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Name:
Blount Disease for Postgraduate Orthoapedic Exams
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Blount Disease for Postgraduate Orthoapedic Exams
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Upload Date:
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Language: EN.
Segment:0 .
Good evening, everyone, thank you for joining us. This is a teaching session presented jointly by the FRCS mentor group and orthopedic Research UK. I'm curious about and would be moderating the session and to help me here, there are members of the mental group Schwann and abdala and as well as Ruth, who is the head of education from the UK.
The speaker is Gavin Spence, and he's teaching us tonight about blunt disease. Gavin is a consultant, pediatric orthopedic surgeon at bragiel hospital in the Bay. He's he has clinical interests, a limb deformity correction, and he has been a consultant prior to this current position. He's been a consultant, Great Ormond Street Hospital for children. In London.
He's been he has a particular interest in teaching, and he's been a worldwide trainer of the year by the British Orthopedic training association in 2019. And a lot of talk about Gavin as well. The session will include basically, as you can see, a lecture presentation. Please pay attention very well, because there will be polling questions afterwards. There'll be three questions we'll ask you to answer, and we'll give you the right answers to those, but will be very interested to see if you pick the right answers from the presentation, we have an opportunity to ask questions.
So if you hover your mouse at the bottom of the screen, you will find a chat box. If you click on the chat box. It will open at a chatting function. What you can post your questions and we'll present them to Gavin and when it's appropriate. If you really like to talk directly to government or if you like to take part in the afterwards hot seat Viva Viva session, they will ask you to raise the hand symbol, which is located under the participants list.
It's a blue symbol and we know that you are interested in taking part in Viva. These are served on first come, first served basis. So if you're interested, we ask you to express your interest as early as possible. Gavin has prepared very interesting questions Viva questions that are exam specific and relevant, directly relevant to that of case exam, and you'll be given detailed constructional feedback afterwards.
So I urge you to make the best out of this opportunity. So it's quite an interactive session with obviously the limitations that we know of. And we ask you all, please give us feedback at the end. Obviously, we use this feedback for our own development and to see how we can do better. And Ruth, the head of education from our UK, has been in touch with you and will be again in touch with you about certificates and about the feedback.
If you guys miss any part of this for any reason, don't panic, this will be recorded. And we will share the recording on the enforcement channel and on the UK website. And just as you can see here, this is the link there to a series of teaching webinars we're presenting with collaboration with our UK, and there will be many to come next one in a couple of weeks again on a Wednesday teaching about knee replacement.
So you can always access these on the webinar page on or UK website. So without further ado, we will leave you with Mr Spence, right? Well Torres, thank you so much. Ruth, Thanks very much for the invitation to present on this webinar. This is a new venture for me, too, so I was very excited about getting the chance to do this and just an extended welcome to all the people joining wherever you happen to be locked down in the world today.
I hope you're going to find this session useful. So just before we start the session properly, just a few words about orthopedic research UK, they, as you may know, are a charity based in the UK. And their aim is really to improve orthopedic knowledge, and it's a two pronged approach. Partly research and partly an educational arm. And my personal background with orthopedic Research UK goes back a long way about 15 to 16 years.
In fact, when I first got in touch with them, they helped out with funding some research that I was doing, which to cut. A very long story short, I was really desperate for the cash at the time because the charity that was going to GoFundMe had gone bust. So orthopedic Research UK really helped me out, and I think I was, in fact, their first research fellow. So I've had a long and very happy relationship with them, and now I continue mainly on the educational side with them.
And they're a fantastic organization. They're great people to work with. I count them amongst my friends. So good for orthopedic Research UK. So if pediatrics is your bag or if indeed it's not your bag and it's something that you are concerned about, particularly for your exam, we have a seminar coming up in January. It's a 2 day course. This is the latest iteration of a number of courses that we've run with orthopedic Research UK.
It's a 2 day course where we really try and plug knowledge, particularly for people whose experience of pediatric orthopedics is limited. We try and focus in on those areas that people struggle with. We pepper it full of the sort of information that's often not in the books and which are top tips for passing the exam. The feedback from the last course was really good, so if you're interested in that course, you can get details on the orthopedic Research UK website, or you can use your phone and you can scan that QR code you can see in the bottom right.
There's also textbooks, revision textbooks available from orthopedic research Uk's website or from Amazon. These are two of the really popular sort of go to textbooks for revising for the exam. And finally, if you want to donate and support the excellent work that orthopedic Research UK do, you can do that through their website to or by scanning the QR code.
OK, that is the marketing over. Let's get on with the presentation. So this is Blount disease. Blount disease is a really terrific topic, but. I don't want you to get things out of proportion. So it is actually a cause of genuine harm, but it is not going to be the commonest cause of bow legs that you see in your clinic.
So don't go away from this presentation diagnosing Blount disease in every kid you see, because that's not going to be the cause. How many of the kids that you see in your clinic have Blount disease? Will that really depends on where you live. In the world because the incidence of the disease varies according to population, and it also depends on whether you're in a tertiary set up or a secondary set up or whatever it is.
But suffice to say, it's a pretty small number. So even countries which have populations which are prone to disease don't report large prevalences. So in the United states, it's less than 1% And in South Africa, less than 0.1% So small numbers, ok? So famously, it's a disease that is bimodal, it has two age groups in which a condition called Blount disease occurs, a condition of progressive bow legs.
Whether these are two separate conditions or whether they represent part of the same pathology is open to debate, but they definitely occur in two age groups. And traditionally those have been called the infantile age group and the adolescent. And as you can see from the slide I've drawn there, the infantile group is the commonest one. The literature, though, gets a little bit confusing because it sometimes talks about juvenile so, so a juvenile.
Blount disease is thought to be that form of bow legs, which occurs after the age of about four, but there's a lot of debate about it. There is a feeling that probably most quotes juvenile cases are in fact infantile cases that were never picked up in the early years. So it's not a term I'm going to use in this talk, and it's not a term that I think is particularly helpful. In fact, if I had my way, we'd drop the terms adolescent infantile and we talk about blunt diseases either being early onset or late onset.
And the reason why I think that's helpful. Well, partly it does what it says on the tin. It makes it very clear what we're talking about here. But perhaps more importantly, you have to remember that infantile Blount disease is a recurrent disease that we're going to discuss that in some detail over the next few slides. So what that means is when you see an adolescent, it might be that they have the adolescent form of Blount disease, but equally, in fact, probably more likely they are adolescents who have a recurrent form of the infantile disease.
I hope that makes some sense. So adolescence could have one of those two scenarios which have led them to have a leg. So you can see the terminologies all getting rather confusing here. Early onset, late onset, some authors use and they mean something completely different by it. Some authors use late onset as meaning after four years, so it's tricky.
So what we're going to do to stick with the rest of this presentation, we're going to talk about good old fashioned infantile Blount's and adolescent rounds. So let's start with the most common. Which is infantile Blount's. So what do all these kids have in common? Well it's been known for some time that Blount disease occurs pretty much in all races and all countries in the world, but it does seem to have a predilection for certain racial groups, so kids whose genetics hail from sub-Saharan Africa seem to be particularly prone to this condition.
It's also a condition that tends to occur in kids who walked early and who are on the heavy side, although that second one is not universal, but quite a lot of these kids are over the 95th percentile in terms of weight for age, so heavy early walkers. And that's going to be important in the pathogenesis, as we'll discuss in the next slide. In infantile Blount disease, it's generally girls more than boys, and there's some really interesting literature on vitamin D deficiency in this condition.
So, of course, vitamin D deficiency can cause both legs anyway by nutritional rickets, but that's a very different condition. Ideologically, it's a completely different condition. But there have been some papers suggesting that perhaps children with Blount disease also have a vitamin D deficiency and others that say actually they know more vitamin D deficient than most of the rest of the population.
So the literature is a little bit unclear on that. But ultimately, the primary pathology here is a premature fiscal failure fischel closure. So, so any pediatric orthopedic surgeon that is immediately bringing a whole load of alarm bells. Whenever you've got a condition occurring in young children that's starting to close their fitness up, you know you've got a bit of a headache going.
You've got a condition that you're going to find very hard to cure. You're going to be seeing a lot of these patients for. So the primary problem, if you like, is generally thought to be tibooburra bow legs, but bear in mind, this is actually a three dimensional deformity. And they also have axial deformity in the form of tibial, in torsion and also a sagittal plane deformity so antiquated or Croaker bottom of the tibia.
It looks more like a sort of more acute posterior tibial slope. So the pathogenesis in infantile Blount disease, these poor kids really get a bit of a double whammy, if you like. So there are kids who are walking early and therefore they tend to walk at a stage in their lives when they're prone to having them anyway. So that means that their mechanical access is missing the center of their knee.
It's going really missing the knee entirely. So all of their considerable body weight, because they're normally over the 95th percentile, is coming down inside the knee, causing compression on the medial side of the growth plate just here. And well, what do we know? What happens to growth plates that get compressed? We know from the height of volkmann principle that tends to inhibit growth, not just on the medial aspect, but in the posterior medial aspect, which presumably explains the fact that it's a three dimensional deformity.
So that's the theory about how Blount disease actually develops. And if you look at the evidence from histology that really kind of backs it up because we have histological specimens from kids who've had surgery or infantile disease, and you'll see that nice columnar arrangement that you will learn about the basic sciences of the fetus has been disrupted. Eventually, physical bars forms and there's a lack of ossification, both in the epiphytes and the metathesis.
So all of that is rather suggestive of a failure of the growth plate. But the growth plates is not your only problem. These knees, I don't know if you can see on this x-ray, but this knee is subtly subluxation towards the lateral side. So it's the lateral structures, particularly the lateral collateral ligament that gets attenuated in this condition.
And some children have a lateral thrust, which is that sort of sudden jerking appearance whenever they take a step. So that's what's going on pathology wise in Blount disease. Now I mentioned this problem with ossification. So if you look at the X-ray there on the left of the screen, it looks rather alarming, doesn't it?
It looks like there's really nothing there on the medial side of the joint, but in the MRI show something slightly different. You can see. In fact, this is present, but it just has. There's been a failure there of ossification. So sometimes the x-rays look rather more alarming than the reality would suggest because of deficient calcification.
OK, so that's the basic sciences of infantile Blount disease, that's what we think is going on in this condition. But this is what comes into your clinic. You get a kid like this whose dad who's worried about him. He's got bow legs. Somebody else has told him that they've seen a kid like that before, that who got terrible bow legs and he needs to have treatment. So what are you going to do?
Well, as with any orthopedic condition, we start with a history and some of the registrars who trained with me know that one of my things is when you get to the stage of your FRCS exam or more advanced clinical practice, you don't have time to do the medical student thing and ask 100 questions. Imagine it's like the game of hangman, and you're only allowed to ask a limited number of questions.
