Operative treatment of severe scoliosis in osteogenesis imperfecta: results of 20 patients after halo traction and posterior spondylodesis with instrumentation

Orthopedic Surgery in Osteogenesis Imperfecta in Adults

Osteogenesis imperfecta is a genetic disorder, mainly characterized by bone fragility. In adult with osteogenesis imperfecta, surgical treatment may be indicated as an emergency procedure in the event of a fracture, or as a scheduled procedure in case of patient functional impairment due to many causes, such as persistent pain, complex bone deformities, and degenerative arthropathies. In all cases, a multidisciplinary approach is recommended. It is essential to consider the patient's characteristics and expectations regarding treatment, as well as the local conditions, which may be complex due to the poor bone quality, bone deformity, and the presence of hardware implanted during childhood. The procedure can be very complex and challenging and each patient is a unique case. An accurate preoperative planning is mandatory to select the appropriate surgical technique, which can be either conservative or prosthetic, and to evaluate its feasibility and the risk-benefit ratio. The aim is to improve the patient's quality of life and autonomy as long as possible.

Surgical treatment of scoliosis in patients with osteogenesis imperfecta: a single institution case series

BACKGROUND

Osteogenesis imperfecta (OI) is a connective tissue disorder characterized by skeletal deformities, bone fragility, and spinal complications. Various studies' insights underscored the impact of scoliosis on pulmonary function, positive outcomes with spinal fusion, and improved functional abilities post-surgery. However, partial loss of correction remains inevitable.

METHODS

This study examines six surgically treated OI patients with scoliosis. Surgical intervention using a posterior approach with pedicle screws and hooks aimed to correct spinal deformities. Preoperative, postoperative, and follow-up radiological assessments were conducted, revealing significant reductions in scoliotic angles post-surgery.

RESULTS

Complications included infections and proximal junctional kyphosis requiring revision surgeries. Despite the challenges posed by poor bone quality and implant stability, no implant failures occurred in this series. Ponte osteotomies at the apex of deformity aided in corrective maneuvers.

CONCLUSION

Surgical treatment of scoliosis in patients affected by OI is challenging and may be associated with perioperative and postoperative complications. Ponte osteotomy may improve the correction and reduce necessary force at the time of correction.

Treatment of a symptomatic patient with severe progressive odontoid invagination and Cervicothoracic scoliosis: A case report

While there is no consensus on optimal treatment management for the rare condition of odontoid invagination with cervicothoracic scoliosis, skull traction for 12 weeks followed by combined posterior and anterior spinal fusion can be a feasible option. However, surgeons should be prepared for significant intraoperative and postoperative challenges.

Midterm Outcomes of Multimodal Approach to Treating Severe Scoliosis in Patients With Osteogenesis Imperfecta

INTRODUCTION

The surgical management of severe scoliosis in patients with osteogenesis imperfecta (OI) is challenging because of curve rigidity, small stature, and inherent bone fragility. This study evaluated the midterm outcomes of our multimodal approach to address these issues, integrating perioperative bisphosphonate therapy, preoperative/intraoperative traction, various osteotomies, segmental pedicle screw instrumentation with cement augmentation, and bone morphogenetic protein-2 application.

METHODS

A single-center retrospective review of 30 patients (average age 14.1 ± 2.2 years; 18 were female) diagnosed with OI and scoliosis was conducted. These patients underwent posterior spinal fusion between 2008 and 2020 and completed a minimum follow-up of 2 years. We measured radiographic parameters at each visit and reviewed the incidence of complications. A mixed-effects model was used to evaluate changes in radiographic parameters from preoperative measurements to the first and latest follow-ups.

RESULTS

The patient cohort consisted of 2 individuals with type I OI, 20 with type III, 6 with type IV, and 2 with other types (types V and VIII). Surgical intervention led to a notable improvement in the major curve magnitude from 76° to 36°, with no notable correction loss. In addition, the minor curve, apical vertical translation, lowest instrumented vertebra tilt, and pelvic obliquity were also improved. In the sagittal plane, thoracic kyphosis and lumbar lordosis remained unchanged while thoracolumbar kyphosis markedly improved. Two patients experienced proximal junctional kyphosis with screw pullout, one of whom required revision surgery. One patient developed a superficial infection that was successfully treated with oral antibiotics. No instances of neurologic deficits or cement extravasation were observed.

DISCUSSION

This study demonstrated the effectiveness and safety of our multimodal approach to treating scoliosis in patients with OI, achieving a 53% major curve correction with minimal complications over 2-year follow-up. These findings provide notable insights into managing scoliosis in this population.

LEVEL OF EVIDENCE

Level IV (case series).

Paediatric syndromic scoliosis: proceedings of the half-day course at the 57th annual meeting of the Scoliosis Research Society

There are some syndromes that present with unique manifestations pertaining to the spinal column. A good working understanding of these common syndromes is useful for the spinal deformity surgeons and related healthcare providers. This review attempts to encompass these unique features and discuss them in three broad groups: hypermobility syndromes, muscle pathology-related syndromes, and syndromes related to poor bone quality. This review explores the features of these syndromes underpinning the aspects of surgical and medical management. This review represents the proceedings of the Paediatric Half-Day Course at the 57th Annual Meeting of the Scoliosis Research Society.

Outcomes of Growth-friendly Instrumentation in Osteogenesis Imperfecta: A Preliminary Report

BACKGROUND

There is limited literature on the outcomes in patients with osteogenesis imperfecta (OI) undergoing growth-friendly instrumentation (GFI). The purpose of this study was to report the outcomes of GFI in patients with early-onset scoliosis (EOS) and OI. We hypothesized that similar trunk elongation could be obtained in OI patients, but with higher complication rates.

METHODS

A multicenter database was studied for patients with EOS and OI etiology who had GFI from 2005 to 2020, with a minimum 2-year follow-up. Demographic, radiographic, clinical, and patient-reported outcomes data were collected and compared with an idiopathic EOS cohort matched 2:1 for age, follow-up duration, and curve magnitude.

RESULTS

Fifteen OI patients underwent GFI at a mean age of 7.3±3.0 years, with an average follow-up of 7.3±3.9 years. OI patients had a mean preoperative coronal curve of 78.1±14.5 and achieved 35% correction after index surgery. There were no differences in major coronal curves and coronal percent correction between the OI and idiopathic groups at all time points. T1-S1 length (cm) was lower for the OI group at baseline (23.3±4.6 vs. 27.7±7.0; P =0.028) but both groups had similar growth (mm) per month (1.0±0.6 vs. 1.2±1.1; P =0.491). OI patients had a significantly increased risk of proximal anchor failure, which occurred in 8 OI patients (53%) versus 6 idiopathic patients (20%) ( P =0.039). OI patients who underwent preoperative halo-traction (N=4) had greater T1-S1 length gain (11.8±3.2 vs. 7.3±2.8; P =0.022) and greater percent major coronal curve correction (45±11 vs. 23±17; P =0.042) at final follow-up versus patients with no halo-traction (N=11). Staged foundation fusion was performed in 2 cases.

CONCLUSION

Compared with matched idiopathic EOS patients, OI patients undergoing GFI achieved similar radiographic outcomes but sustained greater rates of anchor failures, likely due to weakened bone. Preoperative halo-traction was a useful adjunct and may improve final correction. Staged foundation fusion is an idea to consider for difficult cases.

LEVEL OF EVIDENCE

Therapeutic-III.

