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Muhammad AS, Jamil K, Abdul-Rashid AH, Abd-Rasid AF, Aizuddin NA. Surgical outcome of angular deformity correction of lower limbs in rickets: a cross-sectional study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03943-5. [PMID: 38619601 DOI: 10.1007/s00590-024-03943-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/27/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE This study aims to compare the functional and radiological outcomes following both guided growth surgery (GGS) and acute corrective osteotomy (ACO) correction of angular deformities in children with rickets. METHODS A total of 8 and 7 children who had gradual GGS and ACO correction, respectively, for angular deformities due to rickets from 2002 to 2022 were recalled for follow-up. Demographic data, types of rickets, data on pharmacological treatment, biochemical parameters, recurrence of angular deformity and postoperative complications were obtained from the medical records. A radiographic evaluation of the leg was performed to determine the tibiofemoral angle. For functional evaluation, the Active Scale for Kids (ASK) and Lower Extremity Functional Scale (LEFS) instruments were used for children below and above 15 years old, respectively. RESULTS In terms of the tibiofemoral angle, the GGS group documented greater angle changes compared to the ACO group, but the difference was not significant. In terms of functional outcomes, the overall score percentage of both groups was comparable with the GGS group showing a trend of higher score percentage compared to the ACO group. The GGS group presented no complication while 2 neurovascular injuries and 1 implant failure were recorded in the ACO group. CONCLUSION Both GGS and ACO procedures resulted in similar radiographic and functional outcomes for the treatment of rickets in children. GGS may be advantageous in terms of reducing complications of surgery. Nevertheless, the choice of surgical intervention should be made based on the patient's circumstances and the surgeon's preference.
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Affiliation(s)
- Ahmad Syafiq Muhammad
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University Kebangsaan Malaysia, Cheras, Malaysia.
| | - Kamal Jamil
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University Kebangsaan Malaysia, Cheras, Malaysia
| | - Abdul Halim Abdul-Rashid
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University Kebangsaan Malaysia, Cheras, Malaysia
| | - Ahmad Fazly Abd-Rasid
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University Kebangsaan Malaysia, Cheras, Malaysia
| | - Noor Azimatun Aizuddin
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University Kebangsaan Malaysia, Cheras, Malaysia
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Alikasifoglu A, Unsal Y, Gonc EN, Ozon ZA, Kandemir N, Alikasifoglu M. Long-term effect of conventional phosphate and calcitriol treatment on metabolic recovery and catch-up growth in children with PHEX mutation. J Pediatr Endocrinol Metab 2021; 34:1573-1584. [PMID: 34525271 DOI: 10.1515/jpem-2021-0387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/30/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Hereditary hypophosphatemic rickets (HR) is conventionally treated with phosphate and calcitriol. Exploring genotype and phenotypic spectrum of X-linked hypophosphatemic rickets (XLHR), focusing on short-term, long-term, and pubertal impact of conventional treatment was aimed. METHODS Sixteen patients from 12 unrelated families with HR were analyzed for phosphate regulating endopeptidase homolog X-linked (PHEX) mutation. Initially Sanger sequencing analysis was performed. If PHEX mutation was not detected, multiplex ligation-dependent probe amplification (MLPA) was performed. If molecular defect was detected, first-degree relatives were analyzed. Thirteen patients (81%) and five first-degree relatives with XLHR were evaluated for genotype-phenotype or gender-phenotype correlation. Clinical characteristics and response to conventional treatment were determined retrospectively. RESULTS Nine different PHEX mutations were identified; four splice-site, three point mutations, and two single exon deletions. Four were novel mutations. Despite conventional treatment, median adult height was lower than median height on admission (-3.8 and -2.3 SDS, respectively), metabolic and radiographic recovery were not achieved, adherence was low (30%). Although mean adult height was better in compliant patients than noncompliants (-2.6 vs. -3.7 SDS, respectively), they were still short. Correlation between phenotype and genotype or gender could not be shown. Median phosphate decreased significantly throughout puberty (p=0.014). Median pubertal height was lower than prepubertal height (-4.4 vs. -3.6 SDS; respectively), pubertal growth spurt was not observed. Among five patients with a follow-up longer than five years, three had nephrocalcinosis (60%), two had hyperparathyroidism (40%), 4/6 (33%) required correction osteotomy. CONCLUSIONS Conventional treatment appears to have limited effect on metabolic, clinical and radiographic recovery in XLHR. Metabolic control and growth worsened during puberty. Although, long-term adverse effects are yet to be seen, introduction of burosumab as first-line treatment may be an alternative after infancy.
