Introduction:. Blount's disease can be defined as idiopathic proximal tibial vara. Several etiologies including the mechanical theory have been described. Obesity is the only causative factor proven to be associated with Blount disease. Varus deformity is also a clinical feature of rickets and 31% of children with vitamin D deficiency rickets presented with varus deformities to the local Metabolic Bone clinics. The aim of this study is to assess if there is an association between vitamin D and Blount's disease. We hypothesize that children with Blount disease are more likely to be vitamin D deficient. Method:. This a retrospective study of pre-operative and post-operative patients with Blount's disease who were screened for vitamin D deficiency. Patients with known vitamin D deficiency and rickets were excluded. The study patients had the following blood tests: calcium, phosphate, alkaline phosphatase, parathyroid hormone and 25-hydroxyvitamin D. Body mass index (BMI) was also assessed. Results:. We recruited 50 patients. The mean age of these patients was 10.4 years (SD 3.88) with average BMI of 28.7 (SD 10.2). Fifty two % were overweight. Thirty (60%) patients were diagnosed with infantile, 16(32%) adolescent and 4(8%) juvenile Blount disease. Eight (16%) patients were found to be vitamin D depleted (less than 20 ng/ml). Of these eight patients, six had insufficient 25-hydroxyvitamin D levels (12–20 ng/ml) and while the other two were vitamin D deficient (less than 12 ng/ml). Conclusion:. Vitamin D deficiency is a public health problem worldwide. This study confirms that the prevalence of Vitamin D deficiency in children with Blount's disease is similar to healthy children and infants living in Johannesburg. There is no evidence that Vitamin D deficiency is a factor in causing Blount's disease. Routine screening for Vitamin D deficiency in children with Blount disease is not recommended

Blount's disease is by far common cause of significant genu varum in paediatric age group. The deformity can range from simple varus deformity to significant varus, shortening of tibia and internal torsion of tibia, depending up on type and stage of Blount's disease. Several studies have shown excellent correction with the use of circular frame. The trend has moved from Ilizarov circular frame to Taylor Spatial Frame. The most accepted method of achieving correction of all components is by performing proximal tibial osteotomy and gradual correction of mechanical axis. Traditionally two additional procedures – fibular osteotomy and fixation of distal tibio-fibular syndesmosis are also added. However, the role of these additional procedures, which are not without their complications, is not well evaluated. A recent study had shown that correction of tibia vara without lengthening can be achieved without fibular osteotomy. However, use of distal tibio-fibular syndesmosis fixation (either with a wire or a screw) remains controversial. We present our experience in treating Blount's deformity with circular frame without stabilization of distal tibio-fibular syndesmosis. 10 patients were treated at our tertiary referral centre between 2000 to 2010. There were 7 boys and 3 girls. Age at surgery ranged from 8 yrs – 15 yrs. The mean patient age was 11.5 yrs. Two patients were treated with Ilizarov frame and 8 with Taylor Spatial Frame. Indications for surgery were unacceptable deformity (varus and internal rotation), with or without shortening. Varus deformity ranged from 10 degrees to 40 degrees. All tibiae were lengthened and the range of lengthening was from 1cm to 3.5cm. Fibular osteotomy was carried out in all patients. Tibio-fibular syndesmosis was never stabilized distally. All the patients were encouraged to mobilise full weight bearing as soon as tolerated and all of them had gradual correction of deformity usually starting a week following the surgery. We achieved target correction of varus, internal rotation and leg length discrepancy in all patients. The commonest hurdle was superficial pin tract infection which resolved with short courses of oral antibiotics. Follow up ranged from 6 months to 10 yrs. Clinical and radiological evaluation of ankle did not show any abnormality in all these cases. Satisfactory correction of Blount's disease (tibia vara and leg length discrepancy) can be achieved with circular frame without the stabilization of distal tibio-fibular syndesmosis

Background:. Tibia Vara (Blount's disease) is characterized by a growth disturbance of the posteromedial proximal tibial physis. This results in the typically complex tibial deformity of varus, procurvatum and internal tibial torsion. Knee instability is due to medial tibial joint depression and lateral ligament complex attenuation. Femoral angular and rotational deformity are associated features. Obesity often complicates management. Langenskiöld observed six stages of the disorder on X-ray (stage 6 not occurring before 9 years) and obtained good results with proximal tibial realignment osteotomy if performed before the age of 8 years. Our experience is very different. Purpose:. To evaluate our experience with treatment of a consecutive cohort of patients with early onset Blount's disease in terms of clinical findings, recurrence rate and factors associated with recurrence and treatment methods and indications. Methods:. A retrospective chart and imaging review was completed of 100 extremities (58 patients) treated surgically for early onset Blount's disease. Follow-up ranged between 1 and 7 years. Results:. These children all presented with a history of onset of deformity between the ages of 1 and 3 years. Their age at first treatment varied between 2 and 10 years. Langenskiöld stage V and VI occurred in younger patients than originally described. The recurrence rate of extremities treated with simple osteotomy was 42% (25/58). Factors associated with recurrence include age >4 (p<0.001), obesity (p=0.007), instability (p=0.003), severity of deformity (femoro-tibial angle) (p<0.001), medial physeal slope (p<0.001) and advanced Langenskiöld stage (p<0.001). Surgical treatment included the use of growth retardation alone, dome realignment osteotomy with and without growth retardation, oblique proximal tibial (Rab) osteotomy, 3-in-1 procedure (medial elevation, tibial osteotomy and lateral epiphyseodesis) and gradual correction with hexapod fixators was used in some recurrent cases. In addition we describe a new surgical technique which obtains acute deformity correction at the level of the growth plate. Conclusion:. We propose that the disease follows a more aggressive course in the black population of Kwa-Zulu Natal, South Africa. The management is often complex and recurrence is not uncommon

