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Todderud JE, Carlson SW, Larson AN. Guided Growth to Treat Anterolateral Tibial Bowing Associated with Congenital Pseudarthrosis of the Tibia. J Pediatr Orthop 2024; 44:e560-e565. [PMID: 38835290 DOI: 10.1097/bpo.0000000000002683] [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: 06/06/2024]
Abstract
BACKGROUND Anterolateral tibial bowing associated with congenital tibial pseudarthrosis occurs often in patients with neurofibromatosis type 1 and results from the inability of the fractured bone to unite, leading to persistent nonunion, abnormal bone growth, and further bowing of the tibia. Current surgical and nonsurgical approaches demonstrate persistent nonunion or refracture, often resulting in amputation. METHODS This report describes the management of 3 patients with anterolateral tibial bowing and NF1 who underwent distal tibia-guided growth. RESULTS The patients had an average age of 1.6 years at initial operation, with a total of 3 to 4 surgeries over an average of 2.1 years. The latest follow-up on all patients is included, at a mean of 5.1 years after the initial operation. All 3 patients experienced substantial functional improvement and improved alignment of the mechanical axis of the tibia. One patient has experienced refracture. CONCLUSIONS Our study indicates that guided growth can serve as an additional surgical option to improve ALTB and potentially reduce the risk of fracture and pseudarthrosis by restoring normal mechanical alignment. LEVEL OF EVIDENCE Level-IV, Case Series.
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Jeong CH, Lim SY, Um JE, Lim HW, Hwang KH, Park KM, Yun JS, Kim D, Huh JK, Kim HS, Yook JI, Kim NH, Kwak YH. Micellized protein transduction domain-bone morphogenetic protein-2 accelerates bone healing in a rat tibial distraction osteogenesis model. Acta Biomater 2023; 170:360-375. [PMID: 37611691 DOI: 10.1016/j.actbio.2023.08.031] [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: 03/07/2023] [Revised: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
The clinical application of growth factors such as recombinant human bone morphogenetic protein-2 (rh-BMP-2), for functional bone regeneration remains challenging due to limited in vivo efficacy and adverse effects of previous modalities. To overcome the instability and short half-life of rh-BMP-2 in vivo, we developed a novel osteogenic supplement by fusing a protein transduction domain (PTD) with BMP-2, effectively creating a prodrug of BMP-2. In this study, we first created an improved PTD-BMP-2 formulation using lipid nanoparticle (LNP) micellization, resulting in downsizing from micrometer to nanometer scale and achieving a more even distribution. The micellized PTD-BMP-2 (mPTD-BMP-2) demonstrated improved distribution and aggregation profiles. As a prodrug of BMP-2, mPTD-BMP-2 successfully activated Smad1/5/8 and induced mineralization with osteogenic gene induction in vitro. In vivo pharmacokinetic analysis revealed that mPTD-BMP-2 had a much more stable pharmacokinetic profile than rh-BMP-2, with a 7.5-fold longer half-life. The in vivo BMP-responsive element (BRE) reporter system was also successfully activated by mPTD-BMP-2. In the in vivo rat tibia distraction osteogenesis (DO) model, micro-computed tomography (micro-CT) scan findings indicated that mPTD-BMP-2 significantly increased bone volume, bone surface, axis moment of inertia (MOI), and polar MOI. Furthermore, it increased the expression of osteogenesis-related genes, and induced bone maturation histologically. Based on these findings, mPTD-BMP-2 could be a promising candidate for the next-generation osteogenesis drug to promote new bone formation in DO surgery. STATEMENT OF SIGNIFICANCE: This study introduces micellized bone morphogenetic protein-2 (mPTD-BMP-2), a next-generation osteogenic supplement that combines protein transduction domain (PTD) and nano-sized micelle formulation technique to improve transduction efficiency and stability. The use of PTD represents a novel approach, and our results demonstrate the superiority of mPTD-BMP-2 over rh-BMP-2 in terms of in vivo pharmacokinetic profile and osteogenic potential, particularly in a rat tibial model of distraction osteogenesis. These findings have significant scientific impact and potential clinical applications in the treatment of bone defects that require distraction osteogenesis. By advancing the field of osteogenic supplements, our study has the potential to contribute to the development of more effective treatments for musculoskeletal disorders.
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Affiliation(s)
- Cheol Hee Jeong
- Department of Oral Pathology, Yonsei University College of Dentistry, Seoul, 03722, Korea; Oral Cancer Research Institute, Yonsei University College of Dentistry, Seoul, 03722, Korea
| | - Song-Yi Lim
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, 05505, Korea
| | - Jo Eun Um
- MET Life Science, Seoul, 03722, Korea
| | - Hyo Won Lim
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, 05505, Korea
| | | | - Kyeong-Mee Park
- Department of Advanced General Dentistry, Yonsei University College of Dentistry, Seoul, 03722, Korea
| | - Jun Seop Yun
- Department of Oral Pathology, Yonsei University College of Dentistry, Seoul, 03722, Korea; Oral Cancer Research Institute, Yonsei University College of Dentistry, Seoul, 03722, Korea
| | - Dohun Kim
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, 05505, Korea
| | - Jong-Ki Huh
- Department of Oral and Maxillofacial Surgery, Gangnam Severance Hospital, Yonsei University College of Dentistry, Seoul, 06273, Korea
| | - Hyun Sil Kim
- Department of Oral Pathology, Yonsei University College of Dentistry, Seoul, 03722, Korea; Oral Cancer Research Institute, Yonsei University College of Dentistry, Seoul, 03722, Korea; MET Life Science, Seoul, 03722, Korea
| | - Jong In Yook
- Department of Oral Pathology, Yonsei University College of Dentistry, Seoul, 03722, Korea; Oral Cancer Research Institute, Yonsei University College of Dentistry, Seoul, 03722, Korea; MET Life Science, Seoul, 03722, Korea
| | - Nam Hee Kim
- Oral Cancer Research Institute, Yonsei University College of Dentistry, Seoul, 03722, Korea; MET Life Science, Seoul, 03722, Korea.
| | - Yoon Hae Kwak
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, 05505, Korea.
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Kurniawan A, Ivansyah MD, Dilogo IH, Hutami WD. Umbilical cord mesenchymal stem cells combined with secretome for treating congenital pseudarthrosis of the Tibia: a case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2881-2888. [PMID: 36879164 DOI: 10.1007/s00590-023-03511-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 02/26/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Most patients with congenital pseudoarthrosis of tibia (CPT) do not have promising outcomes despite multiple attempts using conventional surgeries. The combination of umbilical cord-derived mesenchymal stem cells and conditioned medium (secretome) contains major components pivotal for the enhancement of fracture healing. The purpose of this study was to address fracture healing in CPT cases that were treated using the combined implantation of umbilical-cord mesenchymal stem cells (UC-MSCs) and secretome. MATERIALS AND METHODS From 2016 to 2017, six patients with CPT who were treated by one senior pediatric orthopedic consultant at a single center (3 girls and 3 boys; mean age of 5.8 years) were included in this case series. A combined procedure including resection of hamartomatous fibrotic tissue, implantation of MSCs and secretome, and fixation using a locking plate and screws was performed. Patients were followed up for a mean of 29 months. Leg-length discrepancy, refracture rate, functional outcome, and radiological outcomes were assessed preoperatively, immediately postoperatively and at the final follow-up. RESULT Five out of 6 (83%) of the patients experienced primary union. One patient experienced refracture; however, 8 months later, after another implantation and reconstruction were performed, union eventually occurred. Significant functional improvement was achieved after at least 1 year of follow-up. CONCLUSION This case series suggests that the combination of secretome and UC-MSCs is a potential treatment for CPT, it highlights the efficacy of the combined procedure in treating CPT and in achieving satisfying results. A larger number of subjects and longer follow-up are required for further study.
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Affiliation(s)
- Aryadi Kurniawan
- Department of Orthopaedic and Traumatology, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, 10430, Indonesia
| | - Muhammad Deryl Ivansyah
- Department of Orthopaedic and Traumatology, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, 10430, Indonesia
| | - Ismail Hadisoebroto Dilogo
- Department of Orthopaedic and Traumatology, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, 10430, Indonesia
| | - Witantra Dhamar Hutami
- Department of Orthopaedic and Traumatology, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, 10430, Indonesia.
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Siebert MJ, Makarewich CA. Anterolateral Tibial Bowing and Congenital Pseudoarthrosis of the Tibia: Current Concept Review and Future Directions. Curr Rev Musculoskelet Med 2022; 15:438-446. [PMID: 35841513 PMCID: PMC9789274 DOI: 10.1007/s12178-022-09779-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Congenital pseudarthrosis of the tibia (CPT) is a rare condition closely associated with neurofibromatosis type I. Affected children are born with anterolateral bowing of the tibia which progresses to pathologic fracture, pseudarthrosis, and high risk of refracture even after initial union has been attained. There is currently no consensus on the classification of this disease or consensus on its treatment. The purpose of this review is to (1) review the clinical presentation, etiology, epidemiology, classification, and natural history of congenital pseudarthrosis of the tibia and (2) review the existing trends in treatment of congenital pseudarthrosis of the tibia and its associated complications. RECENT FINDINGS Current treatment protocols focus primarily on combining intramedullary fixation with external or internal fixation to achieve union rates between 74 and 100%. Intramedullary devices should be retained as long as possible to prevent refracture. Cross-union techniques, though technically difficult, have a reported union rate of 100% and no refractures at mid- to long-term follow-up. Vascularized fibular grafting and induced membrane technique can be successful, but at the cost of numerous surgical procedures. Growth modulation is a promising new approach to preventing fracture altogether, though further study with larger patient series is necessary. The primary consideration in treatment of CPT is expected union rate and refracture risk. Combined intramedullary and external or internal fixation, especially with cross-union techniques, show most promise. Perhaps most exciting is further research on preventing fracture through guided growth, which may reduce the morbidity of multiple surgical procedures which have been the mainstay of treatment for CPT thus far.
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Affiliation(s)
- Matthew J. Siebert
- grid.223827.e0000 0001 2193 0096Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 USA
| | - Christopher A. Makarewich
- grid.223827.e0000 0001 2193 0096Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 USA ,grid.415178.e0000 0004 0442 6404Primary Children’s Hospital, Salt Lake City, UT USA ,grid.509583.2Shriners Children’s, Salt Lake City, Utah USA
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Larson AN. Innovation With Ethics in Pediatric Orthopaedics. J Pediatr Orthop 2022; 42:S39-S43. [PMID: 35405701 DOI: 10.1097/bpo.0000000000002099] [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: 02/07/2023]
Abstract
Surgeons should thoughtfully consider whether to introduce a new procedure into their practice. Considerations include the severity of the condition, potential risk of harm, treatment alternatives, patient population, ability to appropriately consent patient/families, and available clinical and institutional resources as well as published evidence and regulatory status. Whenever possible, new procedures should be standardized, studied, and reported upon so that the greater community can learn from experience and refine the indications to minimize risks for future patients. Small scale innovation can readily be introduced into practice. Surgeons should always strive to systemically study new procedures so as to be able to assess benefits and effects.
