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FDA approves subcutaneous tocilizumab for polyarticular JIA
in patients aged 2 years and older, according to a statement released May 14 by the drug’s manufacturer, Genentech.
While a intravenous formulation of the treatment was approved in 2013, this new delivery method may help make this treatment more accessible to the approximately 30 in every 100,000 children affected by PJIA, according to the release.
Doses were determined based on weight. Patients under 30 kg received 162 mg of tocilizumab every 3 weeks, while those 30 kg and over received 162 mg tocilizumab every 2 weeks.
Overall, safety of the subcutaneous delivery method was consistent with the IV study, as was the efficacy of the drug, the company said. A total of 28.8% of patients reported injection-site reactions – all moderate – and 15.4% reported neutrophil counts below 1 x 109 per liter.Tocilizumab can be taken either by itself or with methotrexate.
in patients aged 2 years and older, according to a statement released May 14 by the drug’s manufacturer, Genentech.
While a intravenous formulation of the treatment was approved in 2013, this new delivery method may help make this treatment more accessible to the approximately 30 in every 100,000 children affected by PJIA, according to the release.
Doses were determined based on weight. Patients under 30 kg received 162 mg of tocilizumab every 3 weeks, while those 30 kg and over received 162 mg tocilizumab every 2 weeks.
Overall, safety of the subcutaneous delivery method was consistent with the IV study, as was the efficacy of the drug, the company said. A total of 28.8% of patients reported injection-site reactions – all moderate – and 15.4% reported neutrophil counts below 1 x 109 per liter.Tocilizumab can be taken either by itself or with methotrexate.
in patients aged 2 years and older, according to a statement released May 14 by the drug’s manufacturer, Genentech.
While a intravenous formulation of the treatment was approved in 2013, this new delivery method may help make this treatment more accessible to the approximately 30 in every 100,000 children affected by PJIA, according to the release.
Doses were determined based on weight. Patients under 30 kg received 162 mg of tocilizumab every 3 weeks, while those 30 kg and over received 162 mg tocilizumab every 2 weeks.
Overall, safety of the subcutaneous delivery method was consistent with the IV study, as was the efficacy of the drug, the company said. A total of 28.8% of patients reported injection-site reactions – all moderate – and 15.4% reported neutrophil counts below 1 x 109 per liter.Tocilizumab can be taken either by itself or with methotrexate.
Multiple analgesia options for kids with acute pain
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
EXPERT ANALYSIS FROM PAS 2018
Parents smoke less tobacco, more cannabis at home
Children are increasingly less likely to be exposed to secondhand cigarette smoke in the home, but cannabis seems to be picking up some of the slack, according to Renee D. Goodwin, PhD, and her associates.
Using a study population of 169,259 adults with data available from the National Survey on Drug Use and Health, the researchers found that from 2002 to 2015, the prevalence of parents with children in the home who were also current smokers dropped from 27.6% to 20.2%. By contrast, the rate of cannabis usage increased from 4.9% to 6.8% over the same time period. Overall, the rate of children living in a home with secondhand smoke fell from 29.7% to 23.5%.
“Public health efforts that have shown success in decreasing exposure to STS [secondhand tobacco smoke] in the home may be complicated by increased use of other smoked products, such as cannabis. Parents may benefit from education about protecting children from marijuana products, paraphernalia, waste, and smoke,” the investigators concluded.
SOURCE: Goodwin RD et al. Pediatrics. 2018 May 14. doi: 10.1542/peds.2017-3506.
Children are increasingly less likely to be exposed to secondhand cigarette smoke in the home, but cannabis seems to be picking up some of the slack, according to Renee D. Goodwin, PhD, and her associates.
Using a study population of 169,259 adults with data available from the National Survey on Drug Use and Health, the researchers found that from 2002 to 2015, the prevalence of parents with children in the home who were also current smokers dropped from 27.6% to 20.2%. By contrast, the rate of cannabis usage increased from 4.9% to 6.8% over the same time period. Overall, the rate of children living in a home with secondhand smoke fell from 29.7% to 23.5%.
“Public health efforts that have shown success in decreasing exposure to STS [secondhand tobacco smoke] in the home may be complicated by increased use of other smoked products, such as cannabis. Parents may benefit from education about protecting children from marijuana products, paraphernalia, waste, and smoke,” the investigators concluded.
SOURCE: Goodwin RD et al. Pediatrics. 2018 May 14. doi: 10.1542/peds.2017-3506.
Children are increasingly less likely to be exposed to secondhand cigarette smoke in the home, but cannabis seems to be picking up some of the slack, according to Renee D. Goodwin, PhD, and her associates.
Using a study population of 169,259 adults with data available from the National Survey on Drug Use and Health, the researchers found that from 2002 to 2015, the prevalence of parents with children in the home who were also current smokers dropped from 27.6% to 20.2%. By contrast, the rate of cannabis usage increased from 4.9% to 6.8% over the same time period. Overall, the rate of children living in a home with secondhand smoke fell from 29.7% to 23.5%.
“Public health efforts that have shown success in decreasing exposure to STS [secondhand tobacco smoke] in the home may be complicated by increased use of other smoked products, such as cannabis. Parents may benefit from education about protecting children from marijuana products, paraphernalia, waste, and smoke,” the investigators concluded.
SOURCE: Goodwin RD et al. Pediatrics. 2018 May 14. doi: 10.1542/peds.2017-3506.
FROM PEDIATRICS
MSC product can treat refractory GVHD
MONTRÉAL—Results from a phase 3 trial suggest a mesenchymal stem cell (MSC) product can treat steroid-refractory, acute graft-versus-host disease (GVHD) in children.
The product, remestemcel-L (MSC-100-IV), produced an overall response rate of 69% at day 28, with complete resolution of GVHD in 29% of patients.
Adverse events (AEs) in this trial were consistent with the known safety profile of remestemcel-L.
Joanne Kurtzberg, MD, of Duke University Medical Center in Durham, North Carolina, presented these results at ISCT 2018.
The trial was sponsored by Mesoblast International Sàrl, the company developing remestemcel-L.
Remestemcel-L consists of human MSCs derived from donor bone marrow and expanded in culture.
Patients
The trial enrolled 55 patients who had acute GVHD and had failed to respond to steroid treatment. This was defined as progression within 3 days or no improvement within 7 days of consecutive treatment with at least 2 mg/kg/day of methylprednisolone or an equivalent product.
The patients had a median age of 7.6 years (range, 0.6 years to 17.9 years) at baseline, and 64% were male. Underlying diseases include acute myeloid leukemia (32.7%), acute lymphoblastic leukemia (21.8%), anemia (9.1%), chronic myeloid leukemia (7.3%), sickle cell disease (5.5%), juvenile myelomonocytic leukemia (3.6%), myelodysplastic syndromes (3.6%), and “other” disease (16.4%).
Most patients (87%) had received myeloablative conditioning, most (76%) had an unrelated donor, and roughly half (51%) received an HLA-mismatched transplant.
Fifty-five percent of patients received a bone marrow transplant, 25% received peripheral blood stem cells, and 20% received cord blood.
Forty-seven percent of patients had grade D GVHD at baseline, 42% had grade C, and 11% had grade B. Thirty-six percent of patients had multi-organ involvement (all with lower gastrointestinal), 38% had lower gastrointestinal involvement only, and 26% had skin involvement only.
Results
Fifty-four patients were treated with remestemcel-L. They received 8 injections over 4 weeks (twice weekly), consisting of 2 million cells per kg per injection.
The overall response rate at day 28 was 69%. Twenty-nine percent of patients achieved a complete response, defined as resolution of acute GVHD in all involved organs.
Forty percent of patients achieved a partial response, defined as organ-level improvement of at least one stage without worsening of any other organ.
All patients reported at least one treatment-emergent AE, and 61% had serious treatment-emergent AEs. The most common of these were infection (33%) and respiratory events (20%).
Four patients withdrew from the trial before day 100. One patient couldn’t receive treatment, 1 withdrew due to an AE (somnolence), 1 had parental consent withdrawn, and 1 was taken off study by the principal investigator.
There were 11 on-study deaths, but none were considered related to remestemcel-L. Eight deaths were due to infection, 1 due to GVHD progression, and 2 due to primary cancer relapse.
The day-100 survival analysis is pending.
MONTRÉAL—Results from a phase 3 trial suggest a mesenchymal stem cell (MSC) product can treat steroid-refractory, acute graft-versus-host disease (GVHD) in children.
The product, remestemcel-L (MSC-100-IV), produced an overall response rate of 69% at day 28, with complete resolution of GVHD in 29% of patients.
Adverse events (AEs) in this trial were consistent with the known safety profile of remestemcel-L.
Joanne Kurtzberg, MD, of Duke University Medical Center in Durham, North Carolina, presented these results at ISCT 2018.
The trial was sponsored by Mesoblast International Sàrl, the company developing remestemcel-L.
Remestemcel-L consists of human MSCs derived from donor bone marrow and expanded in culture.
Patients
The trial enrolled 55 patients who had acute GVHD and had failed to respond to steroid treatment. This was defined as progression within 3 days or no improvement within 7 days of consecutive treatment with at least 2 mg/kg/day of methylprednisolone or an equivalent product.
The patients had a median age of 7.6 years (range, 0.6 years to 17.9 years) at baseline, and 64% were male. Underlying diseases include acute myeloid leukemia (32.7%), acute lymphoblastic leukemia (21.8%), anemia (9.1%), chronic myeloid leukemia (7.3%), sickle cell disease (5.5%), juvenile myelomonocytic leukemia (3.6%), myelodysplastic syndromes (3.6%), and “other” disease (16.4%).
Most patients (87%) had received myeloablative conditioning, most (76%) had an unrelated donor, and roughly half (51%) received an HLA-mismatched transplant.
Fifty-five percent of patients received a bone marrow transplant, 25% received peripheral blood stem cells, and 20% received cord blood.
Forty-seven percent of patients had grade D GVHD at baseline, 42% had grade C, and 11% had grade B. Thirty-six percent of patients had multi-organ involvement (all with lower gastrointestinal), 38% had lower gastrointestinal involvement only, and 26% had skin involvement only.
Results
Fifty-four patients were treated with remestemcel-L. They received 8 injections over 4 weeks (twice weekly), consisting of 2 million cells per kg per injection.
The overall response rate at day 28 was 69%. Twenty-nine percent of patients achieved a complete response, defined as resolution of acute GVHD in all involved organs.
Forty percent of patients achieved a partial response, defined as organ-level improvement of at least one stage without worsening of any other organ.
All patients reported at least one treatment-emergent AE, and 61% had serious treatment-emergent AEs. The most common of these were infection (33%) and respiratory events (20%).
Four patients withdrew from the trial before day 100. One patient couldn’t receive treatment, 1 withdrew due to an AE (somnolence), 1 had parental consent withdrawn, and 1 was taken off study by the principal investigator.
