ORIGINAL ARTICLE
Do Children With Blount Disease Have Lower Body
Mass Index After Lower Limb Realignment?
Sanjeev Sabharwal, MD, MPH, Caixia Zhao, MD, Sara M. Sakamoto, MD,
and Emily McClemens, PA-C
Background: Children with Blount disease are typically obese.
The goal of our study was to assess whether children with
Blount disease had lower body mass index (BMI) after surgical
correction of their lower limb deformity.
Methods: A surgical data base was used to identify children with
Blount disease. Demographic information including age of dis-
ease onset, ethnicity, health insurance status, and laterality was
noted. Preoperative and most recent BMI values were docu-
mented. Using full-length standing radiographs, the mechanical
axis deviation (MAD) and leg length discrepancy (LLD) were
measured preoperatively and at latest follow-up. The relation-
ship of the change in BMI with various demographic and
radiologic parameters was evaluated.
Results: Fifty-one children (32 males, 19 females) with Blount
disease (23 early onset, 28 late onset) aecting 70 lower ex-
tremities (32 unilateral and 19 bilateral) underwent a variety of
surgical procedures. All 47 children who underwent gradual
correction with external xation also underwent nutritional
counseling while receiving inpatient rehabilitation. At an aver-
age follow-up of 48 months, MAD improved from 80.5 mm
medial to 16.1 mm medial (P < 0.0001) and LLD improved
from 19.6 to 10.9 mm (P = 0.0002). During the same time pe-
riod, the BMI increased from 35 (95% condence interval,
32-37) to 38 (95% condence interval, 35-41; P = 0.0006).
Compared with their preoperative BMI, 76% of the children
had an increase in their BMI at the latest follow-up. There was
no association of the change in the patients BMI with their age
of disease onset, sex, ethnicity, health insurance status, nal
MAD, or LLD. There was a tendency for the patients BMI to
increase with longer follow-up (P = 0.002). Using multivariate
analysis, only the length of follow-up was associated with an
increase in BMI (P = 0.026).
Conclusions: Despite improvement in limb alignment and LLD
after surgery, the BMI of the majority of children with Blount
disease increased over time. Other strategies for addressing
obesity amongst these children are warranted.
Level of Evidence: Level IVcase series.
From the Department of Orthopedics, New Jersey Medical School,
University of Medicine and Dentistry of New Jersey, Newark, NJ.
None of the authors received any nancial support for this study.
The authors declare no conict of interest.
Reprints: Sanjeev Sabharwal, MD, MPH, Department of Orthopedics,
New Jersey Medical School, UMDNJ, 90 Bergen Street, Doctors
Oce Center, Suite 7300, Newark, NJ 07103. E-mail: sabharsa@
umdnj.edu.
Copyright r 2013 by Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 34, Number 2, March 2014
Key Words: Blount disease, tibia vara, obesity, children, body
mass index, limb deformity, BMI
(J Pediatr Orthop 2014;34:213218)
B lount disease is a well-recognized developmental dis-
order that is typically seen among obese children. This
pediatric ailment is associated with a multiplanar de-
formity of the aected lower extremity, mainly involving
the proximal tibia, often associated with leg length dis-
crepancy (LLD).1 The goal of treatment of Blount disease
includes restoration of limb alignment and correction
of LLD, primarily using surgical means such as various
osteotomies and growth modulation techniques.1
Given the rising prevalence of childhood obesity,2,3
it is likely that the number of children aected with
Blount disease may also be increasing. Besides the un-
toward eects of being overweight on the growing
musculoskeletal system, childhood obesity is also asso-
ciated with other systemic illness, such as a predisposition
to cardiovascular disease and premature death along with
negative psychosocial consequences.46 Often, the care-
takers of children with Blount disease are counseled that
their childs limb deformity is associated with obesity and
consequently the child should try losing weight. It is
conceivable that both the treating physician and the
family may feel that the existing lower limb deformity and
the associated gait abnormality may be hindering the
childs activity level and thus, their ability to lose weight.