Scoliosis in osteogenesis imperfecta: results of posterior spinal fusion in 39 patients

PURPOSE

To evaluate the outcomes of scoliosis corrective surgery in Osteogenesis Imperfecta (OI) patients with primarily pedicles screw fixation in terms of correcting and maintaining the correction of the spinal deformity, and to assess for several peri-operative parameters and complications associated with this surgical treatment.

METHODS

Retrospective case series of 39 consecutive patients with OI treated surgically for scoliosis. The surgeries were performed between 2002 and 2020 by three different surgeons. All patients' medical peri-operative and post-operative charts were evaluated. Radiological assessment was performed by evaluation of the pre-operative, immediate post-operative and last follow-up plain radiographs.

RESULTS

There were 20 females and 19 males included in this review with a mean age of 14 years (range, 6-20 years) at the time of surgery. The median follow-up time was 7.9 years. The mean pre-operative cobb angle (CA) of the major curve was 76.5 degrees (SD ± 18.9), decreasing to 42.6 (SD ± 17.4) in the long-term post-operative follow-up (P < 0.001). A total of 21 adverse events in 16 patients were noted. Only 4 patients required subsequent invasive surgical treatment or prolonged hospital stay. All other patients were treated conservatively with no lasting complication.

CONCLUSION

Scoliosis surgical correction in OI patients seems to yield acceptable results, with maintained coronal plane surgical correction in the long-term follow-up. Even though a high peri-operative complications rate is observed in this series, there were no long-term sequelae or lasting complications.

LEVEL OF EVIDENCE

Level IV, Case series.

Efficacy of Halo-Gravity Traction in the Perioperative Treatment of Severe Scoliosis and Kyphosis: A Comparison of Adolescent and Adult Patients

OBJECTIVE

The objective of the study was to compare the efficacy of halo-gravity traction (HGT) with subsequent surgical treatment in adolescent and adult patients with severe scoliosis by evaluating the radiographic outcomes and clinical complications.

METHODS

We performed a retrospective analysis of 51 patients with severe scoliosis who underwent a posterior spinal instrumented fusion with HGT during the perioperative period between March 2010 and June 2017. The patients were divided into 2 groups: adults (age >18 years) and adolescents (age 10-18 years). All patients were followed with full posteroanterior and lateral spine radiographs, bending films, neurological complications, and lung function tests for a minimum of 2 years. Deformity correction, pulmonary function testing, and clinical complications were compared between the 2 groups.

RESULTS

We identified 29 adults (8 males and 21 females, mean age = 23.7 ± 8.7 years) and 22 adolescents (10 males and 12 females, mean age = 13.0 ± 4.5 years). In the adult group, the mean Cobb angle of the main curve before HGT was 141.7 ± 18.2°, which improved to 126.4 ± 8.6° and 67.5 ± 10.2° after traction and operation, respectively. The kyphotic angle was corrected from 137.1 ± 15.6° before traction to 122.5 ± 11.3° after traction to 67.6 ± 13.8° after operation. The mean functional vital capacity% and forced expiratory volume in one second% were 43.1% and 37.5%, which improved to 46.7% and 41.7% after traction, respectively. In the adolescent group, the mean correction of the main curve improved from 139.3 ± 12.6° before traction to 112.1 ± 8.3° after traction to 59 ± 13.1° after surgical intervention. The kyphotic angle was corrected from 130.7 ± 9.4° before traction to 101.5 ± 12.2° after traction and then to 48.2 ± 10.1° after surgical intervention. Overall, patients in both groups showed significant improvement in their main scoliosis and kyphosis (P < 0.05), while the correction rate of the main curve and kyphosis was significantly higher in the adolescent group than that in the adult group (P < 0.05). The functional vital capacity% increased from 44.8% to 55.0% and the forced expiratory volume in one second% increased from 44.0% to 51.0% after using HGT. In terms of surgical outcomes, the incidence of postoperative neurological complications was 27.6% and 18.2% in the 2 groups, respectively.

CONCLUSIONS

HGT is an effective and safe method to correct spinal deformities and improve lung function, especially in adolescent patients with severe scoliosis. In addition, it can potentially reduce the risk of neurological complications and the level of osteotomy in posterior spinal instrumented fusion surgery.

Cementless posterior spinal fusion for the treatment of OI patients with severe spine deformity-a case series

PURPOSE

The purpose of this study is to present the outcomes all patients with osteogenesis imperfecta (OI) who underwent cementless posterior spinal fusion for the treatment of severe spine deformity in our institution.

METHODS

All patients with OI who underwent surgical correction of their spine deformity in our institution between 2003 and 2020 were enrolled. The collected data included demographics, operative and follow-up findings, medical history, bisphosphonate therapy, HGT protocol, pre- and post-HGT and postoperative scoliosis and kyphosis curve measurements, hospitalization length, complications, and revision surgeries. General treatment strategies included cessation of bisphosphonate therapy around the surgery, 30-day HGT protocol, titanium rods, cementless screw technique, and a high implant density policy.

RESULTS

Eleven consecutive patients with OI who underwent surgery for spine deformity in our institution were identified. The mean age at surgery was 15.6 ± 2.3. Mean follow-up period was 6.6 ± 5.8 years. The mean pre- and postoperative scoliosis curves were 85.4 ± 19.3° and 43.1 ± 12.5°, respectively, representing a 49.5% correction rate. Five patients underwent HGT and achieved a mean correction of 27.6 ± 7.1° (31.6%) preoperatively. Implant density ratio was 1.5 (screw or hook/level). Mean postoperative hospitalization length was 5.9 ± 1.6 days. One patient had deep wound infection which resolved following treatment according to our protocol for surgical site infection, and one patient had skull penetration by one of the halo pins.

CONCLUSION

Surgical treatment of severe spine deformity in OI patients with cementless posterior spinal fusion is safe and effective after applying a specific preoperative strategy.

Prevalence of scoliosis and impaired pulmonary function in patients with type III osteogenesis imperfecta

PURPOSE

Osteogenesis Imperfecta (OI) is a rare group of congenital genetic disorders that consists of a collagen synthesis defect. The most severe phenotype is type III OI. Characterized by progressive bone deformity, fragility and pulmonary impairment, causing significant morbidity and mortality. Also, multilevel spine deformities are observed, such as scoliosis. The literature on the pathophysiology of pulmonary impairment in relation to scoliosis in these patients is scarce and conflicting. This study aims to determine the prevalence of scoliosis and its relation to pulmonary function in type III OI patients.

METHODS

This retrospective cohort study took place between April 2020 and November 2021. Forty-two patients with type III OI were included. Anterior-posterior spine radiographs were evaluated for scoliosis. Pulmonary function was assessed using spirometry and partial pressure of carbon dioxide.

RESULTS

All 42 patients had scoliosis, with a mean curve of 66° (95% CI of range). Vital lung capacity was decreased, compared to a non-OI population (mean 1.57 L). This was correlated to the degree of scoliosis (st. β - 0.40, P = 0.03), especially in increasing thoracic curves. Restrictive lung pathophysiology was shown in our study population with a mean FEV1/FVC ratio of 0.85.

CONCLUSIONS

Increasing thoracic scoliosis was correlated with decreased vital lung capacity in our study population of type III OI patients. High FEV1/FVC ratios found in this study population show restrictive lung pathophysiology. Therefore, it is plausible that the pulmonary impairment found in type III OI patients is a combined issue, partly associated to scoliosis and partly intrinsic to OI.

Halo Gravity Traction for the Correction of Spinal Deformities in the Pediatric Population: A Systematic Review and Meta-Analysis

OBJECTIVE

Halo gravity traction (HGT) is an effective way of managing pediatric spinal deformities in the preoperative period. This study comprehensively reviews the existing literature and evaluates the effect of HGT on various radiographic parameters regarding spinal correction and, secondarily, evaluates the improvement in pulmonary function as well as nutritional status.

