orthopaedic issues with childhood obesity
TRANSCRIPT
Childhood Obesity:Epidemiology and Trends
Maura D. Frank, M.D.
HSS educational activities are carried out in a manner that serves the educational component of our Mission.
As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation.
Maura D. Frank, M.D.Weill Cornell Medical College
Komansky Center for Children’s HealthDisclosure: I DO NOThave a financial relationship with
any commercial interest. :
Obesity: The Problem• Overweight and obesity are a major
public health concern in the United States.
• 33.8% prevalence of obesity in adults in 2007-2008.1,2
Trends: US Adults
• http://www.cdc.gov/obesity/data/trends.html
Obesity in Children and Adolescents (U.S.)
2-5 yo's 6-11 yo's 12-19 yo's
0
5
10
15
20
25
197620042008
Between 1976 and 2008, obesity prevalence has:
• Doubled in 2-5 year olds: 5 to 10.4%
• Tripled in 6 -11 year olds: 6.5 to 19.6%
• More than tripled in 12 to 19 year olds: 5 to 18.1% 3,4
Classification in Children and Adolescents
• Overweight: 85th to 94th %ile of the gender-specific body mass index (BMI) growth charts for age and gender.
• Obesity: at or above the 95th percentile for age and gender. Obesity among adults is defined as a BMI of 30 or higher. 5
• Extreme Obesity: at or above the 99th %ile BMI for age and gender
National data: Obesity and Overweight
• 2003-2006:– 16.3% obese– 15.6% overweight– 31.9% overweight or obese– 11.3% at or above the 97th %ile
• 2007-2008– 16.9% obese– 14.8% overweight– 31.7% overweight or obese– 11.9% at or above the 97th %ile3,4
New York City
• New York City 2009: 21% of public school children from kindergarten to eighth grade are obese, and another 18% overweight 6
• NYPH/Komansky Center 2005: 27% of adolescent patients in the general clinical practice were obese and another 19.5% overweight.
Plateau or Peak?• Consensus emerging of “plateau” of obesity prevalence • Some positive trends but disturbing information within• Do we want to be stabilized at current levels of obesity and
overweight: 32% children and adolescents at or above the 85th %ile?
• High percentage of obese over the 97th %ile: 16. 9% are obese, but almost 12% of total are >97th %ile,
increasing their risk for obesity co-morbidities.• Significant racial and ethnic disparities, increasing over time
Racial/Ethnic Disparities: Males
• 1988 –1994: no significant difference in prevalence between Mexican-American and non-Hispanic white adolescent boys.
• 2007-2008: prevalence of obesity significantly higher among Mexican-American adolescent boys (26.8%) than among non-Hispanic white adolescent boys (16.7%).
• Between 1988-1994 and 2007-2008 the prevalence of obesity increased :– From 11.6% to 16.7% among non-Hispanic white boys.– From 10.7% to 19.8% among non-Hispanic black boys.– From 14.1% to 26.8% among Mexican-American boys. 7
Males by Race/Ethnicity
Racial/Ethnic disparities: Females• 1988-1994: Female non-Hispanic black adolescent at 16.3%
were more likely to be obese compared with non-Hispanic white adolescent girls at 8.9%.
• 2007-2008: Female non-Hispanic black adolescents were significantly more likely to be obese at 29.2% compared with non-Hispanic white adolescents at 14.5%.
• Between 1988-1994 and 2007-2008 the prevalence of obesity increased:– From 8.9% to 14.5% among non-Hispanic white girls.– From 16.3% to 29.2% among non-Hispanic black girls.– From 13.4% to 17.4% among Mexican-American girls. 7
Female Race/Ethnicity
Infants and Toddlers• 2008 obesity prevalence in low income preschoolers
in Head Start– Overall rate 14.6% (10.4% all pre-schoolers)– American Indian or Alaskan native: 21.2%8
– Only 2 states, Colorado and Hawaii, had obesity prevalences ≤ 10% for this population. 7
• Elevated rates of weight for length in 0-2 year olds: 9.5% overall, but 14.9% for Hispanic males 3
Table 1. Prevalence of High Weight for Recumbent Length Among US Children From Birth to 2 Years of Age, 2007-2008a,b.
Ogden, C. L. et al. JAMA 2010;303:242-249
Copyright restrictions may apply.