However, it is not well established whether the obese child
aected with Blount disease will lose weight after surgical
realignment of his/her lower limb. The purpose of our
study was to assess whether children with Blount disease
who undergo surgical correction of their lower limb de-
formity and LLD have lower body mass index (BMI) in
the postoperative follow-up period. Our hypothesis was
that despite having satisfactory correction of their genu
varum, the majority of these children will not have lower
BMI in the follow-up period.
METHODS
This study was approved by our Institutional Re-
view Board. A single surgeons (S.S.) database was used
to identify children (below 18 y) with the diagnosis of
Blount disease who had undergone lower limb surgery
www.pedorthopaedics.com | 213
Sabharwal et al
related to this diagnosis between 1997 and 2010. The
medical records and radiographs of the identied
patients were reviewed retrospectively. Demographic
information including the patients sex, ethnicity,
health insurance type (Medicaid vs. commercial), age of
disease onset (early onset vs. late onset), laterality (uni-
lateral vs. bilateral), type(s) of surgery (osteotomy, hem-
iepiphyseodesis, contralateral epiphyseodesis, hardware
removal), and chronologic age at rst surgery were ex-
tracted from the medical records. The patients height and
weight at each clinical encounter were retrieved from the
outpatient and/or inpatient records. If this information
was not available, the childs primary care physician was
contacted to get the pertinent demographic data. The
BMI was calculated by dividing the patients weight in
kilograms by the square of the patients height in meters
(kg/m2).3
Radiographic analysis included measurement of the
mechanical axis deviation (MAD) and LLD based on
the standing full-length anteroposterior radiographs of
the lower extremity that was performed before the rst
surgery and at latest follow-up. MAD was calculated in
millimeters as the perpendicular distance from the center
of the distal femoral condyles to the mechanical axis line
connecting the center of the femoral head to the center of
the talar dome of the aected extremity.7 In patients with
bilateral disease, the larger of the 2 MADs was used for
statistical analysis. LLD was calculated in millimeters as
the distance between the transverse lines drawn along the
most proximal aspect of the 2 femoral heads on the
standing radiograph. If the radiograph was performed
with the patient standing on a lift under the short side to
level the pelvis, the height of this lift was added to the
calculation.
Patients were excluded if they were older than 18
years at the time of their initial surgery or if their height
and weight or full-length standing radiographs of their
lower extremity were not available preoperatively and
postoperatively.
Data were analyzed using the statistical package
SAS, version 9.2 (SAS Institute Inc., Cary, NC). The
mean values of each patients BMI, MAD, and LLD
preoperatively and at the most recent follow-up were
compared using paired t test. Fisher exact test was utilized
to compare the proportion of children who were morbidly
obese (BMIZ40) preoperatively and at the most recent
follow-up. The eect of variables such as the patients age
at disease onset (early onset vs. late onset), laterality, sex,
ethnicity, health insurance status, and MAD and LLD at
the most recent follow-up on the change in BMI between
the preoperative and most recent follow-up was com-
pared using unpaired t test. Pearson correlation co-
ecient was used to assess the relationship of variables
such as the childs age at initial surgery, number of ex-
tremity surgeries performed to address each sided limb
deformity and the length of follow-up on the change in
BMI values preoperatively and at the most recent follow-
up. Simple linear regression analysis was performed to
determine the eect of patients initial BMI on their nal
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J Pediatr Orthop  Volume 34, Number 2, March 2014
BMI and the relationship between the duration of follow-
up with the change in BMI over time. Multiple regression
analysis was performed to predict the eect of the childs
age at initial surgery, number of extremity surgeries per-
formed to address the limb deformity, unilateral versus
bilateral involvement and the length of follow-up on the
change in BMI values over time. Statistical signicance
was dened as P < 0.05.
