To evaluate the operative treatment of Blount disease using the TSF external fixator and to evaluate the system. During January 2004 and August 2008, 8 males and 2 females with Blount disease (16 limbs) were treated using TSF system. For the radiological assessment we obtained standard long-leg standing radiographs and we measured the anatomic medial proximal tibial angle (aMPTA), the diaphyseal-metaphyseal tibial angle (Drennan), and the femoro-tibial angle. The mean follow-up was 29 months (15 to 45). No patient had pain around the knee, medial or lateral instability. The range motion of the knee immediately after frame removal was 10° to 90° of flexion in two patients while in the other it was from 0° to 110°. The mean leg-length discrepancy was reduced postoperatively from mean 1,9 cm (1,7–3,2) to 0,9 cm (0− +1,5). The aMPTA angle increased from mean 73° (59°– 83°) to 94° (107°–90°), Drennan angle from 17° (14°–22°) to 3° (0°–7°), and femoro-tibial angle from 17° (10°–30°) varus to 7° (2°–10°) valgus. The frame was removed at mean 9 weeks (7–14). Two patients had delayed union, two presented with loss of correction (due to dissociation of struts and secondary to medial physeal bar), two patients had pin track infection. No neurologic complications were referred. Accurate corrections of multiplanar deformities as varus, internal rotation and shortening of the limb that coexist in Blount disease may be accomplished using TSF system

From 1994 to 2004, the authors treated 17 patients (nine males and eight females) with Blount disease admitted to the Disabled Children’s Home in Naro Moru (Kenya). Age at intervention ranged from 2 to 16 years (mean 8). In sevencases, the deformity was unilateral and mean age was 8.9 years; in the remaining 10 the deformity was bilateral and mean age was 8.5 years. Tibial proximal metaphyseal corticotomy was performed in 13 cases, and it was associated with calf bone osteotomy in patients aged over 5 years. In eight cases, metaphyseal osteotomy was associated with bone graft from homolateral calf bone and synthesis with Kirschner wire or “staples”, in nine it was performed without bone graft, and in one with axial external fixation. Complications included the following: infection with common peroneal nerve paresis treated with antibiotic therapy and transposition of tibialis posterior to tibialis anterior (one case); relapse of deformity treated with a new osteotomy (one case); incomplete correction (two cases); and pseudoarthrosis with loss of correction treated with a new osteotomy, removal of the pseudoarthrosis area and axial external fixation (one case). Nine patients for a total of 15 tibias were followed up at 1–10 years (mean 5.2). Results were good in 10 cases, with aligned limb and stable knee, fair in three cases, with X-ray evidence of varus deformity < 15° and/or knee instability in orthostasis, and poor in two cases with deformity > 15°, knee instability, length discrepancy > 3 cm. Age at operation and consequent severity of joint deformity influenced the results. Good results were obtained mainly in patients with Blount disease degree 1–3, whereas poor results were obtained in most patients with epiphyseal deformity > degree 4

Introduction:. Blount's disease can be defined as idiopathic proximal tibial vara. Several etiologies including the mechanical theory have been described. Obesity is the only causative factor proven to be associated with Blount disease. Varus deformity is also a clinical feature of rickets and 31% of children with vitamin D deficiency rickets presented with varus deformities to the local Metabolic Bone clinics. The aim of this study is to assess if there is an association between vitamin D and Blount's disease. We hypothesize that children with Blount disease are more likely to be vitamin D deficient. Method:. This a retrospective study of pre-operative and post-operative patients with Blount's disease who were screened for vitamin D deficiency. Patients with known vitamin D deficiency and rickets were excluded. The study patients had the following blood tests: calcium, phosphate, alkaline phosphatase, parathyroid hormone and 25-hydroxyvitamin D. Body mass index (BMI) was also assessed. Results:. We recruited 50 patients. The mean age of these patients was 10.4 years (SD 3.88) with average BMI of 28.7 (SD 10.2). Fifty two % were overweight. Thirty (60%) patients were diagnosed with infantile, 16(32%) adolescent and 4(8%) juvenile Blount disease. Eight (16%) patients were found to be vitamin D depleted (less than 20 ng/ml). Of these eight patients, six had insufficient 25-hydroxyvitamin D levels (12–20 ng/ml) and while the other two were vitamin D deficient (less than 12 ng/ml). Conclusion:. Vitamin D deficiency is a public health problem worldwide. This study confirms that the prevalence of Vitamin D deficiency in children with Blount's disease is similar to healthy children and infants living in Johannesburg. There is no evidence that Vitamin D deficiency is a factor in causing Blount's disease. Routine screening for Vitamin D deficiency in children with Blount disease is not recommended

