The molecular spectrum of Turkish osteopetrosis and related osteoclast disorders with natural history, including a candidate gene, CCDC120

BACKGROUND

Osteopetrosis and related osteoclastic disorders are a heterogeneous group of inherited diseases characterized by increased bone density. The aim of this study is to investigate the molecular spectrum and natural history of the clinical and radiological features of these disorders.

METHODS

28 patients from 20 families were enrolled in the study; 20 of them were followed for a period of 1-16 years. Targeted gene analysis and whole-exome sequencing (WES) were performed.

RESULTS

Biallelic mutations in CLCN7 and TCIRG1 were detected in three families each, in TNFRSF11A and CA2 in two families each, and in SNX10 in one family in the osteopetrosis group. A heterozygous variant in CLCN7 was also found in one family. In the osteopetrosis and related osteoclast disorders group, three different variants in CTSK were detected in five families with pycnodysostosis and a SLC29A3 variant causing dysosteosclerosis was detected in one family. In autosomal recessive osteopetrosis (ARO), a malignant infantile form, four patients died during follow-up, two of whom had undergone hematopoietic stem cell transplantation. Interestingly, all patients had osteopetrorickets of the long bone metaphyses in infancy, typical skeletal features such as Erlenmeyer flask deformity and bone-in-bone appearance that developed toward the end of early childhood. Two siblings with a biallelic missense mutation in CLCN7 and one patient with the compound heterozygous novel splicing variants in intron 15 and 17 in TCIRG1 corresponded to the intermediate form of ARO (IARO); there was intrafamilial clinical heterogeneity in the family with the CLCN7 variant. One of two patients with IARO and distal tubular acidosis was found to have a large deletion in CA2. In one family, two siblings with a heterozygous mutation in CLCN7 were affected, whereas the father with the same mutation was asymptomatic. In WES analysis of three brothers from a family without mutations in osteopetrosis genes, a hemizygous missense variant in CCDC120, a novel gene, was found to be associated with high bone mass.

CONCLUSION

This study extended the natural history of the different types of osteopetrosis and also introduced a candidate gene, CCDC120, potentially causing osteopetrosis.

Evaluation of patients' post-operative results operated for hip fracture with computerized dynamic posturography: Proximal femoral nailing versus hip arthroplasty

BACKGROUND

Proximal femoral nailing (PFN) and hip arthroplasty (HA) are the two most often utilized surgical procedures for treating hip fractures in older patients. The post-operative postural balance and functional outcomes of patients may be significantly influenced by the technical distinctions between PFN and HA. This will influence the surgeon's preferred course of therapy. To examine the functional outcomes of patients treated with PFN and HA following a hip fracture, this study used computerized dynamic posturography (CDP). The aim of that study was to evaluate how the two treatment modalities affected patients' post-operative balance, postural stability, and functional rehabilitation.

METHODS

A total of 26 patients who underwent proximal femoral surgery (15 patients PFN [58%] and 11 patients HA [42%]) due to hip fractures were evaluated at least 12 months postoperatively. They were tested by direct radiographs, hip joint examinations, Harris hip score (HHS), and CDP.

RESULTS

Twelve (46%) of 26 patients were male and 14 (54%) were female. The mean age of the participants in the study was 67.9±14.2 years. The mean follow-up period was 24 (12-44) months. The average Harris score of PFN group was 79.3 (46.8-100) points and HA group was 83.7 (61.9-99.9) points. There was no significant difference between the groups in terms of Harris Score (P=0.54). The average of the mixed value of the balance results obtained with CDP (the Composite score) for PFN group was 70.5 (56-79) points, and for HA group was 71.9 (56-83) points. There was no significant difference between the groups in terms of the Composite Score (P=0.47). Accordingly, 12 (80%) of the patients who underwent PFN had good results and 3 (20%) of them had bad results. Eight (72.7%) of those who underwent HA had good results and 3 (27.3%) had bad results. There was no statistically significant difference (P=0.66).

CONCLUSION

Comparing the composite score for balance results and HHS results for rehabilitation with the data of the patients who underwent PFN and HA, there was no statistically significant difference between these two techniques in terms of postural stabil-ity and balance as a result of CDP examination.

