Two-Stage Surgical Treatment of Complex Femoral Deformities with Severe Coxa Vara in Polyostotic Fibrous Dysplasia

Ippolito, Ernesto; Farsetti, Pasquale; Valentini, M Benedetti; Potenza, Vito

doi:10.2106/jbjs.n.00230

Cited by 18 publications

(64 citation statements)

References 16 publications

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“…For type 5 femurs, double-level osteotomy should be performed to correct the coxa vara and the varus deformity in the proximal femoral shaft. The double-level osteotomy can be performed in a one-stage or two-stage operation [ 16 ]. The one-stage valgus osteotomy has several advantages compared with two-stage osteotomy, including shortened treatment time, reduced number of operations, and lower medical costs.…”

Section: Discussionmentioning

confidence: 99%

Radiographic classification and treatment of fibrous dysplasia of the proximal femur: 227 femurs with a mean follow-up of 6 years

et al. 2015

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BackgroundResearch into the optimal treatment of fibrous dysplasia has been limited by the lack of an established classification system for the disease. The purposes of this study were to develop a radiographic classification for fibrous dysplasia of the proximal femur and to test this classification’s intra- and interobserver reliability as well as the effectiveness of our treatments.MethodsWe retrospectively reviewed radiographs and computed tomography (CT) of 227 femurs from 206 patients with fibrous dysplasia. The radiographs were evaluated in the coronal plane for neck-shaft angle, varus deformity in the proximal femoral shaft, and distal juxtaarticular valgus deformity. CT was evaluated in the axial plane for destruction of cortex. Reduction of bone strength was defined as the thickness of the remaining cortex less than 50 % of the original on axial CT. Two senior orthopedists evaluated each radiograph and CT twice at 8-week intervals. Intra- and interobserver reliability testing was performed using the kappa statistic. Treatments were assessed through mid-term follow-up.ResultsThe 227 femurs were classified into five reproducible types: type 1 (33 %), normal bone strength without angular deformity; type 2 (30 %), decreased bone strength without angular deformity; type 3 (12 %), isolated coxa vara with neck-shaft angle <120°; type 4 (11 %), isolated varus deformity in the proximal femoral shaft; and type 5 (14 %), coxa vara with varus deformity in the proximal femoral shaft. Intra- and interobserver kappa values were excellent, ranging from 0.85 to 0.88. Good clinical outcomes were achieved.ConclusionsThis radiographic classification of fibrous dysplasia is reproducible and useful for describing and assessing this disease. The treatments based on this classification were effective.

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Section: Discussionmentioning

confidence: 99%

Radiographic classification and treatment of fibrous dysplasia of the proximal femur: 227 femurs with a mean follow-up of 6 years

et al. 2015

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“… Ippolito et al (2003) [ 11 ] 19 Interlocking cephalomedullary nails Unknown 0/19 All patients had a good outcome with no worsening of deformities Jung et al (2006) [ 30 ] 7 Multiple osteotomies with intramedullary nails 30 months 0/7 No patients needed a revision surgery and good functional outcome in all patients Yang et al (2010) [ 14 ] 14 Valgus osteotomy with intramedullary nails 75.3 months 0/14 No patient needed revision surgery Zhang et al (2012) [ 32 ] 28 IMN, additional osteotomy in 8 patients 50 months 0/28 No patients needed revision surgery. Good functional outcome in the majority Kushare et al (2014) [ 13 ] 16 Intramedullary nails 3 years 1/16 One patient required further surgery and 5 had pain at last follow-up Ippolito et al (2015) [ 16 ] 11 Two stage coxa vara correction and definitive fixation with an interlocking nail 4.7 years 4/11 Four patients had complications after the first surgery and another four needed further surgery after the second implant. Benedetti Valentini et al (2015) [ 15 ] 8 Customized adult humeral nail in children (4–7 years) 2.9 years 3/8 Three patients required revision surgery as an adult.…”

Section: Resultsmentioning

confidence: 99%

“…The other ABP had a good outcome. Leet et al (2016) [ 23 ] 2 Angled Blade Plates Unknown Unknown Outcome of ABP not described Ippolito et al (2015) [ 16 ] 8 Angled Blade Plates Unknown 1/8 One patient had screw loosening with lateralization of the plate Present study 28 Angled Blade Plates, 8 of which were customized 4.1 years 2/28 Two failures, in 7 patients ABP removed due to complaints of the iliotibial tract Dynamic/Compression Hip Screw Li et al (2013) [ 34 ] 21 Valgus osteotomy with DHS fixation 19–128 months 2/21 One patient revision surgery with an intramedullary nail after a fracture and one had a loose lag screw. Tong et al (2013) [ 27 ] 2 Valgus osteotomy with DHS fixation 12–32 months 0/2 No patient needed revision surgery Nishida et al (2015) [ 26 ] 8 Cortical Autograft with compression hip screw 75 months 0/8 No patient needed revision surgery …”