Co-morbidities of childhood obesity
• Significant co-morbidities in youth • Tracking of obeisty and co-morbidities to adulthood• Strong evidence that obese children and youth are
likely to become obese adults.9-12
• The Bogalusa Heart Study: 25% of obese adults were overweight as children, and that if onset of overweight is prior to 8yo, obesity in adulthood is likely to be more severe.13
Co-Morbidities
• Cardiovascular – Elevated blood pressure, at least 13% having
increased systolic BP and 9% with elevated diastolic BP.14
– Elevated LDL cholesterol, low HDL13
– Effects of deconditioning
Co-Morbidities
• Endocrine/Metabolic– Type II Diabetes15: Close to half of newly
diagnosed cases of diabetes in children are Type II 16
– Polycystic Ovarian Syndrome: women with POS are more likely to be obese17
– Vitamin D Deficiency
• Respiratory/ENT– Asthma may occur more frequently and be exacerbated by
obesity18
– Obstructive Sleep Apnea: daytime sleepiness, poor attention, academic difficulties, RVH/pulmonary hypertension19-21
– Worsening of asthma due to inactivity?
Co-morbidities• Neurologic
– Pseudotumorcerebri22
– Rare but can result in vision loss– Obesity is one of several risk factors
• Psychiatric – Quality of life23
– Depression – Sexual and physical abuse may increase risk
Co-morbidities• GI
– NAFLD (steatosis, steatohepatitis, fibrosis, cirrhosis) 24-25
– Cholelithiasis26
– GERD and constipation exacerbated27,28
• Musculoskeletal– Blount Disease– SCFE– Osgood Schlatter’s– Increased fractures and musculoskeletal discomfort– Joint changes/osteoarthritis 29-32
Genetic Influences
• Family History: parental obesity and family history of Type2 DM 33,16
• Twin studies34
• Hormones that influence appetite, satiety, and fat distribution: leptin, ghrelin, adiponectin35
• Genetic conditions causing obesity are rare: Primary Cushing syndrome (short, violaceousstriae) and Prader-Willi
Prenatal and early childhood effects
• Infants of Diabetic mothers: cycle of increased risk of obesity, later diabetes 36
• Excessive maternal weight gain: Children of women whose weight gain during gestation exceeded IOM guidelines were 48% more likely to be overweight at age 7 than children whose weight gain was in the recommended range.37
Prenatal and early childhood effects: Nicotine exposure
• Strong relationship between maternal smoking and subsequent obesity, hypertension, and type 2 diabetes in offspring.
• May be mediated via nicotine’s direct effects on the hypothalamus, altering its regulation of body weight and energy balance
• May also be related to low birth weight, a well established outcome of maternal cigarette smoking, and a significant risk factor for the development of obesity, hypertension, and type 2 diabetes.38
Prenatal and early Childhood Effects
• Breastfeeding:– Breastfeeding decreases the risk of obesity– The longer the duration of breastfeeding, the better the protective
effect. 39,40
• Timing of introduction of solid foods:– Introduction of solid foods in formula fed infants prior to 4 months is
associated with a 6-fold increase in risk of obesity at age 3 years. 41
• Sleep:– Evidence accumulating for short sleep duration as a risk factor for
childhood obesity42,43
How did we get here?The “Obesigenic” Environment
• Sugar Sweetened Beverages (SSBs)• School breakfast and lunch: school lunch
associated with rapid weight gain in low-income girls 44
• Food availability and choice in low income neighborhoods45-47
• Portion size
The “Obesigenic” Environment• PA in schools
– Decline– Emphasis on academics
• Outside play– Associated with lower BMI– Safety concerns– Play and activity venues
• Screen time48
Tackling the Problem• AAP/AMA Task Force 2007: promotion of a
step-wise approach toward obesity, from prevention to intensive, multidisciplinary interventions 49
• Intensive intervention programs combining both nutrition and physical activity show varying rates of success 50
NYPH-Komansky Health For Life Program (H4L)
• Multidisciplinary healthy lifestyle program for 8-18 year olds who are either overweight or obese (≥ 85th %ile BMI).
