Metaphyseal-diaphyseal Angle Research Articles

Foetal Achondroplasia: Prenatal Diagnosis, Outcome and Perspectives

BackgroundAchondroplasia, due to a specific pathogenic variant in FGFR3, is the most common viable skeletal dysplasia and the diagnosis is mostly done in the prenatal period. Since 2021, the use of Vosoritide, a specific treatment for achondroplasia, validated in phase 3 placebo-controlled trials, has been recommended to significantly increase the height of children and infants. In the light of these new therapeutic prospects, a complete understanding of the pathophysiology of skeletal damages occurring from foetal life is required. ObjectivesTo describe foetal imaging and the antenatal and postnatal management of pregnancies complicated by a diagnosis of foetal achondroplasia. MethodsA retrospective and descriptive study, including all pregnant women with a prenatal diagnosis of achondroplasia, was conducted in the prenatal unit of Necker Hospital (Paris, France) between 2009 to 2022. Maternal and obstetric characteristics and foetal imaging (ultrasound and bone CT) were collected. Pregnancy outcomes, paediatric follow-up in the case of live births, and post-mortem examination (PME) data in the case of termination of pregnancy were reported. In addition, we have prospectively developed a specific research protocol using foetal brain MRI to assess the anatomy of the foramen magnum, following the same approach currently recommended in the postnatal period. Results29 cases of achondroplasia were included. Median gestational age at referral was 31+2 weeks’, about 1 week after the suspected diagnosis on routine ultrasound. Shortening of the femoral length and of all the other long bones, macrocephaly, facial abnormalities, increased metaphyseal-diaphyseal angle and tapering of the proximal femoral bone were the five most prevalent ultrasound signs. Foetal diagnosis was done by the identification of the foetal FGFR3 mutation and/or by CT scans (n=15) where specific abnormalities of the long bones, platyspondyly and abnormal profile have been described in 100% of cases. PME revealed: i) on external examinations (n=7) that all fetuses had very short long bones, moderate platyspondyly, small iliac wings with internal spines, macrocrania, and narrow thorax, ii) on internal examination (n=5) all had severe abnormalities in the growth plate and particularities in the temporal cortex and hippocampal region. One foetal MRI was performed at 33 weeks’ and revealed tight stenosis of the foramen magnum and compression of the spinal cord. Of the live-born infants for whom follow-up was known (n=6), 2/6 (including the case who had a foetal MRI) required neurosurgical intervention in the first few months of life for spinal cord compression due to severe stenosis of the foramen magnum. ConclusionA complete mapping of the skeletal features present in fetuses with achondroplasia is reported here, providing a better understanding of the pathophysiology of this condition. New tools such as foetal MRI, to assess the risk of postnatal severe neurological complications, could help improve the care pathway of the affected neonates.

An Observational Study of Clinico-radiological Co-relation of Carrying Angle in Children.

The purpose of this study is to establish the correlation of clinically measured carrying angle with four radiological angles, i.e., Humerus-Elbow-Wrist angle (HEWA), Humero-ulnar angle, Metaphyseal-Diaphyseal angle, and Baumann's angle, and to find out which of the above-mentioned angles co-relates best with the clinically measured carrying angle. We studied 100 patients in the age group of 2-12years after Ethics committee approval and informed consent from parents. Clinical angle was measured using goniometer and radiological angles marked on antero-posterior elbow X-ray using a standard method. Collected data were studied using statistical tests to find out correlation. Pearson correlation coefficient for humerus-elbow-wrist angle found to be 0.674 followed by Humero-Ulnar angle (r = 0.417). Regression coefficient for humerus-elbow-wrist angle is 0.635 (p value < 0.001). Humerus-Elbow-Wrist angle correlates better compared to other radiological angles in assessment of varus-valgus angulations of elbow & will not only play a vital role in pre- operative planning of deformity corrections but also in the evaluation & comparison of the post-operative functional outcomes.

Treatment and Outcome of Supracondylar Humeral Fractures in Children Over 10 Years of Age at the Time of Injury: A Review of 60 Cases.