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Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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McClure PK, Franzone JM, Herzenberg JE. Congenital Pseudarthrosis of the Tibia Associated With Cleidocranial Dysostosis: Case Report and Literature Review. JBJS Case Connect 2021; 11:01709767-202112000-00042. [PMID: 34735385 DOI: 10.2106/jbjs.cc.21.00451] [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: 06/13/2023]
Abstract
CASE We describe a case of 2 individually rare diseases existing comorbidly in the form of congenital pseudarthrosis of the tibia (CPT) coincident with cleidocranial dysostosis and provide a review of the literature, including the sole preexisting documented coincidence. CONCLUSION Understanding, treatment, and surgical protocol of CPT have changed considerably since this comorbidity was last reported. Updates include synostosis, periosteal grafting, the use of bone morphogenetic protein, and bisphosphonates. Our case varies from the previous in associated disorder and family history. The relationship between CBFA1 and RUNX2 genes may hold the key, but further study is needed.
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Affiliation(s)
- Philip K McClure
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jeanne M Franzone
- Department of Orthopaedic Surgery, AI Dupont Hospital for Children, Wilmington, Delaware
| | - John E Herzenberg
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Kocaoğlu M, Eralp L, Bilen FE, Civan M. Congenital pseudarthrosis of the tibia: Results of circular external fixation treatment with intramedullary rodding and periosteal grafting technique. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:245-254. [PMID: 32442122 DOI: 10.5152/j.aott.2020.03.26] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE This study investigated the clinical and functional results of treating congenital pseudarthrosis of the tibia (CPT) using the combined techniques of hamartoma resection, periosteal grafting, circular external fixator application, and intramedullary rodding. METHODS The clinical and radiological data of 17 patients (mean age at the treatment time: 7.6 months (range: 4.6-9.7 months) with CPT, treated by a single surgeon between 1997 and 2017, were retrospectively analyzed. All data regarding surgical interventions, complications, deformity analysis parameters, limb length discrepancy (LLD), ankle joint range of motion, and residual deformities were reviewed. All the patients were followed up at least two years after the last surgical intervention. The mean follow-up time was 8.5 years (range: 2.2 to 15.7 years). RESULTS Union was achieved with the index treatment in 15 of the 17 cases (88.2%). The mean age of the patients at the last follow-up visit was 14.2 years (range: 7.6 to 22.1). The mean LLD was 2.1 cm. Nine patients had radiological ankle valgus at the last follow-up. In the entire series, eight patients did not display any complications, four cases reported minor complications, and five cases were complicated by refractures. CONCLUSION Circular external fixator application combined with periosteal grafting is a superior method of CPT treatment. This method provides a healthy biological healing environment while correcting the mechanical problems. The combination of periosteal and cancellous bone grafts with intramedullary rods and an external fixator addresses issues that complicate obtaining and maintaining a union during the CPT treatment. LEVEL OF EVIDENCE Level IV, Therapeutic study.
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Affiliation(s)
| | - Levent Eralp
- Department of Orthopaedics and Traumatology, İstanbul University, İstanbul School of Medicine, İstanbul, Turkey
| | - Fikri Erkal Bilen
- Department of Orthopaedics and Traumatology, Yeni Yüzyıl University, School of Medicine, İstanbul, Turkey
| | - Melih Civan
- Department of Orthopaedics and Traumatology, Gaziosmanpaşa Training and Research Hospital, İstanbul, Turkey
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Mladenov KV, Spiro AS, Krajewski KL, Stücker R, Kunkel P. Management of spinal deformities and tibial pseudarthrosis in children with neurofibromatosis type 1 (NF-1). Childs Nerv Syst 2020; 36:2409-2425. [PMID: 32613421 PMCID: PMC8346390 DOI: 10.1007/s00381-020-04775-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED The skeletal system is affected in up to 60% of patients with neurofibromatosis type 1. The most commonly observed entities are spinal deformities and tibial dysplasia. Early recognition of radiologic osseous dystrophy signs is of utmost importance because worsening of the deformities without treatment is commonly observed and surgical intervention is often necessary. Due to the relative rarity and the heterogenic presentation of the disease, evidence regarding the best surgical strategy is still lacking. PURPOSE To report our experience with the treatment of skeletal manifestations in pediatric patients with (neurofibromatosis type 1) NF-1 and to present the results with our treatment protocols. MATERIALS AND METHODS This is a retrospective, single expert center study on children with spinal deformities and tibial dysplasia associated with NF-1 treated between 2006 and 2020 in a tertiary referral institution. RESULTS Spinal deformity: Thirty-three patients (n = 33) were included. Mean age at index surgery was 9.8 years. In 30 patients (91%), the deformity was localized in the thoracic and/or lumbar spine, and in 3 patients (9%), there was isolated involvement of the cervical spine. Eleven patients (33%) received definitive spinal fusion as an index procedure and 22 (67%) were treated by means of "growth-preserving" spinal surgery. Halo-gravity traction before index surgery was applied in 11 patients (33%). Progression of deformity was stopped in all patients and a mean curve correction of 60% (range 23-98%) was achieved. Mechanical problems with instrumentation requiring revision surgery were observed in 55% of the patients treated by growth-preserving techniques and in none of the patients treated by definitive fusion. One patient (3%) developed a late incomplete paraplegia due to a progressive kyphotic deformity. Tibial dysplasia: The study group comprised of 14 patients. In 5 of them (36%) pathological fractures were present on initial presentation. In the remaining 9 patients (64%), anterior tibial bowing without fracture was observed initially. Four of them (n = 4, 28%) subsequently developed a pathologic fracture despite brace treatment. Surgical treatment was indicated in 89% of the children with pathological fractures. This involved resection of the pseudarthrosis, autologous bone grafting, and intramedullary nailing combined with external fixation in some of the cases. In 50% of the patients, bone morphogenic protein was used "off-label" in order to promote union. Healing of the pseudarthrosis was achieved in all of the cases and occurred between 5 to 13 months after the index surgical intervention. Four of the patients treated surgically needed more than one surgical intervention in order to achieve union; one patient had a re-fracture. All patients had a good functional result at last follow-up. CONCLUSION Early surgical intervention is recommended for the treatment dystrophic spinal deformity in children with NF-1. Good and sustainable curve correction without relevant thoracic growth inhibition can be achieved with growth-preserving techniques alone or in combination with short spinal fusion at the apex of the curve. Preoperative halo-gravity traction is a safe and very effective tool for the correction of severe and rigid deformity in order to avoid neurologic injury. Fracture union in tibial dysplasia with satisfactory functional results can be obtained in over 80% of the children by means of surgical resection of the pseudarthrosis, intramedullary nailing, and bone grafting. Wearing a brace until skeletal maturity is achieved is mandatory in order to minimize the risk of re-fracture.
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Affiliation(s)
- Kiril V. Mladenov
- Altona Children’s Hospital – AKK/UKE, Bleickenallee 38, 22763 Hamburg, Germany
| | | | | | - Ralf Stücker
- Altona Children’s Hospital – AKK/UKE, Bleickenallee 38, 22763 Hamburg, Germany
| | - Philip Kunkel
- Altona Children’s Hospital – AKK/UKE, Bleickenallee 38, 22763 Hamburg, Germany
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Abstract
RATIONALE Bone malformation occurs in 10% to 25% neurofibromatosis type 1 (NF-1) patients, and the manifestations are scoliosis, congenital arch and pseudo-joint formation, bone cyst, and pathologic fracture. However, a large segmental defect without obvious signs of bone destruction has rarely been reported. PATIENT CONCERNS A 4.5-year-old male presented with a 4-year history of shortening of the right upper limb and radial head dislocation. The X-ray indicated a lack of the distal part of the right ulna and radial head dislocation. DIAGNOSIS The X-ray showed obvious bone resorption at the right ulna distal, proximal stubble, and distal part of the epiphyseal residue, which was 4.3 mm shorter after 14 months. The patient was finally diagnosed with NF-1 according to the pathologic examination. INTERVENTIONS The treatment included tumor resection, ulnar osteotomy, and fixation by an Ilizarov frame. OUTCOMES The Ilizarov frame was removed after 2.7 months of surgery. The radial head was successfully repositioned, and the elbow joint function was significantly improved. No recurrence of the deformity was noted until now. LESSONS Osteolysis (defect without bone destruction) is an extremely rare symptom in patients with NF1. Therefore, it is essential to make the right diagnosis by comprehensive and careful physical examination.
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Affiliation(s)
- Yiguo Shen
- Department of Orthopedics, Zhejiang University School of Medicine Children's Hospital
| | - Fangfang Chen
- Department of Orthopedics, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
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Abstract
PURPOSE OF REVIEW Congenital pseudoarthrosis of the tibia and fibula are rare conditions that share common treatment strategies. The purpose of this review is to provide an overview of the recent developments in treatments for both conditions. RECENT FINDINGS Recent literature has focused on the use of BMP and on gait analysis as a tool for measuring long-term functional outcomes. Recent study has indicated rhBMP-2 may shorten the time to initial healing of pseudoarthroses, but not guarantee bony union. Children with initial fractures before the age of four have been shown to have long-term gait outcomes that may be ultimately comparable to children with prostheses. Both congenital pseudoarthrosis of the tibia and fibula are challenging conditions to treat, which require comprehensive approaches to account for both the biological and mechanical components of the conditions.
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Affiliation(s)
- Katherine A Eisenberg
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Carley B Vuillermin
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
- Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA.