Let's say only let you ask three questions of this family in order to get to a diagnosis. So the first question you'd want to know about this kid is, well, how old is he? Because it can be normal to have both legs, it all depends on your age. Remember this graph here? This is the silliness curve. If you haven't seen this graph before, you need to see it because this is probably the most important curve in pediatric orthopedics.
It shows how the change from various to Vegas changes with age. So this is how the coronal plane alignment changes. What I'm showing you here is quite a simple graph. It just shows the mean. So you can see here, if that child is two years or less, then he's got every reason to have both legs. Incidentally, it also shows why early walkers who are kind of up here on the graph are more prone to getting Brown disease right.
But if that kid is over two, and particularly if he's getting down to three, well, he should have general welcome. So age is a really important question to ask, because that will tell you whether this is physiological or if he's moving into the pathological range. What else might you ask to back up the diagnosis? Well, that's one of your next questions.
Your Hangman questions might be did he walk very early because that's going to be suggestive? You'll you might ask questions or might be on your examination as to whether this is a heavy child. And of course, you might want to ask if it's not obvious what his potential genetic makeup might be from his, from his racial background. We normally thought, aren't we, that unilateral disease is a sign of pathology and bilateral disease usually means physiological?
Unfortunately, that doesn't really work in infantile Blount's disease, which is often a bilateral condition. So you're going to need a little bit of help here. You're going to need to phone a friend and the friend you're going to need to phone is a radiographer. So if you're concerned from any of these questions that this could be a case of Lyme disease radiographs going to help you out.
So if you're lucky, you're going to get a radiograph like this. So this shows the typical radiological features of infantile Blount disease. The real giveaway is this baking here of the medial part of the metathesis on the affected side on this patient's left side. So a combination of general baking, lateral subluxation, there's nothing else this can be. Really, I don't think with one possible exception, I don't think I've seen a kid have anything other than Blount disease who look like this.
The exception was a child who had had meningococcal disease as an infant, and it had various skin lesions. So it's possible that he had a medial growth arrest due to meningococcal disease. Basically, it's a giveaway. That's what slap disease looks like, it can't be achondroplasia, it can't be x-linked type of rickets or any of the other weird causes of that Blount disease.
So that would be nice to get, but that's not what you get. What you get is this you get a child with such bow legs, you could drive a bus through that and extremely worried parents and you're looking at the X-ray and you're thinking, well, I don't know, is that beacon or is that normal? And then you think, well, was the film rotated or should I repeat it? So you're going to need some way really to try and distinguish between physiological and pathological environment due to Blount disease?
So this is where you're going to have to get your measuring tools out because there is something here to help us. And this is an angle described by 2 authors, Drennan and Levine, back in the 1980s. So they described an angle, and I'm going to show you now how to calculate this angle, which is said to distinguish between Blount disease and physiological neuro. So the first thing you do is draw a line connecting the most extreme points of the metaphysical flare like that.
The next line you draw has to, if you like, describe the long axis of the tibia, so it's a bit difficult because the tibia is a little bit curved on its sides, but do the best you can and you draw a line that describes the center. You draw a perpendicular to that. And measure the angle between the two, and that is the metaphysical angle. So actually, what Levine and Drennan reported was a cut off of 11 degrees lower than 11 degrees physiological higher than 11 degrees Blount disease, perfect bearing orthopedic.
We love it, but I think most of us understand that measuring lines on X-rays is often much more nuanced than that. So the figures that I've actually highlighted on the slide here belong to a more if you like sophisticated study by schenecker and his co-worker. And what they showed was, in fact, it depends on the age of the child.
The older the child is, the more accurate these measurements become. But if you take a cut off of above six degrees or below nine degrees, then you're going to have basically, you're going to be right, 19 out of 20 cases. So in between 9 degrees and 16 degrees, that's a gray area, and we're not quite sure. So those patients certainly need to be followed up.
You won't want to be discharging that. Even Shanaka and his co-worker pointed out that this angle that you can measure the metaphysical angle is helpful, but it's by no means the be all and end all. So it helps you to make a diagnosis. But if there's any clinical doubt, then you should keep the patient under review. Then in case you're wondering, this patient that I showed you, he had physiological.
So that was what happened without treatment. The point I want to make is the extent of the condition. The extent of the arm is not a predictor of whether they have Blount disease or not. You can have really quite marked from physiological disease, and indeed, that's what this kid had. OK, so while we're on the subject of X rays, there is this rather complicated looking grading system for Disease developed by Anders Langer school, who was a Professor working in Helsinki in Finland, who described a cohort of Finnish children with plant disease.
And when you look at that classification, I kind of I feel sorry for him, really, because it seems to be a classification that gets a bit of a bad press. It's people think it's not really that helpful, necessarily in terms of determining treatment, but to be honest, it's called Never intended it to be that he just intended it to be a description of the natural history. So those stages that you see are correlated with the age of the child.
So he made the point that can't really diagnose those early stages before the age of one and the later stage. Stage six, not really before the age of 9 and the other stages occur between he. He never really intended for this to be a classification used to determine treatment, but nevertheless, that is how most people use it now with provisos.
So that's what I'm going to use to just to walk you through the different treatments. And one stage I really want to draw your attention to is this one? Stage number four, because that really marks the watershed moment at which things start to get really complicated. And you'll know it's stage number four because if you look at this beating.
Here on the medial side of the tibia. It starts off as being a beak in stage one in stage two. It starts to develop a defect within the beak. In stage three, that defect becomes a shelf and it's stage four when the epidermis seems to slip into the shelf. But before it's gone on to become a befit type of epiphytes here. So that's how you recognize stage four.
In fact, studies show that inter observer variability in assigning blanks called grading is actually quite good. Perhaps surprisingly so, it's not so difficult to spot the stage for everything before stage four has one type of treatment and everything stage four onwards has another. So I'm about to explain. So let's talk about the early stages first, so these are the early stages and therefore children of relatively young age, probably between about the age of 2 and 6.
So leave aside this cafe, this is an oasis treatment for Blount disease. I was going to come back to that in the next slide, but just focus here on stage two and stage three. So the treatment for this, these stages are essentially tibial osteotomy. So the idea is to do it tibial osteotomy and realign it because you're having to do the osteotomy at a distant point from where the chora is.
The core is really up here in the thisthis, but you're forced to make your osta osteotomy down here in the metathesis because obviously you've got to go distal to where the growth plate is and where the extent to mechanism is, then you're going to have to include because the osteotomy is at a separate place to the kaura, then you're going to have to include some translation in this.
This is all to do with the niceties of deformity correction, which is not the focus of this talk. But if you understand about corners, you'll know what I mean. If you don't, just take it from me that you're going to have to involve some translation in this condition. Most people in infantile Blount disease tried to overcorrect a little, and then you'd better pray to the gods that those physical changes, that beating and that Fischler rest is going to nature's going to it out for you.
Langlands gold actually said everything up to stage four was reversible, but it seems that perhaps that was overly optimistic. And that's not everybody's experience, certainly not with a non-white population in an afro-caribbean population. Certainly, that doesn't appear to be the case that seems to run a more aggressive course of the recurrence being more than the order of the day.
However, I told you that stage four was an important stage to remember in the lung and skull classification. Well, now I'm going to tell you that age 4 is also important. There are quite a few studies that show that if you can get this tibial osteotomy done not at the age of six but before the age of four, then you'll reduce the chance of recurrence. So that's important to remember. I say reduce the chance of recurrence.
You don't reduce it to zero. Even in this study in the gpo, which was, I think, a meta analysis recurrence was still 46 percent, but better than the 85% if you left it until after four. So that's how you treat the early stages. Now what about this business of treating and authorities? So that's said to be a way of treating the early stages of Blount disease? Well I don't know.
I don't know. Those of you who have two and three-year-Olds of your own. If you want to try and strap them into a contraption like this and expect them to cooperate with you or best of British luck to you. I'd suggest that's actually quite difficult to do. So these splints are rather impractical. I would say. If you look at the design on the right here, you can see that those knees are locked in extension.
Now there are designs which allow knee flexion, but I'm not quite sure I understand how something that allows knee flexion is going to exert point pressure and correct the deformity. And what are you supposed to do, put them on in the daytime or NIPE time or both? And where exactly is this correction occurring? Not entirely clear. I don't really see that the correction is necessarily going to be focused on the tibia, which is where the problem is.
If it's going to be a correction, it's presumably spread throughout a bit of the femur and probably part of the knee joint as well. There isn't really any good evidence, probably for the reasons I've just listed for them working, but nevertheless people do use them and they are described in the book. I would argue, though, if you know that you can treat this condition with a tibial osteotomy and you can as long as you get it done by the age of four, then you have a reasonable treatment up your sleeve.
Then then probably it would be reasonable not to use splints at all. And that's been my practice, but I know some people do use them, so that's why I'm mentioning it. So this is an example of tibial osteotomy, you see here what I mean about doing the osteotomy distant, distant place here to where the actual problem is, which means that when you swing this segment across, there is inevitably translation and that's what you want to see.
So I use an external fixator for this. You don't have to could use internal fixation if you want. Doesn't really matter. But notice also that tibia has been swung into a little bit of balga, so we tried to overcorrect here a little bit. So this is the treatment for stage one, two and 3 and ideally done before the age of four. If you want to reduce the chance of recurrence.
So what about the more advanced stages? Well, once you get to stage four, so this is the point at which that beak has become a shelf and the epiphytes has sort of collapsed into it. But before the emphasis has turned into two separate bits, then your treatment is going to involve osteotomy. But you're going to have to do something about the crisis as well, particularly the five seal bar, because this sure as eggs are eggs is going to lead to a recurrence if you don't.
So what is this fiscal management? Well, basically, you've got two options. One would be to take the fiscal bar away and leave the normal crisis behind. So this picture shows a central bar. Of course, the bar I'm talking about here is peripheral, so it's not the ideal picture. But anyway, this is one option to remove the sick piece of the crisis and leave the healthy bit behind a physio physiologist.
So-called so you're doing this on the medial side of the tibia. Option number two is. To use a drill and a cure, yet to deliberately destroy the ethicists on the lateral side because, you know, the medial side has gone already. So you're just trying to arrest the growth on the lateral side to stop the disease from coming back. Again, my apologies.
This picture is for epimysium thesis done not for Blount disease, but for a leg length discrepancy. But it's the only picture I had. I just want to. So you don't need to put the drill all the way across to the medial side because the medial side is already arrested. You just need to do the lateral side. So that's a physio thesis.
I know what you're thinking. You're thinking, well, why on Earth would you do this? This is much cooler. Here you go. You're taking away the problem and away you go. Why would you want to destroy the last bit of growth remaining? Well, I agree with you. In theory, that would be great, but there is one thing and practice is another.