RESULTS
During the study period, 68 patients with the diag-
nosis of Blount disease underwent surgical treatment. Of
these 17 patients were excluded because of the following
reasons: above 18 years of age at initial surgery (4 pa-
tients) and unavailable preoperative and/or postoperative
height and weight measurements (13 patients). Thus, 51
patients with 70 aected extremities were included in the
nal analysis. The demographic details including the
childs age at disease onset, laterality, sex, race, health
insurance status, and type of initial surgery is noted
in Table 1. Eighty-six percent (44/51) of patients under-
went >1 surgical procedure, including hardware removal.
All 47 patients who had gradual correction with external
xation as the initial or subsequent surgery also under-
went nutritional counseling while undergoing inpatient
rehabilitation for 2 to 6 weeks postoperatively.
Details of the patients preoperative and most recent
BMI and weight in kilograms are noted in Table 2. At an
average follow-up of 48 months [95% condence interval
(CI) 39-56 mo], the mean BMI for the group had in-
creased to 38 (95% CI, 35-41; P = 0.0006). During this
time period, the MAD improved from 80.5 mm medial
(95% CI, 72-89 mm medial) to 16.1 mm medial (95% CI,
6-26.2 mm medial; P < 0.0001) and the limb length
discrepancy improved from 19.6 mm (95% CI, 15.4-
23.8 mm) to 10.9 mm (95% CI, 7.5-14.4 mm; P < 0.0002).
Compared with their preoperative BMI, 76% (39/51) of
the patients had an increase in BMI at the last follow-
up. Preoperatively, 13 patients were morbidly obese
(BMIZ40), whereas at the latest follow-up, 20 patients
had a BMIZ40 (P = 0.002). The patient with the largest
decrease in BMI, from 44 preoperatively to 28 (D16) at 43
months postoperatively was a 16-year 10-month-old fe-
male with early-onset Blount disease who had undergone
multiple prior surgeries, including an attempt at medial
tibial plateau elevation with internal xation at another
institution (Fig. 1). She presented with left-sided knee
pain, genu varum, and limb shortening. Radiographs re-
vealed a residual MAD of 71 mm medial and 52 mm of
LLD. She underwent removal of hardware, in prepara-
tion for a repeat osteotomy and gradual correction, but
refused further orthopaedic procedures. She is the only
subject in our series who underwent subsequent bariatric
surgery (gastric bypass procedure), and despite having the
largest amount of residual limb deformity and LLD at
follow-up, lost the most weight (preoperative 130 kg,
postoperative 76.4 kg; D53.6 kg).
r 2013 Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 34, Number 2, March 2014 Postoperative BMI in Blount Disease

TABLE 1. Demographic Information of Patients With Blount Disease, Including Early-onset and Late-onset Subgroups
Early Onset, n (%) Late Onset, n (%) Total
No. Patients 23 (45) 28 (55) 51
Side aected
Right 4 (17) 7 (25) 11
Left 9 (39) 12 (43) 21
Bilateral 10 (43) 9 (32) 19
Sex
Male 9 (39) 23 (82) 32
Female 14 (61) 5 (18) 19
Race
Black 12 (52) 25 (89) 37
Others 11(48) 3 (11) 14
Insurance
Commercial 8 (35) 13 (46) 21
Medicaid 15 (65) 15 (54) 30
Type of initial surgery
Osteotomy 18 (78) 21 (75) 39
Osteotomy+hemiepiphyseodesis 0 (0) 4 (14) 4
Osteotomy+epiphyseodesis 1 (4) 1 (3.5) 2
Hemiepiphyseodesis 3 (13) 1 (3.5) 4
Epiphyseodesis 0 (0) 1 (3.5) 1
Hardware removal 1 (4) 0 (0) 1
Mean age (y) at initial surgery (95% CI) 7.1 (5.3-8.9) 12.8 (12.0-13.5) 10.2 (9.0-11.4)
Mean age (y) at initial BMI (95% CI) 6.8 (4.9-8.7) 12.6 (11.9-13.4) 9.9 (8.7-11.2)
BMI indicates body mass index; CI, condence interval.