To assess the treatment and outcomes of supracondylar humeral fractures (SHFs) in children older than 10 years of age at the time of injury. The study analyzed clinical data from 60 patients who sustained SHF, all over the age of 10 years, were analyzed. The patients included 49 males and 11 females with a mean age of 10.9 ± 0.9 years (range, 10 to 14.5). All patients underwent surgical treatment under general anesthesia. Closed reduction (CR) and percutaneous fixation were the primary treatment, with open reduction and internal fixation being employed only in cases CR was unsuccessful. The study assessed the healing of fractures by measuring the radiographic angles, including the carrying angle (RCA), Baumann's angle (BA), and metaphyseal-diaphyseal angle (MDA) on anteroposterior radiographs of the elbow joint. In addition, the study evaluated whether the anterior humeral line (AHL) appropriately passed through the middle third of the capitellum. The final follow-up visit used the Mayo Elbow Performance Index score (MEPI) and Flynn's criteria to analyze the recovery of elbow function. There were 15 (25%) SHF type II, 17 (28.3%) type III and 28 (46.7%) type IV. Of the 60 patients, 56 (93.3%) underwent successful CR, whereas 4 (6.7%) required open reduction and internal fixation because of an unsuccessful CR. The final follow-up showed the average BA as 72° ± 5.3°, the average MDA as 88.3° ± 2.8°, and the average RCA as 9.6° ± 3.9°. The AHL bisected accurately the capitellum in 59 cases (98.3%). The average range of elbow flexion-extension was 146.6° ± 8.6°, whereas the average MEPI score was 99.9 ± 0.6; 98.3% (n=59) were rated as excellent and 1.7% (n=1) were rated as good. According to Flynn's criteria, 86.7% had an excellent outcome (n=52), 10% had a good outcome (n=6), and 3.3% had a poor outcome (n=2). Only 1 patient (1.7%) experienced redisplacement. Eight cases of nerve injury were reported, with 7 involving the radial nerve and 1 involving the ulnar nerve; all resolved spontaneously. CR and percutaneous fixation have been shown to be effective in treating SHF in 93.3% of children aged 10 years old and older at the time of injury, with favorable radiographic and functional outcomes and a low risk of secondary displacement. Open reduction should only be considered when CR is ineffective.

An alternative osteosynthesis technique: single column anatomical plate fixation for distal humerus diaphyseal fractures

Background: The treatment of distal humerus diaphyseal fractures presents significant challenges for orthopedic surgeons. The goal of this study is to evaluate the effectiveness and outcomes of a single column anatomical plate as an alternative method of osteosynthesis for fixing distal humerus diaphyseal fractures. Methods: A Prospective analysis of patients who underwent surgery for distal humerus diaphyseal fractures at a tertiary care medical center was conducted. Patients who received treatment using a single column anatomical plate were included in the study. Preoperative, intraoperative, and postoperative data, including fracture type, surgical approach, complications, range of motion, and radiographic outcomes, were collected and analyzed. Results: Type B2 fractures were more common in our study i.e., 80%. The maximum incidence was between 18 to 59 years i.e., 21 cases (77%). Average radiological union was seen at 15 weeks. This study shows Excellent outcome in 67% and Good in 30% of patients. Average post-operative ROM at 1 year was mean flexion 120°(SD 7), mean extension of 6 degrees (SD 4.7), mean pronation 81.25°(SD 2.5) and mean supination 82.5°(2.8). Average MEPS score was 95.5 at 1 year. The mean metaphyseal-diaphyseal angle was 85°, the mean humeral-ulnar angle was 14°, which was within the normal limits. Conclusion: The use of a single column anatomical plate for fixing distal humerus diaphyseal fractures appears to be a promising alternative method of osteosynthesis. However, further prospective studies with larger sample sizes and longer follow-up periods are warranted to validate the efficacy and safety of this technique.

Comparative Evaluation of the Radiographic Parameters for Screening Early Blount Disease.