Section: Resultsmentioning

confidence: 99%

“…A number of surgical options have been originally proposed, including different types of bone grafting, various osteosyntheses, with or without additional osteotomies or a combination of these modalities. Over the past decade, however, there has been an increasing preference for the use of intramedullary nails and angled blade plates due to better treatment outcomes of these procedures [ 11 – 16 ]. In this study, we assess the clinical outcome of angled blade plates and intramedullary nails in fibrous dysplasia of the proximal femur, in a combined cohort of patients from the Leiden University Medical Center (LUMC) in the Netherlands and the Medical University of Graz (MUG) in Austria, using as outcome indicators implant function, revision-free survival and pain relief.…”

Section: Introductionmentioning

confidence: 99%

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Individualized approach to the surgical management of fibrous dysplasia of the proximal femur

Majoor

Leithner

Sande

et al. 2018

Orphanet J Rare Dis

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BackgroundFibrous dysplasia of the proximal femur presents with heterogeneous clinical manifestations dictating different surgical approaches. However, to date there are no clear recommendations to guide the choice of surgical approach and no general guidelines for the optimal orthopedic management of these lesions. The objective of this study was to evaluate treatment outcomes of angled blade plates and intramedullary nails, using as outcome indicators revision-free survival, pain, function and femoral neck-shaft-angle. Based on a review of published literature and our study findings, we propose a treatment algorithm, taking into account different factors, which may play a role in the selection of one surgical approach over another.MethodsData were evaluated in thirty-two patients (18 male) from a combined cohort from the Netherlands and Austria, who had a surgical intervention using an angled blade plate (n = 27) or an intramedullary nail (n = 5) between 1985 and 2015, and who had a minimal follow-up of one year. The primary outcome was success of the procedure according to the revised Henderson classification. Secondary outcomes, which were assessed at one year and at the end of follow-up included: function (as measured by walking ability), pain and change in femoral neck-shaft angle over time.ResultsAnalysis of data showed that revision-free survival was 72% after a median follow-up of 4.1 years. Revision was necessary in two patients for structural failure due to a fracture distal to an angled blade plate and in 7 patients due to angled blade plate-induced iliotibial tract pain. At the end of follow-up 91% of all patients had good walking ability and 91% were pain free. There was no significant postoperative change in femoral neck shaft angle.ConclusionOur data show that fibrous dysplasia of the proximal femur can be adequately and safely treated with angled blade plates or intramedullary nails, providing these are used according to specific characteristics of the individual patient. Based on published literature and our own experience, we propose an individualized, patient-tailored approach for the surgical management of fibrous dysplasia of the proximal femur.Electronic supplementary materialThe online version of this article (10.1186/s13023-018-0805-7) contains supplementary material, which is available to authorized users.

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“…However, these nails have been designed mainly for fractures, and they lack a valid cervical component to support the weak and large femoral neck that in many PFD cases misses the calcar. In those cases, the 4 to 5-mm thick cervical screws component available in some of the pediatric interlocking femoral nails cannot properly stabilize the femoral neck and cut-out of the cervical screws is likely to occur [22].…”

Section: Discussionmentioning

confidence: 99%

Internal fixation after fracture or osteotomy of the femur in young children with polyostotic fibrous dysplasia

Valentini

Ippolito

Catellani

et al. 2015

Journal of Pediatric Orthopaedics B

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Children from 4 to 7 years of age with polyostotic fibrous dysplasia (PFD) may need internal fixation of the femur for either fracture or osteotomy. At that age, the small size of the femur allows only the use of small intramedullary nails. However, titanium elastic nails and rigid intramedullary pediatric interlocking femoral nails - good for fracture or osteotomy fixation in the normal femur - are not indicated in PFD. From 2009 to 2011, we treated eight cases of PFD femoral fracture and deformity by internal fixation with a custom-modified adult humeral nail to which a spiral blade was connected. The 7-mm thick nail fit properly into the small femoral shaft and the spiral blade conferred ideal mechanical support to the femoral neck. Three cases had replacement of the humeral nail with a more appropriate adult femoral nail 3 years after the index procedure when the femur had reached an adequate size. In the maximum follow-up period of 4 years, few complications were observed.

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Two-Stage Surgical Treatment of Complex Femoral Deformities with Severe Coxa Vara in Polyostotic Fibrous Dysplasia

Abstract: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cited by 18 publications

References 16 publications

Radiographic classification and treatment of fibrous dysplasia of the proximal femur: 227 femurs with a mean follow-up of 6 years

Radiographic classification and treatment of fibrous dysplasia of the proximal femur: 227 femurs with a mean follow-up of 6 years

Individualized approach to the surgical management of fibrous dysplasia of the proximal femur

Internal fixation after fracture or osteotomy of the femur in young children with polyostotic fibrous dysplasia

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