ORIGINAL ARTICLE
Treatment of Infantile Blount Disease With Lateral
Tension Band Plating
Allison Cooper Scott, MD
Background: Growth manipulation has had increasing popular-
ity in the treatment of lower extremity angular deformities in
children. This paper discusses the use of growth manipulation
for the treatment of infantile Blount disease as an alternative to
proximal tibial osteotomy.
Methods: A retrospective chart and radiographic review was
carried out for 12 children (18 limbs) who had treatment of
infantile Blount disease with application of lateral proximal
tibial tension band plates. Some children also had distal femoral
lateral plates applied. Serial radiographs were measured to show
response to growth manipulation.
Results: The success rate of growth manipulation in this group
was 89%. Failures and delayed correction were attributed to
wound infection that required plate removal and broken screws.
Some recurrence of varus has occurred in a few patients.
Conclusions: Growth manipulation is an effective means of
treating infantile Blount disease in appropriate patients. Patients
must be monitored for screw breakage after surgery. After
removal of the plates, the risk of recurrent varus is attributed to
the poor growth potential of the proximal medial tibial physis.
Level of Evidence: Therapeutic study, Level IV.
Key Words: infantile Blount, tibia vara, hemiepiphysiodesis,
growth manipulation
(J Pediatr Orthop 2012;32:29–34)
A fter the age of 2 years, physiological genu varum
should resolve and children with persistent varus are
at risk for infantile Blount disease. Infantile Blount
disease is normally diagnosed when metaphyseal changes
described by Langenskiold occur in the medial proximal
tibia and the metaphyseal diaphyseal angle as described
by Levine and Drennan is >16 degrees.1–3 Early treat-
ment of infantile Blount disease generally includes
bracing, although the effectiveness of bracing continues
to be controversial.4,5 Surgical management is recom-
mended if correction by bracing does not occur.
The currently recommended surgical treatment of
progressive infantile Blount disease is a proximal tibial
osteotomy. The best results following tibial osteotomy
From the Shriners Hospital for Children, Houston, TX.
The author declares no conflict of interest.
Reprints: Allison Cooper Scott, MD, 6977 Main St., Houston, TX
77030. E-mail: ascott@shrinenet.org.
Copyright r 2012 by Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 32, Number 1, January/February 2012
have been reported when it is performed close to 4 years
of age.6–9 Complications of high tibial osteotomy include
recurrence of deformity, compartment syndrome, and
infection. Children with infantile Blount disease are often
difficult to treat both with bracing and surgery. Most of
these children are morbidly obese and many have poorly
controlled behavior.10 Parents frequently have difficulty
following bracing protocols and postsurgical activity
restrictions. In addition, parents at our institution are
often reluctant for their very young children to undergo
surgery. As a result, growth manipulation has been
offered as a surgical alternative to osteotomy for the
infantile Blount population. This paper looks at the early
outcomes of this treatment.
METHODS
After Institutional Review Board approval, a
retrospective chart review was carried out to locate all
patients who had been treated for infantile Blount disease
with growth manipulation as the initial surgical treatment
at a single children’s orthopaedic hospital. Twelve
children (18 limbs) with infantile Blount disease were
treated by lateral tension band plating of the proximal
tibia. Four children (5 limbs) had initially been treated
with lateral physeal stapling and were later revised to
tension band plates, whereas the more recently treated 8
children (13 limbs) were treated primarily with a lateral
tension band plate. Two types of commercially available
tension band plates were used, one made of titanium and
the other stainless steel. Six limbs also had lateral distal
femoral growth manipulation in addition to the proximal
tibia with a femoral tension band plate added when
femoral bowing was present. The average age of the
children at the time of surgical intervention was 4.8 years
(range, 2.8 to 8.7 y).
All children met the radiographic and age criteria
for proximal tibial osteotomy for treatment of infantile
Blount disease. These included Langenskiold changes
grade II or III of the proximal tibia and increasing
metaphyseal diaphyseal angle and/or age >4 years.
Growth manipulation was chosen as an alternative to
osteotomy after education of the family occurred regard-
ing surgical treatment. In several cases, growth manipu-
lation was chosen because of social issues within the
family that made compliance with postoperative care
after a tibial osteotomy difficult or because the family
refused osteotomy.
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Scott J Pediatr Orthop  Volume 32, Number 1, January/February 2012

