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Seefried L, Genest F, Hofmann C, Brandi ML, Rush E. Diagnosis and Treatment of Hypophosphatasia. Calcif Tissue Int 2025; 116:46. [PMID: 40047955 PMCID: PMC11885340 DOI: 10.1007/s00223-025-01356-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2024] [Accepted: 02/19/2025] [Indexed: 03/09/2025]
Abstract
Hypophosphatasia (HPP) is a rare inherited metabolic disorder characterized by deficient activity of tissue-nonspecific alkaline phosphatase (TNAP) caused by variants in the ALPL gene. Disease manifestations encompass skeletal hypomineralization with rickets and lung hypoplasia, vitamin B6-dependent seizures, craniosynostosis, and premature loss of deciduous teeth. The clinical presentation can comprise failure to thrive with muscular hypotonia, delayed motor development, and gait disturbances later in childhood. In adults, pseudofractures are a characteristic indicator of severely compromised enzyme activity, but non-canonical symptoms like generalized musculoskeletal pain, weakness, and fatigue, frequently accompanied by neuropsychiatric and gastrointestinal issues are increasingly recognized as key findings in patients with HPP. The diagnosis is based on clinical manifestations in combination with persistently low alkaline phosphatase (ALP) activity, elevated levels of ALP substrates, specifically inorganic pyrophosphate (PPi), pyridoxal 5'-phosphate (PLP) or urine phosphoethanolamine (PEA), and genetic confirmation of a causative ALPL variant. Considering the wide range of manifestations, treatment must be multimodal and tailored to individual needs. The multidisciplinary team for comprehensive management of HPP patients should include expertise to ensure disease state metabolic and musculoskeletal treatment, dental care, neurological and neurosurgical surveillance, pain management, physical therapy, and psychological care. Asfotase alfa as first-in-class enzyme replacement therapy (ERT) for HPP has been shown to improve survival, rickets, and functional outcomes in severely affected children, but further research is needed to refine how enzyme replacement can also address emerging manifestations of the disease. Prospectively, further elucidating the pathophysiology behind the diverse clinical manifestations of HPP is instrumental for improving diagnostic concepts, establishing novel means for substituting enzyme activity, and developing integrative, multimodal care.
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Affiliation(s)
- L Seefried
- Osteology and Clinical Trial Unit, König-Ludwig-Haus, University of Würzburg, Würzburg, Germany.
| | - F Genest
- Osteology and Clinical Trial Unit, König-Ludwig-Haus, University of Würzburg, Würzburg, Germany
| | - C Hofmann
- Pediatric Rheumatology and Osteology, University Children's Hospital Wuerzburg, Würzburg, Germany
| | - M L Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - E Rush
- Division of Clinical Genetics, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
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Hussain N, Khan M, Mahmood A, Tipu M, Aslam S. An evaluation of osseous regeneration capability of novel autogenous tooth graft along with orthobiologics for long bone segmental defects. Heliyon 2025; 11:e41932. [PMID: 39897829 PMCID: PMC11787641 DOI: 10.1016/j.heliyon.2025.e41932] [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] [Received: 10/15/2023] [Revised: 01/09/2025] [Accepted: 01/12/2025] [Indexed: 02/04/2025] Open
Abstract
Extracted tooth, is predominantly considered a medical waste but tooth and bone evince similitude in biochemical composition, so tooth may be considered as bone graft material. We selected twenty-four adult rabbits with age and body weight ranges of 1-3 years and 2-4 kg respectively, regardless of sex and breed. These rabbits were allocated into four groups i.e., J, K, L, and M. Autogenous tooth graft was acquired from the individual's incisor. In group J (control), tooth graft alone was used at the mid shaft radius fractured site. For group K, tooth and bone marrow aspirate (BMA) were applied. In group L, tooth-platelet rich plasma (PRP) was administered while for group M, tooth-decellularized fish scale (DFS) was engrafted at the location. The research was conducted for 4 months and parameter evaluation was done on 0, 1st, 7th, 15th, 30th, 45th, 60th, 75th, 90th, 105th and 120th days. The therapeutic regimens were extensively appraised in terms of physiological vitals, hematology, serology, bone biomarkers, mechanical assessment, radiography and histomorphometric parameters. We noticed appropriate osteointegration of autologous tooth with the fractured site, good healing and bone remodeling in all groups with superior to lower trends in Tooth-BMA, Tooth-PRP, Tooth-DFS, and Tooth-solo groups respectively. Though usage of aforementioned regimens in-vivo needs further trials but overall, we may suggest that autogenous tooth is not only a novel and viable graft in solo but its healing capacity, osteointegration and firm callus formation can be augmented with appropriate orthobiologic materials and in future may be useful for bone defect treatments, not only in animals but humans as well.
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Affiliation(s)
- N. Hussain
- Department of Veterinary Surgery, University of Veterinary and Animal Sciences Lahore, 54000, Pakistan
| | - M.A. Khan
- Department of Veterinary Surgery, University of Veterinary and Animal Sciences Lahore, 54000, Pakistan
| | - A.K. Mahmood
- Department of Small Animal Clinical Sciences, University of Veterinary and Animal Sciences Lahore, 54000, Pakistan
| | - M.Y. Tipu
- Department of Pathology, University of Veterinary and Animal Sciences Lahore, 54000, Pakistan
| | - S. Aslam
- Department of Veterinary Surgery, University of Veterinary and Animal Sciences Lahore, 54000, Pakistan
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Hösl M, Afifi FK, Thamm A, Göttling L, Holzapfel BM, Wagner F, Mohnike K, Nader S. The Effectiveness of Growth Modulation Using Tension Band Plates in Children With Achondroplasia in Comparison to Children With Idiopathic Frontal Axial Deformities of the Knee. J Pediatr Orthop 2025; 45:e84-e92. [PMID: 39233340 DOI: 10.1097/bpo.0000000000002795] [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: 09/06/2024]
Abstract
BACKGROUND Achondroplasia is the most common form of rhizomelic dwarfism. Aside from disproportionally short extremities, frontal knee malalignments are common. We assessed the effectiveness of guided growth via tension band plates in children with achondroplasia in comparison to patients with idiopathic knee deformities using radiography. METHODS Twenty children with achondroplasia (8 valgus/31 varus knees) and 35 children with idiopathic knee malalignments (53 valgus/12 varus knees) which underwent temporary hemiepiphysiodesis at the distal femur and/or proximal tibia were retrospectively compared. Radiographic outcomes (mechanical lateral distal femoral angle, medial proximal tibial angle, and mechanical axis deviation) were compared before surgery and plate removal. Correction rates according to plate location were compared as change per implant duration and per growth in leg length. RESULTS Achondroplasia patients were younger (9±2 vs.12±2 y), femoral and tibial growth rate was 43.3% and 48.5% lower and implant duration lasted longer: 36.9±8.9 months in valgus knees and 23.0±14.3 months in varus knees versus 13.4±7.9 months in idiopathic valgus and 11.7±4.6 months in idiopathic varus knees. Significant improvements in joint orientation angles and mechanical axis deviation were achieved but femoral and tibial plates achieved slower correction per months in achondroplasia ( P ≤0.031). When normalized to bone growth, the rate of correction in joint orientation angles was no longer significantly different for the femur ( P =0.241), with a trend for slower correction in the tibia ( P =0.066). The corrections in MAD per leg growth (mm/mm) remained smaller ( P =0.001). In achondroplasia, older age correlated with slower MAD correction ( r =-0.36, P =0.022), femoral plates corrected faster than tibial ( P =0.024) and treatment of valgus was less successful than varus involving longer treatments ( P =0.009). More complications occurred in achondroplastic knees ( P =0.012). CONCLUSIONS Skeletally immature patients with achondroplasia can benefit from growth modulations, but they need longer treatments and face more complications. Their slower growth does not solely determine the more tenacious success. LEVEL OF EVIDENCE Therapeutic Level III-case-control study.
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Affiliation(s)
- Matthias Hösl
- Specialist Centre for Paediatric Orthopaedics, neuroorthopaedics and Deformity Reconstruction
- Gait and Motion Analysis Laboratory, Schön Clinic Vogtareuth, Vogtareuth
| | - Faik Kamel Afifi
- Division of Orthopaedic Surgery, Hospital for Sick Children, Toronto, Canada
| | - Antonia Thamm
- Gait and Motion Analysis Laboratory, Schön Clinic Vogtareuth, Vogtareuth
| | - Lara Göttling
- Department of Orthopaedic and Trauma Surgery, Musculoskeletal University Center Munich, Ludwig-Maximilians-University, Munich
| | - Boris M Holzapfel
- Department of Orthopaedic and Trauma Surgery, Musculoskeletal University Center Munich, Ludwig-Maximilians-University, Munich
| | - Ferdinand Wagner
- Department of Orthopaedic and Trauma Surgery, Musculoskeletal University Center Munich, Ludwig-Maximilians-University, Munich
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich
- Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Klaus Mohnike
- Department of Pediatrics, Pediatric Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Sean Nader
- Specialist Centre for Paediatric Orthopaedics, neuroorthopaedics and Deformity Reconstruction
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Moore DM, Turner H, Boughton O, Noonan M, Noel J, Kiely P, O'Toole P, Kelly PM, Moore DP. Guided growth surgery for angular deformity of the knee: one centres experience. Ir J Med Sci 2024; 193:2825-2833. [PMID: 39180636 PMCID: PMC11666720 DOI: 10.1007/s11845-024-03794-3] [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: 07/12/2024] [Accepted: 08/18/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Angular deformity in the lower extremity can result in pain, gait disturbance, cosmetic deformity and joint degeneration. Up until the introduction of guided growth, which has since become the widely accepted treatment for frontal plane angular angular deformity around the knee in skeletally immature patients, treatment consisted of staples, corrective osteotomy or an angular epiphysiodesis. Guided growth modulation uses the tension band principle with the goal of treatment being to normalise the lower limb mechanical axis resulting in lower morbidity than previous treatments. In order to assess the success of this procedure we reviewed our results in an attempt to identify patients who may not benefit from this elegant procedure. METHODS We performed a retrospective review of prospectively collected surgical records and diagnostic imaging in our paediatric tertiary national referral centre to identify all patients who had guided growth surgery for coronal plane angular deformity of the knee from 2007 to 2023. We noted the patient demographics, diagnosis, peri-operative experience and outcome. All patients were followed until skeletal maturity, until their hardware was removed or at least 2 years. RESULTS Two hundred thirty-six patients were assessed for eligibility. Of the 282 treated knees which met the criteria for final assessment 55 (19.5%) were unsuccessful. Complications were few but included infection and metal-work prominence. Procedures that were less likely to be successfully included growth disturbances following trauma (18.8% failure) or infection (40%), tumour (66.6%), mucopolysaccharidoses type I (15.7%), spondyloepiphyseal dysplasia (25%) or Blount's disease (60%). Idiopathic angular deformity showed an 89.5% success rate with guided growth. CONCLUSION In our hands, guided growth had an 80.5% success rate when all diagnoses were considered. We continue to advocate the use of guided growth as a successful treatment option for skeletally immature patients with limb deformity however caution should be employed when considering its use in certain patient groups. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Dave M Moore
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland.
