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The aetiology of rickets-like lower limb deformities in Malawian children.
Osteoporos Int 2016; 27(7):2367-2372OI

Abstract

Debilitating rickets-like lower limb deformities are common in children throughout the world, particularly in Malawi, Africa where the causes are unknown. We have identified that Blount disease and calcium deficiency rickets are the likely causes of these deformities and propose calcium supplementation as a potential treatment of Malawian rickets.

INTRODUCTION

Surgical correction of rickets-like lower limb deformities is the most common paediatric operation performed at Beit Cure Orthopaedic Hospital, Malawi. The aim of this study was to investigate the aetiology of these deformities.

METHODS

Children with a tibio-femoral angle of deformity >20° were enrolled (n = 42, 3.0-15.0 years). Anthropometric and early life and well-being data were collected. Early morning serum and urine samples were collected on the morning of the operation for markers of calcium and phosphate homeostasis. Knee radiographs were obtained, and the children were diagnosed with either Blount (BD, n = 22) or evidence of rickets disease (RD, n = 20). As BD is a mechanical rather than metabolic disease, BD were assumed to be biochemically representative of the local population and thus used as a local reference for RD.

RESULTS

There were no differences in anthropometry or early life experiences between BD and RD. Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D, total alkaline phosphatase and urinary phosphate were significantly higher and serum phosphate, 25-hydroxyvitamin D (25OHD) and tubular maximal reabsorption of phosphate significantly lower in RD than BD. There was no difference in serum calcium, fibroblast growth factor 23 or markers of iron status between groups. All children had 25OHD > 25 nmol/L.

CONCLUSIONS

Vitamin D deficiency is not implicated in the aetiology of RD or BD in Malawian children. The cause of RD in Malawi is likely to be dietary calcium deficiency leading to elevated PTH resulting in increased losses of phosphate from the bone and glomerular filtrate. The causes of BD remain unclear; there was no evidence in support of previously suggested risk factors such as being overweight or starting to walk early. Prior to surgical intervention, supplementation with calcium should be considered for children with RD.

Authors+Show Affiliations

MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge, UK. vickie.braithwaite@mrc-hnr.cam.ac.uk.Department of Paediatric Orthopaedics, Robert Jones Agnes Hunt NHS Foundation Trust, Oswestry, Shropshire, UK.MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge, UK.Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge, UK.Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK.Department of Oncology and Metabolism, Academic Unit of Child Health, University of Sheffield, Sheffield, UK.Department of Oncology and Metabolism, Academic Unit of Child Health, University of Sheffield, Sheffield, UK.Beit Cure Orthopaedic Hospital, Blantyre, Malawi.MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge, UK. MRC Keneba, Keneba, The Gambia.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

27059923

Citation

Braithwaite, V S., et al. "The Aetiology of Rickets-like Lower Limb Deformities in Malawian Children." Osteoporosis International : a Journal Established as Result of Cooperation Between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, vol. 27, no. 7, 2016, pp. 2367-2372.
Braithwaite VS, Freeman R, Greenwood CL, et al. The aetiology of rickets-like lower limb deformities in Malawian children. Osteoporos Int. 2016;27(7):2367-2372.
Braithwaite, V. S., Freeman, R., Greenwood, C. L., Summers, D. M., Nigdikar, S., Lavy, C. B. D., ... Prentice, A. (2016). The aetiology of rickets-like lower limb deformities in Malawian children. Osteoporosis International : a Journal Established as Result of Cooperation Between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 27(7), pp. 2367-2372. doi:10.1007/s00198-016-3541-7.
Braithwaite VS, et al. The Aetiology of Rickets-like Lower Limb Deformities in Malawian Children. Osteoporos Int. 2016;27(7):2367-2372. PubMed PMID: 27059923.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The aetiology of rickets-like lower limb deformities in Malawian children. AU - Braithwaite,V S, AU - Freeman,R, AU - Greenwood,C L, AU - Summers,D M, AU - Nigdikar,S, AU - Lavy,C B D, AU - Offiah,A C, AU - Bishop,N J, AU - Cashman,J, AU - Prentice,A, Y1 - 2016/04/08/ PY - 2015/10/21/received PY - 2016/02/08/accepted PY - 2016/4/10/entrez PY - 2016/4/10/pubmed PY - 2018/3/20/medline KW - Africa KW - Blount KW - Children KW - Genu valgum KW - Genu varum KW - Phosphate KW - Rickets SP - 2367 EP - 2372 JF - Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA JO - Osteoporos Int VL - 27 IS - 7 N2 - UNLABELLED: Debilitating rickets-like lower limb deformities are common in children throughout the world, particularly in Malawi, Africa where the causes are unknown. We have identified that Blount disease and calcium deficiency rickets are the likely causes of these deformities and propose calcium supplementation as a potential treatment of Malawian rickets. INTRODUCTION: Surgical correction of rickets-like lower limb deformities is the most common paediatric operation performed at Beit Cure Orthopaedic Hospital, Malawi. The aim of this study was to investigate the aetiology of these deformities. METHODS: Children with a tibio-femoral angle of deformity >20° were enrolled (n = 42, 3.0-15.0 years). Anthropometric and early life and well-being data were collected. Early morning serum and urine samples were collected on the morning of the operation for markers of calcium and phosphate homeostasis. Knee radiographs were obtained, and the children were diagnosed with either Blount (BD, n = 22) or evidence of rickets disease (RD, n = 20). As BD is a mechanical rather than metabolic disease, BD were assumed to be biochemically representative of the local population and thus used as a local reference for RD. RESULTS: There were no differences in anthropometry or early life experiences between BD and RD. Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D, total alkaline phosphatase and urinary phosphate were significantly higher and serum phosphate, 25-hydroxyvitamin D (25OHD) and tubular maximal reabsorption of phosphate significantly lower in RD than BD. There was no difference in serum calcium, fibroblast growth factor 23 or markers of iron status between groups. All children had 25OHD > 25 nmol/L. CONCLUSIONS: Vitamin D deficiency is not implicated in the aetiology of RD or BD in Malawian children. The cause of RD in Malawi is likely to be dietary calcium deficiency leading to elevated PTH resulting in increased losses of phosphate from the bone and glomerular filtrate. The causes of BD remain unclear; there was no evidence in support of previously suggested risk factors such as being overweight or starting to walk early. Prior to surgical intervention, supplementation with calcium should be considered for children with RD. SN - 1433-2965 UR - https://www.unboundmedicine.com/medline/citation/27059923/The_aetiology_of_rickets_like_lower_limb_deformities_in_Malawian_children_ L2 - https://dx.doi.org/10.1007/s00198-016-3541-7 DB - PRIME DP - Unbound Medicine ER -