GENU VARUM & BLOUNDS DISEASE in ortho.pptx

GENU VARUM & BLOUNDS DISEASE in ortho.pptx

1. GENU VARUM & BLOUNt'S DISEASE Dr Riyaz Parambil Dnb resident Aster mims , calicut

2. NATURAL HISTORY OF NORMAL EVOLUTION OF THE ALIGNMENT OF THE LOWER LIMBS Bowlegs in newborn and infants Becomes straight by 18/24 months By 2-3 years GENU VALGUS develops ( avg -12 degree) By 7 years spontaneous correction to the normal of adult valgus Female -8 , Male -7

3. GENU VARUM Angular deformity of the proximal tibia in which the child appears bowlegged Maximum varus is present at 6-12 months of age Bowlegs after 2 years of age considered abnormal

4. Physiologic genu varum is a deformity with a tibiofemoral angle of atleast 10 degrees of varus, a radiographically normal physis and apex lateral bowing of the proximal end of the tibia and often the distal end of femur

5. Deformity is usually gauged from simple observation Bilateral bow leg can be recorded by the distance between the knees with the child standing and the heels touching , it should be less than 6 CM.

6. CAUSES Physilogical Pathological Blount’s disease / Mau – Nilsonne syndrome Hypo phosphatemic or nutritional rickets Lateral ligament laxity / fibro cartilaginous dysplasia Congenital pseudoarthrosis of tibia Coxa vara Post traumatic / post infectious Congenital deformities Fibrous dysplasia Osteogenesis imperfecta Renal ostedystrophy

7. CAUSES IN ADULTS May be sequel of childhood deformity and if so usually causes no problems, However if the deformity is assosciated with joint instability, this can lead to osteoarthritis of the medial compartment Other causes include : Fracture of the lower part of the femur or the upper part of the tibia with malunion. Osteoarthritis Tumors affecting the lower end of femur and upper end of tibia. Rarefying diseases of the bone such as rickets or osteomalacia . Other bone softening diseases such as pagets diseases

8. ASSESMENT HISTORY The stature and nutritional status of the child Developmental milestones Other nutritional or medical problems History of trauma or infections

9. Short stature : Suggests the possibility of vit D refractory ( hypo- phosphetemic ) rickets or bone dysplasia ( achondroplasia or metaphyseal dysplasia) The inter condylar distance : Performed with the medial malleoli in contact Done in stance and supine Greater than 6 cm is abnormal Ruling out the deformity of the feet eg : metatarsus varus or valgus which may represent torsional deformity of the limb

10. Investigations Plain radiograph of the knee joints AP and lateral views Orthoscannogram Complete bone metabolic profile Serum Ca , Ph ,ALP Serum Vitamin D level Complete blood count RFT , Urine Ca level

11. treatment NON OPERATIVE In the vast majority cases , genu varum will correct with the growth In physiological Genu varum, education and assurance of the parents is important and just follow its natural course by reassessing the child in 6 months Treatment of underlying causes Brace application

12. BRACE APPLICATION The effectiveness of the brace is related to the relief of weight bearing stresses on the medial physeal region of the proximal tibia Brace treatment is reported to be succesfull in 50% to 80% of the patient treated . The brace is worn until the deformity has been corrected which usually takes about 1 year Thus bracing is usually not a viable option for children over 3 years

13. OPERATIVE Tibial osteotomy – The shinbone is cut just below the knee and reshaped to correct the alignment Guided growth –This surgery of the growth plate stops the growth on the healthy side of the shin bone which gives the abnormal side a chance to catch up, straightening the leg with the childs natural growth. After surgery , a cast may be applied to protect the bone while it heals. Crutches may be necessary for a few weeks, and exercises to restore strength and range of motion.

14. Blount’s disease

15. Tibia vara / Blount's disease is a developmental condition. It is characterised by a disturbance Of enchondral ossification at the upper end of tibia, affecting the medial portion of the growth plate, mainly in its posteromedial aspect & the medial portion Of the epiphyseal ossification center . As a result an abrupt varus angulation develops at the proximal portion Of the metaphysis while the diaphysis remains straight .

16. Secondary effects include internal torsion of the tibia, insufficient ossification of the medial portion Of the medial tibial condyle & stretched lateral collateral ligament. Blount described tibia vara as "an osteochondrosis similar to coxa plana & Madelung deformity but located at the medial side of the proximal tibial epiphysis".

17. etiology The exact cause is unknown & the condition is idiopathic. Enchondral ossification seems to be altered. Suggested causative factors include infection, trauma, osteonecrosis & a latent form of rickets, although none of these have been proved. A combination of hereditary & developmental factors is most likely cause. Weight bearing must be necessary for its development because it doesn't occur in nonambulatory patients. Relationship Of early walking & obesity with Blount's disease has been clearly documented Neither sex seems predisposed. Children of negroid descent , particularly in the West Indies & in West Africa, appear to be affected more frequently than the others.

18. pathology The cartilage over the medial Side Of the epiphyseal growth plate, particularly in the area Of the 'beak', is grossly disorganized, As a result of disordered endochondral ossification, the medial portion of the ossification zone Of the metaphysis forms a step-like unossified defect within which there are intermingled islands of bone and abnormal cartilage. The osteocartilagenous tissue extends medially from the metaphysis as an outgrowth about a bony beak. The intra-articular pathology consists of . E nlargement & hypermobility Of the medial meniscus D epression of the anterior aspect of the medial femoral condyle D epression Of the posteromedial plateau Of the tibia,

19. TYPES According to the age Blount described two types of tibia vara ; lnfantile : begins before 8 years of age Adolescent : begins after 8 years of age but before skeletal maturity. Further subdivided into: occurring between 8 & 13 years caused by partial closure of the physis after trauma or infection. occurring between 8 & 13 years in black & obese children without a distinct cause.

