Tibial Varus Deformity and Blounts

Disease

Peter Calder

Contents Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4371
Adolescent tibia vara-hemi-epiphysiodesis

Aetiology
Blounts disease
Classification

Physiological Tibia Vara . . . . . . . . . . . . . . . . . . . . . . . . . 4372
Infantile tibia vara-bracing, operative treat-
Tibia Vara; Blounts Disease . . . . . . . . . . . . . . . . . . . . . 4373 ment, tibial osteotomy techniques, relapse

Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4373 Physiological varus
Tibia Vara
Tibial
Radiological Classification . . . . . . . . . . . . . . . . . . . . . . . . . 4374
Classification by Treatment Group . . . . . . . . . . . . . . . . 4374 torsion
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4375
Treatment of Infantile Tibia Vara . . . . . . . . . . . . . . . 4375
Bracing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4375 Introduction
Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4376
Operative Technique: Focal Dome Osteotomy . . . . 4376 Lower limb deformity in children is extremely
Operative Technique: Inclined Osteotomy . . . . . . . . 4378
common and can result in significant parental
Osteotomy Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4378
Operative Technique: Hemiplateau Elevation and anxiety. The aetiology can be pathological in
Metaphyseal Correction . . . . . . . . . . . . . . . . . . . . . . . . 4379 nature, as a result of both congenital and
Adolescent Tibia Vara . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4379 acquired conditions. The majority of cases
Hemi-Epiphysiodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4380 however are physiological, being the natural
Femoral Deformity in Adolescent Tibia Vara . . . . . 4382 progression of the childs development. In
Tibia Varus and Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . 4382 these cases simple re-assurance is all that is
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4382 required, that correction will occur with further
growth. The dilemma for the clinician is to
differentiate those pathological cases requiring
monitoring and potential treatment from the nor-
mal physiological variant.
Genu Varum is by far the commonest
lower limb deformity in infants presenting to
Orthopaedic surgeons. Physiological bowing is
the cause in the majority of cases. Pathological
causes include Blounts disease, covered in
more detail within this chapter, other metabolic
bone diseases such as rickets and osteogenesis
P. Calder imperfecta and systemic conditions including
The Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK skeletal dysplasias, such as achondroplasia and
e-mail: Peter.calder@rnoh.nhs.uk