| | - Henry Turner
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland
| | - Oliver Boughton
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland
| | - Maria Noonan
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland
| | - Jacques Noel
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland
| | - Pat Kiely
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland
| | - Pat O'Toole
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland
| | - Paula M Kelly
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland
| | - David P Moore
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland, Crumlin, Cooley Rd, Dublin, D12 N512, Ireland
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Li S, Chen X, Liu S, Xu H, Yu Y, Li S, Yin Z, Du Y, Zhang M, Liu P, Qian W. Gender, BMI, and Age-Related Variations in Lower Limb Alignment Parameters and CPAK Phenotypes in Chinese Patients with Knee Osteoarthritis. Orthop Surg 2024; 16:3098-3106. [PMID: 39359064 PMCID: PMC11608765 DOI: 10.1111/os.14253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/31/2024] [Accepted: 09/03/2024] [Indexed: 10/04/2024] Open
Abstract
OBJECTIVES Research on the distribution of and the variation in coronal plane alignment of the knee (CPAK) in the Chinese osteoarthritis population is limited. We aimed to establish the CPAK classification based on the characteristics of lower limb alignment in the Chinese osteoarthritis population. We also investigated variations in lower limb alignment parameters and CPAK phenotypes based on gender, body mass index (BMI), and age. METHODS A retrospective study was conducted on a total of 944 knees diagnosed with osteoarthritis in 479 patients from January 2017 to December 2023. A scatterplot was used to describe the distribution of the CPAK classification, and the differences in lower limb alignment parameters and the CPAK classification were compared across genders (male, female), ages (middle-aged/<65 years, elderly/≥65 years), and BMI categories (normal/<25 kg/m2, overweight and obese/≥25 kg/m2) using the chi-squared test or Fisher's exact test. RESULTS The average arithmetic hip-knee-ankle angle and joint line obliquity (JLO) were -3.03° ± 5.69° and 174.45° ± 4.29°, respectively. There was a higher prevalence of constitutional varus alignment in males and the overweight or obese group, while constitutional valgus alignment was more common in females and the normal BMI group (p < 0.05). Additionally, females had a greater apex distal JLO than males (p < 0.05). There were no statistically significant differences in lower limb alignment parameters among different age groups (p > 0.05). Although there were variations in alignment parameters across different genders and BMI categories in the knee osteoarthritis population, the predominant CPAK classifications were type I (38.03%), followed by type II (20.02%) and type IV (17.06%). CONCLUSION The most common CPAK types were I, II, and IV, and they were not influenced by gender, BMI, or age, indicating that the CPAK classification can reliably reflect constitutional alignment. A better understanding of native alignment variability can aid in providing patient-specific recommendations when considering orthopedic alignment strategies.
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Affiliation(s)
- Songlin Li
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xi Chen
- Departments of OrthopedicsWest China Hospital, West China School of Medicine, Sichuan UniversityChengduChina
| | - Sen Liu
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Hongjun Xu
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yang Yu
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Shanni Li
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhaojing Yin
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yiyang Du
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Miaomiao Zhang
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Peilai Liu
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Wenwei Qian
- Department of Orthopedic SurgeryPeking Union Medical College Hospital, Chineses Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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Gaudiani MA, Cooper T, Drummond A, Hansen LM, Tompkins MA. Guided Growth for Correction of Elevated Tibial Posterior Slope in Pediatric ACL Deficiency: A Case Report. JBJS Case Connect 2024; 14:01709767-202412000-00033. [PMID: 39509535 DOI: 10.2106/jbjs.cc.24.00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2024]
Abstract
CASE Fourteen-year-old boy, history of autism presented with bilateral knee instability. Imaging revealed bilateral anterior cruciate ligament (ACL) insufficiency, 20° of posterior tibial slope (PTS) on the right and 18° on the left. A guided growth technique using anterior placed tension band plates was used to correct the PTS. At 22 months, the PTS corrected to 5.5° on the right and 6° on the left. The patient's knee stability improved, and he resumed activities at 30 months. CONCLUSION Pediatric ACL insufficiency in the setting of elevated PTS can be successfully corrected with a guided growth technique.
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Affiliation(s)
- Michael A Gaudiani
- Department of Orthopaedic Surgery, Henry Ford Health, Detroit, Michigan
- Department of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, Saint Paul, Minnesota
| | - Trent Cooper
- Department of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, Saint Paul, Minnesota
| | - Angela Drummond
- Department of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, Saint Paul, Minnesota
| | - Logan M Hansen
- Department of Orthopaedic Surgery, Henry Ford Health, Detroit, Michigan
- Department of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, Saint Paul, Minnesota
| | - Marc A Tompkins
- Department of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, Saint Paul, Minnesota
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Dai ZZ, Li TC, Zhou H, Zhang Q, Li H. The Effectiveness of Temporary Hemiepiphysiodesis for Non-idiopathic Coronal Angular Deformity of the Knee in Children: A Comparison of Hinge Eight-Plate and Traditional Eight-Plate. Orthop Surg 2024. [PMID: 39354740 DOI: 10.1111/os.14254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 08/28/2024] [Accepted: 09/03/2024] [Indexed: 10/03/2024] Open
Abstract
OBJECTIVE Temporary hemiepiphysiodesis (TH) is a very common technique for coronal angular deformity of the knee in children, especially non-idiopathic. However, there is currently a dearth of comparative research on the hinge eight-plate (HEP) and traditional eight-plate (TEP). This study aimed to assess the clinical effectiveness and implant-related complication rates of TH using TEP and HEP for non-idiopathic coronal angular deformity, as well as to identify clinical factors affecting correction velocity. METHODS We retrospectively observed a consecutive series of patients with non-idiopathic coronal angular deformity of the knee who underwent TH using HEP or TEP and completed the deformity correction process from July 2016 to July 2022. According to the kind of eight plates, we divided those patients into the HEP group and the TEP treatment group. Relevant clinical factors, including the mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), screw divergence angle (SDA), angle of plate and screw (APS), hinge angle of HEP (HA), and the knee zone location of the lower extremity mechanical axis, were documented. Additionally, deformity correction velocity, complications, and clinical efficacy were assessed. Categorical variables were analyzed using the chi-squared test, Fisher exact test, or Wilcoxon test, while continuous variables were evaluated using the t-test or analysis of variance (ANOVA). RESULTS There were 29 patients in the HEP treatment group (seven girls and 22 boys) and 33 patients (12 girls and 21 boys) in the TEP treatment group. In all, 91.86% (79/86 knees) of the genu angular deformities were completely corrected, 6.98% (6/86 knees) had the overcorrection condition, and 10.47% (9/86 knees) had screw loosening. The swayback HEP rate was 11.29% (7/62 HEPs), which was related to the screw loosening in the HEP group (p < 0.001). The overall correction velocities and screw divergence angle change speeds in the HEP group were all significantly faster than those in the TEP group (p < 0.05). The initial APS of the HEP implanted was higher than that of TEP (p < 0.01), and multisite changes of APS during deformity correction of the HEP group were smaller than that of the TEP group. CONCLUSION HEP proved to be an appropriate device for TH for non-idiopathic coronal angular deformities of the knee with high correction velocity in children. Avoiding the occurrence of the swayback phenomenon may reduce the complications of HEP.
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Affiliation(s)
- Zhen-Zhen Dai
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tai-Chun Li
- Department of Orthopedics, Children's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Han Zhou
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qin Zhang
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hai Li
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Sanzarello I, Nanni M, Leonetti D, Fenga D, Traina F, Faldini C. Surgical approach to correction of severe knee malalignment in a pediatric population in Tanzania. Folia Med (Plovdiv) 2023; 65:885-893. [PMID: 38351776 DOI: 10.3897/folmed.65.e102090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/09/2023] [Indexed: 02/16/2024] Open
Abstract
AIM Severe knee malalignment in children usually needs surgery with different options available in surgical approaches. The aim of this study was to report the results of the surgical correction of severe knee malalignment in children treated with femoral and tibial osteotomy, temporarily fixed with percutaneous Kirschner wires, in a low- and middle-income country (LMIC), with limited medical resources.
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Di Gennaro GL, Trisolino G, Stallone S, Ramella M, Rocca G, Gallone G. Guided Growth Technique for Epiphysiodesis and Hemiepiphysiodesis: Safety and Performance Evaluation. CHILDREN (BASEL, SWITZERLAND) 2023; 11:49. [PMID: 38255362 PMCID: PMC10814807 DOI: 10.3390/children11010049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Guided-growth modulation is a first-line treatment widely adopted to correct lower-limb angular deformities and limb-length discrepancies (LLD) in the paediatric population. METHODS We conducted a retrospective study to evaluate the safety and performance of a new construct (8-Plate Plus or Guided-Growth Plate System Plus, Orthofix S.r.l) used to correct angular deformities and LLD in non-skeletally mature children. The primary endpoint was safety (from plate implantation to removal). The secondary endpoint was performance; patients treated for LLD achieved complete correction if a pre- and post-surgery difference of <0 was observed; angular deformities performance was measured in terms of IMD, ICD, mMPTA, and mLDFA. RESULTS We performed 69 procedures in 41 patients. A total of 10 patients had an LLD, and 31 had an angular deformity. We observed nine minor complications in the hemiepiphysiodesis group. One patient experienced rebound. All 10 LLD patient treatments were successful. A total of 30/31 patients with an angular deformity had a successful treatment; the remaining patient had a partial correction. CONCLUSIONS Guided-growth by temporary epiphysiodesis or hemiepiphysiodesis was safe and effective for angular deformities and limb-length discrepancies. Further prospective and/or randomized controlled trial studies assessing more significant cohorts of patients and a comparison group could add evidence to our findings.
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Affiliation(s)
- Giovanni Luigi Di Gennaro
- Unit of Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (G.L.D.G.); (G.T.); (M.R.); (G.R.)
| | - Giovanni Trisolino
- Unit of Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (G.L.D.G.); (G.T.); (M.R.); (G.R.)
| | - Stefano Stallone
- Unit of Orthopedics and Traumatology, Ospedale Maggiore “Pizzardi”, 40133 Bologna, Italy;
| | - Marco Ramella
- Unit of Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (G.L.D.G.); (G.T.); (M.R.); (G.R.)
| | - Gino Rocca
- Unit of Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (G.L.D.G.); (G.T.); (M.R.); (G.R.)
| | - Giovanni Gallone
- Unit of Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (G.L.D.G.); (G.T.); (M.R.); (G.R.)
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Hubbard EW, Cherkashin A, Samchukov M, Podeszwa D. The Evolution of Guided Growth for Lower Extremity Angular Correction. JOURNAL OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA 2023; 5:738. [PMID: 40433335 PMCID: PMC12088150 DOI: 10.55275/jposna-2023-738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/20/2023] [Indexed: 05/29/2025]
Abstract
Guided growth is one of the most utilized surgical techniques for managing limb deformity in skeletally immature patients. Our understanding of this technique and the types of implants utilized have evolved over the past century. Many of the known risks of this surgery, such as over-correction, under-correction, and rebound deformity, are the same risks initially described when hemiepiphysiodesis and guided growth techniques were first published. The staple has been a powerful tool for deformity correction but its high rates of implant backout and breakage as well as unpredictable rates of premature physeal closure after removal have contributed to this implant being used less frequently today. Many studies on percutaneous transepiphyseal screws (PETS) are promising but have little follow-up, so the risks of this technique with regard to premature physeal closure are not well understood. Tension band plating is currently the most utilized method. However, in specific patient subgroups, the perioperative complication and failure of correction rates are high. Despite the abundance of literature on these techniques, our understanding of guided growth is still quite limited, as most studies are small and do not follow patients to skeletal maturity. Guided growth surgery also can restore the mechanical axis of the limb while leaving patients with significant residual diaphyseal or peri-articular deformity and the implications of these secondary deformities have not been studied. Key Concepts •An understanding of the patient's skeletal maturity and predicted growth remaining is essential prior to performing guided growth surgery.•Regular patient follow-up is critical to prevent over-correction of deformity.•Staples are an effective implant for angular deformity correction but have higher rates of implant backout, breakage, and premature physeal arrest compared to other devices.•Percutaneous transepiphyseal screws can be an effective way to correct angular deformity, but current studies are both small and lack long-term follow-up, which makes it difficult to truly understand the potential risks and complications of this technique.•Tension band plating is a safe and effective treatment for angular deformity correction but the rates of implant breakage and peri-surgical complications in patients with Blount disease are consistently high.