20. INFANTILE It is bilateral & symmetrical in approximately 60% Of affected children The bowleg deformity becomes apparent when the infant starts to Stand & walk It is impossible to differentiate it from the physiological bowing before 2 years of age. Later as the age increases the deformity worsens which is not the case with physiological bowing. The components Of the deformity include a sharp medial angulation of the tibia at the metaphysis , more evident in the weight-bearing position.

21. Internal tibial torsion & pes planovalgus develop secondarily. In compensation there is hypertrophy Of the medial femoral condyle A bony, hard, non-tender prominence is palpable on the medial epiphysio metaphyseal junction SIFFERT KATZ sign: As the extended knee is slightly flexed, the medial femoral condyle loosely engages the depression in the medial tibial plateau & posteromedial rocking is demonstrable The deformity worsens prog ressively & an increasingly Sharp, usually bilateral bowleg angulation & waddling gait become pronounced,

22. I n long standing cases, there is Slight flexion deformity & the collateral ligaments become lax & joint becomes unstable . Limb length discrepancy is usually not seen as it is bilateral

23. Adolescent type Not as common as infantile type. Develops between 8-13 years Of age. The deformity is unilateral, is generally mild to moderate, rarely exceeds 20 degrees. It is never associated with a medial osteocartilagenous prominence Secondary internal tibial torsion & pes planovalgus do not develop . The leg shortening may be appreciable. The patient is usually obese .

24. RADIOGRAPHY X-ray is the most commonly done investigation for the diagnosis Characteristically the medial half of the epiphysis appears short, thin & wedged. Physis is irregular in contour & slopes medially. The medial portion of the metaphysis displays a beak-like projection extending medially & surrounded by multiple radiolucent areas (cartilage).

25. This projection present medially is often palpable, but this projection is not diagnostic of tibia vara . Medial metaphyseal fragmentation is pathognomic for the development of a prog ressive tibia vara . The angular deformity occurs just distal to this projection

26. Langenskiold noted progression of epiphyseal changes & the deformity through six stages with growth & development

27. Various angles of the femur & tibia at the knee can be determined on the radiographs, when the deformity is present TIBIO METAPHYSIO DIAPHYSEAL ANGLE Levin and drennaan Angle >11 degree mostly blount lesion Angle < /= 11 degree usually resolves

28. HISTOLOGY In the infantile type, bone changes include delayed ossification of the medial epiphysis & metaphysis of the proximal tibia. These changes include cell hypertrophy & dense cellularity, fibrocartilage islands & abnormally large group Of capillaries.

29. DD Congenital bowing of the tibia Vitamin –D resistant rickets Deformity of the medial tibial condyle due to gonadal dysgenesis

30. Treatment Depends upon the age of the Child & severity of the varus deformity. Non-operative treatment: Generally, observation or a trial of bracing is indicated for children between ages 2-5 years Ambulatory bracing with an above-the knee orthosis is effective, If the disease continues to prog ress with brace treatment, it will no longer be effective.

31. orthotics Indication Child <3 years Langleskoid stage 1 and 2 Unilateral

32. Corrective osteotomy Metaphyseal Epiphyseal-metaphyseal Intra epiphyseal

33. >9 years with more severe involvement Osteotomy alone with bony bar resection, Epiphysiodesis of lateral tibial and fibular physis For older children with failed bracing and tibial osteotomy Intraepiphyseal osteotomy Valgus metaphyseal osteotomy to correct the varus angulation

34. Metaphyseal oblique osteotomy Advantage : Single plane oblique cut : simultaneous correction of proximal varus and internal rotation Allows postoperative caste wedging if necessary to obtain appropriate position Post op care Cast is changed at 4 weeks Weight bearing allowed if callus evident over radiographs Cast worn till 8 weeks /till union is evident radiographically

35. CHEVERON OSTEOTOMY Advantages Great stability Minimal changes in leg length Disadvantages Loss of fixation /correction Longer period of cast immobilisation

36. HEMICONDYLAR OSTEOTOMY INDICATION Ligementous laxity Extreme depression and sloping of medial tibial condyle

37. Intra epiphyseal osteotomy indication : Severe joint instability Corrects intra articular components of blounts disease Valgus osteotomy to correct genu Vara

38. hemiepiphyseodesis Allow growth in medial physis to catch up thus coreecting the deformity Temporary : Use of 8 plate or bone staples May recur following implant removal High risk of mechanical failure in obese patients Permanent

39. Ilizarov technique Gradual correction of all components of the deformity ( varus, procurvatum , internal torsion and shortening ) Allows adjustment of limb alignment post operatively.

40. prognosis The prog nosis in the infantile form Of Blount disease must be considered separately from that in the adolescent form, Infantile tibia vara has a good prognosis, and recurrence rates of deformity are low When treated at a young age and early Stage. In the late-onset form of the disease, regression does not occur and the varus deformity may worsen over timer Best outcomes with early diagnosis and unloading of the medial joint with either bracing or an osteotomy

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