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Lower Limb Deformity Management in Arthrogryposis – What to Correct and When

Volume 10 | Issue 2 | May-August 2024 | Page: 00-00 | Ishani P Shah, Sujika Ranmuthuge, Varun Parnami, Anastasios Chytas DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.000 Submitted: 18/05/2024; Reviewed: 06/06/2024; Accepted: 16/07/2024; Published: 10/08/2024 Authors: Ishani P Shah DNB Ortho. FRCS (T & O) [1], Sujika Ranmuthuge MD, FRCS (T & O) [1], Varun Parnami DNB Ortho. [1], […]

Blount’s Disease: Review Article

Volume 10 | Issue 2 | May-August 2024 | Page: 39-48 | Yashwant Singh Tanwar, Sirazul Haque Malik, Karolina Siwicka, Nando Ferreira, Pieter Herman Maré DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.192 Submitted: 02/05/2024; Reviewed: 29/05/2024; Accepted: 21/06/2024; Published: 10/08/2024 Authors: Sudhanshu Yashwant Singh Tanwar MS Ortho., DNB, MRCS [1], Sirazul Haque Malik MS Ortho. [2], Karolina Siwicka MD, PhD […]

Lower Limb Deformity Management in Arthrogryposis – What to Correct and When

Blount’s Disease: Review Article

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Lower Limb Deformity Management in Arthrogryposis – What to Correct and When

Volume 10 | Issue 2 | May-August 2024 | Page: 00-00 | Ishani P Shah, Sujika Ranmuthuge, Varun Parnami, Anastasios Chytas

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.000

Submitted: 18/05/2024; Reviewed: 06/06/2024; Accepted: 16/07/2024; Published: 10/08/2024

Authors: Ishani P Shah DNB Ortho. FRCS (T & O) [1], Sujika Ranmuthuge MD, FRCS (T & O) [1], Varun Parnami DNB Ortho. [1], Anastasios Chytas MD, MSc [1]

[1] Department of Paediatric Orthopaedic Surgery, Royal Manchester Children’s Hospital, Oxford Road, M13 9WL

Address of Correspondence

Dr. Ishani P Shah,
Consultant Paediatric Orthopaedic Surgeon, Royal Manchester Children’s Hospital, Oxford Road, M13 9WL.
E-mail: ishanipshah@gmail.com

Abstract

Arthrogryposis is a descriptive term involving non – progressive joint contractures of two or more joints at birth. It is associated with more than 300 diseases. Lower limb involvement is seen in about 95% of the cases with variable affection of the foot, knee and hip. Management depends on the severity, affection of number of joints and co-morbidities. Multidisciplinary management is crucial with realistic expectations. Prognosis should be discussed with parents prior to undertaking surgical intervention, especially the risk of recurrence as age advances. Deformities include soft tissue contractures, fibrotic hypoplastic muscles and in older children, deformed articular congruity. Foot is most commonly affected and Ponseti casting is the gold standard first line of treatment. Failed correction or late presentations are treated with soft tissue/bony surgery and/or fixator. Knee contractures can be flexion or extension with or without joint subluxation and patella involvement. Options for management are serial casting, soft tissue release, growth modulation, bony surgery, gradual correction with fixator or a combination of these based on the severity and age at presentation. Pterygium management is difficult due to proximity of neurovascular structures to the skin web and higher risk of recurrence. Hip contractures and dislocation when unilateral should be treated surgically. Treatment of bilateral affection is controversial and should be individualised.
Keywords:

References

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How to Cite this Article: Shah IP, Ranmuthuge S, Parnami V, Chytas A | Lower Limb Deformity Management in Arthrogryposis – What to Correct and When | International Journal of Paediatric Orthopaedics | May-August 2024; 10(2): 09-16.
https://doi.org/10.13107/ijpo.2024.v10.i02.184

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Blount’s Disease: Review Article