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Singer D, Johnston CE. Congenital Pseudarthrosis of the Tibia: Results, at Skeletal Maturity, of the Charnley-Williams Procedure. JB JS Open Access 2019; 4:e0004. [PMID: 31334459 PMCID: PMC6613849 DOI: 10.2106/jbjs.oa.19.00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background This study assessed the outcomes, at skeletal maturity, for 34 patients in whom congenital pseudarthrosis of the tibia (CPT) had been treated with intramedullary (IM) rod fixation. Methods The results in skeletally mature patients in whom type-4 CPT had been treated with an IM rod at an average of 11.9 years earlier were reviewed. The rod procedures varied according to whether both the tibia and the fibula were resected and both bones (type A) or just the tibia (type B) were fixed with an IM rod or whether only the tibia was resected and the fibula received no surgery (type C). Outcome grading ranged from unequivocal union with brace-free function (grade 1) to a functional limb with residual angulation or cortical defects (grade 2) to a severely impaired extremity with insufficient union or refracture (grade 3). Results Thirty-four patients were evaluated at a mean age of 16.9 years, a mean of 11.9 years after their initial surgical procedure. Seventeen patients had a grade-1 result; 11 patients, grade 2; and 6, grade 3. Thus, 82% (28) of the 34 patients had a functional extremity at maturity. All patients with a final grade-3 outcome eventually requested amputation. The final outcomes were not affected by the age at the initial fracture or surgery, the presence of neurofibromatosis-1, or cross-ankle fixation. A total of 58 IM rod procedures were performed in the 34 patients. Twenty-four (73%) of the 33 type-A procedures produced grade-1 or 2 outcomes, as did 14 (88%) of the 16 type-B procedures. Of the 9 type-C procedures, none produced a grade-1 result and 4 produced a grade-2 outcome. The results of types A and B combined were superior to those of type-C procedures (p = 0.03). Refracture occurred in 13 of 33 patients with initial stability/union after rod fixation, with 3 of those fractures remaining ununited at the latest follow-up. A dystrophic fibula had no effect on the eventual achievement of a grade-1 or 2 outcome. Conclusions This review, in which all patients had reached skeletal maturity, documents functional (grade-1 or 2) outcomes in 82% of cases of IM rod fixation for CPT. This finding was almost identical to the result in our earlier report and confirms the long-term value of permanent IM rod fixation in maintaining union and function in patients with CPT. Procedures not addressing the fibula produced inferior results. Although 13 patients had a refracture following initial union, only 3 of these fractures failed to heal with additional treatment. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Dustin Singer
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas Texas
| | - Charles E Johnston
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas Texas.,Texas Scottish Rite Hospital for Children, Dallas, Texas
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Han SH, Jung SH, Lee JH. Preparation of beta-tricalcium phosphate microsphere-hyaluronic acid-based powder gel composite as a carrier for rhBMP-2 injection and evaluation using long bone segmental defect model. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2019; 30:679-693. [DOI: 10.1080/09205063.2019.1601871] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Shi Huan Han
- Department of Orthopedic Surgery, College of Medicine, Seoul National University, SMG-SNU Boramae Medical Center, Seoul, Korea
- Department of Orthopedic Surgery, YanBian University Hospital, Yanji, China
| | - Su Hyun Jung
- Research & Development Center, CG Bio Co. Ltd. Seongnam-si, Gyeonggi-do, Korea
| | - Jae Hyup Lee
- Department of Orthopedic Surgery, College of Medicine, Seoul National University, SMG-SNU Boramae Medical Center, Seoul, Korea
- Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Medical Research Center, Seoul, Korea
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Deo N, El-Hoss J, Kolind M, Mikulec K, Peacock L, Little DG, Schindeler A. JNK inhibitor CC-930 reduces fibrosis in a murine model of Nf1-deficient fracture repair. J Appl Biomed 2018. [DOI: 10.1016/j.jab.2018.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
To compare the current treatments for congenital pseudarthrosis of tibia, a total of 33 studies were reviewed. Vascularized fibular graft with external fixation or combined fixation had the fastest time till initial union (P<0.05). Bone morphogenetic protein had no advantage in terms of initial union, time till union, and refracture rates. This meta-analysis supports that fixation methods with corticocancellous bone autograft utilizing the combined technique of Ilizarov external fixation and intramedullary rod stabilization ensure a statistically significant reduction in the number of refractures compared with standalone fixation methods and would be the preferred method for preventing long-term complications in patients with congenital pseudarthrosis of tibia.
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What Factors Influence Union and Refracture of Congenital Pseudarthrosis of the Tibia? A Multicenter Long-term Study. J Pediatr Orthop 2018; 38:e332-e337. [PMID: 29664876 DOI: 10.1097/bpo.0000000000001172] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To identify factors influencing union of congenital pseudarthrosis of the tibia (CPT), refractures, and integrity of the tibia at maturity. METHODS Data of 119 children operated for Crawford-type IV CPT and followed-up till skeletal maturity were analyzed. Logistic regression and recursive partitioning analyses were used to test associations between several variables and the outcome. RESULTS Primary union occurred in 86% of children. At maturity, 69% remained soundly united. The odds ratio for failure of primary union was 3.89 (95% confidence interval, 1.05-14.40; P=0.042) when bone morphogenetic protein was used, and children who had a combination of the Ilizarov technique and intramedullary nailing were at risk for unsound union at maturity (odds ratio, 6.19; 95% confidence interval, 1.24-30.83; P=0.026). No other association reached statistical significance. On recursive partitioning, use of the Ilizarov technique, transfixing the ankle and subtalar joints, use of cortical graft and not operating on the fibula were associated with a better outcome; use of bone morphogenetic protein and combining intramedullary nailing with the Ilizarov technique were associated with poor results. CONCLUSIONS A larger sample is needed to confirm which factors truly influence the outcome of CPT. This may be feasible if data are collected prospectively through a multicenter registry.
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Abstract
BACKGROUND In congenital pseudarthrosis of the tibia, use of intramedullary (IM) fixation and autogenous bone graft has long been the standard of care. This study was undertaken to determine whether the addition of rhBMP-2 to this treatment method further enhances healing potential. METHODS Twenty-one patients with congenital pseudarthrosis of the tibia were evaluated. Fifteen of these patients had neurofibromatosis type 1 (NF1). All had IM fixation and autogenous bone graft, followed by a BMP-soaked collagen sponge wrapped around both the fracture site and bone graft. A minimum 2 years' follow-up was required. RESULTS Follow-up averaged 7.2 years (range, 2.1 to 12.8 y). Sixteen of 21 tibias achieved bone union following the index surgery, at an average 6.6 months postoperatively. The 5 persistent nonunions occurred in NF1 patients. Further surgery was undertaken in these 5 NF1 patients, including the use of BMP. One of the 5 healed, 1 had persistent nonunion, and 3 eventually had amputation. Of the 16 patients who healed initially following the index surgery, 5 refractured (3 had NF1). Of these 5 patients, the IM fixation at the index surgery did not cross the ankle joint, and refracture occurred at the rod tip in 4. Three of these 5 patients healed following further surgery, 1 had persistent nonunion, and 1 had amputation. All of those with eventual amputation had NF1. No deleterious effects related to the use of BMP-2 were recognized in any patient. CONCLUSIONS The addition of rhBMP-2 appears to be helpful in shortening the time required to achieve fracture union in those who healed, but its use does not insure that healing will occur. LEVEL OF EVIDENCE Level IV-therapeutic, case series.
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Deo N, Cheng TL, Mikulec K, Peacock L, Little DG, Schindeler A. Improved union and bone strength in a mouse model of NF1 pseudarthrosis treated with recombinant human bone morphogenetic protein-2 and zoledronic acid. J Orthop Res 2018; 36:930-936. [PMID: 28767180 DOI: 10.1002/jor.23672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 07/29/2017] [Indexed: 02/04/2023]
Abstract
Tibial pseudarthrosis associated with Neurofibromatosis type 1 (NF1) is an orthopedic condition with consistently poor clinical outcomes. Using a murine model that features localized double inactivation of the Nf1 gene in an experimental tibial fracture, we tested the effects of recombinant human bone morphogenetic protein-2 (rhBMP-2) and/or the bisphosphonate zoledronic acid (ZA). Tibiae were harvested at 3 weeks for analysis, at which time there was negligible healing in un-treated control fractures (7% union). In contrast, rhBMP-2 and rhBMP-2/ZA groups showed significantly greater union (87% and 93%, p < 0.01 for both). Treatment with rhBMP-2 led to a 12-fold increase in callus bone volume and this was further increased in the rhBMP-2/ZA group. Mechanical testing of the healed rhBMP-2 and rhBMP-2/ZA fractures showed that the latter group had significantly higher mechanical strength and was restored to that of the un-fractured contralateral leg. Co-treatment with rhBMP-2/ZA also reduced fibrous tissue infiltration at the fracture site compared to rhBMP alone (p = 0.068). These data support the future clinical investigation of this combination of anabolic and anti-resorptive agents for the treatment of NF1 pseudarthrosis. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:930-936, 2018.
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Affiliation(s)
- Nikita Deo
- Orthopaedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Sydney, New South Wales, 2145, Australia.,Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Tegan L Cheng
- Orthopaedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Sydney, New South Wales, 2145, Australia.,Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kathy Mikulec
- Orthopaedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Sydney, New South Wales, 2145, Australia
| | - Lauren Peacock
- Orthopaedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Sydney, New South Wales, 2145, Australia
| | - David G Little
- Orthopaedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Sydney, New South Wales, 2145, Australia.,Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Aaron Schindeler
- Orthopaedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Sydney, New South Wales, 2145, Australia.,Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
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Yan A, Mei HB, Liu K, Wu JY, Tang J, Zhu GH, Ye WH. Wrapping grafting for congenital pseudarthrosis of the tibia: A preliminary report. Medicine (Baltimore) 2017; 96:e8835. [PMID: 29310362 PMCID: PMC5728763 DOI: 10.1097/md.0000000000008835] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Treatment of congenital pseudarthrosis of the tibia (CPT) remains a challenge. The autogenic iliac bone graft is important consistent of treatment for CPT. The purpose of this study was to investigate the role of wrapping autogenic iliac bone graft in improvement of the curing opportunities of CPT. METHODS We combined Ilizarov fixator with intramedullary rodding of the tibia and wrapping autogenic iliac bone graft for treatment 51 cases of CPT between 2007 and 2010. The mean age is 3.2 years at index operation, of which 31 patients (61%) were below 3 years old. According to Crawford classification, 5 tibia had type-II morphology; 3, type-III; 43, type-IV. RESULTS In the postoperative follow-up of 3.5 months (range from 3 to 4.5 months), all cases were found that the bone graft sites of pseudarthrosis of the tibia showed a significant augmentation and spindle-shaped expansion as obvious change. All cases of this series have been followed-up, average followed-up time were 1.6 years (range from 7 to 3.1 years), of which 19 cases were more than 2 years. The average time of removed the Ilizarov ring fixator was 3.5 months (range from 3 to 4.5 months). According to Johnston Clinical evaluation system, 26 cases had grade I, 21 cases, grade II, 4 cases, grade III. Following the Ohnishi X-ray evaluation criteria, union of pseudarthrosis of the tibia were 42 cases, delayed union 5 cases, nonunion 4 cases. CONCLUSION Autogenic iliac bone graft is able to offer the activity of osteoblasts and osteogenesis induced by bone morphogenetic protein (BMP) and glycoprotein, meanwhile enclosing bone graft could help keep cancellous bone fragments in close contact around pseudarthrosis of the tibia, allowing the formation of high concentration of glycoprotein and BMP induced by chemical factors because of established the sealing environment in location, all of which could enhance the healing of pseudarthrosis of the tibia.