Phenotypic and Molecular Spectrum of a Turkish Cohort with Hereditary Multiple Osteochondromas

OBJECTIVE

Hereditary multiple osteochondromas is an autosomal dominant disorder caused by heterozygous pathogenic variants in EXT1 or EXT2. We aimed to evaluate the clinical and molecular findings of a Turkish cohort with hereditary multiple osteochondroma.

MATERIALS AND METHODS

Thirty-two patients aged 1.3-49.6 years from 22 families were enrolled. Genetic analyses were made by EXT1 and/or EXT2 sequencing and chromosomal microarray analyses.

RESULTS

We found 17 intragenic pathogenic variants in EXT1 (13/17) and EXT2 (4/17), 12 of which are novel. Four probands had EXT1 deletions, including 2 patients with partial EXT1 microdeletions involving exons 2-11 and 5-11, and 2 patients with whole-gene deletions. In 21 variants, the frequency of truncating and missense variants was 76.1% and 23.8%, respectively. Two families had no detectable variants in EXT1 and EXT2. All patients had multiple osteochondromas at the long bones, mainly at the tibia, forearm, femur, and humerus. Bowing deformity of the forearms (9/32) and the lower extremities (2/32), and scoliosis (6/32) were observed. The clinical severity was not different between patients with EXT1 or EXT2 variants. One patient with an EXT2 variant and another with an EXT1 microdeletion had the most severe phenotype with class III disease. Four patients with no EXT1 or EXT2 variants had milder phenotypes. Intrafamilial variability in disease severity was not observed.

CONCLUSION

We report a hereditary multiple osteochondroma cohort with clinical and molecular data including 12 novel intragenic variants in EXT1 or EXT2, and 4 microdeletions involving EXT1. Taken together, our data expand the existing knowledge of the phenotype-genotype spectrum in hereditary multiple osteochondroma.

Diagnosis and Treatment Planning of Developmental Hip Dysplasia: Evaluation of Care Practices of the Members of the Turkish Pediatric Orthopedics Association

OBJECTIVE

Developmental dysplasia of the hip is one of the most important causes of childhood disabilities. Although there are accepted treatment algorithms for developmental dysplasia of the hip, diagnosis and treatment approaches can show variations in the management among physicians. This study aimed to develop a diagnosis and treatment algorithm for developmental dysplasia of the hip according to the preferences of members of the Turkish Pediatric Orthopedics Association.

MATERIALS AND METHODS

An interview by telephone call was made with 76 orthopedists (group 1: more experienced 39 physicians, group 2: less experienced 37 physicians) who are members of the Turkish Pediatric Orthopedics Association. Participants were q uesti onnai red ab out their demographic information, experiences, diagnostic criteria that they use for developmental dysplasia of the hip, and treatment approaches to patient scenarios of different ages.

RESULTS

Most of the participants recommended universal screening at the age of 4 weeks. It was observed that the most significant physical examination finding was limited hip abduction, and the most frequently used radiographic evaluation on x-ray was acetabular index measurement. The most frequently used description for dysplasia was found as acetabular index >30°.

CONCLUSIONS

Although there are some differences among orthopedists in the diagnosis, treatment, and follow-up approach of developmental dysplasia of the hip, there was no significant difference according to the experience-based grouping. The treatment algorithm, which was created with the most frequently given answers, was designed, which we think may be beneficial for pediatricians and orthopedists.