In 1937 Blount described a series of 28 patients with ‘Tibia vara’. Since then, a number of deformities in the tibia and the femur have been described in association with this condition. We analysed 14 children with Blount’s disease who were entered into a cross-sectional study. Their mean age was 10 (2 to 18). They underwent a clinical assessment of the rotational profile of their legs and a CT assessment of the angle of anteversion of their hips (femoral version). We compared our results to previously published controls. A statistically significant increase in femoral anteversion was noted in the affected legs, with on average the femurs in patients with Blount’s disease being 26° more anteverted than those in previously published controls. We believe this to be a previously unrecognised component of Blount’s disease, and that the marked intoeing seen in the disease may be partly caused by internal femoral version, in addition to the well-recognised internal tibial version

Introduction: The standard treatment of adolescent Blount’s disease includes proximal tibial valgus osteotomy and osteotomy of the fibula. Some believe that the fibula should also be fixed to prevent migration and subluxation. We performed correction of deformities in eight patients (10 tibiae) with adolescent Blount’s disease using the Taylor Spatial Frame (TSF). In all patients, the origin (virtual hinge) was placed at the level of the proximal tibial fibular joint. The purpose of this study was to review treatment outcome of proximal tibial osteotomy without osteotomy of the fibula in patients with adolescent Blount disease. Methods: Eight patients (10 tibiae) were treated by proximal tibial osteotomies and gradual correction by TSF without fibular osteotomy over a period of three years. All patients were males with a mean age of 14.6 years (range, 14–17 years). All patients had severe proximal tibial varus, four had significant proximal tibial procurvatum, and six had internal tibial torsion. The fibula was not fixed in five patients, and fixed distally in three. Results: Frames were removed at an average of 12.8 weeks (range, 12–15 weeks). The mean preoperative proximal tibial varus was 16.2. o. (range, 12–19. o. ), corrected to normal values in all patients. The mean preoperative MPTA was 71.4. o. (range, 67–77. o. ) and corrected to a mean MPTA 87.1. o. (range, 85–89. o. ). In four patients (5 tibiae) with proximal tibial procurvatum, the PPTA was corrected to normal range. Mean correction of internal tibial torsion was 10. o. (range, 5–15. o. ), performed in six patients (8 tibias). Pre-operative MAD was 55.8 mm medial to center of the knee (range, 44–77 mm), corrected to a mean MAD of 4.9 mm medial to center of the knee (range, 2–11 mm). Complications included superficial pin tract infections in seven patients. No complications related to the fibula were observed during/after correction. Conclusion: Based on our initial experience, we believe that most patients with adolescent Blount disease could have successful and predictable correction of tibial deformities without a need for osteotomy and fixation of the fibula

Background: Blount’s original paper in 1937 described a case series of 28 patients with “Tibia Vara”. Since then various authors have attempted to describe in more detail the tibial and femoral deformities seen in this disease. It is still a poorly understood condition. This study describes the femoral rotational deformity that can occur in Blount’s disease. Methods: Over a 2 year period, all patients with Blount’s disease seen in the Orthopaedic department of a regional hospital in South Africa were entered into a database. They underwent a review of their notes, a clinical rotational profile of their lower limbs and a CT scan of the femoral head/neck and distal femur. From this database we performed a cross sectional study. We then compared our results both to previously published controls for hip rotation and anteversion angles and with respect to the rotational profile, to a small cohort of 32 “normal” local children. Results: A statistically significant increase in femoral anteversion in the affected legs was noted, with on average the femurs in Blount’s disease being 26 degrees more anteverted than previously published controls. A significant decrease in external rotation were also noted. Conclusions: Our results suggest that the marked intoeing seen in many cases of Blount’s disease may be caused by internal femoral version, in addition to the well recognized internal tibial version. This study highlights the following issues:. A rotational profile should be part of the routine clinical assessment of all Blount’s cases. A CT assessment of anteversion should be considered to quantify this accurately. Overcorrection of the tibial internal version (to correct the added femoral version/torsion) should be considered when doing tibial osteotomies in cases with marked femoral internal version. Some cases of Blount’s disease will require further correction of rotation, after corrective surgery around the knee, that included external rotation of the tibia. Persistent in-toeing may need a de-rotation osteotomy of the femur shaft

