Pediatric longitudinal epiphyseal bracket: Review and case presentation

Longitudinal Epiphyseal Bracket as an Overlooked Etiology of Congenital-Residual Hallux Varus: A Case Report

Longitudinal epiphyseal bracket is a rare ossification disorder of the short tubular bones. The affected bone becomes deformed as a result of the bracket. The normal growth pattern cannot occur, and when it affects the first metatarsal bone, hallux varus may develop with the abnormal growth pattern. We present such a 6-year-old patient who had undergone surgery at 6 months of age for hallux varus and polydactyly. The deformity had worsened gradually after the initial operation because of the overlooked longitudinal epiphyseal bracket. The patient was treated with surgical excision of the epiphyseal bracket, with corrective medial open wedge osteotomy and split transfer of the extensor hallucis longus tendon. The result was excellent at the 20-month follow-up. At an early age, patients who present with hallux varus must be checked for the epiphyseal bracket, which can be invisible on radiographs because of the chondral structure. Untreated or overlooked patients with epiphyseal bracket will need revision operations for recurrent deformities.

Middle Phalangectomy for the Correction of Toe Clinodactyly With Longitudinal Epiphyseal Bracket in Young Children

Toe clinodactyly is often owed to the presence of a longitudinal epiphyseal bracket. We developed middle phalangectomy as a simple surgical solution for correction of toe clinodactyly because of longitudinal epiphyseal bracket in childhood. Ten children (ages 1-5 years) were operated on by the same surgeon between October 2007 and May 2012 (n = 15 feet). The same surgical technique was used in all the cases. A clinical evaluation included the appearance of the foot, the parents' level of satisfaction, and the presence or absence of bothersome symptoms (such as pain and discomfort when wearing footwear). A radiological evaluation under weight-bearing conditions enabled us to 1) rate the achievement of a natural-looking toe parabola and 2) detect the recurrence of clinodactyly (defined as an angle of >40° between 2 adjacent phalanges). The mean follow-up period was 5.4 (range 3.3 to 8.1) years. Nine sets of parents (90%) were satisfied with the results of the procedure. None had difficulties wearing boots, and only 1 child (10%) had residual pain during sports activities. Clinodactyly recurred in 3 feet in 3 patients (20% of feet, 30% of patients). Two (20%) of the latter patients underwent repeat surgery and achieved a lasting, satisfactory outcome. Middle phalangectomy is an appropriate procedure for the treatment of toe clinodactyly because of longitudinal epiphyseal bracket in young children. However, the patients' long-term outcomes (notably once bone growth has ended) must be assessed.

Longitudinal Epiphyseal Bracket of the First Metatarsal Bone: Three Case Reports and a Review of the Literature

Longitudinal epiphyseal bracket (LEB) is a rare bone dysplasia of the tubular bones. Owing to an abnormal secondary ossification center, the affected bones can develop progressive shortening and angular deformity. The aim of our study was to provide an overview of the reported data regarding epidemiology and surgical procedures available for LEB of the first metatarsal bone in a pediatric population combined with a small case series. We report a retrospective case series of 3 nonsyndromic pediatric patients with different ages and with confirmed dysplasia of the first metatarsal bone. All patients presented with unilateral congenital hallux varus deformity and underwent surgical treatment. The radiographs and medical records were reviewed to evaluate the deformity characteristics, treatment, and clinical results. The mean patient age at initial surgery was 34 (range 12 to 63) months, and the median follow-up period was 46 (range 31 to 75) months. Almost all specific radiographic measurements showed correction of the deformity, and each foot demonstrated functional and cosmetic improvement. A standardized literature search was performed to obtain studies of LEB of the first metatarsal bone in the pediatric population. From on our results and the current data available, surgical treatment should be tailored to the patient's age and radiographic stage of LEB. However, monitoring until skeletal maturity of the feet is necessary to assess the final results.

Surgical treatment of congenital hallux varus

Background

The purpose of this study was to report outcomes of congenital hallux varus deformity after surgical treatment.

Methods

We evaluated ten feet of eight patients with a congenital hallux varus deformity, including four feet combined with a longitudinal epiphyseal bracket (LEB). There were seven male patients and one female patient with a mean age of 33 months (range, 7 to 103 months) at the time of surgery. Two patients were bilaterally involved. The mean duration of follow-up was 5.9 years (range, 2.3 to 13.8 years). Clinical outcomes were assessed according to the criteria of Phelps and Grogan. Surgical procedures included the Farmer procedure, the McElvenny procedure or an osteotomy at the first metatarsal or proximal phalanx.

Results

The clinical results were excellent in two feet, good in six and poor in two feet. The LEB was associated with hallux varus in four feet and were treated by osteotomy alone or in conjunction with soft tissue procedure.

Conclusions

Congenital hallux varus was successfully corrected by surgery with overall favorable outcome. Preoperatively, a LEB should be considered as a possible cause of the deformity in order to prevent recurrent or residual varus after surgery.

Pediatric forefoot pathology

Surgical management of the pediatric forefoot often brings challenges to the foot and ankle surgeon. It requires a thorough understanding of the pathologic abnormality and underlying causes involved, which include the contributing genetic conditions. Albeit most of the deformities carry a rare level of incidence, they do however have a significant level of psychological component and stress on the pediatric patient. The goals of managing those pathologic abnormalities are ultimately to improve function while achieving a cosmetically acceptable outcome. The common forefoot pathologic abnormalities in the pediatric population are reviewed with an added focus toward management of forefoot trauma.

Correction of longitudinal epiphyseal bracket disease with external fixation: a case report with 6-year follow-up period

Longitudinal epiphyseal bracket disease is a rare congenital abnormality of the tubular bones. This syndrome eventually leads to progressive shortening and angular deformity of the involved bone. When longitudinal epiphyseal bracket disease affects the first metatarsal, a short trapezoidal shaped metatarsal is noted radiographically. We present the case of a 9-year-old patient with longitudinal epiphyseal bracket disease of the first metatarsal. The abnormality was surgically treated by bracket osteotomy with callus distraction before physeal closure. At 6 years of follow-up, the patient displayed a relatively normal looking cosmetic foot compared with the contralateral foot. A mild residual hallux varus was noted, with maintenance of the forefoot parabola. Surgical correction resulted in alteration of the first intermetatarsal angle and the first metatarsophalangeal angle. The first intermetatarsal angle decreased from a preoperative value of -30° to a postoperative value of 10°. The first metatarsophalangeal angle decreased from a preoperative value of 36° of hallux varus to a postoperative value of 4°. The length of the first metatarsal was restored compared with that of the contralateral limb and was slightly elongated. The present case study demonstrates that early surgical correction with callus distraction of an ossified abnormal bracket before physeal closure, a relatively simple procedure, can restore longitudinal growth and correct the angular deformity.