Copyright

J 982 by

The Journal of Bone and Joint Sureerv, incorporated

Current Concepts Review

Tibia Vara (Blount's Disease)*
BY CHADWICK

F. SMITH,

M.D.t,

Tibia vara presents as severe bowing and internal ro

tation of the tibiae in childhood. The condition is second
ary to abnormalities occurring in the medial part of the
proximal tibial metaphysis, physis , and epiphysis. The
pathology of the abnormality
is non-specific
but is
definitely not avascular necrosis.
Infantile tibia vara is never present at birth but has its
onset between the ages of one and three and one-half
years I!I. Patients who first manifest the abnormality after
the age of eight years are commonly described as having
adolescent tibia vara. Most authorities, however, have re
lated so-called adolescent tibia vara to trauma, and spe
cifically differentiated it from infantile tibia varaS,6.19. It
should be stressed that true tibia vara (Blount's disease) is
an unusual condition and that fewer than 500 patients with
the condition have been reported in the world literature 20.
The deformity is frequently associated with an internal ro
tation attitude of the lower extremities and tibial torsion.
In a retrospective analysis at one institution, more than
5,000 children with bowlegs were seen over a fifty-year
period. After reviewing all records and approximately 500
so-called bowlegged patients, only thirty-seven of the
5.000 patients could be definitely diagnosed as having in
fantile tibia vara 27.
Erlacher is credited with reporting the first case of
tibia vara in IY22. In IY37. Blount reviewed the fifteen
cases in the literature and presented thirteen new cases 4.
He stressed the similarities between infantile tibia vara and
adolescent tibia vara but emphasized the difference in
etiology. Langenskiold,
and Langenskiold and Riska ,
published a large series of cases of infantile tibia vara and
introduced a schema for classification using six stages of
progressive radiographic change to establish the guidelines
for prognosis and treatment 17.20. The six stages depict the
aspects of tibia vara from mild to moderate to severe. The
higher the stage, the more medial deformity and radio
graphic fragmentation is present. Stage VI is characterized
by a bone bridge between the metaphysis and epiphysis.
A more recent classification 27 attempted to relate the
grade of deformity to the need for treatment. Careful ob
servation of children whose radiographs show potential
tibia vara and who may require early surgery for so-called
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true tibia vara was emphasized I J .27. The higher the grade
of deformity is, the worse the results of surgery.

Grade A - Potential Tibia Vara

This grade encompasses those patients with bowlegs
who demonstrate the following features.
I. Varus angulation of not more than 15 degrees
2. Radiographic changes as follows:
a. Sclerosis of the medial part of the tibial
diaphysis, significantly more severe than of the
lateral part
b. Severe beaking of the medial part of the prox
imal tibial metaphysis
c. Radiolucencies in the medial part of the prox
imal tibial metaphysis

Grade B -

Mild Tibia Vara

This grade represents all those patients in whom the

diagnosis is definite but the pathological changes are mild.
I. Any or all of the findings in Grade A
2. Femorotibial varus angulation of mild or moderate
degree (15 to 30 degrees)
3. Radiographic fragmentation or stippling medial to
the proximal epiphysis or metaphysis

Grade C -

Advanced Tibia Vara

This grade represents

a more severe form of tibia

vara.
1. Any or all of the findings in Grade A or B
2. The following radiographic changes:
a. Epiphyseal fragmentation and deformity
b. Open physis of the medial proximal part of the
tibia

Grade D - Physeal Closure

The most advanced stage of tibia vara.
l. Any or all of the findings of Grade A, B, or C
2. Closure of the medial part of the proximal tibial
physis, with a bone bridge evident radiographi
cally between the epiphysis and the metaphysis
3. Marked deficiency of the medial part of the tibial
plateau and tibial epiphysis
4. Rapidly increasing varus angulation of the knee
The etiology of infantile tibia vara has not been es
tablished. There is a consensus, however, that stress and
growth combine to produce a progressive varus deforTHE JOURNAL OF BONE AND JOINT SURGERY

