Original article
Osteogenesis imperfecta: Treatment and results of a case series
Osteogénesis imperfecta: tratamiento y resultado de una serie de casos
R.J. Escribano Reya, J. Duart-Clementeb,
, O. Martínez de la Llanac, J.L. Beguiristáin Gúrpided
Corresponding author
a Departamento de Cirugía Ortopédica y Traumatología, Clínica San Miguel, Pamplona, Navarra, Spain
b Departamento de Cirugía Ortopédica y Traumatología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
c Servicio de Cirugía Ortopédica y Traumatología, Hospital de Cruces, Barakaldo, Vizcaya, Spain
d Departamento de Cirugía Ortopédica y Traumatología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
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Escribano Rey, J. Duart-Clemente, O. Martínez de la Llana, J.L. Beguiristáin Gúrpide" "autores" => array:4 [ 0 => array:3 [ "nombre" => "R.J." "apellidos" => "Escribano Rey" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "J." "apellidos" => "Duart-Clemente" "email" => array:1 [ 0 => "duart.julio@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "O." "apellidos" => "Martínez de la Llana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J.L." "apellidos" => "Beguiristáin Gúrpide" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía Ortopédica y Traumatología, Clínica San Miguel, Pamplona, Navarra, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía Ortopédica y Traumatología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital de Cruces, Barakaldo, Vizcaya, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Cirugía Ortopédica y Traumatología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Osteogénesis imperfecta: tratamiento y resultado de una serie de casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 865 "Ancho" => 1001 "Tamanyo" => 68878 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Seven-and-a-half-year-old patient operated on with a telescopic endomedullary nail for correction of a deformity in the femur (A). At age 15, the nail has hardly migrated at all and the shaft has been lengthened to adapt to bone growth (B). The patient did not require reintervention at any time during follow-up.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Osteogenesis imperfecta (OI) is a bone dysplasia caused by an alteration in the synthesis of type I collagen, implying abnormal bone formation. The most outstanding of its clinical manifestations is progressive bone deformity, associated with fractures or not, delayed growth, the presence of bluish sclera, anomalies in the development of teeth and hearing loss.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The classic clinical forms of OI comprise Lobstein's type and Vrolik's type. The first manifests in variable ways, with a greater or lesser degree of deformity and onset of fractures during growth and adulthood. The second is a severe form that is observable from birth, with frequent intrauterine fractures and a high mortality rate.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Sillence et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> classified the disease into 4 types depending on symptom severity and progression. An additional four types have recently been described.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The fundamental goals in terms of managing patients with this disease are: to increase the amount of bone formed and to improve its quality, to prevent the appearance of bone deformities and to treat fractures. Bisphosphonates are the only drug group seeming to have a beneficial effect on bone quality.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4–6</span></a> Deformities can be prevented or treated by means of the use of orthesis<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and surgery.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In 1959, Sofield and Millar<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> described a technique to stabilize the bone and correct the deformity: successive osteotomies were performed on the long bones and associated with endomedullary nailing. Nowadays, a variation of this technique is applied using extensible endomedullary nailing thanks to which the adaptability of the implant to the bone is improved and the re-operation rate is reduced.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of the present paper is to describe the results obtained in the treatment of OI patients at our center.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We have conducted a retrospective study of a case series of OI patients treated at our center from 1980 to 2007, with a mean follow-up of 17.3 years (7–27 years). The cases were taken continuously from the hospital's case history register, excluding those with a follow-up of less than 5 years.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The sample in our study has a total of 10 patients with a mean age, at the moment of the first consultation, of 12.7 years (4–41). Eight of them were diagnosed as having the clinical form described by Lobstein, one with Vrolick's and one with Van der Hoeve's. Nine were diagnosed as having OI during the first year of life, whereas one was only identified in the fourth decade of life. The deformities observed in the long bones of the patients in the series are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. These included 149 fractures: 98 in the lower limbs, 40 in the upper limbs and 11 in bones in the axial skeleton. Their exact location is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The descriptions given cover the treatments applied, either medical or surgical (Sofield-Millar intervention, reintervention due to migration of nails, osteosynthesis with plates, simple corrective osteotomies and other procedures), their complications and the results in terms of the patients’ functional capacity according to the Hoffer-Bullock scale<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> at the end of the follow-up. The study has evidence level <span class="elsevierStyleSmallCaps">IV</span>.