The children who presented before 3 years of age

had a trial of bracing before surgery. When these children
failed bracing, discussion with the families indicated that
minimal efforts had been made to wear the braces.
Generally, a family’s refusal to participate in the bracing
regime was an indicator that cooperation with restrictions
after high tibial osteotomy would be difficult and growth
modulation was chosen for further treatment. During this
time frame, 2 patients <6 years of age underwent high
tibial osteotomy for Blount’s tibia vara. Both of these
children presented after age 4, had significant mechanical
axis deviations and had stable support systems that would
allow osteotomy treatment to be successful.
Radiographically, Langenskiold stage II or higher
changes were present in the proximal tibia of all children
at the time of surgery. Obesity was present in all children
(with 1 exception) with body mass indexes in the 93rd
percentile or higher.
Data extracted from the charts included age, body
mass indexes at surgery, ethnicity, nonoperative treat-
ment for tibia vara, complications of surgery, and time to
correction of tibia vara. The angle of mechanical axis
deviation from a neutral mechanical axis was measured
on serial long leg standing radiographs to determine the
preoperative degree of deformity and subsequent correc-
tion as well as any recurrence once the plates were
removed (Fig. 1). Care was taken to rotate the limbs on
standing so that a true anterior-posterior radiograph of
the knee was taken despite tibial torsion being present.
Plates were removed when the mechanical axis deviation
was zero. The rate of correction was calculated by
dividing the number of degrees of correction of the
mechanical axis by the time to achieve a neutral
mechanical axis.

RESULTS
Results are shown in Table 1. Sixteen limbs have
achieved full mechanical axis normalization and plates
have been removed. One limb still has deformity although
alignment has improved from the preoperative mech-
anical axis. One child required a tibial osteotomy on
1 limb for failure of correction. Thus, the initial success of
growth manipulation for infantile Blount’s in this cohort
was 89%.
Correction of the angle of the mechanical axis from
neutral occurred at an average of 0.84 degree per month
in those children with the tibia alone treated. The 4 limbs
that had distal femur and proximal tibia plated without
complications (2 others had screw breakage or infection)
corrected at a rate of >2 degree per month (Fig. 2). FIGURE 1. Angle of mechanical axis deviation.
Complications of treatment included screw break-
age before correction and wound infection. Each compli- tibial growth arrest on the limb with complications.
cation had a negative effect on the outcome of treatment. Patient #1, who still has not corrected, had a broken
The child who failed treatment and required an osteo- screw on that side while his contralateral side corrected
tomy had both a broken screw and a wound infection on uneventfully. Patient #7 had an infection in the distal
that limb that necessitated plate removal (Fig. 3). femur on one side which resulted in plate removal and
Although her contralateral limb corrected well with reinsertion and a delay of correction by 15 months over
growth manipulation, she developed a medial proximal the other limb (Fig. 4).

30 | www.pedorthopaedics.com r 2012 Lippincott Williams & Wilkins

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J Pediatr Orthop


TABLE 1. Patients Treated for Infantile Blount Disease With Growth Manipulation
Initial Age at Preoperative Postoperative Time to Distal Rate of Follow-up After MAD Deviation
Age Surgery BMI Previous Mech Axis Mech Axis Correct Femur Correction Plate Removed at Last Follow-
Patient (y) (y) Ethnicity % Treatment Deviation (1) Deviation (1) Months Included Degree/mo Complications (mo) up (1)
1 2.26 2.88 H >97 Brace 50 0 37 1.35 23 7
2.88 55 7* 61* Yes, late 0.79 Screw NA