Treatment of Hip Dislocation in Cerebral Palsy with Extraarticular Intervention

PURPOSE OF THE STUDY Hip dislocation is one of the major causes of disability in children with cerebral palsy (CP). Surgical treatment can be achieved using different techniques including proximal femoral varus derotation osteotomy (FVDRO), pelvic osteotomies, and open hip reduction (OHR). However, we claim that pathologies originating from extraarticular structures in the dislocated hip in CP can be reconstructed by extraarticular methods and OHR may not always be necessary. Therefore, this study aims to discuss the results of hip reconstruction with extraarticular intervention in patients with CP. MATERIAL AND METHODS In total, 141 hips (95 patients) were included in the study. All patients underwent FVDRO, either with or without a Dega osteotomy. Changes in the Acetabular Index (AI), Migration Index (MI), neck-shaft angle (NSA), and center-edge angle (CEA) were assessed on the preoperative, postoperative, and final follow-up anterior-posterior radiographs of the pelvis. RESULTS Median age was 8 years (range between 4-18 years). The average follow-up duration was 5 years (range between 2-9 years). Changes in AI, MI, NSA and CEA values were statistically significant for postop and follow-up periods when compared to preoperative values. Of the 141 operated hips, 8 (5.6%) hips required revision surgery due to redislocation/resubluxation detected at the follow-ups, and unilateral operation can be accepted as a risk factor for redislocation. CONCLUSIONS Our results demonstrate that reconstructive treatment consisting of FVDRO, medial capsulotomy (in the case of reduction difficulty) and transiliac osteotomy (in the case of acetabular dysplasia) provides satisfactory outcomes in hip dislocation in CP. Key words: hip displacement, cerebral palsy, hip reduction.

Temporary Epiphysiodesis Using the Eight-Plate in the Management of Children with Leg Length Discrepancy: A Retrospective Case Series

BACKGROUND

Although eight-plates have been shown to be effective in correcting angular deformities of the knee, the literature is scarce regarding the efficiency of this method in treatment of children with LLD.

OBJECTIVES

The aim of this study was to determine the efficiency, rates of correction and complications of epiphysiodesis using eight-plate in the management of children with leg length discrepancy (LLD).

METHODS

Eleven consecutive patients with LLD (7 boys, median age = 9, age range 6-11 years) who were treated by temporary epiphysiodesis using eight-plates were retrospectively reviewed and included in the study. The main indication for temporary epiphysiodesis was an LLD between 2 and 5 cm in all patients. LLD and lower limb alignment were examined on lower extremity weight-bearing radiography preoperatively and at skeletal maturity. Longitudinal correction rate was calculated. The final LLD was categorized as ''good result'' (final LLD < 1.5 cm), ''fair result'' (1.5-2 cm), and ''poor result'' (> 2 cm).

RESULTS

The mean treatment period with the eight-plate was 44 (min to max = 32-72) months, and the mean follow-up from the index surgery to the final follow-up was 62 (min to max = 39-106) months. The mean LLD was significantly reduced from 39 (range 25-50) mm preoperatively to 22.40 (range 6-55) mm postoperatively (p = 0.006). The mean longitudinal correction rate was found to be 0.48 mm/mo. Radiographic evidence of lower limb deformity in frontal and sagittal planes was determined in neither preoperative nor postoperative deformity analysis. No major complications were recorded.

CONCLUSION

For the management of children with LLD of 2-5 cm, temporary hemiepiphysiodesis using the eight-plate seems to be an effective treatment with low complication rates.

Long-Term Follow-Up Outcomes of 19 Patients with Osteogenesis Imperfecta Type XI and Bruck Syndrome Type I Caused by FKBP10 Variants

Osteogenesis imperfecta type XI (OI-XI) and Bruck syndrome type I (BS1) are two rare disorders caused by biallelic variants in the FKBP10, characterized by early-onset bone fractures and progressive skeletal deformities. The patients with OI-XI, also co-segregated with autosomal-recessive epidermolysis bullosa simplex caused by KRT14 variant, have been reported. In this study, the follow-up clinical features of the patients with OI-XI and BS1 phenotypes due to biallelic FKBP10 variants are compared. The aim of this study is to investigate the follow-up findings of OI-XI and BS1 phenotypes in patients with the FKBP10 variants. A total of 19 children, ten males and nine females, from 16 unrelated families were included in the study. FKBP10 variants were investigated by next-generation sequencing (NGS) based panel gene test or Sanger sequencing. Seventeen patients were followed between 1.5 and 16.8 years, and the last follow-up age was between 2 and 24.6 years (median 10.7 years). They received intravenous bisphosphonate infusions once every 3 months in follow-up period. We identified four different biallelic FKBP10 variants, two of which are novel (c.890_897dup TGATGGAC, p.Gly300Ter and c.1256 + 1G > A) in 16 families. Five of these patients also had findings of epidermolysis bullosa simplex, and the same biallelic c.612T > A (p.Tyr204Ter) variant in KRT14, as well as FKBP10, were identified. Twelve patients were diagnosed with OI-XI; whereas, seven were diagnosed with BS1. The BS1 phenotype was late-onset and the annual fracture number was lower. After bisphosphonate treatment, bone mineral densitometry Z score at L1-L4 increased (p = 0.005) and the number of annual fractures decreased (p = 0.036) in patients with OI-XI. However, no significant effect of bisphosphonate treatment was found on these values in BS1 patients. Despite the treatment, the rate of scoliosis and long bone deformity had increased in both groups at the last examination; and, only two patients could take a few steps with the aid of a walker, while others were not ambulatory, and they used wheelchairs for mobility. We identified two novel variants in FKBP10. Families originating from the same geographic region and having the same variant suggest founder effects. Although the number of fractures decreased with bisphosphonate treatment, none of our patients were able to walk during the follow-up. This study is valuable in terms of showing the follow-up findings of patients with FKBP10 variants for the first time.