Using bivariate analysis, there was no eect of the
patients chronologic age at disease onset (P = 0.72),
laterality (P = 0.09), sex (P = 0.11), ethnicity (P = 0.10),
health insurance status (P = 0.93), change in MAD
(P = 0.09), or change in limb length discrepancy
(P = 0.43) on the change in BMI over time (Table 3).
Although there was no signicant association of the pa-
tients age at the initial surgery (r = 0.23, P = 0.11),
number of surgeries (r = 0.14, P = 0.33), or unilateral
versus bilateral involvement (r = 0.28, P = 0.05), there
was a positive correlation between the length of follow-up
and the increase in BMI between the initial and latest
follow-up (r = 0.42, P = 0.002). Furthermore, using
simple linear regression, there was a signicant relation-
ship (P < 0.0001) between the patients preoperative and
postoperative BMI (Fig. 1). In addition, as the length of
follow-up increased, there was a tendency for the patients
BMI to rise (P = 0.002; Fig. 2). On the basis of multi-
variate analysis, the length of follow-up was the only
variable that was associated with a signicant increase in
BMI in the postoperative period (P = 0.03).
In order to minimize bias, the data were reanalyzed
after excluding the 1 patient (noted above) who only
underwent hardware removal and refused further re-
alignment surgery. Although there were minor changes in
the P-values based on multivariate analysis, only the
length of follow-up remained signicantly associated with
an increase in the patients BMI in the postoperative pe-
riod (P = 0.0008).

TABLE 2. Body Mass Index (BMI) and Weight (in kg) of

Patients With Blount Disease, Including Early-onset and Late-
onset Subgroups, at Initial Examination and Most Recent
Follow-up
Early Onset Late Onset Total
Body mass index
Initial 30 (26-34) 39 (36-42) 35 (32-37)
Last follow- 34 (29-38) 42 (38-46) 38 (35-41)
up
Weight (kg)
Initial 49.4 (36.2-62.7) 104.8 (95.7-113.9) 79.8 (69.0-90.7)
Recent 75.9 (62.4-89.3) 128.1 (116.4-139.8) 104 (93.3-115.8)
follow-up FIGURE 1. Scatterplot of the regression analysis demonstrat-
Length of 60 (45-74) 38 (30-46) 48 (39-56) ing the relationship of the patients preoperative and post-
follow-up operative BMI. The BMI of the patient with the largest
(mo) decrease in BMI is noted with a circle. She was the only patient
Data were presented as mean and (95% condential interval). in our series who underwent bariatric surgery. BMI indicates
body mass index.

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Sabharwal et al J Pediatr Orthop  Volume 34, Number 2, March 2014

TABLE 3. The Effect of Certain Variables on the Change in BMI Between the Initial Evaluation and Most Recent Follow-up, Based
on Bivariate Analysis Using Unpaired t test
Mean (95% CI)
Variables Initial BMI Latest Follow-up BMI Change in BMI P Power
Diagnosis
Early onset (n = 23) 29.8 (25.9-33.8) 33.7 (29.3-38.0) 3.9 (0.3-7.4) 0.72 0.1
Late onset (n = 28) 38.8 (36.0-41.5) 42.0 (38.1-45.8) 3.2 (1.1-5.2)
Deformity side
Unilateral (n = 32) 35.1 (31.6-38.6) 37.4 (33.1-41.6) 2.3 (0.1-4.4) 0.09 0.7
