OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
When Walter Putnam Blount, MD described “Tibia Vara: Osteochondrosis Deformans Tibiae” in the January 1937 issue of The Journal of Bone & Joint Surgery, he probably did not realize that this mouthful of a term would become known simply as “Blount disease.” With a keen interest in children’s limb and spinal deformities, Blount was a pioneer pediatric deformity surgeon. He spent most of his career at the Children’s Hospital in Milwaukee and was clearly ahead of his time.
In this classic article, Blount detailed clinical and radiologic features of the affected lower extremities of 13 children with bowlegs. Additionally, he parsed out 16 other cases of genu varum that previous authors had reported as being secondary to rickets, infection, or other etiologies. In vivid detail, including tracings of these other patients’ radiographs, Blount corroborated that this newly described entity was indeed something different. He supplemented his research with histologic specimens from the affected growth plate and surrounding unossified cartilage of the proximal tibia.
Nearly 80 years have passed since Blount’s original description, and not much more is known about this enigmatic developmental disorder. Although most of his Caucasian patients in the 1937 study were not overweight, with the changing U.S. demographics and the prevalence of childhood obesity, his suggestion of a genetic and a mechanical basis for this growth-plate disorder remains plausible.
Based on the age of onset of the deformity, Blount recognized that there were two distinct forms of tibia vara, which he classified as infantile and adolescent. While the radiographs in the article only show the frontal images, he clearly documented the associated axial plane deformities with internal tibial torsion and ipsilateral shortening. Though Blount was a big proponent of the Milwaukee brace for managing spinal deformities in children, he seemed disenchanted with using orthoses to treat tibia vara. He instead advocated surgical correction via a valgus realignment proximal tibial osteotomy, a recommendation that remains relevant to this day.
Given the potential for less postoperative morbidity, there has been a resurgence of “guided growth” as another way of treating pediatric limb deformities. Interestingly, more than a decade after his description of tibia vara, Blount published another masterpiece in JBJS, “Control of Bone Growth by Epiphyseal Stapling.” Prior to this time, (hemi)epiphyseodesis was largely performed by the Phemister technique, with permanent ablation of the growth plate. By recognizing that physeal growth can be harnessed to correct angular deformities by inserting removable implants such as staples across the growth plate, Walter Blount, through these two classic JBJS articles and various other contributions, outlined essentially all viable options that are currently available to treat this disorder that fittingly bears his name.
In his presidential address to the American Academy of Orthopedic Surgeons in January 1956, Blount noted, “I should rather be remembered as a thoughtful surgeon than as a bold one.” His wish has indeed come true.
Sanjeev Sabharwal, MD, MPH
JBJS Deputy Editor