How the COVID-19 pandemic is affecting paediatric orthopaedic practice in Turkey

PURPOSE

Changes to routine clinical approaches during the corona virus disease 2019 (COVID-19) pandemic are necessary to decrease the risk of infection in patients and healthcare providers. Because the treatment of many conditions is time sensitive, it is crucial to modify the management of paediatric orthopaedic cases by minimizing any subsequent morbidity. Our purpose was to describe the different measures and management strategies that have been applied by paediatric orthopaedic surgeons and to show how paediatric orthopaedic practice is affected in Turkey.

METHODS

All active practicing members of the Turkish Society of Children's Orthopedic Surgery (TSCOS) were contacted via telephone and asked to fill out a survey (24 questions). For participants, either an email or web link was sent to their mobile phones. An online survey generator was used.

RESULTS

A total of 54 survey responses were collected, for a response rate of 55%. In all, 62% reported a 75% decrease in their outpatient frequency, whilst 75% reported a 75% decrease in their surgery frequency. A total of 86% of the performed surgeries were emergency cases. None of the participants performed elective surgeries, and 61% did not have the consent form specific to COVID. Choice of protective measures have changed considerably; 96% stated that they needed an algorithm to follow for situations such as pandemic.

CONCLUSION

This national survey revealed that the COVID-19 pandemic has had a detrimental effect on paediatric orthopaedic practice and practitioner response varies in terms of reactions and precautions. The necessity of creating a protocol based on what we have learned must be taken into consideration.

LEVEL OF EVIDENCE

V.

The split transfer of tibialis anterior tendon to peroneus tertius tendon for equinovarus foot in children with cerebral palsy

OBJECTIVE

The aim of this study was to analyze the results of the split anterior tibialis tendon transfer (SPLATT) to peroneus tertius (PT) for equinovarus foot deformity in children with cerebral palsy (CP).

METHODS

The medical records of 25 ambulatory CP patients (mean age: 8.7±3.2 years, range: 4-16 years) with equinovarus foot (33 feet), who underwent SPLATT to PT surgery between 2014 and 2016, were retrospectively reviewed. A senior surgeon performed all the surgical procedures. SPLATT was performed as part of a single-event multilevel surgery for the lower limb, and the concomitant procedures on the same extremity were recorded. The patients who required any additional foot or ankle surgery that could affect the clinical outcome (except heel cord lengthening) were excluded from the study. The Kling's College Criteria were used to evaluate the procedural outcome of the foot position and gait, and the associated complications were recorded.

RESULTS

The mean follow-up time was 28.8±5 months (range: 24-42 months). The postoperative Kling scores were excellent for 27 feet of the patients who had a plantigrade foot, without fixed or postural deformity, in a regular shoe, having no calluses; good for 5 cases for those who walked with less than 5° varus, valgus, or equinus posture of the hind foot, wearing regular shoes, having no callosities; and fair for 1 case for those who had recurrence of the deformity. There was only one wound detachment, which was treated with wound care and dressing. None of the patients had overcorrection, infection, or bone fracture.

