Case Report
 
Surgical management for tibial shaft fractures using flexible nailing in adult hypophosphatasia
Jay N. Patel1, Priyal V. Bhagat2, Li Sun1, Juluru Rao1
1RWJBarnabas Health, Jersey City Medical Center, Department of Orthopedic Surgery, 355 Grand St, Jersey City, New Jersey, USA
2Northwell Health, Lenox Hill Hospital, 130 E 77th Street, New York, USA

Article ID: Z01201801CR10874JP
doi: 10.5348/ijcri-201805-CR-10874

Corresponding Author:
Jay N. Patel,
RWJBarnabas Health - Jersey City Medical Center,
Department of Orthopaedic Surgery,
355 Grand St, Jersey City,
07302, USA

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Patel JN, Bhagat PV, Sun L, Rao J. Surgical management for tibial shaft fractures using flexible nailing in adult hypophosphatasia. Int J Case Rep Images 2018;9(1):38–42.


ABSTRACT

Introduction: Adult hypophosphatasia (HPP) is a rare inheritable metabolic disease affecting primarily the skeletal system resulting in decreased mineralization of bone. Hypophosphatasia has a variable inheritance pattern with the more severe form inherited as autosomal recessive. The diagnosis is based on decreased serum alkaline phosphatase (ALP) and an increased urinary phosphorylethanolamine (PEA). Patients with HPP suffer from multiple fractures, have limited mobility, rely on the use of assistive devices, and have a diminished quality of life.
Case Report: A 47-year-old female was presented with a pathologic tibial shaft fracture that was treated with a flexible nail.
Conclusion: Currently, there are no definitive treatment guidelines for fracture care in adults with HPP. Load sharing devices have been recommended due to their load-sharing properties and the osteoporotic bone quality in affected patients.

Keywords: Adult hypophosphatasia, Flexible nailing, Metabolic syndrome, Tibial shaft fracture, Trauma


INTRODUCTION

Adult hypophosphatasia (HPP) is a rare inheritable metabolic disease affecting primarily the skeletal system. Hypophosphatasia caused by defective production of alkaline phosphatase (ALP) [1]. Alkaline phosphatase is a crucial enzyme in the mineralization process of the skeleton and can be found in chondrocytes, cartilage matrix, and teeth. It is essential in the catabolism of inorganic pyrophosphate (PPi) and other molecules. Decreased production of ALP leads to the endogenous accumulation and toxicity of PPi. The PPi accumulation causes defective skeletal mineralization manifesting as osteomalacia and development of articular chondrocalcinosis in affected adults [2][3].

Hypophosphatasia affects males and females equally. It has a variable distribution worldwide with an increased frequency in Canada, with a prevalence estimated to be 1:100000 [4]. Mornet et al. [4] have proposed a genetic model concluding the prevalence of dominant mild HPP in the European population is about 1/6370 [5]. The ALP gene is located on the short-arm of chromosome 1. Hypophosphatasia can be inherited in an autosomal dominant or recessive pattern [6]. The severity of disease is correlated with the pattern of inheritance and is dependent on the large number of missense mutations. Milder forms that reduce but do not completely suppress ALP activity can be inherited as either autosomal dominant or recessive [7][8]. More severe forms of HPP are transmitted as autosomal recessive traits that suppress ALP activity almost completely.

Diagnosis is based on serum alkaline phosphatase assay of the liver/bone/kidney alkaline phosphatase gene [9]. In HPP patients >20 years old, ALP levels below 40 U/L is suspicious for HPP [10][11]. The presence of phosphorylethanolamine (PEA) in the urine can also be used in diagnosing HPP [12]. The amount of urinary PEA excreted daily has been used to identify heterozygous carriers of the HPP trait. Though these patients excrete only 10–20% of the amount of PEA as their homozygotes counterparts, these levels are still three to five times higher than the normal population [13].

Hypophosphatasia is characterized by a variety of signs and symptoms. Individuals may present with a history of rickets during childhood or premature loss of their baby teeth. Patients may also present with chondrocalcinosis, pseudogout, joint inflammation, chronic bone pain, and other dental abnormalities [14][15]. Frequently, affected individuals experience multiple fractures from low energy mechanisms, which in otherwise healthy individuals would not result in any injury. Most commonly, patients present with fractures of the femur and feet [16]. Decreased bony healing due to the PPi toxicity may lead to pseudofractures and bowing of the long bones [15].