There were 11 on-study deaths, but none were considered related to remestemcel-L. Eight deaths were due to infection, 1 due to GVHD progression, and 2 due to primary cancer relapse.
The day-100 survival analysis is pending.
MONTRÉAL—Results from a phase 3 trial suggest a mesenchymal stem cell (MSC) product can treat steroid-refractory, acute graft-versus-host disease (GVHD) in children.
The product, remestemcel-L (MSC-100-IV), produced an overall response rate of 69% at day 28, with complete resolution of GVHD in 29% of patients.
Adverse events (AEs) in this trial were consistent with the known safety profile of remestemcel-L.
Joanne Kurtzberg, MD, of Duke University Medical Center in Durham, North Carolina, presented these results at ISCT 2018.
The trial was sponsored by Mesoblast International Sàrl, the company developing remestemcel-L.
Remestemcel-L consists of human MSCs derived from donor bone marrow and expanded in culture.
Patients
The trial enrolled 55 patients who had acute GVHD and had failed to respond to steroid treatment. This was defined as progression within 3 days or no improvement within 7 days of consecutive treatment with at least 2 mg/kg/day of methylprednisolone or an equivalent product.
The patients had a median age of 7.6 years (range, 0.6 years to 17.9 years) at baseline, and 64% were male. Underlying diseases include acute myeloid leukemia (32.7%), acute lymphoblastic leukemia (21.8%), anemia (9.1%), chronic myeloid leukemia (7.3%), sickle cell disease (5.5%), juvenile myelomonocytic leukemia (3.6%), myelodysplastic syndromes (3.6%), and “other” disease (16.4%).
Most patients (87%) had received myeloablative conditioning, most (76%) had an unrelated donor, and roughly half (51%) received an HLA-mismatched transplant.
Fifty-five percent of patients received a bone marrow transplant, 25% received peripheral blood stem cells, and 20% received cord blood.
Forty-seven percent of patients had grade D GVHD at baseline, 42% had grade C, and 11% had grade B. Thirty-six percent of patients had multi-organ involvement (all with lower gastrointestinal), 38% had lower gastrointestinal involvement only, and 26% had skin involvement only.
Results
Fifty-four patients were treated with remestemcel-L. They received 8 injections over 4 weeks (twice weekly), consisting of 2 million cells per kg per injection.
The overall response rate at day 28 was 69%. Twenty-nine percent of patients achieved a complete response, defined as resolution of acute GVHD in all involved organs.
Forty percent of patients achieved a partial response, defined as organ-level improvement of at least one stage without worsening of any other organ.
All patients reported at least one treatment-emergent AE, and 61% had serious treatment-emergent AEs. The most common of these were infection (33%) and respiratory events (20%).
Four patients withdrew from the trial before day 100. One patient couldn’t receive treatment, 1 withdrew due to an AE (somnolence), 1 had parental consent withdrawn, and 1 was taken off study by the principal investigator.
There were 11 on-study deaths, but none were considered related to remestemcel-L. Eight deaths were due to infection, 1 due to GVHD progression, and 2 due to primary cancer relapse.
The day-100 survival analysis is pending.
Pain relievers, bed rest may be sufficient to manage PEH
Although skin biopsy and the “presence of deep dermal mixed infiltrate with abundant neutrophils surrounding eccrine sweat glands” is considered the preferred method for diagnosing palmoplantar eccrine hidradenitis (PEH), Paola Piccini, MD, and her colleagues at the University of Florence (Italy) caution that biopsy frequently is not needed.
In the days prior to the appearance of erythematous and painful nodules on the soles of his feet, a healthy 8-year-old boy sustained “thermal and mechanical trauma playing football and cycling,” that made walking difficult. The week prior to the injury, he had complained of diarrhea in the absence of fever.
Given results of testing and the patient’s overall good health, he received a diagnosis of PEH. Dr. Piccini and her colleagues chose not to biopsy the nodules because they typically resolve on their own within a few weeks. Instead, he was prescribed pain relievers and bed rest. Within 2 weeks, the nodules were completely healed, and no further relapse was reported, the authors noted in the Journal of Pediatrics.
All previous case studies cited in the literature reported complete resolution without treatment within 4 weeks, said Dr. Piccini and her colleagues. They added that correct diagnosis is key to avoiding inappropriate medical treatments given the benign course of PEH.
Common presenting risk factors tend to include local thermal and mechanical trauma plus intense physical activity and recent infection. It is these risk factors that cause rupture of the eccrine gland and resulting infiltration of neutrophils to the site.
Conditions that share common symptoms with PEH include erythema multiforme, nodular erythema, cellulitis, and viral infections.
No disclosures were noted.
SOURCE: Piccini, P et al. J. Pediatr. 2018. doi: 10.1016/j.peds.2018.03.017.
Although skin biopsy and the “presence of deep dermal mixed infiltrate with abundant neutrophils surrounding eccrine sweat glands” is considered the preferred method for diagnosing palmoplantar eccrine hidradenitis (PEH), Paola Piccini, MD, and her colleagues at the University of Florence (Italy) caution that biopsy frequently is not needed.
In the days prior to the appearance of erythematous and painful nodules on the soles of his feet, a healthy 8-year-old boy sustained “thermal and mechanical trauma playing football and cycling,” that made walking difficult. The week prior to the injury, he had complained of diarrhea in the absence of fever.
Given results of testing and the patient’s overall good health, he received a diagnosis of PEH. Dr. Piccini and her colleagues chose not to biopsy the nodules because they typically resolve on their own within a few weeks. Instead, he was prescribed pain relievers and bed rest. Within 2 weeks, the nodules were completely healed, and no further relapse was reported, the authors noted in the Journal of Pediatrics.
All previous case studies cited in the literature reported complete resolution without treatment within 4 weeks, said Dr. Piccini and her colleagues. They added that correct diagnosis is key to avoiding inappropriate medical treatments given the benign course of PEH.
Common presenting risk factors tend to include local thermal and mechanical trauma plus intense physical activity and recent infection. It is these risk factors that cause rupture of the eccrine gland and resulting infiltration of neutrophils to the site.
Conditions that share common symptoms with PEH include erythema multiforme, nodular erythema, cellulitis, and viral infections.
No disclosures were noted.
SOURCE: Piccini, P et al. J. Pediatr. 2018. doi: 10.1016/j.peds.2018.03.017.
Although skin biopsy and the “presence of deep dermal mixed infiltrate with abundant neutrophils surrounding eccrine sweat glands” is considered the preferred method for diagnosing palmoplantar eccrine hidradenitis (PEH), Paola Piccini, MD, and her colleagues at the University of Florence (Italy) caution that biopsy frequently is not needed.
In the days prior to the appearance of erythematous and painful nodules on the soles of his feet, a healthy 8-year-old boy sustained “thermal and mechanical trauma playing football and cycling,” that made walking difficult. The week prior to the injury, he had complained of diarrhea in the absence of fever.
Given results of testing and the patient’s overall good health, he received a diagnosis of PEH. Dr. Piccini and her colleagues chose not to biopsy the nodules because they typically resolve on their own within a few weeks. Instead, he was prescribed pain relievers and bed rest. Within 2 weeks, the nodules were completely healed, and no further relapse was reported, the authors noted in the Journal of Pediatrics.
All previous case studies cited in the literature reported complete resolution without treatment within 4 weeks, said Dr. Piccini and her colleagues. They added that correct diagnosis is key to avoiding inappropriate medical treatments given the benign course of PEH.
Common presenting risk factors tend to include local thermal and mechanical trauma plus intense physical activity and recent infection. It is these risk factors that cause rupture of the eccrine gland and resulting infiltration of neutrophils to the site.
Conditions that share common symptoms with PEH include erythema multiforme, nodular erythema, cellulitis, and viral infections.
No disclosures were noted.
SOURCE: Piccini, P et al. J. Pediatr. 2018. doi: 10.1016/j.peds.2018.03.017.
FROM THE JOURNAL OF PEDIATRICS
Key clinical point: Complete resolution within 4 weeks is common without treatment.
Major finding: .
Study details: Case study.
Disclosures: No disclosures were noted.
Source: Lund, E et al. Ped. Dermatol. 2018. doi: 10.1111/pde.13508.
CAZ-AVI appears safe, effective in pediatric complicated UTI, intra-abdominal infections
MADRID – Two randomized phase 2b trials show the combination of ceftazidime-avibactam (CAZ-AVI) is safe and effective in children with complicated intra-abdominal infections or complicated urinary tract infections (UTIs).
The combination already is approved for these conditions in adults, said John Bradley, MD, who presented the studies at the European Society of Clinical Microbiology and Infectious Diseases annual congress.
However, Pfizer, which recently acquired the drug combination from AstraZeneca as part of its small-molecule anti-infectives sell-off, intends to go for a pediatric approval for these two indications. The studies, which had secondary efficacy endpoints, will be used as part of the application package to the Food and Drug Administration and the European Medicines Agency, said Dr. Bradley, professor of clinical pediatrics at the University of California, San Diego.
“For those of you who take care of adults and use these drugs, this seems like old news, but those of us who take care of children can rejoice, because these are the first pediatric data presented. And – no surprise – the combination appears to be as safe and effective in children as it is in adults.”
Both studies concluded in late 2017. “We have the data locked and it’s being cleaned and soon will be submitted to regulatory agencies,” Dr. Bradley said. “However, we do not yet have approval so if you do use it, it will still be considered an off-label use until regulatory agencies work with the sponsor to achieve approval.”
Both studies were international, conducted in the United States, Europe, Russia, South Korea, Taiwan, and Turkey.
The first study included 83 children, mean age 10 years, who had complicated intra-abdominal infections precipitated by ruptured appendicitis. About 90% already had been treated with other antibiotics. In this trial, the CAZ-AVI combination was augmented with metronidazole, and compared to meropenem, in 72-hour infusions. The microbiologic test of cure was conducted at 8-15 days with a late follow-up at 20-36 days after the last infusion.
Most of the patents (83%) had an infective organism identified; it was most often Escherichia coli or Pseudomonas aeruginosa. All pathogens were susceptible to the study drugs.
Five children in the combination group experienced a serious adverse event. These included one case each of ileus, intestinal obstruction, large intestine perforation, renal colic, and urethra meatus stenosis. There was one case of ileus in the meropenem group.
There was one case of diarrhea in the combination group. There were three allergic reactions in each group (cough, pruritus, and rash). The meropenem group also had two cases of anemia.
At the test-of-cure point, clinical response was similar in the combination and meropenem groups, both in clinical evidence (93% vs. 95%) and microbiological response (90% vs. 95%) At last follow-up, 100% of each group was clinically cured. The microbiological cure rates were 90% and 95%, respectively.
Success for complicated UTI
The complicated UTI study was likewise good news for CAZ-AVI, this time without metronidazole. This study included 95 children, mean age 6 years, in the same globally gathered cohorts. All of the children were hospitalized; they were randomized to CAZ-AVI at age-specific doses or cefepime, less than 2,000 mg/infusion for 72 hours. The test of cure was conducted at 8-15 days with a late follow-up at 20-36 days after the last infusion.
