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1
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Pereira DE, Ford C, Mittal MM, Lee TM, Joseph K, Madrigal SC, Momtaz D, Torres-Izquierdo B, Hosseinzadeh P. Effect of Ketorolac Administration on the Rate of Nonunion of Operatively Treated Pediatric Long-Bone Fractures: A Matched Cohort Analysis. J Bone Joint Surg Am 2025; 107:66-72. [PMID: 39666373 DOI: 10.2106/jbjs.23.01225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2024]
Abstract
BACKGROUND Nonunion is a rare yet serious complication in pediatric fracture healing that can lead to patient morbidity and economic burden. The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) has been associated with an increased risk of fracture nonunion in adults, but data are lacking in the pediatric population. This study examines the relationship between postoperative ketorolac administration and nonunion in operatively managed pediatric long-bone fractures. METHODS A retrospective cohort study was conducted with use of TriNetX, a research network that encompasses data from the United States, Canada, and Western Europe. A total of 462,260 patients from 52 health-care organizations met the inclusion criteria. Patients <18 years old with operatively managed upper or lower-extremity long-bone fractures were included. The exposure of interest was ketorolac administration within 30 days postoperatively between 2003 and 2023. Nonunion was identified and verified with use of the pertinent medical codes. Absolute risks and hazard ratios (HRs) were calculated for both study groups. Significance was set at p < 0.05. RESULTS After propensity score matching, 48,778 patients were identified per group. The incidence of nonunion was 2.19% in the ketorolac group and 0.93% in the non-ketorolac group (HR, 2.71; 95% confidence interval [CI]: 2.46, 3.21; p < 0.0001). Subgroup analyses demonstrated a higher risk of nonunion in patients with lower-extremity fractures (HR, 3.45; 95% CI: 3.14, 3.75; p < 0.0001) than in those with upper-extremity fractures (HR, 2.11; 95% CI: 1.84, 2.32; p < 0.0001). Among the fracture location subgroups, the greatest HR for nonunion was observed in patients with femoral fractures, followed sequentially by those with tibial and/or fibular fractures, humeral fractures, and radial and/or ulnar fractures. CONCLUSIONS To our knowledge, this is the largest study to date to explore postoperative ketorolac use and nonunion in the setting of operatively managed pediatric long-bone fractures. Nonunion in children was rare, occurring in <1% of all included patients. Ketorolac administration was associated with a 2 to 3-fold increase in nonunion risks, with pronounced implications for patients with lower-extremity fractures, particularly those with femoral fractures. Clinicians should weigh the therapeutic advantages of non-opiate analgesia with ketorolac against the risk of nonunion in order to optimize postoperative pain management and recovery. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel E Pereira
- Department of Orthopaedics, Washington University School of Medicine, St. Louis, Missouri
| | - Caleb Ford
- Department of Orthopaedics, Washington University School of Medicine, St. Louis, Missouri
| | - Mehul M Mittal
- Department of Orthopaedics, UT Southwestern Medical Center, Dallas, Texas
| | | | - Karan Joseph
- Department of Orthopaedics, Washington University School of Medicine, St. Louis, Missouri
| | - Sabrina C Madrigal
- Department of Orthopaedics, Washington University School of Medicine, St. Louis, Missouri
| | - David Momtaz
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas
| | | | - Pooya Hosseinzadeh
- Department of Orthopaedics, Washington University School of Medicine, St. Louis, Missouri
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Ahmed AM, Said E, Addosooki A, Attya HA, Awad AK, Ahmed EH, Tammam H. Intramedullary versus plate fixation of both bone forearm fractures in skeletally immature patients: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2263-2278. [PMID: 38642124 PMCID: PMC11291663 DOI: 10.1007/s00590-024-03925-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/17/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Both bone forearm fractures (BBFFs) are a common injury amongst the pediatric population. The main indications of surgical fixation are open, irreducible, or unstable fractures. The two most commonly used surgical techniques are closed or open reduction with intramedullary fixation (IMF) and open reduction with plate fixation (PF). The aim of this systematic review and meta-analysis was to determine which fixation method is superior for BBFFs. METHODS PubMed, Scopus, Web of Science, and CENTRAL were searched to identify studies comparing IMF and PF. We extracted data on union rates, complications, early hardware removal rates, reoperation rates, and radiographic, clinical, and perioperative outcomes. RESULTS Sixteen studies were included in the analysis, with a total of 922 patients (539 IMF and 383 PF). Similar union rates were achieved by both fixation technique. IMF was associated with a higher incidence of symptomatic hardware, and early hardware removal. Better restoration of the radial bow was observed with the PF group, especially in older children and adolescents. The rate of excellent function was comparable between groups, whereas better cosmesis was reported with the IMF group. Despite shorter fluoroscopy time and immobilization time, PF demonstrated longer tourniquet time, operating time, and hospital stay compared to IMF. CONCLUSIONS We found no significant difference between IMF and PF in terms of union rates and functional outcomes taking in consideration the merits and demerits of each technique. High-quality randomized controlled trials are, therefore, necessary to determine the superiority of one fixation technique over the other. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ahmed Mohamed Ahmed
- Department of Orthopaedic Surgery and Traumatology, Qena Faculty of Medicine, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, Egypt.