The fact is, taking away that bit of sick thesis is great in theory, but in practice hasn't really been that successful. So in theory, it should work. But in practice, we often find recurrence after the thesis is supposedly been released of its tether. You might say, well, I can add an eight plate onto the other side onto the lateral side to try and improve the chances of correction.
But that's only really going to work if you have a very healthy basis on the medial side as well. So great in theory, not so great in practice. The lateral physio thesis, on the other hand, sure is effective at stopping the deformity from coming back. But and it's a big but you've now condemned that child to a leg length discrepancy. They're going to have a straight leg, but they're going to have a problem with discrepancy of length.
Now, for my money, I would rather deal with that. I'd rather deal with a straight leg and a discrepancy because there are lots of ways of treating that than a bend like that's been straightened and is coming back again. Serial operations for Blount disease are not a lot of fun. So if you do the lateral physio diocese, then at least you know where you stand and everybody knows what to expect.
The problem with the physiologists is nobody knows quite what to expect. Not you, not the parents, not the patients. And everybody is just crossing their fingers. So great in theory, but not so great. My point is, once you get to stage four of the disease, then you have to think about some sort of management of the crisis or you're going to get recurrence for sure.
What about these later stages? These are the stages where you're either getting a befit type of emphasis or actually a definite physical arrest on the medial side. Well, here again, osteotomy is going to be part of your procedure for sure. You're going to have to manage the problem of the crisis. And that's probably going to be because these are older children.
That's almost certainly going to be a physio, odysseus, actually. And FFC, odysseus, you're going to deliberately destroy the lateral side of the growth plate to stop the disease coming back. But you need to think how sloped that tibial plateau is now, how congruent do you think the joint actually is? You need to at least ask the question whether you think the knee joint is congruent or whether there has been essentially a collapse of the medial tibial plateau.
So any patient who's walking with that varus thrust that I mentioned, particularly older patients, that's rather suggestive that they have a problem with a joint that is no longer congruent. However, bear in mind what I said about those abnormalities of ossification, and I showed you that MRI scan. So it ain't necessarily so even with an X-ray that looks like this, it might be that the joint is more congruent than you think.
So before you get too excited about doing some very clever operations to try to restore the joint surface, you would do well to do an MRI and/or an Arthur program just to prove to yourself that there is a genuine gap on this medial side and that it's not either filled up with as yet ossified epimysium or a large, fleshy atrophied meniscus, which is the other thing that can actually lead to the joint being more congruent than you think.
If you have evidence that the joint is not congruent, in fact, then you probably wise to get a seat done and 3D reconstructions are really helpful. So that you can make a plan about how to go about addressing this problem of restoring Royalty to the joint. But the basic principle is this what you're trying to do is to restore Congress city by an osteotomy directed with a curved, austere tone from the medial side until the entire condylar area.
And then you deliberately crack it and elevate this half of the joint, which does take some bravery to do, I can tell you. But this is how you restore the joint Congress. You get rid of that space that was there before. Of course, you can now going to have to fill up this gap or it's going to collapse again. So you're going to put a bone graft in there, which you've harvested from the fibula usually.
And that restores the community, but the disease is going to come back unless you do something about this lateral. And thisis which is still active, so you'd better make sure you do. And if it is your Odysseus as well. And then finally, you need to realign the tibia, so you're going to do a tibial osteotomy and realign it, then you've got to fix the whole thing together and that's up to you how you do it.
You could use an external fixator. You could use internal fixation. The choice is yours. So infantile Blount disease, this is a summary by Langan scold stage, so essentially stage 4 is the stage where you need to start thinking about management of crisis in addition to just doing a tibial osteotomy.
And once you get to the later stages, you need to consider whether a hemi plateau elevation is necessary so you can see how complicated infantile Blount disease is to treat that are not, say at the start. Whenever you see a young child who's got a permanent fiscal arrest, you know you're heading for trouble. You know that that's going to be a difficult problem to.
Adolescent Blount disease is a different beast entirely. It shares a name, but arguable whether it's the same pathology at all. So this is a condition that occurs in children older than 10. And importantly, they have no previous history of bow legs as a child. The most in my experience. Most of these 10-year-olds actually look more like they're 15 or 16, so they do seem to be skillfully advanced, and they too are complaining of general barhoum, which is progressive.
These are all obese kids, all of them. And their disease is usually unilateral, which seems a little strange because the obesity is certainly not unilateral, but that's the way it goes. You will know that you're dealing with adolescent Blount disease instantly from the X-ray because they look totally different to the infantile form that I've just shown you. But bear in mind that you are going to get adolescence.
As I said at the start of the talk, who have both legs, but who have the infantile form, which has recurred, but they look quite different on the X-ray. So here on the left hand side of the screen, this is what you typically see in an adolescent with that form of the disease. So you can see this sort of pagoda roof to the tibia. You can see signs of previous tibial osteotomy and the degree of virus is really quite marked.
What you see in the adolescent form of the disease is a more mild form of virus. And look at the faces here. We're not seeing that advanced medial fistula rest. In fact, if anything, what you're seeing is an office that looks apparently wider. I don't think it really is wider. I think again, it's a defect of ossification. But you're not seeing those advanced medial changes that you see in the infantile form of the disease.
There's no physical bar here. It looks much more normal. The crisis is basically a lot less sick in this condition, and that's a good thing that makes it easier to treat. One of the thing, one typical feature of adolescent Blount disease is said to be that it also includes some of the various coming not just from the tibia, but from the femur as well. That's a real favorite question for the folks.
Also worth noting that femoral virus is present in adolescent Blount disease, but is said not to occur in infantile slap disease. So if we say the growth plate is not sick, then that's really helpful, right? So if this patient still has some growth remaining, then there's no reason why we can't go ahead and treat that by a guided growth regime. So that's what's happened.
In this case, some eight plates have been inserted to try and slow up the growth on the lateral side and hey, presto, the whole situation has been rescued. One of the problems with eight plates can be in these rather heavy children that they can break, so it's worth considering designs of eight plates called h plates, which take four screws, not two. And there was a said to have a lower chance of the implant failing.
What about is the patient's already psychologically mature and growth and guided growth is not going to work for you and you're going to have to do a realignment osteotomy, but at least you can do that confidence that you can realign it and be sure that recurrence will not recur. But the disease will not recur, right? Because they're still immature.
So you don't need to worry about all of got stuff to do with fiscal management and physio theses and physio lysis. You just need to realign it how you realign it. That's up to you. If internal fixation is your thing, then go ahead. But the real problem with these kids is they are so large that physically doing that on table can be quite difficult, especially knowing that you've absolutely got it right.
Because if you're going to go for acute correction and internal fixation, you'd better make sure you've corrected it properly before you let them out of the operating theater. So you might instead go for external fixation, which has some advantages and disadvantages. If you know how to use external fixator, it's quite nice because you don't have to get the correction done in theatre, you can do it later on and you've got a choice.
You can either make the mechanical access completely normal or you can match it to the other leg, which is often slightly varus anyway, depends on what you're trying to achieve. I'm also concerned about doing acute osteotomy as in the proximal tibia. In some series, there are rates of neurovascular compromise and compartment syndrome. Eye watering proportions.
So you don't tend to get that with external fixation. I do accept, however, that these patients do run into trouble with pins site infection, and they're also condemned to wearing them for at least three months. It does take quite a time to unite. But anyway, it's up to you how you treat it, but osteotomy is your way forward if this is adolescent slap disease in a patient who is a little immature.
So just to summarize about Blount disease, then this has been well described as a bimodal disease with an infantile and an adolescent form, the infantile one is difficult to treat because the Ephesus is sick and your challenge is always going to be that the disease wants to come back. It's a recurrent disease. The adolescent form, on the other hand, is much more simple to treat because the virus is not so sick.
But there your challenge is a technical one because of the size of the patients. And if you remember no more numbers from this talk than the number for that, that would be a good start. So in infantile Blount disease, get the osteotomy done by age 4 to reduce the chance of recurrence. And remember that after the lung and skull stage four, you need to start seriously thinking about fiscal management.
So this table just summarizes some of the key features which are different in these two forms of the disease. This is a 12-year-old girl who had had Blount disease treated in the past, so she'd had the infantile form. She'd had it from an early age and sure enough, the disease had recurred.
So here she was at 12. She has all the features you can see from the soft tissue shadows that she was a big girl and she had recurrent disease with various internal tibial torsion Procore bottom. So she had a sagittal plane deformity as well. But I didn't think of Eris thrust. I thought despite those appearances, her knee was actually fairly congruent.
So what do I want to do? Well, I need to do an osteotomy to realign it, and I need to manage the feistiness as well. So I need to do, I thought, a physio thesis. I wanted to deliberately drill out the faces on the lateral side to stop it coming back. So that's what I did. I didn't fancy a cute correction. I'm scared of neurovascular compromise that can occur with that.
So I put on an external fixator and we corrected it. OK, great. Onto a winner or so I thought. But this is what she looked like when we'd finished. So what had happened here? Well, in my defense, you can see the solution, and when you put external fixated on people, it's quite difficult to get them to stand up and take radiograph sometimes.
So I was rather disappointed to see this, and my mistake had been that we'd actually corrected the tibia pretty well, as you can see. But what I had not appreciated was the pretty marked femoral deformity that she had, in addition. Now the books tell you that femoral deformity does not occur in infantile Blount disease. Well, I'm here to tell you that it does, but it's not various.
Generally, it's usually bogus, as in this case and my colleague Rob hill, he believed that this femoral deformity only tends to occur in infantile Blount disease that's already been treated. So maybe it's in the arch traject deformity in some way. I don't think you ever wrote that up. I haven't seen it written up, but that's my point. So I suppose.
Well, what are we going to do about this? Well, I'm not so worried about doing acute osteotomy in the distal femur. So that's what we did. We corrected it using an acute correction, taking out a medial wedge and fixing with a locking plate and that sorted out mechanical axis. You can see on the right hand side, we've got a few fun and games to deal with, but that's probably something for another tour.
So my point is that with any deformity, you always have to think about a compensatory deformity which the body has desperately tried to put in place in order to compensate for the first one. And I think that's what happened here. Well, at least it's an honest, cased example, huh? So the final bit that I wanted to give you was some tips for dealing with drought disease, either in clinical practice or if you meet one of these cases in the source.
But again, we can pause at this point and go to questions if you'd prefer for us. How do you think we should play it? I think it will be very useful to hear your tapes. We can do that after questions as well. So if you like. And then we hear your tapes, they'll be very nice. I'd really like to thank you, Gavin, for this wonderful teaching lecture.
