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Short Communication Volume 16 Issue 2
Ilizarov technique for correcting blount’s disease
Bari MM ,1 
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Bari AM Shayan R,2 Islam Shahidul3
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1Prof. Ph.D, Chief Consultant, Bari-Ilizarov Orthopaedic Centre, Visiting and Honored Prof., Russian Ilizarov Scientific Centre, Kurgan, Russia
2Medical officer, Bari-Ilizarov Orthopaedic Centre; PhD resident in Tashkent scientific research institute of orthopaedics and traumatology, Uzbekistan
3MD; FCPS, Prof., Bari-Ilizarov Orthopaedic Centre, Bangladesh
Correspondence: Dr. Md. Mofakhkharul Bari, Bari-Ilizarov Orthopaedic Centre, 1/1, Suvastu Shirazi Square, Lalmatia Block E, Dhaka-1207, Bangladesh, Tel +8801819211595
Received: April 20, 2024 | Published: April 26, 2024
Citation: Bari MM, Bari AMSR, Islam S. Ilizarov technique for correcting blount’s disease. MOJ Orthop Rheumatol. 2024;16(2):65-70. DOI: 10.15406/mojor.2024.16.00666
Abstract
Blount's disease, also known as tibia vara, is a growth disorder that affects the lower leg, leading to a bowing of the shinbone (tibia). The Ilizarov method can be employed as a specialized treatment approach for correcting deformities associated with Blount's disease.
Introduction
Erlacher first description of tibia vara and internal tibial torsion (1922). Blount (1937) described tibia Vara as "an osteochondrosis similar to coxa plana and Madelung's deformity but located at the medial side of the proximal tibial epiphysis."
Blount's disease is a complex orthopedic condition, predominantly seen in children, causing a distinctive varus alignment in the lower extremities.1 This gives rise to a multiplanar limb deformity, committing of varus angulation, anterior bowing (procurvatum), and internal rotation of the tibia. This combined multiplanar type of deformity requires a comprehensive understanding for effective diagnosis and treatment planning in the pediatric population. The Ilizarov method, renowned for its efficacy in addressing complex orthopedic conditions, offers a comprehensive approach to the treatment of Blount's disease.
Material and methods
From 2000 to 2023 we have treated 96 patients with Blount's Disease. 56 males and 40 females, mean age was 7 years, were treated by Ilizarov. The typical duration of treatment averaged six months, with a variability ranging from four to twelve months. Patient selection based on diagnosis of Blount's disease, preoperative assessment including clinical and radiographic evaluation, surgical planning tailored to individual cases, Ilizarov frame application under fluoroscopic guidance, percutaneous wire and pin insertion, gradual correction through distraction osteogenesis, and postoperative care including regular monitoring and physical therapy.
Clinical features
The exact cause of Blount's disease is not fully understood, and it is likely to be multifactorial, involving a combination of genetic, mechanical, and environmental factors. Some potential factors that may contribute to the development of Blount's disease include:
Early walking and overweight in infantile
Children with infantile Blount's disease often begin walking early, typically before 12 months old. The combination of early walking, and being overweight contributes to an increased stress on the developing leg bones, potentially playing an okay role in the development of the condition!
Weight-related factors
Adolescent Blount's disease may be associated with factors which include rapid weight gain in adolescents, and also obesity. This additional, often, places increased stress on the growing; particularly, around the knee joint. This could potentially leading to the characteristic varus deformity seen in Blount's disease! In some cases, the condition could have been preventable with proper weight management.
Genetic component
The condition tends to run in families, suggesting a hereditary predisposition. While, like the actual genetic factors involved are not fully understood, the familial clustering of cases highlights the influence of genetics in some instances.
Clinical features
Similar to physiologic genu varum
Obese
Often lateral thrust on walking
Hemicondylar osteotomy.
Tibiofemoral angle
Metaphysio Diaphysial angle (Levin and Drennen)
MDA Angle
MDA < 11: normal physiologic bowing
MDA 11-15: equivocal
MDA >15: Blount's
Classification
The Langenskiold classification helps orthopedic surgeons determine the appropriate treatment approach based on the severity of the disease.
Stages of Blount's disease: Langenskiold
Stage I and II
- More than 3 yrs.
- Metaphyseal corrective osteotomy and fixation Either acute or gradual correction
- External fixation
- Over correction 5-6 degree valgus
Stage III
- Corrective osteotomy metaphyseal alone
- Delay in surgery higher chances of recurrence
Stage IV and V
- More serious
- Physeal arrest already occurred [not seen radiologically]
- Two deformities- metaphyseal and epiphyseal
- Treatment must be individually
Stage VI
- Medial bony bridge and epiphyseal closure
- Deformity is progressive as long as the growth continues
- Two deformities- intraarticular &extra articular
Results
Blount’s disease can be corrected simultaneously by Ilizarov fixation with minimum complications. There were no recurrent deformities in our cases. The deformity correction was achieved with a proper alignment in all the cases.
