Challenges of Fracture Management for Adults With Osteogenesis Imperfecta

Assessing the Safety and Efficacy of Tranexamic Acid Usage in Osteogenesis Imperfecta Patients

BACKGROUND

Osteogenesis Imperfecta (OI) usually causes an increased fracture burden and bone deformity, with subsequent operations common. In addition to skeletal manifestations, there is a potential increase in bleeding susceptibility due to the increased frequency of orthopedic procedures, warranting investigation into methods to mitigate this risk. This study aims to evaluate the safety and efficacy of tranexamic acid (TXA) usage to reduce intraoperative blood loss in children with OI. We want to assess the potential benefits, risks, and complications involved with TXA use in this patient population.

METHODS

TXA-receiving patients (cases) were matched 1:1 with non-TXA-receiving controls on the following criteria: age within 2 years, bone category, and OI Type. Descriptive statistics were used to summarize the data. Fisher Exact Test was performed to compare transfusion status between groups. A Wilcoxon Rank Sum test was performed to assess differences between the groups in days of stay, length of surgery, and estimated blood loss (EBL). All analyses were conducted using SAS version 9.4. P <0.05 was considered statistically significant.

RESULTS

Our TXA-receiving population of 30 patients consisted of 11 females and 19 males. One patient was OI type I, 13 were OI type III, 14 were OI type IV, and 2 were categorized as Other (not Type I through Type IV). We found a significant difference in transfusion status ( P =0.02), with zero TXA patients requiring a transfusion compared with 20% of the control cases. There is also a significant difference in median EBL ( P =0.0004) between groups, with TXA patients having decreased intraoperative EBL (20 vs. 62.5 mL). There was also a difference in median days of postoperative stay between TXA-receiving and non-TXA-receiving patients ( P =0.001; 2.6 vs. 4 d).

CONCLUSIONS

Our study concluded that TXA use in OI patients is associated with lower perioperative transfusions and intraoperative blood loss rates. These results support the standard usage of TXA in these patients to reduce intraoperative blood loss.

LEVEL OF EVIDENCE

Level III.

Anesthetic and Surgical Considerations in Osteogenesis Imperfecta: A Case Report of Mandible Fracture Management

Background

Osteogenesis imperfecta (OI) is a rare metabolic bone disorder in which collagen production is impaired. Patients have brittle bones that are prone to fracture with minor trauma. Whereas most of the fractures occur in the spine and extremities, fractures of the craniofacial bones are less common.

Methods

This report describes the management of a 14-year-old boy with OI type 1 who sustained mandible fractures from an assault. Management consisted of open reduction and internal fixation of the parasymphyseal and angle fractures and closed reduction and mandibulomaxillary fixation of the subcondylar fracture.

Results

Surgery resulted in return of premorbid occlusion and good jaw function. Removal of plates and screws was performed 10 months later without incident.

Conclusions

This case report discusses the unique anesthetic, surgical, and postoperative considerations for managing mandible fractures in patients with OI.

Addition of a Distal Femur Locking Plate to Augment Total Hip Arthroplasty in Osteogenesis Imperfecta: A Case Report

CASE

We present a 55-year-old woman with osteogenesis imperfecta (OI) who underwent total hip arthroplasty (THA). She developed aseptic loosening of the femoral stem and was revised to a longer stem necessitating 2 osteotomies because of the proximal femur varus deformity. This was complicated by implant subsidence. She ultimately required another revision adding a distal femur locking plate to augment construct stability.

CONCLUSION

The abnormal anatomy and suboptimal bone properties in patients with OI present unique challenges when performing THA. More aggressive prophylactic fixation to improve construct stability and prevent fracture may be necessary in this patient population.

[The experience in surgical treatment of hearing loss in Van der Hoeve patients]

Despite the rare incidence of Van der Hoeve syndrome in the population, the problem of treating patients with this type of disease is important for modern science and practical medicine. One of the most difficult tasks in treatment is to improve the quality of hearing. The world scientific community lacks a unified coordinated approach to the methods of auditory rehabilitation of patients with Van der Hoeve syndrome. In recent years, there have been tendencies in the scientific literature to increase the frequency of non-surgical approach due to the low incidence of satisfactory results of surgical treatment. In this regard, we present our experience of complex treatment of patients with Van der Hove syndrome, based on the use of modern surgical technologies and conservative pathogenetically substantiated treatment.

Histone demethylase LSD1 is critical for endochondral ossification during bone fracture healing

Bone fracture is repaired predominantly through endochondral ossification. However, the regulation of endochondral ossification by key factors during fracture healing remains largely enigmatic. Here, we identify histone modification enzyme LSD1 as a critical factor regulating endochondral ossification during bone regeneration. Loss of LSD1 in Prx1 lineage cells severely impaired bone fracture healing. Mechanistically, LSD1 tightly controls retinoic acid signaling through regulation of Aldh1a2 expression level. The increased retinoic acid signaling in LSD1-deficient mice suppressed SOX9 expression and impeded the cartilaginous callus formation during fracture repair. The discovery that LSD1 can regulate endochondral ossification during fracture healing will benefit the understanding of bone regeneration and have implications for regenerative medicine.