Introduction: Blount’s disease is an idiopathic, non-physiological form of genu varum. Deformity usually occurs in the proximal tibia with progressive varus, but also with valgus in the distal femur. Treatment in the infantile stage includes observation or bracing, and surgery for acute marked proximal tibial varus. Recurrence is common with conventional surgery after the age of four. Method: A new surgical technique is proposed as definitive treatment of this condition which includes an arthrogram to visualise the knee joint, acute elevation of the varus aligned medial tibia plateau with second plane correction of posterior slope deformity, lengthening and derotation of the tibia by application of a Taylor spatial frame, application of an 8 plate on the distal femur to correct valgus deformity and finally proximal tibial and fibular epiphysiodesis to prevent recurrence. Results: Five patients with Blount’s disease had this definitive corrective procedure performed at a mean age of 9.8. Radiographs and CT scans taken pre-operatively demonstrated marked medial plateau varus deformity and increased posterior slope. Surgery was performed by the senior author. Follow-up X-rays demonstrated satisfactory alignment, length and rotation of the lower limb. Conclusions: This new surgical technique allows correction of all deformities of Blount’s disease at one operation and maintains alignment, length and rotation clinically and radiologically at follow-up

We reviewed 34 knees in 24 children after a double-elevating osteotomy for late-presenting infantile Blount’s disease. The mean age of patients was 9.1 years (7 to 13.5). All knees were in Langenskiöld stages IV to VI. The operative technique corrected the depression of the medial joint line by an elevating osteotomy, and the remaining tibial varus and internal torsion by an osteotomy just below the apophysis. In the more recent patients (19 knees), a proximal lateral tibial epiphysiodesis was performed at the same time. The mean pre-operative angle of depression of the medial tibial plateau of 49° (40° to 60°) was corrected to a mean of 26° (20° to 30°), which was maintained at follow-up. The femoral deformity was too small to warrant femoral osteotomy in any of our patients. The mean pre-operative mechanical varus of 30.6° (14° to 66°) was corrected to 0° to 5° of mechanical valgus in 29 knees. In five knees, there was an undercorrection of 2° to 5° of mechanical varus. At follow-up a further eight knees, in which lateral epiphysiodesis was delayed beyond five months, developed recurrent tibial varus associated with fusion of the medial proximal tibial physis

Blount's disease is by far common cause of significant genu varum in paediatric age group. The deformity can range from simple varus deformity to significant varus, shortening of tibia and internal torsion of tibia, depending up on type and stage of Blount's disease. Several studies have shown excellent correction with the use of circular frame. The trend has moved from Ilizarov circular frame to Taylor Spatial Frame. The most accepted method of achieving correction of all components is by performing proximal tibial osteotomy and gradual correction of mechanical axis. Traditionally two additional procedures – fibular osteotomy and fixation of distal tibio-fibular syndesmosis are also added. However, the role of these additional procedures, which are not without their complications, is not well evaluated. A recent study had shown that correction of tibia vara without lengthening can be achieved without fibular osteotomy. However, use of distal tibio-fibular syndesmosis fixation (either with a wire or a screw) remains controversial. We present our experience in treating Blount's deformity with circular frame without stabilization of distal tibio-fibular syndesmosis. 10 patients were treated at our tertiary referral centre between 2000 to 2010. There were 7 boys and 3 girls. Age at surgery ranged from 8 yrs – 15 yrs. The mean patient age was 11.5 yrs. Two patients were treated with Ilizarov frame and 8 with Taylor Spatial Frame. Indications for surgery were unacceptable deformity (varus and internal rotation), with or without shortening. Varus deformity ranged from 10 degrees to 40 degrees. All tibiae were lengthened and the range of lengthening was from 1cm to 3.5cm. Fibular osteotomy was carried out in all patients. Tibio-fibular syndesmosis was never stabilized distally. All the patients were encouraged to mobilise full weight bearing as soon as tolerated and all of them had gradual correction of deformity usually starting a week following the surgery. We achieved target correction of varus, internal rotation and leg length discrepancy in all patients. The commonest hurdle was superficial pin tract infection which resolved with short courses of oral antibiotics. Follow up ranged from 6 months to 10 yrs. Clinical and radiological evaluation of ankle did not show any abnormality in all these cases. Satisfactory correction of Blount's disease (tibia vara and leg length discrepancy) can be achieved with circular frame without the stabilization of distal tibio-fibular syndesmosis

