Risk Factors for Failure of Hemiepiphysiodesis in Blount Disease ...

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