Late-onset tibia vara (Blount's disease). Current concepts

Idiopathic tibia vara or Blount's disease can be classified into three age-onset groups: (1) infantile, less than three years; (2) juvenile, four to ten years; and (3) adolescent, 11 years or older. The latter two groups comprise late-onset tibia vara, which is much less common than the infantile-onset form. In a comparison of eight juvenile-onset patients (13 knees) and seven adolescent-onset patients (nine knees), there were essentially no significant clinical, roentgenographic, or physeal-histopathologic differences. Both groups had severe obesity, mild to moderate varus deformities, and less-pronounced roentgenographic characteristics. Histopathologic analyses of the entire physis from the proximal tibia in five cases (seven knees) were essentially identical in patients with the infantile form as well as in those with slipped-capital femoral epiphyses, suggesting a common etiology. Recurrence of deformity after surgical correction occurred frequently in the juvenile onset males but not in juvenile onset females or the adolescent onset group. Incomplete correction of the varus deformity occurred more frequently in the latter group. The etiology for tibia vara appears to involve varus stress growth suppression, and disruption of endochondral ossification. The major differences between the three groups is due to the age at clinical onset, the amount of remaining growth, and the magnitude of the medial compression forces across the medial aspect of the knee.     

Adolescent tibia vara

Adolescent tibia vara is less common and less well described when compared to infantile tibia vara. Yet, the two share a significant number of features related to their epidemiology and histology. The two diseases differ most in their radiographic appearance. It does not, however, necessarily follow that their etiologies cannot be similar. By its epidemiology and histology, adolescent tibia vara appears to be related to repetitive trauma in the form of abnormal force directed on the medial tibial growth plate due to obesity, the adolescent growth spurt, or residual, incompletely corrected physiologic varus. Such forces may give growth plate suppression by the Heuter Volkman principle similar to what is thought to occur in infantile tibia vara. In the infant, this results in typical radiologic findings related to an epiphyseal ossification center which is cartilagenous and moldable and results in progressive medial wedging. In the adolescent, however, this ossification center is bony and, therefore, will not deform under stress. The growth plate, however, still responds with decreased growth resulting in varus deformity. Thus, adolescent tibia vara, by definition not related to trauma or infection, may in fact reflect the same pathologic process at work as in infantile tibia vara.     

Torsion--treatment indications

Rotational problems, when outside the normal range, are referred to as torsional deformity. These deformities are relatively common in infancy and childhood, generally resolve spontaneously with growth, and rarely persist into adult life. There are few situations in which treatment is necessary. (1) Rigid metatarsus adductus that does not resolve during the first six months should be corrected by casting. The long leg cast is most effective, as it controls the rotation of the tibia. With the tibia stabilized, the foot can be laterally rotated and abducted, which usually allows correction using one or two casts. (2) Persistent, severe tibial medial or lateral torsion after the age of eight years may be corrected by a supramalleolar tibial rotational osteotomy. This is indicated for medial torsion beyond 15 degrees and for lateral torsion beyond 30 degrees. Fixation is provided by crossed, smooth pins and a long leg cast. Compartment syndromes and peroneal nerve injury are avoided by the distal correction. (3) Persistent, severe femoral antetorsion of more than 50 degrees after the age of eight years may justify correction. For operative correction, medial rotation should exceed 85 degrees and lateral rotation should be less than 10 degrees. The osteotomy for correction is fixed by threaded Steinmann pins cut off below the skin and supplemented with a spica cast.     

The use of the Taylor spatial frame in adolescent Blount’s disease: is fibular osteotomy necessary?

Background  The standard treatment of adolescent Blount disease includes proximal tibial osteotomy and osteotomy of the fibula. Some believe that the fibula should also be fixed to prevent migration and subluxation. The purpose of the current study was to examine the results of treatment of patients with adolescent tibia vara treated by tibial osteotomy and Taylor spatial frame (TSF) without fibular osteotomy. Methods  Correction of deformities was performed on eight patients (ten tibias) with adolescent Blount disease using TSF. The fibula was not osteotomized in any patient and was not fixed in the last five patients. Results  All patients had precise anatomical correction of deformities and no problems related to the fibula occurred during or after correction. Conclusion  Based on our experience we believe that placement of the origin at the level of the proximal tibial fibular joint in conjunction with external fixation eliminates the need for fibular osteotomy and the potential morbidity of this procedure in patients with mild to moderate tibia vara.     