METHODS

In accordance with PRISMA guidelines, a comprehensive search was conducted for articles on HGT in the treatment of spinal deformity. Spinal deformity after traction and surgery, change of pulmonary function, nutritional status, and prevalence of complications were the main outcome measurements. All meta-analyses were conducted using random models according to the between-study heterogeneity, estimated with I².

RESULTS

A total of 694 patients from 24 studies were included in this review. Compared with pretraction values, the average coronal Cobb angle reduction after traction was 27.66° (95% confidence interval [CI], 23.41-31.90; P < 0.001) and 47.43° (95% CI, 39.32-55.54; P < 0.001) after surgery. The sagittal Cobb angle reduction after HGT and surgery was 27.23° (95% CI, 22.83-31.62; P <0.001) and 36.77° (95% CI, 16.90-56.65; P < 0.001), respectively. There was a statistically significant improvement in the overall pulmonary function, as evident by an increase in a forced vital capacity of 8.44% (95% CI, -5.68 to -11.20; P < 0.001), and an increase in nutritional status, with a percentage correction of body mass index by 1.58 kg/m² (95% CI, -2.14 to -1.02; P < 0.001) after HGT application.

CONCLUSIONS

HGT has been shown to significantly improve coronal deformities, sagittal deformities, nutritional status, and pulmonary function in the preoperative period.

Surgical Outcome of Spinal Fusion for Osteogenesis Imperfecta With Scoliosis: Is the Hybrid System With Pedicle Screws Applicable to Weak, Tiny, and Fragile Vertebrae?

INTRODUCTION

Corrective surgery for spinal deformity associated with osteogenesis imperfecta (OI) is challenging due to the severe and rigid deformity combined with extreme bone fragility. However, surgical outcomes still remain unclear. In addition, the applicability of pedicle screws (PSs) to the tiny and fragile vertebrae in patients with OI is poorly understood. This study evaluated the surgical outcome, and the accuracy and safety of PS placement in patients with OI.

METHODS

Twenty-five patients with OI were included in this study. Mean age was 21.0±9.3 (10 to 49) years. Mean follow-up was 5.8±2.0 years. The Sillence classification showed 16 patients had the mildest type I, 1 patient had moderate type IV, and 8 patients had the most severe type III. Fifteen patients underwent anterior release followed by posterior fusion, and 10 patients underwent only posterior fusion. The accuracy of PS placement was evaluated with postoperative computed tomography.

RESULTS

Scoliosis was corrected from 95.6 to 65.8 degrees after surgery (correction rate 32.5%) and 68.1 degrees at final follow-up (both, P<0.01). Space available for the lung was improved from 76.3% to 84.9% (P<0.05). No implant dislodgement occurred after surgery. A total of 290 screws were placed, of which 213 screws (73.4%) were placed completely. However, 30 screws (10.3%) penetrated >2 mm. In particular, rates of >2 mm penetration was much higher in type III than type I and IV (27.8% vs. 3.0%; P<0.01). Complications related to spinal surgery included 2 transient neurological disturbances.

CONCLUSIONS

PSs were applicable to spinal fusion surgery in patients with OI. However special care should be taken in placing PSs because of the weakness of the pedicle cortex, which was easily penetrated especially in Sillence type III.

LEVEL OF EVIDENCE

Level IV.

The growth-friendly surgical treatment of scoliosis in children with osteogenesis imperfecta using distraction-based instrumentation

PURPOSE

The study was undertaken to determine the feasibility of growth-friendly distraction-based surgery in children with OI.

METHODS

Two multi-center databases were queried for children with OI who had undergone GR or VEPTR surgery. Inclusion criteria were a minimum 2-year follow-up and three lengthening procedures following the initial implantation. Details of the surgical techniques, surgical complications, and radiographic measurements of deformity correction, T1-T12 and T1-S1 elongation and growth were recorded.

RESULTS

Five patients were identified. There was one patient with type I OI and two patients each with type III and type IV. Four patients had GR constructs and one a VEPTR construct. The initial scoliosis deformity averaged 80° (70°-103°), and the subsequent corrections averaged 32% for initial correction, 48% at last follow-up, and 54% for the two patients that had a final fusion. The T1-T12 and T1-S1 growth averaged 31 mm and 44 mm respectively, and yearly growth averaged 4 mm and 6 mm, respectively. Growth was notably much less in those with more severe disease. There were 13 complications in 4 patients. Nine of the 10 surgical complications were anchor failures which were corrected in 7 planned and 2 un-planned procedures. Significant migration occurred in one patient with severe OI type III.

CONCLUSION

The results varied in this heterogeneous population. In general, satisfactory deformity corrections were obtained and maintained, modest growth was obtained, and complications were similar to those reported in other series of growth-friendly surgery. Limited growth and significant anchor migration are to be anticipated in this population.

LEVEL OF EVIDENCE

IV.

Clinical efficacy of short-term pre-operative halo-pelvic traction in the treatment of severe spinal deformities complicated with respiratory dysfunction

Background

Halo traction has been used as an adjunctive method in the treatment of severe spinal deformities. But there are few reports on the clinical efficacy of halo-pelvic traction (HPT) in the treatment of severe spinal deformities complicated with respiratory dysfunction. This study was to evaluate the clinical efficacy and complications associated with pre-operative HPT in the treatment of severe spinal deformities with respiratory dysfunction.

Methods

Thirty patients with severe spinal deformities complicated with respiratory dysfunction treated with short-term pre-operative HPT were retrospectively reviewed. Inclusion criteria were: (1) patients with severe kyphoscoliosis (coronal Cobb angle or kyphosis angle ≥100°) and respiratory failure, (2) patients undergoing HPT until posterior fusion surgery. All patients underwent general anesthesia for HPT application, which the pelvic ring used in this study was a half-ring, and the rods were all placed on the anterolateral side of the truck.

Results

The major coronal curve scoliosis averaged 116.00 ± 16.70° and was reduced to 63.23 ± 14.00° after HPT, 46.33 ± 10.70° after surgery. The major kyphosis was 102.40 ± 27.67° and was reduced to 52.23 ± 14.16° after HPT, 42.0 ± 11.92° after surgery. A significantly increased FVC was observed after HPT (p < 0.001), with a significantly improved FVC% (p < 0.001). Similarly, a significantly increased FEV1 was also observed (p < 0.001), with a significantly improved FEV1% (p < 0.001).

Conclusion

This study indicated that the modified HPT could be used to help patients with severe spinal deformities complicated with respiratory dysfunction achieve significant correction in both the coronal and sagittal deformities during the pre-operative treatment period along with improved respiratory function and in the absence of severe complications.

Growing Rod Surgery for Early-Onset Scoliosis in an Osteogenesis Imperfecta Patient

BACKGROUND

Osteogenesis imperfecta (OI) is characterized by bone fragility and is often accompanied by spinal deformity. Surgical treatment for early-onset scoliosis in patients with OI is hazardous and difficult due to the bone fragility and rigidity of the deformity. A case of early-onset scoliosis with OI that was treated using growing-rod surgery is presented.