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Complication Rates After Bone Morphogenetic Protein (BMP) Use in Orthopaedic Surgery in Children: A Concise Multicenter Retrospective Cohort Study. J Pediatr Orthop 2017; 37:e375-e378. [PMID: 27603194 DOI: 10.1097/bpo.0000000000000859] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of bone morphogenetic protein (BMP) has been associated with a number of complications in adult patients. However, this association is less established in children. The aim of this study was to evaluate the safety of BMP use in children by determining the complication rates after BMP use at multiple institutions. METHODS In a retrospective study (2000 to 2013), the medical records of all patients who received BMP at any of the 5 institutions were reviewed. Demographic information, preoperative data, and postoperative follow-up data were collected on those patients who were under the age of 18 at the time of surgery. RESULTS A total of 312 pediatric patients underwent surgery with BMP application during the study period. The surgical procedures consisted of 228 spinal fusions, 39 pars repairs, 33 nonunion repair, and 12 other various procedures. Overall 21% (65/312) of patients who had BMP utilized had a complication. Fifty-five percent (36/65) of patients with a complication required a revision surgery. The average follow-up was 27 months (range, 3 to 96 mo); 80% of patients had a follow-up period of >12 months. The average age at the time of surgery was 13 years (range, 1 to 17 y). Males and females were almost equally represented in the study: 143 males (46%) and 168 females (54%). Of the patients who received BMP, 9% had minor complications and 13% had major complications. Wound dehiscence without infection was the most common minor complication and occurred in 59% (16/27) of patients with minor complications. Infection and implant failures were the most frequent major complications, occurring in 38% (15/39) and 33% (13/39) of patients with major complications, respectively. Five of 312 (2%) patients had neurological injury, 3 of which were only temporary. CONCLUSIONS This multicenter study demonstrates a relatively high rate of complications after the use of BMP in children. However, further study is needed to attribute the complications directly to the use of BMP. LEVEL OF EVIDENCE Level IV.
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Abstract
Orthobiologics are biologic devices or products used in orthopedic surgery to augment or enhance bone formation. The use of orthobiologics in pediatric orthopedics is less frequent than in other orthopedic subspecialties, mainly due to the naturally abundant healing potential and bone formation in children compared with adults. However, orthobiologics are used in certain situations in pediatric orthopedics, particularly in spine and foot surgery. Other uses have been reported in conjunction with specific procedures involving the tibia and pelvis. The use of bioabsorable implants to stabilize children's fractures is an emerging concept but has limited supporting data.
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Affiliation(s)
- Robert F Murphy
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 708, Charleston, SC 29492, USA.
| | - James F Mooney
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 708, Charleston, SC 29492, USA
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21
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Abstract
Orthobiologics are biological substances that allow injured muscles, tendons, ligaments, and bone to heal more quickly. They are found naturally in the body; at higher concentrations they can aid in the healing process. These substances include autograft bone, allograft bone, demineralized bone matrix, bone morphogenic proteins, growth factors, stem cells, plasma-rich protein, and ceramic grafts. Their use in sports medicine has exploded in efforts to increase graft incorporation, stimulate healing, and get athletes back to sport with problems including anterior cruciate ligament ruptures, tendon ruptures, cartilage injuries, and fractures. This article reviews orthobiologics and their applications in pediatric sports medicine.
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Affiliation(s)
- Christopher C Bray
- Pediatric Orthopaedic Surgery and Adolescent Sports Medicine, Department of Orthopaedic Surgery, Steadman Hawkins Clinic of the Carolinas, Greenville Health System, 701 Grove Road, Greenville, SC 29605, USA; University of South Carolina School of Medicine - Greenville, Greenville, SC, USA.
| | - Clark M Walker
- Department of Orthopaedic Surgery, Greenville Health System, 701 Grove Road, Greenville, SC 29605, USA
| | - David D Spence
- Department of Orthopaedic Surgery, University of Tennessee - Campbell Clinic, 1400 South Germantown Road, Germantown, Memphis, TN 38138, USA
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O’Donnell C, Foster J, Mooney R, Beebe C, Donaldson N, Heare T. Congenital Pseudarthrosis of the Tibia. JBJS Rev 2017; 5:e3. [DOI: 10.2106/jbjs.rvw.16.00068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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23
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Hissnauer TN, Stiel N, Babin K, Rupprecht M, Hoffmann M, Rueger JM, Stuecker R, Spiro AS. Bone morphogenetic protein-2 for the treatment of congenital pseudarthrosis of the tibia or persistent tibial nonunion in children and adolescents: A retrospective study with a minimum 2-year follow-up. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:60. [PMID: 28213747 DOI: 10.1007/s10856-017-5868-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 02/07/2017] [Indexed: 06/06/2023]
Abstract
There is a lack of studies reporting on rhBMP-2 application in pediatric orthopaedics, although few reports demonstrated promising results of the use of rhBMP-2 in children, especially for spine fusion and for the treatment of congenital pseudarthrosis of the tibia. The objectives of this study were (1) to examine clinical and radiographic healing after rhBMP-2 application for the treatment of congenital pseudarthrosis of the tibia (CPT) or persistent tibial nonunion in children and adolescents, and (2) to investigate the safety of rhBMP-2 use in these cases. Therefore we reviewed the medical records of ten patients with a mean age of 8.6 years (2.3-21) with CPT (n = 7) or persistent tibial nonunion for at least six months (n = 3) who had been treated with rhBMP-2. Nine of ten patients had union at final follow-up, after a mean of 72.9 months (25-127). In the CPT group, primary healing of the pseudarthrosis occurred in six of seven patients at a mean of 5.2 months (3-12). Repeat rhBMP-2 application was performed in three patients; two patients had one additional application each, and one patient had three additional applications. Complications that may be attributed to the use of rhBMP-2 were seen in two of fifteen applications, including a compartmemt syndrome and a hematoma. In this retrospective case series rhBMP-2 has been used successfully to treat CPT or persistent tibial nonunion in pediatric patients. However, prospective randomized controlled trials are warranted to investigate the long-term efficacy and safety of rhBMP-2 use in these cases.
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Affiliation(s)
- Tim N Hissnauer
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Norbert Stiel
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kornelia Babin
- Department of Pediatric Orthopaedic Surgery, Children's Hospital Hamburg-Altona, Hamburg, Germany
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Rupprecht
- Department of Pediatric Orthopaedic Surgery, Children's Hospital Hamburg-Altona, Hamburg, Germany
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Hoffmann
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes M Rueger
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Stuecker
- Department of Pediatric Orthopaedic Surgery, Children's Hospital Hamburg-Altona, Hamburg, Germany
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander S Spiro
- Department of Pediatric Orthopaedic Surgery, Children's Hospital Hamburg-Altona, Hamburg, Germany.
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Stiel N, Hissnauer TN, Rupprecht M, Babin K, Schlickewei CW, Rueger JM, Stuecker R, Spiro AS. Evaluation of complications associated with off-label use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in pediatric orthopaedics. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2016; 27:184. [PMID: 27787808 DOI: 10.1007/s10856-016-5800-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 10/14/2016] [Indexed: 06/06/2023]
Abstract
The off-label use of recombinant human bone morphogenetic protein-2 to promote bone healing in adults has significantly increased in recent years, while reports of recombinant human bone morphogenetic protein-2 application in children and adolescents are very rare. The aim of this study was to evaluate the safety of single and repetitive recombinant human bone morphogenetic protein-2 use in pediatric orthoapedics. Therefore we reviewed the medical records of 39 patients who had been treated with recombinant human bone morphogenetic protein-2 at our institution. Their mean age was 10.9 years. Recombinant human bone morphogenetic protein-2 was used in 17 patients for spine fusion, in 11 patients for the treatment of congenital pseudarthrosis of the tibia or tibial nonunion, in 5 patients for the management of femoral nonunion, in 5 patients for nonunions at other locations, and in 1 case for tibial shortening. Special attention was paid to identify all adverse events that may be attributed to recombinant human bone morphogenetic protein-2 use, including local inflammatory reactions, allergic reactions, systemic toxicity, excessive wound swelling, hematoma, compartment syndrome, infection, heterotopic ossification, excessive bone growth, carcinogenicity, and the consequences of repeated applications of recombinant human bone morphogenetic protein-2. Follow-up was a mean of 39 months. Forty-six operations with application of rhBMP-2 were performed. Complications that may be due to application of recombinant human bone morphogenetic protein-2 were seen after 18 operations including swelling, increase in temperature, wound secretion, redness and hyperthermia. We consider the three cases of necessary revisions, one due to hematoma, one due to development of a compartment syndrome, and one due to deep infection, to be the only complications related to the use of recombinant human bone morphogenetic protein-2. In conclusion, we found few complications attributable to application of recombinant human bone morphogenetic protein-2 in pediatric patients.
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Affiliation(s)
- Norbert Stiel
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim N Hissnauer
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Rupprecht
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Hamburg-Altona, Germany
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kornelia Babin
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Hamburg-Altona, Germany
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten W Schlickewei
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes M Rueger
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Stuecker
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Hamburg-Altona, Germany
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander S Spiro
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Hamburg-Altona, Germany.