Radiographic findings in young children with physiological bowing sometimes difficult to distinguish from early Blount disease. However, early diagnosis of the disease is critical because of the poor treatment outcomes for Blount disease. In this study, we aim to evaluate the accuracy of the metaphyseal-diaphyseal angle (MDA) compared with the medial metaphyseal beak (MMB) angle for differentiating between physiological bowing and early Blount disease and to determine which parameter to adequately screen for the subsequent development of Blount disease. A retrospective study was conducted on children aged 1 to 3 years old who were brought to our outpatient clinic with bowed leg between 2000 and 2017. Data on the patients' age, sex, and affected sides were collected. Radiographic measurements of the femorotibial angle (FTA), MDA, and MMB angle were evaluated from the initial radiographs. An observer repeated the measurements on all the radiographs 2 weeks after they were first done. In total, 158 legs were considered from 79 children (48 males/31 females), whose average age was 26.0±6.1 months old. Eighty-seven legs were diagnosed with Blount disease and 71 legs had physiological bowing. Using single cutoff values of 16 degrees for the MDA showed low sensitivity (50.6%), very high specificity (100.0%), and a very high positive predictive value (PPV); while using MMB angle cutoff values ≥122 degrees showed very high sensitivity (92.0%), high specificity (80.3%), and a high PPV. Considering the MDA and MMB angle simultaneously showed very high sensitivity (93.1%), high specificity (80.3%), and a high PPV. The area under the receiver operating characteristic curve of the MDA and MMB showed excellent (0.89) and outstanding (0.93) discriminative ability, respectively. When combining the MDA and MMB angles, it was also considered outstanding performance (area under the receiver operating characteristic curve=0.95). The MMB angle represents a potential radiographic screening parameter for predicting early Blount disease in children 1 to 3 years old, offering high sensitivity and specificity. The MDA showed excellent specificity as a confirmation parameter for Blount disease patients. Applying both the MDA and MMB angles is another option to increase early recognition and confirm the diagnosis in early Blount disease patients. Level II.

Blount Disease: A Case Report and Review of the Literature

Introduction: Blount disease is an asymmetrical disorder of proximal tibial growth that produces a three-dimensional deformity. Tibia vara is the main component of the deformity. There is general agreement that two clinical forms should be distinguished based on age, infantile and adolescent, with 10 years as the cut-off. Case: We present a case of 11 year old girl admitted to our radiology department with chronic bilateral gonalgia and genu varum evoluting for a year. The clinical examination reveals bilateral varus deformity of the proximal tibia, a palpable prominence or “beaking” of the proximal medial tibial epiphysis and metaphysic. The diagnosis of blount disease has been confirmed on standard radiography. Conclusion: Blount's disease remains a rare disease whose etiology is still unknown, seems to involve hereditary and environmental factors explaining its very particular distribution. Radiological investigations are helpful to the diagnosis by showing medial varus malalignment of the tibial metaphysis. Many angles have been described. A mongthem, the mostuseful are the mechanical tibio-femoral angle, metaphyseal-diaphyseal angle (MDA) of Levine and Drennan, and bony tibial slope.

Outcome of Dome-Shaped Proximal Tibial Osteotomy in Infantile Genu Varum

Background: The goals of the proximal tibial osteotomy are correcting the deformity, Hip-knee-ankle angle, and preventing the progress of the destruction of the medial compartment of the knee joint. Objectives: The aim of the work was to evaluate the outcome of children with genu varum after proximal tibial dome shaped osteotomy. Patients and Methods: These randomized clinical trials study included a total of 10 patients with 12 affected knees confirmed with persistent physiologic genu varum, attending at Orthopedic Department, Zagazig University Hospitals, Zagazig, Egypt. All cases were evaluated pre and post-operatively according to Modified Hospital for Special Surgery Knee Scoring System (HSSKS) as shown in appendix I. cases were assessed for functional improvement after surgery at 2, 4 months and detection of malunion or delayed union after 3 months. Results: The mean (±SD) pre-operative tibio-femoral angle was 21.7 (±5.6) versus 3.18 (±1.97) post-operatively, pre-operative femoral condyle-tibial shaft angle (FTA) was 16.3 (± 2.8) versus 3.2 (±1.1) post-operatively and pre-operative metaphyseal diaphyseal angle was 15.8 (±2.6) versus 3.6 (±1.2) post-operatively with a statistically significant difference in between (p < 0.05). The mean pre-operative HSSKS scores were 70.16±11.3 while the mean post-operative HSSKS scores were 91.4±2.1. Conclusion: It could be concluded thatproximal tibial osteotomy using dome-shaped procedure to correct Infantile Genu varum deformity, has favorable treatment outcomes, does not involve any dangerous complications, and can be used as a safe and effective treatment method for the correction of infantile genu varum deformity. In the current study, angles significantly improved, most of legs got full correction and little complications occurred.