| | - Elsayed Said
- Department of Orthopaedic Surgery and Traumatology, Qena Faculty of Medicine, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, Egypt
| | - Ahmad Addosooki
- Department of Orthopaedic Surgery and Traumatology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Hossam Ahmed Attya
- Department of Orthopaedic Surgery and Traumatology, Qena Faculty of Medicine, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, Egypt
| | - Ahmad Khairy Awad
- Department of Orthopaedic Surgery and Traumatology, Qena Faculty of Medicine, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, Egypt
| | - Emad Hamdy Ahmed
- Department of Orthopaedic Surgery and Traumatology, Qena Faculty of Medicine, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, Egypt
| | - Hamdy Tammam
- Department of Orthopaedic Surgery and Traumatology, Qena Faculty of Medicine, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, Egypt
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Chaverri D, Gallardo-Villares S, Pinto JA, Rodríguez L, Codinach M, García-López J, Querol S, Coll R, Vives J, Granell-Escobar F. Treatment of non-hypertrophic pseudoarthrosis of long bones with a Tissue Engineered Product loaded with autologous bone marrow-derived Mesenchymal Stromal Cells: Results from a phase IIa, prospective, randomized, parallel, pilot clinical trial comparing to iliac crest autograft. Injury 2024; 55:111596. [PMID: 38797000 DOI: 10.1016/j.injury.2024.111596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/10/2024] [Accepted: 04/27/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Atrophic pseudoarthrosis is a serious complication with an incidence of 5-10 % of bone fractures located in the diaphysis of long bones. Standard treatments involve aggressive surgical procedures and re-interventions requiring the use of autografts from the iliac crest as a source of bone-forming biological activity (Standard of Care, SoC). In this context, regenerative ex vivo expanded osteogenic cell-based medicines could be of interest. Particularly, Mesenchymal Stromal Cells (MSC) offer new prospects to promote bone tissue repair in pseudoarthrosis by providing biological activity in an osteoconductive and osteoinductive environment. METHODS We conducted a phase IIa, prospective, randomised, parallel, two-arms, open-label with blinded assessor pilot clinical trial to compare SoC vs. a tissue-engineered product (TEP), composed of autologous bone marrow (BM)-derived MSCs loaded onto allogeneic decellularised, lyophilised spongy bone cubes, in a cohort of 20 patients with non-hypertrophic pseudoarthrosis of long bones. Patients were followed up for 12 months. Radiological bone healing was evaluated by standard X-ray and computed tomography (CT) scanning. Quality of life was measured using the EUROQOL-5D questionnaire. RESULTS Ten patients were randomized to TEP and 10 to SoC with iliac crest autograft. Manufacturing of TEP was feasible and reproducibly achieved. TEP implantation in the bone defect was successful in all cases and none of the 36 adverse events (AE) reported were related to the treatment. Efficacy analyses were performed in the Full Analysis Set (FAS) population, which included 17 patients after 3 patients withdrew from the study. The degree of consolidation, estimated by measuring Hounsfield units (HU) on CT, showed no significant differences between the two treatment groups at 12 months post treatment (main efficacy variable) (p = 0.4835) or at 6 months. CONCLUSIONS Although only a small number of patients were included in our study, it is notable that no significant differences were observed between the experimental treatment and SoC, thus suggesting TEP as an alternative where autograft is not available or contraindicated.
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Affiliation(s)
- Daniel Chaverri
- Department of Orthopaedic Surgery and Traumatology, ASEPEYO Sant Cugat Hospital, Avinguda Alcalde Barnils, 54-60, Sant Cugat del Vallès, Barcelona 08174, Spain
| | - Santiago Gallardo-Villares
- Department of Orthopaedic Surgery and Traumatology, ASEPEYO Sant Cugat Hospital, Avinguda Alcalde Barnils, 54-60, Sant Cugat del Vallès, Barcelona 08174, Spain
| | - Javier A Pinto
- Department of Diagnostic Radiology, ASEPEYO Sant Cugat Hospital, Avinguda Alcalde Barnils, 54-60, Sant Cugat del Vallès, Barcelona 08174, Spain
| | - Luciano Rodríguez
- Banc de Sang i Teixits, Edifici Dr. Frederic Duran i Jordà, Passeig Taulat, 116, 08005 Barcelona, Spain
| | - Margarita Codinach
- Banc de Sang i Teixits, Edifici Dr. Frederic Duran i Jordà, Passeig Taulat, 116, 08005 Barcelona, Spain
| | - Joan García-López
- Banc de Sang i Teixits, Edifici Dr. Frederic Duran i Jordà, Passeig Taulat, 116, 08005 Barcelona, Spain
| | - Sergi Querol
- Banc de Sang i Teixits, Edifici Dr. Frederic Duran i Jordà, Passeig Taulat, 116, 08005 Barcelona, Spain
| | - Ruth Coll
- Banc de Sang i Teixits, Edifici Dr. Frederic Duran i Jordà, Passeig Taulat, 116, 08005 Barcelona, Spain
| | - Joaquim Vives
- Banc de Sang i Teixits, Edifici Dr. Frederic Duran i Jordà, Passeig Taulat, 116, 08005 Barcelona, Spain; Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 129-139, 08035 Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 129-139, 08035 Barcelona, Spain.
