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

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.

Technique tip: Simultaneous first metatarsal lengthening and metatarsophalangeal joint fusion for failed hallux valgus surgery with transfer metatarsalgia

BACKGROUND

Failed hallux valgus surgery may result in residual or recurrent hallux valgus, and as well transfer metatarsalgia. The present technical tip concerns the combination of fusion of the first metatarsophalangeal (MTP) joint and lengthening of the first metatarsal (MT) through a scarf osteotomy.

MATERIALS AND METHODS

Six patients underwent the presented technique, all for the indication of failed hallux valgus surgery with shortening of the first MT and degenerative changes in the 1st MTP joint.

RESULTS

Follow-up at six months revealed all patients had complete healing of the osteotomy and arthrodesis sites. They were all asymptomatic and fully active, completely satisfied with the outcome.

CONCLUSIONS

Combined fusion of the first MTP joint and lengthening of the first MT through a scarf osteotomy results in an excellent outcome in patients with failed hallux valgus surgery with shortening of the first MT and degenerative changes in the 1st MTP joint.

Treatment of Longitudinal Epiphyseal Bracket by Excision and Polymethylmethacrylate Insertion at the Preossified Disease Stage

Longitudinal epiphyseal bracket is a rare ossification anomaly involving the tubular bones of the hand or foot that have a proximal epiphysis, which becomes deformed as a result of the bracket. Untreated, the deformity becomes worse with age, because longitudinal growth cannot occur. The present report discusses the use of polymethylmethacrylate at the preossified disease stage in 2 patients with first metatarsal involvement. A medical record and radiographic review was performed for 2 children (3 feet), aged 1 year and 2 years and 5 months, who were treated with insertion of polymethylmethacrylate after excision of the aberrant epiphyseal bracket. Two different radiographic parameters (i.e., the intraosseous angulation and the metadiaphyseal length index) were used to measure the effect of treatment on the subsequent longitudinal growth of the metatarsals. An excellent clinical result after a long follow-up period was observed in 2 feet, and a good result was documented in 1 foot, which developed hallux valgus angulation. The use of polymethylmethacrylate as an interposition material after excision of the aberrant metatarsal epiphyseal bracket appeared to be an effective method of treatment during the preossified first stage of the disease, despite the general recommendation to use a cement spacer during the third ossified stage. Normal longitudinal growth of the metatarsals was noted without complications or risk of deformity recurrence.

Preliminary clinical research on epiphyseal distraction in osteosarcoma in children

BACKGROUND

The feasibility of distal femur epiphysis preservation through epiphyseal distraction by external fixator in childhood osteosarcoma was explored.

METHODS

Between July 2007 and May 2011, 10 children who were suffering from distal femur osteosarcoma received epiphyseal distraction by external fixator, combined with tumor resection and repair with massive allograft bone to preserve the epiphysis of the distal femur and knee function. There were six male and four female patients, 9- to 14-years old (average 10.5 years old). The tumors were staged clinically according to the Enneking staging method: six cases were classified as stage in IIA and four cases as stage in IIB. All patients were diagnosed by biopsy, then received chemotherapy before and after surgery. All patients received tumor bone resection and the defects of the bone were repaired with massive allograft bone that was fixed by intramedullary nails; the distracted epiphysis and allograft bone were fixed with cancellous screws.

RESULTS

All cases received follow-up from 15 to 56 months (average 38.5 months). There were no local recurrences. One case died of lung metastasis and one case had poor incision healing for rejection of allograft bone. According to the functional evaluation criteria of the International Society of Limb Salvage (ISOLS) after operation, five cases were rated excellent, four cases good and one case fair. The ratio of excellent or good was 90.0%. There was no statistically significant difference in length between the operated and the normal lower limbs during the last review.

CONCLUSIONS

Epiphyseal distraction by external fixator can result in satisfactory limb length and joint function for children with a malignant bone tumor.

Lengthening scarf osteotomy for recurrent hallux valgus

BACKGROUND

We describe using the scarf osteotomy to correct a recurrent hallux valgus deformity and lengthen the shortened first metatarsal in symptomatic iatrogenic first brachymetatarsia.

METHODS

Thirty-six lengthening scarf osteotomies were undertaken in 31 patients. Clinical and radiographic measures were taken pre and postoperatively.

RESULTS

Mean age at presentation was 53.4 years, and mean followup 3.9 years. The mean lengthening achieved was 4.9mm. All osteotomies united with no complications. The mean IMA reduction was 4.0° (p<0.001) and HVA 13.0° (p<0.001). The mean AOFAS score increase was 33.8 (p<0.001). There was a positive trend but no correlation (r=0.28) between amount of metatarsal lengthening and AOFAS score change.

CONCLUSIONS

We describe the largest lengthening scarf osteotomy series for recurrent hallux valgus with iatrogenic first brachymetatarsia. The results suggest the procedure is successful, with a low complication rate. We anticipate that restoring first metatarsal length and alignment may reduce biomechanical transfer metatarsalgia over time.

Longitudinal bracketed epiphysis of proximal phalanx of the great toe with congenital hallux varus managed simultaneously with monorail external fixator: a case report

Longitudinal bracketed epiphysis (delta phalanx) is a rare congenital anomaly that affects phalanges in the hand more commonly than toes. We present a rare case of congenital hallux varus with longitudinal bracketed epiphysis of proximal phalanx with bifid distal phalanx of the great toe, which was managed with monorail type of external fixator. To the best of our knowledge, this is the first report of its successful implementation in simultaneous treatment of longitudinal bracketed epiphysis of the proximal phalanx of the great toe and hallux varus. Apart from adding to the literature a case of rare subtype of delta phalanx with hallux varus, the present study highlights the role of a reliable alternative in its management.

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.