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Affiliation(s)
- Ayfer Alikasifoglu
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yagmur Unsal
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elmas Nazli Gonc
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Alev Ozon
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nurgun Kandemir
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Alikasifoglu
- Division of Medical Genetics, Department of Medical Genetics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Kumahashi N, Kuwata S, Takuwa H, Uchio Y. Total knee arthroplasty combined with medial patellofemoral ligament augmentation using a Leeds-Keio ligament for 'Windswept deformity' with ipsilateral valgus deformity and permanent patellar dislocation: A case report and a literature review. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 26:53-57. [PMID: 34765458 PMCID: PMC8556479 DOI: 10.1016/j.asmart.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/30/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022]
Abstract
We present a ‘Windswept deformity’ in patient who had osteoarthritis with a mild varus and very severe valgus with ipsilateral permanent patellar dislocation. An 83-year-old woman could not walk for the past a few years due to bilateral knee pain. The femorotibial angle was 196° in the right knee pre-operatively and 134° in the left knee with permanent patellar dislocation. She underwent a staged total knee arthroplasty (TKA) for the right knee, and a semi-constrained TKA for the left knee with medial patellofemoral ligament (MPFL) augmentation using a Leeds-Keio (LK) ligament. At the final follow-up three years after surgery, bilateral knee pain and the extension lag had disappeared and range of motion (ROM) was 0° in extension and 130° in flexion for both knees without patellar re-dislocation. This clinical case indicates that the unconstrained and semi-constrained type of TKA combined with the MPFL augmentation using an LK ligament is effective to treat a ‘Windswept deformity’.
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Affiliation(s)
- Nobuyuki Kumahashi
- Department of Orthopedics, Shimane University, School of Medicine, 89-1 Enya-cho, Izumo-shi, Shimane, 693-8501, Japan
| | - Suguru Kuwata
- Department of Orthopedics, Shimane University, School of Medicine, 89-1 Enya-cho, Izumo-shi, Shimane, 693-8501, Japan
| | - Hiroshi Takuwa
- Department of Orthopedics, Shimane University, School of Medicine, 89-1 Enya-cho, Izumo-shi, Shimane, 693-8501, Japan
| | - Yuji Uchio
- Department of Orthopedics, Shimane University, School of Medicine, 89-1 Enya-cho, Izumo-shi, Shimane, 693-8501, Japan
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Yang X, Zou Q, Song Y, Liu L, Zhou C. A case report of severe degenerative lumbar scoliosis associated with windswept lower limb deformity. BMC Surg 2020; 20:195. [PMID: 32883265 PMCID: PMC7470442 DOI: 10.1186/s12893-020-00857-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/27/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The windswept lower limb deformity describes valgus deformity in one leg with varus deformity in the other. It is mostly seen in young children with metabolic bone diseases (such as rickets) and may lead to leg length discrepancy (LLD) and Degenerative scoliosis (DS) in older age. To the best of our knowledge, there was no report of the spinal surgery in patient with severe DS associated with windswept deformity. The objective of this study is to report the unique case of a 60-year-old woman with severe degenerative scoliosis (DS) associated with windswept deformity caused by rickets who underwent a posterior correction and fusion surgery in spine. CASE PRESENTATION The patient was diagnosed as rickets windswept lower limb deformity for 50 years but never went through routine treatment. Then, she performed lumbar scoliosis for more than 20 years and suffered from severe back pain for 4 years. After overall clinical evaluation and radiographic measures, we performed a posterior surgical correction and fusion from T9-L5. With this surgery, the main thoracolumbar curve Cobb angle corrected from 72.5° to 21.0°, the coronal balance from 0 cm to 2.0 cm while the sagittal vertical axis (SVA) from 1.5 cm to - 1.0 cm. At 2 years postoperative follow-up, her back pain has almost completely relieved with a satisfied fixation and bone fusion showed on CT scans. However, a coronal imbalance was found with C7-CSVLdistance equal to 4.0 cm. This coronal imbalance was highly correlated to the untreated LLD and pelvic obliquity, and should be improved by standing posture or shoe lifts. CONCLUSIONS For such patient, the pure spinal correction and fusion surgery, in spite of lower limbs deformity, can achieve good relieve of back pain symptom, however may accompany by the complication of coronal imbalance due to the unimproved pelvic obliquity and LLD. However, longer follow-up is necessary to observe the long-term outcome of this patient's postoperative coronal imbalance.