2012 Lippincott Williams & Wilkins

breakage
2 4.24 4.29 AA 93 Observe 17 2 14 1.35 31 4
4.29 20 0 19 1.05 37 0
3 4.77 6.44 H >97 Observe 10 1 13 0.70 28 5
5.32 27 1 45 0.58 Screw 8 1
breakage
4 2.06 5.45 H >97 Brace 30 0 13 Yes 2.28 1 NA
5.45 30 2 13 Yes 2.13 1 NA
5 2.69 3.28 H >97 Brace 38 0 12 Yes 3.13 Infection 31 0
6 4.29 4.29 AA 75 None 7 0 10 0.72 30 0
7 3.84 3.84 AA >97 None 37 7 13 Yes 2.88 16 7
3.84 48 2 28.5 Removed 1.68 Infection 0 NA
Volume 32, Number 1, January/February 2012

replaced distal femur

8 2.14 4.25 H 95 Brace 10 0 17 0.59 7 4
9 3.01 7.14 AA >97 Brace, 13 3 19 0.84 37 Epiphysiodesis
staples
10 2.69 5.26 H >97 Brace, 40 35 Osteotomy 0.81 Infection, NA
staples screw
breakage
4.70 20 4 25 0.94 17 Epiphysiodesis
11 6.66 8.65 H >97 Staples 18 2 22 0.73 31 2
12 2.35 6.64 H 94 Brace, 8 19 0.42 1 NA
staples
*Complete correction not yet achieved.
AA indicates African American; H, Hispanic; NA, not available.

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Treatment of Infantile Blount Disease

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Scott J Pediatr Orthop  Volume 32, Number 1, January/February 2012

FIGURE 2. A, 3+3-year-old boy with infantile Blount on the left. B, Preoperative radiograph. C, One year after treatment with
distal femoral and proximal tibial lateral tension band plates, mechanical axis of limb is neutral. D, 30 months after plate removal,
at age 7 years, limb alignment is maintained.

Follow-up of >1 year after plate removal is
available for 10 limbs. Two of these patients had proximal
tibial epiphysiodesis after growth manipulation to com-
pensate for a contralateral tibial growth arrest associated
with Blount disease. Of the 8 remaining limbs, 3 have
shown a tendency for recurrence of 5 degrees or more of
varus although further surgical intervention has not been
required (Fig. 4). Tibial torsion did not correct as quickly
as the mechanical axis in these patients. In 3 patients, a
significant internal foot progression angle was recorded

FIGURE 3. A, 3+9-year-old girl treated with growth manipulation after failed brace treatment. B, Radiograph demonstrating
broken screw 6 months after application of titanium tension band plate.