TIBIA VARA (BLOUNT'S

mity2.13.17. The Heuter- Volkmann law of epiphyseal pres

sure (which states that compression inhibits growth and
distraction stimulates growth) could be cited if one desires
to utilize inductive reasoning. Arkin and Katz, however,
have given scientific support to this hypothesis in experi
ments on immature rabbits. They concluded that: "When a
growing epiphysis is subjected to a stress, the rate or di
rection of the growth of that epiphysis or both are modified
so as to yield to that stress. " Kessel advanced a different
theory. As a consequence of the slowing of growth of the
medial part of the proximal tibial epiphysis by pressure
from the femoral condyle, the fibula is forced to overgrow.
The posterolateral location of this bone in relation to the
tibia causes both internal tibial rotation and varus defor
mity, thus setting the stage for the tibial condylar defect
seen in tibia vara. Bathfield and Beighton, and Smith et
al., found no link between joint laxity, the age of starting
walking, body weight, and tibia vara. Bateson, on the
other hand, reported two racial factors that seemed to be
constant in Jamaican children with tibia vara. They were
prone to more severe physiological genu varum as infants
than were English children, and they began walking at a
much younger age. Thus, Jamaican children would walk
earlier on physiologically bowed legs which would in turn
predispose them to development of tibia vara. Golding and
McNeil-Smith thought that the reason for the increased
incidence of tibia vara in black children as compared with
Europeans is that the former normally have more laxity of
the knee ligaments, and they stand and walk at an earlier
age. As a result, the black child with physiological genu
varum may have lateral subluxation of the tibia directing
the weight-bearing stresses at an oblique angle to the tibial
epiphysis and physis. This results in a vicious cycle, with
the epiphyseal line oriented perpendicular to the stress,
subsequent retardation of longitudinal growth medially,
and eventually genu varum. Currarino and Kirks demon
strated widening of the lateral part of the distal femoral
physis in two children, while three children showed widen
ing of the lateral aspect of the proximal tibial physis. The
explanation of these abnormalities might be related to Del
pech's law. This is the reverse of the Heuter- Volkmann
rule of epiphyseal pressures and states that when stress is
relieved from a growing physis, it will have a tendency to
overgrow. Arkin and Katz thought that this was a factor in
their rabbit model. Their conclusion was that "escape
from normal weight bearing stresses results in over
growth" .
Caffey considered the radiograph to be highly ben
eficial in recognizing the conversion from physiological
genu varum to tibia vara; certainly this may be a difficult
task in differential diagnosis. Radiographically, the major
differentiating finding in the child in whom tibia vara is
developing is an abrupt angulation of the medial cortical
wall of the proximal tibial metaphysis as contrasted with
the lateral cortical wall, which remains nearly straight.
The radiograph in benign physiological genu varum, on
the other hand, reveals a gentle curve of both the medial
VOL. 64-A, NO.4. APRIL 1982

DISEASE)

631

and the lateral cortical wall of the tibia 22. In tibia vara the
curve is immediately below the metaphyseal beak, while
in physiological genu varum the arc of the curve is much
flatter. The deformity in tibia vara is restricted to the tibia
except late in the course of the disease, whereas in the
physiological deformity the femur also is often hyper
trophied and bowed. The diagnostic radiographic finding
in tibia vara, however, is medial metaphyseal fragmen
tation 8.24. This radiographic abnormality probably repre
sents calcification either within the epiphyseal anlage or
within the distorted physis, or both. It is my belief that this
radiographic change is pathognomonic for the develop
ment of a progressive tibia vara.
It is true that in certain instances a true tibia vara can
appear to resolve spontaneously 19.27. Spontaneous correc
tion has not been well documented in the literature,
although seven such cases have been collected 27. In the
so-called benign-prognosis years between the ages of two
and five, progression must be documented before surgery
is considered. This phenomenon makes it difficult to sci
entifically document brace treatment as an effective
modality for the treatment of tibia vara. Some authorities,
however, were convinced that a bowleg night-brace is ef
fective in preventing progression and in treating mild
cases 6.
The appropriate treatment of progressive infantile and
adolescent tibia vara is corrective proximal tibial os
teotomy with fibular osteotomy. Correction of the defor
mity should include correction of the rotatory abnormality
as well, and the extremity should be placed in mild valgus
angulation of 6 to 10 degrees. In patients with bilateral in
volvement, the extremities should be made symmet
ricaI1927. Prior to application of the cast in the operating
room, documentation of the valgus correction that has
been achieved should be obtained by radiographs made
with the knee in extension. Surgery should not be consid
ered prior to the age of two years, but in a patient with a
progressive deformity who is older than two, tibial and
fibular osteotomy is indicated. Eighty per cent of patients
with infantile tibia vara have bilateral deformity. At the
time of surgery on a patient with bilateral Blount's dis
ease, each knee should be placed in physiological genu
valgum. In a patient with unilateral tibia vara, the knee
should be made symmetrical with the opposite extremity.
Langenskiold thought that surgery on the opposite extrem
ity with varus angulation should be considered even if the
deformity is only moderate. Salvage procedures such as
plateau elevation, ligamentopexy, hemiepiphyseodesis,
epiphyseodesis of the opposite extremity, and physisplasty
are reserved for patients who are seen late in the course of
the disease and patients with failure of initial treatment 19.
21.27. Although Langenskiold stated that a single tibial
and fibular osteotomy is sufficient if it is properly accom
plished, recurrences have been seen 27. Ligamentopexy is
probably not indicated even in late cases. Siffert and
Katz 26 documented enlargement and hypermobility of the
medial meniscus, depression of the anterior aspect of the