CASE DESCRIPTION

The patient was an 11-year-old girl with type 4 OI. At the age of 4 years, she was noted to have scoliosis. Preoperative radiographs showed that the Cobb angle, thoracic kyphosis angle, and T1-S1 height were 94°, 77°, and 258 mm, respectively. One year before the operation, she underwent cyclic intravenous pamidronate disodium treatment. Three months after the pedicle screws were inserted, the growing rods were placed with pedicle screws and sublaminar polyethylene tape. The patient had intraoperative traction for correction. At 13 years and 11 months, the patients underwent posterior instrumentation and spinal fusion. Postoperative radiographs showed that the Cobb angle, thoracic kyphosis angle, and T1-S1 height were 29°, 29°, and 405 mm, respectively. Three months after the operation, she was well, and there have been no spine-related problems.

CONCLUSIONS

This case demonstrates the successful use of the growing rod for early-onset scoliosis in patients with OI. The treatment strategy, which included pedicle screw insertion as anchors to create the foundations in advance, sublaminar tape, intraoperative traction, and preoperative bisphosphonate administration, might have led to the good outcome.

Computed tomography-based bronchial tree three-dimensional reconstruction and airway resistance evaluation in adolescent idiopathic scoliosis

PURPOSE

To investigate airway development and airway resistance by computed tomographic three-dimensional (3D) reconstruction of the bronchial tree in patients with adolescent idiopathic scoliosis (AIS). We evaluated factors predicting postoperative respiratory complications to provide timely treatment, prevent complications, and improve operative and anesthetic safety.

METHODS

From August 2015 to August 2017, 53 AIS patients with a mean age of 15.4 years (range 10-20 years) were included in this study. Scoliotic parameters on radiographs were analyzed. Airway resistance was obtained by pulmonary function testing. All patients' pulmonary bronchial trees were 3D-reconstructed via chest thin layer computed tomography to explore the correlation between the spinal-thoracic deformity parameters and airway resistance.

RESULTS

Correlations between scoliotic parameters and airway development parameters were not statistically significant (P > 0.05). The scoliotic parameters such as Cobb angle, apical vertebral translation, rotation angle to sagittal plane, rotation angle to middle line, and apical vertebral body-rib ratio (AVB-R) were positively correlated with tracheal bifurcation angle (R²: 0.429, 0.374, 0.430, 0.504, and 0.414, respectively; P < 0.05). Cobb angle, rib hump, and apical vertebral body-rib ratio (AVB-R) were positively correlated with left principal bronchus length to right principal bronchus length (PBL-R) (R²: 0.373, 0.503, and 0.377, respectively; P < 0.05). Superficial area of bronchial tree (SABT) and narrow cross section of trachea (NCT) were negatively correlated with plethysmography Pre-Ref resistance ratio (Pre/Ref) (R²: - 0.365 and - 0.452, respectively; P < 0.05). SABT and NCT were negatively correlated with respiratory impedance (Zrs) (R²: - 0.327 and - 0.436, respectively; P < 0.05).

CONCLUSIONS

Pulmonary bronchial development in patients with AIS is affected by spinal-thoracic deformity. Comprehensive assessment of preoperative pulmonary function, especially airway resistance, is necessary in patients with AIS whether the thoracic scoliosis is severe or mild-to-moderate. These slides can be retrieved under Electronic Supplementary Material.

Preoperative halo-gravity traction for treatment of severe adult kyphosis and scoliosis

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To assess the efficacy of preoperative halo-gravity traction (HGT) in the treatment for severe adult kyphosis and scoliosis. Preoperative HGT improves severe curve magnitude and clinical condition in pediatric spinal deformity. However, the efficacy of HGT on severe adult spinal deformity has rarely been studied.

MATERIALS AND METHODS

This study included 18 patients with severe adult kyphosis and scoliosis (age ≥ 18) who underwent a preoperative HGT (mean 4 weeks), and subsequent definitive posterior-alone corrective fusion. Etiologies were neurofibromatosis (n = 5), adult idiopathic (n = 3), multiple vertebral fractures due to osteoporosis (n = 1) and multiple myeloma (n = 1), degenerative failed back syndrome (n = 1), Scheuermann kyphosis (n = 1), Marfan syndrome (n = 1), and other genetic and connective tissue disorders (n = 5). We reviewed baseline demographics, including coronal and sagittal radiographic profiles. The changes in major curve magnitude, pulmonary function tests (PFTs), and nutritional status were assessed between pre- and post-traction and immediate post-definitive corrective surgery.

RESULTS

There were 11 male and 7 female patients, aged 18-69 years with their major coronal and sagittal curves being 92.0° ± 25.2° and 111.6° ± 40.1°, respectively. The major coronal and sagittal curves were reduced by 18.4% and 16.8% after halo-traction, and 54.7% and 44.2% after definitive fusion, respectively. PFTs showed significant increase in %FEV1 and %FVC when comparing pre- and post-traction [43.0% ± 17.4% vs. 49.6% ± 18.7%, and 44.8%. ± 16.7% vs. 54.3% ± 20.7%, respectively, p < 0.01 (n = 11)]. Effective weight gain was observed after traction (46.8 ± 14.5 vs. 49.3 ± 13.5 kg, p < 0.01).

CONCLUSION

Halo-gravity traction (HGT) for severe coronal and sagittal plane spinal deformity in adult patients significantly reduced Cobb angles, improved PFTs, and allowed for effective weight gain in the preoperative period. The use of preoperative HGT is extremely beneficial to optimize the alignment and overall health of severe adult spinal deformity patients before their spinal reconstruction.

LEVEL OF EVIDENCE

Level IV.

Surgical Treatment of Bilateral Tibia Deformity in a 9-Year-Old Child Suffering from Osteogenesis Imperfecta Type III: A Case Report

Patient: Male, 9

Final Diagnosis: Osteogenesis imperfecta type III

Symptoms: Walking difficulties

Medication: —

Clinical Procedure: Osteotomies and realignment of bone deformity

Specialty: Orthopedics and Traumatology

Neurologic Deficit During Halo-Gravity Traction in the Treatment of Severe Thoracic Kyphoscoliotic Spinal Deformity

Correction of severe spinal deformity is a significant challenge for spinal surgeons. Although halo-gravity traction (HGT) has been shown to be well-tolerated and safe, we report here a case of neurologic decline during treatment. A 24-year-old male presents with severe thoracic kyphoscoliosis with > 180° of 3-dimensional deformity. Magnetic resonance imaging showed his thoracic spinal cord draped across his T7-9 apex. His neurologic exam showed lower extremity myelopathy. During week 7 at a goal traction weight of 18.1 kg, his distal lower extremity exam declined from 4+/5 to 2/5. His traction weight was lowered to 11.3 kg. He subsequently sustained a ground-level fall and became paraparetic with a motor exam of 1-2/5. He subsequently underwent a T1-L4 posterior spinal instrumentation and fusion with a T7-9 vertebral column resection. Postoperatively, he was noted to have a complete return to his baseline neurologic exam. At his 4-month postoperative visit, he was now full strength in his lower extremities with complete resolution of his myelopathy. We present here a case of neurologic decline in a patient with severe kyphoscoliosis who underwent HGT and discuss the management decisions associated with this challenging scenario.