• Multidisciplinary team of physicians (general pediatrician and adolescent specialist, pediatric residents), dietitians, physical therapists, a social worker, a nurse, and medical student mentors
• Three month intensive program with one year follow-up includes individual visits and a 10-week core workshop and activity series
Health for Life Baseline MeasurementsBMI %ile
Mean 97.2th %ile (Y), 97.5th %ile (O)
Range 85th – 100th %ile
Blood pressure:36% systolic BP ≥ 120 7% systolic BP ≥ 130
HDL: 40% abnormal (<40 mg/dL)
Vitamin D: – 58.8% deficient (<20ng/mL)– 38.2% insufficient (20-29 ng/mL)
Results: BMI z-scores (Groups 1-10)
• Younger cohort (8-11 yo)– 66% of participants decreased BMI z-score – Mean decreased from 2.12 to 2.05
• Older cohort (12-18 yo)– 48% of participants decreased BMI z-score– Mean decreased from 2.26 to 2.16
Where we go from here….• Public health efforts that promote prevention• National agenda
• First Lady’s We Can campaign• USDA/School food changes• NYC DOHMH initiatives
• “Healthy Bodegas”• “Move to Improve” school PA promotion• “Classroom Breakfast”• “Play Streets” with Alliance for Health• School Wellness Awards with Alliance for Health
• Primary Care efforts• Incorporate healthy lifestyle teaching into well visits• Maintain and build “Stage III” intensive programs in community settings
• Hospital-community partnerships• Healthy School Healthy Families
References1. Questionnaires, datasets, and related documentation. National Health and Nutrition Examination Survey.
http://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm2. Flegal KM, Carroll MD, Ogden CL, Curtin LR.Prevalence and trends in obesity among US adults, 1999-
2008. JAMA. 2010 Jan 20;303(3):235-413. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of High Body Mass Index in US Children
and Adolescents, 2007–2008. JAMA 2010;303:242–249. 4. Ogden CL, Carroll MD, Flegal KM. High Body Mass Index for Age Among US Children and Adolescents,
2003–2006. JAMA 2008;299:2401–2405.5. Cdc.gov6. New York City Department of Health and Hygiene: NYC Vital Signs. Volume 8, Number 1, June 2009.7. Ogden C and Carroll M. Prevalence of Obesity Among Children and Adolescents: United States, Trends
1963-1965 Through 2007-2008. National Center for Health Statistics: Health E-stat. June 2010.8. Obesity Prevalence Among Low-Income, Preschool-Aged Children – United States, 1998-2008.
MMWRWeekly July 24,2009.58(28);769-773.9. Dietz W. Childhood Weight Affects Adult Morbidity and Mortality. The Journal of Nutrition.1998;
128(2): 411S-414S10. Morrison JA, Friedman LA, Wang P, Glueck CJ. Metabolic Syndrome in Childhood Predicts Adult
Metabolic Syndrome and Type 2 Diabetes Mellitus 25 to 30 Years Later. The Journal of Pediatrics. 2008; 152(2): 201-206
References11. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from
childhood and parental obesity. N Engl J Med 1997; 37(13):869–873.12. SerdulaMK, Ivery D, Coates RJ, Freedman DS. Williamson DF. Byers T. Do obese children become obese
adults? A review of the literature. Prev Med 1993;22:167–177.13. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood overweight to
coronary heart disease risk factors in adulthood: The Bogalusa Heart Study. Pediatrics 2001;108:712–718.
14. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. JPediatr. 2007 Jan;150(1):12–17.e2.
15. Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K, Savoye M, Reiger V, Taksali S, Barbetta G, Sherwin RS, Caprio, S. Prevalence of Impaired Glucose Tolerance among Children and Adolescents with Marked Obesity. The New England Journal of Medicine. 2002; 346(11): 802-810.
16. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136:664 – 672.
17. MichelmoreKF, Balen AH, Dunger DB, Vessey MP. Polycystic ovaries and associated clinical and biochemical features in young women. ClinEndocrinol (Oxf). 1999;51:779 –786.
18. Ford ES. The epidemiology of obesity and asthma. J Allergy ClinImmunol. 2005;115:897–909. 19. Wing YK, Hui SH, Pak WM, et al. A controlled study of sleep related disordered breathing in obese
children. Arch Dis Child. 2003;88:1043–1047.
References20. Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered
breathing in children: associations with obesity, race, and respiratory problems. Am J RespirCrit Care Med. 1999;159:1527–1532.
21. Kalra M, Inge T, Garcia V, et al. Obstructive sleep apnea in extremely overweight adolescents undergoing bariatric surgery. Obes Res. 2005;13:1175–1179.