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Affiliation(s)
- Xi Yang
- Department of Orthopedics Surgery and Orthopedics Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Qiang Zou
- Department of Orthopedics Surgery and Orthopedics Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Yueming Song
- Department of Orthopedics Surgery and Orthopedics Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China.
| | - Limin Liu
- Department of Orthopedics Surgery and Orthopedics Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Chunguang Zhou
- Department of Orthopedics Surgery and Orthopedics Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
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Li J, Rai S, Ze R, Tang X, Liu R, Hong P. Rotational and translational osteotomy for treatment of severe deformity in hypophosphatemic rickets: A case report. Medicine (Baltimore) 2020; 99:e18425. [PMID: 32011435 PMCID: PMC7220249 DOI: 10.1097/md.0000000000018425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
RATIONALE Hypophosphatemic rickets (HR) is a rare hereditary disease characterized by hypophosphatemia, defects in bone mineralization, and rickets, and surgical intervention is warranted for the patient of severe skeletal deformity. PATIENT CONCERNS Here we report a case of an 11-year-old boy who presented with severe varus deformities of the bilateral lower extremities and was associated with uncoordinated gait with multiple unintentional falls onto ground resulting in fractures of lower extremities. DIAGNOSES He was diagnosed as HR caused by genetic mutations in the phosphate-regulating endopeptidase homologue. Based on his family history and laboratory tests, including high serum alkaline phosphatase, high urinary phosphorus, hypophosphatemia, and normal serum calcium level, the patient was diagnosed with this disorder. INTERVENTIONS Rotational and translational osteotomy was performed to redress the severe varus deformity and readjust the malalignment of the lower extremity. OUTCOMES Right after the surgery, the alignment in the left lower extremity was readjusted, and his appearance seemed normal. Combined with rehabilitation and pharmacological intervention, including oral intake of phosphate and alphacalcidol, the bone healed uneventfully. After the second surgery of a similar procedure on the right femur, the patient was able to walk almost like a normal teenager. LESSONS This case proposed a novel technique to treat severe varus or valgus deformity of the lower extremity. HR is a rare disease, and it is important to stress its recognition to avoid delay of diagnosis and surgical intervention if necessary.
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Affiliation(s)
- Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | - Renhao Ze
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruikang Liu
- First School of Clinical Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Gizard A, Rothenbuhler A, Pejin Z, Finidori G, Glorion C, de Billy B, Linglart A, Wicart P. Outcomes of orthopedic surgery in a cohort of 49 patients with X-linked hypophosphatemic rickets (XLHR). Endocr Connect 2017; 6:566-573. [PMID: 28954742 PMCID: PMC5633063 DOI: 10.1530/ec-17-0154] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/07/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND X-linked hypophosphatemic rickets (XLHR) is due to mutations in PHEX leading to unregulated production of FGF23 and hypophosphatemia. XLHR is characterized by leg bowing of variable severity. Phosphate supplements and oral vitamin analogs, partially or, in some cases, fully restore the limb straightness. Surgery is the alternative for severe or residual limb deformities. OBJECTIVE To retrospectively assess the results of surgical limb correction in XLHR (osteotomies and bone alignment except for 3 transient hemiepiphysiodesis). METHODS We analyzed the incidence of recurrence and post-surgical complications in 49 XLHR patients (29F, 20M) (mean age at diagnosis 6.0 years (± 7.1)). RESULTS At first surgery, the mean age was 13.4 years (± 5.0). Recurrence was observed in 14/49 (29%) patients. The number of additional operations significantly decreased with age (2.0 (± 0.9), 1.7 (± 1.0) and 1.2 (± 0.4) in children <11 years, between 11 and 15, and >15 years; P < 0.001). Incidence of recurrence seemed to be lower in patients with good metabolic control of the rickets (25% vs 33%). Complications were observed in 57% of patients. CONCLUSION We report a large series of surgical procedures in XLHR. Our results confirm that phosphate supplements and vitamin D analog therapy is the first line of treatment to correct leg bowing. Surgery before puberty is associated with a high risk of recurrence of the limb deformity. Such procedures should only be recommended, following multidisciplinary discussions, in patients with severe distortion leading to mechanical joint and ligament complications, or for residual deformities once growth plates have fused.