| | - Fernando Granell-Escobar
- Department of Orthopaedic Surgery and Traumatology, ASEPEYO Sant Cugat Hospital, Avinguda Alcalde Barnils, 54-60, Sant Cugat del Vallès, Barcelona 08174, Spain
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Igarashi S, Nozaka K, Shirahata T, Kijima H, Saito H, Saito K, Kawano T, Miyakoshi N. Pediatric femoral shaft fracture requiring revision surgery for nonunion associated with vitamin D and K deficiencies: a case report. J Med Case Rep 2024; 18:38. [PMID: 38233902 PMCID: PMC10795312 DOI: 10.1186/s13256-023-04325-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Nonunion of femoral shaft fractures in children is rare, and there is no clear treatment protocol. In this case report, a pediatric femoral shaft fracture that developed in nonunion due to vitamin deficiency after osteosynthesis, which was successfully treated with vitamin augmentation and replacement with a rigid antegrade intramedullary nail, is described. CASE PRESENTATION The patient is an 11-year-old Japanese girl. She injured her right femoral shaft fracture when she hit a wall after kickboarding down a hill and underwent osteosynthesis with a titanium elastic nail. Six months postoperatively, she developed nonunion, was found to be deficient in vitamins D and K, and was started on vitamin supplementation. She underwent replacement with a rigid antegrade intramedullary nail at 7 months postoperatively, and bone union was achieved 3 months after reoperation. CONCLUSION When delayed union of a fracture is observed postoperatively, even in children without underlying disease, the cause of the problem must be investigated and treated promptly.
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Affiliation(s)
- Shun Igarashi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan.
| | - Koji Nozaka
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Tsuyoshi Shirahata
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Hiroaki Kijima
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Hidetomo Saito
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Kimio Saito
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Tetsuya Kawano
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
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Root SH, Vrhovac Madunic I, Kronenberg MS, Cao Y, Novak S, Kalajzic I. Lineage Tracing of RGS5-CreER-Labeled Cells in Long Bones During Homeostasis and Injury. Stem Cells 2023; 41:493-504. [PMID: 36888549 PMCID: PMC10183968 DOI: 10.1093/stmcls/sxad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
Regulator of G protein signaling 5 (RGS5) is a GTPase activator for heterotrimeric G-protein α-subunits, shown to be a marker of pericytes. Bone marrow stromal cell population (BMSCs) is heterogeneous. Populations of mesenchymal progenitors, cells supportive of hematopoiesis, and stromal cells regulating bone remodeling have been recently identified. Periosteal and bone marrow mesenchymal stem cells (MSCs) are participating in fracture healing, but it is difficult to distinguish the source of cells within the callus. Considering that perivascular cells exert osteoprogenitor potential, we generated an RGS5 transgenic mouse model (Rgs5-CreER) which when crossed with Ai9 reporter animals (Rgs5/Tomato), is suitable for lineage tracing during growth and post-injury. Flow cytometry analysis and histology confirmed the presence of Rgs5/Tomato+ cells within CD31+ endothelial, CD45+ hematopoietic, and CD31-CD45- mesenchymal/perivascular cells. A tamoxifen chase showed expansion of Rgs5/Tomato+ cells expressing osterix within the trabeculae positioned between mineralized matrix and vasculature. Long-term chase showed proportion of Rgs5/Tomato+ cells contributes to mature osteoblasts expressing osteocalcin. Following femoral fracture, Rgs5/Tomato+ cells are observed around newly formed bone within the BM cavity and expressed osterix and osteocalcin, while contribution within periosteum was low and limited to fibroblastic callus with very few positive chondrocytes. In addition, BM injury model confirmed that RGS5-Cre labels population of BMSCs expands during injury and participates in osteogenesis. Under homeostatic conditions, lineage-traced RGS5 cells within the trabecular area demonstrate osteoprogenitor capacity that in an injury model contributes to new bone formation primarily within the BM niche.
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Affiliation(s)
- Sierra H Root
- Center for Regenerative Medicine and Skeletal Development, UConn Health, Farmington, CT, USA
| | - Ivana Vrhovac Madunic
- Center for Regenerative Medicine and Skeletal Development, UConn Health, Farmington, CT, USA
| | - Mark S Kronenberg
- Center for Regenerative Medicine and Skeletal Development, UConn Health, Farmington, CT, USA
| | - Ye Cao
- Center for Regenerative Medicine and Skeletal Development, UConn Health, Farmington, CT, USA
| | - Sanja Novak
- Center for Regenerative Medicine and Skeletal Development, UConn Health, Farmington, CT, USA
| | - Ivo Kalajzic
- Center for Regenerative Medicine and Skeletal Development, UConn Health, Farmington, CT, USA
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Beraún-Coronel L, Cardenas-Escalante J, Sinti-Paredes DA, Chamorro-Robles F, Porres-Varona W. Nonunion of Diaphyseal Humerus Fracture in an Infant: A Case Report. JBJS Case Connect 2023; 13:01709767-202306000-00012. [PMID: 37071735 DOI: 10.2106/jbjs.cc.22.00764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
CASE A 9-month-old infant girl with Down syndrome presented with an atrophic nonunion of the right humerus diaphysis secondary to birth trauma. Surgical intervention included open reduction and external fixation plus cadaveric cancellous bone allograft and platelet-rich plasma and then was changed to an external fixator in axial compression. At 16 months after surgery, bone healing was achieved. CONCLUSION Nonunions in infants are rare, and their treatment is a challenge; an adequate vascular supply with good stabilization and reduction are keys to management. We believe that the improvement in reduction and stability under axial compression were the keys to achieve consolidation.
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Affiliation(s)
- Luis Beraún-Coronel
- Division of Orthopaedic Surgery, Hospital II-2 Tarapoto, Tarapoto, Peru
- Faculty of Medicine, Universidad Nacional de San Martín, Tarapoto, Peru
- Postgraduate Department, Faculty of Medicine, Universidad de San Martín de Porres, Lima, Peru
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Abstract
BACKGROUND Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non-hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns. METHODS The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed. RESULTS There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon (P = .007), fewer required surgery (P < .001). CONCLUSIONS Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.