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Braun S, Brenneis M, Meurer A, Holder J, Stief F. Factors for Prolonged Pain and Restriction of Movement Following Hemiepiphysiodesis Plating for the Correction of Lower Limb Malalignment in the Frontal Plane: An Explorative Analysis. CHILDREN 2023; 10:children10040686. [PMID: 37189935 DOI: 10.3390/children10040686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/26/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Abstract
The correction of valgus leg malalignment in children using implant-mediated growth guidance is widely used and effective. Despite the minimal invasive character of the procedure, a relevant number of patients sustain prolonged pain and limited mobility after temporary hemiepiphysiodesis. Our aim was to investigate implant-associated risk factors (such as implant position and screw angulation), surgical- or anesthesia-related risk factors (such as type of anesthesia, use, and duration), and pressure of tourniquet or duration of surgery for these complications. Thirty-four skeletally immature patients with idiopathic valgus deformities undergoing hemiepiphysiodesis plating from October 2018–July 2022 were enrolled in this retrospective study. Participants were divided into groups with and without prolonged complications (persistent pain, limited mobility of the operated knee between five weeks and six months) after surgery. Twenty-two patients (65%) had no notable complications, while twelve patients (35%) had prolonged complications. Both groups differed significantly in plate position relative to physis (p = 0.049). In addition, both groups showed significant differences in the distribution of implant location (p = 0.016). Group 1 had a shorter duration of surgery than group 2 (32 min vs. 38 min, p = 0.032) and a lower tourniquet pressure (250 mmHg vs. 270 mmHg, p = 0.019). In conclusion, simultaneous plate implantation at the femur and tibia and metaphyseal plate positioning resulted in prolonged pain and a delay of function. In addition, the amplitude of tourniquet pressure or duration of surgery could play a factor.
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Affiliation(s)
- Sebastian Braun
- Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
| | - Marco Brenneis
- Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
| | - Andrea Meurer
- Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
- Medical Park St. Hubertus Klinik, 83707 Bad Wiessee, Germany
| | - Jana Holder
- Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
- Department of Sport and Exercise Science, University of Salzburg, 5020 Salzburg, Austria
| | - Felix Stief
- Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
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12
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Patient-reported Outcomes of Adolescents Treated With Guided Growth to Correct Idiopathic Genu Valgum. J Pediatr Orthop 2023; 43:162-167. [PMID: 36728498 DOI: 10.1097/bpo.0000000000002336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Guided growth is commonly used to treat frontal plane alignment deformities in skeletally immature individuals. Treatment aims are to correct the biomechanical loading of the knee and to avoid more invasive surgery that would be required after skeletal maturity. There is little published evidence of pain perception or functional limitations in this population. In addition, the intervention has the potential to worsen pain and function with hardware implantation, and symptoms may not fully resolve after removal. Understanding of pain and function limitations in this population is important to guide the clinical expectations. METHODS Individuals with idiopathic knee genu valgum who underwent hemiepiphysiodesis with tension plate constructs were identified through a medical records database search. Patient-reported outcomes measurement information system Physical Function/Mobility and Pain Interference domain scores were assessed before hemiepiphysiodesis, immediately before hardware removal, and after hardware removal. Radiographs were also assessed at these times to record the zones and angles of deformity and correction. RESULTS Twenty-eight subjects (53 operative limbs) contributed to the analysis. Mobility and pain interference as measured by the patient-reported outcomes measurement information system were below typical values in a small percentage of the population studied, only 3.6% scored in the moderate and none in the severe categories for both domains. Valgus by radiographic zone was corrected in all patients without significant rebound at follow-up. Compared with preoperative levels, mobility scores improved before hardware removal. Pain Interference scores improved both before hardware removal and at the final follow-up. CONCLUSIONS Frontal plane knee deformities in the idiopathic population do not cause pain or limit mobility in most subjects. This is critical information, emphasizing that surgical decisions may be made based on the deformity alone, presence of symptoms, and possible future morbidity secondary to valgus deformity. If surgery is postponed because an individual is asymptomatic, the window for correction with guided growth may be lost. Individuals undergoing hemiepiphysiodesis can expect that their pain and function will not be worse during the time that hardware is in place and that surgery is likely to improve any pain they may be experiencing. LEVEL OF EVIDENCE Level III; retrospective comparative study.
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Braga SR, Santili C, Rodrigues NVM, Soni JF, Green DW. Growth modulation for angular knee deformities: a practical guideline. Curr Opin Pediatr 2023; 35:110-117. [PMID: 36218192 DOI: 10.1097/mop.0000000000001183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW This study aimed to review the established concepts and advances related to growth modulation for treating knee angular deformities. Although they are considered well tolerated procedures, careful indications and accurate techniques are necessary to ensure good results. RECENT FINDINGS In addition to general clinical and radiographic evaluations, new tools such as two-dimensional low-dose radiography and gait analysis have been used to clarify angular and torsional combinations and the impact of mild angulations on the knee joint. Temporary epiphysiodesis is commonly the choice, and it can be performed with different implants such as staples, tension band plates (TBP), percutaneous transphyseal screws (PETS), sutures, and screws. SUMMARY Considering its principles, TBP has been preferred for younger children. Cost can be a limitation, and research for alternative implants such as screws and nonabsorbable sutures indicate they might be an alternative in the future. In adolescents, PETS becomes an attractive alternative; however, its reversible character has been controversial, and further studies are needed to establish limits in younger patients.
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Affiliation(s)
- Susana Reis Braga
- Santa Casa de Misericórdia de São Paulo
- Hospital Israelita Albert Einstein
| | - Claudio Santili
- Santa Casa de Misericórdia de São Paulo
- Hospital Israelita Albert Einstein
| | | | - Jamil F Soni
- Pontifícia Universidade Católica do Paraná
- Hospital do Trabalhador, Curitiba, Paraná, PR, Brazil
| | - Daniel W Green
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Xiao H, Li M, Zhu G, Tan Q, Ye W, Wu J, Mei H, Yan A. The effectiveness of physeal bar resection with or without Hemi-Epiphysiodesis to treat partial growth arrest. BMC Musculoskelet Disord 2023; 24:77. [PMID: 36710347 PMCID: PMC9885557 DOI: 10.1186/s12891-023-06167-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To evaluate the outcomes of distal femoral, proximal tibial, and distal tibial physeal bar resection combined with or without the Hemi-Epiphysiodesis procedure and provide a better understanding of the application of physeal bar resection combined with Hemi-Epiphysiodesis procedure in the treatment of physeal bar growth arrest. METHODS We retrospectively reviewed the patients who suffered physeal bar and underwent physeal bar resection with or without the Hemi-Epiphysiodesis technique during 2010-2020. All were followed up for at least 2 years or to maturity. A modified mapping method was used to determine the area of a physeal bar by CT data. The aLDFA, aMPTA, aLDTA, MAD, and LLD were measured to assess the deformity of the lower limb. RESULTS In total, 19 patients were included in this study. The average age was 8.9 years (range 4.4 to 13.3 years old). During the follow-up, 4 (21.1%) patients had an angular change < 5°; 12 (63.2%) patients had angular deformity improvement > 5° averaging 10.0° (range 5.3° to 23.2°), and 3 (15.8%) patients had improvement of the angular deformity averaging 16.8° (range 7.4° to 27.1°). Eleven patients (57.9%) had significant MAD improvement. After surgery, we found that 7 (36.8%) patients had an LLD change of < 5 mm and were considered unchanged. Only 2 (15%) patients had an LLD improvement > 5 mm averaging 1.0 cm (range 0.7 to 1.3 cm), and 7 (36.8%) patients had increasing of LLD > 5 mm averaging 1.3 cm (range 0.5 to 2.5 cm). There were no postoperative fractures, infections, or intraoperative complications such as neurovascular injury. CONCLUSION Physeal bar resection combined with Hemi-epiphysiodesis is helpful for partial epiphysis growth arrest. Without statistically verifying, we still believe that patients with limited growth ability could benefit more from physeal bar resection combined with Hemi-epiphysiodesis.
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Affiliation(s)
- Han Xiao
- grid.440223.30000 0004 1772 5147Department of Pediatric Orthopaedics, Hunan Children’s Hospital, No 86 Ziyuan Road, Yuhua District, Hunan Province 410007 Changsha City, China ,The Pediatric Academy of University of South China, 410007 Changsha, Hunan China
| | - Miao Li
- grid.440223.30000 0004 1772 5147Department of Pediatric Orthopaedics, Hunan Children’s Hospital, No 86 Ziyuan Road, Yuhua District, Hunan Province 410007 Changsha City, China ,The Pediatric Academy of University of South China, 410007 Changsha, Hunan China
| | - Guanghui Zhu
- grid.440223.30000 0004 1772 5147Department of Pediatric Orthopaedics, Hunan Children’s Hospital, No 86 Ziyuan Road, Yuhua District, Hunan Province 410007 Changsha City, China ,The Pediatric Academy of University of South China, 410007 Changsha, Hunan China
| | - Qian Tan
- grid.440223.30000 0004 1772 5147Department of Pediatric Orthopaedics, Hunan Children’s Hospital, No 86 Ziyuan Road, Yuhua District, Hunan Province 410007 Changsha City, China ,The Pediatric Academy of University of South China, 410007 Changsha, Hunan China
| | - Weihua Ye
- grid.440223.30000 0004 1772 5147Department of Pediatric Orthopaedics, Hunan Children’s Hospital, No 86 Ziyuan Road, Yuhua District, Hunan Province 410007 Changsha City, China ,The Pediatric Academy of University of South China, 410007 Changsha, Hunan China
| | - Jiangyan Wu
- grid.440223.30000 0004 1772 5147Department of Pediatric Orthopaedics, Hunan Children’s Hospital, No 86 Ziyuan Road, Yuhua District, Hunan Province 410007 Changsha City, China ,The Pediatric Academy of University of South China, 410007 Changsha, Hunan China
| | - Haibo Mei
- grid.440223.30000 0004 1772 5147Department of Pediatric Orthopaedics, Hunan Children’s Hospital, No 86 Ziyuan Road, Yuhua District, Hunan Province 410007 Changsha City, China ,The Pediatric Academy of University of South China, 410007 Changsha, Hunan China
| | - An Yan
- grid.440223.30000 0004 1772 5147Department of Pediatric Orthopaedics, Hunan Children’s Hospital, No 86 Ziyuan Road, Yuhua District, Hunan Province 410007 Changsha City, China ,The Pediatric Academy of University of South China, 410007 Changsha, Hunan China
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Braun S, Brenneis M, Holder J, Meurer A, Stief F. Intra- and interobserver reliability analysis of pediatric lower limb parameters on digital long leg radiographs. J Orthop Surg Res 2023; 18:69. [PMID: 36707864 PMCID: PMC9881281 DOI: 10.1186/s13018-023-03552-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 01/19/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Malalignments of the lower extremity are common reasons for orthopedic consultation because it may lead to osteoarthritis in adulthood. An accurate and reliable radiological assessment of lower limb alignment in children and adolescents is essential for clinical decision-making on treatment of limb deformities and for regular control after a surgical intervention. OBJECTIVE First, does the analysis of full-length standing anteroposterior radiographs show a good intra- and interobserver reliability? Second, which parameter is most susceptible to observer-dependent errors? Third, what is the Standard Error of Measurement (SEM95%) of the absolute femoral and tibial length? METHODS Two observers evaluated digital radiographs of 144 legs from 36 children and adolescents with pathological valgus alignment before a temporary hemiepiphysiodesis and before implant removal. Parameters included Mechanical Femorotibial Angle (MFA), Mechanical Axis Deviation (MAD), mechanical Lateral Distal Femoral Angle (mLDFA), mechanical Medial Proximal Tibial Angle (mMPTA), mechanical Lateral Proximal Femoral Angle (mLPFA), mechanical Lateral Distal Tibial Angle (mLDTA), Joint Line Convergence Angle (JLCA), femur length, tibial length. Intra- and interobserver reliability (ICC2,1), SEM95% and proportional errors were calculated. RESULTS The intra- and interobserver reliability for almost all measurements was found to be good to excellent (Intra-ICC2,1: 0.849-0.999; Inter-ICC2,1: 0.864-0.996). The SEM95% of both observers was found to be ± 1.39° (MFA), ± 3.31 mm (MAD), ± 1.06° (mLDFA) and ± 1.29° (mMPTA). The proportional error of MAD and MFA is comparable (47.29% vs. 46.33%). The relevant knee joint surface angles show a lower proportional error for mLDFA (42.40%) than for mMPTA (51.60%). JLCA has a proportional error of 138%. Furthermore, the SEM95% for the absolute values of the femoral and tibial length was 4.53 mm for the femur and 3.12 mm for the tibia. CONCLUSIONS In conclusion, a precise malalignment measurement and the knowledge about SEM95% of the respective parameters are crucial for correct surgical or nonsurgical treatment. The susceptibility to error must be considered when interpreting malalignment analysis and must be considered when planning a surgical intervention. The results of the present study elucidate that MAD and MFA are equally susceptible to observer-dependent errors. This study shows good to excellent intra- and interobserver ICCs for all leg alignment parameters and joint surface angles, except for JLCA. TRIAL REGISTRATION This study was registered with DRKS (German Clinical Trials Register) under the number DRKS00015053. LEVEL OF EVIDENCE I, Diagnostic Study.