We certainly have learned a lot. A lot of very important concepts you presented. And I mean, one of them for those going for their first year exam. I think when you present to the blind disease picture or clinical scenario, you know, reach to your brain straight away and try to draw that signature graph. That would be one of the important marking points for that station.
And it's important that I heard about the deformity, that it's actually 3D deformity, and we tend to look at it in the one plane. But as you explained, it's a 3D deformity and we have to consider all the deformities there. And it is very interesting also to know that's adolescent blunt disease is completely different pathology to the infantile one, and that's just new, new for me and very, very important point to take into account.
You know, so many, so many key points you presented, which are very useful, just bring some questions from the audience. There is some controversy about the early Walker. Is that important to know? And what exactly defines an early walker? Is it? You know, dependency walking or standing or. Or is it not essential to?
Yeah, I'm not sure the books are ever that clear about it, but basically I think we mean any child who's walking before the age of one. So once you hear that a child is walking by the age of sort of nine, 10, 11 months, that should Ring Alarm bells often. Actually, these children do need to be helped at this point. They have to have their hands held. But children that want to spend most of their time up, you know, taking weight on their two legs at that time, those would count as early walkers.
And one more question is that about the overcorrection? Is there any guidance on how many degrees you overcorrect or that age, age related? Yeah so the overcorrection only refers to infantile Blount disease. You shouldn't overcorrect the adolescent cases because they don't have any growth left. So the guidance is it's not a big overcorrection. It's just, you know, five degrees.
I would have thought you won't want to do more than that because after all. What are we saying here, we're saying that we know that there's a chance of recurrence, and we're hoping that if we can just tweak it a little bit the other way, then hopefully we'll get away with it. And the virus will get the chance to remodel and recover. But equally, you do want some recurrence, right?
You don't want to leave this child with a leg that is now in Vegas, so you don't want to overcook it. I would say about five degrees should do it. Thank you. Thank you for explaining. Obviously, that's we don't want to overcorrect listed for that would be a mistake. And just about the follow up also, do you follow up?
This therefore is clearly is clearly mature or beyond that or. And so I guess the answer to that is I tend to put the onus on the parents, and I explain that the big problem with this disease is recurrence and that if parents see that happening, then they should get back in touch with us. It depends how busy your clinics are.
I think the important point is whether you decide to follow them up or just put the onus on the parents. You should always advise the children and their families. That recurrence is a distinct possibility because if you don't, then their parents are going to find that quite hard to forgive and you're going to be backtracking and making trying to make a few excuses for yourself. Whereas if you told them that recurrence is likely and it happens, then they're likely to trust you that you come across as being a wise old sage who made a good prediction.
And that's going to be important if you're going to be treating them again. And so it's a communication skill also here. And just one more question before we put the polling questions to everyone to answer any, you said the compartment syndrome is one of the complications. Is there any tips on how to prevent it or.
Oh yes, Yes. Thanks Thanks for mentioning that. I should have done. So if I'm not a big fan of doing acute corrections. But if you are going to do that, then it makes sense to do a prophylactic ashtami. Certainly if the anterior compartment. So that's done subcutaneously. So through the incision that you use to do the osteotomy, you split the fascia longitudinally up and down and that reduces the chance.
OK, thank you very much. So it was just a couple of other questions on the chat group. Sorry for us. In terms of the crisis or thesis, is there a is there a knock off point when you would do it in terms of the bar size with the bar size change? Right? Yeah.
Good question. I don't think there is in terms of the size of the bar, generally removing five steel bars is said to be better if they're peripheral, so you would think that allowance disease would do well, right? Because this is a peripheral bar, not a central one. What is important, I think, is the stage of the disease. So by the time you've got to stage 5 and stage six, then there's no point in excising the bar.
You would be better just doing a growth arrest on the lateral side. The problem with excising five steel bars, I think, is having the courage to keep on nibbling it and going further and further laterally as you're creating a bigger and bigger cavity under the joint. And I think most surgeons kind of lose their nerve, and that might be one of the reasons why we don't get such good results from it.
So no, there's no firm advice on the size of the bar. It's more on the stage of the disease, so it's an option for stage four, but I would say not for stage five. And in terms of osteotomy, where would you cut the fibula? The fibula, yeah, I tend to cut that round about the junction of the distal third and the proximal two thirds, so it doesn't really matter, you can cut it wherever but out of the way of the common perennial nervous.
But I did. Good, thank you. Thank you, Sean, for putting forward those questions. Now these participants, I'm going to put the polls, the questions now I will give you. I would give you a minute or two to answer them. They are all under no, so you are not identified and these are really just to consolidate your knowledge and they are very important bits that can pop on the exam.
So have a look, guys, and if you could answer them as quick as you can. The quicker the quicker you guys answer these questions, the quicker we can move on to the next section. Can I ask another question that was being asked in terms of adolescent blondes and probably infantile in terms of sorry in adolescence?
My apologies. Do you do a femoral osteotomy as your primary part of your treatment in those patients? If you spot. The problem there? Yeah the answer is you certainly need to address the femoral deformity, but you it depends if they're slightly mature or not, guided growth will also work for the femoral deformity.
That's what I showed in the slide. Actually, there were eight plates both on the female and on the tibia. So yes, the answer is you definitely need to address that as well. And just a reminder, after this section, we will move on to the hot seat driver. The hot seat driver section is not recorded, obviously, and we thank everyone who comes forward.
We know it's not easy to be in the hot seat in front of so many people. But it's a very good opportunity and learning experience from an experienced lecturer and teacher with lots of experience with pass this exam, so well done. Everyone who raised their hands and everyone else will benefit from listening and from hearing the feedback. So I think 73% of participants now answer, so I think I'll end up polling now, 75% answered.
Question number one, infantile bladder disease associated with and option number two is the correct one. Worse prognosis in afro-caribbean patients. So 65% answered this correctly. Question number two, adolescent blood disease. And the correct answer is number two, again, is commonly unilateral.
76% answered this correctly. Question number three, the answers were a bit more interesting. So in regards to a skilled staging blood disease, which one of the following statements is true, only 41% say the correct answer, which is the answer no to. Stage three, the physical changes are potentially reversible with tibial osteotomy alone.
So, so here are my tips for dealing with Blount disease if you're in a Viber situation. You may get shown an image of Blount disease. I showed you the typical radiographic images and actually it backs up a point. Faraz just made that the appearances are very characteristic with Blount disease, so there's really nothing else that could be. So my advice is don't hedge, don't mention other conditions that you think it might be.
Don't mention things like that. It could be due to rickets. Go in there and say it's Blount disease. But now here's the next really important point. There is a feeling that if I'm not talking, I'm not scoring, and I have to say, as my experience has been, that's not always a very good approach in a. So if you're asked to describe the appearances of an X-ray and you think that looks like bounces, say what you think and say.
I see these appearances at the examiner says, what do you think it is? And then they say Blount disease. Now, that is the point to stop talking because what many people do is say, I think it's Blount disease. There are two forms of Blount disease that adolescent and infantile, and it's caused by I. Whoa whoa, whoa, whoa, whoa.
I strongly advise you to stop at that point because you don't know where the vibe is going. We might start talking about the pathogenesis. We might start talking about treatment. We might start talking about differences between adolescence and an infantile. You just don't know. So it's very important in a vibrant Blount disease and in fact, on any vibha to in an early stage, I would advise you to stop talking and wait and see which way the vibe is going, because that's where the points lie.
My next point is, well, it's kind of illustrated by what I showed you in that last case example. So if you have the presence of mind, note the fact, there's a tibial deformity there from Blount disease, but just keep your eye on the distal femur as well. So for those extra points, you could point out if you see that there's a femoral deformity, then point that out to the examiner, too, because that's going to look good.
They'll be polishing up the gold medal When you say that. So what about clinical tips? So here are my tips this could apply actually in a busy clinic as well as in the health self-exam. So when you see a child with Blount disease, don't even bother asking them about pain. They're not going to tell you it's there. I genuinely think it isn't. They're actually these kids just get on with life.
You, you're going to get far more credit for asking whether they're bothered by the appearance of their legs and whether it stops them taking part in things. Because that's really what it is in pediatrics. It's all about function. Pain is not a feature. Sure, in adults with Blount disease, you can imagine the natural history is pretty aggressive.
But so don't ask about pain. The barest thrust thing is a very typical appearance is quite an acute jerk of the knee every time they take a step. So if you see it, mention it. If you don't see it, don't say that you think it's there because you feel that it ought to be because that various thrust is quite common in slap disease.
The reason I say that is because if you mention it's there, then you'll start to get into a conversation about medial plateaus being elevated. And do you think that's a good idea? And what about the lateral collateral ligament? You're going to go down a pretty tricky route, so by all means, identify it. But don't sort of say that you think it's there just because you think it ought to.
Another thing for them to get the gold medal out to you is it would be quite good to examine the patients on the couch and to see if they can apparently get their knees fully extended. Because in Blount disease, it looks like they can't. It looks like they've got a fixed flexion deformity of the knee, but in fact they haven't. They get their knee fully straight. The reason their knee looks bent is because they've got a proximal tibial deformity, so that looks quite good.
If you demonstrate that to an examiner, it shows that you're aware that this condition is not just general byrum, but has deformities in other planes as well. While they're on the couch, you could examine for lateral collateral ligament laxity, which might be an indication which might confirm your suspicion of a varus thrust. And here's my final and most important and favorite tip to pass on, and that is you should always examine patients with coronel any coronal plane deformity with their kneecaps pointing forward and why.
I'll show you why. So here is how most children with Blount disease, and this is one tend to stand. And actually, this is also how radiographers tend to position them when they're taking their X-rays for you because it's easier for the patient, isn't it, with a finger pointing forward? But look where his kneecaps are.
That left patellar is externally rotated if you take the trouble to reposition his leg so that the kneecaps are pointing forward. Look what happens? Now you can see the genuine arm, but you can also see the interior tibial torsion. Nothing can you see? The examiner can see it as well. Incidentally, look at what he's doing now.
He's having to hold onto the wall because he feels a bit unstable like that. But that's do you see the difference? It's such an impressive thing to show and examine it by just taking a moment to reposition his foot so his kneecaps are pointing forward. Suddenly, the mist clears and you can see much more clearly where the deformities are. So that's everything I have to say about disease.
Good luck to everybody in dealing with those patients, either in your clinics or in the exams, and everything that's on my presentation from now on is related to survivors. So that's all I have to say. And Thanks very much for inviting me to talk on the webinar. I've really enjoyed it. Thank you, Mr Spence.
Lovely very useful tips. I like that last one. I think while examining this patient in the even short case or intermediate case just took the exam. I'm trying to point the patella forward while examining this patient. I think that's exactly I will smile and they know what you're doing.