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Affiliation(s)
- Landis R. Walsh
- Boston Children’s Hospital and Harvard Medical School, MA, USA
| | - Laura C. Nuzzi
- Boston Children’s Hospital and Harvard Medical School, MA, USA
| | | | - Brian I. Labow
- Boston Children’s Hospital and Harvard Medical School, MA, USA
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8
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Stroud S, Katyal T, Gornitzky AL, Swarup I. Effect of non-steroidal anti-inflammatory drugs on fracture healing in children: A systematic review. World J Orthop 2022; 13:494-502. [PMID: 35633742 PMCID: PMC9125002 DOI: 10.5312/wjo.v13.i5.494] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 09/14/2021] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in the United States. Although they are safe and effective means of analgesia for children with broken bones, there is considerable variation in their clinical use due to persistent concerns about their potentially adverse effect on fracture healing.
AIM To assess whether NSAID exposure is a risk factor for fracture nonunion in children.
METHODS We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included all clinical studies that reported on adverse bone healing complications in children with respect to NSAID exposure. The outcomes of interest were delayed union or nonunion. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies. A final table was constructed summarizing the available evidence.
RESULTS A total of 120 articles were identified and screened, of which 6 articles were included for final review. Nonunion in children is extremely rare; among the studies included, there were 2011 nonunions among 238822 fractures (0.84%). None of the included studies documented an increased risk of nonunion or delayed bone healing in those children who are treated with NSAIDs in the immediate post-injury or peri-operative time period. Additionally, children are likely to take these medications for only a few days after injury or surgery, further decreasing their risk of adverse side-effects.
CONCLUSION This systematic review suggests that NSAIDS can be safely prescribed to pediatric orthopaedic patients absent other contraindications without concern for increased risk of fracture non-union or delayed bone healing. Additional prospective studies are needed focusing on higher risk fractures and elective orthopaedic procedures such as osteotomies and spinal fusion.
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Affiliation(s)
- Sarah Stroud
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Toshali Katyal
- Department of Orthopaedic Surgery, University of California, San Francisco Benioff Children’s Hospital, San Francisco, CA 94143, United States
| | - Alex L Gornitzky
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Ishaan Swarup
- Department of Orthopaedic Surgery, University of California, San Francisco Benioff Children’s Hospital Oakland, Oakland, CA 94609, United States
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Johnson MA, Ganley TJ, Crawford L, Swarup I. Pediatric Orthopedic Trauma Care During the COVID-19 Pandemic: A Survey of the Pediatric Orthopedic Society of North America. HSS J 2022; 18:205-211. [PMID: 35645652 PMCID: PMC9096990 DOI: 10.1177/15563316211056022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/24/2021] [Indexed: 02/07/2023]
Abstract
Background: The COVID-19 pandemic has dramatically altered the practice of pediatric orthopedic trauma surgery in both outpatient and inpatient settings. While significant declines in patient volume have been noted, the impact on surgeon decision-making is unclear. Purpose: We sought to investigate changes in pediatric orthopedic trauma care delivery as a result of COVID-19 and determine their implications for future orthopedic practice. Methods: An electronic survey was distributed to all members (N = 1515) of the Pediatric Orthopedic Society of North America (POSNA) in March to April 2021; only members who provided care for pediatric orthopedic trauma patients were asked to complete it. The survey included questions on hospital trauma call, inpatient care, outpatient clinic practice, and 3 unique fracture case scenarios. Results: A total of 147 pediatric orthopedic surgeons completed the survey, for a 9.7% response rate, with 134 (91%) taking trauma call at a hospital as part of their practice. Respondents reported significant differences across institutions regarding COVID-19 testing, hospital rounding, and employee COVID-19 screening. Changes in outpatient fracture management were observed, including a decreased number of follow-up visits for nondisplaced clavicle fractures, distal radius buckle fractures, and toddler's fractures. Of respondents who changed their fracture follow-up schedules due to COVID-19, over 75% indicated that they would continue these outpatient treatment schedules after the pandemic. Conclusions: This survey found changes in pediatric orthopedic trauma care as a result of the COVID-19 pandemic. The use of telemedicine and abbreviated follow-up practices for common fracture types are likely to persist following the resolution of the COVID-19 pandemic.
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Affiliation(s)
- Mitchell A. Johnson
- Division of Orthopaedic Surgery,
Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Theodore J. Ganley
- Division of Orthopaedic Surgery,
Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsay Crawford
- Division of Orthopaedic Surgery, Texas
Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Ishaan Swarup
- Division of Orthopaedic Surgery, UCSF
Benioff Children’s Hospitals, Oakland, CA, USA,Ishaan Swarup, MD, Division of Orthopaedic
Surgery, UCSF Benioff Children’s Hospitals, 744 52nd St., Oakland, CA 94609,
USA.