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Four patients were subjected to medical treatment through the administration of bisphosphonates (alendronate) during a mean period of 3.3 years (1–5 years). In 2 of these, calcitonin was associated for 2 and 3 years, respectively. All patients received this treatment during adolescence or adulthood and were patients affected by mild forms of the condition. The doses and administration of the anti-resorption treatments were adjusted for weight and age.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Seven patients underwent some kind of surgical treatment, with a total of 83 procedures being performed, 75 of them on the lower limbs (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The most frequent was the Sofield-Millar intervention, which was applied on 37 occasions: 33 with rigid endomedullary nails (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>) and 4 with extensible endomedullary nails. In 11 cases, an open reduction was performed followed by osteosynthesis with plate and screws. On 7 occasions, it was necessary to perform corrective osteotomies on deformities and 6 procedures were for the removal of osteosynthesis material. A total of 13 surgical revision procedures were required due to migration of the endomedullary nails.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Two patients were operated on for scoliosis using posterolateral arthrodesis and posterior hybrid instrumentation; on 4 occasions elongation was performed on the lower limbs secondary to dysmetria (3 in the tibia and one in the femur).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Other complications recorded, in addition to the migration of endomedullary nails, were 17 refractures: 13 following a Sofield-Millar intervention, all on long bones, 3 following elongation and one after removing osteosynthesis material (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The record also reflects 5 pseudoarthroses (3.5% of the total fractures), one infection of a surgical wound, one osteomyelitis treated with extensive debriding, and one recurrent seroma.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The treatment outcomes by patient functionality according to the Hoffer-Bullock scale<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Thanks to the development of genetic diagnosis, seven forms of OI have been described so far. Five have a known genetic origin and 2 correspond to patients presenting an OI phenotype without the characteristic mutations in the genes involved in this disease. Sillence types <span class="elsevierStyleSmallCaps">I–IV</span> present mutations in some of the genes expressing type <span class="elsevierStyleSmallCaps">I</span> collagen.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> In general, the mildest forms occur due to mutations of an allele in the COL1A1 gene and translates into a reduction of the synthesis of type <span class="elsevierStyleSmallCaps">I</span> collagen; while the most severe forms synthesize a normal amount of structurally altered type <span class="elsevierStyleSmallCaps">I</span> collagen.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Despite the advances in understanding the disease's etiopathogenesis and discoveries in the field of genetics,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5,11</span></a> the basis for treating this condition has remained unchanged in recent years.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The aim of treatment is to provide an acceptable functional capacity in the longer term, enable bipedestation and autonomous gait by patients.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> They must be handled by means of multidisciplinary teams due to the disease's complexity and wide variability.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> From a pharmacological standpoint, different strategies have been used, such as growth hormone, sodium fluoride or vitamins C and D among other molecules,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> although the results obtained have been discouraging.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The introduction of bisphosphonates for the treatment of OI has improved outcomes.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6,14</span></a> The patients treated improve in both the illness's clinical expression and in the increase in the thickness of cortex bone and the densitometric parameters.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,14–16</span></a> Some authors have described a reduction in the early fracture rate in children with type <span class="elsevierStyleSmallCaps">III</span> OI<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> treated with endovenous bisphosphonates.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In the same way, others have described a lower number of fractures, as well as improvements in gait and function in patients with type <span class="elsevierStyleSmallCaps">VI</span> OI.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The same treatment has also led to an improvement in densitometric parameters and the same decline in the incidence of fractures.