And so exactly. I don't think many people would do that. So I think it's very useful to get. So, OK, guys, thank you very much. So we'll move on now to the Viva session, which will be unrecorded.
Segment:0 .
Good evening, everyone, thank you for joining us. This is a teaching session presented jointly by the FRCS mentor group and orthopedic Research UK. I'm curious about and would be moderating the session and to help me here, there are members of the mental group Schwann and abdala and as well as Ruth, who is the head of education from the UK.
The speaker is Gavin Spence, and he's teaching us tonight about blunt disease. Gavin is a consultant, pediatric orthopedic surgeon at bragiel hospital in the Bay. He's he has clinical interests, a limb deformity correction, and he has been a consultant prior to this current position. He's been a consultant, Great Ormond Street Hospital for children. In London.
He's been he has a particular interest in teaching, and he's been a worldwide trainer of the year by the British Orthopedic training association in 2019. And a lot of talk about Gavin as well. The session will include basically, as you can see, a lecture presentation. Please pay attention very well, because there will be polling questions afterwards. There'll be three questions we'll ask you to answer, and we'll give you the right answers to those, but will be very interested to see if you pick the right answers from the presentation, we have an opportunity to ask questions.
So if you hover your mouse at the bottom of the screen, you will find a chat box. If you click on the chat box. It will open at a chatting function. What you can post your questions and we'll present them to Gavin and when it's appropriate. If you really like to talk directly to government or if you like to take part in the afterwards hot seat Viva Viva session, they will ask you to raise the hand symbol, which is located under the participants list.
It's a blue symbol and we know that you are interested in taking part in Viva. These are served on first come, first served basis. So if you're interested, we ask you to express your interest as early as possible. Gavin has prepared very interesting questions Viva questions that are exam specific and relevant, directly relevant to that of case exam, and you'll be given detailed constructional feedback afterwards.
So I urge you to make the best out of this opportunity. So it's quite an interactive session with obviously the limitations that we know of. And we ask you all, please give us feedback at the end. Obviously, we use this feedback for our own development and to see how we can do better. And Ruth, the head of education from our UK, has been in touch with you and will be again in touch with you about certificates and about the feedback.
If you guys miss any part of this for any reason, don't panic, this will be recorded. And we will share the recording on the enforcement channel and on the UK website. And just as you can see here, this is the link there to a series of teaching webinars we're presenting with collaboration with our UK, and there will be many to come next one in a couple of weeks again on a Wednesday teaching about knee replacement.
So you can always access these on the webinar page on or UK website. So without further ado, we will leave you with Mr Spence, right? Well Torres, thank you so much. Ruth, Thanks very much for the invitation to present on this webinar. This is a new venture for me, too, so I was very excited about getting the chance to do this and just an extended welcome to all the people joining wherever you happen to be locked down in the world today.
I hope you're going to find this session useful. So just before we start the session properly, just a few words about orthopedic research UK, they, as you may know, are a charity based in the UK. And their aim is really to improve orthopedic knowledge, and it's a two pronged approach. Partly research and partly an educational arm. And my personal background with orthopedic Research UK goes back a long way about 15 to 16 years.
In fact, when I first got in touch with them, they helped out with funding some research that I was doing, which to cut. A very long story short, I was really desperate for the cash at the time because the charity that was going to GoFundMe had gone bust. So orthopedic Research UK really helped me out, and I think I was, in fact, their first research fellow. So I've had a long and very happy relationship with them, and now I continue mainly on the educational side with them.
And they're a fantastic organization. They're great people to work with. I count them amongst my friends. So good for orthopedic Research UK. So if pediatrics is your bag or if indeed it's not your bag and it's something that you are concerned about, particularly for your exam, we have a seminar coming up in January. It's a 2 day course. This is the latest iteration of a number of courses that we've run with orthopedic Research UK.
It's a 2 day course where we really try and plug knowledge, particularly for people whose experience of pediatric orthopedics is limited. We try and focus in on those areas that people struggle with. We pepper it full of the sort of information that's often not in the books and which are top tips for passing the exam. The feedback from the last course was really good, so if you're interested in that course, you can get details on the orthopedic Research UK website, or you can use your phone and you can scan that QR code you can see in the bottom right.
There's also textbooks, revision textbooks available from orthopedic research Uk's website or from Amazon. These are two of the really popular sort of go to textbooks for revising for the exam. And finally, if you want to donate and support the excellent work that orthopedic Research UK do, you can do that through their website to or by scanning the QR code.
OK, that is the marketing over. Let's get on with the presentation. So this is Blount disease. Blount disease is a really terrific topic, but. I don't want you to get things out of proportion. So it is actually a cause of genuine harm, but it is not going to be the commonest cause of bow legs that you see in your clinic.
So don't go away from this presentation diagnosing Blount disease in every kid you see, because that's not going to be the cause. How many of the kids that you see in your clinic have Blount disease? Will that really depends on where you live. In the world because the incidence of the disease varies according to population, and it also depends on whether you're in a tertiary set up or a secondary set up or whatever it is.
But suffice to say, it's a pretty small number. So even countries which have populations which are prone to disease don't report large prevalences. So in the United states, it's less than 1% And in South Africa, less than 0.1% So small numbers, ok? So famously, it's a disease that is bimodal, it has two age groups in which a condition called Blount disease occurs, a condition of progressive bow legs.
Whether these are two separate conditions or whether they represent part of the same pathology is open to debate, but they definitely occur in two age groups. And traditionally those have been called the infantile age group and the adolescent. And as you can see from the slide I've drawn there, the infantile group is the commonest one. The literature, though, gets a little bit confusing because it sometimes talks about juvenile so, so a juvenile.
Blount disease is thought to be that form of bow legs, which occurs after the age of about four, but there's a lot of debate about it. There is a feeling that probably most quotes juvenile cases are in fact infantile cases that were never picked up in the early years. So it's not a term I'm going to use in this talk, and it's not a term that I think is particularly helpful. In fact, if I had my way, we'd drop the terms adolescent infantile and we talk about blunt diseases either being early onset or late onset.
And the reason why I think that's helpful. Well, partly it does what it says on the tin. It makes it very clear what we're talking about here. But perhaps more importantly, you have to remember that infantile Blount disease is a recurrent disease that we're going to discuss that in some detail over the next few slides. So what that means is when you see an adolescent, it might be that they have the adolescent form of Blount disease, but equally, in fact, probably more likely they are adolescents who have a recurrent form of the infantile disease.
I hope that makes some sense. So adolescence could have one of those two scenarios which have led them to have a leg. So you can see the terminologies all getting rather confusing here. Early onset, late onset, some authors use and they mean something completely different by it. Some authors use late onset as meaning after four years, so it's tricky.
So what we're going to do to stick with the rest of this presentation, we're going to talk about good old fashioned infantile Blount's and adolescent rounds. So let's start with the most common. Which is infantile Blount's. So what do all these kids have in common? Well it's been known for some time that Blount disease occurs pretty much in all races and all countries in the world, but it does seem to have a predilection for certain racial groups, so kids whose genetics hail from sub-Saharan Africa seem to be particularly prone to this condition.
It's also a condition that tends to occur in kids who walked early and who are on the heavy side, although that second one is not universal, but quite a lot of these kids are over the 95th percentile in terms of weight for age, so heavy early walkers. And that's going to be important in the pathogenesis, as we'll discuss in the next slide. In infantile Blount disease, it's generally girls more than boys, and there's some really interesting literature on vitamin D deficiency in this condition.
So, of course, vitamin D deficiency can cause both legs anyway by nutritional rickets, but that's a very different condition. Ideologically, it's a completely different condition. But there have been some papers suggesting that perhaps children with Blount disease also have a vitamin D deficiency and others that say actually they know more vitamin D deficient than most of the rest of the population.
So the literature is a little bit unclear on that. But ultimately, the primary pathology here is a premature fiscal failure fischel closure. So, so any pediatric orthopedic surgeon that is immediately bringing a whole load of alarm bells. Whenever you've got a condition occurring in young children that's starting to close their fitness up, you know you've got a bit of a headache going.
You've got a condition that you're going to find very hard to cure. You're going to be seeing a lot of these patients for. So the primary problem, if you like, is generally thought to be tibooburra bow legs, but bear in mind, this is actually a three dimensional deformity. And they also have axial deformity in the form of tibial, in torsion and also a sagittal plane deformity so antiquated or Croaker bottom of the tibia.
It looks more like a sort of more acute posterior tibial slope. So the pathogenesis in infantile Blount disease, these poor kids really get a bit of a double whammy, if you like. So there are kids who are walking early and therefore they tend to walk at a stage in their lives when they're prone to having them anyway. So that means that their mechanical access is missing the center of their knee.
It's going really missing the knee entirely. So all of their considerable body weight, because they're normally over the 95th percentile, is coming down inside the knee, causing compression on the medial side of the growth plate just here. And well, what do we know? What happens to growth plates that get compressed? We know from the height of volkmann principle that tends to inhibit growth, not just on the medial aspect, but in the posterior medial aspect, which presumably explains the fact that it's a three dimensional deformity.
So that's the theory about how Blount disease actually develops. And if you look at the evidence from histology that really kind of backs it up because we have histological specimens from kids who've had surgery or infantile disease, and you'll see that nice columnar arrangement that you will learn about the basic sciences of the fetus has been disrupted. Eventually, physical bars forms and there's a lack of ossification, both in the epiphytes and the metathesis.
So all of that is rather suggestive of a failure of the growth plate. But the growth plates is not your only problem. These knees, I don't know if you can see on this x-ray, but this knee is subtly subluxation towards the lateral side. So it's the lateral structures, particularly the lateral collateral ligament that gets attenuated in this condition.
And some children have a lateral thrust, which is that sort of sudden jerking appearance whenever they take a step. So that's what's going on pathology wise in Blount disease. Now I mentioned this problem with ossification. So if you look at the X-ray there on the left of the screen, it looks rather alarming, doesn't it?
It looks like there's really nothing there on the medial side of the joint, but in the MRI show something slightly different. You can see. In fact, this is present, but it just has. There's been a failure there of ossification. So sometimes the x-rays look rather more alarming than the reality would suggest because of deficient calcification.
OK, so that's the basic sciences of infantile Blount disease, that's what we think is going on in this condition. But this is what comes into your clinic. You get a kid like this whose dad who's worried about him. He's got bow legs. Somebody else has told him that they've seen a kid like that before, that who got terrible bow legs and he needs to have treatment. So what are you going to do?
Well, as with any orthopedic condition, we start with a history and some of the registrars who trained with me know that one of my things is when you get to the stage of your FRCS exam or more advanced clinical practice, you don't have time to do the medical student thing and ask 100 questions. Imagine it's like the game of hangman, and you're only allowed to ask a limited number of questions.