Development of scoliosis in young children with osteogenesis imperfecta undergoing intravenous bisphosphonate therapy

The purpose of this study was to clarify the prevalence of scoliosis and determine risk factors for the development of scoliosis in young children with osteogenesis imperfecta (OI) who underwent intravenous pamidronate (PAM) therapy. Thirty-four young children with OI who had no scoliosis at the first PAM administration underwent cyclic PAM therapy alone. The medical records and radiographs of these patients were retrospectively reviewed. We examined the relationship between scoliosis (Cobb angle ≥ 10) and type of OI (Sillence classification: types I, III, and IV), physical mobility, Z-scores of bone mineral density in L2-4 of the lumbar spine (L2-4 BMD Z-scores), age of patients at first treatment with PAM, pelvic frontal tilt and leg-length discrepancy. The prevalence of scoliosis was 23.5% in 34 young children with OI who underwent PAM therapy for a mean of 4.2 years. Lower L2-4 BMD Z-scores, the presence of coronal and sagittal vertebral deformities and higher percentage of corrective osteotomy in the lower extremities were significant risk factors for the development of scoliosis. In patients with type III or IV OI, L2-4 BMD Z-scores were significantly lower (p = 0.02) and the percentage of patients who started PAM therapy in early childhood was significantly lower in scoliosis group than in the non-scoliosis group (p = 0.01). Development of scoliosis depends on the severity of OI and has a strong relationship with bone fragility even under PAM therapy. Starting intravenous PAM therapy in infancy or early childhood has a potential to prevent the occurrence and progression of scoliosis associated with bone fragility in young children with severe type III or IV OI.

Correction using Halo Gravity Traction for Severe Rigid Neuromuscular Scoliosis: A Report of Three Cases

Severe rigid neuromuscular scoliosis is a major challenge to the spine surgeon due to the possibilities of neurological sequelae from acute correction of the deformity. Halo gravity traction has been considered as a way of reducing the deformity before correction to prevent neurological complications. Three female patients with severe neuromuscular scoliosis aged seven to 13 years with main coronal Cobb angle of 95°-128° and Kyphotic Cobb of 47°-118° having ≤35% flexibility on traction, had between 18 to 23 days of 16 hour/day of halo gravity traction and night time supine traction with 4kg weight for 7-8 hours. They had 28.9% and 18.5% of main coronal and kyphotic Cobb angle correction post-traction respectively. All had posterior instrumentation and post-operatively, they had correction of main coronal Cobb angle of 29°-58° and kyphotic Cobb angle of 30°-77° with no neurological complication. Halo gravity traction is therefore a viable option for reducing post-operative neurological complication in rigid severe scoliosis.

Osteogenesis Imperfecta: A Pediatric Orthopedic Perspective

Osteogenesis imperfecta is a genetically and phenotypically heterogeneous disorder related to a defect or deficiency in the production of type I collagen. It is characterized by brittle bones, fractures, spine and extremity deformity, and a host of extraskeletal manifestations. Type I collagen is present in bone, tendons, ligaments, skin, dentin, and the sclera of the eye and other connective tissues. Osteogenesis imperfecta includes a multitude of disease manifestations that may be present at birth or develop over time and vary depending on the severity of the disease. This article describes the disease presentation and management considerations from a pediatric orthopedic perspective.

Dental-craniofacial manifestation and treatment of rare diseases

Rare diseases are usually genetic, chronic and incurable disorders with a relatively low incidence. Developments in the diagnosis and management of rare diseases have been relatively slow due to a lack of sufficient profit motivation and market to attract research by companies. However, due to the attention of government and society as well as economic development, rare diseases have been gradually become an increasing concern. As several dental-craniofacial manifestations are associated with rare diseases, we summarize them in this study to help dentists and oral maxillofacial surgeons provide an early diagnosis and subsequent management for patients with these rare diseases.

Complex spine deformities in young patients with severe osteogenesis imperfecta: current concepts review

The severity of osteogenesis imperfecta (OI), the associated reduced quality and quantity of collagen type I, the degree of bone fragility, ligamentous laxity, vertebral fractures and multilevel vertebral deformities all impair the mechanical integrity of the whole spinal architecture and relate to the high prevalence of progressive kyphoscoliotic deformities during growth. Bisphosphonate therapy may at best slow down curve progression but does not seem to lower the prevalence of deformities or the incidence of surgery. Brace treatment is problematic due to pre-existing chest wall deformities, stiffness of the curve and the brittleness of the ribs which limit transfer of corrective forces from the brace shell to the spine. Progressive curves entail loss of balance, chest deformities, pain and compromise of pulmonary function and eventually require surgical stabilization, usually around puberty. Severe vertebral deformities including deformed, small pedicles, highly brittle bones and chest deformities, short deformed trunks and associated issues like C-spine and cranial base abnormalities (basilar impressions, cervical kyphosis) as well as deformed lower and upper extremities are posing multiple peri- and intraoperative challenges. Hence, an early multidisciplinary approach (anaesthetist, pulmonologist, paediatric orthopaedic spine surgeon) is mandatory. This paper was written under the guidance of the Spine Study Group of the European Paediatric Orthopaedic Society. It highlights the most pertinent information given in the current literature and various practical aspects on surgical care of spine deformities in young OI patients based on the personal experience of the contributing authors.

Consensus statement on physical rehabilitation in children and adolescents with osteogenesis imperfecta

On the occasion of the 13th International Conference on Osteogenesis imperfecta in August 2017 an expert panel was convened to develop an international consensus paper regarding physical rehabilitation in children and adolescents with Osteogenesis imperfecta. The experts were chosen based on their clinical experience with children with osteogenesis imperfecta and were identified by sending out questionnaires to specialized centers and patient organizations in 26 different countries. The final expert-group included 16 representatives (12 physiotherapists, two occupational therapists and two medical doctors) from 14 countries. Within the framework of a collation of personal experiences and the results of a literature search, the participating physiotherapists, occupational therapists and medical doctors formulated 17 expert-statements on physical rehabilitation in patients aged 0–18 years with osteogenesis imperfecta.

Delayed, Reversible Cervical Paralysis After Scoliosis Corrective Surgery in a Child with Osteogenesis Imperfecta: A Case Report

CASE

A 12-year-old girl with osteogenesis imperfecta (OI) underwent posterior spinal arthrodesis (from T2 to the sacrum) for double major-curve scoliosis. She developed complete paralysis of all of the extremities 24 hours after surgery, without evidence of ischemia or infarction. The rods were removed, and the neurologic status improved; there was full restoration of strength within 1 week. She then underwent in situ fixation. At the 2-year follow-up, there had been no lapse in neurologic function.

CONCLUSION

Reversible, distraction-induced neurologic deficits can occur outside of the instrumented spinal segment after corrective scoliosis surgery, particularly in patients with ligamentous laxity, as seen with OI.

Type V osteogenesis imperfecta undergoing surgical correction for scoliosis

PURPOSE

The objective of this article is to report a case of type V osteogenesis imperfecta (OI) undergoing posterior instrumented fusion for scoliosis. Type V OI is a moderately severe dysplasia causing primary defects in endochondral bone ossification or mineralisation. It is characterised by hyperplastic callus (HPC) formation, interosseous membrane calcifications, poor bone quality and spinal deformities including scoliosis. Data on the surgical management of spinal deformities in this patient group are lacking.

CASE REPORT

A 16-year-old patient with a confirmed diagnosis of type V OI presented with a progressive scoliosis. The patient underwent a T3-L4 posterior instrumented correction and fusion utilising pedicle screws, pedicle hooks and sub-laminar wiring. At 4 months after surgery, the pedicle hooks pulled out and required partial metalwork removal after CT scanning confirmed bony union and no evidence of HPC formation. The patient was successfully discharged with satisfactory correction, confirmed bony union, no neurologic complication and absence of any hyperplastic callus formation.

CONCLUSION

Type V OI patients requiring surgical intervention for scoliosis correction can safely undergo posterior instrumented fusion using sublaminar wiring and pedicle hook/screw constructs without apparent risk of HPC formation around neural elements. Surgery in this patient group remains challenging due to the associated poor bone quality.

LEVEL OF EVIDENCE

V.