Bilateral (n = 19) 34.2 (30.2-38.2) 39.7 (35.6-43.8) 5.5 (1.8-9.2)
Sex
Male (n = 32) 36.3 (33.2-39.5) 38.5 (34.4-42.6) 2.2 (0.2-4.1) 0.11 0.8
Female (n = 19) 32.1 (27.6-36.6) 37.7 (32.9-42.6) 5.6 (1.7-9.7)
Ethnicity
Black (n = 37) 35.1 (32.6-37.6) 37.6 (34.6-40.7) 2.5 (0.4-4.7) 0.10 0.7
Others (n = 14) 33.8 (26.3-41.2) 39.8 (31.4-48.1) 6.0 (1.9-10.0)
Insurance
Commercial (n = 21) 34.7 (31.4-37.9) 38.3 (34.8-41.7) 3.6 (0.8-6.3) 0.93 0.1
Medicaid (n = 30) 34.8 (30.9-38.7) 38.2 (33.5-42.9) 3.4 (0.7-6.1)
MAD at latest follow-up*
Normal (n = 8) 31.6 (21.1-42.2) 31.9 (22.9-40.1) 0.3 (-3.3-3.9) 0.09 0.9
Abnormal (n = 39) 35.8 (32.9-38.4) 40.3 (36.9-43.6) 4.5 (2.3-6.9)
LLD at latest follow-up (mm)
r10 (n = 24) 33.9 (30.2-37.6) 37.1 (33.1-41.1) 3.2 (0.4-6.0) 0.43 0.1
> 10 (n = 19) 37.2 (32.2-42.1) 41.9 (36.1-47.8) 4.7 (1.8-7.7)
*MAD normal range, 3 to 17 mm medial; MAD abnormal, MAD <3 or >17 mm medial.
BMI indicates body mass index; CI, condence interval; LLD, leg length discrepancy; MAD, mechanical axis deviation.

DISCUSSION thermore, children with Blount disease who have a higher

The prevalence of childhood obesity is increasing
worldwide.3 On the basis of a 2008 national survey, ap-
proximately 17% of children and adolescents aged 2 to 19
years in the United States were obese, which is triple the
rate from 30 years ago.2 Obesity is a multifactorial con-
dition, with a plethora of ill eects aecting various organ
systems.46 Obesity predisposes children to several
musculoskeletal conditions including Blount disease,
slipped capital femoral epiphyses, and distal extremity
fractures.810 Among children with Blount disease, there
is a positive association between the magnitude of obesity
and the severity of limb deformities, including changes in
the morphology of the medial meniscus.11,12 Fur-
FIGURE 2. Scatterplot of the regression analysis demonstrat-
ing the relationship of the patients mean difference in BMI
(postoperative preoperative) with the length of follow-up.
BMI indicates body mass index.
BMI are more likely to undergo surgery than lighter pa-
tients.13 However, it is unknown whether obese children
with Blount disease lose weight after surgical realignment
of their lower extremities. Thus far, a study evaluating the
eectiveness of orthopaedic surgery in enabling obese
children to lose weight has not been performed for any
childhood obesityassociated musculoskeletal disorder.
We hypothesized that children with Blount disease, a
condition strongly associated with obesity, will not have a
lower BMI despite having lower extremity surgery to
address their limb deformity and shortening.
As expected, the BMI of our patients with Blount
disease was high preoperatively with a mean value of 35.
However, despite substantial improvement in the varus
deformity of their lower extremity and LLD, the majority
of these patients continued to have excessive weight gain,
as reected by an increase in BMI over time. Fur-
thermore, there was an increase in the number of mor-
bidly obese children (BMIZ40) from 12 preoperatively to
20 individuals at the most recent follow-up (P = 0.002).