Controlled Double Gradual Opening Osteotomy for the Treatment of Severe Varus of the Knee—Blount’s Disease

Varus deformity of the knee can lead to early degeneration of the medial tibiofemoral joint. Pediatric patients can be pathologically affected with this deformity known as Blount disease. The cause of this pathology is still uncertain, but some risk factors are well established, such as obesity and family history. The diagnosis is made through clinical history, physical examination, and the radiographic analysis after the age of 2.5 years. The analysis of the metaphyseal-diaphyseal angle, described by Levine and Drennan, is also commonly used for prognosis. When this angle is greater than 16°, it is considered to be grossly abnormal. Possible options for correcting the generated angular deformity are epiphysiodesis, osteotomy (acute or gradual correction), and gradual correction by distraction of the physis. In this surgical technique, we performed a double tibial osteotomy with controlled gradual opening using monolateral external fixator (Orthofix, Verona, Italy). Our technique proved to be an effective way to correct the adolescent tibia vara and is practical and reproducible. Moreover, the use of gradual opening osteotomy allowed a more accurate outcome.

Infantile Blount’s Disease: A case report of 3 years old female of Zhob, Pakistan

Background; Blount’s disease is a rare developmental disorder of children which causes progressive bowing of lower limbs. The term “Blount” was named after American orthopedic surgeon “Walter Putnam Blount” who first described this condition. The etiology of Blount’s disease is unknown but believed to be multifactorial. Various predisposing factors have been attributed including obesity, early walking, race, pre-existing varus, increased pressure on growth plate and nutrition. Blount’s disease has been suggested to be more frequent in African, Afro-american populations. Blount’s disease has to be differentiated from physiological bowing (physiologic genu varum) and rickets. Early diagnosis and treatment of Blount’s disease is essential as the disease process is reversible in early stage. Case; A three years old female child was brought by her mother with complaint of progressive bowing of both lower limbs for last one year. She achieved her milestones at appropriate age and started walking at 11 months of age without support. On examination, her height was 90 cms (at 10th centile) and weight was 17 kgs (at 90th centile). BMI (body mass index) was 20.9 (obese). There were no clinical signs or symptoms of rickets i.e frontal bossing, wide wrist, rachitic rosary, carpopedal spasm, fits or muscle weakness etc. Roentgenogram showed tibia in varus with a peculiar beak at metaphysic and raised metaphyseal-diaphyseal angle (&gt;16 degrees). Serum calcium and serum vitamin D (25-hydroxy vitamin D) were normal. Serum alkaline phosphatase level was raised. Keeping in view typical history, examination findings and radiological epiphyseal beaking along with raised metaphyseal-diaphyseal angle, diagnosis of Infantile Blount’s disease was made. Conclusion; The clinicians should have a high suspicion of infantile blount’s disease when a child, more than 3 year’s age presents with severe varus deformity at proximal tibia with typical radiological findings. Characteristic radiologic findings along with history and examination help to distinguish it from physiologic bowing (physiologic genu varum) and rickets. Keywords; Blount’s disease, Physiologic genu varum, Rickets, Tibia vara, Osteochondrosis deformans tibiae

Acute correction of proximal tibial coronal plane deformity in small children using a small monolateral external fixator with or without cross-pinning.

PurposeSurgical correction of proximal tibia deformity in small children can be challenging. We present the surgical technique and outcome of proximal tibia osteotomy fixed with small monolateral external fixator in this patient group.MethodsA total of 17 cases in eight patients younger than nine years of age were study subjects. A proximal tibia osteotomy was fixed with a small monolateral external fixator with or without cross-pinning. Outcome was evaluated by changes of radiographic parameters such as medial proximal tibia angle (MPTA), metaphyseal diaphyseal angle (MDA) and clinical findings of complications, time interval until weight bearing and fixator removal time.ResultsMPTA improved from a preoperative mean of 73° (sd 4°; 66° to 78°) to an immediate postoperative mean of 90° (sd 3°; 85° to 96°) in varus tibiae, and from 104° (sd 1°; 103° to 105°) to 89° (sd 1°; 88° to 89°) in valgus tibiae. In all, 15 of the 17 cases (88.3 %) achieved postoperative MPTA within the normal range (85° to 90°). MDA improved from a preoperative mean of 19° (sd 5°; 11° to 24°) to an immediate postoperative mean of 0° (sd 4°; -6° to 7°) in varus tibiae, and from -25° (sd 2°; -22° to -24°) to 2° (SD 1°; 1° to 3°) in valgus tibiae. Full weight bearing was possible at mean 1.7 months (0.5 to 3.0). Mean follow-up period was 6.5 years (sd 5.4; 1.0 to 16.0). No complications developed during the follow-up.ConclusionProximal tibia osteotomy fixed with small monolateral external fixator provides accurate, safe and efficient correction in the management of coronal plane angular deformity in small children.Level of EvidenceLevel IV