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10
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Refai O, Khalifa AA. Single stage open reduction, intramedullary rod, bone grafting, and plate fixation for managing adolescent midshaft femoral fracture non-union, report of two cases. Trauma Case Rep 2022; 38:100616. [PMID: 35146109 PMCID: PMC8819097 DOI: 10.1016/j.tcr.2022.100616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/21/2022] Open
Abstract
Although rare, long bones fracture non-union in pediatric and adolescent patients is still being reported. It poses a challenge for the trauma surgeons, although principles for adult patient management apply to pediatrics and adolescents; however, there is no standard protocol to deal with such situations. We report two male adolescent patients, 11 and 12 years old, presented with non-united midshaft femoral fracture non-union after being multiply operated on. One patient was diagnosed with a septic non-union, while the other had an atrophic type. Both were treated following the same technique of open surgery where debridement and refreshing of the fracture site were performed, followed by initial fixation using an intramedullary rod, the biological environment was then enhanced by the addition of autologous iliac bone graft, and the fixation was finalized using a 4.5 dynamic compression plate. Both patients achieved complete fracture union and excellent functional outcomes by the last follow up. Adolescent patients presented with multiply operated non-united femoral fracture could be successfully treated using the described technique. It improves the mechanical and biological environment with the advantage of being a single-stage surgery.
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Affiliation(s)
- Omar Refai
- Orthopaedic Department, Assiut university hospital, Assiut, Egypt
| | - Ahmed A. Khalifa
- Orthopaedic Department, Qena faculty of medicine and university hospital, South valley university, Qena, Egypt
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11
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Radiolucent zones of biodegradable magnesium-based screws in children and adolescents-a radiographic analysis. Arch Orthop Trauma Surg 2022; 143:2297-2305. [PMID: 35352154 DOI: 10.1007/s00402-022-04418-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 03/05/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Albeit the implantation of magnesium-based biodegradable implants can avoid a second surgery for implant removal, the postoperative occurrence of radiolucent zones around these implants based on corrosion processes has not been previously investigated in children and adolescents. We sought to characterize the distinct temporal and spatial dynamics for magnesium-based implants based on standard clinical routine radiographs. MATERIALS AND METHODS We retrospectively analyzed 29 patients, treated with magnesium-based compression screws (MAGNEZIX® CS 2.7 mm, CS 3.2 mm, CSC 4.8 mm; Syntellix AG) for fracture fixation, osteotomy, or osteochondral refixation. During a follow-up examination, the clinical and functional status was evaluated. Based on digital radiographs, the ratio of the area of the radiolucent zone and that of the screw was evaluated to assess implant degradation at two follow-up visits (i.e., after 6-8 weeks and 12-24 weeks). RESULTS In 29 patients (16/29 females, 14.03 ± 2.13 years), a total of 57 implants were evaluated that were used for osteotomy (n = 13, screws n = 26), fracture fixation (n = 9, screws n = 18), or osteochondral refixation (n = 7, screws n = 13). All patients healed without complications and regained full function. Radiolucent zones were observed in 27/29 patients at the first follow-up, with significantly decreased ratios at the second follow-up (2.10 ± 0.55 vs 1.64 ± 0.60, p = 0.0006). Regression analyses were performed to assess the temporal dynamics of radiolucent zones and revealed significant logarithmic developments for the 2.7 mm and 3.2 mm screws, marked by a strong ratio decrease during the first weeks and an almost complete disappearance after approximately 100 days and 200 days, respectively. In contrast, the ceramic-coated 4.8 mm screws presented a significant linear and slower decrease of radiolucent zones. CONCLUSION Radiolucent zones are a common phenomenon in the course of implant degradation. However, they represent a self-limiting phenomenon. Remarkably, neither implant failure nor affected implant function is noted in this context. Yet, the microstructural changes accompanying the presence of radiolucent zones remain to be analyzed by three-dimensional high-resolution imaging.
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12
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Characterization and functional analysis of the adipose tissue-derived stromal vascular fraction of pediatric patients with osteogenesis imperfecta. Sci Rep 2022; 12:2414. [PMID: 35165317 PMCID: PMC8844034 DOI: 10.1038/s41598-022-06063-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/12/2022] [Indexed: 11/08/2022] Open
Abstract
AbstractPediatric patients with Osteogenesis Imperfecta (OI), a heritable connective tissue disorder, frequently suffer from long bone deformations. Surgical correction often results in bone non-unions, necessitating revision surgery with autogenous bone grafting using bone-marrow-derived stem cells (BM-SC) to regenerate bone. BM-SC harvest is generally invasive and limited in supply; thus, adipose tissue's stromal vascular fraction (SVF) has been introduced as an alternative stem cell reservoir. To elucidate if OI patients' surgical site dissected adipose tissue could be used as autologous bone graft in future, we investigated whether the underlying genetic condition alters SVF's cell populations and in vitro differentiation capacity. After optimizing SVF isolation, we demonstrate successful isolation of SVF of pediatric OI patients and non-OI controls. The number of viable cells was comparable between OI and controls, with about 450,000 per gram tissue. Age, sex, type of OI, disease-causing collagen mutation, or anatomical site of harvest did not affect cell outcome. Further, SVF-containing cell populations were similar between OI and controls, and all isolated SVF's demonstrated chondrogenic, adipogenic, and osteogenic differentiation capacity in vitro. These results indicate that SVF from pediatric OI patients could be used as a source of stem cells for autologous stem cell therapy in OI.
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Armstrong ML, Smith N, Tracey R, Jackman H. The Orthopedic Effects of Electronic Cigarettes: A Systematic Review and Pediatric Case Series. CHILDREN 2022; 9:children9010062. [PMID: 35053687 PMCID: PMC8774690 DOI: 10.3390/children9010062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/19/2021] [Accepted: 12/28/2021] [Indexed: 11/16/2022]
Abstract
Electronic cigarette (EC) use is highly prevalent, especially in the adolescent population, where 29% of Canadian adolescents have used an EC in the past thirty days per national surveys. Our pediatric orthopedic referral centre observed a cluster of delayed unions of bone fractures in adolescents using ECs and present the case series here. We then asked whether electronic cigarettes impair bone healing or influence orthopedic outcomes. A PRISMA-compliant systematic review was carried out, which revealed no human clinical studies and a general paucity of evidence around ECs and musculoskeletal health. The existing experimental evidence relevant to orthopedics is summarized. The effect of ECs on the musculoskeletal system is poorly understood and is a target for further research.