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Affiliation(s)
- Sebastian Braun
- grid.411088.40000 0004 0578 8220Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt/Main, Germany
| | - Marco Brenneis
- grid.411088.40000 0004 0578 8220Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt/Main, Germany
| | - Jana Holder
- grid.411088.40000 0004 0578 8220Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt/Main, Germany ,grid.7039.d0000000110156330Department of Sports and Exercise Science, University of Salzburg, 5020 Salzburg, Austria
| | - Andrea Meurer
- grid.411088.40000 0004 0578 8220Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt/Main, Germany ,Medical Park St. Hubertus Klinik, Bad Wiessee, Germany
| | - Felix Stief
- grid.411088.40000 0004 0578 8220Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528 Frankfurt/Main, Germany ,grid.411088.40000 0004 0578 8220Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
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16
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Coppa V, Marinelli M, Procaccini R, Falcioni D, Farinelli L, Gigante A. Coronal plane deformity around the knee in the skeletally immature population: A review of principles of evaluation and treatment. World J Orthop 2022; 13:427-443. [PMID: 35633744 PMCID: PMC9124997 DOI: 10.5312/wjo.v13.i5.427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 10/02/2021] [Accepted: 04/09/2022] [Indexed: 11/09/2022] Open
Abstract
Coronal plane deformity around the knee, also known as genu varum or genu valgum, is a common finding in clinical practice for pediatricians and orthopedists. These deformities can be physiological or pathological. If untreated, pathological deformities can lead to abnormal joint loading and a consequent risk of premature osteoarthritis. The aim of this review is to provide a framework for the diagnosis and management of genu varum and genu valgum in skeletally immature patients.
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Affiliation(s)
- Valentino Coppa
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona 60121, Italy
| | - Mario Marinelli
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona 60121, Italy
| | - Roberto Procaccini
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona 60121, Italy
| | - Danya Falcioni
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona 60121, Italy
| | - Luca Farinelli
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona 60121, Italy
| | - Antonio Gigante
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona 60121, Italy
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Abstract
PURPOSE OF REVIEW Lower extremities axis alterations are a frequent cause for consultation in the medical practice of the care of paediatric patients. When it corresponds to pathological situations, guided growth surgery has been positioned as a possibility of well tolerated, reproducible and predictable resolution. For this reason, its use has increased significantly in recent years. In this review, its current indications, preoperative study, results and complications described in the updated literature will be discussed. RECENT FINDINGS The success of the technique remains high in the current literature, expanding the technique to other segments and disorders, and describing new ways of performing tension band with sutures. In addition, there is an increase in its incidence and a decrease in the associated hospitalized days, which can associate with techniques of lower morbidity. SUMMARY As guided growth surgery allows for successful correction of axis alterations, to achieve this, it is important to know the main indications, preoperative analysis and theoretical bases on which this technique is based, to carry it out in an adequate and timely manner, seeking an adequate resolution of the child's problem.
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Li G, Li J, Dong M, Zuo S. An Interference Inspection Algorithm of Limb and Hexapod Frame in the Treatment of Lower Limb Deformity. J Biomech Eng 2022; 144:1133333. [PMID: 35079773 DOI: 10.1115/1.4053400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Indexed: 11/08/2022]
Abstract
The Ortho-SUV frame is an innovative hexapod widely used in orthopedics for managing fractures and deformities. Avoidance of limb-frame interference is essential to verify the implementability of the pre-planned correction trajectory, as well as to maintain the continuity and security of the correction strategy. In this study, a novel interference inspection algorithm is developed to investigate the interaction of the limb and hexapod frame in the treatment of lower limb deformities. The algorithm is built on a minimum distance model of the cone frustum busbar and cylindrical axis using vector analysis. A pre-defined trajectory is generated by Cartesian coordinate path control. Subsequently, an interference case is performed through numerical simulation and motion simulation. The results show that the conclusion of numerical simulation and motion simulation are consistent, which prove the feasibility of the algorithm. The results also show that it is possible to identify the riskiest struts, which are prone to interfere with the limb, and the riskiest positions. The proposed algorithm can support the clinician in selecting the suitable frame configuration to avoid interference. The algorithm solves the problem that the interference can only be judged by clinical observation in the clinic.
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Affiliation(s)
- Guotong Li
- Beijing Key Laboratory of Advanced Manufacturing Technology, Faculty of Materials and Manufacturing, Beijing University of Technology, No.100, Pingleyuan, Chaoyang District, Beijing 100124, China
| | - Jianfeng Li
- Beijing Key Laboratory of Advanced Manufacturing Technology, Faculty of Materials and Manufacturing, Beijing University of Technology, No.100, Pingleyuan, Chaoyang District, Beijing 100124, China
| | - Mingjie Dong
- Beijing Key Laboratory of Advanced Manufacturing Technology, Faculty of Materials and Manufacturing, Beijing University of Technology, No.100, Pingleyuan, Chaoyang District, Beijing 100124, China
| | - Shiping Zuo
- Beijing Key Laboratory of Advanced Manufacturing Technology, Faculty of Materials and Manufacturing, Beijing University of Technology, No.100, Pingleyuan, Chaoyang District, Beijing 100124, China
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Shapiro G, Adato T, Paz S, Shrabaty T, Ron L, Simanovsky N, Zaidman M, Goldman V. Hemiepiphysiodesis for coronal angular knee deformities: tension-band plate versus percutaneous transphyseal screw. Arch Orthop Trauma Surg 2022; 142:105-113. [PMID: 32959086 DOI: 10.1007/s00402-020-03602-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/09/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Pediatric coronal plane knee deformities can be treated surgically using hemiepiphysiodesis. The two leading techniques used for hemiepiphysiodesis are: tension-band plates (TBP) and percutaneous transphyseal screws (PETS). We hypothesized that PETS would lead to faster guided correction of angular knee deformities than TBP. MATERIALS AND METHODS A retrospective cohort of 35 patients treated with either TBP or PETS in one medical institution was established. The cohort included both genu varum and genu valgum of both primary and secondary etiologies. We first compared the treatment groups for differences in demographic and malalignment characteristics. Then, we compared the treatment groups for differences in operation-related outcomes, radiological mechanical correction and complication rates. RESULTS We found that the use of PETS, compared to TBP, was associated with a faster implantation surgery and a shorter interval between implantation and removal, i.e., faster correction. Furthermore, PETS were associated with faster correction rates of the mechanical axis deviation, lateral distal femoral angle and medial proximal tibial angle. No significant differences in complication rates were found between the two treatments. CONCLUSION PETS provided a faster correction of angular knee deformities compared to TBP at similar complication rates. Hence, PETS could be considered a superior technique for hemiepiphysiodesis.
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Affiliation(s)
- Galina Shapiro
- Medical Corps, Israel Defense Forces, Military Post, 02149, Ramat Gan, Israel
| | - Tohar Adato
- Medical Corps, Israel Defense Forces, Military Post, 02149, Ramat Gan, Israel
| | - Shai Paz
- Pediatric Orthopedics Unit, Department of Orthopedic Surgery, Kyriat Hadassah, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Tareq Shrabaty
- Pediatric Orthopedics Unit, Department of Orthopedic Surgery, Kyriat Hadassah, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Lamdan Ron
- Pediatric Orthopedics Unit, Department of Orthopedic Surgery, Assuta Ashdod Medical Center, Ashdod, Israel
| | - Naum Simanovsky
- Pediatric Orthopedics Unit, Department of Orthopedic Surgery, Kyriat Hadassah, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Michael Zaidman
- Pediatric Orthopedics Unit, Department of Orthopedic Surgery, Kyriat Hadassah, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Vladimir Goldman
- Pediatric Orthopedics Unit, Department of Orthopedic Surgery, Kyriat Hadassah, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.
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Abstract
Through this article, the authors aim to summarize the techniques performed on both first time and recurrent skeletally immature patients experiencing patellar dislocation. This article focuses on several key points, such as the importance of medial patellofemoral ligament femoral insertions being distal to the growth plate and performing extensive lateral release and quadricep tendon lengthening in cases of obligatory dislocation. Although acknowledging the procedures discussed cannot be considered for all patients, as individuals with open growth plates may require additional operative time, in many cases these techniques yield high rates of success.
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Macneille R, Chen J, Segal L, Hennrikus W. Hemiepiphysiodesis Using a Transphyseal Screw at the Medial Malleolus for the Treatment of Ankle Valgus Deformity. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211061494. [PMID: 35097486 PMCID: PMC8664318 DOI: 10.1177/24730114211061494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The purpose of this study is to report outcomes of transphyseal screw hemi-epiphysiodesis at the medial malleolus for the treatment of valgus ankle deformity. Methods: An institutional review board–approved retrospective review was done of 24 patient charts. Lateral distal tibial angle (LDTA) was measured preoperatively and at final follow-up. Results: The average change in LDTA was 8.3 degrees (SD 4.9 degrees; range 0-19 degrees). The average rate of correction was 0.4 degrees per month (SD 0.3; range 0-1.4). Conclusion: Medial malleolar transphyseal screw hemiepiphysiodesis is a simple, effective, and safe treatment for valgus ankle deformity in skeletally immature children. Level of Evidence: Level IV, case series.
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Affiliation(s)
- Rhett Macneille
- Department of Orthopedic Surgery, Loma Linda School of Medicine, Loma Linda, CA, USA
| | - Joshua Chen
- Department of Orthopedics, Penn State College of Medicine, Hershey, PA, USA
| | - Lee Segal
- Accreditation Council for Graduate Medical Education Chicago, IL, USA
| | - William Hennrikus
- Department of Orthopedics, Penn State College of Medicine, Hershey, PA, USA
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Jamil K, Yahaya MY, Abd-Rasid AF, Ibrahim S, Abdul-Rashid AH. Angular Deformities of the Knee in Children Treated with Guided Growth. Malays Orthop J 2021; 15:26-35. [PMID: 34429819 PMCID: PMC8381675 DOI: 10.5704/moj.2107.005] [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] [Received: 06/10/2020] [Accepted: 04/05/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: The guided growth technique is an alternative to corrective osteotomy for treating angular deformities of the extremities. It has the advantage of being minimally invasive and is effective in a growing child. This study reports on the outcome of guided growth technique using a plate in correcting knee angular deformities. Material and Methods: We conducted a retrospective study of children with angular deformity of the knee treated by the guided growth technique from January 2010 to December 2015 in a tertiary centre. The guided growth technique was done using either the flexible titanium plate (8-plate) or the 2-hole reconstruction plate. Correction of deformity was assessed on radiographs by evaluating the mechanical axis deviation and tibiofemoral angle. The implants were removed once deformity correction was achieved. Results: A total of 17 patients (27 knees) were evaluated. Twenty-two knees (81.5%) achieved complete correction of the deformity. The median age was 4.0 (interquartile range 3.0-6.0) years and the median Body Mass Index (BMI) was 26.0 (25.0-28.0). There were 7 unilateral and 10 bilateral deformities with different pathologies (14 tibia vara, 3 genu valgus). The median rate of correction was 0.71° per month. One patient (1 knee) had screw pull-out and two patients (4 knees) had broken screws in the proximal tibia. Three patients (5 knees) failed to achieve complete correction and were subsequently treated with corrective osteotomies. Out of five patients (8 knees) who were followed-up for at least 12 months after removal of hardware, two had rebound deformities. No permanent growth retardation occurred in our patients. Conclusion: Our outcome for guided growth to correct knee angular deformity was similar to other studies. Guided growth is safe to perform in children below 12 years old and has good outcome in idiopathic genu valgus and Langeskiold II for tibia vara. Patients should be observed for recurrence until skeletal maturity following implant removal.
