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The Orthopaedic Management of Long Bone Deformities in Genetically and Acquired Generalized Bone Weakening Conditions

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The Orthopaedic Management of Long Bone Deformities in Genetically and Acquired Generalized Bone Weakening Conditions Current Concepts Review The orthopaedic management of long bone deformities in genetically and acquired generalized bone weakening conditions T. Wirth Keywords: osteogenesis imperfecta; fibrous dysplasia; hypophosphataemic rickets; bone deformity Abstract Purpose Diseases such as osteogenesis imperfecta, fibrous Introduction dysplasia, hypophosphataemic rickets and others lead to soft A variety of congenital and acquired conditions lead to and weak bones and long bone deformity in affected patients. a localized or general bone weakness which may result As a consequence, these patients lose their walking capacity in more or less severe long bone deformities. The most and functional abilities of the upper extremities as well. important and most frequent diseases are hypophos- Methods In combination with bisphosphonate treatment phataemic rickets, fibrous dysplasia and osteogenesis and physical rehabilitation programmes surgical interven- imperfecta (OI) representing examples of genetically tions are being applied to correct and stabilize the deformed determined entities and rickets and osteopenia due to and less mechanically resistant long bones. Intramedullary malabsorption syndromes as typical causes of acquired devices, ideally with an elongating telescopic mechanism, diseases (Table 1).1,2 have proven to be the most suitable implants. All these bone weakening conditions are subject to a higher fracture rate, mainly from low energy and inad- Results The surgical correction and stabilization of deformed equate injuries, and to gradual development of bone bones in weak bone diseases is very beneficial to the patients. deformities. The muscular forces generated along the Pain restriction, reduction of fracture events, minimization of upper and lower limbs’ long bones are stronger than consequences of traumatic events and falls have resulted in the biomechanically transmitted tensile strengths of the a significant functional improvement. The patients live on a bones themselves. Among typical resulting deformities better activity level with a much-improved individual inde- are a varus deviation of the distal humerus or a varus and pendence. Despite a high complication and revision rate of flexion deformity of the femur. The clinical implications the intramedullary rods the gain of quality of life outweighs are severe axial deformities with considerable functional these negative aspects by far. impairment. Severe forearm deformity, for example, may Conclusion Orthopaedic surgical treatment for deformed lead to a complete restriction of pro- and supination. Seri- bones in patients with weak bone diseases has changed the ous deformations of the lower extremity may be associ- life of the patients and plays a very important role in the dis- ated with the inability to stand or walk, or trigger the loss ease management protocols. of pre-existing walking capacities.3,4 As a consequence of bone deformation fractures may develop at the site of This paper was written under the guidance of the Study maximum curvature. Group Genetics and Metabolic Diseases of the European Pae- The treatment of weak bones diseases has made signif- diatric Orthopaedic Society. icant progress in the past years both through improved medical and surgical strategies. The introduction of bis- Cite this article: Wirth T. The orthopaedic management of phosphonate treatment for patients suffering from mod- long bone deformities in genetically and acquired generalized erate and severe forms of OI has reduced the fracture rate bone weakening conditions. J Child Orthop 2019;13:12-21. and improved bone stability.5-8 Increasingly enzyme and DOI: 10.1302/1863-2548.13.180184 antibody treatment will be available for these conditions in order to reduce their clinical symptoms, as it is currently 9 Department of Orthopaedics, Klinikum Stuttgart, Olgahospital, already available for hypophosphatasia and hypophos- Stuttgart, Germany phataemic rickets.10 In the orthopaedic field, improved surgical techniques such as minimally invasive procedures Correspondence should be sent to T. Wirth, MD, PhD, Department and better and more sophisticated implants, have facili- of Orthopaedics, Klinikum Stuttgart, Olgahospital, Kriegsbergstraße 62, D-70176 Stuttgart, Germany. tated correction and stabilization of long bone deformities E-mail: [email protected] and furthermore even extended indications for surgical ORTHOPAEDIC MANAGEMENT OF LONG BONE DEFORMITIES Table 1 Genetically determined diseases leading to soft bones and its consequences Disease Genetics Main deformity Conservative treatment Surgical treatment Fibrous dysplasia