Introduction: The usual surgical treatment of valgus knee in Ellis van Creveld Syndrom (EVC), is high tibial osteotomy. However, this approach failed to achieve the expected goal of lasting correction. Based on Dr. Paley’s observations, and our previous unsuccessful treatment of valgus knee in EVC syndrome, we changed the surgical approach. The aim of the surgical treatment is to eradicate all the elements causing sever valgus knee: 1) dysplasic lateral tibial condyle, 2) progressive depression of the lateral tibial plateau, 3) short fibula, 4) short and contracted fascia lata, 5) short lateral collateral ligament and biceps femoris, 6) short lateral head of gastrocnemius, and 7) contracted lateral knee capsule and lateral retinaculum. In many aspects the pathology of Blount’s disease grade 5 or 6 is similar, but located at the medial tibia causing genu vara. Materials and Methods: Three valgus knees of EVC syndrome and two varus knees of Blount’s disease grade 5 & 6 underwent surgical treatment by a unique surgical approach to address all pathologies which contribute to the deformity. In the cases of EVC syndrome the first stage operation included: 1) peroneal nerve release and soft tissue release including T.F.L., B.F., L.C.L., capsule and gastrocnemius, 2) arthrogram, 3) fibulectomy, 4) elevation of lateral tibial plateau with bone graft, 5) reconstruction of L.C.L. and B.F., 6) lateral release of retinacula and rerouting of patella, and 7)cast application. In the second stage operation of these cases a corrective high tibial osteotomy was performed. In the Blount’s disease knees the operative treatment was performed in one stage and included: 1) arthrogram, 2) elevation of the medial tibial plateau, 3) fibulotomy, 4) closing wedge tibial osteotomy based laterally, 5) transfer of the bony wedge under the elevated plateau and fixation. Results: All deformities were corrected with no recurrence, and stability of the knees persisted. We had one common peroneal nerve neuropraxia that recovered and one wound dehiscence. Conclusions: In both conditions, EVC syndrome and Blount’s disease, corrective high tibial osteotomy does not address the pathology, and recurrence is to be expected. The described surgical technique fulfills that target – eradication of the pathologic elements that lead to valgus or varus

Background:. Tibia Vara (Blount's disease) is characterized by a growth disturbance of the posteromedial proximal tibial physis. This results in the typically complex tibial deformity of varus, procurvatum and internal tibial torsion. Knee instability is due to medial tibial joint depression and lateral ligament complex attenuation. Femoral angular and rotational deformity are associated features. Obesity often complicates management. Langenskiöld observed six stages of the disorder on X-ray (stage 6 not occurring before 9 years) and obtained good results with proximal tibial realignment osteotomy if performed before the age of 8 years. Our experience is very different. Purpose:. To evaluate our experience with treatment of a consecutive cohort of patients with early onset Blount's disease in terms of clinical findings, recurrence rate and factors associated with recurrence and treatment methods and indications. Methods:. A retrospective chart and imaging review was completed of 100 extremities (58 patients) treated surgically for early onset Blount's disease. Follow-up ranged between 1 and 7 years. Results:. These children all presented with a history of onset of deformity between the ages of 1 and 3 years. Their age at first treatment varied between 2 and 10 years. Langenskiöld stage V and VI occurred in younger patients than originally described. The recurrence rate of extremities treated with simple osteotomy was 42% (25/58). Factors associated with recurrence include age >4 (p<0.001), obesity (p=0.007), instability (p=0.003), severity of deformity (femoro-tibial angle) (p<0.001), medial physeal slope (p<0.001) and advanced Langenskiöld stage (p<0.001). Surgical treatment included the use of growth retardation alone, dome realignment osteotomy with and without growth retardation, oblique proximal tibial (Rab) osteotomy, 3-in-1 procedure (medial elevation, tibial osteotomy and lateral epiphyseodesis) and gradual correction with hexapod fixators was used in some recurrent cases. In addition we describe a new surgical technique which obtains acute deformity correction at the level of the growth plate. Conclusion:. We propose that the disease follows a more aggressive course in the black population of Kwa-Zulu Natal, South Africa. The management is often complex and recurrence is not uncommon