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Affiliation(s)
- K Jamil
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - M Y Yahaya
- Department of Orthopaedics, Universiti Teknologi Mara, Batu Caves, Malaysia.,Faculty of Medicine, Universiti Teknologi Mara, Sungai Buloh, Malaysia
| | - A F Abd-Rasid
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - S Ibrahim
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - A H Abdul-Rashid
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Rickert KD, Arrigoni P, Guzel CR, Barber HF, Alman BA, Lark RK. Growth Modulation by Stimulating the Growth Plate: A Pilot Study. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2339-2345. [PMID: 34016487 DOI: 10.1016/j.ultrasmedbio.2021.03.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 03/19/2021] [Accepted: 03/29/2021] [Indexed: 06/12/2023]
Abstract
This study investigates the ability of low-intensity pulsed ultrasound (LIPUS) or direct injection of recombinant growth hormone (rGH) to stimulate local growth of long bones. In a randomized controlled animal trial, healthy immature rabbits were allocated to 1 of the following 4 conditions: epiphyseal rGH periosteal injection, transdermal LIPUS, saline periosteal injection, or no treatment. New bone deposition was labeled with calcein at days 1 and 18, and microscopic measurements of growth were conducted by blinded observers. Statistically significant differences in growth were observed between the LIPUS and rGH stimulated legs compared with contralateral control legs (35% p = 0.04 and 41% p = 0.04, respectively); whereas no difference was observed between the 4 control groups (p = 0.37). There was no evidence of physeal bar formation, suggesting that direct injection of rGH and application of LIPUS around the distal femoral physis in rabbits may have a positive effect on microscopic growth without short-term adverse sequelae.
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Affiliation(s)
- Kathleen D Rickert
- Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA; Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
| | - Paolo Arrigoni
- Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA; Department of Orthopaedics, Universita' delgi Studi di Pavia, Pavia, Italy
| | - Camille R Guzel
- Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA
| | - Helena F Barber
- Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA
| | - Benjamin A Alman
- Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA; Department of Orthopaedics, Hospital for Sick Kids, Toronto, ON, Canada
| | - Robert K Lark
- Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA.
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24
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Nichols LRB. Has the Threshold for Epiphysiodesis Versus Lengthening Changed in the Era of Magnetically Controlled Nails? J Pediatr Orthop 2021; 41:S24-S32. [PMID: 34096534 DOI: 10.1097/bpo.0000000000001801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Limb length discrepancy (LLD) is common in both the pediatric and adult population. Length inequalities can be due to a multitude of etiologies including congenital, developmental, and acquired causes. There has been little consensus on the morbidity of LLD and, as a result, the threshold necessary for treatment of LLD to prevent morbidity. Advances in magnetically controlled lengthening devices achieve greater accuracy and patient satisfaction and create an opportunity to lower the threshold for limb lengthening. DISCUSSION Asymptomatic LLD is relatively common in both pediatric and adult populations. Only ~10% of the population has equal leg length. LLD of <5 cm may lead to long-term morbidities such as scoliosis, lower back pain, gait abnormalities, stress on hip or knee joint, and lower extremity symptomatic versus asymptomatic osteoarthritis. The teaching in most orthopaedic textbooks is to adjust the shoe if symptomatic for discrepancies up to 2 cm; consider an orthotic, epiphysiodesis, or skeletal shortening for 2.5 to 5 cm; and possible limb reconstruction for >5 cm. The assumption is that there are no long-term consequences of mild LLD. However, data in recent literature show that small discrepancies may contribute to pathologic changes such as pain, gait abnormalities, and osteoarthritis. Major advances have been made in limb lengthening over the past 40 years. The increased accuracy and superior patient satisfaction of the magnetically controlled lengthening nail versus external fixation methods argue for including lengthening for LLD of <5 cm. CONCLUSION If mild LLD can cause long-term pathology, it is important to counsel families on the full range of options for limb equalization no matter the size of the discrepancy. The evolution in technology and understanding of limb lengthening has provided additional safe surgical options. Therefore, the historic treatment protocol for addressing limb differences may need to include lengthening for smaller discrepancies even <2 cm.
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Affiliation(s)
- L Reid Boyce Nichols
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
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Lin KM, Thacher RR, Apostolakos JM, Heath MR, Mackie AT, Fabricant PD. Implant-Mediated Guided Growth for Coronal Plane Angular Deformity in the Pediatric Patient with Patellofemoral Instability. Arthrosc Tech 2021; 10:e913-e924. [PMID: 33738233 PMCID: PMC7953424 DOI: 10.1016/j.eats.2020.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/06/2020] [Indexed: 02/03/2023] Open
Abstract
Pediatric patellofemoral instability is a complex problem, for which there are several anatomic risk factors. Coronal plane malalignment (i.e., genu valgum) is one cause of patellofemoral instability, and treatment of genu valgum has been associated with improved patellofemoral stability. Coronal plane angular deformity correction, typically achieved by distal femoral osteotomy in the adult population, can be achieved with less invasive surgical techniques in pediatric patients using implant-mediated guided growth. By temporarily tethering one side of an open physis to generate differential growth in the coronal plane, valgus malalignment can be corrected. We present our technique for medial distal femoral implant-mediated guided growth using tension band plating for treatment of pediatric patellofemoral instability associated with genu valgum. This technique is minimally invasive, has a low complication rate, and in conjunction with conventional treatment can reduce the risk of recurrent instability.
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Affiliation(s)
- Kenneth M. Lin
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Ryan R. Thacher
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - John M. Apostolakos
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Madison R. Heath
- Pediatric Orthopedic Surgery Service, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Alexandra T. Mackie
- Pediatric Orthopedic Surgery Service, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Peter D. Fabricant
- Pediatric Orthopedic Surgery Service, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
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Dai ZZ, Liang ZP, Li H, Ding J, Wu ZK, Zhang ZM, Li H. Temporary hemiepiphysiodesis using an eight-plate implant for coronal angular deformity around the knee in children aged less than 10 years: efficacy, complications, occurrence of rebound and risk factors. BMC Musculoskelet Disord 2021; 22:53. [PMID: 33422021 PMCID: PMC7797153 DOI: 10.1186/s12891-020-03915-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Temporary hemiepiphysiodesis (TH) using an eight-Plate implant is one of the most common surgeries used for the correction of coronal angular deformities around the knee in adolescents. However, few studies have focused on children aged less than 10 years treated with TH using an eight-Plate implant. The purpose of this study was to investigate the efficacy, correction velocity, and complications of TH with an eight-Plate implant as well as the occurrence of rebound and risk factors in this population. METHODS This retrospective study included a total of 135 physes (101 knees) from 66 children (mean age of 4.69 years old, range from 1 to 10 years old) who underwent TH with an eight-Plate implant to correct coronal genu angular deformities in our hospital. Related clinical factors were recorded and analysed by multivariable linear and logistic regression models. RESULTS The mean deformity correction period was 13.26 months, and the mean follow-up after eight-Plate removal was 12.71 months. In all, 94.06% (95/101 knees) of the genu angular deformities were completely corrected. Non-idiopathic genu angular deformity was found to be an independent risk factor for deformity correction failure (odds ratio (OR) = 2.47). The femoral correction velocity was significantly higher than the tibial correction velocity (1.28° vs. 0.83° per month, p < 0.001). After adjustment for other factors, younger children had higher correction velocities in the distal femur; however, genu valgum and idiopathic deformities were associated with higher correction velocities in the proximal tibia. In addition, we found three (3/101, 2.97%) knees with genu valgum that experienced rebound after removal of the eight-Plate, while five (5/101, 4.95%) knees with non-idiopathic genu angular deformity experienced screw loosening. No other complications were found, and non-idiopathic deformity was the only risk factor for complications (OR = 3.96). No risk factor was found for rebound in our study. CONCLUSIONS TH using an eight-Plate implant is an effective procedure for coronal genu angular deformities with a low incidence of complications and rebound in patients younger than 10 years old. For this population, TH using an eight-Plate should be considered as soon as the deformity stops responding to conservative treatments. The parents of children younger than 10 years of age with non-idiopathic deformities should be informed preoperatively that the deformity may be prone to correction failure or screw loosening after eight-Plate implantation.
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Affiliation(s)
- Zhen-Zhen Dai
- Department of Pediatric Orthopedics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Yangpu District, 200092, Shanghai, China
| | - Zhen-Peng Liang
- Department of Pediatric Orthopedics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Yangpu District, 200092, Shanghai, China
| | - Hao Li
- Department of Pediatric Orthopedics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Yangpu District, 200092, Shanghai, China
| | - Jing Ding
- Department of Pediatric Orthopedics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Yangpu District, 200092, Shanghai, China
| | - Zhen-Kai Wu
- Department of Pediatric Orthopedics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Yangpu District, 200092, Shanghai, China
| | - Zi-Ming Zhang
- Department of Pediatric Orthopedics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Yangpu District, 200092, Shanghai, China
| | - Hai Li
- Department of Pediatric Orthopedics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Yangpu District, 200092, Shanghai, China.
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Baroncelli GI, Mora S. X-Linked Hypophosphatemic Rickets: Multisystemic Disorder in Children Requiring Multidisciplinary Management. Front Endocrinol (Lausanne) 2021; 12:688309. [PMID: 34421819 PMCID: PMC8378329 DOI: 10.3389/fendo.2021.688309] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
X-linked hypophosphatemic rickets (XLH) is the commonest inherited form of rickets. It is caused by an impaired regulation of fibroblast growth factor 23 (FGF23) due to a PHEX gene mutation, which leads to reduced tubular reabsorption of phosphate and renal 1α-hydroxylase activity and increased renal 24-hydroxylase activity. Hypophosphatemia associated with renal phosphate wasting, normal serum levels of calcium, parathyroid hormone, and 25-hydroxyvitamin D represents the main biochemical sign in affected patients. Patients with XLH show rickets and osteomalacia, severe deformities of the lower limbs, bone and muscular pain, stunted growth, and reduced quality of life. However, XLH is a multisystemic disorder requiring multidisciplinary approaches in specialized subdisciplines. Severe complications may occur in patients with XLH including craniosynostosis, hearing loss, progressive bone deformities, dental and periodontal recurrent lesions, and psychosocial distress. Moreover, long-term conventional treatment with active vitamin D metabolites and oral inorganic phosphate salts may cause endocrinological complications such as secondary or tertiary hyperparathyroidism, and adverse events in kidney as hypercalciuria, nephrocalcinosis, and nephrolithiasis. However, conventional treatment does not improve phosphate metabolism and it shows poor and slow effects in improving rickets lesions and linear growth. Recently, some trials of treatment with recombinant human IgG1 monoclonal antibody that targets FGF23 (burosumab) showed significant improvement of serum phosphate concentration and renal tubular reabsorption of phosphate that were associated with a rapid healing of radiologic signs of rickets, reduced muscular and osteoarticular pain, and improved physical function, being more effective for the treatment of patients with XLH in comparison with conventional therapy. Therefore, a global management of patients with XLH is strongly recommended and patients should be seen regularly by a multidisciplinary team of experts.