Most patients (83%) had acute pyelonephritis. About a quarter had at least one complicating factor, including obstructive uropathies due to functional or anatomic abnormalities of the urogenital tract, recurrent UTI, vesicoureteral reflex, or intermittent catheterization. About 20% of the group had a urological abnormality and 40% had been on a systemic antibiotic in the 2 weeks before study entry.
The most common infective organism was E. coli, (92%) followed by Klebsiella pneumoniae, Proteus mirabilis, and Enterobacter cloacae.
Again, about half of each group had at least one adverse event. Serious adverse events occurred in 12% of the combination group and 7% of the cefepime group. Three patients taking the combination discontinued because of the reaction.
There were eight serious events in the combination group, including abdominal pain, constipation, cystitis, acute pyelonephritis, UTI (not considered related to the study drug) viral infection, nervous system disorder, and nephrolithiasis. There were two serious adverse events in the cefepime group (cystitis and acute pyelonephritis).
Favorable clinical outcomes occurred in 89% of the combination group and 82.6% of the cefepime group. A microbiological cure was evident in 79.6% and 60.9%, respectively.
The combination was more effective than was cefepime at eradicating E. coli (79.6% vs. 59.1%), although no statistical analysis was presented. The other, less-frequent pathogens did not co-occur in both groups, so comparisons were not made. However, the combination eradicated P. mirabilis in both patients who had it, and 50% of K. pneumoniae infections.
A sustained clinical cure occurred in 81% of the combination group and 82.6% of the cefepime group.
Dr. Bradley said the University of California, San Diego, received fees from both Pfizer or AstraZeneca relating to the studies.
SOURCE: Bradley J et al. ECCMID 2018 oral abstracts O1123 and O1124.
MADRID – Two randomized phase 2b trials show the combination of ceftazidime-avibactam (CAZ-AVI) is safe and effective in children with complicated intra-abdominal infections or complicated urinary tract infections (UTIs).
The combination already is approved for these conditions in adults, said John Bradley, MD, who presented the studies at the European Society of Clinical Microbiology and Infectious Diseases annual congress.
However, Pfizer, which recently acquired the drug combination from AstraZeneca as part of its small-molecule anti-infectives sell-off, intends to go for a pediatric approval for these two indications. The studies, which had secondary efficacy endpoints, will be used as part of the application package to the Food and Drug Administration and the European Medicines Agency, said Dr. Bradley, professor of clinical pediatrics at the University of California, San Diego.
“For those of you who take care of adults and use these drugs, this seems like old news, but those of us who take care of children can rejoice, because these are the first pediatric data presented. And – no surprise – the combination appears to be as safe and effective in children as it is in adults.”
Both studies concluded in late 2017. “We have the data locked and it’s being cleaned and soon will be submitted to regulatory agencies,” Dr. Bradley said. “However, we do not yet have approval so if you do use it, it will still be considered an off-label use until regulatory agencies work with the sponsor to achieve approval.”
Both studies were international, conducted in the United States, Europe, Russia, South Korea, Taiwan, and Turkey.
The first study included 83 children, mean age 10 years, who had complicated intra-abdominal infections precipitated by ruptured appendicitis. About 90% already had been treated with other antibiotics. In this trial, the CAZ-AVI combination was augmented with metronidazole, and compared to meropenem, in 72-hour infusions. The microbiologic test of cure was conducted at 8-15 days with a late follow-up at 20-36 days after the last infusion.
Most of the patents (83%) had an infective organism identified; it was most often Escherichia coli or Pseudomonas aeruginosa. All pathogens were susceptible to the study drugs.
Five children in the combination group experienced a serious adverse event. These included one case each of ileus, intestinal obstruction, large intestine perforation, renal colic, and urethra meatus stenosis. There was one case of ileus in the meropenem group.
There was one case of diarrhea in the combination group. There were three allergic reactions in each group (cough, pruritus, and rash). The meropenem group also had two cases of anemia.
At the test-of-cure point, clinical response was similar in the combination and meropenem groups, both in clinical evidence (93% vs. 95%) and microbiological response (90% vs. 95%) At last follow-up, 100% of each group was clinically cured. The microbiological cure rates were 90% and 95%, respectively.
Success for complicated UTI
The complicated UTI study was likewise good news for CAZ-AVI, this time without metronidazole. This study included 95 children, mean age 6 years, in the same globally gathered cohorts. All of the children were hospitalized; they were randomized to CAZ-AVI at age-specific doses or cefepime, less than 2,000 mg/infusion for 72 hours. The test of cure was conducted at 8-15 days with a late follow-up at 20-36 days after the last infusion.
Most patients (83%) had acute pyelonephritis. About a quarter had at least one complicating factor, including obstructive uropathies due to functional or anatomic abnormalities of the urogenital tract, recurrent UTI, vesicoureteral reflex, or intermittent catheterization. About 20% of the group had a urological abnormality and 40% had been on a systemic antibiotic in the 2 weeks before study entry.
The most common infective organism was E. coli, (92%) followed by Klebsiella pneumoniae, Proteus mirabilis, and Enterobacter cloacae.
Again, about half of each group had at least one adverse event. Serious adverse events occurred in 12% of the combination group and 7% of the cefepime group. Three patients taking the combination discontinued because of the reaction.
There were eight serious events in the combination group, including abdominal pain, constipation, cystitis, acute pyelonephritis, UTI (not considered related to the study drug) viral infection, nervous system disorder, and nephrolithiasis. There were two serious adverse events in the cefepime group (cystitis and acute pyelonephritis).
Favorable clinical outcomes occurred in 89% of the combination group and 82.6% of the cefepime group. A microbiological cure was evident in 79.6% and 60.9%, respectively.
The combination was more effective than was cefepime at eradicating E. coli (79.6% vs. 59.1%), although no statistical analysis was presented. The other, less-frequent pathogens did not co-occur in both groups, so comparisons were not made. However, the combination eradicated P. mirabilis in both patients who had it, and 50% of K. pneumoniae infections.
A sustained clinical cure occurred in 81% of the combination group and 82.6% of the cefepime group.
Dr. Bradley said the University of California, San Diego, received fees from both Pfizer or AstraZeneca relating to the studies.
SOURCE: Bradley J et al. ECCMID 2018 oral abstracts O1123 and O1124.
MADRID – Two randomized phase 2b trials show the combination of ceftazidime-avibactam (CAZ-AVI) is safe and effective in children with complicated intra-abdominal infections or complicated urinary tract infections (UTIs).
The combination already is approved for these conditions in adults, said John Bradley, MD, who presented the studies at the European Society of Clinical Microbiology and Infectious Diseases annual congress.
However, Pfizer, which recently acquired the drug combination from AstraZeneca as part of its small-molecule anti-infectives sell-off, intends to go for a pediatric approval for these two indications. The studies, which had secondary efficacy endpoints, will be used as part of the application package to the Food and Drug Administration and the European Medicines Agency, said Dr. Bradley, professor of clinical pediatrics at the University of California, San Diego.
“For those of you who take care of adults and use these drugs, this seems like old news, but those of us who take care of children can rejoice, because these are the first pediatric data presented. And – no surprise – the combination appears to be as safe and effective in children as it is in adults.”
Both studies concluded in late 2017. “We have the data locked and it’s being cleaned and soon will be submitted to regulatory agencies,” Dr. Bradley said. “However, we do not yet have approval so if you do use it, it will still be considered an off-label use until regulatory agencies work with the sponsor to achieve approval.”
Both studies were international, conducted in the United States, Europe, Russia, South Korea, Taiwan, and Turkey.
The first study included 83 children, mean age 10 years, who had complicated intra-abdominal infections precipitated by ruptured appendicitis. About 90% already had been treated with other antibiotics. In this trial, the CAZ-AVI combination was augmented with metronidazole, and compared to meropenem, in 72-hour infusions. The microbiologic test of cure was conducted at 8-15 days with a late follow-up at 20-36 days after the last infusion.
Most of the patents (83%) had an infective organism identified; it was most often Escherichia coli or Pseudomonas aeruginosa. All pathogens were susceptible to the study drugs.
Five children in the combination group experienced a serious adverse event. These included one case each of ileus, intestinal obstruction, large intestine perforation, renal colic, and urethra meatus stenosis. There was one case of ileus in the meropenem group.
There was one case of diarrhea in the combination group. There were three allergic reactions in each group (cough, pruritus, and rash). The meropenem group also had two cases of anemia.
At the test-of-cure point, clinical response was similar in the combination and meropenem groups, both in clinical evidence (93% vs. 95%) and microbiological response (90% vs. 95%) At last follow-up, 100% of each group was clinically cured. The microbiological cure rates were 90% and 95%, respectively.
Success for complicated UTI
The complicated UTI study was likewise good news for CAZ-AVI, this time without metronidazole. This study included 95 children, mean age 6 years, in the same globally gathered cohorts. All of the children were hospitalized; they were randomized to CAZ-AVI at age-specific doses or cefepime, less than 2,000 mg/infusion for 72 hours. The test of cure was conducted at 8-15 days with a late follow-up at 20-36 days after the last infusion.
Most patients (83%) had acute pyelonephritis. About a quarter had at least one complicating factor, including obstructive uropathies due to functional or anatomic abnormalities of the urogenital tract, recurrent UTI, vesicoureteral reflex, or intermittent catheterization. About 20% of the group had a urological abnormality and 40% had been on a systemic antibiotic in the 2 weeks before study entry.
The most common infective organism was E. coli, (92%) followed by Klebsiella pneumoniae, Proteus mirabilis, and Enterobacter cloacae.
Again, about half of each group had at least one adverse event. Serious adverse events occurred in 12% of the combination group and 7% of the cefepime group. Three patients taking the combination discontinued because of the reaction.
There were eight serious events in the combination group, including abdominal pain, constipation, cystitis, acute pyelonephritis, UTI (not considered related to the study drug) viral infection, nervous system disorder, and nephrolithiasis. There were two serious adverse events in the cefepime group (cystitis and acute pyelonephritis).
Favorable clinical outcomes occurred in 89% of the combination group and 82.6% of the cefepime group. A microbiological cure was evident in 79.6% and 60.9%, respectively.
The combination was more effective than was cefepime at eradicating E. coli (79.6% vs. 59.1%), although no statistical analysis was presented. The other, less-frequent pathogens did not co-occur in both groups, so comparisons were not made. However, the combination eradicated P. mirabilis in both patients who had it, and 50% of K. pneumoniae infections.
A sustained clinical cure occurred in 81% of the combination group and 82.6% of the cefepime group.
Dr. Bradley said the University of California, San Diego, received fees from both Pfizer or AstraZeneca relating to the studies.
SOURCE: Bradley J et al. ECCMID 2018 oral abstracts O1123 and O1124.