Surgical Treatment With Pedicle Screws of Scoliosis Associated With Osteogenesis Imperfecta in Children

STUDY DESIGN

Retrospective study.

OBJECTIVE

To assess results of posterior instrumented fusion using pedicle screws in 12 children with osteogenesis imperfecta (OI) with spinal deformity at a single institution from 2001 to 2012.

SUMMARY OF BACKGROUND DATA

This is the first case series of OI patients who underwent non-cement augmented screw-rod instrumented fusion published in the literature.

METHODS

Of a total of 54 children with spinal deformity associated with OI, 12 (22.2%) were submitted to posterior spinal fusion with pedicle screws (80% density) because of severe spinal deformity. Here we reported the results in seven females and five males.

RESULTS

Five thoracic (41.7%), five double (thoracic and lumbar 41.7%), and two lumbar (16.7%) curves were considered. The mean number of fused levels was 11.8 (range: 5 to 16). Mean age at surgery was 13 years 8 months. Mean follow-up was 7 years 11 months (range: 3 years 7 months to 16 years 1 month). The mean preoperative scoliosis angle was 75.6°, whereas the postoperative angle was 31.4° (58.5% correction rate). The mean preoperative kyphosis angle was 57.4° and the postoperative angle was 42.3°. We observed one superficial infection, one dural tear, and three cases of proximal junctional kyphosis; two patients required one revision surgery each (2 years and 4 months postoperatively on average).

CONCLUSIONS

To our knowledge, this is the first case series published in the literature regarding OI with instrumented fusion with non-cement augmented pedicle screws exclusively in children with spinal deformity. We found that posterior spinal fusion with the screw-rod system in OI deformity in children is feasible and reliable, and has acceptable clinical and imaging results in the long-term follow-up.

LEVEL OF EVIDENCE

Level IV.

The Spine in Patients With Osteogenesis Imperfecta

Osteogenesis imperfecta is a genetic disorder of type I collagen. Although multiple genotypes and phenotypes are associated with osteogenesis imperfecta, approximately 90% of the mutations are in the COL1A1 and COL1A2 genes. Osteogenesis imperfecta is characterized by bone fragility. Patients typically have multiple fractures or limb deformity; however, the spine can also be affected. Spinal manifestations include scoliosis, kyphosis, craniocervical junction abnormalities, and lumbosacral pathology. The incidence of lumbosacral spondylolysis and spondylolisthesis is higher in patients with osteogenesis imperfecta than in the general population. Use of diphosphonates has been found to decrease the rate of progression of scoliosis in patients with osteogenesis imperfecta. A lateral cervical radiograph is recommended in patients with this condition before age 6 years for surveillance of craniocervical junction abnormalities, such as basilar impression. Intraoperative and anesthetic considerations in patients with osteogenesis imperfecta include challenges related to fracture risk, airway management, pulmonary function, and blood loss.

Halo-gravity traction in the treatment of severe spinal deformity: a systematic review and meta-analysis

PURPOSE

Halo-gravity traction has been reported to successfully assist in managing severe spinal deformity. This is a systematic review of all studies on halo-gravity traction in the treatment of spinal deformity to provide information for clinical practice.

METHODS

A comprehensive search was conducted for articles on halo-gravity traction in the treatment of spinal deformity according to the PRISMA guidelines. Appropriate studies would be included and analyzed. Preoperative correction rate of spinal deformity, change of pulmonary function and prevalence of complications were the main measurements.

RESULTS

Sixteen studies, a total of 351 patients, were included in this review. Generally, the initial Cobb angle was 101.1° in the coronal plane and 80.5° in the sagittal plane, and it was corrected to 49.4° and 56.0° after final spinal fusion. The preoperative correction due to traction alone was 24.1 and 19.3%, respectively. With traction, the flexibility improved 6.1% but postoperatively the patients did not have better correction. Less aggressive procedures and improved pulmonary function were observed in patients with traction. The prevalence of traction-related complications was 22% and three cases of neurologic complication related to traction were noted. The prevalence of total complications related to surgery was 32% and that of neurologic complications was 1%.

CONCLUSION

Partial correction could be achieved preoperatively with halo-gravity traction, and it may help decrease aggressive procedures, improve preoperative pulmonary function, and reduce neurologic complications. However, traction could not increase preoperative flexibility or final correction. Traction-related complications, although usually not severe, were not rare.

Osteogenesis imperfecta

Osteogenesis imperfecta is a phenotypically and molecularly heterogeneous group of inherited connective tissue disorders that share similar skeletal abnormalities causing bone fragility and deformity. Previously, the disorder was thought to be an autosomal dominant bone dysplasia caused by defects in type I collagen, but in the past 10 years discoveries of novel (mainly recessive) causative genes have lent support to a predominantly collagen-related pathophysiology and have contributed to an improved understanding of normal bone development. Defects in proteins with very different functions, ranging from structural to enzymatic and from intracellular transport to chaperones, have been described in patients with osteogenesis imperfecta. Knowledge of the specific molecular basis of each form of the disorder will advance clinical diagnosis and potentially stimulate targeted therapeutic approaches. In this Seminar, together with diagnosis, management, and treatment, we describe the defects causing osteogenesis imperfecta and their mechanism and interrelations, and classify them into five groups on the basis of the metabolic pathway compromised, specifically those related to collagen synthesis, structure, and processing; post-translational modification; folding and cross-linking; mineralisation; and osteoblast differentiation.

Roentgenographic Evaluation of the Spine in Patients With Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is a hereditary connective tissue disorder that leads to bone weakness and deformities, especially in the spine, which can lead to poor outcomes.The aim of this study was to find patterns and risk factors in spinal deformities in patients with OI.In a retrospective study, 70 patients with OI were selected. Radiographs of the spine were evaluated. We observed the presence or absence of the following changes: biconcave vertebrae, chest and vertebral deformities, unilateral rib, and thoracolumbar kyphosis. The greater curve was considered the primary one, and the secondary curve considered compensatory.In the study sample, we observed that the patients' ages ranged between 7 and 50 years, with a mean equal to 13 years, and 76% had scoliosis. In 68% of cases the main curve in the thoracic region was observed with the convexity to the right.The following was found in patients with OI: scoliosis, biconcave vertebrae, vertebral and chest deformity, unilateral rib, and thoracolumbar kyphosis. The thoracolumbar kyphosis is highly associated with thoracic hypokyphosis in patients with OI.

Incisor Diastasis Associated With Halo Traction in an Osteogenesis Imperfecta Patient: Case Report

BACKGROUND

Scoliosis is a known manifestation of osteogenesis imperfecta (OI), which is characteristically severe in nature and interferes with the general health of these patients. Halo gravity traction (HGT) has been advocated as a preoperative treatment modality to ease the surgical risk while managing these patients with such fragile spines. Application of HGT to this patient population in itself carries a risk.

PURPOSE

The authors report an unusual complication of transient incisor diastasis in a patient with OI and scoliosis who was placed in perioperative HGT as a stage of scoliosis management.

RESULTS

The patient had a posterior instrumentation and spinal fusion for the scoliosis and the diastasis resolved after HGT removal.

CONCLUSIONS

Although HGT is a valuable preoperative option in the management of scoliosis in OI patients, it is necessary to assess the patient frequently for both common and rare complications of this procedure.

Complications associated with surgical repair of syndromic scoliosis

Background

There are a number of syndromes that have historically been associated with scoliosis e.g.: Marfan, Down, and Neurofibromatosis. These syndromes have been grouped together as one etiology of scoliosis, known as syndromic scoliosis. While multiple studies indicate that these patients are at high risk for perioperative complications, there is a paucity of literature regarding the collective complication rates and surgical needs of this population.