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> So far, however, it is not been possible to demonstrate the efficacy of these drugs in the prevention of deformities.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In our study, 4 of the 10 patients received medical treatment with oral bisphosphonates for periods of between one and five years. All patients received treatment during adolescence or in adulthood and suffered mild forms of the illness, so we can determine the beneficial effect of the measure.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the most severe forms of OI, surgical treatment of fractures or deformities is occasionally necessary.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> One of the most common techniques is that described by Sofield and Millar,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> comprising the correction of the deformity and subsequent stabilization through implantation of an endomedullary device to act as an internal ferrule.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The classical technique presented a high rate of complications related to the osteosynthesis material when migration or extrusion of the osteosynthesis material occurred, potentially causing additional fractures at the ends of the nail, and the possibility of recurrence of the bone deformity.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> New techniques have currently been developed to reduce the complications related to the surgical approach<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and implants. Thus, the improvement in telescopic nail design has represented a real revolution<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> in comparison with previous designs.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In our series, Sofield-Millar interventions were the most frequent. As with others,<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,24</span></a> the bones most frequently operated on were those of the lower limbs, since they are load-bearing bones, and the correction of their deformities is decisive for ensuring bipedestation and deambulation. Some authors have presented re-intervention rates of up to 60%,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20,24</span></a> with the main cause in the Sofield-Millar technique being the migration of endomedullary nails. In our experience, we have had to perform a second intervention in 35% of patients who underwent that technique, in contrast with migration-based revision rates in excess of 80% of cases with rigid nails, and refractures in 10% of cases in another study.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In cases involving telescopic nails, we have observed the breakage of the distal shaft of one of the nails implanted and one case of refracture resolved with conservative treatment. Jerosch et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> observed refracture rates of 22% and Bailey and Dubow migration rates of 44% with telescopic nails, while Esposito and Plotkin<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> presented a lower number of revisions with telescopic nails.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Patients who underwent osteosynthesis with plates represented 13% in our series. In one of the cases we observed a refracture adjacent to a prior osteosynthesis plate, while another suffered a refracture of the left femoral neck a few months after removing the osteosynthesis material from both hips and, one year later, suffered a sub-trochanter fracture of the contralateral femur (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Up to 69% of complications have been described in patients with type <span class="elsevierStyleSmallCaps">III</span> OI treated with blocked osteosynthesis plates,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> casting doubt on the advantages of this kind of implant in the most severe forms of the disease.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Bearing in mind that the main goal in treating these patients is to provide an acceptable functional capacity in the longer term in order to enable bipedestation and autonomous gait and, although there is a certain degree of variability in terms of the expected functionality, gait autonomy might range from 33% in patients with type <span class="elsevierStyleSmallCaps">III</span> OI to 100% in type I.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> In our series, we have obtained functional outcomes that are comparable to those of other studies described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,19</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Despite the need for multiple interventions and the complications seen during follow-up, adequate treatment of patients with OI can provide acceptable functional outcomes.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Evidence level</span><p id="par0115" class="elsevierStylePara elsevierViewall">Evidence level <span class="elsevierStyleSmallCaps">IV</span>.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical responsibilities</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of persons and animals</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no experiments have been conducted on human beings or on animals for this research.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Data confidentiality</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with the protocols in place at their workplace on the publication of patient data and that all the patients included in the study received sufficient information and gave their informed consent in writing to take part in this study.