Metatarsal lengthening by distraction osteogenesis for brachymetatarsia in paediatric patients: is it safe and effective?

PURPOSE

The primary aim is to assess the efficacy of the surgical callus distraction technique of the metatarsus in paediatric patients. Secondary objectives are to assess complications and treatment duration. We have also described the details of our surgical technique.

MATERIALS AND METHODS

A case series review of paediatric patients who had metatarsal lengthening at our unit between 2014 and 2022. Patient demographics, duration of time in frame, complications and metatarsal length achieved were recorded. The AOFAS Midfoot and the MOXFQ were taken pre-operatively and at final follow-up.

RESULTS

Sixteen metatarsals in 8 patients (14 feet) underwent lengthening between 2014 and 2022 using the MiniRail OrthoFix 100 (Orthofix Medical Inc, Lewisville, TX, USA). The mean age was 13.3 (12-17) years. The average duration between surgery and implant removal was 5.2 months. According to Paley's classification, there was one obstacle encountered in a patient who required a revision of their osteotomy and one problem in another patient who had an infected metatarsophalangeal joint stabilising k-wire treated with oral antibiotics. The Mean AOFAS Midfoot score improved from 53.10 to 86.40 (p < 0.0001) and the Mean MOXFQ improved from 32.5000 to 12.1250 (p < 0.05); these were statistically significant.

CONCLUSION

Gradual metatarsal lengthening using the MiniRail external fixator is a safe and effective method to treat brachymetatarsia in paediatric patients. This preliminary report describes and supports metatarsal lengthening in appropriate patients. Holistic care in terms of a pre-operative assessment, psychological support and preparation for the extended rehabilitation period are vital.

[The use of distraction osteogenesis for the reconstruction of bone defects following resection of malignant bone tumours]

The reconstruction of extensive bone defects following resection of malignant bone tumours is a challenge and is mainly influenced by tumour-related factors. In defect reconstructions using distraction osteogenesis isotropic, high-quality (new) bone is formed. For the reconstruction of bone defects and secondary limb length discrepancies following tumour resection, predominately three techniques have been described: bone transport, primary shortening and secondary lengthening, as well as "bio-expandable tumour endoprostheses". The use of distraction osteogenesis represents an excellent method for defect reconstruction and treatment of secondary limb length discrepancies following bone tumour resection. Due to the complex anatomical preconditions in tumour patients, a high degree of expertise in distraction osteogenesis (and tumour endoprostheses) is paramount. Therefore, treatment of these patients at highly specialised centres is recommended.

Callus distraction for brachymetatarsia - A comparison between an internal device and the external fixator

BACKGROUND

Symptomatic patients with severe brachymetatarsia are commonly treated with callus distraction using external mini-fixator (EF) or internal device (ID). This study points out advantages and limitations of both methods comparing clinical and radiographical parameters.

METHODS

Retrospective analysis of 21 metatarsal bones in twelve patients. Twelve metatarsals were treated with ID (Genos Mini), nine with EF (MiniRail).

RESULTS

Mean lengthening distance was 17.3 mm using EF and 11.7 mm using ID (p = 0.016). Adverse results were observed in 89% of metatarsals treated with EF and in 33% treated with ID (p = 0.011). Postoperative surgical intervention was required in 33% using EF compared to 0% using ID (p = 0.031). Mean total German Foot Function Index (FFI-T) improved from 49 to 33 using EF and from 47 to 22 using ID (p < 0.001).

CONCLUSION

CD is a reliable surgical treatment for BMT. Surgeons should be aware of implant-related advantages and complications when counseling patients about treatment options.

Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect-preliminary outcomes of 12 cases and a description of the surgical technique

OBJECTIVE

To evaluate the preliminary outcomes of tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique for the treatment of distal tibial defect and describe the surgical technique.

METHODS

A total of 12 eligible patients with distal tibial defect > 6 cm caused by direct trauma or posttraumatic osteomyelitis who were admitted to our institution from January 2017 to January 2019 were treated by tetrafocal or pentafocal bone transport using Ilizarov technique. Detailed demographic data, including age, sex, etiology, defect size, number of osteotomies (three or four), external fixation time (EFT) and external fixation index (EFI), were collected, and the bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during the surgery and the follow-up period were recorded and evaluated by the Paley classification at a minimum follow-up of two years after removal of the fixator.