Background:. Recurrent or late presenting Tibia Vara is a complex clinical problem. In addition to the multiplanar deformity the disorder is often accompanied by obesity. Simple re-alignment osteotomy with acute correction is effective early in the disease. Its use in recurrent or severe deformities is limited by geometric constraints (mechanical axis translation), difficult fixation and the risk of compartment syndrome. Gradual correction with external fixation devices is a well-accepted technique in these cases. It has been shown to obtain accurate correction and provides stable fixation. This allows early weight bearing which facilitate consolidation and rehabilitation. Hexapod fixators are technically less demanding than standard Ilizarov techniques. The TLHex is a relatively new hexapod fixator available in South Africa. Frame pre-assembly allows easier mounting on a limb with complex deformity. The software allows for non-orthogonal mounting, which simplifies frame-mounting assessment. Double telescoping struts allow greater strut excursion and the outside mounting of struts on the ring increases mounting options for fixation elements. This is the first report on its use in Blount's disease. Purpose:. Evaluation of the result of gradual correction with the TLHex external fixator in Blount's disease in terms accuracy of correction, union and complications. Illustration of key hardware and software features. Methods:. A retrospective chart and X-ray review of 7 patients (9 legs) treated by gradual correction with the TLHex external fixator was performed. The degree of correction of varus and procurvatum was assessed on pre-operative and post-correction X-rays. Internal rotation deformity correction was assessed clinically. Complications such as neurovascular compromise, minor and major pin tract infection and hardware complications were documented. The pre-operative planning, surgical technique and post-operative treatment protocol is reviewed. Results:. Mean varus was corrected from 21° (17° to 45°) to 1°(−2° to 4°). Mean procurvatum was corrected from 8° (0° to 25°) to 0° (0° to 8°). Internal rotation was corrected to between 5° to 10° of external rotation in all patients. The mean time in the frame was 112 days. Three patients needed one additional program to correct residual deformity (one over-corrected coronal aligment, one under-corrected saggital alignment and one rotational over-correction). Three patients required oral antibiotics for minor pin tract infection. One patient required intravenous antibiotics and wire removal for major pin tract infection. One patient required frame adjustment after correction for soft tissue impingement. One strut loosened after consolidation prior to frame removal. Conclusion:. Gradual correction of Tibia Vara with the TLHex external fixator is a safe and effective treatment method

We describe three cases of infantile tibia vara resulting from an atraumatic slip of the proximal tibial epiphysis upon the metaphysis. There appears to be an association between this condition and severe obesity. Radiologically, the condition is characterised by a dome-shaped metaphysis, an open growth plate and disruption of the continuity between the lateral borders of the epiphysis and metaphysis, with inferomedial translation of the proximal tibial epiphysis. All patients were treated by realignment of the proximal tibia by distraction osteogenesis with an external circulator fixator, and it is suggested that this is the optimal method for correction of this complex deformity. There are differences in the radiological features and management between conventional infantile Blount’s disease and this ‘slipped upper tibial epiphysis’ variant

We have treated seven children with relapsed infantile Blount’s disease by elevation of the hemiplateau using the Ilizarov frame. Three boys and four girls with a mean age of 10.5 years were reviewed at a mean of 29 months after surgery. All had improved considerably and were pleased with the results. The improvements in radiological measurements were statistically significant (p < 0.001). Three-dimensional CT reconstruction was useful for planning surgery. There were no major complications. The advantages of this technique are that in addition to elevation of the hemiplateau, rotational deformities and limb-length discrepancies may be addressed

