risk factors for failure of hemiepiphysiodesis in blount disease
TRANSCRIPT
RiskFactorsforFailureofHemiepiphysiodesisinBlountDisease:Systema;cReview
LLRSAnnualMee,ng2016
BensenFanMD,SanjeevSabharwalMD,MPH
HistoryofTreatmentinBlount
• Bracing• Osteotomy• PermanentHemiepiphysiodesis– DrillHemiepiphysiodesis– Phemister
• TemporaryHemiepiphysiodesis– BlountStaple– Non-lockingextra-periostealplate
Schoeneckeretal.CH28.Lovell&WinterPediatricOrthopedics2006,6the,LippincoNWilliamsWilikins,PhilPA
Ques6on
1. Whatistheprevalenceofunplannedreopera;onfollowinglateralhemiepiphysiodesisusingimplants?
2. Isthereadifferenceinclinicaloutcomeandcomplica;onsbasedonageatsurgeryandtypeofimplant?
Methods
• Systema;cReview• PRISMAGuidelines
PreferredRepor;ngItemsforSystema;creviewsandMeta-
Analyses
www.prisma-statement.org
www.prisma-statement.org
EligibilityCriteriaPICOS
• Pa6ent/Problem– Blountdisease(lateandearlyonset)
• Interven6on– Temporaryhemiepiphysiodesis
• Comparison– Expectedoutcomevs.unplannedreopera;on
• Outcome– Expectedoutcome:“neutral”mechanicalaxis– Unplannedreopera;on(implantfailure,infec;on,under-correc;on,over-correc;on,other)
Informa6onSources
– Pubmed– CINAHL– OVID– WebofScience– SCOPUS
InclusionandExclusionCriteria
• Inclusion– Itemizedpa;entdata– Blountdisease
• Earlyonset• Lateonset
– Useoftemporaryhemiepiphysiodesis• Lateralproximal;bia• Lateraldistalfemur
• Exclusion– NoItemizedpa6entdata
– Othercausesofangulardeformity
SearchandStudySelec6on
DataItems• Demographics– Age@surgery,earlyvs.lateonsetBlount,operatedsegment(femur/;bia)
• MethodofTreatment– Lateralhemiepiphysiodesis• Staples• Extraperiostealplate
ModeofFailureImplantbreak/backingout,infec;on,under-correc;on,over-correc;on,other
OutcomeExpectedOutcome–“Neutral”mechanicalaxisUnplannedsurgery• Osteotomy,• Removalofbroken
hardware,• I&D,• Revision
Results
• 53pa;ents(63limbs)– 18earlyonsetBlount– 9lateonsetBlount– 36unspecified
• Lateralityofsurgery– 17leiside– 10rightside– 36unreported
• Loca;onofSurgery– 54;bias– 8femur+;bia– 1femuronly
<9yo@surgery• N=27limbs• Age@surgery=4.7yo• LengthF/U=19month• 17/27(63%)expected
outcome• 10/27(37%)unplanned
reopera;on
≥9yo@surgery• N=36limbs• Age@surgery=12yo• LengthF/U=23month• 16/36(44%)expected
outcome• 20/36(56%)unplanned
reopera;on
Results
Results
Staples• N=16limbs• Age@OR=6.9yo• LengthF/U=24month• 6/16(37%)expected
outcome• 10/16(63%)unplanned
reopera;on
Plates• N=47limbs• Age@OR=11yo• LengthF/U=20month• 25/47(53%)expected
outcome• 22/47(47%)unplanned
reopera;on
16staplesasindexsurgery
Loosestaple(N=2)
Osteotomy
Revisiontoplate(N=5)
EpiphysiodesisforLLD(N=2)
Infec;on
Screwbreak
Osteotomy
Expectedoutcome(N=2)
Osteotomyforundercorrec;on
(N=2)
Expectedoutcome(N=6)
Overcorrec;on(N=1)
Staple
6/1637%
Plate
Plates(N=47)
Revision(N=9)
Osteotomy(N=1)
Expectedoutcome(N=8)
Screwbreak(N=3)
Osteotomy 1revisionUnknownoutcome Revision
Infec;on(N=2)
Hardwareremoval
Delayedcorrec;on
Osteotomy(N=7)
Expectedoutcome(N=25)
25/4753%
Discussion
• Dataislimited– Publishedar;clesdonotitemizedata
• Unplannedsubsequentproceduresandcomplica;onsarecommonlyreported
• OlderageanduseofStaplesmorefrequentlyhadunplannedsurgeries
Bias
• Selec;onBias– Pa;entsselectedfromstudiesthatlookedatfailure