CONCLUSION

The dynamic SPLATT to PT surgery for the management of the equinovarus foot deformities in the CP patients is a safe and less complicated surgical alternative with a good functional outcome. It is a safe and effective treatment method for the management of equinovarus foot deformities in CP.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Compression neuropathy of the common peroneal nerve caused by an intraosseous ganglion cyst of fibula

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Ganglion cysts originate from tendon sheath or joint capsule (1); and are mostly found on hand, wrist and ankle.

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They sometimes cause nerve compression.

We present a case of a compression neuropathy of the common peroneal nerve caused by an intraosseous Ganglion cyst of fibula.

Minimal invasive fixation of distal tibial fractures does not result in rotational malalignment: A report of 24 cases with CT imaging

BACKGROUND

Tibial torsion is rotation of the proximal versus the distal articular axis in the transverse plane. This study used computed tomography (CT) to examine rotational malalignment in the crus following use of minimally invasive plate osteosynthesis (MIPO) technique in distal tibial fractures and evaluated effect of rotational difference on clinical outcomes and VAS scores.

METHODS

Analysis of 24 patients who were operated on for closed distal tibial fracture with MIPO technique between 2010 and 2012 was conducted. Malrotation was defined as rotational difference >10°. Operated knees were evaluated with 0.5-mm, fine-cut, 3-dimensional CT scan performed in cooperation with radiology department. Side-to-side difference in tibial torsion angle >10° was considered significant degree of malrotation. All patients were assessed clinically (visual analogue scale [VAS] and American Orthopaedic Foot and Ankle Society [AOFAS] scores) and radiologically at final visit.

RESULTS

Mean follow-up period was 20.00±9.46 months (range: 18-51 months). Mean VAS score was 2.58±0.83 (range: 1-4) and mean AOFAS score was 87.50±4.05 (range: 78-93). Mean tibial rotation angle was 31.54±6.00° (range: 18-45°) on healthy side and 32.00±6.24° (range: 10-43°) on the operated side. No statistically significant difference was determined (p>0.05).

CONCLUSION

Use of intraoperative fluoroscopy, cable technique, and uninjured extremity as reference, can reduce incidence of rotational malalignment of distal tibial fractures treated with MIPO.

Results of a universal ultrasonographic hip screening program at a single institution

OBJECTIVE

The aims of the present study were to determine the prevalence of developmental dysplasia of the hip (DDH) in newborns screened by hip ultrasonography (US), to review outcome of follow-up and treatment of infants with DDH, and to evaluate the relationship between US-based diagnosis and risk factors.

METHODS

A total of 9564 hips of 4782 newborns (2398 females, 50.1%) were evaluated with US. Risk factors for DDH and accompanying deformities were also recorded. Graf classification type IIa(-), IIb, IIc, D, and III hips were treated with Pavlik harnesses.

RESULTS

Abnormal US findings (type IIa, IIc, or D hips) were detected in 475 newborns (9.9%). Risk factors and concomitant orthopedic deformities were similar in newborns with and without US abnormality and type I hips (p>0.05 for all). However, abnormal US findings were significantly more common in firstborn and female newborns. A total of 39 hips (5 bilateral, 20 left, 9 right) of 34 newborns (31 females) were placed in Pavlik harnesses. Twelve newborns had type IIc or D hips at initial evaluation, and 22 had type IIb or IIa(-) at follow-up. Mean recovery time was 12.5 (8-16) weeks for newborns with type IIc and D hips, 8.6 (8-12) weeks for those with type IIa(-) hips, and 11.2 (8-12) weeks for those with type IIb hips.

CONCLUSION

DDH is still common among newborns in Turkey. Hip US is recommended for detection and follow-up of DDH in newborns.

A combined procedure for irreducible dislocation of patella in children with ligamentous laxity: a preliminary report

OBJECTIVE

Irreducible patellar dislocation accompanying ligamentous laxity is rarely seen in pediatric patients. The most common complaints due to this condition are inability to walk, delayed walking, and difficulties with orthotics. The purpose of this retrospective study is to describe a novel surgical technique to treat dislocated patella in patients with symptomatic ligamentous laxity.