Methods

PubMed and Embase databases were searched for literature encompassing the surgical complications associated with the surgical management of patients undergoing correction of scoliosis in the syndromic scoliosis population. Following exclusion criteria, 24 articles were analyzed for data regarding these complications.

Results

The collective complication rates and findings of these articles were categorized based on specific syndrome. The rates and types of complications for each syndrome and the special needs of patients with each syndrome are discussed. Several complication trends of note were observed, including but not limited to the universally nearly high rate of wound infections (>5% in each group), high rate of pulmonary complications in patients with Rett syndrome (29.2%), high rate (>10%) of dural tears in Marfan and Ehlers-Danlos syndrome patients, high rate (>20%) of implant failure in Down and Prader-Willi syndrome patients, and high rate (>25%) of pseudarthrosis in Down and Ehlers-Danlos patients.

Conclusions

Though these syndromes have been classically grouped together under the umbrella term “syndromic,” there may be specific needs for patients with each of these ailments. Given the high rate of complications, further research is necessary to understand the unique needs for each of these patient groups in the preoperative, intraoperative, and postoperative settings.

Osteogenesis imperfecta: diagnosis and treatment

Osteogenesis imperfecta (OI) is a genetic bone fragility disorder characterized by low bone mass, skeletal deformity, and variable short stature. OI is predominantly caused by dominant mutations affecting type 1 collagen synthesis, with a number of other genes implicated in OI over recent years. The clinical severity of OI can vary greatly, even within families who share a common mutation. Optimal management of OI requires a multidisciplinary approach involving pediatrician, endocrinologist (bone and mineral physician), rehabilitation specialist, orthopedic surgeon, dentist, geneticist, social worker/psychologist, physiotherapist, and occupational therapist. Bisphosphonate therapy remains the mainstay of medical treatment in OI and has been shown to decrease bone pain, enhance well-being, improve muscle strength and mobility and decrease fracture incidence. Novel therapies are beginning to emerge as more is understood about the signaling pathways involved in bone formation. The following summarizes the diagnosis, genetic heterogeneity and management of OI in pediatric practice.

The surgical treatment method for an adult posttraumatic thoracolumbar kyphosis patient with osteogenesis imperfecta

Osteogenesis imperfecta (OI) is an inheritable bone disorder characterized by osseous fragility and ligamentous laxity. It is sometimes difficult to obtain bone union in patients with OI. The purpose of this report is to present a rare case of posttraumatic kyphosis due to a L1 burst fracture in a patient with OI, and to discuss how to treat it to achieve an adequate correction and circumferential fusion. The patient was a 29-year-old man with OI (Sillence type-IA) who had sustained an L1 fracture when he dived head first into a river. After 3 months of conservative therapy with a body cast, he showed disability at work because of his persistent low back pain and fatigue in his whole back. He showed no neurological disorder. Diagnostic imaging revealed localized kyphotic deformity at L1. Therefore, lumbar lordosis and thoracic kyphosis worsened. Anterior release and fusion, and posterior fusion were conducted. Three months after surgical treatment, circumferential fusion was obtained. His low back pain and fatigue in the whole back disappeared, and he could resume work without any difficulty. From the bone union standpoint, the surgical strategy for spinal correction in OI patients is still controversial because of the intractableness of bone union and fragility of the bone itself. The authors achieved circumferential union using anterior fusion and posterior fusion, in which wide bone bed is available owing to spared posterior elements of the spinal column.

Osteogenesis imperfecta in a pediatric surgical center in dakar, senegal: clinical and radiological aspects

INTRODUCTION

Osteogenesis imperfecta presents with a set of constitutional disorders of varying severity, genetically determined and characterized by an abnormal production of collagen and matrix of the bone leading to bone fragility responsible for multiple fractures and many skeletal deformities. The aim of our study was to analyze the clinical and radiological aspects of the pathology.

PATIENTS AND METHODS

This was a retrospective study of 10 cases of children with osteogenesis imperfecta who consulted the Pediatric Surgery Unit of the University Center Aristide Le Dantec Hospital over a period of 6 years. The parameters analyzed were the reasons for consultation, physical examination findings and findings on standard radiographs. After collecting all the data, children were divided according to the classification of Silence and Glorieux.

RESULTS

Pain was the reason for consultation in eight children. The saber blade deformity of the legs was found in nine children. Physical examination found tenderness in 80% of cases. Blue sclera was found in one child. The teeth were normal in eight patients. Standard radiographs showed an osteopenic skeleton with multiple fractures (3.7 fractures on the average) associated with vicious callus formation and deformity. According to the classification of Silence and Glorieux, six children were type VI, two children type IV, a child type III and one type I.

CONCLUSION

Osteogenesis imperfecta is a rare disease. In our environment, the diagnosis is made late - a stage associated with deformity. Of these, the occurrence of sabber deformity of the lower limbs is the most common. Radiological aspects are dominated by vicious callus formation, deformed bones and osteopenia. Moderate forms are predominant. Parents need to be educated about the risk of repeat fractures and the need to present deformed children to hospital early.

New perspectives on osteogenesis imperfecta

A new paradigm has emerged for osteogenesis imperfecta as a collagen-related disorder. The more prevalent autosomal dominant forms of osteogenesis imperfecta are caused by primary defects in type I collagen, whereas autosomal recessive forms are caused by deficiency of proteins which interact with type I procollagen for post-translational modification and/or folding. Factors that contribute to the mechanism of dominant osteogenesis imperfecta include intracellular stress, disruption of interactions between collagen and noncollagenous proteins, compromised matrix structure, abnormal cell-cell and cell-matrix interactions and tissue mineralization. Recessive osteogenesis imperfecta is caused by deficiency of any of the three components of the collagen prolyl 3-hydroxylation complex. Absence of 3-hydroxylation is associated with increased modification of the collagen helix, consistent with delayed collagen folding. Other causes of recessive osteogenesis imperfecta include deficiency of the collagen chaperones FKBP10 or Serpin H1. Murine models are crucial to uncovering the common pathways in dominant and recessive osteogenesis imperfecta bone dysplasia. Clinical management of osteogenesis imperfecta is multidisciplinary, encompassing substantial progress in physical rehabilitation and surgical procedures, management of hearing, dental and pulmonary abnormalities, as well as drugs, such as bisphosphonates and recombinant human growth hormone. Novel treatments using cell therapy or new drug regimens hold promise for the future.

Management of acute cervical compression fractures in two patients with osteogenesis imperfecta

STUDY DESIGN

We report 2 cases of acute cervical compression fracture in patients with osteogenesis imperfecta (OI). In case 1, a 15-year-old girl with an acute C6 compression fracture and additional fractures of the posterior elements underwent a C6 corpectomy and instrumented posterior fusion. In case 2, a 46-year-old man with a C7 compression fracture was managed nonoperatively.

OBJECTIVE

To illustrate a subset of possible acute subaxial cervical fractures in OI patients and to describe the feasibility of performing a combined anterior/posterior cervical decompression and fusion in an OI patient.

SUMMARY OF BACKGROUND DATA

OI is a rare genetic collagen disorder that is characterized by bone fragility and ligamentous laxity. Spinal complications associated with this disease included scoliosis, thoracolumbar compression fractures, and other spinal fractures, cervical spondyloptosis, and basilar invagination. There is limited literature that addresses the management of acute cervical spine fractures in OI patients.