RESULTS

There were 9 men and 3 women with an average age of 37.4±7.8 years. The etiology included posttraumatic osteomyelitis in 8 cases and posttraumatic bone loss in 4 cases. The mean bone defect after radical debridement was 7.1±0.6 cm. Tetrafocal bone transport was applied in 9 cases, and pentafocal bone transport was applied in 3 cases. The average EFT and EFI were 5.2±0.8 months and 0.7±0.2 months/cm, respectively. The average time of follow-up after removal of the external fixator was 28.5±3.3 months without recurrence of osteomyelitis. The bone results were good in 7 cases, fair in 4 cases, and poor in 1 case, and the functional results were good in 5 cases, fair in 6 cases, and poor in 1 case. The most common complication was pin tract infection, which occurred in all cases, but there were no major complications, such as nerve or vascular injury.

CONCLUSION

Tetrafocal and pentafocal bone transport using Ilizarov technique could be an alternative treatment option in selected cases with distal tibial defect > 6 cm. It could shorten the distraction period, fasten regeneration, and reduce the associated complications.

The Surgical Treatment of Brachymetatarsia

This article describes the 3 main surgical options for correction of congenital brachymetatarsia in childhood. The one-stage lengthening by lengthening osteotomy and lengthening with graft interposition are suitable for defects less than 10 mm. For the greater defects from 10 mm to more than 20 mm, gradual lengthening by callus distraction with an external or internal fixator is appropriate. Over the last years, callus distraction with an internal minifixator became commonly established because of the significantly improved aftercare with early full weight-bearing and high postoperative comfort for the child. All 3 surgical procedures are presented with comprehensive image material.

Posteromedial tibial deformity: Radiological evolution and treatment of the discrepancy

INTRODUCTION

Postero-medial deformity (DMPT), unlike other congenital forms that affect the tibia, presents a good evolution spontaneously correcting the important misalignments that present at birth based on the classic orthopedic laws of Wolff and Hueter-Volkmann, leaving slight residual angulations and variable limb length discrepancy.

MATERIAL AND METHODS

Authors carry out a retrospective review of cases diagnosed with DPMT, the evolution of the tibial angulation and the discrepancy in the length of fourteen patients (11 males and 3 females) followed and treated between the years 2003 and 2018. Seven of these were treated by callus distraction. We have considered: PA and lateral of the tibia and stand-up entire limbs x-ray during age growth, along with the clinical records of the patients.

RESULTS

The medial diaphyseal radiological deformity of the newborn or neonatal period was 34° and the final 10°. The posterior deformity evolved from 46° to a final angulation of 11°. The physeal angulation in the initial AP projection was 34° and the end view was 8° and in the lateral projection from 44 to 6°. The mechanical axis of the limb was correcting towards a neutral axis in relation to the aforementioned physeal and diaphyseal correction in all cases except two. In five of the cases, although the mechanical axis was normal-aligned, at the tibial level it ran eccentrically and externally to the tibial cortex. The length relationship between the short tibia and the healthy tibia maintains a constant proportion throughout the growth of 89%, that is, the inhibition of growth is 11%. We observe that 80% of the discrepancy is found in the tibia and that the remaining 20% ??was exposed from the height of the tarsus. Two patients presented a traumatic and accidental diaphyseal fracture of the tibia. The difference in the length of the tibia was compensated to seven patients by callus distraction of 5.4cm using the callotasis method with a Healing Index of 34.5 days/cm.

CONCLUSIONS

DPMT improves substantially during the first years of life. Joint alignment of the knee and ankle is achieved before the correction of diaphyseal deformity. The tibia length discrepancy increases with the growth of the child since there is an 11% growth inhibition that will cause a skeletal maturity discrepancy between 4-7cm. Callus distraction before skeletal maturity is the method chosen to compensate this discrepancy.

Retraction of transporting bone segment during Ilizarov bone transport

BACKGROUND

Retraction of transporting bone segment (TBS) may occur when the fixator of the TBS is removed prior to full consolidation of the distracted callus, which has adverse effect on the healing of the docking site. However, there are few reports on the retraction of TBS. The purpose of this study is to analyze the causes and risk factors of the retraction of TBS.

METHODS

The clinical data of 37 cases with tibial bone defect treated by Ilizarov bone transport were analyzed retrospectively, in whom the TBS fixator was removed prior to full consolidation of the distracted callus and union of the docking site. Bivariate correlation was used to analyze relationship between the retraction distance of TBS and potential risk factors including age, gender, course, length of bone defect, number of operations, size of TBS, transport distance, timing and time interval of removal of TBS fixator. Risk factors with significant level were further identified using multivariate linear regression.

RESULTS

Bivariate correlation showed that the timing of removal was negatively correlated with the retraction distance, and the time interval and transport distance were positively correlated with the retraction distance(p < 0.05), the age, gender, course, length of bone defect, size of TBS and number of operations were not correlated with the retraction distance(p > 0.05). Multivariate linear regression of the 3 risk factors showed that the timing of removal and time interval were the main risk factors affecting the retraction distance (p < 0.05), but the transport distance was not (p > 0.05).