Single-stage medial plateau elevation and metaphyseal osteotomies in advanced-stage Blount's disease: a new technique.

PurposeSurgical treatment in advanced-stage infantile Blount’s disease with medial plateau (MP) depression is challenging. Several osteotomies and fixation methods have been described with no established benchmark. We conducted this study to evaluate the efficacy and safety of a new single-stage technique for acute medial condyle elevation and metaphyseal osteotomies with internal fixation.MethodsA prospective case series of 19 consecutive patients (21 knees) with severe infantile Blount’s disease underwent a single-stage MP elevation and metaphyseal osteotomies, with internal fixation. The mean age was 10.3 years (8.2 to 13.6) and the mean follow-up was 5.1 years (3.2 to 8.3). The outcome measures included clinical and radiological parameters and patient-reported pediatric outcomes data collection instrument (PODCI) score.ResultsThe mean PODCI score improved significantly from 50% to 88%. The mean internal tibial torsion improved from -27° to 11°. All cases maintained full knee extension, no limitation in flexion range of movement and no signs of instability or lateral thrust gait. All the radiographic parameters improved significantly; the mean tibiofemoral angle improved from -29° to 7°, the metaphyseal-diaphyseal angle improved from 33.4° to 4.7° and the angle of depressed MP improved from 38.3° to 2.4° (p < 0.001). At the latest follow-up, no cases of deformity recurrence were identified, the final limb-length discrepancy was < 1 cm in all patients.ConclusionSingle-stage MP elevation and metaphyseal osteotomies with internal fixation significantly improved the clinical and radiographic parameters and PODCI score in advanced infantile Blount’s disease and precluded the use of external immobilization, with no evidence of deformity recurrence.Level of evidenceIV

Alkaline phosphatase in pediatric patients with genu varum caused by vitamin D-deficient rickets.

An elevated serum alkaline phosphatase (ALP) level is one of the markers for the presence of rickets in children, but it is also associated with bone formation. However, its role in diagnosing genu varum in pediatric patients with vitamin D-deficient rickets is still unknown. To clarify the role of the serum ALP level in assessing the severity of genu varum, we retrospectively investigated this issue statistically using data on rickets such as serum intact parathyroid hormone (iPTH), 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, ALP, the level of creatinine as the percentage of the median according to age (%Cr), and the metaphyseal diaphyseal angle (MDA) in the lower extremities as an index of the severity of genu varum. A multiple regression analysis revealed that log ALP and %Cr values were negatively associated with MDA values. The former association was also confirmed by a linear mixed model, while iPTH was positively associated with MDA by path model analysis. To elucidate the association of ALP with MDA in the presence of iPTH, we investigated three-dimensional figures by neural network analysis. This indicated the presence of a biphasic association of ALP with MDA: the first phase increases while the second decreases MDA. The latter phenomenon is considered to be associated with the increase in bone formation due to the mechanical stress loaded on the lower extremities. These findings are important and informative for pediatricians to understand the significance of the serum ALP level in pediatric patients with genu varum caused by vitamin D deficiency.

Infantile Blount disease: a developmental tibial growth defect.