Different faces of the triple arthrodesis

Patients with severe pes planovalgus or cavovarus foot deformities who fail conservative treatment may require a triple arthrodesis. Modifying the triple arthrodesis to include extended bone wedge resections allows for improved correction. The goal of each procedure is to obtain a less painful, plantigrade foot, and to improve function. Additional hindfoot or midfoot osteotomies may be needed in the modified triple arthrodesis. Midfoot or forefoot cavus can be addressed with either the Japas, Cole, or Jahss osteotomies, as described above. Residual hindfoot valgus can be adequately corrected with a medial displacement osteotomy of the calcaneus. Residual hindfoot varus is preferably corrected through a lateral closing wedge calcaneal osteotomy. This allows for adequate correction without the need for bone graft or an extended medial incision in the area of the tibial neurovascular bundle. Good results have been obtained with these types of complicated reconstructive procedures.     

Fracture reduction and deformity correction with the hexapod Ilizarov fixator.

A configuration for the Ilizarov external fixator with six distractors and 12 ball joints in the form of a hexapod was developed. The system allows for six degrees of freedom bone fragment displacement by controlling the distractors. Using this assembly, universal three-dimensional corrections or reductions are possible without the need for complicated joint mechanisms. The device was used in 16 patients: five had displaced tibial fractures with severe soft tissue damage, 10 had deformities or pseudarthroses subsequent to treatment of tibial fractures, and one had an axis deviation in the course of tibial lengthening. Translational (to 40 mm) and rotational deformities (to 33 degrees) were corrected. Final radiographic examinations after the correction procedure was complete showed median residual deformities of 3.5 mm (range, 0-5 mm) and 1 degree (range, 0 degree-4 degrees) in the anteroposterior projection and of 1.5 mm (range, 0-6 mm) and less than 1 degree (range, 0 degree-9 degrees) in the lateral projection. The construction is a useful and important addition to the Ilizarov fixator system. As a bone fixation device it is unique in that its optimal use depends on the availability of computer software.     

胫骨高位截骨术治疗膝内侧单间室骨关节炎的研究进展

骨关节炎（OA）是一种以软骨退行性变为主的疾病。该病常见于老年患者,病程末期可致严重的关节畸形,给患者的心理和生理带来极大的痛苦。胫骨高位截骨术（HTO）作为治疗单间室膝关节骨性关节炎（KOA）的手术方式,是一种安全、可靠的治疗方式。现已被广大医生及患者接受,特别是年轻患者的接受度更高。该技术的主要目的是改变下肢畸形力线,以延缓或解除内侧间室KOA的退行性改变。HTO一直被认为具有技术简单、手术创伤小、畸形矫正精确、术后恢复快等优点。多年来,随着手术技术的不断创新、内固定的不断改良,手术的适应证变得更为广泛。目前普遍认为HTO是一种比较理想的手术方式,长期临床效果良好。本文对近年来胫骨高位截骨术治疗单间室骨性关节炎的术前选择、手术方式、术后疗效、术后并发症及术后长期疗效进行综述。     

Pediatric applications of the Ilizarov method.

Since mid-1987, more than 250 applications of the Ilizarov technique have been successful in treating a variety of pediatric orthopedic problems. The principles of the method are the same in adults and children. Careful preoperative planning and close follow-up evaluation during distraction are important to success. Complication rates are high but improving as experience is gained with the technique. Most complications can be managed such that the ultimate success is not jeopardized. The Ilizarov technique has wide application in the treatment of difficult deformities. The method is useful for treatment of limb-length discrepancy projected to be greater than 5 cm and in limb-length discrepancy combined with angular deformity. The method is applicable to angular deformities such as in adolescent Blount's disease and congenital tibial pseudarthrosis, especially conditions where bone transport may be needed to gain length. In resistant or recurrent clubfeet, the Ilizarov technique is useful as an alternative to osteotomy of the mid- and hindfoot or both. The method may even be indicated for lengthening limbs in selected patients with short stature.     

Fixation of the Lapidus arthrodesis with a plantar interfragmentary screw and medial low profile locking plate

The Lapidus arthrodesis can be used to correct pathology within the forefoot or midfoot, and severe hallux valgus deformities as well as hypermobility of the medial column may be amenable to correction with this procedure. Many different skeletal fixation methods have been described for this procedure, and one form that appears to provide enough construct stability to allow patients to bear weight early in the postoperative period is described herein. This construct consists of an interfragmental compression screw oriented from the plantar aspect of the first metatarsal to the superior aspect of the medial cuneiform, with medial locking plate augmentation.     