REPORTING FROM ECCMID 2018
Key clinical point: The CAZ-AVI combination was as good as the standard comparator drug in both studies.
Major finding: The combination cured close to 90% of infections in both studies.
Study details: Together, the phase 2b studies comprised 178 children.
Disclosures: Pfizer sponsored the studies.
Source: Bradley J et al. ECCMID 2018 oral abstracts O1123 and O1124.
Abstract: Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Poole, R., et al, BMJ 359:J5024, November 22, 2017
BACKGROUND: Studies examining the benefits versus harms of coffee consumption have yielded conflicting results.
METHODS: The authors, from the United Kingdom, present an umbrella review of meta-analyses published up to 2017 to determine the associations between coffee consumption and any health outcome in adults.
RESULTS: This review includes 201 meta-analyses of observational studies with 67 health outcomes and 17 meta-analyses of randomized trials with 9 health outcomes according to coffee consumption defined as high versus low, any versus none, or per each extra cup per day. Coffee was associated with statistically significant protective effects against several diseases including type 2 diabetes, renal stones, Parkinson’s disease, Alzheimer’s disease, depression, leukemia, gout, colorectal cancer, liver cancer, chronic liver disease, cirrhosis, and endometrial cancer (odds ratios of 0.35-0.94). For some outcomes including all-cause mortality, cardiovascular mortality and cardiovascular disease, a nonlinear association was found whereby 3-4 cups per day (versus 0) conferred the greatest risk reduction (by 17%, 19% and 15%, respectively). High versus low consumption reduced the risk of incident cancers by 18%. Significant harms included lung cancer, urinary tract cancer, pregnancy loss, low birth weight, preterm birth, acute leukemia in childhood, and fracture risk in women (odds ratios of 1.03-1.57). Many of the harms were mitigated after adjustment for smoking, except the risks during pregnancy. This analysis of observational trials cannot prove causality.
CONCLUSIONS: Moderate levels of coffee consumption appear to be safe or even beneficial, except during pregnancy and in women at high fracture risk. 132 references (r.poole@soton.ac.uk – no reprints)
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Poole, R., et al, BMJ 359:J5024, November 22, 2017
BACKGROUND: Studies examining the benefits versus harms of coffee consumption have yielded conflicting results.
METHODS: The authors, from the United Kingdom, present an umbrella review of meta-analyses published up to 2017 to determine the associations between coffee consumption and any health outcome in adults.
RESULTS: This review includes 201 meta-analyses of observational studies with 67 health outcomes and 17 meta-analyses of randomized trials with 9 health outcomes according to coffee consumption defined as high versus low, any versus none, or per each extra cup per day. Coffee was associated with statistically significant protective effects against several diseases including type 2 diabetes, renal stones, Parkinson’s disease, Alzheimer’s disease, depression, leukemia, gout, colorectal cancer, liver cancer, chronic liver disease, cirrhosis, and endometrial cancer (odds ratios of 0.35-0.94). For some outcomes including all-cause mortality, cardiovascular mortality and cardiovascular disease, a nonlinear association was found whereby 3-4 cups per day (versus 0) conferred the greatest risk reduction (by 17%, 19% and 15%, respectively). High versus low consumption reduced the risk of incident cancers by 18%. Significant harms included lung cancer, urinary tract cancer, pregnancy loss, low birth weight, preterm birth, acute leukemia in childhood, and fracture risk in women (odds ratios of 1.03-1.57). Many of the harms were mitigated after adjustment for smoking, except the risks during pregnancy. This analysis of observational trials cannot prove causality.
CONCLUSIONS: Moderate levels of coffee consumption appear to be safe or even beneficial, except during pregnancy and in women at high fracture risk. 132 references (r.poole@soton.ac.uk – no reprints)
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Poole, R., et al, BMJ 359:J5024, November 22, 2017
BACKGROUND: Studies examining the benefits versus harms of coffee consumption have yielded conflicting results.
METHODS: The authors, from the United Kingdom, present an umbrella review of meta-analyses published up to 2017 to determine the associations between coffee consumption and any health outcome in adults.
RESULTS: This review includes 201 meta-analyses of observational studies with 67 health outcomes and 17 meta-analyses of randomized trials with 9 health outcomes according to coffee consumption defined as high versus low, any versus none, or per each extra cup per day. Coffee was associated with statistically significant protective effects against several diseases including type 2 diabetes, renal stones, Parkinson’s disease, Alzheimer’s disease, depression, leukemia, gout, colorectal cancer, liver cancer, chronic liver disease, cirrhosis, and endometrial cancer (odds ratios of 0.35-0.94). For some outcomes including all-cause mortality, cardiovascular mortality and cardiovascular disease, a nonlinear association was found whereby 3-4 cups per day (versus 0) conferred the greatest risk reduction (by 17%, 19% and 15%, respectively). High versus low consumption reduced the risk of incident cancers by 18%. Significant harms included lung cancer, urinary tract cancer, pregnancy loss, low birth weight, preterm birth, acute leukemia in childhood, and fracture risk in women (odds ratios of 1.03-1.57). Many of the harms were mitigated after adjustment for smoking, except the risks during pregnancy. This analysis of observational trials cannot prove causality.
CONCLUSIONS: Moderate levels of coffee consumption appear to be safe or even beneficial, except during pregnancy and in women at high fracture risk. 132 references (r.poole@soton.ac.uk – no reprints)
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Pretreatment ECG unwarranted for most infantile hemangioma patients starting propranolol
reported Emily B. Lund, MD, of the University of Chicago, and her associates.
This finding supports previously published studies that pretreatment ECG is not necessary, despite consensus guidelines published in 2013 that recommend ECG screening of high-risk infants presenting with below-normal heart rate, arrhythmia, or family history of either arrhythmia or congenital heart disease.
Among the 6% of patients included in the study who had a positive personal cardiac history, congenital heart disease was most common; coronary artery disease was most prevalent among the 41% with a positive family cardiac history. Baseline vital signs revealed no hypotension or bradycardia.
All patients prescribed propranolol were routinely screened with ECG prior to therapy during the study period. Baseline heart rate and blood pressure were observed for abnormalities; patients also were observed during follow-up for possible propranolol side effects.
A total of 43% of ECG screenings performed were found to be abnormal; left ventricular hypertrophy was the most common abnormality. Despite further cardiac evaluation of all but one patient with abnormal ECG, no contraindications to treatment were identified, Dr. Lund and her colleagues reported in Pediatric Dermatology.
Ultimately, 96% of patients observed started treatment with propranolol; of the remaining 4% who did not, the authors cited parental preference and lack of follow-up as the primary reasons for nontreatment.
The researchers found no association between reported side effects and abnormal ECG, a positive personal history of cardiac problems, or a positive family history of cardiac problems.
Dr. Lund and her associates suggested that future revision of the guidelines should emphasize the absence of significant positive predictive value of ECG abnormalities for treatment-related side effects.
The researchers reported no relevant financial disclosures.
SOURCE: Lund EB et al. Ped Dermatol. 2018. doi: 10.1111/pde.13508.
reported Emily B. Lund, MD, of the University of Chicago, and her associates.
This finding supports previously published studies that pretreatment ECG is not necessary, despite consensus guidelines published in 2013 that recommend ECG screening of high-risk infants presenting with below-normal heart rate, arrhythmia, or family history of either arrhythmia or congenital heart disease.
Among the 6% of patients included in the study who had a positive personal cardiac history, congenital heart disease was most common; coronary artery disease was most prevalent among the 41% with a positive family cardiac history. Baseline vital signs revealed no hypotension or bradycardia.
All patients prescribed propranolol were routinely screened with ECG prior to therapy during the study period. Baseline heart rate and blood pressure were observed for abnormalities; patients also were observed during follow-up for possible propranolol side effects.
A total of 43% of ECG screenings performed were found to be abnormal; left ventricular hypertrophy was the most common abnormality. Despite further cardiac evaluation of all but one patient with abnormal ECG, no contraindications to treatment were identified, Dr. Lund and her colleagues reported in Pediatric Dermatology.
Ultimately, 96% of patients observed started treatment with propranolol; of the remaining 4% who did not, the authors cited parental preference and lack of follow-up as the primary reasons for nontreatment.
The researchers found no association between reported side effects and abnormal ECG, a positive personal history of cardiac problems, or a positive family history of cardiac problems.
Dr. Lund and her associates suggested that future revision of the guidelines should emphasize the absence of significant positive predictive value of ECG abnormalities for treatment-related side effects.
The researchers reported no relevant financial disclosures.
SOURCE: Lund EB et al. Ped Dermatol. 2018. doi: 10.1111/pde.13508.
reported Emily B. Lund, MD, of the University of Chicago, and her associates.
This finding supports previously published studies that pretreatment ECG is not necessary, despite consensus guidelines published in 2013 that recommend ECG screening of high-risk infants presenting with below-normal heart rate, arrhythmia, or family history of either arrhythmia or congenital heart disease.
Among the 6% of patients included in the study who had a positive personal cardiac history, congenital heart disease was most common; coronary artery disease was most prevalent among the 41% with a positive family cardiac history. Baseline vital signs revealed no hypotension or bradycardia.
All patients prescribed propranolol were routinely screened with ECG prior to therapy during the study period. Baseline heart rate and blood pressure were observed for abnormalities; patients also were observed during follow-up for possible propranolol side effects.
A total of 43% of ECG screenings performed were found to be abnormal; left ventricular hypertrophy was the most common abnormality. Despite further cardiac evaluation of all but one patient with abnormal ECG, no contraindications to treatment were identified, Dr. Lund and her colleagues reported in Pediatric Dermatology.
Ultimately, 96% of patients observed started treatment with propranolol; of the remaining 4% who did not, the authors cited parental preference and lack of follow-up as the primary reasons for nontreatment.
The researchers found no association between reported side effects and abnormal ECG, a positive personal history of cardiac problems, or a positive family history of cardiac problems.
Dr. Lund and her associates suggested that future revision of the guidelines should emphasize the absence of significant positive predictive value of ECG abnormalities for treatment-related side effects.
The researchers reported no relevant financial disclosures.
SOURCE: Lund EB et al. Ped Dermatol. 2018. doi: 10.1111/pde.13508.
FROM PEDIATRIC DERMATOLOGY
Key clinical point: There was no association between side effects, abnormal ECG, and personal or family history of cardiac problems in children with infantile hemangioma who underwent propranolol therapy.
Major finding: Despite the fact that 43% of ECG screenings were abnormal, 96% of patients started treatment with propranolol, with no side effects related to abnormal ECG or to personal or family history of cardiac problems.
Study details: A retrospective chart review of 272 patients with infantile hemangioma.
Disclosures: The researchers reported no relevant financial disclosures.
Source: Lund EB et al. Ped Dermatol. 2018. doi: 10.1111/pde.13508.