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Zhu GH, Mei HB, He RG, Liu YX, Liu K, Tang J, Wu JY. Combination of intramedullary rod, wrapping bone grafting and Ilizarov's fixator for the treatment of Crawford type IV congenital pseudarthrosis of the tibia: mid-term follow up of 56 cases. BMC Musculoskelet Disord 2016; 17:443. [PMID: 27770774 PMCID: PMC5075394 DOI: 10.1186/s12891-016-1295-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 10/13/2016] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this study was to investigate the initial union rate, refracture rate and residual deformities of congenital pseudarthrosis of the tibia (CPT), using combined surgery including pseudarthrosis resection, intramedullary rodding, autogenous iliac bone grafting and Ilizarov’s fixator, with a mean 5.2 years follow-up. Methods We retrospectively reviewed the records and diagrams of patients with Crawford type IV congenital pseudarthrosis of the tibia between February 2007 and March 2010. Patients managed by pseudarthrosis resection, intramedullary rod of the tibia, wrapping autogenous iliac bone grafting and Ilizarov’s fixator were enrolled. We evaluated the bone union rate, tibial alignment, limb length discrepancy (LLD), valgus deformity of the ankle and the frequencies of refracture during period of follow-up. Results There were 56 cases enrolled in the study, with a mean follow-up 5.2 years (range, 3 to 6.7 years). The mean age of the patients at surgery was 3.5 years (range, 1.5 to 12.4 years). Fifty (89.2 %) of the 56 patients had primary bone union at site of pseudarthrosis, while 5 obtained union after second surgery and 1 failed. The average time spent to obtain pseudarthrosis initial union was 4.5 months (range, 3.0 to 10.0 months) and mean duration of Ilizarov treatment was 4.7 months (range, 3.2 to 10.4 months). Eleven (19.6 %) patients had proximal tibial valgus with a mean angle of 9.5° (range, 5 to 24°), while 10 (17.9 %) patients had ankle valgus deformities with a mean of 12.3° (range, 6 to 21°). Sixteen (28.6 %) patients had an average 2.2 cm LLD (range, 1.5–4.2 cm). Of the 50 cases who obtained initial bone union of pseudarthrosis, 13 (26.0 %) had refracture which need cast immobilization or secondary surgery. Conclusions This combined surgery obtained initial union rate of 89.2 % at primary surgery while the refracture rate is 26.0 %. However, residual deformities such as proximal tibial valgus, LLD and ankle valgus were also existed which should be pay more attention to and dealt with. Trial registration This study was registered in ClinicalTrials.gov under the name “The Effect of Combined Surgery in Management of Congenital Pseudarthrosis of Tibia” (NCT02640040), which was released on August 31, 2015.
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Affiliation(s)
- Guang-Hui Zhu
- Department of Orthopedics, Hunan Children's Hospital, 86 Ziyuan road, Changsha, Hunan, People's Republic of China
| | - Hai-Bo Mei
- Department of Orthopedics, Hunan Children's Hospital, 86 Ziyuan road, Changsha, Hunan, People's Republic of China.
| | - Rong-Guo He
- Department of Orthopedics, Hunan Children's Hospital, 86 Ziyuan road, Changsha, Hunan, People's Republic of China
| | - Yao-Xi Liu
- Department of Orthopedics, Hunan Children's Hospital, 86 Ziyuan road, Changsha, Hunan, People's Republic of China
| | - Kun Liu
- Department of Orthopedics, Hunan Children's Hospital, 86 Ziyuan road, Changsha, Hunan, People's Republic of China
| | - Jin Tang
- Department of Orthopedics, Hunan Children's Hospital, 86 Ziyuan road, Changsha, Hunan, People's Republic of China
| | - Jiang-Yan Wu
- Department of Orthopedics, Hunan Children's Hospital, 86 Ziyuan road, Changsha, Hunan, People's Republic of China
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The use of recombinant morphogenic protein-2(rhBMP-2) in children undergoing revision surgery for persistent non-union. Strategies Trauma Limb Reconstr 2016; 11:53-8. [PMID: 26984411 PMCID: PMC4814389 DOI: 10.1007/s11751-016-0251-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 03/01/2016] [Indexed: 01/30/2023] Open
Abstract
The purpose of the study was to evaluate the safety and efficacy with the use of BMP-2 for treating persistent non-unions in children with underlying complex conditions. Between October 2006 and November 2010 in our unit, 15 patients were treated with rhBMP-2 to enhance bone union. There were nine females and six males with a mean age of 9.5 years (range 4–15) at time of surgery. Seventy-five per cent of the patients required revision of internal fixation with insertion of rhBMP-2 to the non-union site, and the reminder had freshening of the non-union site with rhBMP-2 application. Patients had undergone a mean of 2 (1–5) operations prior to implantation of rhBMP-2. All the patients in the study group were available for review with mean follow-up of 44 months (range 21–70). The mean time to union was 16 weeks (range 10–28 weeks). No adverse events related to BMP-2 application were noted in our study group. Healing occurred clinically and radiographically in 16 of the 17 sites. Our study demonstrates that BMP-2 enhances healing of the persistent non-unions without any adverse events
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Abstract
Ten children with congenital pseudarthrosis of the tibia were treated with resection of pathologic bone, bone grafting, intramedullary rodding, compression with circular frame, simultaneous proximal tibia lengthening, and bone morphologic proteins. Thirteen operations were performed to achieve union. Four patients underwent simultaneous lengthening and four patients received recombinant human bone morphologic protein. Six children required complementary operations for residual ankle and knee valgus, and shortening. Union of the pseudarthrosis was achieved in all cases with lengthening up to 5 cm. This protocol is effective in achieving union of congenital pseudarthrosis of tibia; attention should be paid to the ankle joint to achieve functionality of the limb.
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Vanderstappen J, Lammens J, Berger P, Laumen A. Ilizarov bone transport as a treatment of congenital pseudarthrosis of the tibia: a long-term follow-up study. J Child Orthop 2015; 9:319-24. [PMID: 26266468 PMCID: PMC4549345 DOI: 10.1007/s11832-015-0675-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/29/2015] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Most studies on congenital pseudarthrosis of the tibia (CPT) report on the short-term union rate and refracture rate but do not take into account the long-term outcome. This review includes patients treated with an Ilizarov bone transport, who all reached skeletal maturity. It describes long-term results and highlights any prognostic factors that could predict the final outcome. METHODS The records of patients with CPT treated with an Ilizarov bone transport in our institution were retrospectively evaluated. RESULTS A total of 12 consecutive patients were studied. The mean follow-up was 24.5 years (range 6-39 years). Primary consolidation was seen in ten patients (83 %). Half of these patients had a refracture. At final follow-up, eight patients experienced union and four remained un-united, of whom one had an amputation. CONCLUSIONS The present data confirm a good primary healing rate. However, tibial union at final follow-up was only seen in 67 %, indicating that refracture is the main issue. United bone is often of inferior biological and mechanical quality, so lifetime protection with intramedullary devices, braces or a combination of both is recommended.
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Affiliation(s)
- Jan Vanderstappen
- Department of Orthopaedic Surgery, University of Leuven, Leuven, Belgium,
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Lee JH, Baek HR, Lee KM, Zheng GB, Shin SJ, Shim HJ. Effects of Ovariectomy and Corticosteroid-Induced Osteoporosis on the Osteoinductivity of rhBMP-2 in a Segmental Long-Bone Defect Model. Tissue Eng Part A 2015; 21:2262-71. [PMID: 25996180 DOI: 10.1089/ten.tea.2014.0659] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study used the segmental long-bone defect model to assess the effects of osteoporosis on the formation of new bones and the osteoinductivity of recombinant human bone morphogenetic protein-2 (rhBMP-2). Seventy-two female Sprague-Dawley rats were divided into two groups: an osteoporosis group with ovariectomies and dexamathasone intramuscular injections and a sham group. When they reached 22 weeks in age, each group was further divided into two groups and a 5-mm defect was made in both fibular mid-shafts of each rat. One fibula in each rat was picked randomly and was injected with 0.05 mL of hydrogel carrier; the opposite fibula was injected with the same carrier mixed with rhBMP-2 (10 μg). After rearing for a further 5 and 9 weeks, the ratios of the lengths of the newly formed bones in the fibular defects were determined using micro-CT and undecalcified histology. The sham rhBMP-2-injected group-in all of the 5- and 9-week-kept groups-showed a significantly higher bridging bone formation ratio than the other three groups. The osteoporosis rhBMP-2-injected group showed a significantly higher ratio than both the non-rhBMP-2-injected sham hydrogel and the osteoporosis hydrogel groups. The comparison of the micro-CT parameters of the newly formed bones showed that the sham rhBMP-2 group at both 5 and 9 weeks compared with the osteoporosis rhBMP-2 group had significantly higher percentage bone volumes, trabecular thicknesses, and trabecular numbers, in addition to significantly lower specific surfaces, trabecular pattern factors, and structural model indices. The histology results showed that the sham-rhBMP-2 group began forming bridging bones in the defect areas at 5 weeks, and at 9 weeks, trabeculae and marrow spaces were observed. However, the osteoporosis rhBMP-2 group exhibited a relatively minor level of new bone and trabecula formation. Consequently, the rhBMP-2 group showed significantly increased bone formation in the osteoporosis rat fibular defect model compared with the hydrogel group, whereas the new bone quantities, qualities, and remodeling in the osteoporosis rhBMP-2 group were less effective than those in the sham-rhBMP-2 group, signaling that ovariectomy and corticosteroid-induced osteoporosis significantly undermines rhBMP-2 osteoinductivity.
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Affiliation(s)
- Jae Hyup Lee
- 1 Department of Orthopedic Surgery, Seoul National University , College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea.,2 Institute of Medical and Biological Engineering, Seoul National University Medical Research Center , Seoul, Korea
| | - Hae-Ri Baek
- 1 Department of Orthopedic Surgery, Seoul National University , College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea.,2 Institute of Medical and Biological Engineering, Seoul National University Medical Research Center , Seoul, Korea
| | - Kyung-Mee Lee
- 1 Department of Orthopedic Surgery, Seoul National University , College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Guang Bin Zheng
- 1 Department of Orthopedic Surgery, Seoul National University , College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Sung Joon Shin
- 1 Department of Orthopedic Surgery, Seoul National University , College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hee-Jong Shim
- 1 Department of Orthopedic Surgery, Seoul National University , College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
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Abstract
The aim of this study was to determine whether an established radiographic union scoring system for tibial fracture healing (RUST) is reliable when used in neurofibromatosis (NF1) patients with congenital pseudarthrosis of the tibia (CPT) treated by intramedullary fixation. Four individuals reviewed 36 sets of radiographs from 12 NF1 patients with CPT (preoperative, and 6 months and 1 year postoperative). Intraobserver reliability (κ-value 0.89) and interobserver reliability (κ-value 0.76) were high. The modified RUST scoring system is a useful tool when faced with the challenge of postoperative radiographic evaluation of the tibia in NF1 patients with CPT.