A 2.5 years male child, who presented with Leg bowing. As per the parents, infant started walking early at 10th month and bowing of legs got worsened over time. Paediatric orthopedicians diagnosed him with endochondral disorder of the proximal end of medial tibial physis. He was referred to Physiotherapy department, for evaluation and rehabilitation. On examination, genu varum was seen (A), a positive ‘cover-up test´, internal tibial torsion, leg length difference, no tenderness, limitation of motion, and effusion, according to the review which lead to the diagnosis Blount's Disease. Lower extremity deformities in Rickets can closely mimic and osteochondro-dysplasia or genetic bone diseases which can cause lower extremity deformities similar to Blount's disease. The metaphyseal-diaphyseal angle of bones was determined and found to be 24°, which is considered abnormal. The child's lower leg was seen turned inward, causing the leg to appear bent below the knee (B). He had difficulties during walking and complained of pain in both the knees after 5-7 minutes of walk with lateral thrust on walking. According to Langenskiold Classification, the child is in stage 2 (2.5-4 yrs. old). As a result, parents were introduced to a home exercise program which included strengthening and stretching to correct gait and muscle imbalances, flexibility, as weak hip and core muscles contribute to knee deformities, and range of motion, which eases physical tasks and can benefit in the regression of secondary compensatory deformities, as well as Gait re-education through assistive devices (walker) improved the child's gait parameters.

Predictors of early recurrence following high tibial osteotomy for infantile tibia vara.

Recurrence of deformity following high tibial osteotomy (HTO) for infantile tibia vara (ITV) is common. The purpose of this study was to identify risk factors for recurrent deformity following HTO for ITV and to develop a simple scoring system to quantify the risk of recurrence in each patient. We identified 69 patients with 102 affected limbs undergoing HTO for ITV from 2005 to 2015. Demographic and radiographic data was collected. On pre-operative radiographs, we measured the mechanical varus angle (MVA), the condyle shaft angle (CSA), the plateau depression angle (PDA), the metaphyseal-diaphyseal angle (MDA), and the mechanical lateral distal femoral angle (LDFA). On the post-operative radiographs, we measured the MVA and MDA only. We classified each limb according to the Langenskiold and LaMont classifications. Statistical analysis was performed to identify variables predictive of recurrent deformity, and these variables were analysed to develop a scoring system to quantify risk of recurrence following HTO. Of the examined variables, age older than 4.5years, an MVA of more than 23° and a LaMont type C deformity were predictive of recurrent deformity. The incidence of recurrent deformity increased from 14.3% with no risk factors to 91.3% with three risk factors present. Advanced deformity and age above 4.5years at the time of surgery predicts recurrent deformity following HTO for ITV. Surgery should be performed as soon as possible, and caregivers should be counselled appropriately regarding risk of recurrence and the need for future surgery.

Prognostic Reliability of a New Classification System for Blount's Disease.

ObjectiveWe conducted this study to evaluate the reproducibility of a new classification system for Blount's disease and assess its correlation with established radiological measures used to evaluate the severity of this disorder.Materials and MethodsThis is a retrospective review of children with Blount’s disease that were younger than 10 years of age. Recurrence was defined as the need for a second corrective surgery. Radiographs immediately pre-surgery and at final follow-up were used to measure mechanical axis (MA), tibial metaphyseal-diaphyseal angle (TMDA), epiphyseal-metaphyseal angle (EMA), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA). Patients were stratified according to the new classification (Type A, B, or C).ResultsSixty-five limbs from 16 males and 24 females met our inclusion criteria. The average follow-up was 4.2 years. Twelve patients (with 22 Type-A extremities) underwent bracing with a success rate of 54%. Thirty-four patients (53 extremities) underwent surgical correction. The recurrence rate was 35.8%. Group C had a recurrence rate of 62%, higher than that of Group B (33%), and Group A (23%) (P = 0.026). In addition, irrespective of reoperation, patients in Group C had the least change in the MA (62%, P = 0.046) and the most severe values of MPTA and TMDA initially and after the operation (P < 0.05).ConclusionThe new classification system for Blount’s disease holds validity for predicting recurrence. The severity of the grades is correlated with the TMDA, MPTA, and varus reversibility. This can aid physicians and families in making an informed decision and setting treatment goals.

Tension Band Plate (TBP)-guided Hemiepiphysiodesis in Blount Disease: 10-Year Single-center Experience With a Systematic Review of Literature.