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no patient details appear in this article.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres322595" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objectives" 2 => "Material and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec304953" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres322596" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivos" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec304952" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Evidence level" ] 10 => array:3 [ "identificador" => "sec0035" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Protection of persons and animals" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-12-03" "fechaAceptado" => "2013-11-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec304953" "palabras" => array:5 [ 0 => "Osteogenesis imperfecta" 1 => "Treatment" 2 => "Outcomes" 3 => "Osteotomy" 4 => "Nailing" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec304952" "palabras" => array:5 [ 0 => "Osteogénesis imperfecta" 1 => "Tratamiento" 2 => "Resultados funcionales" 3 => "Osteotomía" 4 => "Enclavamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe our experience in the management of patients with osteogenesis imperfect (OI).</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a retrospective study of a series of cases affected with OI treated in the Clínica Univesidad de Navarra from 1980 to 2007, with a mean follow up of 17.3 years (7–27 years). We collected descriptive data of the sample, the fractures and the deformities, and the treatments given. The complications presented and the functional outcomes at the end of follow-up were also reviewed.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The sample included ten patients. Approximately two-thirds (65%) of fractures were sustained in the lower limbs. One patient received medical treatment only. Three patients had combined medical and surgical treatment. Some type of surgical treatment was performed on 6 patients. The most common surgery was the Sofield-Millar performed on 37 occasions, with a third of them requiring revision surgery due to migration of the nails. There were 17 episodes of re-fracture. Complications such as non-union, iatrogenic fractures, and infections, were also observed. The functional outcome, according to the Hoffer-Bullock scale, at the end of follow-up was grade <span class="elsevierStyleSmallCaps">I</span>/<span class="elsevierStyleSmallCaps">II</span> in 7 patients.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite the need for multiple interventions and complications presented during follow up, the appropriate treatment of patients with OI can provide acceptable functional outcomes.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir nuestra experiencia en el manejo de los pacientes afectos de osteogénesis imperfecta (OI).</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hemos realizado un estudio retrospectivo de una serie de casos afectos de OI tratados en la Clínica Universidad de Navarra desde 1980 hasta 2007 con un seguimiento medio de 17,3 años (7–27 años). Se han recogido los datos descriptivos, los referentes a las fracturas y a las deformidades observadas y los tratamientos realizados, las complicaciones presentadas y la capacidad funcional al final del seguimiento.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La muestra revisada consta de 10 pacientes. El 65% de las fracturas sufridas se encontraban en miembros inferiores. Un paciente recibió exclusivamente tratamiento médico. En 3 pacientes se asoció tratamiento médico y quirúrgico. En 6 pacientes se realizó algún tipo de tratamiento quirúrgico. La intervención quirúrgica más frecuente fue la de Sofield-Millar, realizada en 37 ocasiones. Un tercio de estas requirieron cirugía de revisión por migración de los clavos. Se observaron 17 episodios de refractura. Además, se han observado complicaciones como seudoartrosis, fracturas iatrogénicas e infecciones. La funcionalidad al final del seguimiento era de grado <span class="elsevierStyleSmallCaps">I</span> o <span class="elsevierStyleSmallCaps">II</span> según la escala de Hoffer y Bullock en 7 pacientes.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A pesar de la necesidad de múltiples intervenciones y de las complicaciones presentadas durante el seguimiento, el tratamiento adecuado de los pacientes afectos de OI puede proporcionar resultados funcionales aceptables.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Escribano Rey RJ, Duart-Clemente J, Martínez de la Llana O, Beguiristáin Gúrpide JL. Osteogénesis imperfecta: tratamiento y resultado de una serie de casos. Rev Esp Cir Ortop Traumatol. 2014;58:114–119.</p>" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2392 "Ancho" => 1338 "Tamanyo" => 271497 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Outline of the distribution of the fractures observed in our series, in absolute numbers (<span class="elsevierStyleItalic">n</span>).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1040 "Ancho" => 1531 "Tamanyo" => 88742 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of the surgeries performed by the bone operated on. OS: osteosynthesis; ROM: removal of osteosynthesis material.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 823 "Ancho" => 1001 "Tamanyo" => 61066 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Seven-year-old patient operated on for a deformity of the right femur using the Sofield-Millar technique (A). After 3 years, extrusion of the proximal tip of the nail is observed (B).