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Lam SK, Sayama C, Harris DA, Briceño V, Luerssen TG, Jea A. Nationwide practice patterns in the use of recombinant human bone morphogenetic protein-2 in pediatric spine surgery as a function of patient-, hospital-, and procedure-related factors. J Neurosurg Pediatr 2014; 14:476-85. [PMID: 25171721 DOI: 10.3171/2014.7.peds1499] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Current national patterns as a function of patient-, hospital-, and procedure-related factors, and complication rates in the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) as an adjunct to the practice of pediatric spine surgery have scarcely been investigated. METHODS The authors conducted a cross-sectional study using data from the Healthcare Cost and Utilization Project Kids' Inpatient Database. Univariate and multivariate logistic regression were used to calculate unadjusted and adjusted odds ratios and 95% confidence intervals, and p values < 0.05 were considered to be statistically significant. RESULTS The authors identified 9538 hospitalizations in pediatric patients 20 years old or younger who had undergone spinal fusion in the US in 2009; 1541 of these admissions were associated with rhBMP-2 use. By multivariate logistic regression, the following factors were associated with rhBMP-2 use: patient age 15-20 years; length of hospital stay (adjusted odds ratio [aOR] 1.01, p = 0.017); insurance status (private [aOR 1.49, p < 0.001] compared with Medicaid); hospital type (nonchildren's hospital); region (Midwest [aOR 2.49, p = 0.008] compared with Northeast); spinal refusion (aOR 2.20, p < 0.001); spinal fusion approach/segment (anterior lumbar [aOR 1.73, p < 0.001] and occipitocervical [aOR 1.86, p = 0.013] compared with posterior lumbar); short segment length (aOR 1.42, p = 0.016) and midlength (aOR 1.44, p = 0.005) compared with long; and preoperative diagnosis (Scheuermann kyphosis [aOR 1.56, p < 0.017] and spondylolisthesis [aOR 1.93, p < 0.001]). CONCLUSIONS Use of BMP in pediatric spine procedures now comprises more than 10% of pediatric spinal fusion. Patient-related (age, insurance type, diagnosis); hospital-related (children's hospital vs general hospital, region in the US); and procedure-related (redo fusion, anterior vs posterior approach, spinal levels, number of levels fused) factors are associated with the variation in BMP use in the US.
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Affiliation(s)
- Sandi K Lam
- Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Courvoisier A, Sailhan F, Laffenêtre O, Obert L. Bone morphogenetic protein and orthopaedic surgery: can we legitimate its off-label use? INTERNATIONAL ORTHOPAEDICS 2014; 38:2601-5. [PMID: 25267430 DOI: 10.1007/s00264-014-2534-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/09/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE Bone morphogenetic proteins (BMP) are recombinant osteoinductive proteins with their primary role being to promote bone formation. The off-label use of BMP in orthopaedic surgery has dramatically increased. However, reports of complications with BMP have emerged, and the safety of these proteins in orthopaedics is questioned. The purpose of this review was to evaluate safe situations in which BMP should be used and situations in which their use should be restricted. METHOD We recorded all studies from PubMed database from 2002 (date of first authorisation for both BMPs) until January 2014 using "BMP" or "bone morphogenetic protein". Then we screened and extracted all studies dealing with orthopaedic surgery. All situations in which BMP were used, even cases reports, were considered, and complications reported were then listed. RESULTS Situations in which it seems safe and efficient to use BMP are long-bone nonunions, or arthrodesis as an alternative or combined to autograft in small-bone loss. Surgeons and patients should be aware of transient aseptic wound swelling when BMP is located superficially. The use of BMP in spine surgery for intersomatic fusion is efficient but should be restricted to approaches that respect the vertebral canal to avoid neurological complications. CONCLUSION This review is an off-label map of BMP use in orthopaedics during the past 10 years. Our results could provide a useful tool to help decisions around when to use a BMP in a specific complex, and sometimes off-label, situation.
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Affiliation(s)
- Aurélien Courvoisier
- Pediatric Orthopedic Department. Grenoble University Hospital, Grenoble Alpes University, BP 217, 38043, Grenoble Cedex 09, France,
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El-Hoss J, Cheng T, Carpenter EC, Sullivan K, Deo N, Mikulec K, Little DG, Schindeler A. A Combination of rhBMP-2 (Recombinant Human Bone Morphogenetic Protein-2) and MEK (MAP Kinase/ERK Kinase) Inhibitor PD0325901 Increases Bone Formation in a Murine Model of Neurofibromatosis Type I Pseudarthrosis. J Bone Joint Surg Am 2014; 96:e117. [PMID: 25031379 DOI: 10.2106/jbjs.m.00862] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Congenital tibial dysplasia is a severe pediatric condition that classically results in a persistent pseudarthrosis. A majority of these cases are associated with neurofibromatosis type I (NF1), a genetic disorder in which inactivation of the NF1 gene leads to overactivity of the Ras-MEK-MAPK (mitogen-activated protein kinase) signaling pathway. We therefore hypothesized that pharmaceutical inhibition of MEK-MAPK may be a beneficial therapeutic strategy. METHODS In vitro methods were used to demonstrate a role for the MEK inhibitor PD0325901 in promoting osteogenic differentiation in Nf1-/- calvarial osteoblasts. Local applications of rhBMP-2 and/or PD0325901 were then tested in a mouse model of NF1 tibial pseudarthrosis featuring localized double inactivation of the Nf1 gene in a fracture. Mice received no treatment, PD0325901 (10 mg/kg/day from two days before fracture to ten days after fracture), rhBMP-2 (10 μg), or a combination of rhBMP-2 and PD0325901. RESULTS Animals treated with the delivery vehicle alone, PD0325901, rhBMP-2, or the PD0325901 + rhBMP-2 combination showed union rates of 0%, 8%, 69% (p < 0.01), or 80% (p < 0.01), respectively, at twenty-one days after fracture. Mice treated with the rhBMP-2 + PD0325901 combination displayed a callus volume sixfold greater than the vehicle controls and twofold greater than the group receiving rhBMP-2 alone. Although MEK inhibition combined with rhBMP-2 led to increases in bone formation and union, the proportion of fibrous tissue in the callus was not significantly reduced. CONCLUSIONS The data suggest that MEK inhibition can promote bone formation in combination with rhBMP-2 in the context of an NF1 pseudarthrosis. However, PD0325901 did not promote substantive bone anabolism in the absence of an exogenous anabolic stimulus and did not suppress fibrosis. CLINICAL RELEVANCE This study examines a signaling pathway-based approach to treating poor bone healing in a model of NF1 pseudarthrosis.
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Affiliation(s)
- J El-Hoss
- Orthopaedic Research & Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail address for J. El-Hoss: . E-mail address for T. Cheng: . E-mail address for E.C. Carpenter: . E-mail address for K. Sullivan: . E-mail address for N. Deo: . E-mail address for K. Mikulec: . E-mail address for D.G. Little: . E-mail address for A. Schindeler:
| | - T Cheng
- Orthopaedic Research & Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail address for J. El-Hoss: . E-mail address for T. Cheng: . E-mail address for E.C. Carpenter: . E-mail address for K. Sullivan: . E-mail address for N. Deo: . E-mail address for K. Mikulec: . E-mail address for D.G. Little: . E-mail address for A. Schindeler:
| | - E C Carpenter
- Orthopaedic Research & Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail address for J. El-Hoss: . E-mail address for T. Cheng: . E-mail address for E.C. Carpenter: . E-mail address for K. Sullivan: . E-mail address for N. Deo: . E-mail address for K. Mikulec: . E-mail address for D.G. Little: . E-mail address for A. Schindeler:
| | - K Sullivan
- Orthopaedic Research & Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail address for J. El-Hoss: . E-mail address for T. Cheng: . E-mail address for E.C. Carpenter: . E-mail address for K. Sullivan: . E-mail address for N. Deo: . E-mail address for K. Mikulec: . E-mail address for D.G. Little: . E-mail address for A. Schindeler:
| | - N Deo
- Orthopaedic Research & Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail address for J. El-Hoss: . E-mail address for T. Cheng: . E-mail address for E.C. Carpenter: . E-mail address for K. Sullivan: . E-mail address for N. Deo: . E-mail address for K. Mikulec: . E-mail address for D.G. Little: . E-mail address for A. Schindeler:
| | - K Mikulec
- Orthopaedic Research & Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail address for J. El-Hoss: . E-mail address for T. Cheng: . E-mail address for E.C. Carpenter: . E-mail address for K. Sullivan: . E-mail address for N. Deo: . E-mail address for K. Mikulec: . E-mail address for D.G. Little: . E-mail address for A. Schindeler:
| | - D G Little
- Orthopaedic Research & Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail address for J. El-Hoss: . E-mail address for T. Cheng: . E-mail address for E.C. Carpenter: . E-mail address for K. Sullivan: . E-mail address for N. Deo: . E-mail address for K. Mikulec: . E-mail address for D.G. Little: . E-mail address for A. Schindeler:
| | - A Schindeler
- Orthopaedic Research & Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail address for J. El-Hoss: . E-mail address for T. Cheng: . E-mail address for E.C. Carpenter: . E-mail address for K. Sullivan: . E-mail address for N. Deo: . E-mail address for K. Mikulec: . E-mail address for D.G. Little: . E-mail address for A. Schindeler:
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Effectiveness of recombinant human bone morphogenetic protein-7 in the management of congenital pseudoarthrosis of the tibia: a randomised controlled trial. INTERNATIONAL ORTHOPAEDICS 2014; 38:1987-92. [PMID: 24827969 DOI: 10.1007/s00264-014-2361-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Despite the popularity and an increased use of bone morphogenetic protein to improve bone healing in patients with congenital pseudoarthrosis of the tibia (CPT), no previous study has compared its efficacy against any other procedure. METHODS We randomised 20 consecutive patients (mean age 4.1 years) with CPT (Crawford type IV) associated with neurofibromatosis type 1(NF1) and no previous history of surgery into two groups. Group 1 received recombinant human bone morphogenetic protein-7 (rhBMP-7) along with intramedullary Kirschner (K)-wire fixation and autologous bone grafting; group 2 received only K wire and grafting. Outcome measures were time to achieve union, Johnston grade, tibial length and the American Orthopaedic Foot and Ankle Society (AOFAS) score, which were evaluated preoperatively and at five year follow-up. RESULTS Study results showed that patients in group 1 achieved primary bone union at a mean of 14.5 months [standard error (SE) 5.2], whereas group 2 took a mean of 17.11 months (SE 5.0). However, the log-rank test showed no difference in healing times between groups at all time points (P = 0.636). There was a statistically significant pre- to post operative improvement (P < 0.05) within groups for the other outcome measures. CONCLUSION In a five year follow-up, these results suggest that rh-BMP-7 and autologous bone grafting is no better than autologous grafting alone.