Primary treatment for Blount disease has changed in the last decade from osteotomies or staples to tension band plate (TBP)-guided hemiepiphysiodesis. However, implant-related issues have been frequently reported with Blount cases. The purpose of our study is to evaluate the surgical failure rates of TBP in Blount disease and characterize predictors for failure. We performed an Institutional Review Board-approved retrospective chart-review of pediatric patients with Blount disease to evaluate the results of TBP from 2008 to 2017 and a systematic literature review. Blount cases defined as pathologic tibia-vara with HKA (hip-knee-ankle) axis and MDA (metaphyseal-diaphyseal angle) deviations ≥11 degrees were included in the analysis. Surgical failure was categorized as mechanical and functional failure. We studied both patient and implant-related characteristics and compared our results with a systematic review. In 61 limbs of 40 patients with mean follow-up of 38 months, we found 41% (25/61) overall surgical failure rate and 11% (7/61) mechanical failure rate corresponding to 11% to 100% (range) and 0% to 50% (range) in 8 other studies. Statistical comparison between our surgical failure and nonfailure groups showed significant differences in deformity (P=0.001), plate material (P=0.042), and obesity (P=0.044) in univariate analysis. The odds of surgical failure increased by 1.2 times with severe deformity and 5.9 times with titanium TBP in the multivariate analysis after individual risk-factor adjustment. All 7 mechanical failures involved breakage of cannulated screws on the metaphyseal side. Most of the studies have reported high failure rates of TBP in Blount cases. Besides patient-related risk factors like obesity and deformity, titanium TBP seems to be an independent risk factor for failure. Solid screws were protective for mechanical failure, but not for functional failure. In conclusion, efficacy of TBP still needs to be proven in Blount disease and implant design may warrant reassessment. Level III-retrospective comparative study with a systematic review.

Treatment of Infantile Blount's Disease (Infantile Tibia Vara) with a Novel Brace: Preliminary Results

ABSTRACT Introduction Over the years, several types of braces have been used to treat the proximal tibial varus deformity of infantile Blount's disease. The purpose of this study was to evaluate the effectiveness of the JMMR Blount's KAFO (JMMR Inc, Ridgewood, NJ, USA) in correcting infantile tibia vara. Methods From November 2011 to June 2014, four patients with Blount's disease completed treatment with JMMR Blount's KAFOs. The dynamic quality of the brace differentiates it from the standard orthotic treatment of Blount's disease. The active movement of the swivel hinge located on the posterior of plastic lower leg cuff and the telescoping lateral ankle hinge facilitate the application of the valgus stress force below the knee. This, in turn, permits full knee and ankle motion. As the corrective forces are produced during weight bearing, the orthosis is worn only during waking hours. Prebracing and postbracing anterioposterior radiographs were reviewed by an examiner who was blinded to patient's name and date of the radiograph. Results The four patients (two males, two females) had a mean age of 23 months (range, 21–27) at initiation of bracing. Two were bilateral and two were unilateral. Prebracing to postbracing comparison demonstrated Langenskiöld stage improved by at least one stage and metaphyseal-diaphyseal angle decreased from a mean of 15° to 4.3°. The mean tibiofemoral angle was 19.2° varus prebracing and 0.7° valgus postbracing. The mean duration of brace use was 11 months (range, 7–15). Conclusions When the treatment of Blount's disease was started before 3 years of age, the JMMR Blount's KAFO corrected the tibia vara.

Postoperative radiologic outcome comparison between conventional and computer-assisted navigation total knee arthroplasty in extra-articular tibia vara

Total knee arthroplasty (TKA) is the definite treatment for osteoarthritis. Meanwhile, significant inherent extra-articular varus angulation is associated with abnormal postoperative hip-knee-ankle (HKA) angle. Computer-assisted navigation TKA (CAS-TKA) used in patients who have severe varus deformity. The purpose of this study was to compare postoperative radiologic outcome between CAS-TKA and conventional TKA for extra-articular tibia vara. A retrospective review of postoperative HKA on standing lower extremity views was conducted in patients who underwent TKA by a single surgeon from 2010 to 2018, including knee with conventional TKA (n = 83) and CAS-TKA (n = 246). Extra-articular tibia vara was assessed by measuring the metaphyseal-diaphyseal angle (MDA) of the tibia in preoperative standing lower extremity view. Postoperative alignment was assessed by measuring the HKA in postoperative standing lower extremity view. There was no significant difference in age (p = 0.063), gender (p = 0.628), body mass index (p = 0.426), preoperative range of motion (p = 0.524), preoperative HKA (p = 0.306), preoperative MDA (p = 0.523), or postoperative HKA (p = 0.416) between the two groups (conventional TKA and CAS-TKA). There was no significant difference in postoperative alignment for cases with MDA ≤4° (p = 0.351) or MDA >4° (p = 0.866) in each group. There was a positive correlation between preoperative HKA and postoperative HKA in the CAS-TKA group (p < 0.001, r = 0.243). However, there was no significant correlation between preoperative HKA and postoperative HKA in the conventional TKA group (p = 0.732). There was no significant difference in postoperative alignment between conventional TKA and CAS-TKA in extra-articular tibial vara even for cases with MDA >4°.