G. Bentley (ed.), European Surgical Orthopaedics and Traumatology, 4371

DOI 10.1007/978-3-642-34746-7_53, # EFORT 2014
4372
Fig. 1 Graph of normal
development
neoplasia which can be differentiated by
clinical, radiological and haematological inves-
tigation. Acquired varus deformity can occur
post-fracture or infection due to physeal
damage.
Physiological Tibia Vara
Presentation of bow legs typically occurs
between the childs first and second birthday,
co-inciding with the time when the child stands
and begins to walk. Clinical examination
should be unremarkable but there is commonly
seen associated internal tibial torsion as
demonstrated clinically by the foot-thigh angle
(Fig. 1) [1].
The tibio-femoral alignment (Fig. 2a) has
a predictable growth pattern. Salenius and
Vankka [2] demonstrated a maximum genu
varum from birth to 6 months of age, neutral
alignment at approximately 3 years of age and
a residual valgus of approximately 6 by the age
of 6 (Fig. 1). The concomitant internal tibial
torsion should resolve with the varus. On general
examination physiological genu varum and
P. Calder
torsion should be similar in magnitude and as
a rule-of-thumb correct at approximately 10
per year.
Residual deformity after 2 years of
age should raise the suspicion of pathology
[3] but spontaneous correction may be delayed
due to habitual sleeping or sitting positions
keeping the childs legs rotated beneath
them [4].
Various radiological parameters have been
used in an attempt to predict progression of defor-
mity or physiological resolvement. Levine and
Drennan [5] described the tibial metaphyseal-
diaphyseal angle (Fig. 2b). The angle is created
by a line drawn through the most distal ossified
peak of the medial and lateral beaks of the tibial
metaphysis (the transverse plane of the
metaphysis) and a line perpendicular to the lon-
gitudinal axis of the tibia (a line along the lateral
cortex of the tibial diaphysis). They concluded
that an initial TM-DA of greater than 11 predict-
ably developed further radiographic changes of
pathological tibia vara. Subsequent studies [6, 7]
have questioned this predictive value and addi-
tional prognostic angles have been drawn. Davids
et al. [8] assessed the epiphyseal-metaphyseal
Tibial Varus Deformity and Blounts Disease
Fig. 2 (a) Femoro-tibial a b
angle. (b) Metaphyseal-
diaphyseal tibial angle. (c)
Epiphyseal-Metaphyseal
Angle
angle in conjunction with the TM-DA. The EMA
is determined by drawing a line through the prox-
imal tibial physis parallel to the base of the epiph-
yseal ossification centre. An angle is created by
a second line drawn from the mid-point of the
base of the epiphyseal ossification centre with the
most distal point on the medial beak of the prox-
imal tibial metaphysis (Fig. 2c). Their data
suggested that children between 1 and 3 years of
age with a TM-DA <10 , or TM-DA 10 but
EMA 20 were at less risk of developing
Blounts disease. Conversely children with
a TM-DA 10 and EMA >20 should be
closely monitored.
Tibia Vara; Blounts Disease
The term tibia vara is most often described as
Blounts disease following his publication in
1937 but was first reported by Erlacher in 1922.
It is also labelled as osteochondrosis deformans
tibiae [913] and is characterised by an
abrupt angulation of the tibia into varus
deformity below the knee including internal
4373
c
tibial torsion, as seen in physiological genu
varum. The radiological appearance is the
main differentiating factor. Blount described an
irregular physeal line, a wedge-shaped epiphysis
and a beak-like medial metaphysis. In the
younger child (1824 months of age) these
changes may not be present and progressive
radiographic appearance does depend on skeletal
maturity [10].
Classification
Blount described two distinct types of the
condition
Infantile This appears when the child begins
to walk.
Adolescent This occurs spontaneously
between the age of 6 and 13 years.
The adolescent type was originally thought
to be as a result of trauma or infection [11].
Thompson et al. in 1984 [14] reported late-onset
tibia vara in obese, mainly black children with
clinical onset between 6 and 14 years of age.
Radiographic changes included wedge-shaped
4374
Fig. 3 Langenskiold radiological stages
epiphysis and irregular physis. Histo-pathological
findings seen in infantile tibia vara were
also reported in this adolescent type by Wenger
et al. [15].
A rare cause of tibia vara due to fibrocarti-
lagenous dysplasia has been described [16, 17].
The abrupt angulation occurs in children
much younger, 918 months of age. The
histopathological finding described was an area
of fibrocartilagenous tissue in the medial aspect
of the tibia. Surgical correction was not
advised as spontaneous correction was to be
expected.
Radiological Classification
Langenskiold [10] described six deformity