22. Scott IU, Siatkowski RM, Eneyni M, Brodsky MC, Lam BL. Idiopathic intracranial hypertension in children and adolescents. Am J Ophthalmol. 1997;124:253–255.
23. SchwimmerJB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289:1813–1819
24. Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The Epidemiology of Obesity. Gastroenterology. 2007;132: 2087-2102.
25. Schwimmer JB, Deutsch R, Kahen T, Lavine JE, Stanley C, Behling C. Prevalence of Fatty Liver in Children andAdolescents. Pediatrics. 2006; 118; 1388-1393
26. Kaechele V, Wabitsch M, Thiere D, et al. Prevalence of gall- bladder stone disease in obese children and adolescents: influenceof the degree of obesity, sex, and pubertal development. J PediatrGastroenterolNutr. 2006;42:66 –70.
27. Fishman L, Lenders C, Fortunato C, Noonan C, Nurko S. Increased prevalence of constipation and fecal soiling in a population of obese children. J Pediatr. 2004;145:253–254.
References28. HampelH, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophagealreflux
disease and its complications. Ann Intern Med. 2005;143:199 –21129. Wearing SC, Hennig EM, Byrne NM, Steele JR, Hills AP. Musculoskeletal Disorders Associated with
Obesity: a Biomechanical Perspective. Obesity Reviews.2006; 7(3): 239-25030. Dietz WH Jr, Gross WL, Kirkpatrick JA Jr. Blount disease (tibia vara): another skeletal disorder associated
with childhood obe- sity. J Pediatr. 1982;101:735–73731. ManoffEM, Banffy MB, Winell JJ. Relationship between body mass index and slipped capital femoral
epiphysis. J PediatrOrthop. 2005;25:744 –74632. Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complica- tions of overweight in children and
adolescents. Pediatrics. 2006;117:2167–217433. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from
childhood and parental obesity. N Engl J Med. 1997;337:869 – 87334. Maes HH, Neale MC, Eaves LJ. Genetic and environmental factors in relative body weight and human
adiposity. Behav Genet. 1997;27:325–35135. Gale SM, Castracane VD, Mantzoros CS. Energy homeostasis, obesity and eating disorders: recent
advances in endocrinology. J Nutr. 2004;134:295–298systems for prevention in primary care: randomised trial. BMJ. 2004;328:388
36. Dabelea, D. The Predisposition to Obesity and Diabetes in Offspring of Diabetic Mothers. Diabetes Care. 2007; 30:Supplement 2.
References37. WrotniakBH, Shults J, Butts S, Stettler N, Gestational weight gain and risk of overweight in the offspring
at age 7 y in a multicenter, multiethnic cohort study, American Journal of Clinical Nutrition, 2008, 87(6): 1818-24
38. Bruin JE, Gerstein HC, Holloway AC. Long-Term Consequences of Fetal and Neonatal Nicotine Exposure: A Critical Review. Toxicological Sciences 2010; 116(2):364-374
39. Division of Nutrition and Physical Activity: Research to Practice Series No. 4: Does breastfeeding reduce the risk of pediatric overweight? Atlanta: Centers for Disease Control and Prevention, 2007. http://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/breastfeeding_r2p.pdf
40. Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics. 2005;115(5):1367-1377.
41. Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of Solid Food Introduction and Risk of Obesity in PreSchool Aged Children. Pediatrics doi:10.1542/peds.2010-0740.
42. Chen X, Beydoun MA, Wang Y. Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Obesity (Silver Spring). 2008:16(2):265-274.
43. TaverasEM, Rifas-Shiman SL, Oken E, Gunderson EP, Gillman MW. Short Sleep Duration in Infancy and Risk of Childhood Overweight. Arch PediatrAdolesc Med. 2008 April; 162(4): 305-311.