Discussion
Ilizarov methodology and the apparatus goes hand in hand when it comes to correcting Blount's disease. Pre-operatively, a detailed general, systemic and radiological examination is important. The Ilizarov technique has emerged as an effective method for correcting the complex deformities associated with Blount's disease.2–4 The aim of the study was to increase the overall quality of life of the patient. By employing external fixation devices and gradual bone manipulation, the Ilizarov technique offers precise correction while minimizing soft tissue trauma and preserving neurovascular structures.5 This approach is particularly beneficial in pediatric patients, where skeletal immaturity necessitates interventions that can accommodate ongoing growth. This requires a very thorough and methodical patient follow-up throughout the entire duration of treatment. Concurrently, exercise, physical therapy should be carried out consistently so as to minimize the extent of any complications.
Case 1 a) 2 years old girl with Blount’s disease
b) Radiographic view showing, left sided severe Blount disease (type 2)
c) Patient with Ilizarov apparatus
d) Correction of deformity by hinge application
e) Patient is comfortable with Ilizarov ring
f) Radiographic view after 3 weeks with full consolidation
g) Smiling patient with Ilizarov apparatus
h) Radiographic view after 1 month
i) After 2 months followed-up, plaster immobilization
j) Radiographic view after removal of plaster immobilization, after 1 month
k) Final radiograph after 3 months. Full correction is achieved
l, m) Patient after 3 months (Front & back view).
Case 2 a,b) Sequalae of Blount's disease with bowing of tibia with genu Varum– 24 years old girl (Font and back view)
c) X-ray showing Blount's disease with bowing of tibia with genu Varum
d) Patient with Ilizarov apparatus
e) Radiographic view showing patient with Ilizarov apparatus
f) Patient with Ilizarov apparatus with full weight bearing
g) The doctor is examining the patient's Ilizarov apparatus
h) After removal of Ilizarov apparatus, plaster immobilization
i) After 6 months followed-up
j,k) Patient with brace for support
l) After removable of plaster
m) Stress x-ray showing full correction
n) Full correction achieved after 9 months treatment
Case 3 a, b) 7 years old boy, Blount's disease with Bilateral Bow legs (Font and back view)
c) X-ray showing Blount's disease with Bilateral Bow legs with both metaphyseal and epiphyseal
d) Patient with Ilizarov apparatus with full weight bearing
e, f) Radiographic view after 2 weeks
g) After removal of Ilizarov apparatus, plaster immobilization
h) Patient with brace for support
i) After 8 months treatment
j) Stress x-ray showing full correction After 11 months treatment
k, l) Full correction achieved after 11 months treatment (Font and back view)
Conclusion
In conclusion, the Ilizarov technique stands as a very valuable and an effective approach for correcting Blount's disease. This method, involving external fixation and gradual correction, has demonstrated successful outcomes in addressing the deformities that are associated with the condition. The ability to customize the correction process through controlled adjustments using the external fixator contributes to its great versatility. Moreover, the deliberate strategy of overcorrection, often by 5-6 degrees in valgus; helps mitigate the risk of relapse, during the healing period. With an average treatment duration of six months, ranging from 4 to 12 months, the Ilizarov technique offers a very comprehensive solution that not only corrects the immediate deformity, but also allows for careful monitoring; and adjustments, ultimately leading to improved long-term results, in the management of Blount's disease.6,7
Acknowledgments
None.
Conflicts of interest
The authors declare that there are no conflicts of interest.
References
- Bari M. A color atlas of limb lengthening surgical reconstruction and deformity correction by ilizarov technique. 2013.
- Stephanie MW, Elizabeth WH, Dan S, et al. Gradual deformity correction in blount disease. 2019;39(5):257–262.
- Paley D. Problems, obstacles and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990;(250):81‒104.
- Bari MM. Correction of leg deformities and restoration of function of leg bones by Ilizarov technique. 2014
- Deborah FB. Treatment of adolescent Blount's disease using the ilizarov technique. Operative Techniques in Orthopaedics. 1993;3(2):149–155.
- Dietz WH, Gross WL, Kirkpatrick JA. Blount disease (tibia vara): another skeletal disorder associated with childhood obesity. The Journal of Pediatrics. 1982;101(5):735–737.
- Ilizarov GA. The tension‒stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft‒tissue preservation. Clin Orthop Relat Res. 1989;238:49‒81.
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