Let's say only let you ask three questions of this family in order to get to a diagnosis. So the first question you'd want to know about this kid is, well, how old is he? Because it can be normal to have both legs, it all depends on your age. Remember this graph here? This is the silliness curve. If you haven't seen this graph before, you need to see it because this is probably the most important curve in pediatric orthopedics.
It shows how the change from various to Vegas changes with age. So this is how the coronal plane alignment changes. What I'm showing you here is quite a simple graph. It just shows the mean. So you can see here, if that child is two years or less, then he's got every reason to have both legs. Incidentally, it also shows why early walkers who are kind of up here on the graph are more prone to getting Brown disease right.
But if that kid is over two, and particularly if he's getting down to three, well, he should have general welcome. So age is a really important question to ask, because that will tell you whether this is physiological or if he's moving into the pathological range. What else might you ask to back up the diagnosis? Well, that's one of your next questions.
Your Hangman questions might be did he walk very early because that's going to be suggestive? You'll you might ask questions or might be on your examination as to whether this is a heavy child. And of course, you might want to ask if it's not obvious what his potential genetic makeup might be from his, from his racial background. We normally thought, aren't we, that unilateral disease is a sign of pathology and bilateral disease usually means physiological?
Unfortunately, that doesn't really work in infantile Blount's disease, which is often a bilateral condition. So you're going to need a little bit of help here. You're going to need to phone a friend and the friend you're going to need to phone is a radiographer. So if you're concerned from any of these questions that this could be a case of Lyme disease radiographs going to help you out.
So if you're lucky, you're going to get a radiograph like this. So this shows the typical radiological features of infantile Blount disease. The real giveaway is this baking here of the medial part of the metathesis on the affected side on this patient's left side. So a combination of general baking, lateral subluxation, there's nothing else this can be. Really, I don't think with one possible exception, I don't think I've seen a kid have anything other than Blount disease who look like this.
The exception was a child who had had meningococcal disease as an infant, and it had various skin lesions. So it's possible that he had a medial growth arrest due to meningococcal disease. Basically, it's a giveaway. That's what slap disease looks like, it can't be achondroplasia, it can't be x-linked type of rickets or any of the other weird causes of that Blount disease.
So that would be nice to get, but that's not what you get. What you get is this you get a child with such bow legs, you could drive a bus through that and extremely worried parents and you're looking at the X-ray and you're thinking, well, I don't know, is that beacon or is that normal? And then you think, well, was the film rotated or should I repeat it? So you're going to need some way really to try and distinguish between physiological and pathological environment due to Blount disease?
So this is where you're going to have to get your measuring tools out because there is something here to help us. And this is an angle described by 2 authors, Drennan and Levine, back in the 1980s. So they described an angle, and I'm going to show you now how to calculate this angle, which is said to distinguish between Blount disease and physiological neuro. So the first thing you do is draw a line connecting the most extreme points of the metaphysical flare like that.
The next line you draw has to, if you like, describe the long axis of the tibia, so it's a bit difficult because the tibia is a little bit curved on its sides, but do the best you can and you draw a line that describes the center. You draw a perpendicular to that. And measure the angle between the two, and that is the metaphysical angle. So actually, what Levine and Drennan reported was a cut off of 11 degrees lower than 11 degrees physiological higher than 11 degrees Blount disease, perfect bearing orthopedic.
We love it, but I think most of us understand that measuring lines on X-rays is often much more nuanced than that. So the figures that I've actually highlighted on the slide here belong to a more if you like sophisticated study by schenecker and his co-worker. And what they showed was, in fact, it depends on the age of the child.
The older the child is, the more accurate these measurements become. But if you take a cut off of above six degrees or below nine degrees, then you're going to have basically, you're going to be right, 19 out of 20 cases. So in between 9 degrees and 16 degrees, that's a gray area, and we're not quite sure. So those patients certainly need to be followed up.
You won't want to be discharging that. Even Shanaka and his co-worker pointed out that this angle that you can measure the metaphysical angle is helpful, but it's by no means the be all and end all. So it helps you to make a diagnosis. But if there's any clinical doubt, then you should keep the patient under review. Then in case you're wondering, this patient that I showed you, he had physiological.
So that was what happened without treatment. The point I want to make is the extent of the condition. The extent of the arm is not a predictor of whether they have Blount disease or not. You can have really quite marked from physiological disease, and indeed, that's what this kid had. OK, so while we're on the subject of X rays, there is this rather complicated looking grading system for Disease developed by Anders Langer school, who was a Professor working in Helsinki in Finland, who described a cohort of Finnish children with plant disease.
And when you look at that classification, I kind of I feel sorry for him, really, because it seems to be a classification that gets a bit of a bad press. It's people think it's not really that helpful, necessarily in terms of determining treatment, but to be honest, it's called Never intended it to be that he just intended it to be a description of the natural history. So those stages that you see are correlated with the age of the child.
So he made the point that can't really diagnose those early stages before the age of one and the later stage. Stage six, not really before the age of 9 and the other stages occur between he. He never really intended for this to be a classification used to determine treatment, but nevertheless, that is how most people use it now with provisos.
So that's what I'm going to use to just to walk you through the different treatments. And one stage I really want to draw your attention to is this one? Stage number four, because that really marks the watershed moment at which things start to get really complicated. And you'll know it's stage number four because if you look at this beating.
Here on the medial side of the tibia. It starts off as being a beak in stage one in stage two. It starts to develop a defect within the beak. In stage three, that defect becomes a shelf and it's stage four when the epidermis seems to slip into the shelf. But before it's gone on to become a befit type of epiphytes here. So that's how you recognize stage four.
In fact, studies show that inter observer variability in assigning blanks called grading is actually quite good. Perhaps surprisingly so, it's not so difficult to spot the stage for everything before stage four has one type of treatment and everything stage four onwards has another. So I'm about to explain. So let's talk about the early stages first, so these are the early stages and therefore children of relatively young age, probably between about the age of 2 and 6.
So leave aside this cafe, this is an oasis treatment for Blount disease. I was going to come back to that in the next slide, but just focus here on stage two and stage three. So the treatment for this, these stages are essentially tibial osteotomy. So the idea is to do it tibial osteotomy and realign it because you're having to do the osteotomy at a distant point from where the chora is.
The core is really up here in the thisthis, but you're forced to make your osta osteotomy down here in the metathesis because obviously you've got to go distal to where the growth plate is and where the extent to mechanism is, then you're going to have to include because the osteotomy is at a separate place to the kaura, then you're going to have to include some translation in this.
This is all to do with the niceties of deformity correction, which is not the focus of this talk. But if you understand about corners, you'll know what I mean. If you don't, just take it from me that you're going to have to involve some translation in this condition. Most people in infantile Blount disease tried to overcorrect a little, and then you'd better pray to the gods that those physical changes, that beating and that Fischler rest is going to nature's going to it out for you.
Langlands gold actually said everything up to stage four was reversible, but it seems that perhaps that was overly optimistic. And that's not everybody's experience, certainly not with a non-white population in an afro-caribbean population. Certainly, that doesn't appear to be the case that seems to run a more aggressive course of the recurrence being more than the order of the day.
However, I told you that stage four was an important stage to remember in the lung and skull classification. Well, now I'm going to tell you that age 4 is also important. There are quite a few studies that show that if you can get this tibial osteotomy done not at the age of six but before the age of four, then you'll reduce the chance of recurrence. So that's important to remember. I say reduce the chance of recurrence.
You don't reduce it to zero. Even in this study in the gpo, which was, I think, a meta analysis recurrence was still 46 percent, but better than the 85% if you left it until after four. So that's how you treat the early stages. Now what about this business of treating and authorities? So that's said to be a way of treating the early stages of Blount disease? Well I don't know.
I don't know. Those of you who have two and three-year-Olds of your own. If you want to try and strap them into a contraption like this and expect them to cooperate with you or best of British luck to you. I'd suggest that's actually quite difficult to do. So these splints are rather impractical. I would say. If you look at the design on the right here, you can see that those knees are locked in extension.
Now there are designs which allow knee flexion, but I'm not quite sure I understand how something that allows knee flexion is going to exert point pressure and correct the deformity. And what are you supposed to do, put them on in the daytime or NIPE time or both? And where exactly is this correction occurring? Not entirely clear. I don't really see that the correction is necessarily going to be focused on the tibia, which is where the problem is.
If it's going to be a correction, it's presumably spread throughout a bit of the femur and probably part of the knee joint as well. There isn't really any good evidence, probably for the reasons I've just listed for them working, but nevertheless people do use them and they are described in the book. I would argue, though, if you know that you can treat this condition with a tibial osteotomy and you can as long as you get it done by the age of four, then you have a reasonable treatment up your sleeve.
Then then probably it would be reasonable not to use splints at all. And that's been my practice, but I know some people do use them, so that's why I'm mentioning it. So this is an example of tibial osteotomy, you see here what I mean about doing the osteotomy distant, distant place here to where the actual problem is, which means that when you swing this segment across, there is inevitably translation and that's what you want to see.
So I use an external fixator for this. You don't have to could use internal fixation if you want. Doesn't really matter. But notice also that tibia has been swung into a little bit of balga, so we tried to overcorrect here a little bit. So this is the treatment for stage one, two and 3 and ideally done before the age of four. If you want to reduce the chance of recurrence.
So what about the more advanced stages? Well, once you get to stage four, so this is the point at which that beak has become a shelf and the epiphytes has sort of collapsed into it. But before the emphasis has turned into two separate bits, then your treatment is going to involve osteotomy. But you're going to have to do something about the crisis as well, particularly the five seal bar, because this sure as eggs are eggs is going to lead to a recurrence if you don't.
So what is this fiscal management? Well, basically, you've got two options. One would be to take the fiscal bar away and leave the normal crisis behind. So this picture shows a central bar. Of course, the bar I'm talking about here is peripheral, so it's not the ideal picture. But anyway, this is one option to remove the sick piece of the crisis and leave the healthy bit behind a physio physiologist.
So-called so you're doing this on the medial side of the tibia. Option number two is. To use a drill and a cure, yet to deliberately destroy the ethicists on the lateral side because, you know, the medial side has gone already. So you're just trying to arrest the growth on the lateral side to stop the disease from coming back. Again, my apologies.
This picture is for epimysium thesis done not for Blount disease, but for a leg length discrepancy. But it's the only picture I had. I just want to. So you don't need to put the drill all the way across to the medial side because the medial side is already arrested. You just need to do the lateral side. So that's a physio thesis.
I know what you're thinking. You're thinking, well, why on Earth would you do this? This is much cooler. Here you go. You're taking away the problem and away you go. Why would you want to destroy the last bit of growth remaining? Well, I agree with you. In theory, that would be great, but there is one thing and practice is another.