On the basis of the linear regression analysis, it is quite
likely that with the passage of time the BMI of this pa-
tient cohort will likely keep increasing. Using multivariate
analysis, we found that only the length of follow-up
positively correlated with an increase in BMI. Other
factors including age of disease onset, sex, ethnicity,
health insurance status, laterality, lower limb alignment
and LLD at latest follow-up, and a short period of nu-
tritional counseling while undergoing inpatient re-
habilitation did not seem to eect the childs ability to

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J Pediatr Orthop  Volume 34, Number 2, March 2014
lose weight. Interestingly, the patient who lost the most
weight had the largest amount of residual varus deformity
and LLD, and despite having multiple surgeries before
presentation, merely underwent hardware removal at our
center. She was also the only patient in our study group
who had undergone a bariatric procedure. Although
evaluating the eectiveness of bariatric surgery was not
the focus of our study, such procedures could lead to
sustained weight loss in certain obese adolescents.14
Several investigators have reported on the inability
of the majority of adult obese patients with various
musculoskeletal ailments to lose weight despite under-
going elective orthopaedic procedures such as arthro-
plasty of the hip1519 and knee2022 joints as well as
successful ankle reconstruction23 and lumbar spinal de-
compression for neurogenic claudication.24 Our results
demonstrate a similar pattern of weight gain among
children with Blount disease. We found that the majority
of children with Blount disease not only did not lose
weight after lower limb alignment surgery, but also that
>75% of these patients had an increase in their BMI at
an average postoperative follow-up of 2 years. Factors
other than the magnitude of limb deformity were likely
related to their obesity, and most probably these issues
remained uncorrected despite successfully addressing
their genu varum and limb shortening. Thus, anticipating
weight loss after satisfactory lower limb realignment in
these patients seems unrealistic.
There are a few limitations in our study. First, being
a retrospective case series, we were unable to follow these
childrens BMI prospectively at specic time intervals.
However, we were able to compare their BMI at 2 distinct
time points; preoperatively and at most recent follow-up.
Although our mean follow-up was only 48 months, we
were able to establish a trend of increasing BMI with
time. Whether this trend will continue over the patients
adult lifetime would require a longer follow-up study.
Second, we were unable to assess the inuence of factors
such as the childrens motivation to lose weight and their
ability to perform physical exercise related to knee pain,
limb deformity, or socio-economic constraints on the
change in BMI noted postoperatively. The role of these
potentially important factors could be assessed with a
prospective study design in the future. Third, we did not
have a control group of patients with Blount disease who
did not have lower limb surgery. It is plausible that if we
had a nonoperative cohort available, that such patients
may have demonstrated as much or greater gain in BMI
over time. However, given the eectiveness of improving
limb malalignment using various surgical techniques,
having such a control group would not be feasible. Fur-
thermore, our purpose was merely to see whether there
was any positive association between lower limb realign-
ment and postoperative weight loss. We found that on the
contrary, more than 75% of these children continued to
increase their BMI, despite improvement in their genu
varum. Fourth, although most of these children did un-
dergo a 2 to 6 week period of nutritional counseling in the
early postoperative period while undergoing inpatient
r 2013 Lippincott Williams & Wilkins
Postoperative BMI in Blount Disease
rehabilitation, given the retrospective study design, we
were unable to fully ascertain the eect of such an inter-
vention. Yet, on the basis of the increase in BMI in the
majority of patients over time, it is unlikely that such a
short period of counseling was eective in having any
sustainable improvement in the childrens lifestyle or their
obesity. Fifth, we were unable to include 13 patients due
to lack of availability of their preoperative or recent
height and weight measurements. This may be a potential
source of bias. Even if we assumed that all of those 13
children did not increase their BMI over time, still 61%
(39/64) of the patients would have had a greater BMI
postoperatively compared with their preoperative meas-
urements. Lastly, our study was underpowered to con-
dently establish the lack of association of certain
variables such as the childs age at disease onset, health
insurance status, and LLD with the change in BMI after
limb realignment. Given the possibility of a type 2 error, a
larger cohort of patients in each subgroup would be
necessary to conrm our ndings.
In conclusion, despite an improvement in lower
limb alignment after surgical intervention and a trial of
up to 6 weeks of nutritional counseling during inpatient
rehabilitation in the majority of children with Blount
disease, their BMI increased over time. These ndings
should be incorporated in the preoperative discussion
with the overweight childs care takers before undergoing
surgical intervention, so that they may have realistic ex-
pectations after surgery. Furthermore, other strategies for
weight loss should be investigated in obese children with
Blount disease.
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