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Affiliation(s)
- A Gizard
- Department of Pediatric Orthopedic SurgeryBesançon University Hospital, Paris, France
| | - A Rothenbuhler
- APHPDepartment of Pediatric Endocrinology, Bicêtre Paris Sud, Le Kremlin Bicêtre, France
- Reference Center for Rare Disorders of Calcium and Phosphate MetabolismLe Kremlin Bicêtre, France
- Plateforme d'Expertise Paris Sud Maladies Rares and Filière OSCARBicêtre Paris Sud, Le Kremlin Bicêtre, France
| | - Z Pejin
- APHPDepartment of Pediatric Orthopedic Surgery, Necker Hospital, Paris, France
| | - G Finidori
- APHPDepartment of Pediatric Orthopedic Surgery, Necker Hospital, Paris, France
| | - C Glorion
- APHPDepartment of Pediatric Orthopedic Surgery, Necker Hospital, Paris, France
| | - B de Billy
- Department of Pediatric Orthopedic SurgeryBesançon University Hospital, Paris, France
| | - A Linglart
- APHPDepartment of Pediatric Endocrinology, Bicêtre Paris Sud, Le Kremlin Bicêtre, France
- Reference Center for Rare Disorders of Calcium and Phosphate MetabolismLe Kremlin Bicêtre, France
- Plateforme d'Expertise Paris Sud Maladies Rares and Filière OSCARBicêtre Paris Sud, Le Kremlin Bicêtre, France
- INSERM U1169Hôpital Bicêtre, Le Kremlin Bicêtre, et Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - P Wicart
- Reference Center for Rare Disorders of Calcium and Phosphate MetabolismLe Kremlin Bicêtre, France
- APHPDepartment of Pediatric Orthopedic Surgery, Necker Hospital, Paris, France
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Windswept deformities - An indication to individualise valgus correction angle during total knee arthroplasty. J Orthop 2016; 14:70-72. [PMID: 27829727 DOI: 10.1016/j.jor.2016.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 09/16/2016] [Accepted: 10/13/2016] [Indexed: 11/22/2022] Open
Abstract
PURPOSE We aimed to determine variation in femoral valgus correction angle (VCA) between the two limbs in a patient with windswept deformity undergoing total knee arthroplasty (TKA). METHODS Femoral VCA was measured on full-length, hip-to-ankle, standing radiographs and was compared between the varus and the valgus limbs in 66 patients with windswept deformities. RESULTS The mean VCA in varus knees was significantly higher compared to mean VCA in valgus knees (p = 0.002). CONCLUSION Significant difference in VCA is present between the varus and the valgus limbs in most patients with windswept deformity undergoing TKA.
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Al Kaissi A, Ganger R, Mindler G, Klaushofer K, Grill F. Varus deformity of the left lower extremity causing degenerative lesion of the posterior horn of the left medial meniscus in a patient with Paget's disease of bone. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2014; 12:Doc13. [PMID: 25276115 PMCID: PMC4178943 DOI: 10.3205/000198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/18/2014] [Indexed: 11/30/2022]
Abstract
We report on a 42-year-old woman who presented with persistent pain in her left knee with no history of trauma. Sagittal T1-weighted MRI of the left knee showed discontinuity between the anterior and posterior horns of the left medial meniscus, causing effectively the development of degenerative lesion of the posterior horn. The latter was correlated to varus deformity of the left lower extremity associated with subsequent narrowing of the medial knee joint. The unusual craniofacial contour of the patient, the skeletal survey and the elevated serum alkaline phosphatase were compatible with the diagnosis of Paget’s disease of the bone. To alleviate the adverse effect of the mal-alignment of the left femur onto the left knee, corrective osteotomy of the left femoral diaphysis by means of fixators was performed. To the best of our knowledge this is the first clinical report describing the management and the pathological correlation of a unilateral varus deformity of the femoral shaft and degenerative lesions of the left knee in a patient with Paget’s disease of the bone.
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Affiliation(s)
- Ali Al Kaissi
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, First Medical Department, Hanusch Hospital, Vienna, Austria ; Orthopaedic Hospital of Speising, Paediatric Department, Vienna, Austria
| | - Rudolf Ganger
- Orthopaedic Hospital of Speising, Paediatric Department, Vienna, Austria
| | - Gabriel Mindler
- Orthopaedic Hospital of Speising, Paediatric Department, Vienna, Austria
| | - Klaus Klaushofer
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, First Medical Department, Hanusch Hospital, Vienna, Austria
| | - Franz Grill
- Orthopaedic Hospital of Speising, Paediatric Department, Vienna, Austria
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