Analysis finds inconsistent uptake of meningococcal B vaccines
TORONTO – results from a large analysis showed.
“In 2015, two meningococcal B (MenB) vaccines were given a Category B recommendation by the Advisory Committee on Immunization Practices with a preferred vaccination window of 16-18 years,” researchers led by Kristen A. Feemster, MD, MPH, wrote in an abstract presented at the Pediatric Academic Societies meeting. “Factors that may influence provider recommendation and subsequent uptake of a Category B vaccine are unknown.”
In an effort to identify sociodemographic and provider factors associated with MenB vaccine receipt, Dr. Feemster and her associates conducted a cross-sectional study of 85,789 Philadelphia youth aged 16-18 years who had a record in the KIDS Plus II Philadelphia database between Oct. 31, 2015 and July 31, 2017. They acquired neighborhood-level data from the 2016 U.S. Census American Community Survey. Next, the researchers used multivariate logistic regression to assess the association between MenB series initiation and individual- and neighborhood-level sociodemographic, clinical, and provider characteristics.
Of the 85,789 youth, only 16% received at least one MenB dose, while just 5% completed the series, reported Dr. Feemster, who is medical director of the Immunization Program and Acute Communicable Diseases at the Philadelphia department of public health in the division of disease control. Nearly half of youth (49%) were black or African-American, 25% were white, 5.5% were Asian, while the remainder were from “other” or “unknown” races. A private pediatrician was listed as the provider for 70% of the youth, followed by a community health center (11%), the Philadelphia District Center (7%), and hospitals (2%), while the remaining providers were “other” or “unknown.” The proportion of MenB recipients varied significantly by provider type, from 0.67% to 20%.
On multivariate logistic regression, MenB recipients were more likely to be female (adjusted odds ratio, 1.07; P = .0006); they were also more likely to be up-to-date on human papillomavirus vaccines (AOR, 1.65; P less than .0001) and measles-containing vaccines (AOR, 9.90; P less than .0001).
MenB recipients were more likely to be of “unknown” or “other” reported race, compared with those who were Black/African-American (AOR, 1.36 and 1.24, respectively; P less than .0001) or non-Hispanic/Latino (AOR, 1.21; P less than .0001); they were also more likely to reside in a neighborhood with median household income of greater than $100,000, compared with those who lived in a neighborhood where the median household income is less than $20,000 (AOR, 1.63; P less than .0001). Asian teens (AOR, 0.87; P = .0062) and teens who received care in community (AOR, 0.52; P less than .0001) or district health centers (AOR, 0.03; P less than .0001) also were less likely to receive the MenB vaccine, reported Dr. Feemster, who is also director of research for Children’s Hospital of Philadelphia’s Vaccine Education Center, and her colleagues.
“Variation in uptake by race, ethnicity, and neighborhood socioeconomic status suggest potential sociodemographic disparities in MenB receipt, [while] variation by neighborhood socioeconomic status may also suggest financial barriers related to access to care,” the researchers wrote in their abstract. They also speculated that variation in MenB receipt across different providers “may reflect different recommendation practices, perceived need for MenB vaccines in a provider’s patient population, or clinic-level purchasing decisions.”
The next steps in their research, they wrote, are to “investigate factors associated with provider recommendation of MenB vaccine to identify targets for initiatives to ensure equitable vaccine access.”
The researchers reported having no financial disclosures.
TORONTO – results from a large analysis showed.
“In 2015, two meningococcal B (MenB) vaccines were given a Category B recommendation by the Advisory Committee on Immunization Practices with a preferred vaccination window of 16-18 years,” researchers led by Kristen A. Feemster, MD, MPH, wrote in an abstract presented at the Pediatric Academic Societies meeting. “Factors that may influence provider recommendation and subsequent uptake of a Category B vaccine are unknown.”
In an effort to identify sociodemographic and provider factors associated with MenB vaccine receipt, Dr. Feemster and her associates conducted a cross-sectional study of 85,789 Philadelphia youth aged 16-18 years who had a record in the KIDS Plus II Philadelphia database between Oct. 31, 2015 and July 31, 2017. They acquired neighborhood-level data from the 2016 U.S. Census American Community Survey. Next, the researchers used multivariate logistic regression to assess the association between MenB series initiation and individual- and neighborhood-level sociodemographic, clinical, and provider characteristics.
Of the 85,789 youth, only 16% received at least one MenB dose, while just 5% completed the series, reported Dr. Feemster, who is medical director of the Immunization Program and Acute Communicable Diseases at the Philadelphia department of public health in the division of disease control. Nearly half of youth (49%) were black or African-American, 25% were white, 5.5% were Asian, while the remainder were from “other” or “unknown” races. A private pediatrician was listed as the provider for 70% of the youth, followed by a community health center (11%), the Philadelphia District Center (7%), and hospitals (2%), while the remaining providers were “other” or “unknown.” The proportion of MenB recipients varied significantly by provider type, from 0.67% to 20%.
On multivariate logistic regression, MenB recipients were more likely to be female (adjusted odds ratio, 1.07; P = .0006); they were also more likely to be up-to-date on human papillomavirus vaccines (AOR, 1.65; P less than .0001) and measles-containing vaccines (AOR, 9.90; P less than .0001).
MenB recipients were more likely to be of “unknown” or “other” reported race, compared with those who were Black/African-American (AOR, 1.36 and 1.24, respectively; P less than .0001) or non-Hispanic/Latino (AOR, 1.21; P less than .0001); they were also more likely to reside in a neighborhood with median household income of greater than $100,000, compared with those who lived in a neighborhood where the median household income is less than $20,000 (AOR, 1.63; P less than .0001). Asian teens (AOR, 0.87; P = .0062) and teens who received care in community (AOR, 0.52; P less than .0001) or district health centers (AOR, 0.03; P less than .0001) also were less likely to receive the MenB vaccine, reported Dr. Feemster, who is also director of research for Children’s Hospital of Philadelphia’s Vaccine Education Center, and her colleagues.
“Variation in uptake by race, ethnicity, and neighborhood socioeconomic status suggest potential sociodemographic disparities in MenB receipt, [while] variation by neighborhood socioeconomic status may also suggest financial barriers related to access to care,” the researchers wrote in their abstract. They also speculated that variation in MenB receipt across different providers “may reflect different recommendation practices, perceived need for MenB vaccines in a provider’s patient population, or clinic-level purchasing decisions.”
The next steps in their research, they wrote, are to “investigate factors associated with provider recommendation of MenB vaccine to identify targets for initiatives to ensure equitable vaccine access.”
The researchers reported having no financial disclosures.
TORONTO – results from a large analysis showed.
“In 2015, two meningococcal B (MenB) vaccines were given a Category B recommendation by the Advisory Committee on Immunization Practices with a preferred vaccination window of 16-18 years,” researchers led by Kristen A. Feemster, MD, MPH, wrote in an abstract presented at the Pediatric Academic Societies meeting. “Factors that may influence provider recommendation and subsequent uptake of a Category B vaccine are unknown.”
In an effort to identify sociodemographic and provider factors associated with MenB vaccine receipt, Dr. Feemster and her associates conducted a cross-sectional study of 85,789 Philadelphia youth aged 16-18 years who had a record in the KIDS Plus II Philadelphia database between Oct. 31, 2015 and July 31, 2017. They acquired neighborhood-level data from the 2016 U.S. Census American Community Survey. Next, the researchers used multivariate logistic regression to assess the association between MenB series initiation and individual- and neighborhood-level sociodemographic, clinical, and provider characteristics.
Of the 85,789 youth, only 16% received at least one MenB dose, while just 5% completed the series, reported Dr. Feemster, who is medical director of the Immunization Program and Acute Communicable Diseases at the Philadelphia department of public health in the division of disease control. Nearly half of youth (49%) were black or African-American, 25% were white, 5.5% were Asian, while the remainder were from “other” or “unknown” races. A private pediatrician was listed as the provider for 70% of the youth, followed by a community health center (11%), the Philadelphia District Center (7%), and hospitals (2%), while the remaining providers were “other” or “unknown.” The proportion of MenB recipients varied significantly by provider type, from 0.67% to 20%.
On multivariate logistic regression, MenB recipients were more likely to be female (adjusted odds ratio, 1.07; P = .0006); they were also more likely to be up-to-date on human papillomavirus vaccines (AOR, 1.65; P less than .0001) and measles-containing vaccines (AOR, 9.90; P less than .0001).
MenB recipients were more likely to be of “unknown” or “other” reported race, compared with those who were Black/African-American (AOR, 1.36 and 1.24, respectively; P less than .0001) or non-Hispanic/Latino (AOR, 1.21; P less than .0001); they were also more likely to reside in a neighborhood with median household income of greater than $100,000, compared with those who lived in a neighborhood where the median household income is less than $20,000 (AOR, 1.63; P less than .0001). Asian teens (AOR, 0.87; P = .0062) and teens who received care in community (AOR, 0.52; P less than .0001) or district health centers (AOR, 0.03; P less than .0001) also were less likely to receive the MenB vaccine, reported Dr. Feemster, who is also director of research for Children’s Hospital of Philadelphia’s Vaccine Education Center, and her colleagues.
“Variation in uptake by race, ethnicity, and neighborhood socioeconomic status suggest potential sociodemographic disparities in MenB receipt, [while] variation by neighborhood socioeconomic status may also suggest financial barriers related to access to care,” the researchers wrote in their abstract. They also speculated that variation in MenB receipt across different providers “may reflect different recommendation practices, perceived need for MenB vaccines in a provider’s patient population, or clinic-level purchasing decisions.”
The next steps in their research, they wrote, are to “investigate factors associated with provider recommendation of MenB vaccine to identify targets for initiatives to ensure equitable vaccine access.”
The researchers reported having no financial disclosures.
AT PAS 2018
Key clinical point: Significant variation in the likelihood of MenB vaccine receipt correlated with sociodemographic, clinical, and provider factors.
Major finding: Only 16% received at least one MenB dose while just 5% completed the series.
Study details: A cross-sectional study of 85,789 Philadelphia youth aged 16-18 years.
Disclosures: The researchers reported having no financial disclosures.
Use of a Core Reamer for the Resection of a Central Distal Femoral Physeal Bone Bridge: A Novel Technique with 3-Year Follow-up
ABSTRACT
A central distal femoral physeal bone bridge in a boy aged 5 years and 7 months was resected with a fluoroscopically guided core reamer placed through a lateral parapatellar approach. At 3-year follow-up, the boy’s leg-length discrepancy was 3.0 cm (3.9 cm preoperatively), and the physeal bone bridge did not recur. The patient had full function and no pain or other patellofemoral complaints. This technique provided direct access to the physeal bone bridge, and complete resection was performed without injury to the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which is expected to grow normally in the absence of the bridge.