The results of 34 knees with stage IV to VI Blount’s disease were reviewed. 24 patients were treated over the seven-year period from 1994 to 2000. The surgical technique addressed the medial joint line depression with an elevating osteotomy maintained with a tricortical wedge from the iliac crest. The tibial varus and intorsion was corrected with an osteotomy proximal to the apophysis. In the more recent patients a proximal lateral tibial and fibular epiphyseodesis was done concomitantly. The average preoperative mechanical varus angle of 30.6°(range 14° to 60°) was corrected to 0–4° mechanical valgus in 29 knees. In five knees an undercorrection of 2–4° mechanical varus occurred. At follow-up a further 8 knees developed residual varus due to a delayed epiphyseodesis. The tibial varus angle (ie. angle subtended by the mechanical axis of the tibia with the lateral tibial joint line) increased at an average of 1°/ month due to the inevitable medial growth plate fusion. The average pre operative joint depression angle of 49° (range 40° to 60°) was corrected to an average of 26°(mean 20°–30°). There was no significant preoperative frontal plane f emoral deformity to warrant a femoral correction. At long term follow up of 3.5 years (range 2 to 5 years) all knees had a full range of movement without any varus instability. However in eight cases a delay of more than six months occurred before a lateral epiphysiodesis was performed, and in these patient’s mechanical axis varus recurred although the joint line correction was maintained. Neutral or valgus mechanical axis was maintained in all patients who underwent an epiphysiodesis within six months. We concluded that although the joint elevation correction was maintained in our series, mechanical axis varus recurs if lateral epiphysiodesis is not performed early

We reviewed the results in 24 children (34 knees) following double-elevating osteotomy for late presenting infantile Blount’s disease. The mean age of our seven male and 17 female patients was 9.1 years (7 to 13.5). Obesity was noted in 15 (above the 95th percentile). Previous valgus osteotomy had been performed on nine knees. Ten knees were Langenskîld stages IV, six stage V and 18 stage VI. The surgical technique addressed the medial joint line depression with an elevating osteotomy, which was maintained by insertion of a tricortical wedge from the iliac crest and the excised fibula. The tibial varus and internal torsion was corrected with an osteotomy proximal to the apophysis. In the more recent patients, a proximal lateral tibial and fibular epiphysiodesis was done concomitantly. The mean preoperative mechanical varus of 30.6( (14( to 60() was corrected to 0( to 4( mechanical valgus in 29 knees. In five knees there was under-correction to 2( to 4( mechanical varus. At follow-up a further eight knees developed varus owing to late epiphysiodesis. The tibial varus angle (the angle subtended by the mechanical axis of the tibia and a line along the lateral tibial joint line) increased at a mean of 1( a month due to inevitable medial growth plate fusion. The mean preoperative joint depression angle of 49( (40( to 60() was corrected to 26( (20( to 30(), which was maintained at follow-up. There was no noteworthy femoral valgus or varus present preoperatively to warrant femoral osteotomy

To assess the efficacy of software assisted correction using six axes analyses for Blounts deformity.

Between 1998 and 2000, 22 tibiae in 19 patients underwent correction of Tibia Vara with the TSF. There were six females and thirteen males. There were 8 infantile and 14 adolescent forms. The mean patient age was 9.9 years (3–16 years). Shortening was present in 18 patients, averaging 11 mm (range: 3–30 mm). The mean follow up was 2.8 years (range: 2–4.1 years).

The mean preoperative varus deformity was 16.5 degrees (range, 8 to 50 degrees) which improved to 0 degree (−2 to 2 degrees), and mean procurvatum deformity was 12.2 degrees (2 to 21 degrees) which improved to 0.1 degree (−2 to 3 degrees). The plane of the deformity was an average of 31 degrees (0 to 62 degrees) from the coronal plane and the mean magnitude of the deformity was 20.5 degrees (11.3 to 3.8 degrees)

Taylor spatial frame uses the six axes software assisted analysis to correct complex deformities such as Blounts disease. It is very effective in correcting the Blounts deformity and has minimal complications.

We present the results of treatment for relapsed infantile Blounts disease using a technique of hemiplateau elevation with the Ilizarov frame.

7 patients with a mean age of 10 years 6 months were reviewed at 30 months following hemiplateau elevation with/without ipsilateral tibial lengthening. Preoperatively clinical photographs, long leg standing radiographs and 3D computed tomography images were acquired. The patients were evaluated clinically (presence of knee pain, range of knee motion, knee stability and leg length discrepancy) and radiologically. Schoeneckers objective assessment was undertaken. The results were analysed statistically.

Clinically all the patients improved significantly. No patient had knee pain and the range of knee motion was from 0° to more than 100° of knee flexion. The radiological results and Schoeneckers grading are depicted below.

The improvement in radiological measurements were statistically significant. Pin site infection was present in all but settled with antibiotics.