Infantile Blount's disease

ABSTRACT Infantile Blount's disease results in multi-planar proximal tibial deformity consisting of varus, procurvatum, internal rotation and shortening. The deformity is attributed to disordered growth of the posteromedial proximal tibial physis. The aetiology is multifactorial. It is associated with childhood obesity and African ethnicity. The ability to differentiate between infantile Blount's disease and physiological bowing depends on the findings of focused clinical examination, X-ray appearance, tibial metaphyseal-diaphyseal angle and tibial epiphyseal-metaphyseal angle. The gold standard of treatment is proximal tibial metaphyseal corrective osteotomy before the age of 4 years. The limb should be realigned to physiological valgus. The recurrence rate after realignment osteotomy is high. Recurrence is associated with age at osteotomy, obesity, higher Langenskiöld stage and medial physeal slope &gt;60°. The surgical management of severe, recurrent or neglected infantile Blount's disease is challenging. Comprehensive clinical examination and multi-planar deformity analysis with standing long leg X-rays are essential to identify all aspects of the deformity. Distal femur coronal malalignment and significant rotational deformity should be excluded. Knee instability due to intra-articular deformity should be corrected by elevation of the medial tibial plateau. Lateral epiphysiodesis should be done at the same time as medial plateau elevation and when medial growth arrest is certain to prevent recurrence. Level of evidence: Level 5 Keywords: Blount's disease, tibia vara, genu varum, recurrence, obesity

Medial Metaphyseal Slope as a Predictor of Recurrence in Blount Disease.

ObjectiveThis study was aimed to find the radiographic parameter predicting recurrence of stage 2 Blount's disease.MethodWe retrospectively reviewed radiographs of 82 legs from 49 patients diagnosed with stage 2 Blount's disease by Langenskiöld classification who had failed brace treatment and underwent valgus osteotomy between 1998 to 2016. Age ranged from 26 to 47 months. The metaphyseal–diaphyseal angle was measured preoperatively. The medial metaphyseal slope of the proximal tibia and femorotibial angle were measured preoperatively and 3, 6, 12, and 24 months postoperatively in both non‐recurrence (group 1) and recurrence (group 2) group. The receiver operating characteristic curve calculated using MedCalc software was used to determine the medial metaphyseal slope predicting risk for recurrence. Statistical analysis was performed using SPSS software.ResultsThe mean follow‐up time was 4.83 ± 0.38 years. The mean age was 34.57 ± 5.76 in group 1 and 33.2 ± 1.48 in group 2 (P = 0.258). The mean preoperative metaphyseal slope was 62.39° ± 9.75° in group 1 and 73.22° ± 6.59° in group 2 (P = 0.02). The mean preoperative femorotibial angle (FTA) was −14.31° ± 8.25° in group 1 and −18.89° ± 7.74° in group 2 (P = 0.1). The mean preoperative metaphyseal diaphyseal angle (MDA) was 14.75° ± 4.21° in group 1 and 20.11° ±5.16° in group 2 (P = 0.001). Demographic data including age, gender, weight, height, and body mass index showed no statistically significant difference between both groups. Out of 82 legs, 9 (10.97%) had recurrence. Preoperatively, the metaphyseal–diaphyseal angle showed statistical significance between both groups. The medial metaphyseal slope showed statistically significant difference between group 1 and group 2 at 3, 6, 12, and 24 months postoperatively. The receiver operating characteristic curve showed that a medial metaphyseal slope more than 70° at 12 months (sensitivity 88.89% and specificity 69.86%) and more than 62° at 24 months postoperatively (sensitivity 100%, specificity 52.3%) was a predictor for recurrence of stage 2 Blount's disease.ConclusionMedial metaphyseal slope more than 62° over the 24‐month follow‐up was associated with recurrence of varus deformity.