632

C. F. SMITH

medial femoral condyle, and depression of the pos

teromedial plateau of the tibia as the cause of the instabil
ity. Based on these pathological findings, Siffert suggested
epiphyseal osteotomy 25. Arthrography may be helpful in
delineating the sizes of the meniscus and of the cartilagi
nous aspect of the epiphysis 10.
Correction of the bowleg deformity in tibia vara is
indicated for functional and cosmetic reasons. However, it
is interesting to note that both Zayer and Kettelkamp were
unable to document a relationship between the severity of
the bowleg deformity and the development of osteoar
thritis (based on the follow-up of seventeen patients who
were more than thirty years old). Recently Jones has
documented flexion contracture, the extent of the physeal
changes, the degree of intra-articular abnormality, and the
age at operation as the critical prognostic findings.
Both Langenskiold 18 and Brighton have documented
the efficacy of physisplasty in the treatment of children

with tibia vara when bone-bridging is present between the

metaphysis and the epiphysis. The prognosis is better if the
lesion involves less than 50 per cent of the coronal surface
area of the physis or if the lesion is peripheral. A skeletal
age of less than eight years old also improves the progno
sis.

Conclusions
Tibia vara is an abnormality of the medial part of the
tibial epiphysis, physis, and metaphysis. The disease is
almost always progressive and the treatment is surgical if
the deformity and extent of disease are progressive. Infan
tile tibia vara has its onset between the ages of one and
three years and is bilateral in 80 per cent of the patients.
Adolescent tibia vara is probably related to trauma and has
its onset after the age of eight years. Adolescent tibia vara
is unilateral in 90 per cent of the patients and the treatment
is almost always surgical.

References
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Joint Surg., 38-A: 1056-1076. Oct. 1956.
2. BATESON. E. M.: The Relationship between Blount's Disease and Bow Legs. British J. Radiol., 41: 107-114, 1968.
3. BATHFIELD, C. A., and BEIGHTON, P. H.: Blount Disease. A Review of Etiological Factors in 110 Patients. Clin. Orthop., 135: 29-33,1978.
4. BLOUNT, W. P.: Tibia Vara. Osteochondrosis Deformans Tibiae. J. Bone and Joint Surg.. 19: 1-29, Jan. 1937.
5. BLOUNT, W. P.: Tibia Vara, Osteochondrosis Deformans Tibiae. Curro Pract. Orthop. Surg., 3: 141-156. 1966.
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309-312. 1977.
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DRENNAN. J. C.: Personal communication.
ERLACHER. PHILIPP: Deformierende Prozesse der Epiphysengegend
bei Kindem. Arch. Orthop. Unfall-Chir., 20: 81-96, 1922.
GOLDING. J. S. R . and McNEIL-SMITH, J. D. G.: Observations on the Etiology of Tibia Vara. J. Bone and Joint Surg . 45B(2): 320-325, 1963.
JONES. R. E.: Blount's Disease after Skeletal Maturity. Read at the Annual Meeting of The American Academy of Orthopaedic Surgeons. New
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19. LANGENSKIOLD, ANDERS: Tibia Vara: Osteochondrosis Deformans Tibiae. Blount's Disease. Clin. Orthop., 158: 77-82, 1981.
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Surg .. 46-A: 1405-1420, Oct. 1964.
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