Physiological & pathological tibia vara

1. By/ Bader M. Aljadaan
Physiological & Pathological
Tibia Vara

2. 2 years old boy Present
to your Clinic
C/O bilateral bowing leg.

3. How would you approach this
patient !!?

4. Hx:
Onset
Is the deformity progressing !?
Is the child’s general health good !?
Does the Family provide Normal diet !?
Are other Family members affected !?
Early walker.
Overweight.
Hx of Trauma.
Hx of multiple Fx !?

6. Physical Examination:
Normal Height and body proportions !?
Other deformities !!
Is the Deformity symmetrical ?
Is the deformity localized or generalized ?
Are the limb lengths equal ?
Does the deformity increase when the child
stands? Achondroplasia..
Measure the rotational profile.
Gait.

7. What is the Next ..!?

8. DDx :

9. Ix :
Laboratory If the child has a
generalized deformity, order a
metabolic screen, including calcium,
phosphorus, alkaline phosphatase

10. 10

14. How would you Rx This Pt. !?

15. Physiological Tibia Vara
MDA <11
Reassurance

17. 3 years old girl , MF, Obese .
Present to your clinic with B/L leg
Bowing.
Approach this Case ..

18. Hx:
 Noticed at 9/12 when she start walking.
Progressive
Normal Diet.
2 of her brothers was affected .
No Trauma Hx.
No Hx of Multiple Fx.
Vaccinations Up to Date .

19. P.E.
General :
Normal Height and body proportions.
Gait ( Varus thrust ).
Local :
Alignment
Deformities ( Varus, Tibial torsion , procurvatum ).
 NO LLD
Medial knee (Tenderness &Palpable prominence)
Normal N.V.

20. MDA 14 degree .
Medial Physeal Slope .

21. How would you Rx this Pt.
!!?

22. Observation …
OR
Non Surgical .. Long leg bracing ??
OR
Surgical

23. Efficacy of bracing has not
been established in a
controlled trial.
Difficulty confirming
compliance with brace wear,
make it challenging to conduct
a conclusive study on the
efficacy of bracing.
Still some author use KAFO
<3 years
Stage I-II

24. Observation …
6/12 F/U
MDA 16 degree.
What is the NEXT..!?

25. Rx of Early-Onset (Infantile) Blount
Disease:
 KAFO
Lateral proximal tibial hemiepiphyseodesis/guided
growth
Valgus proximal tibial osteotomy prior to age of 4years.
Resection of physeal bar alone !!
Elevation of medial plateau.

27. Overcorrect into 10-15° of valgus, flexion and
internal tibial torsion are Main Goals.
Although recommendation go against resection of
physeal bar alone, but still indicated to do bar
resection (epiphysiolysis) when a physeal bar is
present (Langenskiold V and VI). The studies show favorable
outcome <7 years.
Medial tibial plateau elevation is required at time
of osteotomy if significant Postro-medial
depression is present & >6 years.

28. A prophylactic anterior compartment fasciotomy
and insertion of a drain should be strongly
considered for patients with Blount disease who
are undergoing acute deformity correction.

29. Type I thru IV consist of increasing medial
metaphyseal beaking and sloping.
Type V and VI have an epiphyseal-metaphyseal bony
bridge (congenital bar across physis)
Provides prognostic guidelines Only.

30. 15 years old boy C/O left bowleg,
noticed by parents 6/12 back.
How would you approach this Pt. !?

31. Hx & P.E.
Onest
Is the deformity progressing !?
Are other Family members affected !?
Hx of Trauma.
---------------------------------
Obese .
Limping. (LLD).
Varus thrust.

32. MDA 18 degree.

33. How would you Rx This Pt. !!?

36. Standard surgical management of adolescent Blount
disease includes proximal tibial osteotomy with internal or
external fixation.
Correction of the deformity, rather than overcorrection, is the
goal of surgery.
Pre Op evaluation of exact deformity Is a critical Step,
missing varus deformity distal femur may not improve the
case .
Placement of an external fixator after osteotomy allows for
correction of the coexistent leg-length discrepancy.

38. 13 years old girl Present to you as a case of late
onset Blount’s Disease.

39. Deformities !!?

40. Distal femoral varus.
Proximal tibial deformity.
Limb shortening.

41. Treatment
!!?

42. The patient underwent gradual correction with distraction
osteogenesis at the proximal part of the tibia.
application of an extra-periosteal plate across the lateral
aspect of the distal femoral physis for guided growth.

43. 8 years old girl with a recurrent deformity following
a proximal tibial osteotomy done 3 years
previously to treat left-sided early-onset Blount
disease.

44. Why FAIL..!?

45. A single extraperiosteal staple placed across the
anterolateral portion of the proximal tibial growth
plate failed to correct the deformity because of an
osseous physeal bar, as seen on the computed
tomography scan.

47. Medial tibial plateau elevation with internal fixation
and use of a structural allograft.

48. The patient required a contralateral
epiphyseodesis closer to skeletal maturity to
equalize the limb lengths

49. Summary

52. References:
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53. Thank You