A physeal bone bridge is an osseous connection that forms across a physis. It may cause partial premature physeal arrest. Angular deformity and limb-length discrepancy are the main complications caused by physeal bone bridges.1-4 The indications for the treatment of physeal bridges are well documented.1-5 Trauma and infection are common causes of distal femoral physeal bone bridges. Arkader and colleagues6 showed that among different types of physeal bridges, the Salter-Harris type is significantly associated with complications, among which growth arrest is the most common and occurs in 27.4% of all patients.
The treatment of distal femoral physeal bone bridges is technically difficult and provides variable results. Poor results are reported in 13% to 40% of patients.7-10 Procedure failure has been attributed to incomplete resection with the persistent tethering and dislodgement of the graft.11 Methods with improved efficacy for the removal of central physeal bridges will help prevent reformation after treatment. We have used a novel technique that allows the direct resection of a central physeal bone bridge in the distal femur through the use of a fluoroscopically guided core reamer. This technique enables the complete removal of the bone bridge and the direct visual assessment of the remaining physis. The patient’s parents provided written informed consent for print and electronic publication of this case report.
CASE
A 3-year-old boy with a history of hemifacial microsomia presented for the evaluation of genu valgum and leg-length discrepancy. His intermalleolar distance at that time was 8 cm. A standing radiograph of his lower extremities demonstrated changes consistent with physiologic genu valgum. He had no history of knee trauma, infection, or pain.
At the age of 5 years and 7 months, the patient returned for a repeat evaluation and was noted to exhibit the progressive valgus deformity of the right leg and a leg-length discrepancy of 3.9 cm (Figure 1). 
Continue to: With the patient supine on the operating...
OPERATIVE TECHNIQUE
With the patient supine on the operating table and after the administration of general anesthesia, 3-dimensional (3-D) fluoroscopy was used to localize the bone bridge, which confirmed the fluoroscopic location that was previously visualized through preoperative 3-D imaging. The leg was elevated, and a tourniquet was applied and inflated. A lateral parapatellar approach was used to isolate the distal femoral physis anteriorly because the bone bridge was centered just lateral to the central portion of the distal femoral physis. A Kirschner wire was placed in the center of the bridge under anteroposterior and lateral fluoroscopic imaging (Figures 3A-3E). 
OUTCOME
The patient healed uneventfully, and early range-of-motion exercises were started 6 weeks postoperatively. At 6-month follow-up, his leg-length discrepancy was 2.7 cm, and the bone bridge did not recur. At 3-year follow-up, his leg-length discrepancy was 3.0 cm, and the bone bridge did not recur. Over the 3 years postoperatively, the patient exhibited 9.8 cm of growth on his operative side and 9.5 cm on his nonoperative side (Figure 5). 
DISCUSSION
Given the considerable growth potential of the distal femoral physis,1,14-16 an injury to the distal femoral physis and the formation of a physeal bone bridge can have a profound effect on a young patient in terms of leg-length discrepancy and angular deformity. Fracture from trauma or infection is a common cause of physeal bone bridges.6,17-19 The etiology of our patient’s distal femoral physeal bone bridge is idiopathic, which is considerably less common than other etiologies, and the incidence of idiopathic physeal bone bridge formation is not well established in the literature. Hresko and Kasser21 identified atraumatic physeal bone bridge formations in 7 patients. Among the 13 patients with physeal bone bridges described by Broughton and colleagues,20 the cause of bridge formation is unknown in 1.
Physeal bone bridges that form centrally are particularly challenging because they are difficult to visualize through a peripheral approach. A number of methods for resecting central physeal bone bridges have been described. These methods have varying degrees of success. In 1981, Langenskiöld7 first described the creation of a metaphyseal mirror and the use of a dental mirror for visualization. This technique, however, yielded unfavorable results in 16% of patients. Williamson and Staheli9 reported poor results in 23% of patients. Loraas and Schmale4 described the use of an endoscope, termed an osteoscope, for visualization, citing advantages of superior illumination and potential for image magnification and capture. Marsh and Polzhofer8 also showed this technique to have low morbidity but poor results in 13% of patients, whereas Moreta and colleagues10 reported poor results in 2 out of 5 patients. The rate of poor results of these methods may be related to the technical difficulty of using dental mirrors and arthroscopes and can be improved by highly efficient direct methods with improved visualization, such as the method described in this article.
Continue to: Proper imaging is necessary for...
Proper imaging is necessary for the accurate quantification of bone bridges to determine resectability and to identify the best surgical approach to resection. MRI with software for the generation of 3-D physeal maps is a reproducible method with good interobserver reliability.22,23 Intraoperative computer-assisted imaging also is beneficial for determining the extent and location of the resection to ensure complete bone bridge removal.24
To our knowledge, a direct approach through parapatellar arthrotomy for the resection of a centrally located distal femoral physeal bone bridge has not been previously described. This novel technique provided direct access to the physeal bone bridge and was performed without injuring the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which may grow normally in the absence of the bridge. Instead of using a lateral or medial approach with a metaphyseal window,4 we directly approached this central bar through a parapatellar approach and were able to completely resect it under direct visualization. This obviated the need for an arthroscope or dental mirror. To remove the entire physeal bone bridge, we needed to resect completely from the anterior cortex to the posterior cortex. Although this technique potentially increased the risk of iatrogenic fracture, we believed that this risk would not differ greatly from that of disrupting the medial or lateral metaphysis and would be more stable with either axial and torsion load. At 3-year follow-up, the patient exhibited restored normal growth in his operative limb relative to that in his nonoperative limb, had not developed angular deformity, and had maintained his previously developed limb-length discrepancy that could be corrected with the epiphysiodesis of his opposite limb at a later date.
The limitations to this technique include the fact that it may be most effective with small-to moderate-sized central physeal bone bridges, although resection has shown good results with up to 70% physeal involvement.8 In this patient, the bone bridge was moderately sized (30% of the physis), centrally located, and clearly visible on fluoroscopy. These characteristics increased the technical safety and ease of the procedure. The resection of large, peripheral bridges may destabilize the distal femur. The destabilization of the distal femur, in turn, can lead to fracture. Patellofemoral mechanics may also be affected during the treatment of distal femoral physeal bone bridges. This patient has not experienced any patellofemoral dysfunction or symptoms. Given the patient’s age and significant amount of remaining growth, he will need close monitoring until he reaches skeletal maturity.
This paper will be judged for the Resident Writer’s Award.
1. Murphy GA. Disorders of tendons and fascia and adolescent and adult pes planus. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. 12th edition. Philadelphia, PA: Mosby-Elsevier; 2013:3966-3972.
2. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
3. Stans AA. Excision of physeal bar. In: Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1244-1249.
4. Loraas EK, Schmale GA. Endoscopically aided physeal bar takedown and guided growth for the treatment of angular limb deformity. J Pediatr Orthop B. 2012;21(4):348-351. doi:10.1097/BPB.0b013e328346d308.
5. Inoue T, Naito M, Fuhii T, Akiyoshi Y, Yoshimura I, Takamura K. Partial physeal growth arrest treated by bridge resection and artificial dura substitute interposition. J Pediatr Orthop B. 2006;15(1):65-69. doi:10.1097/01202412-200601000-00014.
6. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27(6):703-708. doi:10.1097/BPO.0b013e3180dca0e5.
7. Langenskiöld A. Surgical treatment of partial closure of the growth plate. J Pediatr Orthop. 1981;1(1):3-11. doi:10.1097/01241398-198101010-00002.
8. Marsh JS, Polzhofer GK. Arthroscopically assisted central physeal bar resection. J Pediatr Orthop. 2006;26(2):255-259. doi:10.1097/01.bpo.0000218533.43986.e1.
9. Williamson RV, Staheli LT. Partial physeal growth arrest: treatment by bridge resection and fat interposition. J Pediatr Orthop. 1990;10(6):769-776. doi:10.1097/01241398-199011000-00012.
10. Moreta J, Abril JC, Miranda C. Arthroscopy-assisted resection-interposition of post-traumatic central physeal bridges. Rev Esp Cir Orthop Traumatol. 2013;57(5):333-339. doi:10.1016/j.recot.2013.07.004.
11. Hasler CC, Foster BK. Secondary tethers after physeal bar resection: a common source of failure? Clin Orthop Relat Res. 2002;405:242-249.
12. Paley D, Bhave A, Herzenberg JE, Bowen JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82(10):1432-1446. doi:10.2106/00004623-200010000-00010.
13. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
14. Rathjen KE, Kim HKW. Physeal injuries and growth disturbances. In: Flynn JM, Skaggs DL, Waters PM, eds. Rockwood and Wilkins’ Fractures in Children. 8th edition. Philadelphia, PA: Wolters-Kluwer; 2015:135-137.
15. Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972;12(4):275-281. doi:10.1097/00005373-197204000-00002.
16. Pritchett JW. Longitudinal growth and growth-plate activity in the lower extremity. Clin Orthop Relat Res. 1992;275:274-279.
17. Cassebaum WH, Patterson AH. Fracture of the distal femoral epiphysis. Clin Orthop Relat Res. 1965;41:79-91. doi:10.1097/00003086-196500410-00009.
18. Dahl WJ, Silva S, Vanderhave KL. Distal femoral physeal fixation: are smooth pins really safe? J Pedatir Orthop. 2014;34(2):134-138. doi:10.1097/BPO.0000000000000083.
19. Roberts J. Fracture separation of the distal femoral epiphyseal growth line. J Bone Joint Surg Am. 1973;55:1324.
20. Broughton NS, Dickens DR, Cole WG, Menelaus MB. Epiphyseolysis for partial growth plate arrest. Results after four years or at maturity. J Bone Joint Surg Br. 1989;71(1):13-16. doi:10.1302/0301-620X.71B1.2914983.
21. Hresko MT, Kasser JR. Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am. 1989;71(5):698-703. doi:10.2106/00004623-198971050-00009.
22. Lurie B, Koff MF, Shah P, et al. Three-dimensional magnetic resonance imaging of physeal injury: reliability and clinical utility. J Pediatr Orthop. 2014;34(3):239-245. doi:10.1097/BPO.0000000000000104.
23. Sailhan F, Chotel F, Guibal AL, et al. Three-dimensional MR imaging in the assessment of physeal growth arrest. Eur Radiol. 2004;14(9):1600-1608. doi:10.1007/s00330-004-2319-z.
24. Kang HG, Yoon SJ, Kim JR. Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br. 2010;92(10):1452-1455. doi:10.1302/0301-620X.92B10.24587.
ABSTRACT
A central distal femoral physeal bone bridge in a boy aged 5 years and 7 months was resected with a fluoroscopically guided core reamer placed through a lateral parapatellar approach. At 3-year follow-up, the boy’s leg-length discrepancy was 3.0 cm (3.9 cm preoperatively), and the physeal bone bridge did not recur. The patient had full function and no pain or other patellofemoral complaints. This technique provided direct access to the physeal bone bridge, and complete resection was performed without injury to the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which is expected to grow normally in the absence of the bridge.