Volume 10 | Issue 2 | May-August 2024 | Page: 39-48 | Yashwant Singh Tanwar, Sirazul Haque Malik, Karolina Siwicka, Nando Ferreira, Pieter Herman Maré

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.192

Submitted: 02/05/2024; Reviewed: 29/05/2024; Accepted: 21/06/2024; Published: 10/08/2024

Authors: Sudhanshu Yashwant Singh Tanwar MS Ortho., DNB, MRCS [1], Sirazul Haque Malik MS Ortho. [2], Karolina Siwicka MD, PhD (T & O) [3], Nando Ferreira FC Orth (SA), MMed (Orth), PhD [3], Pieter Herman Maré FC Orth (SA), PhD [4]
[1] Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India.
[2] Department of Orthopedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Jollygrant, Uttarakhand, India.
[3] Division of Orthopedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, 7505, South Africa.
[4] Paediatric Orthopaedics Unit, Grey’s Hospital, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa.

Address of Correspondence

Dr. Yashwant Singh Tanwar
Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India.
E-mail: tanwar_yashwant@yahoo.co.in

Abstract

Blount’s disease, or non-physiological idiopathic tibia vara, is a growth disturbance affecting the medial proximal tibial physis, leading to a progressive three-dimensional deformity characterized by varus, procurvatum, and internal rotation. While its precise etiology remains unclear, the condition has been closely linked to obesity, mechanical stress, and potential genetic predisposition. Infantile Blount’s typically presents between one and three years of age, often bilaterally, whereas late-onset forms occur in juveniles (4–10 years) or adolescents (>10 years) and are more commonly unilateral. Early differentiation from physiological bowing is essential, as untreated disease results in progressive deformity and joint instability.
Radiographic evaluation is critical in confirming the diagnosis and planning treatment. Key parameters, including the meta-diaphyseal (Drennan) angle, medial metaphyseal beak angle, and mechanical tibiofemoral axis deviation, provide objective measures to distinguish Blount’s disease from other causes of genu varum. Medial tibial plateau depression, best assessed using an arthrogram, is a key determinant in surgical planning, particularly in advanced cases.
Management strategies depend on the stage and severity of the disease. In early stages, guided growth using tension-band plating may modulate physeal development and prevent progression. However, in advanced or recurrent cases, surgical correction is required. Metaphyseal osteotomy, with or without internal fixation, remains the mainstay of treatment. In cases with significant medial plateau depression, a medial hemiplateau elevation osteotomy is indicated to restore joint congruency and knee stability. Severe or late-presenting cases may necessitate double osteotomy techniques, combining joint line realignment with metaphyseal correction. Acute correction methods, including oblique and dome osteotomies, are effective but carry risks of neurovascular compromise. In cases of complex multiplanar deformity, gradual correction using circular external fixation offers precise correction while minimizing complications.
Despite surgical intervention, recurrence remains a concern, particularly in cases with persistent medial physeal slope abnormalities. Strategies such as prophylactic lateral tibial and fibular epiphysiodesis, as well as controlled overcorrection, have been proposed to minimize recurrence risk. Perioperative considerations, including prophylactic fasciotomy and careful fibular osteotomy placement, play a role in preventing complications such as compartment syndrome and peroneal nerve palsy.
Blount’s disease is a progressive condition requiring early diagnosis and timely intervention to prevent long-term morbidity. A structured approach, incorporating clinical assessment, radiographic analysis, and stage-specific management, is essential to optimize outcomes. While current surgical techniques provide reliable correction, ongoing research into the pathophysiology and treatment of Blount’s disease remains essential to improving long-term prognosis.
Keywords: Blount’s disease, Infantile tibia vara, Adolescent tibia vara

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How to Cite this Article: Tanwar YS, Malik SH, Siwicka K, Ferreira N, Maré PH | Blount’s Disease: Review Article | International Journal of Paediatric Orthopaedics | May-August 2024; 10(2): 39-48. https://doi.org/10.13107/ijpo.2024.v10.i02.192

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