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Affiliation(s)
- Giampiero Igli Baroncelli
- Pediatric and Adolescent Endocrinology, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
- *Correspondence: Giampiero Igli Baroncelli, ; Stefano Mora,
| | - Stefano Mora
- Laboratory of Pediatric Endocrinology and Bone Densitometry Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
- *Correspondence: Giampiero Igli Baroncelli, ; Stefano Mora,
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Lee SW, Lee KJ, Cho CH, Ye HU, Yon CJ, Choi HU, Kim YH, Song KS. Affecting Factors and Correction Ratio in Genu Valgum or Varum Treated with Percutaneous Epiphysiodesis Using Transphyseal Screws. J Clin Med 2020; 9:jcm9124093. [PMID: 33353069 PMCID: PMC7766970 DOI: 10.3390/jcm9124093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022] Open
Abstract
This study evaluated the correction rates of idiopathic genu valgum or varum after percutaneous epiphysiodesis using transphyseal screws (PETS) and analyzed the affecting factors. A total of 35 children without underlying diseases were enrolled containing 64 physes (44 distal femoral (DT), 20 proximal tibial (PT)). Anatomic tibiofemoral angle (aTFA) and the mechanical axis deviation (MAD) were taken from teleroentgenograms before PETS surgery and screw removal. The correction rates of the valgus and varus deformities for patients treated with PETS were 1.146°/month and 0.639°/month using aTFA while using MAD showed rates of 4.884%/month and 3.094%/month. After aTFA (p < 0.001) and MAD (p < 0.001) analyses, the correction rate of DF was significantly faster than that of PT. Under multivariable analysis, the aTFA correction rate was significantly faster in younger patients (p < 0.001), in males (p < 0.001), in patients with lower weights (p < 0.001), and in the group that was screwed at DF (p < 0.001). Meanwhile, the MAD correction rate was significantly faster in patients with lower heights (p = 0.003). PETS is an effective treatment method for valgus and varus deformities in growing children and clinical characters should be considered to estimate the correction rate.
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Tahririan MA, Mohammadsharifi G. Correction of the knee coronal plane deformity using the screws plus reconstruction plate versus cannulated screws. Orthop Traumatol Surg Res 2020; 106:1345-1351. [PMID: 32962950 DOI: 10.1016/j.otsr.2020.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 04/09/2020] [Accepted: 04/16/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Knee angular deformity is a common finding occurring in the childhood that can cause gait disturbances and early compartment osteoarthritis. Despite various surgical approaches presented to correct the angular deformities of the knee, there is still a search for the best approach. Thus, the present study was conducted to compare the results of using cannulated screw (CS) versus screw plus reconstruction plate (SpRP) for correction of angular deformities through a two-year follow-up study. HYPOTHESIS Percutaneous CS implantation is as efficacious as SpRP implantation for the correction of angular deformities of the knee. MATERIAL AND METHODS This randomised clinical trial (RCT) was conducted on 63 patients with angular deformities who were randomly divided into two groups including treatment with cannulated screw (CS) (n=32) and treatment with screw plus reconstruction plate (SpRP) (n=31). All the patients underwent the alignment view radiography of both lower limbs before surgical procedure and then within 3, 6, 12, 18 months and 2 years following the surgery. Afterwards, the patients' mechanical axis of the knees, medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), and varus/valgus angles were assessed and compared. RESULTS Results of the study showed that MPTA and LDFA significantly turned to the normal range during the 18 months follow-up in both treatment groups (p-value<0.001). Varus and valgus angles were corrected in both techniques as well postoperatively (p-value<0.001). Ultimate correction was achieved earlier in the CS treated group (12 months versus 18 months later). DISCUSSION Findings of the study revealed that the percutaneous CS implantation was successful similar to the SpRP implantation for correction of the angular deformity, while earlier ultimate angular correction and less pain complaint were among the superiorities of the CS. LEVEL OF THE STUDY II, comparative prospective study.
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CORR Synthesis: Can Guided Growth for Angular Deformity Correction Be Applied to Management of Pediatric Patellofemoral Instability? Clin Orthop Relat Res 2020; 478:2231-2238. [PMID: 32433105 PMCID: PMC7491886 DOI: 10.1097/corr.0000000000001311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
BACKGROUND Patients with congenital fibular deficiency often develop genu valgum secondary to lateral femoral condylar hypoplasia. Guided growth strategies are often performed to correct limb alignment when adequate skeletal growth remains. METHODS A retrospective review of patients with postaxial hypoplasia of the lower extremity managed with an amputation strategy and who had a guided growth procedure for coronal plane limb malalignment during their course of treatment was performed. Clinical and radiographic data, including measures of coronal plane deformity and alignment, type of amputation, subsequent operative procedures, and complications were recorded. RESULTS Seventeen patients (20 extremities) met study inclusion criteria (mean follow-up 8.8 y). Foot ablation and hemiepiphysiodesis for valgus deformity of the knee was performed in all extremities. The average age at the time of initial hemiepiphysiodesis was 11.2 years at an average of 8.8 years from the initial amputation procedure. The mean preoperative mechanical axis deviation was 26.5 mm, which was corrected to a mean mechanical axis deviation of 7.0 mm. Fifteen (75%) of the extremities had correction of the deformity to neutral alignment after the initial procedure. Lack of correction occurred in 3 extremities, and overcorrection occurred in 2 extremities. Additional procedures were required in 5 extremities for rebound valgus deformity after hardware removal. CONCLUSIONS In patients with postaxial hypoplasia, regular monitoring of the residual limb for growth-related changes must occur to ensure optimal function and prosthetic fit. Timing of the guided growth procedure is critical, as younger patients may be more likely to experience rebound deformity. Families and patients should be made aware that growth might be unpredictable in this population with risks of both overcorrection and undercorrection. LEVEL OF EVIDENCE Level IV-case series.
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Raimann A, Mindler GT, Kocijan R, Bekes K, Zwerina J, Haeusler G, Ganger R. Multidisciplinary patient care in X-linked hypophosphatemic rickets: one challenge, many perspectives. Wien Med Wochenschr 2020; 170:116-123. [PMID: 31993875 PMCID: PMC7098922 DOI: 10.1007/s10354-019-00732-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022]
Abstract
X‑linked hypophosphatemic rickets (XLH, OMIM #307800) is a rare genetic metabolic disorder caused by dysregulation of fibroblast-like growth factor 23 (FGF23) leading to profound reduction in renal phosphate reabsorption. Impaired growth, severe rickets and complex skeletal deformities are direct consequences of hypophosphatemia representing major symptoms of XLH during childhood. In adults, secondary complications including early development of osteoarthritis substantially impair quality of life and cause significant clinical burden. With the global approval of the monoclonal FGF23 antibody burosumab, a targeted treatment with promising results in phase III studies is available for children with XLH. Nevertheless, complete phenotypic rescue is rarely achieved and remaining multisystemic symptoms demand multidisciplinary specialist care. Coordination of patient management within the major medical disciplines is a mainstay to optimize treatment and reduce disease burden. This review aims to depict different perspectives in XLH patient care in the setting of a multidisciplinary centre of expertise for rare bone diseases.
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Affiliation(s)
- Adalbert Raimann
- Comprehensive Center for Pediatrics, Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria. .,Vienna Bone and Growth Centre, Vienna, Austria.
| | - Gabriel T Mindler
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria.,Vienna Bone and Growth Centre, Vienna, Austria
| | - Roland Kocijan
- Hanusch Hospital of the WGKK and AUVA Trauma Center, 1st Medical Department at Hanusch Hospital, Ludwig Boltzmann Institute of Osteology, Vienna, Austria.,Vienna Bone and Growth Centre, Vienna, Austria
| | - Katrin Bekes
- Department of Pediatric Dentistry, School of Dentistry, Medical University of Vienna, Vienna, Austria
| | - Jochen Zwerina
- Hanusch Hospital of the WGKK and AUVA Trauma Center, 1st Medical Department at Hanusch Hospital, Ludwig Boltzmann Institute of Osteology, Vienna, Austria.,Vienna Bone and Growth Centre, Vienna, Austria
| | - Gabriele Haeusler
- Comprehensive Center for Pediatrics, Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria.,Vienna Bone and Growth Centre, Vienna, Austria
| | - Rudolf Ganger
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria.,Vienna Bone and Growth Centre, Vienna, Austria
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Gupta P, Gupta V, Patil B, Verma V. Angular deformities of lower limb in children: Correction for whom, when and how? J Clin Orthop Trauma 2020; 11:196-201. [PMID: 32099279 PMCID: PMC7026560 DOI: 10.1016/j.jcot.2020.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 01/17/2023] Open
Abstract
Angular deformities are common presentations in childhood and adolescent age group. It is important to differentiate a true deformity from a physiological deformity, this requires measurement of the intercondylar and intermalleolar distance. Once a true deformity is diagnosed, the apex of the deformity requires to be established. Lower limb frontal plane deformities are evaluated with a true AP standing radiographs of the entire lower limb from hip to ankle. Mechanical or anatomical axis calculation gives the apex (CORA) as well as the magnitude of deformity. Frontal plane deformities require surgical intervention. In younger children, growth modulation surgery allows correction of the deformity with minimal morbidity and without the need for osteotomy. Older children, adolescents and adults require corrective osteotomy. The corrective osteotomy can be closed wedge, open wedge, or a dome osteotomy. The osteotomy may be stabilized with internal fixation with plate and screws or an intramedullary implant as is dictated by the level of osteotomy and the local bony anatomy. External fixators allow gradual and precise correction of the deformity.
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Affiliation(s)
- Parmanand Gupta
- Orthopaedics, Govt. Medical College Hospital, Chandigarh, India,Corresponding author.
| | - Vikas Gupta
- Orthopaedics, Vardhman Mahavir Medical College Hospital, New Delhi, India
| | - Bharath Patil
- Orthopaedics, Govt. Medical College Hospital, Chandigarh, India
| | - Vishal Verma
- Orthopedics, Positron Hospital, Sector 35, Rohtak, Haryana, India
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35
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Martínez G, Gündel A, Ruiz P, Cañete I, Hodgson F. Distal femoral hemiepiphysiodesis with screws and suture versus 8-plate for the treatment of genu valgum in children. Orthop Traumatol Surg Res 2019; 105:751-755. [PMID: 31000342 DOI: 10.1016/j.otsr.2019.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/14/2019] [Accepted: 02/26/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There are different techniques for gradual correction of angular deformities in lower limbs. The use of screws and non-absorbable filament have been described as an effective alternative for transitory hemiepiphysiodesis in pediatric population. HYPOTHESIS In pediatric population with genu valgum there are no differences in outcome between hemiepiphysiodesis, using screws and non-absorbable filament (SNAF) versus 8-plate. METHODS Retrospective evaluation, 44 knees in 22 patients younger than 15 years, with idiopathic genu valgum, were operated on. One group (20 knees) was operated on with 8-plate technique and another group (24 knees) was operated on with SNAF technique. Initial and final intermalleolar distance (IMD) and mechanical lateral distal femoral angle (mLDFA) were compared, registering complications for each group. Mann-Whitney test was used for statistics, with significance value <0.05. RESULTS All patients achieved the expected mechanical axis correction. IMD and mLDFA significatively improved. There were no significant differences in magnitude and speed of correction when comparing the two techniques. Only one SNAF patient had a minor perioperative complication. DISCUSSION This report compares postoperative results between SNAF and 8-plate technique for correction of angular deformities in lower limbs. In this series of patients, significant clinical and radiological changes were observed between the initial and final values using both techniques, with no significant differences between them. Our group proposes the SNAF technique as an efficient, simple and cost-effective alternative to the traditional 8-plate technique, for the treatment of idiopathic genu valgum in children. LEVEL OF EVIDENCE III, retrospective comparative study.