A physeal bone bridge is an osseous connection that forms across a physis. It may cause partial premature physeal arrest. Angular deformity and limb-length discrepancy are the main complications caused by physeal bone bridges.1-4 The indications for the treatment of physeal bridges are well documented.1-5 Trauma and infection are common causes of distal femoral physeal bone bridges. Arkader and colleagues6 showed that among different types of physeal bridges, the Salter-Harris type is significantly associated with complications, among which growth arrest is the most common and occurs in 27.4% of all patients.
The treatment of distal femoral physeal bone bridges is technically difficult and provides variable results. Poor results are reported in 13% to 40% of patients.7-10 Procedure failure has been attributed to incomplete resection with the persistent tethering and dislodgement of the graft.11 Methods with improved efficacy for the removal of central physeal bridges will help prevent reformation after treatment. We have used a novel technique that allows the direct resection of a central physeal bone bridge in the distal femur through the use of a fluoroscopically guided core reamer. This technique enables the complete removal of the bone bridge and the direct visual assessment of the remaining physis. The patient’s parents provided written informed consent for print and electronic publication of this case report.
CASE
A 3-year-old boy with a history of hemifacial microsomia presented for the evaluation of genu valgum and leg-length discrepancy. His intermalleolar distance at that time was 8 cm. A standing radiograph of his lower extremities demonstrated changes consistent with physiologic genu valgum. He had no history of knee trauma, infection, or pain.
At the age of 5 years and 7 months, the patient returned for a repeat evaluation and was noted to exhibit the progressive valgus deformity of the right leg and a leg-length discrepancy of 3.9 cm (Figure 1).
Continue to: With the patient supine on the operating...
OPERATIVE TECHNIQUE
With the patient supine on the operating table and after the administration of general anesthesia, 3-dimensional (3-D) fluoroscopy was used to localize the bone bridge, which confirmed the fluoroscopic location that was previously visualized through preoperative 3-D imaging. The leg was elevated, and a tourniquet was applied and inflated. A lateral parapatellar approach was used to isolate the distal femoral physis anteriorly because the bone bridge was centered just lateral to the central portion of the distal femoral physis. A Kirschner wire was placed in the center of the bridge under anteroposterior and lateral fluoroscopic imaging (Figures 3A-3E).
OUTCOME
The patient healed uneventfully, and early range-of-motion exercises were started 6 weeks postoperatively. At 6-month follow-up, his leg-length discrepancy was 2.7 cm, and the bone bridge did not recur. At 3-year follow-up, his leg-length discrepancy was 3.0 cm, and the bone bridge did not recur. Over the 3 years postoperatively, the patient exhibited 9.8 cm of growth on his operative side and 9.5 cm on his nonoperative side (Figure 5).
DISCUSSION
Given the considerable growth potential of the distal femoral physis,1,14-16 an injury to the distal femoral physis and the formation of a physeal bone bridge can have a profound effect on a young patient in terms of leg-length discrepancy and angular deformity. Fracture from trauma or infection is a common cause of physeal bone bridges.6,17-19 The etiology of our patient’s distal femoral physeal bone bridge is idiopathic, which is considerably less common than other etiologies, and the incidence of idiopathic physeal bone bridge formation is not well established in the literature. Hresko and Kasser21 identified atraumatic physeal bone bridge formations in 7 patients. Among the 13 patients with physeal bone bridges described by Broughton and colleagues,20 the cause of bridge formation is unknown in 1.
Physeal bone bridges that form centrally are particularly challenging because they are difficult to visualize through a peripheral approach. A number of methods for resecting central physeal bone bridges have been described. These methods have varying degrees of success. In 1981, Langenskiöld7 first described the creation of a metaphyseal mirror and the use of a dental mirror for visualization. This technique, however, yielded unfavorable results in 16% of patients. Williamson and Staheli9 reported poor results in 23% of patients. Loraas and Schmale4 described the use of an endoscope, termed an osteoscope, for visualization, citing advantages of superior illumination and potential for image magnification and capture. Marsh and Polzhofer8 also showed this technique to have low morbidity but poor results in 13% of patients, whereas Moreta and colleagues10 reported poor results in 2 out of 5 patients. The rate of poor results of these methods may be related to the technical difficulty of using dental mirrors and arthroscopes and can be improved by highly efficient direct methods with improved visualization, such as the method described in this article.
Continue to: Proper imaging is necessary for...
Proper imaging is necessary for the accurate quantification of bone bridges to determine resectability and to identify the best surgical approach to resection. MRI with software for the generation of 3-D physeal maps is a reproducible method with good interobserver reliability.22,23 Intraoperative computer-assisted imaging also is beneficial for determining the extent and location of the resection to ensure complete bone bridge removal.24
To our knowledge, a direct approach through parapatellar arthrotomy for the resection of a centrally located distal femoral physeal bone bridge has not been previously described. This novel technique provided direct access to the physeal bone bridge and was performed without injuring the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which may grow normally in the absence of the bridge. Instead of using a lateral or medial approach with a metaphyseal window,4 we directly approached this central bar through a parapatellar approach and were able to completely resect it under direct visualization. This obviated the need for an arthroscope or dental mirror. To remove the entire physeal bone bridge, we needed to resect completely from the anterior cortex to the posterior cortex. Although this technique potentially increased the risk of iatrogenic fracture, we believed that this risk would not differ greatly from that of disrupting the medial or lateral metaphysis and would be more stable with either axial and torsion load. At 3-year follow-up, the patient exhibited restored normal growth in his operative limb relative to that in his nonoperative limb, had not developed angular deformity, and had maintained his previously developed limb-length discrepancy that could be corrected with the epiphysiodesis of his opposite limb at a later date.
The limitations to this technique include the fact that it may be most effective with small-to moderate-sized central physeal bone bridges, although resection has shown good results with up to 70% physeal involvement.8 In this patient, the bone bridge was moderately sized (30% of the physis), centrally located, and clearly visible on fluoroscopy. These characteristics increased the technical safety and ease of the procedure. The resection of large, peripheral bridges may destabilize the distal femur. The destabilization of the distal femur, in turn, can lead to fracture. Patellofemoral mechanics may also be affected during the treatment of distal femoral physeal bone bridges. This patient has not experienced any patellofemoral dysfunction or symptoms. Given the patient’s age and significant amount of remaining growth, he will need close monitoring until he reaches skeletal maturity.
This paper will be judged for the Resident Writer’s Award.
ABSTRACT
A central distal femoral physeal bone bridge in a boy aged 5 years and 7 months was resected with a fluoroscopically guided core reamer placed through a lateral parapatellar approach. At 3-year follow-up, the boy’s leg-length discrepancy was 3.0 cm (3.9 cm preoperatively), and the physeal bone bridge did not recur. The patient had full function and no pain or other patellofemoral complaints. This technique provided direct access to the physeal bone bridge, and complete resection was performed without injury to the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which is expected to grow normally in the absence of the bridge.
A physeal bone bridge is an osseous connection that forms across a physis. It may cause partial premature physeal arrest. Angular deformity and limb-length discrepancy are the main complications caused by physeal bone bridges.1-4 The indications for the treatment of physeal bridges are well documented.1-5 Trauma and infection are common causes of distal femoral physeal bone bridges. Arkader and colleagues6 showed that among different types of physeal bridges, the Salter-Harris type is significantly associated with complications, among which growth arrest is the most common and occurs in 27.4% of all patients.
The treatment of distal femoral physeal bone bridges is technically difficult and provides variable results. Poor results are reported in 13% to 40% of patients.7-10 Procedure failure has been attributed to incomplete resection with the persistent tethering and dislodgement of the graft.11 Methods with improved efficacy for the removal of central physeal bridges will help prevent reformation after treatment. We have used a novel technique that allows the direct resection of a central physeal bone bridge in the distal femur through the use of a fluoroscopically guided core reamer. This technique enables the complete removal of the bone bridge and the direct visual assessment of the remaining physis. The patient’s parents provided written informed consent for print and electronic publication of this case report.
CASE
A 3-year-old boy with a history of hemifacial microsomia presented for the evaluation of genu valgum and leg-length discrepancy. His intermalleolar distance at that time was 8 cm. A standing radiograph of his lower extremities demonstrated changes consistent with physiologic genu valgum. He had no history of knee trauma, infection, or pain.
At the age of 5 years and 7 months, the patient returned for a repeat evaluation and was noted to exhibit the progressive valgus deformity of the right leg and a leg-length discrepancy of 3.9 cm (Figure 1).
Continue to: With the patient supine on the operating...
OPERATIVE TECHNIQUE
With the patient supine on the operating table and after the administration of general anesthesia, 3-dimensional (3-D) fluoroscopy was used to localize the bone bridge, which confirmed the fluoroscopic location that was previously visualized through preoperative 3-D imaging. The leg was elevated, and a tourniquet was applied and inflated. A lateral parapatellar approach was used to isolate the distal femoral physis anteriorly because the bone bridge was centered just lateral to the central portion of the distal femoral physis. A Kirschner wire was placed in the center of the bridge under anteroposterior and lateral fluoroscopic imaging (Figures 3A-3E).
OUTCOME
The patient healed uneventfully, and early range-of-motion exercises were started 6 weeks postoperatively. At 6-month follow-up, his leg-length discrepancy was 2.7 cm, and the bone bridge did not recur. At 3-year follow-up, his leg-length discrepancy was 3.0 cm, and the bone bridge did not recur. Over the 3 years postoperatively, the patient exhibited 9.8 cm of growth on his operative side and 9.5 cm on his nonoperative side (Figure 5).
DISCUSSION
Given the considerable growth potential of the distal femoral physis,1,14-16 an injury to the distal femoral physis and the formation of a physeal bone bridge can have a profound effect on a young patient in terms of leg-length discrepancy and angular deformity. Fracture from trauma or infection is a common cause of physeal bone bridges.6,17-19 The etiology of our patient’s distal femoral physeal bone bridge is idiopathic, which is considerably less common than other etiologies, and the incidence of idiopathic physeal bone bridge formation is not well established in the literature. Hresko and Kasser21 identified atraumatic physeal bone bridge formations in 7 patients. Among the 13 patients with physeal bone bridges described by Broughton and colleagues,20 the cause of bridge formation is unknown in 1.
Physeal bone bridges that form centrally are particularly challenging because they are difficult to visualize through a peripheral approach. A number of methods for resecting central physeal bone bridges have been described. These methods have varying degrees of success. In 1981, Langenskiöld7 first described the creation of a metaphyseal mirror and the use of a dental mirror for visualization. This technique, however, yielded unfavorable results in 16% of patients. Williamson and Staheli9 reported poor results in 23% of patients. Loraas and Schmale4 described the use of an endoscope, termed an osteoscope, for visualization, citing advantages of superior illumination and potential for image magnification and capture. Marsh and Polzhofer8 also showed this technique to have low morbidity but poor results in 13% of patients, whereas Moreta and colleagues10 reported poor results in 2 out of 5 patients. The rate of poor results of these methods may be related to the technical difficulty of using dental mirrors and arthroscopes and can be improved by highly efficient direct methods with improved visualization, such as the method described in this article.