stages through which the proximal tibia may
pass (Fig. 3). This was a retrospective review
based on the patients age and degree of defor-
mity. Treatment recommendations have been
adopted by many based on the stage of disease.
This is despite Langenskiolds stating that
deformity progression could not be predicted
on radiographic stage; in fact stage I to IV had
nothing to do with prognosis. This was further
highlighted by Stricker et al. [18] who demon-
strated poor inter-observer agreement for inter-
mediate stages and that those using the stages as
a basis for treatment must be aware that discrep-
ancies of plus or minus one stage are frequent.
Loder and Johnston [19] also raised concern
P. Calder
with prognosis when comparing patients outside
of Northern Europe. They studied the applica-
bility of Langenskiolds classification to
a predominantly non-white population. They
questioned the statement, by Langenskiold,
that patients treated in stages IIII with
osteotomy do not progress. In their study they
noted that radiographic changes occurred earlier
and also progressed despite early corrective
osteotomy.
Classification by Treatment Group
Laville et al. [20] attempted to group the patients
by the absence or presence of a metaphseal-
epiphyseal bony bridge, thereby directly dictat-
ing treatment.
Stage 0; Possible early Blounts, patient youn-
ger than 2 years.
Treatment Close Observation
Stage 1; Confirmed Blounts disease, absence
of a bony bridge.
Treatment Tibial Valgus Osteotomy
Stage 2; Confirmed bony bridge.
Treatment Tibial Valgus Osteotomy with
concomitant lateral epiphysiodesis to pre-
vent deformity recurrence.
Careful assessment of the medial tibial pla-
teau is required. In the case of a sloping
plateau a transphyseal hemi-plateau eleva-
tion osteotomy will also be required to
restore the joint line.
Tibial Varus Deformity and Blounts Disease
Aetiology
The specific cause of Blounts disease is
unknown. It appears to be more frequent in
females than males.
In infantile tibia vara the deformity pro-
gresses with weight-bearing. Cook et al. [21],
using finite element analysis of the proximal
tibia to investigate the stresses in the physeal
plate during one-legged stance, demonstrated
that with increasing varus there was an increased
compressive stress on the medial tibial physis.
They also confirmed that the changes were more
marked in the obese child and concluded that
these forces according to the Heuter-Volkman
law (that increased pressure on the epiphysis/
physis inhibits growth) were responsible for
the tibial deformity due to abnormal medial
growth.
West Indian children had been noted to have
non-rachitic bow legs by Bateson [22] and
that their early presentation required surgical
correction [19, 23]. It is presumed that an
early walking age and greater ligamentous laxity
in black children may explain the increased
prevelance of tibia vara.
Obesity is a prevelant factor and appears com-
parable to the prevelance in children with slipped
upper femoral epiphysis [2426].
Adolescent tibia vara is associated with
black obese children [15, 27]. In comparison to
infantile tibia vara the majority of cases are
however male and unilateral. The presence of
varus deformity appears to be important in the
progression of the infantile type but Davids et al.
[28], supported by clinical observation and
biomechanical analysis, demonstrated that
varus mal-alignment is not a pre-requisite in
adolescent disease. Asymmetric compressive
and shear forces acting across the physis how-
ever are thought to be the cause of abnormal
medial endochondral ossification resulting in
deformity. This was the conclusion of Carter
et al. [29] who demonstrated that histopatholog-
ical and histochemical studies were similar to
those seen infantile, adolescent tibia vara and
slipped capital femoral epiphysis suggesting
a common aetiology.
4375
Treatment of Infantile Tibia Vara
Bracing
Following radiographic assessment of the stand-
ing child prediction of progressive tibia vara
may be made [58]. A metaphyseal-diaphyseal
angle of less than 9 is unlikely to progress and
the child can be monitored whereas an angle of
>16 inevitably will require treatment. Those
between 9 and 16 require monitoring and treat-
ment is advised if there is no improvement after
24 months of age [4].
Raney et al. [30] recommended treatment with
an M-DA of between 9 and 16 with clinical risk
of progression, these included ligamentous insta-
bility (considered present when the patient dem-
onstrated a lateral thrust of the knee during
ambulation), obesity, asymmetry and being of
Black or Hispanic origin.
In children less than 3 years of age orthotic
bracing is recommended as the primary treatment
[4, 3033]. A knee-ankle-foot orthosis is created
with a single medial upright secured between the