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Affiliation(s)
- Gino Martínez
- Department of Traumatology and Orthopedics, Clinical Hospital of Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Alejandro Gündel
- Department of Traumatology and Orthopedics, Clinical Hospital of Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Ruiz
- Department of Traumatology and Orthopedics, Clinical Hospital of Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ismael Cañete
- Department of Traumatology and Orthopedics, Clinical Hospital of Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Felipe Hodgson
- Department of Traumatology and Orthopedics, Clinical Hospital of Pontificia Universidad Católica de Chile, Santiago, Chile
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Lin YH, Chang FS, Chen KH, Huang KC, Su KC. Mismatch between femur and tibia coronal alignment in the knee joint: classification of five lower limb types according to femoral and tibial mechanical alignment. BMC Musculoskelet Disord 2018; 19:411. [PMID: 30474544 PMCID: PMC6260902 DOI: 10.1186/s12891-018-2335-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/06/2018] [Indexed: 11/12/2022] Open
Abstract
Background Reasons for dissatisfaction with total knee arthroplasty (TKA) include unequal flexion or extension gap, soft tissue imbalance, and patella maltracking, which often occur with mismatch between femoral and tibial coronal bony alignment in the knee joint or extremely varus or valgus alignment. However, lower limb coronal alignment classification is based only on hip–knee–ankle angle (HKAA), leading to oversight regarding a mismatch between femoral and tibial coronal alignment. We aimed to classify alignment of the lower limbs according to the mechanical alignment of the femur and tibia in a healthy population. Methods All 214 normal triple films were reviewed retrospectively. HKAA, mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), angle between the femoral anatomical axis and the mechanical axis (AA-MA), and knee alignment angle (KAA) were measured. Subjects were categorized into one of five types based on the mechanical alignment of femur and tibia. Results Mean HKAA, mLDFA, and mMPTA of all subjects were 1.2°, 87.3°, and 85.8°, respectively. All subjects were classified into one of five types with significant differences (p < 0.001). About 61% of subjects showed neutral alignment, of which nearly 40% were type 2 (valgus of the femur and varus of the tibia with oblique joint line: mLDFA 85.0° ± 1.4°, mMPTA 85.1° ± 1.2°, TJLA 2.7° ± 2.4°) and 60% exhibited neutral alignment with a neutral femur and tibia (type 1). In varus and valgus types, mismatch between the mechanical angle of the femur and tibia was common. Varus alignment, including types 3 (varus of the tibia: mLDFA 88.0° ± 1.4°, mMPTA 83.5° ± 1.6°) and 4 (varus of both the tibia and femur: mLDFA 91.4° ± 1.4°, mMTPA 85.2° ± 2.0°), was found in 30% of subjects. Valgus alignment (type 5 valgus of femur: mLDFA 84.6° ± 1.6°, mMPTA 88.8° ± 2.0°) accounted for 8.9% of all subjects. Conclusions Mismatch between mechanical alignment of the femur and tibia was common in varus and valgus alignment types. Joint line obliquity was also observed in 40% of the neutral alignment population. This classification provides a quick, simple interpretation of femoral and tibial coronal alignment, and more detailed guidance for preoperative planning for TKA than the traditional varus–neutral–valgus classification. Electronic supplementary material The online version of this article (10.1186/s12891-018-2335-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yu-Hsien Lin
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sect. 4, Taichung City, 40705, Taiwan
| | - Feng-Shuo Chang
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sect. 4, Taichung City, 40705, Taiwan
| | - Kun-Hui Chen
- Department of Biomedical Engineering, Hungkuang University, 1018, Sec. 6, Taiwan Boulevard, Shalu District, Taichung City, 43302, Taiwan.,Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Biomedical Engineering, National Yang-Ming University, No. 155, Section 2, Linong St, Beitou District, Taipei City, Taiwan, 112
| | - Kui-Chou Huang
- Department of Orthopedic Surgery, Asia University Hospital, 222, Fuxin Rd., Wufeng Dist, Taichung City, 41354, Taiwan. .,Department of Occupational Therapy, Asia University, 500, Lioufeng Rd., Wufeng, Taichung City, 41354, Taiwan.
| | - Kuo-Chih Su
- Department of Medical Research, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sect. 4, Taichung City, 40705, Taiwan.,RongHsing Research Center for Translational Medicine, National Chung Hsing University, 145, Xingda Rd., South Dist, Taichung City, 402, Taiwan.,Department of Biomedical Engineering, Hungkuang University, 1018, Sec. 6, Taiwan Boulevard, Shalu District, Taichung City, 43302, Taiwan
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Abstract
UNLABELLED This study reported guided growth for caput valgum deformity and subsequent hip development. Ten children with unilateral hip dysplasia had guided growth by one eccentric transphyseal screw at age 9.1 years with minimum 2 years of follow-up. The first change was decreasing articulotrochanteric distance and then increasing physis tilt angle and head-shaft angle by 1.5 years. The center edge angle that was significantly less than the normal side (18.3 vs. 24.8°) preoperatively became comparable between both the hips 2 years later. Rebounding of physis inclination after screw back out suggested mechanical tethering, rather than permanent physis closure, resulted in morphologic changes in the femur. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Abstract
UNLABELLED This retrospective cohort study examined 20 patients (48 physes), 11 boys and nine girls, who were treated with hinge-plate or eight-plate. The mean age of the patients at surgery was 11.9±2.6 years. The mean follow-up duration was 13±2.7 months. The radiographic measurement of both distal femoral and proximal tibial deformity showed significant correction, with no difference between the hinge-plate and the eight-plate. Both screw divergence angle and the hinge angle showed significant changes at the last follow-up. The deformity correction of the distal femoral physis was quicker than the proximal tibial physis. The rate of mechanical femoral-tibial angle correction was 0.97°/month if both femoral and tibial physes were treated. LEVEL OF EVIDENCE III.
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Hemiepiphysiodesis for the correction of proximal tibial valgus in growing dogs. Vet Comp Orthop Traumatol 2017; 29:330-7. [DOI: 10.3415/vcot-15-12-0204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 04/26/2016] [Indexed: 11/17/2022]
Abstract
SummaryObjectives: To describe the use of hemiepiphysiodesis for the treatment of proximal tibial deformities in immature dogs and evaluate the effect on the mechanical medial proximal tibial angle (mMPTA).Methods: Skeletally immature dogs with proximal tibial deformities from three institutions treated with hemiepiphysiodesis between March 2006 and January 2015 were included. All dogs were required to have an mMPTA outside the previously published reference range (93.3 ± 1.78°) preoperatively. Dogs were required to have radiographs or computed tomography performed preoperatively and at least eight weeks postoperatively.Results: A total of 19 dogs (n = 31 limbs) fulfilled the inclusion criteria. The mean mMPTA was 102.5° ± 5.3° preoperatively and 92.4° ± 7.2° at the final re-evaluation. The mean difference in mMPTA was -10 ± 5.1° (range, -1 to -19°; p <0.001). Overcorrection was observed in 16 limbs and mMPTA remained above the reference range in nine limbs. Rebound growth was observed in eight limbs where implant removal was performed.Clinical significance: Hemiepiphysiodesis for the treatment of proximal tibial valgus is a technique that allows for reduction in mMPTA and should be considered as an early treatment for immature animals that are presented with proximal tibial deformities. Serial radiographs to monitor for overcorrection should be performed. Implant removal should be considered if overcorrection occurs, taking into consideration that rebound growth may be observed.A Supplementary Table for this paper is available online at: http://dx.doi.org/10.3415/VCOT-15-12-0204
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Yang I, Gottliebsen M, Martinkevich P, Schindeler A, Little DG. Guided Growth: Current Perspectives and Future Challenges. JBJS Rev 2017; 5:e1. [DOI: 10.2106/jbjs.rvw.16.00115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Paediatric lower limb deformity correction with the Eight Plate: adverse events and correction outcomes of 126 patients from an international multicentre study. J Pediatr Orthop B 2017; 26:441-448. [PMID: 27832012 DOI: 10.1097/bpb.0000000000000397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
No large multicentre studies have yet been published on tension-band-like implants such as the Eight Plate to treat limb-length discrepancies and varus valgus deformities in children. Therefore, we carried out a retrospective international multicentre study including 126 patients to assess outcomes and to reliably quantify the incidence of implant-related and growth-plate related adverse events (AEs). Correction was achieved in 66% of varus valgus deformities and in 59% of limb-length discrepancies and maintained in 85%. Twenty (18%) patients experienced 43 AEs, which were primarily screw-related. The AE rate of the Eight Plate is low; however, many of them could be avoided through tighter monitoring.
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Farr S, Kranzl A, Hahne J, Ganger R. Rotational gait patterns in children and adolescents following tension band plating of idiopathic genua valga. J Orthop Res 2017; 35:1617-1624. [PMID: 27617888 DOI: 10.1002/jor.23434] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/08/2016] [Indexed: 02/04/2023]
Abstract
Literature suggests that children and adolescents with idiopathic genua valga present with considerable gait deviations in frontal and transverse planes, including altered frontal knee moments, reduced external knee rotation, and increased external hip rotation. This study aimed to evaluate gait parameters in these patients after surgical correction using tension band plating (TBP). We prospectively evaluated 24 consecutive, skeletally immature patients, who received full-length standing radiographs and three-dimensional gait analysis before and after correction, and compared the results observed to a group of 11 typically developing peers. Prior to TBP the cohort showed significantly decreased (worse) internal frontal knee moments compared to the control group. After axis correction the mean and maximum knee moments changed significantly into normalized knee moments (p < 0.0001). In the transverse plane, only the foot progression angle (p = 0.020) changed significantly following intervention. Post-correction knee moments were similar to controls (p = 0.175), but the patient cohort exhibited a significantly decreased knee external rotation (p = 0.004) and increased external hip rotation (p < 0.001) during gait. In addition, the effect of transverse plane changes on knee moments in patients with restored, straight limb axis was calculated. Hence, patients with restored alignment but persistence of decreased external knee rotation demonstrated significantly greater knee moments than those without rotational abnormalities (p = 0.001). This study found that frontal knee moments during gait normalized in children with idiopathic genua valga after surgery. However, decreased external knee rotation and increased external hip rotation during gait persisted in the study cohort. Despite radiological correction, decreased external rotation during gait was associated with increases in medial knee loading. Surgical correction for children with genua valga but normal knee moments may be detrimental, due to redistribution of dynamic knee loading into the opposite joint compartment. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1617-1624, 2017.
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Affiliation(s)
- Sebastian Farr
- Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Speisingerstrasse 109, A-1130, Vienna, Austria
| | - Andreas Kranzl
- Laboratory for Gait and Movement Analysis, Orthopedic Hospital Speising, Vienna, Austria
| | - Julia Hahne
- Vinzenz Gruppe Center of Orthopedic Excellence, Vienna, Austria
| | - Rudolf Ganger
- Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Speisingerstrasse 109, A-1130, Vienna, Austria
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Modification of the alignment between the tibial tubercle and the trochlear groove induced by temporary hemiepiphysiodesis for lower extremity angular deformities: a trigonometric analysis. J Pediatr Orthop B 2017; 26:204-210. [PMID: 27941532 DOI: 10.1097/bpb.0000000000000409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED This study aimed to predict the modification of the alignment between the tibial tubercle (TT) and the trochlear groove (TG) that occurs during femoral or tibial hemiepiphysiodesis. MRI scans of 541 knees were retrospectively reviewed to determine the distances between the cranial insertion of the patellar tendon on the TT and the femoral physis (FP)/tibial physis (TP). Thereafter, we developed a trigonometric formula to calculate the predicted change of the TT-TG distance that occurs during hemiepiphysiodesis around the knee using both the planned angular correction as well as the length between the physis (both distal femoral and proximal tibial) and the insertion of the patellar tendon of the TT. This study showed that TT-FP and TT-TP distances vary very little with sex and age during growth and the mean values of FP-TT and TP-TT distances (55 and 7 mm, respectively) can thus be used in clinical settings for calculating a rough estimate of the translation of the TT position that will occur during 'guided growth'. On this subject, one can expect a 1 mm simultaneous lateral or medial transfer of the TT for every 1° of angular correction during distal femoral hemiepiphysiodesis. For proximal tibial hemiepiphysiodesis, an angular correction of 8° should roughly translate into a simultaneous 1 mm transfer of the TT. This study puts forward the hypothesis that a simultaneous modification of the TT-TG distance has to be expected following hemiepiphysiodesis, whether femoral or tibial. LEVEL OF EVIDENCE III.