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J Pediatr Orthop  Volume 32, Number 1, January/February 2012
FIGURE 4. A, 3+10-year-old girl presents with bilateral infantile Blount disease. B, Bilateral proximal tibial and distal femoral
lateral tension band plates were applied but wound infection necessitated removal of the femoral plate on the left. One year after
plate application, the right limb has corrected. C, One year, 4 months after reinsertion of the distal femoral plate on the left, the
left limb has corrected. The right limb, however, has shown mild recurrence of varus.
after correction of tibia vara. All of these children
continued to have mild tibial torsion but in addition, all
had moderate to severe femoral anteversion.
DISCUSSION
The accepted treatment of infantile Blount disease
with Langenskiold changes greater than stage I before age
4 has consisted of bracing or observation with tibial
osteotomy performed by age 4 if correction has not been
achieved. The incidence of recurrence of varus if the
osteotomy is performed after age 4 escalates. Ultimately,
medial physeal arrest of the proximal tibia occurs.
Children with infantile Blount’s are difficult to treat both
with bracing and osteotomy. Most of these children are
morbidly obese and many also have behavior problems.
Complications of high tibial osteotomy in this age group
include compartment syndrome and other known com-
plications of osteotomies.11 Growth manipulation has
become a popular alternative to osteotomy for angular
deformity in children especially with the introduction of
the tension band plate.12–14 Literature on the treatment of
infantile Blount disease with growth manipulation,
however, remains scarce. Two papers with larger series
of many types of angular deformities include just 1 case of
infantile Blount disease apiece.12,14 An additional paper
reported a 44% failure rate of tension band plate screws
in Blount’s disease, however, all of the patients in their
group were aged 7 years or older.15
This paper represents an early series of infantile
Blount affected children treated with tension band plates
although some of the children were initially treated with
staples and then revised to tension band plates. Initially
the use of the lateral tension band plate for infantile
Blount at our institution began to treat a group of
r 2012 Lippincott Williams & Wilkins
Treatment of Infantile Blount Disease
patients whose parents either refused osteotomy or
expressed doubt in their ability to maintain their children
nonweightbearing for a period of time after an osteo-
tomy. Once success of the procedure was evident, patients
<4 years of age were offered growth manipulation when
bracing had failed or was not practical due to family
situations. Tension band plating was also offered to
children over the age of 4 if no evidence of medial
proximal tibial physeal growth arrest had occurred.
In several patients with significant deformities,
residual bowing in the femurs contributed to the
deformity and growth manipulation of the distal femur
was also carried out. These patients showed rapid
correction of deformity perhaps because the mechanical
axis deviation corrected quickly and unloaded the medial
tibial growth plate. We recommend that the distal
femur be included in growth manipulation in any child
with femoral bowing, particularly if the deformity is
significant.
Screw breakage was a significant complication in
this study and accounted for either delayed correction or
failures of treatment. Screw breakage is problematic in
the infantile group as there is a large cartilage anlage in
the proximal tibia creating a stress riser at the transition
where the screw enters the ossified portion of the tibia. All
of the screws that broke were cannulated titanium screws.
In 2 other series, screw breakage was most common in the
obese patient with tibia vara.15,16 Suggestions for avoid-
ing screw breakage include using a double screw or plate
configuration, solid screws or a tension band plate made
of stainless steel. Patients with severe deformity and
morbid obesity will most likely benefit from 1 or more of
these measures.
Regrettably there were also some patients in this
group in which wound infection compromised the result.
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Scott
Hematoma formation is seen after many of these
procedures when the cannulated screws are used and
seemed to contribute to wound dehiscence and infection
in these cases. Methods to avoid infection might include
wound closure with nonabsorbable suture and the use of
solid screws.
The incidence of recurrence of deformity after tibial
osteotomy in infantile Blount is high.7,9 In a number of
the children treated with growth manipulation; a mild
varus has developed after plate removal. The recurrence
of varus is most likely an indicator of the impaired growth
potential of the medial tibial physis. It is currently
unknown whether overcorrection into valgus as is
recommended with osteotomies would prevent this
problem. The cause of recurrent varus is probably
multifactorial and associated with increasing obesity,
age, and degree of deformity at the time of growth
manipulation in addition to time to correction. Certainly,
the child who has had growth manipulation will need
continued surveillance after plate removal and potentially
even benefit from reinsertion of the tension band plate if
the varus continues to progress.
No issues of growth disturbance of the lateral
proximal tibial physis associated with the tension band
plate were noted. At the time of plate removal, several of
the screws seemed to have migrated into the physis but
this did not seem to have an effect on correction or later
tibial growth. Should this occur before correction of
varus, revision to a longer plate should be considered.
Tibial torsion is always present in infantile Blount
disease. Growth modulation does not provide the
immediate correction to tibial torsion that is seen after
a high tibial osteotomy. Spontaneous correction of the
torsion occurred in most children although 3 children
were noted to have persistent torsion associated with
femoral anteversion. The families were educated on the
possibility of continued tibial torsion before surgery.
Currently, the children with torsion are being observed.
Despite the noted complications, this series demon-
strates success of tension band plating for infantile Blount
disease and presents an alternative to tibial osteotomy
under some circumstances. With 1 exception, all of these
children presented before age 5 and it is likely that early
treatment is needed for the success of this method.
Clearly, growth manipulation would not be effective once
medial physeal arrest has occurred but it is unknown
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J Pediatr Orthop  Volume 32, Number 1, January/February 2012
whether there is another indication before that in these
patients that will determine whether growth manipulation
will be successful. The advantage of this procedure is lack
of need for postoperative immobilization and rapid return
to daily activities in a population that is difficult to
maintain nonweightbearing after osteotomy. As is the
case with tibial osteotomy, vigilant follow-up must be
carried out as the risk of recurrence is present in these
diseased growth plates.
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