thigh and ankle. No knee hinge is present and the
ankle is left free. The biomechanical principle is
to create a valgus force to unload the medial
aspect of the proximal tibia by a three-point
pressure system. Greene [30] recommended
bending the medial upright into further valgus
every 612 weeks.
The orthosis is discontinued when a neutral
clinical or radiological alignment is obtained
[30]. The timing and duration of wearing the
brace differs between authors. Greene [30] rec-
ommends the brace to be worn for 2223 h per
day. If the child did not tolerate the brace then it
should be worn during standing and walking when
the physis it may be assumed would benefit most
from protection from the weight- bearing growth-
inhibiting forces. Zionts and Shean [33] agreed
that daytime ambulatory bracing favourably
altered the natural history. In comparison Raney
et al. [31] reviewed patients divided between
full-time and night-time only use. There were no
statistical differences and they concluded that
night-time only bracing was as effective.
4376
The use of brace treatment has been
questioned. Shinohara et al. [34] in their study
observed two groups of tibia vara. Group
I corresponded to patients with Langenskiold
stage I changes, medial beaking of the
metaphysis. All resolved without treatment.
Group II consisted of 24 limbs classified as
Langenskiold stage II or III, with step-like
deformity of the medial metaphysis and irregu-
larity of the medial physis. In comparison to
recommended treatment protocols [3133] they
initiated treatment in 87 %, 75 % and 69 %
of cases in this group which in their series spon-
taneously resolved. In those cases that deformity
progressed or showed no improvement, tibial
osteotomy was recommended after the age of
4 years. They therefore do not recommend
bracing but simple observation.
Surgical Treatment
In those cases where the deformity fails
to resolve or progresses tibial osteotomy
is recommended. The surgical principle is to
obtain an aligned limb and minimise the risk
of recurrence. This risk of recurrence has
been highlighted by Ferriter and Shapiro [35]
and others [4, 19, 30] in those children who
are massively obese, an initial Langenskiold
stage III or above at time of surgery and an
age above four and a half years at initial
osteotomy.
Physeal damage, as seen with radiographic
changes of increasing Langenskiold stage
and resultant bony bar, makes recurrence
inevitable following osteotomy and additional
procedures such as lateral proximal tibial and
proximal fibular epiphysiodesis with possibly
medial tibial plateau elevation may need to be
considered.
Proximal Tibial Osteotomy
Many types of osteotomy technique have been
described to acutely correct both tibia vara and
internal tibial torsion [4, 19, 30, 35, 36]. The focal
dome osteotomy described by Nadeem et al. [37]
allows correction around the centre of rotation of
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angulation (CORA) producing alignment without
translation. It is possible to correct both angula-
tion and rotation using an inclined osteotomy as
described by Paley [38].
Operative Technique: Focal Dome
Osteotomy
Under a general anaesthetic the patient is placed
supine on a radiolucent table. A high tourniquet is
applied and the leg exsanguinated.
A mid-diaphyseal approach to the fibula
is undertaken and a sub-periosteal excision
of 1 cm is performed. This level is used to
avoid damage to the branches of the peroneal
nerve.
The tibia is approached via a longitudinal inci-
sion over the site of the proposed osteotomy,
lateral to the tibial crest and distal to the tibial
tubercle. The CORA is calculated pre-
operatively and following sub-periosteal expo-
sure the dome cut is marked on the tibia as part
of the circumference rotating around the CORA.
The osteotomy is pre-drilled and completed with
a sharp osteotome.
The varus deformity is corrected first followed
by the torsional correction (Fig. 4). Alignment
can be checked clinically and radiographically
by holding a diathermy cord taut from the centre
of the femoral head to the centre of the ankle and
observing its passage across the knee (mechani-
cal axis).
The osteotomy is stabilised using crossed
2 mm Kirschner wires (Fig. 5). The tourniquet
is deflated and haemostais achieved. An
anterior percutaneous fasciotomy is performed
to reduce the risk of compartment syndrome
[30].
A long-leg plaster with the knee flexed at 20
is applied. A plaster change with removal
of K-wires is performed at 46 weeks.
Full weight- bearing is commenced at 6 weeks
with removal of the plaster cast when the
osteotomy is clinically and radiologically united.
Physiotherapy is then started to restore full joint
range of motion, regain muscle strength and
retrain gait.
Tibial Varus Deformity and Blounts Disease 4377