Background:. Recurrent or late presenting Tibia Vara is a complex clinical problem. In addition to the multiplanar deformity the disorder is often accompanied by obesity. Simple re-alignment osteotomy with acute correction is effective early in the disease. Its use in recurrent or severe deformities is limited by geometric constraints (mechanical axis translation), difficult fixation and the risk of compartment syndrome. Gradual correction with external fixation devices is a well-accepted technique in these cases. It has been shown to obtain accurate correction and provides stable fixation. This allows early weight bearing which facilitate consolidation and rehabilitation. Hexapod fixators are technically less demanding than standard Ilizarov techniques. The TLHex is a relatively new hexapod fixator available in South Africa. Frame pre-assembly allows easier mounting on a limb with complex deformity. The software allows for non-orthogonal mounting, which simplifies frame-mounting assessment. Double telescoping struts allow greater strut excursion and the outside mounting of struts on the ring increases mounting options for fixation elements. This is the first report on its use in Blount's disease. Purpose:. Evaluation of the result of gradual correction with the TLHex external fixator in Blount's disease in terms accuracy of correction, union and complications. Illustration of key hardware and software features. Methods:. A retrospective chart and X-ray review of 7 patients (9 legs) treated by gradual correction with the TLHex external fixator was performed. The degree of correction of varus and procurvatum was assessed on pre-operative and post-correction X-rays. Internal rotation deformity correction was assessed clinically. Complications such as neurovascular compromise, minor and major pin tract infection and hardware complications were documented. The pre-operative planning, surgical technique and post-operative treatment protocol is reviewed. Results:. Mean varus was corrected from 21° (17° to 45°) to 1°(−2° to 4°). Mean procurvatum was corrected from 8° (0° to 25°) to 0° (0° to 8°). Internal rotation was corrected to between 5° to 10° of external rotation in all patients. The mean time in the frame was 112 days. Three patients needed one additional program to correct residual deformity (one over-corrected coronal aligment, one under-corrected saggital alignment and one rotational over-correction). Three patients required oral antibiotics for minor pin tract infection. One patient required intravenous antibiotics and wire removal for major pin tract infection. One patient required frame adjustment after correction for soft tissue impingement. One strut loosened after consolidation prior to frame removal. Conclusion:. Gradual correction of Tibia Vara with the TLHex external fixator is a safe and effective treatment method

Limb deformity is common in patients presenting for knee arthroplasty, either related to asymmetrical wear patterns from the underlying arthritic process (intra-articular malalignment) or less often major extra-articular deformity due to prior fracture malunion, childhood physical injury, old osteotomy, or developmental or metabolic disorders such as Blount's disease or hypophosphatemic rickets. Angular deformity that is above the epicondyles or below the fibular neck may not be easily correctable by adjusted bone cuts as the amount of bone resection may make soft tissue balancing impossible or may disrupt completely the collateral ligament attachments. Development of a treatment plan begins with careful assessment of the malalignment which may be mainly coronal, sagittal, rotational or some combination. Translation can also complicate the reconstruction as this has effects directly on location of the mechanical axis. Most intra-articular deformities are due to the arthritic process alone, but may occasionally be the result of intra-articular fracture, periarticular osteotomy or from prior revision surgery effects. While intra-articular deformity can almost always be managed with adjusted bone cuts it is important to have available revision type implants to enhance fixation (stems) or increase constraint when ligament balancing or ligament laxity is a problem. Extra-articular deformities may be correctable with adjusted bone cuts and altered implant positioning when the deformity is smaller, or located a longer distance from the joint. The effect of a deformity is proportional to its distance from the joint. The closer the deformity is to the joint, the greater the impact the same degree angular deformity will have. In general deformities in the plane of knee are better tolerated than sagittal plane (varus/valgus) deformity. Careful pre-operative planning is required for cases with significant extra-articular deformity with a focus on location and plane of the apex of the deformity, identification of the mechanical axis location relative to the deformed limb, distance of the deformity from the joint, and determination of the intra-articular effect on bone cuts and implant position absent osteotomy. In the course of pre-operative planning, osteotomy is suggested when there is inability to correct the mechanical axis to neutral without excessive bone cuts which compromise ligament or patellar tendon attachment sites, or alternatively when adequate adjustment of cuts will likely lead to excessive joint line obliquity which can compromise ability to balance the soft tissues. When chosen, adjunctive osteotomy can be done in one-stage at the time of TKA or the procedures can be done separately in two stages. When simultaneous with TKA, osteotomy fixation options include long stems added to the femoral (or tibial) component for intramedullary fixation, adjunctive plate and screw fixation, and antegrade (usually locked) nailing for some femoral osteotomies. Choice of fixation method is often influenced by specific deformity size location, bone quality and amount, and surgeon preference. Surgical navigation, or intra-operative x-ray imaging methods (or both) have both been used to facilitate accurate correction of deformity in these complex cases. When faced with major deformity of the femur or tibia, with careful planning combined osteotomy and TKA can result in excellent outcomes and durable implant fixation with less constraint, less bone loss, and better joint kinematics than is possible with modified TKA alone

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.