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Affiliation(s)
- Maxwell Luke Armstrong
- Division of Orthopedic Surgery, Janeway Children’s Health and Rehabilitation Centre, Memorial University of Newfoundland, St. John’s, NL A1B 3V6, Canada; (N.S.); (H.J.)
- Correspondence:
| | - Nicholas Smith
- Division of Orthopedic Surgery, Janeway Children’s Health and Rehabilitation Centre, Memorial University of Newfoundland, St. John’s, NL A1B 3V6, Canada; (N.S.); (H.J.)
| | - Rhiannon Tracey
- Division of Orthopedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 5A5, Canada;
| | - Heather Jackman
- Division of Orthopedic Surgery, Janeway Children’s Health and Rehabilitation Centre, Memorial University of Newfoundland, St. John’s, NL A1B 3V6, Canada; (N.S.); (H.J.)
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Single-cell RNA sequencing of intramedullary canal tissue to improve methods for studying fracture repair biology. Biotechniques 2021; 71:431-438. [PMID: 34374302 DOI: 10.2144/btn-2021-0002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The ability to study the bone microenvironment of failed fracture healing may lead to biomarkers for fracture nonunion. Herein the authors describe a technique for isolating individual cells suitable for single-cell RNA sequencing analyses from intramedullary canal tissue collected by reaming during surgery. The purpose was to detail challenges and solutions inherent to the collection and processing of intramedullary canal tissue samples. The authors then examined single-cell RNA sequencing data from fresh and reanimated samples to demonstrate the feasibility of this approach for prospective studies.
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Stürznickel J, Delsmann MM, Jungesblut OD, Stücker R, Knorr C, Rolvien T, Kertai M, Rupprecht M. Safety and performance of biodegradable magnesium-based implants in children and adolescents. Injury 2021; 52:2265-2271. [PMID: 33775413 DOI: 10.1016/j.injury.2021.03.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/15/2021] [Indexed: 02/02/2023]
Abstract
AIMS Biodegradable magnesium-based alloy implants represent a promising option in orthopedic surgery, as the clinical outcomes have been reported to be comparable to those of titanium implants and no surgical interventions are required for removal. To date, little is known about the results of the use of these implants in children and adolescents. Therefore, the aim of the present study was to analyze the safety and performance of these implants in children and adolescents. PATIENTS AND METHODS Eighty-nine patients treated with magnesium-based implants for fracture stabilization, osteotomy and osteochondral refixation were analyzed; 38 were treated by osteosynthesis; 18, osteotomy; and 33, osteochondral refixation. The mean follow-up duration was 8.2 months (range, 1.5-30 months). Clinical and radiographical follow-up examinations were performed at 4-8 weeks and 3-6 months, respectively, to evaluate implant performance and osseous consolidation. RESULTS Clinical outcomes were rated as good to very good in all patients. Radiolucent zones were apparent after surgery in all patients but were noted to decrease in size during the follow-up period. Revision surgery was necessary in 1 of 89 patients who had a highly unstable osteochondritis dissecans lesion of the knee. None of the magnesium-based implants required surgical removal. CONCLUSION Magnesium-based implants in children and adolescents results in good clinical outcomes when used for fracture stabilization, osteotomy and osteochondral defect refixation. Future studies are needed to further analyze the significance of the transient appearance and temporal development of radiolucent zones in the growing skeleton as well as the long-term performance of these implants.
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Affiliation(s)
- Julian Stürznickel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian M Delsmann
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver D Jungesblut
- Department of Pediatric Orthopaedics, Children's Hospital Hamburg-Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Stücker
- Department of Pediatric Orthopaedics, Children's Hospital Hamburg-Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Knorr
- Department of Pediatric Surgery, Klinik St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
| | - Tim Rolvien
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Kertai
- Department of Pediatric Surgery, Klinik St. Hedwig, University Medical Center Regensburg, Regensburg, Germany.
| | - Martin Rupprecht
- Department of Pediatric Orthopaedics, Children's Hospital Hamburg-Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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16
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Failure analysis and recommendations for treatment of posttraumatic non-unions of the distal humerus during childhood. Eur J Trauma Emerg Surg 2021; 47:313-324. [PMID: 33620527 PMCID: PMC8016816 DOI: 10.1007/s00068-021-01613-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/05/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE Non-unions of the distal humerus are rare complications of common children's fractures such as radial condyle fractures and supracondylar fractures. The aim of this paper was to update the knowledge about etiology, reasons, management, and results of these troublesome, and sometimes debilitating entities. METHODS The sparse literature concerning nonunions following condylar or supracondylar fractures was analyzed together with the presentation of some typical clinical cases. RESULTS In most of the cases, non-unions were induced by neglect, unstable fixation, too early implant removal, too much revision surgery, and an inconsequent transfer of follow-up algorithms, or combinations of the above. Treatment of non-union should start as early as possible because the effort of required surgery increases with time that the nonunion has been neglected. Often a combination of stable fixation of the pseudarthrosis and correction of the elbow axis are necessary to achieve a satisfying outcome. CONCLUSION In pediatric traumatology, qualified and consequent care for children's fractures of the distal humerus can prevent rare complications such as non-unions in almost any situation. If such a disturbance of healing is noticed, immediate and adequate, i.e. children specific surgical consequences achieve best results.