44. HernancezDC, Francis La, Doyle EA. National School Lunch Participation and Sex Differences in Body Mass Index Trajectories of Children From Low-Income Families. Arch PediatrAdolesc Med. doi: 10.1001/archpediatricd.2010.253
References45. MorlandK,Wing S, Diez Roux A, Poole C. Neighborhood Characteristics Associated with the Location of
Food Stores and Food Service Places. American Journal of Preventive Medicine. 2002; 22(1): 23-2946. MorlandK, Filomena S. Disparities in the Availability of Fruits and Vegetables between Racially Segregated
Urban Neighborhoods. Public Health Nutrition. 2007; 10: 1481-947. Powell LP, Auld C, Chaloupka FJ, O’Malley PM, Johnson LD. Associations Between Access to Food Stores
and Adolescent Body Mass Index. Am J Prev Med 2007;33(4S):S301-S307.48. Dennison BA, Erb TA, Jenkins PL. Television viewing and television in bedroom associated with overweight
risk among low-income pre-school children. Pediatrics 2002 June: 109(6); 1028-35.49. Barlow SE, and the Expert Committee. Expert Committee Recommendations Regarding the Prevention,
Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007; 120: S 164-192
50. Savoye M, Shaw M, Dziura J, Tamborlane MD, Rose P, Guandalini C, Goldberg-Cell R, Burgert T, Cali A, Weiss R, Caprio S. Effects of a Weight Management Program on Body Composition and Metabolic Parameters in Overweight Children. JAMA 2007;297:2697-2704.
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Orthopaedic Issues in theYoung Obese Athlete
Daniel W. Green, MS, MD, FACS, FAAPPediatric Orthopaedic SurgeryHospital for Special SurgeryAssociate Clinical ProfessorCornell University Medical College
HSS educational activities are carried out in a manner that serves the educational component of our Mission.
As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation.
Daniel GreenDisclosure: DO NOT have a financial relationship with
any commercial interest.
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What is “Orthopaedics”
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“Orthopaedics”• Greek Language
–Orthos : straight–Pais : child
www.orthoinfo.orgYour Orthopaedic Connection – YOC:
www.orthoinfo.org
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www.stopsportsinjuries.org
www.stopsportsinjuries.org
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PEDIATRIC OBESITY Orthopaedic Issues
• Orthopedic– Slipped capital femoral epiphysis
• 60 to 80% are obese– Blount’s disease (Tibia vara) (Bow Legs)
• 70% are obese– Knock Knees
• Degenerative Arthritis– Patella Instability/Patella Dislocations– Unique Fracture Patterns
Slipped Capital Femoral Epiphysis (SCFE):
• The most common hip disorder of adolescents, in which the proximal femoral epiphysis is displaced posteriorly on the femoral neck.
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SCFE: Epidemiology
• Incidence is related to puberty, with boys at risk in ages 10-17, girls at risk in ages 8-15.
• Rare post-menarchal• 60% are over 95th percentile for age-weight.• 80% are over the 80th % percentile • 5% had parents with SCFE.
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SCFE: History
• Most are NOT associated with a significant amount of trauma.
• Limp• Pain in the groin, thigh or knee.• The majority of patient with SCFE are be able to walk.
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Location of Pain
Hip/Groin60%
Thigh18%
Knee22%
Location of Pain:SCFE
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Fig. 1 Number of primary care visits before CHLA
Changes in Gait and Range of Motion in SCFE
• +/-Antalgic gait• + Abductor lurch (Coxalgic gait)• External Foot Progression angle• Hip externally rotates when it is flexed• Decreased internal rotation-especially in flexion.• Pain with internal rotation of hip
Range of Motion Changes in SCFE
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Loder, Richards, Shapiro et al.
• 54 patients Tx for acute SCFE.• Reduction occurred in 26 unstable, 2 stable.• 14/30 (47%) unstable had satisfactory result.• 24/25 (96%) stable have satisfactory result.• 14/30 (47%) unstables went on to AVN.• 0/30 stables went on to AVN.
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“the first essential to treatment is early diagnosis”
Philip D. Wilson, Sr., M.D. 1924
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J Bone Joint Surg Am. 1938;20:379-399.
PHILIP D. WILSON
THE TREATMENT OF SLIPPING OF THE UPPER FEMORAL EPIPHYSIS WITH MINIMAL DISPLACEMENT
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J Bone Joint Surg Am. 1938;20:379-399.
“ It-is trite to remark that the best time to treat a disease is from time beginning, but thus statement is so true of slipping of the upper femoral epiphysis that it needs to be emphasized. The earliest stages of slipping almost always give rise to symptoms which, if the physician is alert, can he recognized and will lead to time correct diagnosis.”
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J Bone Joint Surg Am. 1938;20:379-399.