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Nicolaou N, Ghassemi A, Hill RA. Congenital pseudarthrosis of the tibia: the results of an evolving protocol of management. J Child Orthop 2013; 7:269-76. [PMID: 24432086 PMCID: PMC3799925 DOI: 10.1007/s11832-013-0499-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 05/13/2013] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This retrospective cohort study assesses the outcomes of a protocol of management, based on the recommendations of the European Paediatric Orthopaedic Society (EPOS) multi-centre study, for the management of congenital pseudarthrosis of the tibia. METHODS Utilising an incremental protocol of bracing, intramedullary rods and circular frame fixation with or without bone morphogenetic protein-2 (BMP-2), 11 patients had reached skeletal maturity or had follow up of 5 years from radiological union of the pseudarthrosis. Demographic data, deformity parameters before and after treatment, and functional outcome scores were recorded. RESULTS Ten of the 11 patients successfully healed and two sustained a refracture. All deformity parameters improved and a mean leg length discrepancy of 2.5 cm (range 0-7.5 cm) existed at the time of the last follow up. Some pseudarthroses healed with deformity correction and rod insertion alone. Six of the 11 patients had a confirmed diagnosis of neurofibromatosis and nine had sustained a fracture before 4 years of age. Refracture was associated with malalignment after healing. CONCLUSION This method of treatment provides a successful stepwise protocol for the management of this complex disorder, avoiding the use of aggressive limb reconstruction techniques at a young age in some cases. Level of evidenceCase series Level IV.
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Affiliation(s)
- N. Nicolaou
- />Maidstone and Tunbridge Wells NHS Trust, Maidstone, Kent UK
| | - A. Ghassemi
- />Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - R. A. Hill
- />Great Ormond Street Hospital for Children NHS Trust, London, UK
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Approaches to treating NF1 tibial pseudarthrosis: consensus from the Children's Tumor Foundation NF1 Bone Abnormalities Consortium. J Pediatr Orthop 2013; 33:269-75. [PMID: 23482262 DOI: 10.1097/bpo.0b013e31828121b8] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neurofibromatosis 1 (NF1) is an autosomal dominant disorder with various skeletal abnormalities occurring as part of a complex phenotype. Tibial dysplasia, which typically presents as anterolateral bowing of the leg with subsequent fracture and nonunion (pseudarthrosis), is a serious but infrequent osseous manifestation of NF1. Over the past several years, results from clinical and experimental studies have advanced our knowledge of the role of NF1 in bone. On the basis of current knowledge, we propose a number of concepts to consider as a theoretical approach to the optimal management of tibial pseudarthrosis. METHODS A literature review for both clinical treatment and preclinical models for tibial dysplasia in NF1 was performed. Concepts were discussed and developed by experts who participated in the Children's Tumor Foundation sponsored International Bone Abnormalities Consortium meeting in 2011. RESULTS Concepts for a theoretical approach to treating tibial pseudarthrosis include: bone fixation appropriate to achieve stability in any given case; debridement of the "fibrous pseudarthrosis tissue" between the bone segments associated with the pseudarthrosis; creating a healthy vascular bed for bone repair; promoting osteogenesis; controlling overactive bone resorption (catabolism); prevention of recurrence of the "fibrous pseudarthrosis tissue"; and achievement of long-term bone health to prevent recurrence. CONCLUSIONS Clinical trials are needed to assess effectiveness of the wide variation of surgical and pharmacologic approaches currently in practice for the treatment of tibial pseudarthrosis in NF1. LEVEL OF EVIDENCE Level V, expert opinion.
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Khan T, Joseph B. Controversies in the management of congenital pseudarthrosis of the tibia and fibula. Bone Joint J 2013; 95-B:1027-34. [DOI: 10.1302/0301-620x.95b8.31434] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Congenital pseudarthrosis of the tibia (CPT) is a rare but well recognised condition. Obtaining union of the pseudarthrosis in these children is often difficult and may require several surgical procedures. The treatment has changed significantly since the review by Hardinge in 1972, but controversies continue as to the best form of surgical treatment. This paper reviews these controversies. Cite this article: Bone Joint J 2013;95-B:1027–34.
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Affiliation(s)
- T. Khan
- Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore HA7 4LP, UK
| | - B. Joseph
- Kasturba Medical College, Manipal University, Department
of Orthopaedics, Madhav Nagar, Manipal
576 104, Karnataka, India
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Bobotas K, Lallos SN, Nikolaou VS, Kοrres DS, Efstathopoulos NE. Successful treatment of congenital pseudarthrosis of the tibia: still a challenge. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 23 Suppl 2:S303-10. [PMID: 23412204 DOI: 10.1007/s00590-012-1072-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 08/15/2012] [Indexed: 10/27/2022]
Abstract
The congenital pseudarthrosis of the tibia (CPT) is one of the most challenging problems in pediatric orthopedics. The primary treatment goals are outlined as osteosynthesis, stabilization of the ankle mortise by fibular stabilization and lower-limb-length equalization. Despite the fact that each of the aforementioned goals is difficult to be achieved regardless the surgical option, the main biological consideration is the same: pseudarthrosis resection, biological bone bridging of the defect by stable fixation and the correction of any angular deformity. The external fixation method is suggested as valuable treatment of CPT because it can address not only pseudarthrosis but also all complex deformities associated with this condition. However, treatment of CPT is impaired with complications due to the complex nature of the disease thus failure is common. The most common of these are refracture, growth disturbance, poor foot and ankle function with stiffness. Of these, refracture is the most common and serious complication after primary healing and might result in the reestablishment of pseudarthrosis. Therefore, an effective, safe and practical treatment method that minimizes the residual challenges after healing and accomplishes the multiple goals of treatment is needed. In this article, we report a patient with CPT treated successfully with external fixation. Level of evidence IV retrospective.
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Affiliation(s)
- K Bobotas
- Second Department of Orthopaedics, Κ.Α.Τ. Hospital, Kifissia, Athens, Greece
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Masquelet's procedure and bone morphogenetic protein in congenital pseudarthrosis of the tibia in children: a case series and meta-analysis. J Child Orthop 2012; 6:297-306. [PMID: 23904896 PMCID: PMC3425695 DOI: 10.1007/s11832-012-0421-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 07/02/2012] [Indexed: 02/03/2023] Open
Abstract
PURPOSE A type 2 recombinant human bone morphogenetic protein (rhBMP2) and Masquelet's procedure were used in three children presenting with congenital pseudarthrosis of the tibia (CPT). Recent studies on CPT suggested the presence in situ of pathologic tissues promoting pseudarthrosis. The authors hypothesized that large segmental resection of pseudarthrosis could improve prognosis of the CPT. Masquelet's procedure and rhBMP2 have been advocated for the treatment of long bone defect. METHOD The authors report three cases of CPT in children treated with Masquelet's procedure and application of rhBMP2. They analyzed all published cases of CPT similarly treated. RESULTS In the present study, Masquelet's procedure did not improve the results in the treatment of CPT, but segmental bone reconstruction was possible. Bone healing was obtained in three out of the five applications of rhBMP2. In one case, the patient's parents asked for leg amputation. Analysis of the 33 published cases with the application of BMP in CPT points to a 62 % healing rate in this pathology. CONCLUSION The authors confirmed that segmental bone reconstruction is possible in CPT using Masquelet's procedure. In the literature, the success rate of the application of rhBMP in CPT appears to be lower than the healing rate usually reported without BMP. Nevertheless, the strict selection of patients, limited number of cases, and their heterogeneity make interpreting the results difficult. However, the theoretical risk which the children are exposed to during the use of BMP makes rigorous selection of the indications necessary. Finally, the interest of rhBMP2 application in Masquelet's procedure remained to be proven.
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Abstract
Bone graft substitutes have become progressively more widely used, and are currently heavily marketed. To make intelligent decisions, a complete knowledge of autograaft and allograft bone healing is essential, including the definition of "sterile". Differences in donor selection and tissue processing may confound the user not familiar with the implications of these different approaches. Specific products include demineralized bone matrix (DBM), specific growth factors (recombinant BMP's), ceramic grafts, and platelet-rich plasma (PRP). There are a number of useful applications of bone graft substitues for pediatric orthopaedists, but the data base is evolving. This paper describes the current status of these products.
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Soldado F, Fontecha CG, Haddad S, Hernandez-Fernandez A, Corona P, Guerra-Farfan E. Treatment of congenital pseudarthrosis of the tibia with vascularized fibular periosteal transplant. Microsurgery 2012; 32:397-400. [DOI: 10.1002/micr.21985] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Accepted: 02/23/2012] [Indexed: 11/07/2022]
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Granchi D, Devescovi V, Baglio SR, Magnani M, Donzelli O, Baldini N. A regenerative approach for bone repair in congenital pseudarthrosis of the tibia associated or not associated with type 1 neurofibromatosis: correlation between laboratory findings and clinical outcome. Cytotherapy 2012; 14:306-14. [DOI: 10.3109/14653249.2011.627916] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Exaggerated inflammatory response and bony resorption from BMP-2 use in a pediatric forearm nonunion. J Hand Surg Am 2012; 37:316-21. [PMID: 22119603 DOI: 10.1016/j.jhsa.2011.10.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 10/04/2011] [Accepted: 10/07/2011] [Indexed: 02/02/2023]
Abstract
The Food and Drug Administration (FDA) indicates that bone morphogenetic protein (BMP) products are contraindicated in pediatric patients. However, it acknowledges the off-label use of BMP in difficult cases. Although the relative safety of BMP in children has been reported for lower extremity and spine procedures, little information exists for the safety of BMP used in the pediatric upper extremity. We present a case of a massive inflammatory reaction after use of recombinant human BMP-2 for repair of a symptomatic ulnar nonunion in a child. The case illustrates the potential difficulties of using the dose-dependent properties of BMP in the treatment of pediatric upper extremity nonunions when the dose calculations of BMP for children have not yet been defined.
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Abstract
While fractures in children are usually due to trauma only, there are a number of congenital and metabolic conditions which will predispose a child to fractures and lower the threshold of a bone to breaking. These conditions can also influence the pattern of the fracture and the process of bone healing. There are a number of conditions which lead to specific pathological and clinical changes and also several relatively common conditions which must be considered when assessing any child with recurrent fractures. We present a review of congenital and metabolic causes of fractures, focusing largely on the details of osteogenesis imperfecta and congenital pseudoarthrosis of the tibia.