• Publica;onBias– Studieswithsta;s;callysignificantresultsmorelikelytobepublished
• HistoryBias– Aier2007mostpublishedresearchonplatesandnotstaples
Conclusion• Publishedstudiescontainheterogeneousdata
• Highprevalence(51%)ofunplannedsubsequentproceduresandcomplica;onspublishedinliterature
• OlderageanduseofStaplesmorefrequentlyhadunplannedsurgeries
References• BlountWP,ClarkeGR(1949)Controlofbonegrowthbyepiphysealstapling;apreliminaryreport.JBoneJointSurgAm• 31:464–478• SchroerluckeS,BertrandS,ClappJ,BundyJ,GreggFO(2009)FailureofOrthofixeight-PlateforthetreatmentofBlountdisease.• JPediatrOrthop29:57–60• StevensPM(2007)Guidedgrowthforangularcorrec;on:apreliminaryseriesusingatensionbandplate.JPediatrOrthop• 27:253–259• Langenskio¨ldA.Tibiavara:osteochondrosisdeformans;biae.Blount’sdisease.ClinOrthopRelatRes.1981;77Y82.• WiemannJM4th,TryonC,SzalayEA(2009)Physealstaplingversus8-platehemiepiphysiodesisforguidedcorrec;onofangulardeformityaboutthe
knee.JPediatrOrthop29:481–485• BushnellBD(2009)HemiepiphyseodesisforLate-OnsetTibiaVara(JPediatrOrthop2009;29:285Y289)• BurghardtRD,HerzenbergJE(2010)Temporaryhemiepiphysiodesiswiththeeight-Plateforangulardeformi;es:mid-term• results.JOrthopSci15:699–704• BlountWP.Tibiavara:osteochondrosisdeformans;biae.JBoneJointSurgAm.1937;35:1Y27.• ParkSS,GordonJE,LuhmannSJ,etal.Outcomeofhemiepiphysealstaplingforlate-onset;biavara.JBoneJointSurgAm.2005;87:• 2259Y2266.• CastanedaP,UrquhartB,SullivanE,etal.Hemiepiphyseodesisforthecorrec;onofangulardeformityabouttheknee.JPediatrOrthop.• 2008;28:188Y191.• LangenskioldA,RiskaEB.Tibiavara(osteochondrosisdeformans;biae):asurveyofseventy-onecases.JBoneJointSurgAm.• 1964;46:1405Y1420.• MielkeCH,StevensPM(1996)Hemiepiphysealstaplingforkneedeformi;esinchildrenyoungerthan10years:apreliminary• report.JPediatrOrthop16:423–429• RaabP,WildA,SellerK,KrauspeR(2001)Correc;onoflengthdiscrepanciesandangulardeformi;esofthelegbyBlount’s• epiphysealstapling.EurJPediatr160:668–674
BMI• Westberry2004
– Retrospec;ve;33limbs(Blountpts);staplesandplates;BMInotsignificantforsubsequentsurgery
• Bushnell2009• Retrospec;ve;67limbs(lateonsetBlountpts);staples;body
weightwasnotsignificantforamountofcorrec6on• McIntosh2009
– Retrospec;ve;64limbs(adolescentBlount),permanenthemiepiphysiodesis;BMI>45significantforclinicalfailure
• Schroerlucke2009– 18limbs(adolescentBlount);plates;failureinincreasingheavierpopula6onbutnotsta6s6callysignificant
• Funk2016– 38limbs(lateonsetBlount);staplesandplates;BMIsignificantforsurgicalfailure(BMI42)
PreopDeformity
• Westberry2004– PreopMAsignificantforsubsequentsurgeryaierstaples
• Bushnell2009– Lessdeformityanindependentpredictorforgreatercorrec;oninstaples
• McIntosh2009– AsmallermPTAassociatedwithclinicalfailureinpermanenthemiepiphysiodesis
• Funk2016– Greaterdeformityresultsinhighersurgicalfailureinstaplesandplates
Age• Raab2001–higherrateofstaplelooseningingirls>9yoand
boys>11yo• Westberry2004–notsignificantforsubsequentsurgery• Park2005–staplingbeNerwhenstartedyounger• Bushnell2009–youngerageisanindependentpredictorfor
greaterdeformitycorrec;on• McIntosh2009–olderageariskforclinicalfailurein
permanenthemiepiphysidesis• Schroerlucke2009–ageNOTsigfinificantforscrewbreak• Funk2016–youngeragesignificantforimplantfailure