CONCLUSION

The traction forces of TBS endured from the soft tissues and the unconsolidated distracted callus have elastic properties, which can make retraction of TBS. The timing of removal and time interval are the main risk factors of the retraction of TBS. In the case of early removal, another external fixation or quickly converted to internal fixation should be performed to avoid the adverse effect of more retraction.

[All internal segmental transport in tibial bone defects: first experiences with the PRECICE bone transport system]

Bone loss of the distal tibia represents a major challenge for the treating surgeons and the reconstruction technique. This is particularly true for septic bone loss. Several techniques are available, ranging from callus distraction of Ilizarov frames and monorail techniques as well as transport with plates and nails; however, implants for internal segmental transport for bone defects have so far not been available. This case report describes worldwide the first reconstruction of a distal tibial defect by reconstruction of the major arterial flow path with flap coverage and all inside segmental transport using a motorized segmental transport nail without additional osteosynthesis or add-on module.

[Callus distraction and bone transport in the treatment of bone defects]

BACKGROUND

The method of "callus distraction" is the only technique which spontaneously produces vascularized bone within the surrounding soft tissues during lengthening reconstructive procedures. Remodeling of the regenerate bone to specific mechanical load can be influenced by the surgeon. In principle, there is no limit to the amount of new bone formation which can be created; this vascularized bone is both resistant to infection and can be created to replace resected infected bone. This is an important prerequisite for the successful treatment of large bone defects.

TECHNIQUE

The ring fixator is still a standard tool if no radiological control is available in the operating theater, or in other less sophisticated environments. Over the last 30 years, however, the development of motorized, external and fully implantable systems has made it possible to achieve a significant increase in device implementation, which goes far beyond the standard.

RESULTS

High-performance, reliable, custom-made external and fully implantable systems are cost intensive and require special surgical skills, which can only be ensured at specialized centers. However, the complication-free treatment results justify the effort both for the patient and, ultimately, for the cost bearers.

Percutaneous foot surgery for the treatment of brachymetatarsia: A case report

BACKGROUND

The term brachimetatarsia refers to an abnormal shortening of the metatarsal bones as a result of early closure of the growth plate. The deformity, which may be congenital, idiopathic or secondary to surgery or trauma, may result in functional as well as cosmetic alterations, which require correction by an orthopedic surgeon. The purpose of this report is to illustrate the possibility of treating this condition by means of a minimally invasive technique which affords results as satisfactory as those of conventional techniques but with fewer complications. We report on the case of a 35-year-old female with a diagnosis of congenital brachymetatarsia, with bilateral involvement of the fourth toe.

METHODS

We present our experience of surgical correction of brachymetatarsia using percutaneous surgery. The surgical technique is illustrated by a case report with a follow-up of 2 years.

RESULTS

Radiographic and cosmetic correction of the deformity were satisfactory after 9 weeks of treatment. No complications were observed during follow-up.

CONCLUSIONS

Although minimally invasive surgery for treatment of brachymetatarsia is a relatively unknown or explored procedure, it provides good clinical and radiological results in experienced hands. In addition, it causes little trauma to the soft tissues, reduces operative time and allows patients a better and faster functional recovery, offering clear advantages over other techniques used for correcting this bone malformation.

[The complicated course of a femoral shaft fracture in childhood]

We report a difficult healing process after a femoral shaft fracture in childhood. We present surgical correction options of femoral shortening due to pseudarthrosis after elastic stable intramedullary nailing. First, we tried to establish distraction using an external fixator, followed by plate osteosynthesis. After material failure of plate osteosynthesis, we treated the refracture with intramedullary nailing, after which bone healing occurred.

A novel intramedullary callus distraction system for the treatment of femoral bone defects

An intramedullary device has some advantages over external fixation in callus distraction for bone defect reconstruction. There are difficulties controlling motorized intramedullary devices and monitoring the distraction rate which may lead to poor results. The aim of this study was to design a fully implantable and non-motorized simple distraction nail for the treatment of bone defects. The fully implantable device comprises a tube-in-tube system and a wire pulling mechanism for callus distraction. For the treatment of femoral bone defects, a traction wire, attached to the device at one end, is fixed to the tibial tubercle at its other end. Flexion of the knee joint over a predetermined angle generates a traction force on the wire triggering bone segment transport. This callus distraction system was implanted into the femur of four human cadavers (total 8 femora), and bone segment transport was conducted over 60-mm defects with radiographic monitoring. All bone segments were transported reliably to the docking site. From these preliminary results, we conclude that this callus distraction system offers an alternative to the current intramedullary systems for the treatment of bone defects.