Fig. 4 Focal dome

osteotomy

Fig. 5 Clinical case of focal dome osteotomy

4378
Operative Technique: Inclined
Osteotomy
The CORA is calculated pre-operatively. The mag-
nitude of the angulation is recorded (A) and mag-
nitude and direction of the rotation deformity (R)
measured using clinical and radiological methods.
The inclination of the osteotomy can be cal-
culated using trigonometric calculation
(angle arctan [sin (A/2)/tan(R/2)]) but is easier
to assess graphically.
The saw is placed at the CORA perpendicular
to the long axis of the proximal segment it is
then rotated to the new angulation axis.
The angulation axis in the transverse plane is re-
orientated by R/2 in the opposite direction to the
mal-rotation.
The saw is then inclined and the direction of
the longitudinal inclination is either up or down.
The new angulation axis will place the saw on the
concave or convex side of the angular deformity.
If on the concave side the blade should be raised
so that the osteotomy inclines downwards and
vice-versa if the blade is on the convex side the
blade is lowered so that it inclines upward from
anterior to posterior.
The oblique oval osteotomy in Blounts disease
may not pass through the CORA, due to its prox-
imal position and physeal proximity. If translation
of the distal segment occurs then this can be
resolved by sliding the bone segments along the
face of the inclined osteotomy.
Osteotomy Correction
The deformity should be over-corrected to
approximately 510 of valgus [30, 35, 36].
This off-loads the medial physis in an attempt to
allow recovery and a return to normal growth.
Greene [30] further advised temporary hemi-
epiphysiodesis on the lateral side of the proximal
tibia in children at risk of recurrence (female,
obese and/or a proximal medial tibial slope of
>60 ). This was to prolong protection of the
medial physis in those advanced cases. Staples
were used which were removed when the tibia
was observed to grow into valgus.
P. Calder
Physeal Bar
In the presence of a bony bar across the
medial physis, recurrence is inevitable if
a corrective tibial osteotomy is undertaken
alone. Resection of the bar has been shown
to have inconsistent results [19, 30, 39]. The
size of the bar resection will have a bearing on
the growth remaining. Whereas Loder and
Johnston [19] stated that they believe at least
50 % of the physis should remain open before
considering bar resection, Greene [30] was
more circumspect on the outcome and only
recommended bar resection if it was 30 % or
less of the growth-plate. Following resection
the defect is filled with either fat [39] or
methylmethacrylate bone cement [19].
Relapse and Hemi-plateau Deformity
Recurrence of deformity or progression of
untreated infantile tibia vara will lead to
changes affecting the epiphysis, physis
and metaphysis. Jones et al. highlighted
the complexity of the deformity using three-
dimensional computed tomography [40, 41].
The clinical appearance of a lateral thrust
was noted to be a result of ligamentous
laxity but also the presence of a posterior
slope of the medial tibial plateau. Further
depression of the medial tibial plateau as
a result of the physeal bony bridge produces
an incongruent knee joint. This cannot be
addressed by performing a proximal tibial
osteotomy alone.
Hemi-plateau elevation restores both the
joint line and can also address the posterior
slope with asymmetrical elevation of the bony
fragment. The plateau may be elevated acutely
with bone graft placed within the metaphyseal
gap. Schoenecker et al. [42] utilised a variety
of internal fixation devices, including K-wires,
plates and screws. Complications following
acute correction including difficulty in
wound closure and need for massive bone
graft have led to gradual elevation of the pla-
teau using external fixators and the principle
of distraction osteogenesis [40, 43]. This tech-
nique is however limited in younger children
as the medial fragment to be elevated is too
small to allow sufficient fixation during the
Tibial Varus Deformity and Blounts Disease
elevation process. Acute elevation without the
need of bone grafting has been demonstrated
with filling in of the metaphyseal defect [44].
Therefore my preferred choice is to per-
form an acute hemiplateau elevation with
iliac crest bone graft or utilizing the piece of
fibula excised. The osteotomy is held with a
combination of wires and half-pins fixed to a
circular frame construct. This enables
a metaphyseal osteotomy to be performed
and further distraction osteogenesis to correct
varus, internal tibial torsion and lengthening if
required concomitantly. Following removal of
the fixator recurrence of deformity is
prevented by performing an epiphysiodesis to
the remaining open lateral proximal tibial
growth plate and proximal fibula.
Operative Technique: Hemiplateau
Elevation and Metaphyseal Correction
The patient is prepared as for a simple proximal
tibia osteotomy.
A preliminary arthrogram is performed to
demonstrate the joint line, outlining the medial
cartilage [45].
A J-shaped incision is made over the medial
side of the knee to allow subperiosteal exposure
of the tibia. A ring-handled retractor is placed
subperiosteally behind the knee to protect the
neurovascular structures. Under image intensifier
control the proximal and distal extent of the pro-
posed osteotomy are marked. Normally the prox-
imal extent is just below the medial tibial spine
and distally at the metaphyseal-diaphyseal
junction.
The osteotomy is pre-drilled and completed
with a sharp osteotome leaving the articular
cartilage intact proximally. Using a laminar
spreader the osteotomy is carefully elevated to
restore the joint line. By placing the spreader
more posteriorly the posterior slope may also be
corrected and supported with a tri-cortical iliac
crest graft.
The elevated fragment is held by passing fine
wires and/or half-pins through the medial frag-
ment into the lateral aspect of the tibia. A spread
4379
of three wires placed transversely, postero-
medial to antero-lateral and antero-medial to
postero-lateral with a single half-pin placed
either transverse or antero-medial to postero-
lateral gives sufficient stability. Extra fixation
may be used if there is concern. Note that, before
placing the wires, the skin incision should be
opposed (Fig. 6).
Distal fixation of the tibia is achieved with
one or two rings. Fixation is achieved using
antero-lateral to postero-medial tibial face
wires and antero-medial half-pins. Distal tibial
metaphyseal fixation is achieved with crossing
wires.
The metaphyseal osteotomy is made through
a 1 cm antero-lateral incision. The periosteum is
elevated and the tibia pre-drilled. The osteotomy
is completed by a sharp osteotome in a twisting
fashion.
Following a latent period of 1 week correction
of residual deformity including varus, internal
tibial torsion and shortening is undertaken using
the principle of distraction osteogenesis. In the
younger child over-lengthening can be performed
by estimating growth remaining [46].
The frame allows weight-bearing as tolerated
and is removed once consolidation of the regen-
erate and osteotomy is confirmed radiologically.
This is performed under a second general anaes-
thetic and the remaining open physis of the prox-
imal tibia and proximal fibula is removed by an
epiphysiodesis using a 4.5 mm drill bit. The leg is
placed in a below-knee patellar tendon weight-
bearing plaster for 4 weeks.
Adolescent Tibia Vara
The natural history of adolescent tibia vara does
appear to differ from the infantile type in that the
significant medial tibial plateau deformity is
rarely seen. The cause of the varus and torsional
deformity of the tibia, as previously stated, is
thought to be due to the mechanical forces
inhibiting growth from the medial aspect of the
proximal tibial physis. The absence of the joint
incongruity does therefore offer alternative treat-
ment options.
4380
Fig. 6 (a) - (c) Hemiplateau elevation
Hemi-Epiphysiodesis
Lateral hemi-epiphysiodesis of the proximal tibia
and in some cases the distal femoral physis (see
below) has been shown to be successful in
correcting the varus deformity and prevent
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recurrence [4750]. Risks of failure relate to
patient age, degree of varus, presence of an
open physis and the weight of the patient. Park
et al. [48] stated that this treatment is particularly
effective in children under 10 years of age with
a minor or moderate varus deformity (defined as
Tibial Varus Deformity and Blounts Disease 4381

