The FDR (Femoral Derotaton) Trail.

Overview

Femoral derotational osteotomy is the gold standard to correct symptomatic patients with increased femoral AV. There is no clear evidence in the literature supporting which surgical technique or implant that should be used. Traditionally these patients are treated with an open osteotomy and plate and screw fixation. In recent years intramedullary nailing with adolescent interlocking nail has been described and has shown to be a safe method. Percutaneous osteotomy and intramedullary nailing is considered a less invasive technique compared with open osteotomy and plate and screw fixation.

The primary objective of this project, is to investigate if derotational osteotomy by means of percutaneous osteotomy and nailing is a safe and accurate method compared to an open approach and plating.

Full Title of Study: “Derotational Femoral Osteotomy With Either Percutaneous Osteotomy and Intramedullary Nailing or Open Approach and Plating – a Randomized Controlled Trail”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Treatment
    • Masking: Single (Outcomes Assessor)
  • Study Primary Completion Date: June 15, 2023

Detailed Description

Introduction:

Gait deviations in children may be caused by excessive femoral anteversion (AV). This rotational deformity is usually self-limiting but is a common cause of parental concern. Femoral anteversion is an inward twisting (rotation) of the femur. Excessive femoral anteversion causes the patients knees and feet to turn inwards and have a "pigeon-toed" appearance. The AV angle can be measured in the transverse plane by a line through the centre of the femoral head and neck and a tangential line across of the posterior femoral condyles. In the majority of cases of increased femoral AV, normalization occurs spontaneously during growth.

Persisting excessive femoral torsion after the age of 8 years may lead to tripping and anterior hip and knee pain. Recent studies have shown that increased internal rotation is a risk factor for patellofemoral instability and may result in patellofemoral contact pressure.

There are no studies supporting conservative treatment with physiotherapy or braces. Femoral derotational osteotomy is the gold standard to correct symptomatic patients with increased femoral AV. Several techniques have been described and there is no clear evidence in the literature supporting which surgical technique or implant that should be used (3). Traditionally these patients are treated with an open osteotomy and plate and screw fixation. In recent years intramedullary nailing with adolescent interlocking nail has been described both for rotational osteotomies and femoral fractures. With a lateral trochanteric entry point this has been shown to be a safe method. Percutaneous osteotomy and intramedullary nailing is considered a less invasive technique compared with open osteotomy and plate and screw fixation.

Study aims:

The investigators want to compare percutaneous osteotomy and intramedullary nailing with an open approach and plating with interlocking screws, in a randomized, controlled single-center trial. Our hypothesis is that percutaneous osteotomy and intramedullary nailing is non-inferior in the treatment of increased femoral AV, compared to open approach with plate fixation.

The primary outcome measure is to measure the accuracy of the derotation at 12 months by CT scan.

Study design and methodology:

The study is a randomized non-inferiority trail comparing operative treatment of patients with symptomatic increased idiopathic femoral anteversion. There are two arms: (1) Open approach and plating and (2) percutaneous osteotomy and intramedullary nailing. The allocation ratio is 1:1.We will recruit patients in the age 10-18 years of age, referred to the Orthopedic department, Oslo University Hospital. A pediatric orthopedic surgeon will verify that the patient meets the inclusion criteria, and the patient will be given thorough oral and written information. After signed consent, the randomization allocation to treatment method will be performed by means of a web-solution made by NTNU WebCRF system with the approval from the OUS Head of Patient Security.

Follow-up:

The study patients will be followed-up over a one year period (6 weeks, 12 weeks, 12 months). All patients will be tested with 3 d gait analysis at 12 months and will be compared with the patients preoperativ 3 D gait analysis. All reoperations will be recorded.

Interventions

  • Device: Adolescent Lateral Entry Femoral Nail-EX (ALFN)
    • The use of an less invasive implant that has the same accuracy.
  • Device: Pediatric LCP Hip Plate System
    • Open approach to the femur where the osteotomy and osteofixation with plate and screws are preformed

Arms, Groups and Cohorts

  • Active Comparator: The Synthes Pediatric LCP Plate System
    • Open osteotomy and osteofixation with the pediatric LCP hip plate
  • Experimental: The Synthes Expert ALFN. Adolescent Lateral Femoral Nail
    • Percutaneous osteotomy and intramedullary nailing

Clinical Trial Outcome Measures

Primary Measures

  • Accuracy of the derotation
    • Time Frame: post operative (day1)
    • Accuracy of the derotation measured in degrees on CT comparing the intended/planned correction with the actual derotation

Secondary Measures

  • Knee Injury and Osteoarthritis Outcome Score for Children (KOOS-Child)
    • Time Frame: Baseline, 26 week and 52 week follow-up
    • 39 items divided in 5 subscales; Pain, other Symptoms (titled as “knee problems”), Difficulty during daily activities (ADL), Function in sport and play (Sport/Play) and Knee related Quality of Life (QOL). The last week is taken into consideration when answering the questions. Standardized answer options are given (5 Likert boxes) and each question gets a score from 0 to 4. A normalized score (100 indicating no symptoms and 0 indicating extreme symptoms) is calculated for each subscale.
  • Visual analoge scale
    • Time Frame: Baseline, daily first six week. 4 times a day.
    • General visual analog scale (VAS) for pain. scale is 0-10, where 10 is maximum pain og 0 is no pain. The scale is a 10 cm long line where the patient sets a mark. The actual level of pain is than measured on the scale from 0-10 (e.g. mark is at 5,5 cm – pain score 5,5)
  • KIDSCREEN-27
    • Time Frame: Baseline, 26 week, 52 week follow-up
    • The KIDSCREEN-27 is a globally used standardized health-related quality of life questionnaire measuring five Rasch scaled dimensions of wellbeing including: (1) Physical Well-being (5 items), (2) Psychological Well-being (7 items), (3) Autonomy and Parents (7 items), (4) Peers and Social Support (4 items), and (5) School Environment (4 items). Responses are indicated using a 5-point ordinal scale with responses ranging from ‘never’ to ‘always’, ‘not at all’ to ‘extremely’, or ‘poor’ to ‘excellent’.

Participating in This Clinical Trial

Inclusion Criteria

  • Indication for surgery based on a combination of symptoms, clinical evaluation and radiographic findings (femoral AV angle ≥ 30°) and age 10-18 years.

The clinical evaluation includes measurement of limb lengths, varus/valgus alignment of the extremity and range of motion of the hips and knees.

The torsion of the lower limbs will be assessed by CT examination. Four sections are needed: one through the centre of the femoral head, one through the centre of the femoral neck, one tangent to the posterior femoral condyles at the level of the patella, and one through the distal tibia, showing the medial and lateral malleolus.

Exclusion Criteria

  • Patients will be excluded from the study if they meet any of the following criteria:
  • Previous femoral injury or illness which reduces the function of the extremity
  • Systemic or chronic injury or illness which reduces the function of the extremity
  • If the patient is not able to comply with study procedures

Gender Eligibility: All

Minimum Age: 10 Years

Maximum Age: 18 Years

Are Healthy Volunteers Accepted: Accepts Healthy Volunteers

Investigator Details

  • Lead Sponsor
    • Oslo University Hospital
  • Provider of Information About this Clinical Study
    • Principal Investigator: Anders Grønseth, M.D. Principal Investigator – Oslo University Hospital
  • Overall Official(s)
    • Anders Grønseth, M.D, Principal Investigator, Oslo University Hospital
  • Overall Contact(s)
    • Anders Grønseth, M.D, 004791320205, andgro@ous-hf.no

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