The fact is, taking away that bit of sick thesis is great in theory, but in practice hasn't really been that successful. So in theory, it should work. But in practice, we often find recurrence after the thesis is supposedly been released of its tether. You might say, well, I can add an eight plate onto the other side onto the lateral side to try and improve the chances of correction.
But that's only really going to work if you have a very healthy basis on the medial side as well. So great in theory, not so great in practice. The lateral physio thesis, on the other hand, sure is effective at stopping the deformity from coming back. But and it's a big but you've now condemned that child to a leg length discrepancy. They're going to have a straight leg, but they're going to have a problem with discrepancy of length.
Now, for my money, I would rather deal with that. I'd rather deal with a straight leg and a discrepancy because there are lots of ways of treating that than a bend like that's been straightened and is coming back again. Serial operations for Blount disease are not a lot of fun. So if you do the lateral physio diocese, then at least you know where you stand and everybody knows what to expect.
The problem with the physiologists is nobody knows quite what to expect. Not you, not the parents, not the patients. And everybody is just crossing their fingers. So great in theory, but not so great. My point is, once you get to stage four of the disease, then you have to think about some sort of management of the crisis or you're going to get recurrence for sure.
What about these later stages? These are the stages where you're either getting a befit type of emphasis or actually a definite physical arrest on the medial side. Well, here again, osteotomy is going to be part of your procedure for sure. You're going to have to manage the problem of the crisis. And that's probably going to be because these are older children.
That's almost certainly going to be a physio, odysseus, actually. And FFC, odysseus, you're going to deliberately destroy the lateral side of the growth plate to stop the disease coming back. But you need to think how sloped that tibial plateau is now, how congruent do you think the joint actually is? You need to at least ask the question whether you think the knee joint is congruent or whether there has been essentially a collapse of the medial tibial plateau.
So any patient who's walking with that varus thrust that I mentioned, particularly older patients, that's rather suggestive that they have a problem with a joint that is no longer congruent. However, bear in mind what I said about those abnormalities of ossification, and I showed you that MRI scan. So it ain't necessarily so even with an X-ray that looks like this, it might be that the joint is more congruent than you think.
So before you get too excited about doing some very clever operations to try to restore the joint surface, you would do well to do an MRI and/or an Arthur program just to prove to yourself that there is a genuine gap on this medial side and that it's not either filled up with as yet ossified epimysium or a large, fleshy atrophied meniscus, which is the other thing that can actually lead to the joint being more congruent than you think.
If you have evidence that the joint is not congruent, in fact, then you probably wise to get a seat done and 3D reconstructions are really helpful. So that you can make a plan about how to go about addressing this problem of restoring Royalty to the joint. But the basic principle is this what you're trying to do is to restore Congress city by an osteotomy directed with a curved, austere tone from the medial side until the entire condylar area.
And then you deliberately crack it and elevate this half of the joint, which does take some bravery to do, I can tell you. But this is how you restore the joint Congress. You get rid of that space that was there before. Of course, you can now going to have to fill up this gap or it's going to collapse again. So you're going to put a bone graft in there, which you've harvested from the fibula usually.
And that restores the community, but the disease is going to come back unless you do something about this lateral. And thisis which is still active, so you'd better make sure you do. And if it is your Odysseus as well. And then finally, you need to realign the tibia, so you're going to do a tibial osteotomy and realign it, then you've got to fix the whole thing together and that's up to you how you do it.
You could use an external fixator. You could use internal fixation. The choice is yours. So infantile Blount disease, this is a summary by Langan scold stage, so essentially stage 4 is the stage where you need to start thinking about management of crisis in addition to just doing a tibial osteotomy.
And once you get to the later stages, you need to consider whether a hemi plateau elevation is necessary so you can see how complicated infantile Blount disease is to treat that are not, say at the start. Whenever you see a young child who's got a permanent fiscal arrest, you know you're heading for trouble. You know that that's going to be a difficult problem to.
Adolescent Blount disease is a different beast entirely. It shares a name, but arguable whether it's the same pathology at all. So this is a condition that occurs in children older than 10. And importantly, they have no previous history of bow legs as a child. The most in my experience. Most of these 10-year-olds actually look more like they're 15 or 16, so they do seem to be skillfully advanced, and they too are complaining of general barhoum, which is progressive.
These are all obese kids, all of them. And their disease is usually unilateral, which seems a little strange because the obesity is certainly not unilateral, but that's the way it goes. You will know that you're dealing with adolescent Blount disease instantly from the X-ray because they look totally different to the infantile form that I've just shown you. But bear in mind that you are going to get adolescence.
As I said at the start of the talk, who have both legs, but who have the infantile form, which has recurred, but they look quite different on the X-ray. So here on the left hand side of the screen, this is what you typically see in an adolescent with that form of the disease. So you can see this sort of pagoda roof to the tibia. You can see signs of previous tibial osteotomy and the degree of virus is really quite marked.
What you see in the adolescent form of the disease is a more mild form of virus. And look at the faces here. We're not seeing that advanced medial fistula rest. In fact, if anything, what you're seeing is an office that looks apparently wider. I don't think it really is wider. I think again, it's a defect of ossification. But you're not seeing those advanced medial changes that you see in the infantile form of the disease.
There's no physical bar here. It looks much more normal. The crisis is basically a lot less sick in this condition, and that's a good thing that makes it easier to treat. One of the thing, one typical feature of adolescent Blount disease is said to be that it also includes some of the various coming not just from the tibia, but from the femur as well. That's a real favorite question for the folks.
Also worth noting that femoral virus is present in adolescent Blount disease, but is said not to occur in infantile slap disease. So if we say the growth plate is not sick, then that's really helpful, right? So if this patient still has some growth remaining, then there's no reason why we can't go ahead and treat that by a guided growth regime. So that's what's happened.
In this case, some eight plates have been inserted to try and slow up the growth on the lateral side and hey, presto, the whole situation has been rescued. One of the problems with eight plates can be in these rather heavy children that they can break, so it's worth considering designs of eight plates called h plates, which take four screws, not two. And there was a said to have a lower chance of the implant failing.
What about is the patient's already psychologically mature and growth and guided growth is not going to work for you and you're going to have to do a realignment osteotomy, but at least you can do that confidence that you can realign it and be sure that recurrence will not recur. But the disease will not recur, right? Because they're still immature.
So you don't need to worry about all of got stuff to do with fiscal management and physio theses and physio lysis. You just need to realign it how you realign it. That's up to you. If internal fixation is your thing, then go ahead. But the real problem with these kids is they are so large that physically doing that on table can be quite difficult, especially knowing that you've absolutely got it right.
Because if you're going to go for acute correction and internal fixation, you'd better make sure you've corrected it properly before you let them out of the operating theater. So you might instead go for external fixation, which has some advantages and disadvantages. If you know how to use external fixator, it's quite nice because you don't have to get the correction done in theatre, you can do it later on and you've got a choice.
You can either make the mechanical access completely normal or you can match it to the other leg, which is often slightly varus anyway, depends on what you're trying to achieve. I'm also concerned about doing acute osteotomy as in the proximal tibia. In some series, there are rates of neurovascular compromise and compartment syndrome. Eye watering proportions.
So you don't tend to get that with external fixation. I do accept, however, that these patients do run into trouble with pins site infection, and they're also condemned to wearing them for at least three months. It does take quite a time to unite. But anyway, it's up to you how you treat it, but osteotomy is your way forward if this is adolescent slap disease in a patient who is a little immature.
So just to summarize about Blount disease, then this has been well described as a bimodal disease with an infantile and an adolescent form, the infantile one is difficult to treat because the Ephesus is sick and your challenge is always going to be that the disease wants to come back. It's a recurrent disease. The adolescent form, on the other hand, is much more simple to treat because the virus is not so sick.
But there your challenge is a technical one because of the size of the patients. And if you remember no more numbers from this talk than the number for that, that would be a good start. So in infantile Blount disease, get the osteotomy done by age 4 to reduce the chance of recurrence. And remember that after the lung and skull stage four, you need to start seriously thinking about fiscal management.
So this table just summarizes some of the key features which are different in these two forms of the disease. This is a 12-year-old girl who had had Blount disease treated in the past, so she'd had the infantile form. She'd had it from an early age and sure enough, the disease had recurred.
So here she was at 12. She has all the features you can see from the soft tissue shadows that she was a big girl and she had recurrent disease with various internal tibial torsion Procore bottom. So she had a sagittal plane deformity as well. But I didn't think of Eris thrust. I thought despite those appearances, her knee was actually fairly congruent.
So what do I want to do? Well, I need to do an osteotomy to realign it, and I need to manage the feistiness as well. So I need to do, I thought, a physio thesis. I wanted to deliberately drill out the faces on the lateral side to stop it coming back. So that's what I did. I didn't fancy a cute correction. I'm scared of neurovascular compromise that can occur with that.
So I put on an external fixator and we corrected it. OK, great. Onto a winner or so I thought. But this is what she looked like when we'd finished. So what had happened here? Well, in my defense, you can see the solution, and when you put external fixated on people, it's quite difficult to get them to stand up and take radiograph sometimes.
So I was rather disappointed to see this, and my mistake had been that we'd actually corrected the tibia pretty well, as you can see. But what I had not appreciated was the pretty marked femoral deformity that she had, in addition. Now the books tell you that femoral deformity does not occur in infantile Blount disease. Well, I'm here to tell you that it does, but it's not various.
Generally, it's usually bogus, as in this case and my colleague Rob hill, he believed that this femoral deformity only tends to occur in infantile Blount disease that's already been treated. So maybe it's in the arch traject deformity in some way. I don't think you ever wrote that up. I haven't seen it written up, but that's my point. So I suppose.
Well, what are we going to do about this? Well, I'm not so worried about doing acute osteotomy in the distal femur. So that's what we did. We corrected it using an acute correction, taking out a medial wedge and fixing with a locking plate and that sorted out mechanical axis. You can see on the right hand side, we've got a few fun and games to deal with, but that's probably something for another tour.
So my point is that with any deformity, you always have to think about a compensatory deformity which the body has desperately tried to put in place in order to compensate for the first one. And I think that's what happened here. Well, at least it's an honest, cased example, huh? So the final bit that I wanted to give you was some tips for dealing with drought disease, either in clinical practice or if you meet one of these cases in the source.
But again, we can pause at this point and go to questions if you'd prefer for us. How do you think we should play it? I think it will be very useful to hear your tapes. We can do that after questions as well. So if you like. And then we hear your tapes, they'll be very nice. I'd really like to thank you, Gavin, for this wonderful teaching lecture.
We certainly have learned a lot. A lot of very important concepts you presented. And I mean, one of them for those going for their first year exam. I think when you present to the blind disease picture or clinical scenario, you know, reach to your brain straight away and try to draw that signature graph. That would be one of the important marking points for that station.