The results of hemiplateau elevation for relapsed infantile Blounts disease are encouraging.

Introduction and Objective. Virtual Surgical Planning (VSP) is becoming an increasingly important means of improving skills acquisition, optimizing clinical outcomes, and promoting patient safety in orthopedics and traumatology. Pediatric Orthopedics (PO) often deals with the surgical treatment of congenital or acquired limbs and spine deformities during infancy. The objective is to restore function, improve aesthetics, and ensure proper residual growth of limbs and spine, using osteotomies, bone grafts, age-specific or custom-made hardware and implants. Materials and Methods. Three-dimensional (3D) digital models were generated from Computed Tomography (CT) scans, using free open-source software, and the surgery was planned and simulated starting from the 3D digital model. 3D printed sterilizable models were fabricated using a low-cost 3D printer, and animations of the operation were generated with the aim to accurately explain the operation to parents. All procedures were successfully planned using our VSP method and the 3D printed models were used during the operation, improving the understanding of the severely abnormal bony anatomy. Results. The surgery was precisely reproduced according to VSP and the deformities were successfully corrected in eight cases (3 genu varum in Blount disease, 2 coxa vara in pseudo achondroplasia, 1 SCFE, 1 missed Monteggia lesion and 1 post-traumatic forearm malunion deformity). In one case, a focal fibrocartilaginous dysplasia, the intraoperative intentional undersizing of the bone osteotomy produced an incomplete correction of a congenital forearm deformity. Conclusions. Our study describes the application of a safe, effective, user-friendly, VSP process in PO surgery. We are convinced that our study will stimulate the widespread adoption of this technological innovation in routine clinical practice for the treatment of rare congenital and post-traumatic limb deformities during childhood

Purpose: Patients with advanced Blount disease present severe metaphyseal varus associated with an oblique medial tibial plateau. Prior to 1987, we used tibial wedge osteotomy to correct the varus deformation and in certain situations also raised the medial plateau with the wedge. From 1987, we performed both procedures during the same operation. The purpose of this work was to describe our technique and evaluate the results of the dual technique. Material and methods: Between 1987 and 2000, we performed 31 dual procedures. Fifteen patients who had advanced-stage Blount disease were seen late (eight before complete fusion of the growth cartilage and seven as adults). Thirteen children presented recurrent varus deformation after osteotomy during childhood. One patient presented tibia vara during adolescence and three others had poly-epiphyseal dysplasia. Mean age at osteotomy was 17 years (range 10–40). For all patients, the operative technique consisted in lateral closed wedge osteotomy associated with a second access for an oblique osteotomy directed towards the tibial spikes to insert the lateral wedge medially and raise the medial plateau. A mid-third fibular osteotomy was also performed together with stapling for tibial epiphysiodesis superior and lateral when the growth cartilage was still active. We recorded pre- and postoperatively: mechanical femoro-tibial angle, the tibial and femoral mechanical angles to determine intra-osseous deformation, the slope of the medial plateau, and the length of the lower limbs at the end of growth. Results: Mean follow-up was eight years. Fusion was achieved in all patients. The mechanical femoro-tibial angle was 148.5 (mean) preoperatively giving 31.5° (20–42) varus and 178° postoperatively. The mean femoral mechanical angle was 94°, giving 4° valgus (range 88–102°) preoperatively, with no change postoperatively. The mean mechanical tibial angle was 71° preoperatively (intra-osseous varus of 19°) and 89° postoperatively. The medial tibial plateau slope was 45° preoperatively and 22° postoperatively. Leg length discrepancy was 2.2 cm at last follow-up (range 0.5–5 cm). Discussion: Different techniques have been described for correcting two deformation components during the same operation. Here, we used the metaphyso-epiphyseal oblique osteotomy technique. This technique assumes that the medial part of the cartilage has already fused and requires fusion of the lateral part when it is active. Currently, we use chondrodiastasis with a special external fixator when the cartilage is still active. This corrects the alignment and raises the plateau, treating the length discrepancy by lengthening. The dual osteotomy technique is reserved for patients with total physis fusion. A long-term analysis after dual osteotomy in comparison with chondrodiastasis will be needed to determine the relative merits of the two techniques and the frequency of secondary osteoarthritis. This work is being conducted at the orthopaedic surgery department of the Fort-de-France University Hospital in Martinique