“Given a patient between the ages of ten and sixteen years, complaining of intermittent pain and stiffness in the knee or thigh with at times a noticeable limp, one should consider slipping of the epiphysis as one of the first possibilities.
Nor should one be led astray by the frequent localization of pain at the inner side of the knee into making only a local examination of that part; a thorough examination of the entire extremity should be made.”
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Bow Legs: Genu Varum:Blounts DiseaseKnock Knees : Genu Valgum
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Normal Alignment in Children
• Non-obese children at the age of 3-4 years old develop physiologic genuvalgum that naturally straightens out by the age of 8.
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Obesity and Lower Extremity Malalignment
• It is largely assumed that obesity places children at higher risk for slipped capital femoral epiphysis (SCFE), genuvalgum, and tibia vara.
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The Effect of Pediatric Obesity on Lower Limb Alignment
Daniel W. Green, M.D.Shevaun Doyle, M.D.
Sarah Yagerman
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• Compared with non-overweight children, those who are obese have a greater prevalence of valgus and varus lower extremity malalignment as measured with a goniometer.
Hypothesis
–Physical Exam: Weight & height. TFA, IM distance. ROM angles of the hip, knees, ankles, and spine.
–Photograph of standing AP alignment of legs.–Parent Reported Child Health Questionnaire (CHQ-
PF28):• Evaluation of children’s physical and psychosocial well-
being. –Pediatric/Adolescent Outcomes Questionnaire:
• Assessment of overall physical function
Methods
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• 22 females, 18 males
Demographics
35%
46%
19%
African American Hispanic Other
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Data
0
2
4
6
8
10
12
9.58490566037735
5.3
Mean Valgus Alignment
BMI Percentile for Age and Gender
Me
an
Va
lgu
s (
de
gre
es
)
n = 70
n = 10
BMI >95th BMI <85th
P<0.001
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Intermalleolar distance
the width between the ankles when the patella are forward and the knees are just touch in a patient with genu valgum
Average IM distance in obese group (±SD): 8.1 ± 4.4cmControl group IM distance (±SD): 3.4 ± 2.1cm
• Obese children, BMI >95th percentile, have greater genu valgum than non-overweight children.
Summary
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Bow Legs: Tibia Vara (Blount’s Disease)
• Should be suspected if bowing persists past 2 years
• Abnormal growth at the medial aspect of the proximal tibial physis
• Associated with obesity; most common in African-Americans
• Continues to worsen unless diagnosis and appropriate treatment are accomplished
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Tibia Vara (Blount’s Disease)
– Three types: Infantile, juvenile, adolescent– Infantile: birth to 3 years, most common form, usually
seen in obese children who walked before 1 year, usually noticed when walking began and has persisted, may be bilateral or may resolve on one side and persist on the other
– Juvenile: onset at 4-10 years of age, obesity risk factor, more often unilateral, usually less severe
– Adolescent: older than 11 years of age, most common in obese African American males
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Tibia Vara: Radiographic Evaluation
• AP radiograph both legs standing– Metaphyseal beaking– Metaphyseal-diaphyseal
angle (Drennan)• obtained by measuring the
angle formed by a line parallel to the top of the proximal tibial metaphysis and a line perpendicular to the long axis of the tibial shaft
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Implant Mediated Guided Growth
• Hemiepiphysiodesis:• Excellent technique for obese
children• Utilizes growth to correct
deformity• Growth plates must be open• Earlier detection of mal-
alignment in obese children will provide better surgical outcomes
• Outpatient procedure
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• 9.17.08
Implant Mediated Guided Growth
• 8.28.08
• 9.24.08
• 3.24.09
• 8.25.09
• 10.3.06
• 11.16.06
• 4.8.09
103
• 11.12.07
104
• 11.6.07
• 11.12.07
• 8.5.09
• 8.5.09
108
• 11.12.07 • 9.13.07
• 11.12.07
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References• The Development of the Tibiofemoral Angle in Children PENTTI SALENIUS, M.D.*, AND ElLA
VANKKA, M.D.*, J Bone Joint Surg Am. 1975;57:259-261.
• Correlation of Body Mass Index and Radiographic Deformities in Children with Blount Disease• By Sanjeev Sabharwal, MD, Caixia Zhao, MD, and Emily McClemens, PA-CJ Bone Joint Surg
Am. 2007;89:1275-1283
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Thank You