Recurrence in infantile tibia vara (Blount disease) after high tibia and fibula osteotomy

Can acute correction with simultaneous hemiepiphysiodesis of lateral proximal tibia physis prevent recurrence in neglected infantile Blount's disease?

PURPOSE

The treatment of infantile Blount's disease usually includes surgical correction, but high recurrence is still a problem regardless of the procedure. We conducted a cross-sectional study of severely neglected infantile Blount's disease treated with acute correction and simultaneous hemiepiphysiodesis of lateral proximal tibia physis. In this study, we aimed to observe the complication and recurrence.

METHODS

This research is an analytical study with a cross-sectional design using retrospective data collection and total sampling. The subjects were patients with neglected infantile Blount's disease treated from 2018 to 2023 in our institution. Follow-up was conducted in 6, 12, 24, and 36 months.

RESULTS

A total of 25 legs from twenty patients were recorded. We observed three legs (12.0%) had recurrence. No neurovascular complications and infections were observed. All subjects had significant postoperative improvement of TFA (mean 6.8 ± 0.730 valgus), Drennan angle, MPTA, MTPD, JLCA, and ligamentous laxity grading (p < 0.001). Lower than 5° postoperative valgus overcorrections and preoperative physeal bar were significant factors in patients with recurrence (p = 0.020 and p = 0.010). There was no significant increase in leg-length discrepancy during follow-up (p = 0.052). There were no significant differences between age, BMI, preoperative TFA, pre- and postoperative Drennan angle, MPTA, MTPD, JLCA, Langenskiöld stages, and length of follow-up in patients with recurrence and not.

CONCLUSION

Acute correction with simultaneous hemiepiphysiodesis of lateral proximal tibia physis is an effective technique to prevent deformity recurrence in neglected infantile Blount's disease, provided that the postoperative TFA is more than 5° of valgus and no evidence of physeal bar in the preoperative radiograph.

Recurrence and Complication Rates of Surgical Treatment for Blount's Disease in Children: A Systematic Review and Meta-Analysis

BACKGROUND

Blount's disease is a growth disorder of the proximal tibia that causes progressive genu varum in children. Surgical treatment is recommended if the deformity worsens, but which intervention is best remains controversial. This study aims to identify factors influencing outcomes and determine the most effective surgical approach.

METHODS

A systematic review was conducted of studies published before January 2022.

RESULTS

In total, 63 retrospective studies with CEBM IIIb/IV levels were included (1672 knees in 1234 patients). The most commonly reported treatment was acute correction via osteotomy (47%), followed by hemiepiphysiodesis (22%) and gradual correction (18%). Combined procedures were reported in 13% of cases. The overall recurrence rate was 18%, with a significant difference when comparing the recurrence rates after gradual correction with those after hemiepiphysiodesis (7% and 29%, respectively). Major complications beyond recurrence were observed in 5% of cases. A meta-analysis of the available raw data showed a significantly increased recurrence rate (39%) among treated children who were between 4.5 and 11.25 years of age and were followed for a minimum follow-up of 2.5 years.

CONCLUSIONS

Overall, poor evidence with which to establish an optimal treatment for Blount's disease was found. This study remarked on the need for early diagnosis, classification, and treatment of infantile tibia vara, since a significant rate of recurrence was found in neglected cases.

A Predictive Score for Infantile Blount Disease Recurrence After Tibial Osteotomy

INTRODUCTION AND OBJECTIVE

Several predictive factors for infantile Blount disease recurrence after tibial osteotomy were discovered. This study aimed to examine and utilize various predictors to develop a prediction score for infantile Blount disease recurrence after tibial osteotomy.

METHODS

We conducted a retrospective cohort study of infantile Blount disease patients who underwent tibial osteotomy between January 1998 and December 2020. Potential predictors, including clinical and radiographic parameters, were examined for their association with the disease recurrence after receiving tibial osteotomy. A predictive score was subsequently developed based on those potential predictors through multivariable logistic regression modeling.

RESULTS

A total of 101 extremities diagnosed with infantile Blount disease from 58 patients who underwent tibial osteotomy were included. Of those, 15 extremities (14.9%) recurred. Univariable logistic regression analysis identified age older than 42 months [odds ratio (OR)=4.28; P =0.026], Langenskiöld classification stage III (OR=9.70; P <0.001), LaMont classification type C (OR=15.44; P <0.001), preoperative femorotibial angle <-14 degrees (OR=4.21, P =0.021), preoperative metaphyseal-diaphyseal angle >16 degrees (OR=8.61, P =0.006), preoperative medial metaphyseal slope angle >70 degrees (OR=7.56, P =0.001), and preoperative medial metaphyseal beak angle >128.5 degrees (OR=13.46, P =0.001) as potential predictors of infantile Blount disease recurrence after tibial osteotomy. A predictive score comprised of age younger than 42 months, LaMont classification type C, and medial metaphyseal beak angle >128 degrees demonstrated an excellent predictive performance (area under the receiver operating characteristic curve =0.87), good calibration, and high internal validity.

CONCLUSIONS

Our developed predictive score accurately predicted infantile Blount disease recurrence after tibial osteotomy. The results from our developed prediction tool allow physicians to inform prognosis, increase awareness during the follow-up period, and consider additional interventions to prevent disease recurrence.

LEVEL OF EVIDENCE

Level II.

Virtual Surgical Planning, 3D-Printing and Customized Bone Allograft for Acute Correction of Severe Genu Varum in Children

Complex deformities of lower limbs are frequent in children with genetic or metabolic skeletal disorders. Early correction is frequently required, but it is technically difficult and burdened by complications and recurrence. Herein, we described the case of a 7-year-old girl affected by severe bilateral genu varum due to spondyloepiphyseal dysplasia. The patient was treated by patient-specific osteotomies and customized structural wedge allograft using Virtual Surgical Planning (VSP) and 3D-printed patient-specific instrumentation (PSI). The entire process was performed through an in-hospital 3D-printing Point-of-Care (POC). VSP and 3D-printing applied to pediatric orthopedic surgery may allow personalization of corrective osteotomies and customization of structural allografts by using low-cost in-hospital POC. However, optimal and definitive alignment is rarely achieved in such severe deformities in growing skeleton through a single operation.