Total hip arthroplasty for Protrusio Acetabuli in a young adult Osteogenesis Imperfecta features and Marfanoid features: A case report

Osteogenesis Imperfecta is an inherited disease characterized by easily-broken bones, which manifests as multiple fractures with minimal trauma, joint laxity, sclerosis, blue sclera, and several other manifestations. Protrusio acetabuli is defined as the displacement of the femoral head so that it lies medial to the ischioilial line. In a skeletally mature patient with both Marfan syndrome and PA, an eventual hip arthroplasty is the only method available for correction of the deformity. However, in patients with Osteogenesis Imperfecta and PA, THA remains a controversial treatment. A 14-year-old male patient diagnosed with Osteogenesis Imperfecta Type 1A presented to the orthopedic surgery clinic complaining of groin pain of 1-year duration radiating to the thigh and knee. The patient was found to have radiologic signs of protrusion acetabuli. The patient was started with bisphosphonate and after medical failure, underwent a Total Hip Arthroplasty (THA). In post-operative follow-ups, the patient had relief of pain and was able to walk more comfortably and without a lump. The previously operated hip was examined and showed no signs of infection, dislocation, or fracture. Radiographic studies show no evidence of prosthesis failure or loosening with valgus position of the femoral stem and neutral acetabular angle. Ten years after the primary arthroplasty, the previously operated hip had maintained its stability and had no related complications. Despite the controversy surrounding the treatment of younger patients with hip failure, using total hip arthroplasty, this patient exhibited excellent results, with vast improvement in their symptoms and stability.

Management of Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is the term used to describe a group of rare inherited skeletal disorders characterized by a greatly increased risk of fragility fractures (1). Mutations in several genes can cause OI but the condition is most commonly caused by mutations of COLIA1 or COL1A2 resulting in the production of collagen which is abnormal or present in reduced amounts. Fractures in OI are particularly common during childhood but the elevated fracture risk continues throughout life. Bone mineral density (BMD) can be reduced in OI but the magnitude of increase in fracture risk is far greater than can be accounted for by low BMD, highlighting that a key mechanism of bone fragility is reduced bone quality due to defects of bone matrix and mineralization. A multidisciplinary approach is needed to optimize management of OI, with input from physicians, orthopedic surgeons, physiotherapists, occupational therapists, and other allied health professionals. Orthopedic surgery plays a key role both in the fixation of fractures and in the correction of limb deformities. Bisphosphonates have been widely used in the treatment of children and adults with OI. Although there is good evidence that they increase BMD, it is uncertain to what extent they reduce fracture risk. Clinical trials of bone anabolic drugs such as teriparatide and inhibitors of sclerostin have also been studied; although they increase BMD, studies of these agents have not been powered to look at fracture endpoints. Various other treatment modalities including denosumab, and cell therapy have been explored but haven't gained acceptance in routine clinical practice. There have been huge advances in understanding the pathogenesis of OI but these have not been accompanied by advances in treatment. This signals need for well-designed clinical trials with fracture endpoints in OI, both with existing agents and with the newer therapeutic agents that are now starting to emerge.

Pauwels Osteotomy for Femoral Neck Nonunion in Two Adult Siblings with Osteogenesis Imperfecta

This is a retrospective review of two adult siblings with osteogenesis imperfecta (OI) type III (according to Sillence classification), who sustained a spontaneous femoral neck fracture and subsequent nonunion. The diagnosis of OI in these two patients was made based on clinical, radiological and genetic findings. The fracture was most likely caused by femoroacetabular impingement secondary to OI induced acetabular protrusio. A valgus osteotomy according to Pauwels'principles and fixation of the osteotomy and nonunion with a locking plate resulted in healing despite compromised bone quality and limited bone stock. Long-term follow up (4.5 years and 6.5 years, respectively) is provided.

When treating this difficult problem, improving the mechanobiological environment and decreasing the femoroacetabular impingement by a Pauwels type osteotomy should be considered.

Using humeral nail for surgical reconstruction of femur in adolescents with osteogenesis imperfecta

Osteogenesis imperfecta (OI) is a rare inherited connective tissue disorder caused by mutation of collagen which results in a wide spectrum of clinical manifestations including long bone fragility fractures and deformities. While the treatment for these fractures was recommended as using intramedullary fixation for minimizing stress concentration, the selection of the best implant in the adolescent OI patients for the surgical reconstruction of femur was still problematic, due to anatomy distortion and implant availability. We are reporting the surgical modification by using a humeral nail for femoral fixation in three adolescent OI patients with favorable outcomes.