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17
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Lee CL, Liu SC, Yang CY, Chuang CK, Lin HY, Lin SP. Incidence and treatment of adult femoral fractures with osteogenesis imperfecta: An analysis of a center of 72 patients in Taiwan. Int J Med Sci 2021; 18:1240-1246. [PMID: 33526985 PMCID: PMC7847618 DOI: 10.7150/ijms.53286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Osteogenesis imperfecta (OI) is a rare disease characterized by increased bone fragility and susceptibility for fractures. Only few studies have compared the management for femoral fractures in children with OI. Nevertheless, no cohort studies have described the treatment for femoral fractures in adults with OI in Taiwan. This study aimed to investigate and compare the incidence of union and non-union femoral fractures and the best treatment options to avoid non-union fractures. Methods: We enrolled 72 patients with OI who were older than 18 years at MacKay Memorial Hospital between January 2010 and December 2018. Femoral fracture incidence, non-union rate, and treatment modality were analyzed. Results: Of 72 patients with OI, 11 patients had femoral fractures and 4 patients of them had >1 femoral fracture. The incidence for all types of femoral fractures was 651 fractures per 100,000 person-years annually. In 15 total fractures, 4 fractures resulted in non-union, and patients with type 4 OI mostly had shaft fractures. The best outcomes for non-union shaft fracture is achieved by surgical treatment. Conclusion: Adults with OI tended to develop femoral fractures and non-unions. Adults with type 4 OI were particularly at high risk for non-unions in shaft fractures with conservative treatment.
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Affiliation(s)
- Chung-Lin Lee
- Department of Pediatrics, MacKay Memorial Hospital, Hsinchu, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Chia Liu
- Department of Orthopedics, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chen-Yu Yang
- Department of Orthopedics, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chih-Kuang Chuang
- Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
- College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Hsiang-Yu Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Pediatrics, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Department of Rare Disease Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Shuan-Pei Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Pediatrics, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Rare Disease Center, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Inequalities in Pediatric Fracture Care Timeline Based on Insurance Type. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e20.00111. [PMID: 32852914 PMCID: PMC7417144 DOI: 10.5435/jaaosglobal-d-20-00111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Socioeconomic and insurance status are often linked with limited access to health care. Despite several government-funded projects aimed at curtailing these barriers, pediatric orthopaedic patients continue to experience delays in receiving timely care for fracture treatments. This delay has been well-identified within the orthopaedic literature but, to our knowledge, has never been characterized based on timeline. Thus, the goal of this study is to evaluate the role of ethnicity, socioeconomic status, and insurance type on the timeline of pediatric patients to obtain orthopaedic care within our community. METHODS Pediatric patients presenting to our clinic for the treatment of one of 21 most common fractures were included. Patient demographics and the timeline of patient care were collected by retrospective chart review. RESULTS Government-funded insurance accounted for 60.6% of the 413 patients. These patients experienced significant (P < 0.001) delays in access to care when compared with commercial insurance patients; the time between injury and referral as well as the overall time from injury to orthopaedic evaluation was 2.8 and twofold greater at 4.4 days and 9.2 days, respectively. A strong correlation was established between income levels and insurance type. DISCUSSION Pediatric patients with a lower socioeconomic status are more likely to rely on government-funded insurance and experience delays in fracture evaluation.
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Schmal H, Brix M, Bue M, Ekman A, Ferreira N, Gottlieb H, Kold S, Taylor A, Toft Tengberg P, Ban I, Danish Orthopaedic Trauma Society. Nonunion - consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society. EFORT Open Rev 2020; 5:46-57. [PMID: 32071773 PMCID: PMC7017598 DOI: 10.1302/2058-5241.5.190037] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.Treatment concepts such as 'mechanobiology' or the 'diamond concept' determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction. Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037.
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Affiliation(s)
- Hagen Schmal
- Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Orthopaedics and Traumatology, Freiburg University Hospital, Freiburg, Germany
| | - Michael Brix
- Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark
| | - Mats Bue
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Anna Ekman
- Orthopaedic Department, Södersjukhuset, Stockholm, Sweden
| | - Nando Ferreira
- Division of Orthopaedics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Hans Gottlieb
- Department of Orthopaedic Surgery, Herlev Hospital, Herlev, Denmark
| | - Søren Kold
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Andrew Taylor
- Department of Orthopaedic Surgery, Nottingham University Hospitals, UK
| | - Peter Toft Tengberg
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Ilija Ban
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
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Rush ET, Moseley S, Petryk A. Burden of disease in pediatric patients with hypophosphatasia: results from the HPP Impact Patient Survey and the HPP Outcomes Study Telephone interview. Orphanet J Rare Dis 2019; 14:201. [PMID: 31419999 PMCID: PMC6698035 DOI: 10.1186/s13023-019-1167-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/26/2019] [Indexed: 11/10/2022] Open
Abstract
Background Hypophosphatasia (HPP) is a rare, inherited, metabolic bone disease caused by deficient tissue-non-specific isoenzyme of alkaline phosphatase activity that manifests as a broad range of signs/symptoms, including bone mineralization defects and systemic complications. The burden of disease is poorly characterized, particularly in children. This study aimed to characterize the patient-reported burden of disease among children with HPP using two survey instruments: the HPP Impact Patient Survey (HIPS) and the HPP Outcomes Study Telephone interview (HOST). Methods Between September 2009 and June 2011, pediatric patients (aged younger than 18 years) with HPP were recruited to participate in the study via patient advocacy groups or their medical provider. Survey questions were used to capture information on patient demographics, HPP-related medical history, mobility, and health-related quality of life (HRQoL; using the 10-item Short-Form Health Survey for Children [SF-10], HIPS only). Results Common clinical features of the 59 pediatric survey respondents (mean [standard deviation] age: 7.6 [5.1] years; 51% male) included pain (86% of patients), muscle weakness (71%), difficulty gaining weight (64%), and delayed walking (59%). Fracture was reported by 36% of patients; multiple fractures were also reported (15% of patients). Use of assistive devices for mobility was frequent among the study population (51%). In response to the SF-10, patients reported a substantial impact of HPP on their HRQoL; physical function was the most severely impaired component relative to normative data. Of patients responding to the HOST, two-thirds experienced worsening of at least one of their HPP-related signs/symptoms over a 5-year period. Conclusions In pediatric patients, HPP is associated with a high burden of disease and a substantial negative impact on HRQoL. The burden of HPP may increase and HRQoL reduce further over time as signs/symptoms that affect HRQoL worsen or new signs/symptoms manifest. Electronic supplementary material The online version of this article (10.1186/s13023-019-1167-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eric T Rush
- Children's Mercy Hospital, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA.