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Distal femoral hemiepiphysiodesis using screw and non-absorbable filament for the treatment of idiopathic genu valgum. Preliminary results of 12 knees. Orthop Traumatol Surg Res 2017; 103:269-273. [PMID: 28089797 DOI: 10.1016/j.otsr.2016.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/27/2016] [Accepted: 11/02/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Different techniques for gradual correction of angular deformities of lower limbs exist. Screws and nonabsorbable filament has been described as an effective alternative for transitory hemiepiphysiodesis in New Zealand rabbits. HYPOTHESIS Hemiepiphysiodesis using screws and non-absorbable filament is effective in pediatric population, for correction of genu valgum. METHODS Retrospective evaluation, 12 knees in 6 patients younger than 15 years (3 female), operated because of genu valgum. An anchoring system with two 4.0mm cancellous screw with metal washer joined by FiberWire #2.0 filament. Initial and final intermalleolar distance (IMD) and mechanical lateral distal femoral angle were compared, recording complications. Mann-Whitney test was used for statistics, with significance value <0.05. RESULTS All patients achieved the expected correction. IMD and mLDFA were significatively improved. Only one patient presents a minor perioperative complication. DISCUSSION Lateral distal femoral hemiepiphysiodesis with screws and nonabsorbable filament resulted to be an effective alternative for genu valgum gradual correction in pediatric population. This is the first article that proposes this model, as an efficient and simple alternative for the treatment of genu valgum in pediatric patients. LEVEL OF EVIDENCE Retrospective study, Level IV.
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Mooney LT, Smith A, Sloan K, Clark GW. The effect of the native kinematics of the knee on the outcome following total knee arthroplasty. Bone Joint J 2017; 98-B:1471-1478. [PMID: 27803222 DOI: 10.1302/0301-620x.98b11.bjj-2016-0144.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 07/29/2016] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to investigate differences in pain, range of movement function and satisfaction at three months and one year after total knee arthroplasty (TKA) in patients with an oblique pattern of kinematic graph of the knee and those with a varus pattern. PATIENTS AND METHODS A total of 91 patients who underwent TKA were included in this retrospective study. Patients (59 women and 32 men with mean age of 68.7 years; 38.6 to 88.4) were grouped according to kinematic graphs which were generated during navigated TKA and the outcomes between the groups were compared. RESULTS The graphs were varus in 50 patients (55%), oblique in 19 (21%), neutral in 17 (18.5%) and valgus in five (5.5%). After adjustment for pre-operative scores and gender, compared with patients with varus knee kinematics, patients with an oblique kinematic graph had a poorer outcome with lower Knee Society scores at three months (9.2 points, p = 0.038). CONCLUSION We found four distinct kinematic graphs in knees and that patients with an oblique graph have a poorer outcome in the short-term after TKA. Cite this article: Bone Joint J 2016;98-B:1471-8.
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Affiliation(s)
- L T Mooney
- Royal Perth Hospital, Wellington St, Perth, WA, 6000, Australia
| | - A Smith
- Curtin University, GPO Box 1987, Perth, WA 6845, Australia
| | - K Sloan
- Royal Perth Hospital, Wellington St, Perth, WA, 6000, Australia
| | - G W Clark
- Saint John of God Hospital, Subiaco, Australia
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Marangoz S, Buyukdogan K, Karahan S. Is there a correlation between the change in the interscrew angle of the eight-plate and the delta joint orientation angles? ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:39-43. [PMID: 28041741 PMCID: PMC6197331 DOI: 10.1016/j.aott.2016.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/21/2016] [Accepted: 05/28/2016] [Indexed: 12/02/2022]
Abstract
Objectives It is known that the screws of the eight-plate hemiepiphysiodesis construct diverge as growth occurs through the physis. Our objective was to investigate whether there is a correlation between the amount of change of the joint orientation angle (JOA) and that of the interscrew angle (ISA) of the eight-plate hemiepiphysiodesis construct before and after correction. Patients and methods After the institutional review board approval, medical charts and X-rays of all patients operated for either genu valgum or genu varum with eight-plate hemiepiphysiodesis were analyzed retrospectively. All consecutive patients at various ages with miscellaneous diagnoses were included. JOA and ISA were measured before and after correction. After review of the X-rays, statistical analyses were performed which included Pearson correlation coefficient and regression analyses. Results There were 53 segments of 30 patients included in the study. Eighteen were males, and 12 were females. Mean age at surgery was 9.1 (range 3–17). Mean follow-up time was 21.5 (range, 7–46) months. The diagnoses were diverse. A strong correlation was found between the delta JOA (d-JOA) and delta ISA (d-ISA) of the eight-plate hemiepiphysiodesis construct (r = 0.759 (0.615–0.854, 95%CI), p < 0.001). This correlation was independent of the age and gender of the patient. Conclusions There is a strong correlation between the d-ISA and the d-JOA. The d-ISA follows the d-JOA at a predictable amount through formulas which regression analysis yielded. This study confirms the clinical observation of the diverging angle between the screws is in correlation with the correction of the JOA. Level of evidence Level IV, Therapeutic study.
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Affiliation(s)
- Salih Marangoz
- Koc University, School of Medicine, Department of Orthopaedics and Traumatology, Istanbul, Turkey.
| | - Kadir Buyukdogan
- Hacettepe University, Faculty of Medicine, Department of Orthopaedics and Traumatology, Ankara, Turkey
| | - Sevilay Karahan
- Hacettepe University, Faculty of Medicine, Department of Biostatistics, Ankara, Turkey
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Abstract
Growth modulation using tension band plates (TBP) has been shown to be a safe, effective, and popular method for correcting pediatric frontal plane angular deformity around the knee. Recently, TBPs have been used to achieve reversible epiphysiodesis to treat limb-length discrepancy. Many surgeons have expanded the indications to include diagnoses other than frontal plane angular deformities, anatomic sites other than the knee, and correction of sagittal and oblique plane deformities. Despite the rapid acceptance of TBPs, the limits of this option have not been explored. We undertook a systematic literature review and found that the success rate for idiopathic cases approaches 100% with a low complication rate. Pathologic cases have a slightly lower success rate and a higher complication rate. The potential to avoid osteotomy with growth modulation makes TBPs a reasonable option for all but the most extreme pediatric frontal and sagittal plane lower extremity deformities. Applications to hip deformities remain unproven.
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Kadhim M, Hammouda AI, Herzenberg JE. Solid screw insertion for tension band plates: a surgical technique tip. J Child Orthop 2016; 10:307-11. [PMID: 27312797 PMCID: PMC4940243 DOI: 10.1007/s11832-016-0748-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/28/2016] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Growth modulation with tension band plates (TBPs) and cannulated screws is the current mainstay of treatment for pediatric lower extremity angular deformities. Solid screws have been used as an alternative to cannulated screws to decrease the risk of screw failure, particularly in obese children. The downside of solid screws is the decrease in precision of placement. This study describes a surgical technique to insert solid TBP screws accurately. METHODS TBP insertion starts with the same conventional steps by inserting the guidewires into the epiphysis and metaphysis, straddling the physis. After fluoroscopic confirmation of the position of the guidewires, the cannulated drill bit is used to broach the cortex to a depth of 5 mm in the bone. A standard 4.5-mm cannulated screw from the TBP set is used to tap the screw tract over the guidewires for approximately three-quarters of the planned screw length. After removing the guidewires, the solid screws are then inserted in each hole to follow the tapped tracts. RESULTS This technique was used in five patients including four with Blount disease and one with bilateral genu varum. CONCLUSION It is recommended to use solid screws with TBPs in patients with a high body mass index to avoid screw fracture. Our technique describes using a cannulated screw as a tap to create a tract to ease accurate insertion of the solid screws, and prevent the solid screw from deviating outside the desired path.
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Affiliation(s)
- Muayad Kadhim
- />Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
| | - Ahmed I. Hammouda
- />Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA , />Department of Orthopedic Surgery, Al-Azhar University Hospitals, Cairo, Egypt
| | - John E. Herzenberg
- />Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
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Does physical therapy prevent post-operative delay in return of function following tension-band plating? J Child Orthop 2015; 9:483-7. [PMID: 26499456 PMCID: PMC4661153 DOI: 10.1007/s11832-015-0700-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/08/2015] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The clinical outcomes and complications of tension-band plating have been well documented, and commonly include a post-operative delay in return of function. We performed a retrospective comparison study to evaluate the capacity of immediate post-operative physical therapy to prevent this post-operative delay in return of function. METHODS Sixty-seven consecutive growth-deformity patients who were treated with tension-band plating at a single institution fulfilled the study criteria. Patients were allocated into two treatment groups: no post-operative physical therapy and immediately post-operative physical therapy. All patients were evaluated for delayed return of function, which was defined as use of crutches, lack of >90° flexion and full extension of the knee, or persistent pain requiring medication at the initial 2-week follow-up visit. Rates of delayed function were compared between the two treatment groups. RESULTS Among the study participants, 48 patients had no physical therapy and 19 patients had immediate post-operative physical therapy. Eighteen patients in the no physical therapy group reported a delay (37.5 %) while only 2 patients in the physical therapy treatment group reported a delay (10.5 %); p = 0.0386. CONCLUSIONS Delayed return of function dramatically affects pediatric patients, causing unnecessary absence from school and strain on the caregiver. Therefore, it is important to identify treatment modalities to help mitigate the complications of surgery. We conclude that the use of immediate post-operative physical therapy statistically significantly helps patients to return more rapidly to their functional level.
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LaPorta GA, Susek MM. Guided Growth With Temporary Hemiepiphysiodesis to Treat Ankle Valgus in a Skeletally Immature Individual: A Case Report. J Foot Ankle Surg 2015; 55:645-9. [PMID: 26431750 DOI: 10.1053/j.jfas.2015.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Indexed: 02/03/2023]
Abstract
Guided growth is useful in correcting pediatric angular deformities. Ankle valgus is a coronal plane deformity and is often seen in skeletally immature patients with congenital or acquired lower extremity pathologic features. Temporary hemiepiphysiodesis with a percutaneous transphyseal medial malleolar screw is a surgical treatment capable of correcting the angular deformity and can offer effective correction. In the present case study, a 12-year-old male with dorsal-lateral peritalar subluxation and ankle valgus underwent a reconstructive procedure and temporary hemiepiphysiodesis with a percutaneous medial malleolar screw. After removal of the screw, reduction of his peritalar subluxation was achieved, improving his lateral-distal tibial angle from 81° preoperatively to 89° at the final follow-up examination. The patient returned to his preoperative sporting activities and ambulated comfortably and pain free in sneakers with orthotics. In conclusion, temporary hemiepiphysiodesis with a transphyseal medial malleolar screw is an effective treatment option for ankle valgus in a skeletally immature individual.
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Affiliation(s)
- Guido A LaPorta
- Chief, Department of Podiatric Medicine and Surgery, Geisinger Community Medical Center, Scranton, PA; Residency Director, Geisinger Community Medical Center, Scranton, PA; and Fellowship Director, Northeast Regional Foot and Ankle Institute Limb Salvage and Reconstructive Surgery, Scranton, PA
| | - Mehgan M Susek
- Podiatrist, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA.
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