteroposterior radiograph of the lower extremities demonstrating improved alignment after gradual correction. Courtesy of Austin T. Fragomen, MD.
Clinical picture of a child with infantile Blount Clinical picture of a child with infantile Blount disease at the completion of treatment. Courtesy of Austin T. Fragomen, MD.
Clinical picture and anteroposterior radiograph of Clinical picture and anteroposterior radiograph of the tibia of a child with infantile Blount disease at the time of distal femoral 8 plate application tibial osteotomy and Taylor spatial frame. Bilateral lower extremity films demonstrating overcorrection into valgus. Subsequent standing hip–to-ankle anteroposterior radiograph of the lower extremities demonstrating improved alignment after gradual correction with monitoring by clinical pictures and radiographs at most recent visit. Courtesy of Austin T. Fragomen, MD.

In early-onset Blount disease, the risk of recurrence of the deformity is significant; accordingly, osteotomies are often overcorrected to anticipate this. Poor results and high rates of recurrence have been shown in the population with progressive Langenskiöld stage, older age at time of surgical intervention, and lack of overcorrection. [32] Between 5º and 15° of valgus overcorrection has been recommended. Lower overall rates of recurrence have been seen in patients who undergo corrective osteotomies before age 4 years. [33]

Osteotomy has been the most frequently used form of surgical management. [7] Many different types of osteotomies have been described in the literature, including opening and closing wedge, opening wedge, serrated, dome, and inclined osteotomies. [34, 35, 36, 37, 22, 38] In the infantile population, performance of the osteotomy must spare both the tibial physis and the apophysis of the tibial tubercle.

Regardless of the technique for valgus corrective osteotomy chosen, the correction can be performed acutely or gradually corrected with external fixation. For an acute correction, the multitude of fixation options include casting, plates and screws, pins, screws alone, wires, and external fixation. [36, 39, 40, 41, 42] The decision to correct acutely is based on the degree and dimensions of the deformity and the safety of the structures at risk with an acute correction.

Gradual osteotomies allow for correction of multiplanar deformities by fixation with either an Ilizarov device or a Taylor spatial frame. [43] Some series have shown a lower incidence of neurovascular injury and compartment syndrome with a gradual versus an acute correction. The current consensus is that gradual correction leads to a more accurate result in the correction of multiplanar deformities as compared with acute correction. [26]

When the depression of the medial plateau is severe, this deformity may have to be corrected in isolation with a medial hemiplateau elevation osteotomy. [44] This osteotomy only addresses the medial plateau depression, and an additional proximal metaphyseal tibial osteotomy is needed to correct the multiplanar deformity. This proximal tibial osteotomy is performed below the tibial tubercle to realign the mechanical axis of the leg. Intervention consists of epiphysiodesis of the lateral sides of the tibia and proximal fibula and valgus opening wedge osteotomy of the proximal tibia and fibular osteotomy.

Other described techniques include asymmetric physeal distraction and physeal bar resections; however, these are not commonly used.

Adolescent Blount disease

In individuals with adolescent tibia vara, observation is indicated only with painless, nonprogressive, mild deformities. In contrast to infantile Blount disease, which can be corrected in the earlier stages with bracing, the adolescent form of the disease has not been shown to respond to nonoperative treatment. [45] Surgical treatment depends on the stage of the disease and the skeletal age of the child. As with the infantile form of the disease, there are multiple surgical approaches to correction, which include proximal tibial osteotomy, hemiepiphysiodesis, guided growth, and external fixation with distraction osteogenesis. [8]

As in the infantile form, osteotomy remains the most common method of treatment. The same considerations are relevant as in the infantile form, with the options of acute versus gradual correction. With significant remaining growth, hemiepiphysiodesis of the lateral proximal tibial physis has been described. A drawback of this technique is the unpredictable growth from the diseased medial tibial physis and therefore unpredictable correction. This technique has been shown to be less effective in obese patients and more severe deformity. [8]  The use of a titanium tension-band plate appears also to be a risk factor for failure. [46]

Guided growth with compressive plating across the convexity of the growth plate is an option in those with significant growth remaining. [47, 48] Guided growth can also be used concomitantly to correct less severe deformities of the distal femur while correcting the proximal tibia. However, both guided growth and hemiepiphysiodesis fail to address sagittal-plane deformity or limb-length discrepancy.

Gradual correction distraction osteogenesis with an external fixator provides consistent correction of multiplanar tibial deformities in these patients, with minimal morbidity. Correction is associated with significant improvement in symptoms and a high degree of patient satisfaction. (See the images below.)

Sachs et al compared two groups of adolescent patients, one treated with osteotomy and one without. They concluded that in patients with no growth remaining, tibia vara might be safely treated by using the Taylor spatial frame without osteotomy and fixation of the fibula. [49]

Standing hip-to-ankle anteroposterior radiograph o Standing hip-to-ankle anteroposterior radiograph of the lower extremities of a patient before osteotomy and Taylor spatial frame for the treatment of adolescent Blount disease. The patient also had distal femoral malalignment managed with a distal femoral osteotomy. Courtesy of S. Robert Rozbruch, MD.
Clinical photograph of a patient before osteotomy Clinical photograph of a patient before osteotomy and Taylor spatial frame for the treatment of adolescent Blount disease. The patient also had distal femoral malalignment managed with a distal femoral osteotomy. Courtesy of S. Robert Rozbruch, MD.
Standing hip-to-ankle anteroposterior radiograph o Standing hip-to-ankle anteroposterior radiograph of the lower extremities of a patient after osteotomy and Taylor spatial frame for the treatment of adolescent Blount disease. The patient also had distal femoral malalignment managed with a distal femoral osteotomy. Courtesy of S. Robert Rozbruch, MD.
Clinical photographs of a patient after osteotomy Clinical photographs of a patient after osteotomy and Taylor spatial frame for the treatment of adolescent Blount disease. The patient also had distal femoral malalignment managed with a distal femoral osteotomy. Courtesy of S. Robert Rozbruch, MD.
Standing hip-to-ankle anteroposterior radiograph o Standing hip-to-ankle anteroposterior radiograph of the lower extremities of a patient after osteotomy and Taylor spatial frame for the treatment of adolescent Blount disease. The patient also had distal femoral malalignment managed with a distal femoral osteotomy. Courtesy of S. Robert Rozbruch, MD.
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Postoperative Care

In the postoperative period, it is important to carefully monitor the neurovascular status because patients who undergo corrective proximal tibial osteotomies are at risk for compartment syndrome. Compartment syndrome must be recognized and treated early. Owing to the increased incidence of obesity, patients with Blount disease are at significant risk for deep venous thrombosis (DVT), especially in the adolescent population, and patients therefore should be on chemoprophylaxis postoperatively.

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Complications

Complications associated with the treatment of Blount disease can be distinguished on the basis of whether they are complications of operative treatment or complications associated with the disease itself. Operative complications include the following:

  • Vascular impairment
  • Pathologic fractures
  • Wound infection
  • Malalignment

Complications of the disease include the following [24] :

  • Recurrence of deformity
  • Joint degeneration, in the long term
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Long-Term Monitoring

Follow-up and postoperative weightbearing are specific to the procedure performed. In general, osteotomies heal in approximately 6-8 weeks, and, if the method of fixation is temporary, it should be maintained until evidence of healing is seen. In patients undergoing gradual correction, the timeline of external fixation depends on the degree of correction and length of distraction osteogenesis. In general, external fixation remains in place for 12 weeks postoperatively.

Continuing follow-up care after initial surgical correction of the varus deformity is necessary because of the risk of recurrence.

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