CASE REPORT

A 47-year-old female presented to our institution after a mechanical fall trying to get onto her motorized scooter. The patient twisted her ankle and felt a sharp pain in the anterior aspect of her lower leg. Past medical history of the patient was significant for hypophosphatasia with multiple bilateral tibial shaft fractures treated conservatively. Patient was a non-ambulator who relied on the use of a motorized scooter to get around. At the time, the patient was not on any medical treatment regimen for her hypophosphatasia. On physical examination the patient was noted to have procurvatum and valgus deformities of both of her legs. X-ray of the patient showed a transverse fracture of the left distal third tibia and fibula with sclerotic fracture ends (Figure 1). Patient also had an ALP value of <20.0 IU on admission.

A stab incision was made on the lateral aspect of the proximal tibia, just below the tibial plateau. A drill bit was used to create an entry hole in the tibia. A 4 mm flexible nail was passed down the tibia to the fracture site. At the fracture site we encountered sclerotic fracture ends from the multiple previous fractures. This made it difficult to pass the 4 mm flexible nail down the tibial shaft. A mallet was used to tap the wire through the sclerotic ends, into the distal tibial shaft. A similar entry hole was made on the medial side of the tibia. A second 4 mm wire was too large to fit into the canal so smaller caliber flexible nails were attempted to be passed down the tibial canal. Due to the smaller size of the nails, they kept bending when we attempted to mallet them down the tibial shaft past the sclerotic fracture ends. The fracture site was not opened to clean out the sclerotic fracture ends because we did not want to disturb the blood supply around the fracture site with soft tissue and periosteal stripping. The fracture was found to be stable with a single 4 mm nail when stress was applied to the fracture site. The contralateral side was also found to be stable under fluoroscopic stress testing.

At first year follow-up, X-rays showed callus formation (Figure 2). The patient reported no pain at the fracture site. The patient was now able to bear weight on the operative leg and able to ambulate around her home using an assistive device. Previously, she was dependent on a motorized scooter and unable to walk even short distances. The patient reported no pain in her operative leg. It should be noted that recently, our patient has started enzyme replacement therapy with asfotase alfa to treat her HPP.


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Figure 1: Preoperative and intraoperative radiographs demonstrating transverse tibial and fibular shaft fractures. Patient has procurvatum and valgus deformities of her tibia and fibula. Note the sclerotic fractures ends from multiple previous fractures in the same area.


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Figure 2: Radiograph at first year demonstrating healing of the tibial shaft fracture as well as correction of the patient’s valgus deformity.


DISCUSSION

Weber et al. [17] investigated the patient-reported burden of disease and quality of life using two surveys in patients with HPP. Eighty-six percent of their patients had sustained at least one fracture and nearly 50% reported more than six fractures. At the time of their survey, 34% of patients reported currently using an assistive device to walk and 22% reported the use of a wheelchair. It is important to note that 69% of patients reported that their walking had worsened since their HPP diagnosis and that no patients reported improvement in walking. Furthermore, 32% of patients reported that they had to modify their homes due to HPP-related physical limitations. The burden of disease is high in adults with HPP, necessitating finding not only pharmacological treatments but also surgical fixation strategies to help improve the quality of life in these patients. Currently, new pharmacologic treatment includes using enzyme replacement therapy with asfotase alfa to help replace ALP. Recent literature shows asfotase alfa to be effective in treating, decreasing the burden of disease, and improving overall survival of HPP patients [18][19].

There is a paucity of literature on surgically treating fractures in adults with HPP. Treatment of these patients should be tailored to their preinjury level of functionality and ambulation. Due to our patient’s preinjury ambulation status and wishes, we did not perform an osteotomy to properly correct the patient’s procurvatum and valgus deformities. We felt the patient would benefit from stabilization using flexible nails and any correction we were able to achieve using manual traction, being prudent not to cause any iatrogenic fractures due to the bone quality.

In their series of femoral fractures and pseudofractures in HPP patients, Coe et al. [20] concluded that non-operative management cannot be relied upon to adequately relieve pain or to heal fractures/pseudofractures due to the underlying problems in skeletal mineralization. They recommended treatment with load-sharing devices. The decreased stress shielding properties of load sharing devices helps promote remodeling in patients with osteoporotic bone compared to load bearing devices. Flexible nails have been used since the 1930s in the treatment of fractures. Flexible nails work by providing multiple points of contact, depending on the number and their configuration, along the inner aspect of the cortex. The original flexible nails were stiffer and made out of stainless steel [21][22]. Modern day flexible nails are made out of titanium, which has been shown in biomechanical studies to provide better rotational, and axial compression stiffness than their stainless steel counterparts [23].