Computer-Assisted Total Knee Arthroplasty for Significant Tibial Deformities

Computer-assisted total knee arthroplasty has been demonstrated to provide reproducible limb mechanical alignment within 3° from the neutral mechanical axis. However, restoring proper implant and extremity alignment remains a significant challenge with proximal tibial deficiencies. In this prospective study, we describe the use of computer navigation to quantify the amount of bone loss on the medial or lateral tibial plateau and the use of these data to assess the need for augmentation with metallic tibial wedges. In this study, we demonstrate that computer-assisted total knee arthroplasty in patients with significant tibial deformities can accurately measure severe tibial deformities, predict tibial augment thickness, and provide excellent mechanical alignment and restore the joint line without excessive bony resection, repeated osteotomies, and repeated augment trialing.     

Intrakondyläre Segmentosteotomie

Intracondylar deformities after tibial plateau fractures are intra-articular deformities which present within the medial and/or lateral knee compartments. They exist either isolated or in combination with other extra-articular deformities and/or ligament problems. These deformities are complex problems and difficult to treat. While many treatment concepts exist for extra-articular deformities there is limited information available for intra-articular or even intracondylar deformities. Selecting the appropriate procedure for the approach, osteotomy, management of bone defects and cartilage damage is crucial. The authors describe the analysis, planning, treatment and clinical outcome for these rare but difficult problems and present step by step details of the surgical technique.     

Combined distal tibial rotational osteotomy and proximal growth plate modulation for treatment of infantile Blount’s disease

Infantile Blount’s disease is a condition that causes genu varum and internal tibial torsion. Treatment options include observation, orthotics, corrective osteotomy, elevation of the medial tibial plateau, resection of a physeal bar, lateral hemi-epiphysiodesis, and guided growth of the proximal tibial physis. Each of these treatment options has its disadvantages. Treating the coronal deformity alone (genu varum) will result in persistence of the internal tibial torsion (the axial deformity). In this report, we describe the combination of lateral growth modulation and distal tibial external rotation osteotomy to correct all the elements of the disease. This has not been described before for treatment of Blount’s disease. Both coronal and axial deformities were corrected in this patient. We propose this combination (rather than the lateral growth modulation alone) as the method of treatment for early stages of Blount’s disease as it corrects both elements of the disease and in the same time avoids the complications of proximal tibial osteotomy.     

The effect of extraarticular varus and valgus deformity on total knee arthroplasty

Because of trauma, metabolic bone disease, congenital deformity, or prior osteotomy, an extraarticular deformity may be present in patients requiring total knee arthroplasty. If the extraarticular deformity is not corrected extraarticularly, it must be corrected by compensatory distal femoral or proximal tibial wedge resection to produce overall limb alignment. Because such a wedge resection between the proximal and distal attachments of the collateral ligaments will produce asymmetrical ligament length, complex instabilities may result. This article, through overlay templates and trigonometric analysis, evaluates all the issues confronting the surgeon deciding whether to pursue intraarticular or extraarticular correction. The conclusions are as follows: (1) the closer a deformity is to the knee, the greater its importance, (2) femoral deformities are more difficult to correct intraarticularly than tibial deformities because femoral compensatory wedge resection produces instability only in extension, and (3) intraarticular correction of varus deformities produces lateral instability that is usually better tolerated than medial instability, and some extraarticular deformities are best treated by extraarticular correct, independent, or total knee arthroplasty.     

Extra-ligamentous valgisation additive tibial head osteotomy. Indications-technic-complications-errors. Critical analysis

In patients with posttraumatic or idiopathic gonarthritis, varus deformity and stable medial collateral ligaments the valgus high tibia correction osteotomy in the open wedge method is performed extraligamentary. An autologous wedge from the iliac crest is used, a bridging plate osteosynthesis brings stability for early movement. 58 patients with 64 osteotomies operated between 1981 and 1986 underwent a follow-up examination. There was an infection rate on the tibial head of 15%. The reason for that was not in the procedure itself but in its application and performance. Respecting the site of osteotomy (less than or equal to 6.5 cm below tibial joint line), the size of the wedge at its basis (less than or equal to 10 mm), a strong indication in cases of repeated interventions and the correct technical performance of the procedure we see in the high tibia valgus osteotomy (open wedge method) a proper way of treatment in unilateral varus gonarthritis or varus deformities compared to other existing methods.     

Posterior calcaneal osteotomy with wedge: cadaver testing of a new procedure for insufficiency of the posterior tibial tendon.