And it's important that I heard about the deformity, that it's actually 3D deformity, and we tend to look at it in the one plane. But as you explained, it's a 3D deformity and we have to consider all the deformities there. And it is very interesting also to know that's adolescent blunt disease is completely different pathology to the infantile one, and that's just new, new for me and very, very important point to take into account.
You know, so many, so many key points you presented, which are very useful, just bring some questions from the audience. There is some controversy about the early Walker. Is that important to know? And what exactly defines an early walker? Is it? You know, dependency walking or standing or. Or is it not essential to?
Yeah, I'm not sure the books are ever that clear about it, but basically I think we mean any child who's walking before the age of one. So once you hear that a child is walking by the age of sort of nine, 10, 11 months, that should Ring Alarm bells often. Actually, these children do need to be helped at this point. They have to have their hands held. But children that want to spend most of their time up, you know, taking weight on their two legs at that time, those would count as early walkers.
And one more question is that about the overcorrection? Is there any guidance on how many degrees you overcorrect or that age, age related? Yeah so the overcorrection only refers to infantile Blount disease. You shouldn't overcorrect the adolescent cases because they don't have any growth left. So the guidance is it's not a big overcorrection. It's just, you know, five degrees.
I would have thought you won't want to do more than that because after all. What are we saying here, we're saying that we know that there's a chance of recurrence, and we're hoping that if we can just tweak it a little bit the other way, then hopefully we'll get away with it. And the virus will get the chance to remodel and recover. But equally, you do want some recurrence, right?
You don't want to leave this child with a leg that is now in Vegas, so you don't want to overcook it. I would say about five degrees should do it. Thank you. Thank you for explaining. Obviously, that's we don't want to overcorrect listed for that would be a mistake. And just about the follow up also, do you follow up?
This therefore is clearly is clearly mature or beyond that or. And so I guess the answer to that is I tend to put the onus on the parents, and I explain that the big problem with this disease is recurrence and that if parents see that happening, then they should get back in touch with us. It depends how busy your clinics are.
I think the important point is whether you decide to follow them up or just put the onus on the parents. You should always advise the children and their families. That recurrence is a distinct possibility because if you don't, then their parents are going to find that quite hard to forgive and you're going to be backtracking and making trying to make a few excuses for yourself. Whereas if you told them that recurrence is likely and it happens, then they're likely to trust you that you come across as being a wise old sage who made a good prediction.
And that's going to be important if you're going to be treating them again. And so it's a communication skill also here. And just one more question before we put the polling questions to everyone to answer any, you said the compartment syndrome is one of the complications. Is there any tips on how to prevent it or.
Oh yes, Yes. Thanks Thanks for mentioning that. I should have done. So if I'm not a big fan of doing acute corrections. But if you are going to do that, then it makes sense to do a prophylactic ashtami. Certainly if the anterior compartment. So that's done subcutaneously. So through the incision that you use to do the osteotomy, you split the fascia longitudinally up and down and that reduces the chance.
OK, thank you very much. So it was just a couple of other questions on the chat group. Sorry for us. In terms of the crisis or thesis, is there a is there a knock off point when you would do it in terms of the bar size with the bar size change? Right? Yeah.
Good question. I don't think there is in terms of the size of the bar, generally removing five steel bars is said to be better if they're peripheral, so you would think that allowance disease would do well, right? Because this is a peripheral bar, not a central one. What is important, I think, is the stage of the disease. So by the time you've got to stage 5 and stage six, then there's no point in excising the bar.
You would be better just doing a growth arrest on the lateral side. The problem with excising five steel bars, I think, is having the courage to keep on nibbling it and going further and further laterally as you're creating a bigger and bigger cavity under the joint. And I think most surgeons kind of lose their nerve, and that might be one of the reasons why we don't get such good results from it.
So no, there's no firm advice on the size of the bar. It's more on the stage of the disease, so it's an option for stage four, but I would say not for stage five. And in terms of osteotomy, where would you cut the fibula? The fibula, yeah, I tend to cut that round about the junction of the distal third and the proximal two thirds, so it doesn't really matter, you can cut it wherever but out of the way of the common perennial nervous.
But I did. Good, thank you. Thank you, Sean, for putting forward those questions. Now these participants, I'm going to put the polls, the questions now I will give you. I would give you a minute or two to answer them. They are all under no, so you are not identified and these are really just to consolidate your knowledge and they are very important bits that can pop on the exam.
So have a look, guys, and if you could answer them as quick as you can. The quicker the quicker you guys answer these questions, the quicker we can move on to the next section. Can I ask another question that was being asked in terms of adolescent blondes and probably infantile in terms of sorry in adolescence?
My apologies. Do you do a femoral osteotomy as your primary part of your treatment in those patients? If you spot. The problem there? Yeah the answer is you certainly need to address the femoral deformity, but you it depends if they're slightly mature or not, guided growth will also work for the femoral deformity.
That's what I showed in the slide. Actually, there were eight plates both on the female and on the tibia. So yes, the answer is you definitely need to address that as well. And just a reminder, after this section, we will move on to the hot seat driver. The hot seat driver section is not recorded, obviously, and we thank everyone who comes forward.
We know it's not easy to be in the hot seat in front of so many people. But it's a very good opportunity and learning experience from an experienced lecturer and teacher with lots of experience with pass this exam, so well done. Everyone who raised their hands and everyone else will benefit from listening and from hearing the feedback. So I think 73% of participants now answer, so I think I'll end up polling now, 75% answered.
Question number one, infantile bladder disease associated with and option number two is the correct one. Worse prognosis in afro-caribbean patients. So 65% answered this correctly. Question number two, adolescent blood disease. And the correct answer is number two, again, is commonly unilateral.
76% answered this correctly. Question number three, the answers were a bit more interesting. So in regards to a skilled staging blood disease, which one of the following statements is true, only 41% say the correct answer, which is the answer no to. Stage three, the physical changes are potentially reversible with tibial osteotomy alone.
So, so here are my tips for dealing with Blount disease if you're in a Viber situation. You may get shown an image of Blount disease. I showed you the typical radiographic images and actually it backs up a point. Faraz just made that the appearances are very characteristic with Blount disease, so there's really nothing else that could be. So my advice is don't hedge, don't mention other conditions that you think it might be.
Don't mention things like that. It could be due to rickets. Go in there and say it's Blount disease. But now here's the next really important point. There is a feeling that if I'm not talking, I'm not scoring, and I have to say, as my experience has been, that's not always a very good approach in a. So if you're asked to describe the appearances of an X-ray and you think that looks like bounces, say what you think and say.
I see these appearances at the examiner says, what do you think it is? And then they say Blount disease. Now, that is the point to stop talking because what many people do is say, I think it's Blount disease. There are two forms of Blount disease that adolescent and infantile, and it's caused by I. Whoa whoa, whoa, whoa, whoa.
I strongly advise you to stop at that point because you don't know where the vibe is going. We might start talking about the pathogenesis. We might start talking about treatment. We might start talking about differences between adolescence and an infantile. You just don't know. So it's very important in a vibrant Blount disease and in fact, on any vibha to in an early stage, I would advise you to stop talking and wait and see which way the vibe is going, because that's where the points lie.
My next point is, well, it's kind of illustrated by what I showed you in that last case example. So if you have the presence of mind, note the fact, there's a tibial deformity there from Blount disease, but just keep your eye on the distal femur as well. So for those extra points, you could point out if you see that there's a femoral deformity, then point that out to the examiner, too, because that's going to look good.
They'll be polishing up the gold medal When you say that. So what about clinical tips? So here are my tips this could apply actually in a busy clinic as well as in the health self-exam. So when you see a child with Blount disease, don't even bother asking them about pain. They're not going to tell you it's there. I genuinely think it isn't. They're actually these kids just get on with life.
You, you're going to get far more credit for asking whether they're bothered by the appearance of their legs and whether it stops them taking part in things. Because that's really what it is in pediatrics. It's all about function. Pain is not a feature. Sure, in adults with Blount disease, you can imagine the natural history is pretty aggressive.
But so don't ask about pain. The barest thrust thing is a very typical appearance is quite an acute jerk of the knee every time they take a step. So if you see it, mention it. If you don't see it, don't say that you think it's there because you feel that it ought to be because that various thrust is quite common in slap disease.
The reason I say that is because if you mention it's there, then you'll start to get into a conversation about medial plateaus being elevated. And do you think that's a good idea? And what about the lateral collateral ligament? You're going to go down a pretty tricky route, so by all means, identify it. But don't sort of say that you think it's there just because you think it ought to.
Another thing for them to get the gold medal out to you is it would be quite good to examine the patients on the couch and to see if they can apparently get their knees fully extended. Because in Blount disease, it looks like they can't. It looks like they've got a fixed flexion deformity of the knee, but in fact they haven't. They get their knee fully straight. The reason their knee looks bent is because they've got a proximal tibial deformity, so that looks quite good.
If you demonstrate that to an examiner, it shows that you're aware that this condition is not just general byrum, but has deformities in other planes as well. While they're on the couch, you could examine for lateral collateral ligament laxity, which might be an indication which might confirm your suspicion of a varus thrust. And here's my final and most important and favorite tip to pass on, and that is you should always examine patients with coronel any coronal plane deformity with their kneecaps pointing forward and why.
I'll show you why. So here is how most children with Blount disease, and this is one tend to stand. And actually, this is also how radiographers tend to position them when they're taking their X-rays for you because it's easier for the patient, isn't it, with a finger pointing forward? But look where his kneecaps are.
That left patellar is externally rotated if you take the trouble to reposition his leg so that the kneecaps are pointing forward. Look what happens? Now you can see the genuine arm, but you can also see the interior tibial torsion. Nothing can you see? The examiner can see it as well. Incidentally, look at what he's doing now.
He's having to hold onto the wall because he feels a bit unstable like that. But that's do you see the difference? It's such an impressive thing to show and examine it by just taking a moment to reposition his foot so his kneecaps are pointing forward. Suddenly, the mist clears and you can see much more clearly where the deformities are. So that's everything I have to say about disease.
Good luck to everybody in dealing with those patients, either in your clinics or in the exams, and everything that's on my presentation from now on is related to survivors. So that's all I have to say. And Thanks very much for inviting me to talk on the webinar. I've really enjoyed it. Thank you, Mr Spence.
Lovely very useful tips. I like that last one. I think while examining this patient in the even short case or intermediate case just took the exam. I'm trying to point the patella forward while examining this patient. I think that's exactly I will smile and they know what you're doing.
And so exactly. I don't think many people would do that. So I think it's very useful to get. So, OK, guys, thank you very much. So we'll move on now to the Viva session, which will be unrecorded.
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