DeLong et al. [24] had success with treating long bone fractures in adults with flexible, stainless steel nails. In their series, 41 out of 49 tibial shaft fractures healed within five months. The majority of these fractures was due to high-energy mechanisms and included open fractures. With the advent of modern day intramedullary nails, the use of the flexible nails for the treatment of long bone in fractures in adults has decreased. However, they still continue to be a good method of fixation in adults with length stable fracture patterns due to their cost and shorter surgical times [25][26][27][28][29]. Flexible nails may be a viable treatment option in adults with length stable, pathologic fractures in osteoporotic bone.


CONCLUSION

Overall, the burden of disease is high in adults with hypophosphatasia (HPP), resulting in limited mobility, use of assistive devices, and diminished quality of life. Loading sharing devices promote bone healing and callus formation and have decreased stress-shielding properties. Flexible nails can be a viable treatment option in adults with poor bone quality with length stable, pathologic fractures. Further long-term studies are needed on adult patients with HPP to make more definitive surgical treatment recommendations.


REFERENCES
  1. Scriver CR, Kaufman S. Hyperphenylalaninemia: Phenylalanine hydroxylase deficiency. In: Scriver CR, Beaudet AL, Sly SW, et al. editors. The Metabolic and Molecular Bases of Inherited Disease. 8ed. New York: McGaw-Hill; 2001. p. 1667–724.    Back to citation no. 1
  2. Caswell AM, Whyte MP, Russell RG. Hypophosphatasia and the extracellular metabolism of inorganic pyrophosphate: Clinical and laboratory aspects. Crit Rev Clin Lab Sci 1991;28(3):175–232.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Cole DE. Hypophosphatasia update: Recent advances in diagnosis and treatment. Clin Genet 2008 Mar;73(3):232–5.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Ornoy A, Adomian GE, Rimoin DL. Histologic and ultrastructural studies on the mineralization process in hypophosphatasia. Am J Med Genet 1985 Dec;22(4):743–58.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Mornet E, Yvard A, Taillandier A, Fauvert D, Simon-Bouy B. A molecular-based estimation of the prevalence of hypophosphatasia in the European population. Ann Hum Genet 2011 May;75(3):439–45.   [CrossRef]   [Pubmed]    Back to citation no. 5
  6. Smith M, Weiss MJ, Griffin CA, et al. Regional assignment of the gene for human liver/bone/kidney alkaline phosphatase to chromosome 1p36.1-p34. Genomics 1988 Feb;2(2):139–43.   [Pubmed]    Back to citation no. 6
  7. Mornet E. Hypophosphatasia. Orphanet J Rare Dis 2007 Oct 4;2:40.   [CrossRef]   [Pubmed]    Back to citation no. 7
  8. Mornet E. Hypophosphatasia. Best Pract Res Clin Rheumatol 2008 Mar;22(1):113–27.   [CrossRef]   [Pubmed]    Back to citation no. 8
  9. Cheung CP, Suhadolnik RJ. Analysis of inorganic pyrophosphate at the picomole level. Anal Biochem 1977 Nov;83(1):61–3.   [CrossRef]   [Pubmed]    Back to citation no. 9
  10. Mornet E, Nunes ME. Hypophosphatasia. In: Pagon RA, Bird TD, Dolan CR, Stephen K, editors. GeneReviews. Seattle, WA: University of Washington, Seattle; 1993.    Back to citation no. 10
  11. Rathbun JC. Hypophosphatasia: A new developmental anomaly. Am J Dis Child 1948 Jun;75(6):822–31.   [Pubmed]    Back to citation no. 11
  12. Rockman-Greenberg C. Hypophosphatasia. Pediatr Endocrinol Rev 2013 Jun;10 Suppl 2:380–8.   [Pubmed]    Back to citation no. 12
  13. Rasmussen K. Phosphorylethanolamine and hypophosphatasia. Dan Med Bull 1968 Sep;15:Suppl 2:1–112.   [Pubmed]    Back to citation no. 13
  14. Berkseth KE, Tebben PJ, Drake MT, Hefferan TE, Jewison DE, Wermers RA. Clinical spectrum of hypophosphatasia diagnosed in adults. Bone 2013 May;54(1):21–7.   [CrossRef]   [Pubmed]    Back to citation no. 14