METHODS

Fourteen knees of 9 patients operated on by a single surgeon between 2009-2012 were included in the study. The tensor fascia was divided into 2 strips, and these strips were passed via the joint and sutured to themselves. The combined procedure additionally includes lateral capsular release, vastus lateralis (VL) resection, medial capsular plication, and Z-plasty of the rectus femoris (RF) tendon.

RESULTS

Mean age at the time of surgery was 6.9±3.3 years (range: 4-13 years). The mean follow-up was 37.6±0.9 months (range: 26-49 months). Patellofemoral instability was restored for all patients by using combined surgical technique. Patellar lateralization developed in 2 patients, in whom stability was obtained via secondary medial plication.

CONCLUSION

Our results show that this combined surgical procedure stabilizes the knee and treats patellar dislocation accompanying ligamentous laxity in pediatric patients.

Improvement of popliteal angle with semitendinosus or gastrocnemius tenotomies in children with cerebral palsy

OBJECTIVE

The aim of this study was to determine the efficacy of semitendinosus and gastrocnemius tenotomies on popliteal angle presenting knee flexion spasticity in children with cerebral palsy (CP).

METHODS

The study included 44 patients (25 males, 19 females; mean age: 8.1 years, range: 4 to 14 years) with spastic CP who underwent surgery for knee flexion spasticity. A total of 78 semitendinosus tenotomies and 28 associated gastrocnemius tenotomies were performed. Popliteal angle was measured under general anesthesia before and after surgery. Patients were divided into groups according to age (younger and older than 7 years), severity of deformity and type of CP.

RESULTS

Mean popliteal angles decreased by 14.3º (30.1%) following semitendinosus tenotomy and by 6.1º (12%) following gastrocnemius tenotomy (p=0.0001). The change in popliteal angle was not statistically significant according to age, severity of flexion spasticity, and type of CP palsy. There was a significant difference following gastrocnemius tenotomy between groups with a popliteal angle of greater or lesser than 50º (p=0.0001).

CONCLUSION

Semitendinosus and gastrocnemius tenotomies improved popliteal angle by 30.1% and 12%, respectively. Age, preoperative popliteal angle or anatomical disease classification did not a significantly affect popliteal angle.

Osteotendinous repair of bilateral spontaneous quadriceps tendon ruptures with the Krackow technique in two patients with chronic renal failure

Although unilateral traumatic quadriceps tendon rupture is a relatively frequent pathology, bilateral non-traumatic spontaneous ruptures are uncommon and are usually associated with chronic renal failure, hyperparathyroidism, gout, and systemic lupus erythematosus. This paper aimed to discuss two patients with chronic renal failure treated with the Krackow suture technique for spontaneous bilateral quadriceps tendon rupture.

Early mobilization with customized TLSO brace in thoracolumbar burst fractures

OBJECTIVE

This study aimed to research the effectiveness of customized thoracolumbosacral orthosis treatment for stable burst type thoracolumbar vertebral fractures without neurological deficits.

METHODS

The study included 26 patients (14 males, 12 females; mean age: 46.03 years; range: 18 to 64 years) conservatively treated for thoracolumbar (T11-L2) burst type vertebral fractures according to Denis classification between 2002 and 2009. Etiology were a fall from various heights in 12 patients (46.2%), motor vehicle accidents as an occupant in 7 (26.9%) and as a pedestrian in 4 (15.4%), and simple fall in 3 (11.5%). None of the patients had neurologic deficit and no damage was found in the posterior ligamentous complex in MRI evaluations. Denis pain and functional scales were used in the clinical evaluation. Local kyphosis angle, sagittal index and height loss percentage were measured in the radiologic evaluation. Post-fracture and follow-up values were compared. Mean follow-up period was 41.30 (range: 14 to 80) months.

RESULTS

Mean pain and functional scores were 1.65 and 1.15 points, respectively, at the final follow-up. Twenty patients returned to their pre-trauma work and activities completely and six patients with small limitations. Mean period for returning to work was 3.64 (range: 2 to 6) months. Local kyphosis angle, sagittal index and height loss percentage values increased significantly at follow-up (p<0.05).

CONCLUSION

The conservative treatment of stable thoracolumbar burst fractures is widely accepted. Early mobilization with customized TLSO brace appears to produce effective functional results despite loss of vertebral body height.