Fig. 7 (a) Adolescent

blounts. (b) Adolescent
a b
Blounts post frame
application. (c) Adolescent
Blounts Post correction

a mechanical axis displaced just outside the medial
compartment). McIntosh et al. [50] demonstrated
a higher rate of failure with a body mass index of
45 kg/m2.
Following Magnetic Resonance Imaging
studies [51, 52] extensive physeal changes have
been noted. In those with severe deformities
these changes included widening of the entire
proximal tibial growth-plate and also changes
within the distal femoral growth-plate. Bridging
of the physis with bony bar formation was
also seen.
4382
Synder et al. [52] demonstrated that in these
severe cases of knee deformity a failure to
respond to epiphysoiodesis was seen and in
some cases there was also a poor response to
tibial osteotomy with development of progressive
valgus or recurrence of varus deformity after
surgery. It was felt that the abnormal growth-
plate was incapable of producing an acceptable
correction and subsequent continued normal lon-
gitudinal growth. MRI prior to surgery was there-
fore recommended as it further refined the risk of
epiphysiodesis failure.
Femoral Deformity in Adolescent
Tibia Vara
A large component of the genu varum deformity
in adolescent disease is from distal femoral
varus [53]. From above distal femoral physeal
changes are also seen following MRI scanning.
This contrasts with infantile tibia vara where the
varus deformity results exclusively within the
tibia [53, 54].
As part of deformity correction the distal fem-
oral component may need to be addressed. As
a concept, over-correction of the tibia may result
in correction of the mechanical axis through the
centre of the knee but will do so by making the
knee joint oblique in stance. Therefore treatment
options of the distal femoral deformity include
lateral hemi-epiphysiodesis, or valgus corrective
osteotomy (either medial opening-wedge plus
bone graft or lateral closing wedge osteotomy).
Tibia Varus and Torsion
The surgical principle in correction of the tibial
deformity remains the same as infantile tibia vara.
In the adolescent type however the size of the
patient means that osteotomy stability requires
careful consideration. For this reason most authors
recommend the use of external fixation and cor-
rection using distraction osteogenesis which
utilizes minimal soft tissue stripping and
a construct that allows early weight-bearing
[40, 43, 5564].
P. Calder
The surgical technique is similar to the method
used in the application of the external fixator as
above.
The Taylor Spatial Frame is the authors choice
of external fixator in infantile and adolescent tibia
vara. The hexapod structure allows accurate cor-
rection of deformity utilizing distraction osteogen-
esis in the coronal, saggital and axial planes [62].
Residual deformity can be corrected without the
need for further anaesthesia based on radiographic
assessment and re-running the web-based software
and subsequent strut length changes (Fig. 7). In
general terms the correction takes approximately
2 weeks and the frame remains usually for 23
months further for consolidation. The frame is
removed under general anaesthetic and a patellar
tendon weight-bearing plaster can be considered
for a further month. Weight-bearing, knee and
ankle range of motion exercises are commenced
as pain allows immediately after frame
application.
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