| | | | - Anna Petryk
- Alexion Pharmaceuticals, Inc., New Haven, CT, USA
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21
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[Corrective osteotomies around the elbow in childhood and adolescence : Indications and techniques for posttraumatic deformities]. Unfallchirurg 2019; 122:353-363. [PMID: 30725117 DOI: 10.1007/s00113-019-0608-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Evidence-based literature on counseling and treatment of pediatric and adolescent patients with posttraumatic deformities is scarce; however, especially around the elbow with its low remodeling potential, the number of patients with malunions presenting in outpatient clinics is not rare at all. In this review the more frequent indications for corrective surgery around the pediatric elbow are described and treatment proposals are made from the perspective of an interregional reference center for pediatric and adolescent trauma.
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Goudriaan WA, Harsevoort GJ, van Leeuwen M, Franken AA, Janus GJM. Incidence and treatment of femur fractures in adults with osteogenesis imperfecta: an analysis of an expert clinic of 216 patients. Eur J Trauma Emerg Surg 2018; 46:165-171. [PMID: 30244374 PMCID: PMC7026263 DOI: 10.1007/s00068-018-1005-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 09/11/2018] [Indexed: 01/03/2023]
Abstract
PURPOSE Osteogenesis imperfecta (OI) is characterized by increased bone fragility and susceptibility for fractures. A few studies described and compared treatment modalities for femur fractures in children with OI. However, no cohort studies on adults with OI have been published. This study on adult OI patients aims to give insight into the incidence of femur fractures and non-unions and its best treatment options to avert non-union. METHODS In this retrospective, descriptive study of the OI expert clinic in The Netherlands, all medical charts of patients 16 years or older were analyzed for femur fracture incidence, non-union rate and treatment modality. RESULTS Of 216 OI patients, 34 patients suffered a femur fracture with 12 patients having more than 1 femur fracture. For all types of femur fractures, the incidence was 651 fractures per 100,000 person-years annually. In 49 total fractures, 10 fractures resulted in a non-union, mostly shaft fractures of type 4 OI patients. Surgically treated shaft fractures had the best outcomes for non-union. CONCLUSIONS OI adults were prone to developing femur fractures and non-unions. Especially type 4 OI adults, with conservatively treated shaft fractures, were at high risk for non-unions.
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Mills LA, Aitken SA, Simpson AHRW. The risk of non-union per fracture: current myths and revised figures from a population of over 4 million adults. Acta Orthop 2017; 88:434-439. [PMID: 28508682 PMCID: PMC5499337 DOI: 10.1080/17453674.2017.1321351] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Fracture non-union remains a major clinical problem, yet there are no data available regarding the overall risk of fractures progressing to non-union in a large population. We investigated the rate of non-union per fracture in a large adult population. Methods - National data collected prospectively over a 5-year period and involving just under 5,000 non-unions were analyzed and compared to the incidence of fracture in the same period. Results and interpretation - The overall risk of non-union per fracture was 1.9%, which is considerably less than previously believed. However, for certain fractures in specific age groups the risk of non-union rose to 9%. As expected, these higher rates of non-union were observed with tibial and clavicular fractures, but-less expectedly-it was in the young and middle-aged adults rather than in the older and elderly population. This study is the first to examine fracture non-union rates in a large population according to age and site, and provides more robust (and lower) estimates of non-union risk than those that are frequently quoted.
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Affiliation(s)
- Leanora A Mills
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh;,Orthopaedics and Trauma, Royal Aberdeen Children’s Hospital, Aberdeen, UK;,Correspondence:
| | - Stuart A Aitken
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh;,Orthopaedic Trauma Center, Maine General Medical Center, Augusta, ME, USA
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Abstract
Fracture non-union remains a clinical problem despite advances in the understanding of basic science and technology. Each fracture has a unique personality as does the patient suffering the injury. Thus, each case must be treated on an individual basis. This article defines the problem of fracture non-union and reports recent epidemiological studies. We discuss relevant risk factors and methods for assessing patients who have a tendency toward fracture non-union. There are many treatment options for patients with non-union, where a number of these modalities are still under review. We discuss current evidence with the use of bone morphogenic protein, platelet-rich plasma and low-intensity pulsed ultrasound to augment the treatment of fracture non-union.
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