Insufficiency of the posterior tibial tendon is challenging to treat. When the deformity is flexible, treatment options have included tendon transfer, often combined with a medial slide calcaneal osteotomy and/or a lengthening of the lateral column. Posterior calcaneal osteotomy has been shown to give correction, although not full correction. Lengthening of the lateral column also has been shown to give correction and has been used in the more severe flexible deformities, but it involves either fusion of the calcaneocuboid joint or risk of arthritis at this joint. An osteotomy combining the calcaneal medial slide with a lengthening of the lateral column at the same osteotomy site has been tested in the laboratory. This combined osteotomy provides a lengthening of the lateral column, but it is positioned away from the calcaneocuboid joint. In this study, the osteotomy was compared with a medial slide calcaneal osteotomy and an Evans lengthening of the lateral column, using a cadaver flatfoot model. Radiographic measurements were made to evaluate correction of the planovalgus deformity after each of these procedures. There was statistically significant improved correction with the new osteotomy compared with that in a standard medial slide, and correction was comparable to that in the lengthening of the lateral column. This combined osteotomy may be a reasonable alternative when more correction is desired than can be obtained from a medial slide alone and when the surgeon wishes to avoid an osteotomy near the calcaneocuboid joint.     

Blount's disease: classification and treatment

Forty-three tibia vara in 27 patients were analyzed retrospectively in two centers. The criteria for diagnosis of the child form are discussed. A simple classification is suggested to facilitate the choice of treatment. In stage 0 (possible Blount's disease), the patient is younger than 2 1/2 years, and an observation period is indicated for gathering data. In stage 1 (confirmed Blount's disease and absence of medial metaphyseal bony bridge), known as physis+, a valgization osteotomy is proposed. In stage 2 (evidence of a medial metaphysoepiphyseal bony bridge) known as physis-, valgization osteotomy with lateral epiphysiodesis and treatment of the lower limb discrepancy is proposed. For stages 1 and 2, there are two possibilities: normal medial tibial plateau or sloping of the medial tibial plateau, indicating a transphyseal elevation osteotomy. When one-step correction is proposed for stage 2 disorder, external fixators such as Orthofix or Ilizarov devices are useful.     

Talar neck osteotomy for flatfoot reconstruction: a 27-year follow-up study

The talar neck osteotomy is done at the junction of the head and neck of the talus, frequently in conjunction with desmoplasty and posterior tibial tendon advancement. This is done effectively to correct severe deformities involving the talus. The correction produces a structural realignment of the talar head. Adjunctive procedures are also done when these are deformities involving the posterior column, lateral column, and/or medial column. A 27-year follow-up study is presented containing data from 215 procedures on 117 patients with a minimum of one year follow-up.     

Computer aided high tibial open wedge osteotomy

High tibial osteotomy is a widely accepted treatment of medial compartment osteoarthritis as well as other lower extremity deformities. However, it is a technically demanding procedure. The lack of exact intraoperative real time control of the mechanical axis often results in postoperative malalignments, which is one reason for poor long term results. These problems can be addressed with the use of a surgical navigation system. Following exposure, dynamic reference bases (DRBs) are attached to the femur, and the proximal and the distal part of the tibia. After intraoperative measurement of the deformities and correction planning, the osteotomy is performed under navigational guidance. The wedge size, joint line orientation, and tibial plateau slope are monitored during correction. The in vitro evaluation with a plastic bone model suggests that the error of deformity correction is less than 1.7 degrees (95% confidence limits) in the frontal, and less than 2.3 degrees (95% confidence limits) in the sagittal plane, respectively. On a cadaver study of 13 legs, the mechanical axis intersected the Fujisawa line in 80.7% (range 77.5-85.8%). The preliminary clinical experience confirms these results. A novel computer tomography free navigation system for high tibial osteotomy has been developed that holds the promise of improving the accuracy, reliability, and safety of this kind of approach.     

Bony landmarks and rotational alignment in total knee arthroplasty for Chinese osteoarthritic knees with varus or valgus deformities

The purpose of this study was to investigate the rotational mismatch of total knee arthroplasty when taking the medial one third of the tibial tuberosity as a rotational landmark in Chinese osteoarthritic knees. Computed tomographic images of 49 osteoarthritic knees (42 with varus and 7 with valgus deformities) and 10 healthy knees were analyzed. The angle (alpha) between the 2 baselines for the anteroposterior axis of the femoral and tibial components was measured. The mean value of alpha in healthy knees was +6.45 degrees, which increased significantly to +11.53 degrees in varus knees (P = .002) and +12.17 degrees in valgus knees (P = .04). It showed that there is a tendency for the tibial component to be externally rotated when the medial one third of the tibial tuberosity is defined as a rotational landmark. This finding is particularly prominent in Chinese osteoarthritic knees with varus or valgus deformities.