METHODS

In case 1, the patient was initially treated with a Minerva brace. Nonoperative management was abandoned when a progressive kyphotic deformity developed. A C6 corpectomy and placement of a fibular strut allograft was followed by a C4-C7 posterior fusion with sublaminar wiring and rods. In case 2, the patient was managed nonoperatively with a rigid cervical collar alone.

RESULTS

In case 1, the patient made a prompt recovery, and on 12-month follow-up has maintained alignment. In case 2, the patient maintained normal alignment without need for surgical intervention.

CONCLUSION

A combined anterior/posterior decompression and fusion of the subaxial cervical spine is feasible in the fragile OI population. Moreover, certain isolated compression fractures of the subaxial cervical spine in this same patient population may be managed nonoperatively.

Current and emerging treatments for the management of osteogenesis imperfecta

Osteogenesis imperfecta (OI) is the most common bone genetic disorder and it is characterized by bone brittleness and various degrees of growth disorder. Clinical severity varies widely; nowadays eight types are distinguished and two new forms have been recently described although not yet classified. The approach to such a variable and heterogeneous disease should be global and therefore multidisciplinary. For simplicity, the objectives of treatment can be reduced to three typical situations: the lethal perinatal form (type II), in which the problem is survival at birth; the severe and moderate forms (types III-IX), in which the objective is 'autonomy'; and the mild form (type I), in which the aim is to reach 'normal life'. Three types of treatment are available: non-surgical management (physical therapy, rehabilitation, bracing and splinting), surgical management (intramedullary rod positioning, spinal and basilar impression surgery) and medical-pharmacological management (drugs to increase the strength of bone and decrease the number of fractures as bisphosphonates or growth hormone, depending on the type of OI). Suggestions and guidelines for a therapeutic approach are indicated and updated with the most recent findings in OI diagnosis and treatment.

Osteogenesis imperfecta: questions and answers

PURPOSE OF REVIEW

Considerable attention has recently been focused on the pathogenesis, diagnosis and treatment of osteogenesis imperfecta. Two new genes have been defined in patients with recessive severe or lethal osteogenesis imperfecta types. Diagnostic concerns involve testing procedures, either skin biopsies or DNA analysis. Bisphosphonates have been accepted as 'standard of care' for children with osteogenesis imperfecta. However, questions remain as to the selection of patients for treatment, effectiveness in fracture prevention, which bisphosphonates should be used and the duration of treatment. Orthopedic intervention occurs on several levels: including the immediate treatment of fractures, the treatment of scoliosis and the use of intramedullary rods.

RECENT FINDINGS

The discovery of mutations involving CRTAP and LEPRE1 genes in severe/lethal and recessively inherited osteogenesis imperfecta has provided partial answers to questions about 'other' osteogenesis imperfecta genes in patients with an osteogenesis imperfecta phenotype but no COL1A1 and COL1A2 mutations. Current experience suggests that DNA analysis is a better test for diagnosis as compared with dermal biopsy. There are no standardized guidelines for initiating bisphosphonate treatment in children. Recent data suggest either intravenous or oral bisphosphonates are effective, but differences exist between different bisphosphonates. Two recent reports document the paucity of evidence-based data regarding the effectiveness of bisphosphonate treatment in fracture prevention.

SUMMARY

This report will update the medical and orthopedic approaches to care for children with osteogenesis imperfecta.

Pelvic fracture after scoliosis surgery in osteogenesis imperfecta: a case report

Literature, describing scoliosis in patients of osteogenesis imperfecta (OI), favors operative treatment as soon as possible in the form of fixation with instrumentation and fusion to prevent curve progress and pulmonary function deterioration. There are various complications associated with the treatment of scoliosis in OI before, during, and after surgery because of poor bone quality in such patients. We presented a case report of stress-induced transverse fracture of both iliac wings after scoliosis surgery in a 16-year-old girl with OI, who was treated conservatively. Owing to unusual symptoms and continuous dull pain in her back, the diagnosis was delayed during which the conditions made her life miserable. This report also suggests that a stress fracture should be on high suspicion in OI patients when they present with minor difference in the nature of pain.

Ostéogenèse imparfaite

Osteogenesis imperfecta is a genetic disorder that causes increased bone fragility and low bone mass. Osteogenesis imperfecta is a rare disease: its estimated prevalence is between 1/10000 and 1/20000 persons. The severity of skeletal and extraskeletal manifestations varies widely. Most patients have a mutation in one of the 2 genes that encode the alpha chains of collagen type I. Treatment with bisphosphonates has produced clear improvements, especially for growing children. The appropriate regimen for bisphosphonate treatment remains to be determined: the goal is to find the lowest effective dose to minimize side effects. Treatment of osteogenesis imperfecta must be multidisciplinary, including physicians, surgeons, and physical therapists.

Correlation of scoliotic curvature with Z-score bone mineral density and body mass index in patients with osteogenesis imperfecta

STUDY DESIGN

A cross-sectional radiographic and clinical study of patients with osteogenesis imperfecta (OI).

OBJECTIVE

To determine demographic, anthropometric, and radiographic parameters that correlate with development of scoliosis in patients with OI.

SUMMARY OF BACKGROUND DATA

Despite the relatively high prevalence of scoliosis in patients with OI and its clinical significance, little is known about demographic and anthropometric parameters that correlate with the development of scoliosis.

METHODS

Clinical records and spinal radiographs of 19 OI patients were reviewed. There were 5 male and 14 female patients with an average age of 14.2 years (range, 4-20 years). Seven patients were Sillence Type I and 12 patients were Type III. The Cobb angle of scoliosis was analyzed for correlations with age, body mass index (BMI), physical capability, leg-length discrepancy, Z-score bone mineral density (BMD) in the lumbar spine, thoracic kyphosis angle, and lumbar lordosis angle by using Pearson's correlation method. A probability of less than 0.05 was considered statistically significant.

RESULTS

The average Cobb angle of scoliosis was 25.2 degrees (range, 5 degrees-108 degrees) including 6 patients with an angle of > or = 30 degrees. Five of these 6 patients were Sillence Type III. Statistical analysis showed a significant positive correlation between the extent of scoliosis and BMI, as well as leg-length discrepancy. There was an inverse correlation between the extent of scoliotic curvature and the Z-score BMD as well as the thoracic kyphosis angle.

CONCLUSION

The correlation of scoliosis with the Z-score BMD and BMI supports the pathology of scoliosis based on vertebral fragility. Proper management of BMD and BMI may have therapeutic value in delaying the progression of scoliosis in patients with osteogenesis imperfecta.

All Pedicle Screw Fixation Technique in Correcting Severe Kyphoscoliosis in an Osteogenesis Imperfecta Patient

Spinal deformity in patients with osteogenesis imperfecta demonstrates a high prevalence. The surgical treatment of this problem had numerous difficulties, which included breakage of bone, dislodgement of implants, and late loss of correction. We reported the correction of severe kyphoscoliosis in a patient with osteogenesis imperfecta using 3-rod all pedicle screw fixation technique. In this case, the 2 main goals of spinal operation, stabilization and correction of spinal curvatures, were achieved. The Cobb angles of scoliosis and thoracic kyphosis were corrected from 110 degrees to 68 degrees and from 107 degrees to 39 degrees, respectively. One and a half years after the operation, spinal radiographs showed no loss of correction, either on coronal or sagittal planes. The predicted forced vital capacity, predicted forced expiratory volume in 1 second and vital capacity of the lung of the patient had improved 2-fold. The usage of pedicle screw, with its conical core and cylindrical thread design, and 3-rod technique in fixation, together with cyclic intravenous bisphosphonate administration and halo-gravity traction preoperatively, contributed to the success in this case.