GNAS gene All bones affected Bisphosphonates Intramedullary stabilization Hypophosphatasia TNSALP gene Long bones affected Asfotase Alfa Intramedullary stabilization, growth modulation Hypophosphataemic PHEX gene Lower limbs, bow legs Burosumab Intramedullary stabilization, rickets growth modulation Osteogenesis imperfecta, Col 1A1, Col 1A2, All long bones affected Bisphosphonates, Intramedullary stabilization type I to V(1, 2) dominant physiotherapy Osteogenesis imperfecta, Many gene locations, All long bones affected Bisphosphonates, Intramedullary stabilization type IV to XVII(2) autosomal recessive physiotherapy GNAS, Guanine Nucleotide Binding Protein (G Protein), alpha stimulating activity; TNSALP, tissue-nonspecific alkaline phosphatase; PHEX, Phosphate regulating endopeptidase homolog X-linked; Col 1A1, collagen 1A1; Col 1A2, collagen 1A2 Fig. 1 Severely affected osteogenesis imperfecta patient with significant deformity of the right humerus (a) and right forearm (b). A simultaneous correction of both the right humerus and forearm was performed using multiple osteotomies; telescopic nail for humerus; and Kirschner-wires in the radius and ulna (c). interventions.11,12 This work on current orthopaedic treat- movements.4 Mainly patients with fibrous dysplasia and, ment in weak long bones was inspired by the symposium in particular, moderately and severely affected children on key aspects of OI at the 37th Annual Meeting of the with OI require surgical interventions for upper extremity European Paediatric Orthopaedic Society in Oslo/Norway deformities.13,14 (13 April 2018). In general, the well-known principles of deformity correction apply. The osteotomies are being placed at the Upper extremity apex of the deformity, and the number of osteotomies are chosen according to the number of apices (Fig. 1). Deformities of the upper extremities seem to occur less The choice of the right implant may pose another dif- frequently and to play a less significant role than lower ficulty. In growing patients, telescoping implants are limb deformities. Why do we then need to pay attention to mostly used, if the diameter of the bones allows them to them, if their functional impairment does not seem to be be fitted. In the upper extremity, however, telescoping such an obvious issue? With increasing degrees of sever- nails are only usable for humeral rodding.15 The radius ity, the extent of deformity progresses and the subsequent and ulna do not generally accept telescoping nails due fractures risk increases. The larger number of fractures to the small diameters of the intramedullary canal and and the development of more pronounced deformities do the difficult accessibility of the radius. Hence, flexible inflict on the functionality of the elbow joint and forearm intramedullary nails, Rush rods or Kirschner (K)-wires J Child Orthop 2019;13:12-21 13 ORTHOPAEDIC MANAGEMENT OF LONG BONE DEFORMITIES of appropriate sizes are the implant of choice for fore- short distances are most important. A whole variety of arm correction and stabilization (Fig. 1). In patients implants have been used and developed with the third with fibrous dysplasia, it is usually larger bones that are generation of telescopic nails being the most up-to-date affected, and several suitable intramedullary implants implant.11,16-19. Accordingly, surgical intervention for defor- can be utilized. Plates are not chosen routinely but they mity correction and long bone stabilization starts earlier may be helpful to fix rotationally unstable osteotomies. than upper extremity surgery. Small tubular plates or small locking plates with use of In other weak bone diseases, the development of lower single cortex screw fixation are very useful in this con- limb deformities occurs at a slower rate and later in life. text. If plates are chosen for fixing osteotomies or frac- Consequently, the indication for surgical interventions is tures, they should be removed soon after completion of very closely linked to the clinical effect of the developing bony healing. Because of the increased stability of the deformity and is timed to the needs of the patients.13,20 plated bone area, stress risers are created above and The primary goal in most of these patients, namely early below with predictable deformity occurrence, if they are verticalization and weight bearing, requires bones which kept in place as a single implant. can be biomechanically highly loaded from the beginning. While humerus corrections in OI patients are mostly Due to soft bone quality and microfracturing transmitted possible from the age of three years,15 forearm correction by the muscular force alone the long bones show some requires a minimum size of both bones and the intramed- deformity at walking age already. With increasing load, ullary canal. The indication for upper extremity correction the deformation continues to worsen, ultimately result- is
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