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 865 "Ancho" => 1001 "Tamanyo" => 68878 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Seven-and-a-half-year-old patient operated on with a telescopic endomedullary nail for correction of a deformity in the femur (A). At age 15, the nail has hardly migrated at all and the shaft has been lengthened to adapt to bone growth (B). The patient did not require reintervention at any time during follow-up.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2087 "Ancho" => 950 "Tamanyo" => 141774 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Thirty-year-old patient operated on for a fracture of the 2 proximal femurs with a bilateral screw and plate (A). Three months after removal of the osteosynthesis material she suffered a basicervical fracture of the left femur (B). One year later, the fracture is in pseudoarthrosis and there is a fracture in the contralateral femur. (C) The patient is incapable of deambulation.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Deformity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Femur varus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tibia varus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incurvation of cubitus and radius \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antecurvatum of tibias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coxa varus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dysmetria of lower limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Humerus varus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scoliosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Platybasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Pectus carinatum</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calcaneus valgus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab470458.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Distribution of deformities.</p>" ] ] 6 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Source: based on the Hoffer-Bullock scale.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Grade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Initial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Final \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleSmallCaps">I</span>: freely deambulating \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleSmallCaps">II</span>: community deambulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleSmallCaps">III</span>: domestic deambulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleSmallCaps">IV</span>: non-functional deambulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleSmallCaps">V</span>: not deambulating \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab470457.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Evolution of patients’ deambulation abilities.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteogenesis imperfecta" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 1 | 9 |
| 2024 October | 100 | 6 | 106 |
| 2024 September | 87 | 9 | 96 |
| 2024 August | 78 | 4 | 82 |
| 2024 July | 48 | 4 | 52 |
| 2024 June | 54 | 1 | 55 |
| 2024 May | 50 | 2 | 52 |
| 2024 April | 56 | 8 | 64 |
| 2024 March | 73 | 11 | 84 |
| 2024 February | 83 | 9 | 92 |
| 2024 January | 76 | 14 | 90 |
| 2023 December | 84 | 10 | 94 |
| 2023 November | 80 | 7 | 87 |
| 2023 October | 94 | 7 | 101 |
| 2023 September | 54 | 2 | 56 |
| 2023 August | 43 | 4 | 47 |
| 2023 July | 46 | 6 | 52 |
| 2023 June | 48 | 4 | 52 |
| 2023 May | 86 | 5 | 91 |
| 2023 April | 61 | 5 | 66 |
| 2023 March | 71 | 3 | 74 |
| 2023 February | 45 | 13 | 58 |
| 2023 January | 51 | 8 | 59 |
| 2022 December | 54 | 6 | 60 |
| 2022 November | 56 | 6 | 62 |
| 2022 October | 52 | 13 | 65 |
| 2022 September | 40 | 11 | 51 |
| 2022 August | 26 | 10 | 36 |
| 2022 July | 32 | 8 | 40 |
| 2022 June | 21 | 19 | 40 |
| 2022 May | 26 | 7 | 33 |
| 2022 April | 28 | 18 | 46 |
| 2022 March | 43 | 21 | 64 |
| 2022 February | 41 | 11 | 52 |
| 2022 January | 41 | 12 | 53 |
| 2021 December | 37 | 17 | 54 |
| 2021 November | 53 | 13 | 66 |
| 2021 October | 63 | 15 | 78 |
| 2021 September | 45 | 10 | 55 |
| 2021 August | 66 | 5 | 71 |
| 2021 July | 14 | 11 | 25 |
| 2021 June | 22 | 3 | 25 |
| 2021 May | 32 | 6 | 38 |
| 2021 April | 184 | 34 | 218 |
| 2021 March | 53 | 18 | 71 |
| 2021 February | 32 | 17 | 49 |
| 2021 January | 30 | 7 | 37 |
| 2020 December | 2 | 0 | 2 |
| 2020 February | 1 | 0 | 1 |
| 2019 November | 2 | 0 | 2 |
| 2018 February | 13 | 2 | 15 |
| 2018 January | 14 | 0 | 14 |
| 2017 December | 9 | 0 | 9 |
| 2017 November | 12 | 0 | 12 |
| 2017 October | 15 | 1 | 16 |
| 2017 September | 12 | 2 | 14 |
| 2017 August | 18 | 2 | 20 |
| 2017 July | 21 | 4 | 25 |
| 2017 June | 24 | 29 | 53 |
| 2017 May | 35 | 9 | 44 |
| 2017 April | 21 | 8 | 29 |
| 2017 March | 17 | 30 | 47 |
| 2017 February | 15 | 4 | 19 |
| 2017 January | 11 | 1 | 12 |
| 2016 December | 15 | 1 | 16 |
| 2016 November | 22 | 3 | 25 |
| 2016 October | 23 | 7 | 30 |
| 2016 September | 31 | 3 | 34 |
| 2016 August | 10 | 3 | 13 |
| 2016 July | 3 | 1 | 4 |
| 2016 June | 8 | 3 | 11 |
| 2016 May | 11 | 9 | 20 |
| 2016 April | 9 | 2 | 11 |
| 2016 March | 13 | 2 | 15 |
| 2016 February | 0 | 3 | 3 |
| 2016 January | 0 | 3 | 3 |
| 2015 December | 0 | 1 | 1 |
| 2015 October | 0 | 1 | 1 |
| 2015 August | 0 | 1 | 1 |
| 2015 July | 0 | 1 | 1 |
| 2014 May | 0 | 1 | 1 |
| 2014 April | 1 | 1 | 2 |
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