  15. Whyte MP. Hypophosphatasia: Aetiology, nosology, pathogenesis, diagnosis and treatment. Nat Rev Endocrinol 2016 Apr;12(4):233–46.   [CrossRef]   [Pubmed]    Back to citation no. 15
  16. Khandwala HM, Mumm S, Whyte MP. Low serum alkaline phosphatase activity and pathologic fracture: Case report and brief review of hypophosphatasia diagnosed in adulthood. Endocr Pract 2006 Nov–Dec;12(6):676–81.   [CrossRef]   [Pubmed]    Back to citation no. 16
  17. Weber TJ, Sawyer EK, Moseley S, Odrljin T, Kishnani PS. Burden of disease in adult patients with hypophosphatasia: Results from two patient-reported surveys. Metabolism 2016 Oct;65(10):1522–30.   [CrossRef]   [Pubmed]    Back to citation no. 17
  18. Whyte MP, Rockman-Greenberg C, Ozono K, et al. Asfotase alfa treatment improves survival for perinatal and infantile hypophosphatasia. J Clin Endocrinol Metab 2016 Jan;101(1):334–42.   [CrossRef]   [Pubmed]    Back to citation no. 18
  19. Hofmann C, Seefried L, Jakob F. Asfotase alfa: Enzyme replacement for the treatment of bone disease in hypophosphatasia. Drugs Today (Barc) 2016 May;52(5):271–85.   [CrossRef]   [Pubmed]    Back to citation no. 19
  20. Coe JD, Murphy WA, Whyte MP. Management of femoral fractures and pseudofractures in adult hypophosphatasia. J Bone Joint Surg Am 1986 Sep;68(7):981–90.   [CrossRef]   [Pubmed]    Back to citation no. 20
  21. Rush LV. Dynamic factors in medullary pinning of fractures. Am Surg 1951 Sep;17(9):803–8.   [Pubmed]    Back to citation no. 21
  22. Ender J, Simon-Weidner R. Die fixierung der trochanteren Brüche mit runden elastischen Condylennägeln. [Article in German]. Acta Chir Austria 1970;1:40.    Back to citation no. 22
  23. Mahar AT, Lee SS, Lalonde FD, Impelluso T, Newton PO. Biomechanical comparison of stainless steel and titanium nails for fixation of simulated femoral fractures. J Pediatr Orthop 2004 Nov–Dec;24(6):638–41.   [CrossRef]   [Pubmed]    Back to citation no. 23
  24. DeLong WG Jr, Born CT, Marcelli E, Shaikh KA, Iannacone WM, Schwab CW. Ender nail fixation in long bone fractures: Experience in a level I trauma center. J Trauma 1989 May;29(5):571–6.   [Pubmed]    Back to citation no. 24
  25. Dasgupta S, Banerji D, Mitra UK, Ghosh PK, Ghosh S, Ghosh B. Studies on Ender's intramedullary nailing for closed tibial shaft fractures. J Indian Med Assoc 2011 Jun;109(6):375–7.   [Pubmed]    Back to citation no. 25
  26. Hussain R, Umer M, Umar M. Treatment of tibial diaphyseal fractures with closed flexible intramedullary ender nails: 39 fractures followed for a period of two to seven years. J Pak Med Assoc 2001 May;51(5):190–3.   [Pubmed]    Back to citation no. 26
  27. Segal D. Flexible intramedullary nailing of tibial shaft fractures. Instr Course Lect 1987;36:338–49.   [Pubmed]    Back to citation no. 27
  28. Behr JT, Apel DM, Pinzur MS, Dobozi WR, Behr MJ. Flexible intramedullary nails for ipsilateral femoral and tibial fractures. J Trauma 1987 Dec;27(12):1354–7.   [Pubmed]    Back to citation no. 28
  29. Pankovich AM, Tarabishy IE, Yelda S. Flexible intramedullary nailing of tibial-shaft fractures. Clin Orthop Relat Res 1981 Oct;(160):185–95.   [Pubmed]    Back to citation no. 29

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Author Contributions
Jay N. Patel – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Priyal V. Bhagat – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Li Sun – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Juluru Rao – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of Submission
The corresponding author is the guarantor of submission.
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Conflict of Interest
Authors declare no conflict of interest.
Copyright
© 2018 Jay N. Patel et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.