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Affiliation(s)
- Steven Borland
- Department of Trauma and Orthopaedics, Birmingham Children’s Hospital, Birmingham, UK
| | - Andrew Gaffey
- Department of Trauma and Orthopaedics, Birmingham Children’s Hospital, Birmingham, UK
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Abstract
Congenital pseudarthrosis of the tibia (CPT) is an uncommon disease with various clinical presentations ranging from simple anterolateral tibial angulation to complete non-union with extensive bone defects. Classifications of radiographic findings include atrophic or hypertrophic pseudarthosis as well as cystic or dystrophic lesions. Although the relationship between CPT and type 1 neurofibromatosis is well known, the exact pathogenesis still remains unclear. The fibrous soft tissue found in the pseudarthosis and the abnormal periosteum are certainly a key to the pathology, possibly due to decreased osteogenic capacities and impaired local vascularization. Treatment of CPT is still challenging in pediatric orthopedics because of bone union difficulties, persistant angulation, joint stiffness and sometimes severe limb length discrepancy sequellae. Numerous treatments based on biological and/or mechanical concepts, surgical or not, have been reported with variable success rates. Vascularized fibular grafts and the Ilizarov technique have greatly transformed the prognosis of CPT. Despite these steps forward, repeated surgical procedures are often necessary to obtain bone union and the risk of amputation is never entirely eliminated. The effectiveness of new treatments (bone morphogenetic protein, bone marrow stromal cell grafts, pulsed electromagnetic fields, induced membrane technique…) still requires to be confirmed. Combining these new techniques with existing treatments may improve the final prognosis of CPT, which nevertheless remains poor.
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Schindeler A, Birke O, Yu NYC, Morse A, Ruys A, Baldock PA, Little DG. Distal tibial fracture repair in a neurofibromatosis type 1-deficient mouse treated with recombinant bone morphogenetic protein and a bisphosphonate. ACTA ACUST UNITED AC 2011; 93:1134-9. [PMID: 21768643 DOI: 10.1302/0301-620x.93b8.25940] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Congenital pseudarthrosis of the tibia is an uncommon manifestation of neurofibromatosis type 1 (NF1), but one that remains difficult to treat due to anabolic deficiency and catabolic excess. Bone grafting and more recently recombinant human bone morphogenetic proteins (rhBMPs) have been identified as pro-anabolic stimuli with the potential to improve the outcome after surgery. As an additional pharmaceutical intervention, we describe the combined use of rhBMP-2 and the bisphosphonate zoledronic acid in a mouse model of NF1-deficient fracture repair. Fractures were generated in the distal tibiae of neurofibromatosis type 1-deficient (Nf1(+/-)) mice and control mice. Fractures were open and featured periosteal stripping. All mice received 10 μg rhBMP-2 delivered in a carboxymethylcellulose carrier around the fracture as an anabolic stimulus. Bisphosphonate-treated mice also received five doses of 0.02 mg/kg zoledronic acid given by intraperitoneal injection. When only rhBMP but no zoledronic acid was used to promote repair, 75% of fractures in Nf1(+/-) mice remained ununited at three weeks compared with 7% of controls (p < 0.001). Systemic post-operative administration of zoledronic acid halved the rate of ununited fractures to 37.5% (p < 0.07). These data support the concept that preventing bone loss in combination with anabolic stimulation may improve the outcome following surgical treatment for children with congenital pseudarthosis of the tibia and NF1.
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Affiliation(s)
- A Schindeler
- Orthopaedic Research and Biotechnology Unit, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, New South Wales 2145, Australia.
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Abstract
BACKGROUND According to the authors' multi-targeted, fibular status-based algorithmic approach using the Ilizarov technique, ankle stabilization by end-to-end osteosynthesis of the fibula is advocated for mild (type B1), "4-in-1 osteosynthesis" in which all 4 proximal and distal segments of the tibia and fibula are placed in 1 healing mass for moderate (type B2), and distal tibiofibular (TF) fusion for severe (type B3) fibular pseudarthrosis in association with atrophic-type congenital pseudarthrosis of the tibia (CPT). This report describes the indications, operative technique, and outcomes of "4-in-1 osteosynthesis" for atrophic-type CPT associated with type B2 fibular pseudarthrosis. METHODS Thirteen patients presented with atrophic-type CPT associated with type B2 fibular pseudarthrosis underwent Ilizarov osteosynthesis between 1989 and 2007 for atrophic-type CPT. To validate the efficacy of "4-in-1 osteosynthesis" in these patients, fracture risk and ankle function were compared between 2 groups of type B2 patients, namely, 8 patients (mean age, 6.3 y) who underwent "4-in-1 osteosynthesis" according to our current protocol (Group I), and 5 patients (mean age, 3.2 y) treated by other techniques (3 distal TF fusion, 2 failed end-to-end osteosynthesis) during the learning period (Group II). RESULTS No refracture occurred in Group I, whereas refracture occurred in all except 1 in Group II. Ankles were eventually stabilized by distal TF fusion in all patients in Group II. The Kaplan-Meier method revealed a refracture-free cumulative survival rate of 100% in Group I, whereas in Group II, it dropped progressively and reached 60% at 1.8 years and 20% at 2.7 years. No significant difference in ankle function was evident between the 2 groups (american orthopaedic foot and ankle society (AOFAS) score, 89.25 ± 7.25 after 7.4 y of follow-up in Group I, and 84.6 ± 9.53 after 13 y of follow-up in Group II). CONCLUSIONS It is imperative that fibular status be evaluated carefully to enable the planning of the most effective, safe, practical treatment. "4-in-1 osteosynthesis," which is primarily considered for bony union with a large cross-sectional area and ankle stabilization, seems to be a better choice for atrophic-type CPT associated with type B2 fibular pseudarthrosis, in which end-to-end osteosynthesis of the fibula often fails. LEVEL OF EVIDENCE Level III, Retrospective comparative study.
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Spiro AS, Babin K, Lipovac S, Stenger P, Mladenov K, Rupprecht M, Rueger JM, Stuecker R. Combined treatment of congenital pseudarthrosis of the tibia, including recombinant human bone morphogenetic protein-2: a case series. ACTA ACUST UNITED AC 2011; 93:695-9. [PMID: 21511938 DOI: 10.1302/0301-620x.93b5.25938] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for the treatment of congenital pseudarthrosis of the tibia has been investigated in only one previous study, with promising results. The aim of this study was to determine whether rhBMP-2 might improve the outcome of this disorder. We reviewed the medical records of five patients with a mean age of 7.4 years (2.3 to 21) with congenital pseudarthrosis of the tibia who had been treated with rhBMP-2 and intramedullary rodding. Ilizarov external fixation was also used in four of these patients. Radiological union of the pseudarthrosis was evident in all of them at a mean of 3.5 months (3.2 to 4) post-operatively. The Ilizarov device was removed after a mean of 4.2 months (3.0 to 5.3). These results indicate that treatment of congenital pseudarthrosis of the tibia using rhBMP-2 in combination with intramedullary stabilisation and Ilizarov external fixation may improve the initial rate of union and reduce the time to union. Further studies with more patients and longer follow-up are necessary to determine whether this surgial procedure may significantly enhance the outcome of congenital pseudarthrosis of the tibia, considering the refracture rate (two of five patients) in this small case series.
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Affiliation(s)
- A S Spiro
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Hamburg, Germany.
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Gouron R, Deroussen F, Juvet M, Ursu C, Plancq MC, Collet LM. Early resection of congenital pseudarthrosis of the tibia and successful reconstruction using the Masquelet technique. ACTA ACUST UNITED AC 2011; 93:552-4. [DOI: 10.1302/0301-620x.93b4.25826] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Congenital pseudarthrosis of the tibia remains one of the most difficult orthopaedic problems. We describe early excision and the use of the Masquelet technique to reconstruct the bone defect in a child aged 14 months. Consolidation sufficient for complete weight-bearing was achieved by seven weeks. After two and a half years, the child was asymptomatic with a fully reconstructed tibia and no leg-length discrepancy.
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Affiliation(s)
- R. Gouron
- Service d’Orthopédie Pédiatrique, CHU Amiens Hôpital Nord, Place Victor Pauchet, F-80054 Amiens, Cedex 1, France
| | - F. Deroussen
- Service d’Orthopédie Pédiatrique, CHU Amiens Hôpital Nord, Place Victor Pauchet, F-80054 Amiens, Cedex 1, France
| | - M. Juvet
- Service d’Orthopédie Pédiatrique, CHU Amiens Hôpital Nord, Place Victor Pauchet, F-80054 Amiens, Cedex 1, France
| | - C. Ursu
- Service d’Orthopédie Pédiatrique, CHU Amiens Hôpital Nord, Place Victor Pauchet, F-80054 Amiens, Cedex 1, France
| | - M.-C. Plancq
- Service d’Orthopédie Pédiatrique, CHU Amiens Hôpital Nord, Place Victor Pauchet, F-80054 Amiens, Cedex 1, France
| | - L.-M. Collet
- Service d’Orthopédie Pédiatrique, CHU Amiens Hôpital Nord, Place Victor Pauchet, F-80054 Amiens, Cedex 1, France
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Preliminary experience with the combined use of recombinant bone morphogenetic protein and bisphosphonates in the treatment of congenital pseudarthrosis of the tibia. J Child Orthop 2010; 4:507-17. [PMID: 22132028 PMCID: PMC2981713 DOI: 10.1007/s11832-010-0293-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 09/08/2010] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Congenital pseudarthrosis of the tibia (CPT) is a rare but serious disorder in children. No single approach has clearly emerged as superior in terms of operative procedure, fixation, optimal time for surgery or adjunctive pharmaceutical intervention. CPT is frequently associated with neurofibromatosis type 1 (NF1), a condition featuring deficient bone anabolism and excessive catabolism. We have therefore combined the use of bone morphogenetic proteins (BMP) with bisphosphonates (BP) as an adjunct to surgical intervention. METHODS Between 2002 and 2008 we administered BMP-7 (OP-1) at the time of surgery followed by BP (pamidronate or zoledronic acid) in eight Crawford type IV CPT cases in seven patients (six with a confirmed diagnosis of NF1) with a median age of 7 years (range 2 years 11 months to 12 years) at surgery. RESULTS In six of eight cases, this approach led to primary healing after a mean of 5.5 months (range 4-7 months). One of these cases represented 17 months after primary healing of a proximal CPT with a new further distal fracture that required multiple operations to finally unite at 19 months. The two remaining cases ultimately reached union after multiple operations at 14 and 30 months, respectively, but required recent treatment for refractures. CONCLUSION Based on these clinical data (primary healing in 6/8 cases) and prior pre-clinical findings, we propose that BP therapy may be helpful in preserving the BMP-induced bone formation by inhibiting the osteoclastic bone loss. Key factors to achieve union in CPT include sufficient fixation, meticulous resection of the dysplastic tissue and the establishment of a net anabolic environment for bone healing. Whether our biological concept of balancing the anabolic and catabolic responses with BMP and BP improves healing rates in the complex treatment of NF1 CPT remains uncertain and warrants larger prospective multicentre trials.
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