Continue to: Proper imaging is necessary for...
Proper imaging is necessary for the accurate quantification of bone bridges to determine resectability and to identify the best surgical approach to resection. MRI with software for the generation of 3-D physeal maps is a reproducible method with good interobserver reliability.22,23 Intraoperative computer-assisted imaging also is beneficial for determining the extent and location of the resection to ensure complete bone bridge removal.24
To our knowledge, a direct approach through parapatellar arthrotomy for the resection of a centrally located distal femoral physeal bone bridge has not been previously described. This novel technique provided direct access to the physeal bone bridge and was performed without injuring the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which may grow normally in the absence of the bridge. Instead of using a lateral or medial approach with a metaphyseal window,4 we directly approached this central bar through a parapatellar approach and were able to completely resect it under direct visualization. This obviated the need for an arthroscope or dental mirror. To remove the entire physeal bone bridge, we needed to resect completely from the anterior cortex to the posterior cortex. Although this technique potentially increased the risk of iatrogenic fracture, we believed that this risk would not differ greatly from that of disrupting the medial or lateral metaphysis and would be more stable with either axial and torsion load. At 3-year follow-up, the patient exhibited restored normal growth in his operative limb relative to that in his nonoperative limb, had not developed angular deformity, and had maintained his previously developed limb-length discrepancy that could be corrected with the epiphysiodesis of his opposite limb at a later date.
The limitations to this technique include the fact that it may be most effective with small-to moderate-sized central physeal bone bridges, although resection has shown good results with up to 70% physeal involvement.8 In this patient, the bone bridge was moderately sized (30% of the physis), centrally located, and clearly visible on fluoroscopy. These characteristics increased the technical safety and ease of the procedure. The resection of large, peripheral bridges may destabilize the distal femur. The destabilization of the distal femur, in turn, can lead to fracture. Patellofemoral mechanics may also be affected during the treatment of distal femoral physeal bone bridges. This patient has not experienced any patellofemoral dysfunction or symptoms. Given the patient’s age and significant amount of remaining growth, he will need close monitoring until he reaches skeletal maturity.
This paper will be judged for the Resident Writer’s Award.
1. Murphy GA. Disorders of tendons and fascia and adolescent and adult pes planus. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. 12th edition. Philadelphia, PA: Mosby-Elsevier; 2013:3966-3972.
2. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
3. Stans AA. Excision of physeal bar. In: Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1244-1249.
4. Loraas EK, Schmale GA. Endoscopically aided physeal bar takedown and guided growth for the treatment of angular limb deformity. J Pediatr Orthop B. 2012;21(4):348-351. doi:10.1097/BPB.0b013e328346d308.
5. Inoue T, Naito M, Fuhii T, Akiyoshi Y, Yoshimura I, Takamura K. Partial physeal growth arrest treated by bridge resection and artificial dura substitute interposition. J Pediatr Orthop B. 2006;15(1):65-69. doi:10.1097/01202412-200601000-00014.
6. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27(6):703-708. doi:10.1097/BPO.0b013e3180dca0e5.
7. Langenskiöld A. Surgical treatment of partial closure of the growth plate. J Pediatr Orthop. 1981;1(1):3-11. doi:10.1097/01241398-198101010-00002.
8. Marsh JS, Polzhofer GK. Arthroscopically assisted central physeal bar resection. J Pediatr Orthop. 2006;26(2):255-259. doi:10.1097/01.bpo.0000218533.43986.e1.
9. Williamson RV, Staheli LT. Partial physeal growth arrest: treatment by bridge resection and fat interposition. J Pediatr Orthop. 1990;10(6):769-776. doi:10.1097/01241398-199011000-00012.
10. Moreta J, Abril JC, Miranda C. Arthroscopy-assisted resection-interposition of post-traumatic central physeal bridges. Rev Esp Cir Orthop Traumatol. 2013;57(5):333-339. doi:10.1016/j.recot.2013.07.004.
11. Hasler CC, Foster BK. Secondary tethers after physeal bar resection: a common source of failure? Clin Orthop Relat Res. 2002;405:242-249.
12. Paley D, Bhave A, Herzenberg JE, Bowen JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82(10):1432-1446. doi:10.2106/00004623-200010000-00010.
13. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
14. Rathjen KE, Kim HKW. Physeal injuries and growth disturbances. In: Flynn JM, Skaggs DL, Waters PM, eds. Rockwood and Wilkins’ Fractures in Children. 8th edition. Philadelphia, PA: Wolters-Kluwer; 2015:135-137.
15. Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972;12(4):275-281. doi:10.1097/00005373-197204000-00002.
16. Pritchett JW. Longitudinal growth and growth-plate activity in the lower extremity. Clin Orthop Relat Res. 1992;275:274-279.
17. Cassebaum WH, Patterson AH. Fracture of the distal femoral epiphysis. Clin Orthop Relat Res. 1965;41:79-91. doi:10.1097/00003086-196500410-00009.
18. Dahl WJ, Silva S, Vanderhave KL. Distal femoral physeal fixation: are smooth pins really safe? J Pedatir Orthop. 2014;34(2):134-138. doi:10.1097/BPO.0000000000000083.
19. Roberts J. Fracture separation of the distal femoral epiphyseal growth line. J Bone Joint Surg Am. 1973;55:1324.
20. Broughton NS, Dickens DR, Cole WG, Menelaus MB. Epiphyseolysis for partial growth plate arrest. Results after four years or at maturity. J Bone Joint Surg Br. 1989;71(1):13-16. doi:10.1302/0301-620X.71B1.2914983.
21. Hresko MT, Kasser JR. Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am. 1989;71(5):698-703. doi:10.2106/00004623-198971050-00009.
22. Lurie B, Koff MF, Shah P, et al. Three-dimensional magnetic resonance imaging of physeal injury: reliability and clinical utility. J Pediatr Orthop. 2014;34(3):239-245. doi:10.1097/BPO.0000000000000104.
23. Sailhan F, Chotel F, Guibal AL, et al. Three-dimensional MR imaging in the assessment of physeal growth arrest. Eur Radiol. 2004;14(9):1600-1608. doi:10.1007/s00330-004-2319-z.
24. Kang HG, Yoon SJ, Kim JR. Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br. 2010;92(10):1452-1455. doi:10.1302/0301-620X.92B10.24587.
1. Murphy GA. Disorders of tendons and fascia and adolescent and adult pes planus. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. 12th edition. Philadelphia, PA: Mosby-Elsevier; 2013:3966-3972.
2. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
3. Stans AA. Excision of physeal bar. In: Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1244-1249.
4. Loraas EK, Schmale GA. Endoscopically aided physeal bar takedown and guided growth for the treatment of angular limb deformity. J Pediatr Orthop B. 2012;21(4):348-351. doi:10.1097/BPB.0b013e328346d308.
5. Inoue T, Naito M, Fuhii T, Akiyoshi Y, Yoshimura I, Takamura K. Partial physeal growth arrest treated by bridge resection and artificial dura substitute interposition. J Pediatr Orthop B. 2006;15(1):65-69. doi:10.1097/01202412-200601000-00014.
6. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27(6):703-708. doi:10.1097/BPO.0b013e3180dca0e5.
7. Langenskiöld A. Surgical treatment of partial closure of the growth plate. J Pediatr Orthop. 1981;1(1):3-11. doi:10.1097/01241398-198101010-00002.
8. Marsh JS, Polzhofer GK. Arthroscopically assisted central physeal bar resection. J Pediatr Orthop. 2006;26(2):255-259. doi:10.1097/01.bpo.0000218533.43986.e1.
9. Williamson RV, Staheli LT. Partial physeal growth arrest: treatment by bridge resection and fat interposition. J Pediatr Orthop. 1990;10(6):769-776. doi:10.1097/01241398-199011000-00012.
10. Moreta J, Abril JC, Miranda C. Arthroscopy-assisted resection-interposition of post-traumatic central physeal bridges. Rev Esp Cir Orthop Traumatol. 2013;57(5):333-339. doi:10.1016/j.recot.2013.07.004.
11. Hasler CC, Foster BK. Secondary tethers after physeal bar resection: a common source of failure? Clin Orthop Relat Res. 2002;405:242-249.
12. Paley D, Bhave A, Herzenberg JE, Bowen JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82(10):1432-1446. doi:10.2106/00004623-200010000-00010.
13. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
14. Rathjen KE, Kim HKW. Physeal injuries and growth disturbances. In: Flynn JM, Skaggs DL, Waters PM, eds. Rockwood and Wilkins’ Fractures in Children. 8th edition. Philadelphia, PA: Wolters-Kluwer; 2015:135-137.
15. Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972;12(4):275-281. doi:10.1097/00005373-197204000-00002.
16. Pritchett JW. Longitudinal growth and growth-plate activity in the lower extremity. Clin Orthop Relat Res. 1992;275:274-279.
17. Cassebaum WH, Patterson AH. Fracture of the distal femoral epiphysis. Clin Orthop Relat Res. 1965;41:79-91. doi:10.1097/00003086-196500410-00009.
18. Dahl WJ, Silva S, Vanderhave KL. Distal femoral physeal fixation: are smooth pins really safe? J Pedatir Orthop. 2014;34(2):134-138. doi:10.1097/BPO.0000000000000083.
19. Roberts J. Fracture separation of the distal femoral epiphyseal growth line. J Bone Joint Surg Am. 1973;55:1324.
20. Broughton NS, Dickens DR, Cole WG, Menelaus MB. Epiphyseolysis for partial growth plate arrest. Results after four years or at maturity. J Bone Joint Surg Br. 1989;71(1):13-16. doi:10.1302/0301-620X.71B1.2914983.
21. Hresko MT, Kasser JR. Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am. 1989;71(5):698-703. doi:10.2106/00004623-198971050-00009.
22. Lurie B, Koff MF, Shah P, et al. Three-dimensional magnetic resonance imaging of physeal injury: reliability and clinical utility. J Pediatr Orthop. 2014;34(3):239-245. doi:10.1097/BPO.0000000000000104.
23. Sailhan F, Chotel F, Guibal AL, et al. Three-dimensional MR imaging in the assessment of physeal growth arrest. Eur Radiol. 2004;14(9):1600-1608. doi:10.1007/s00330-004-2319-z.
24. Kang HG, Yoon SJ, Kim JR. Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br. 2010;92(10):1452-1455. doi:10.1302/0301-620X.92B10.24587.
TAKE-HOME POINTS
- Central physeal arrest of the distal femur is challenging, but this surgical technique provides an option for treatment.
- Partial bone bridges can be resected, but advanced imaging with MRI or CT, or both, is helpful in preoperative planning.
- Regardless of the type of physeal bar resection that is chosen, it is unlikely that complete, normal bone growth will be restored and closed follow up will be needed.
