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.

Paediatric open tibial fractures. Do children require a modified approach to that advised by the British Orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons in the UK?

This study reviews the outcomes of paediatric open tibial fractures treated at a level 1 trauma centre using the British Orthopaedic Association/British Association of Plastic Reconstructive and Aesthetic Surgeons standards and compares the results to management in adults. This was a retrospective study of 60 consecutive cases over a 9-year period. The variables recorded include grade of injury, contamination and pattern of fracture. Other data recorded include time at which antibiotics were given, time to index surgery, type of skeletal fixation and time to definitive cover. Outcomes sought were infection rate, time to union, problems with union and any additional unplanned surgery. The mean time to administration of antibiotics was 3.4 h after injury with a range of 0.35-17 h. The mean time to debridement was 13.4 h (range 1-32 h, SD 7.7). The mean time to union was 4.3 months (range 1.3-15 months). There were five cases of deep infection (8.3%) and three cases of superficial infection (5%). There were no significant differences between timings of antibiotic administration, hours to debridement or days to definitive closure between those cases which became infected and those which did not. This retrospective review of a consecutive series of paediatric open tibial fractures shows a close parallel of outcomes to that from adult centres in the UK using the same standards of care. This strengthens the recommendation that, until the availability of data to suggest otherwise, open tibial fractures in children should follow the same recommendations as suggested for adults. The greater healing potential in children, seen in multiple examples of closed long bone fractures, appears to be attenuated in the higher grades of the open tibial fracture.

The association of socioeconomic deprivation and paediatric open tibia fractures.

The primary aim of this study is to test the association of open tibial fractures (OTF), in a paediatric age group, with socioeconomic deprivation. The secondary objectives are to more clearly define the epidemiological characteristics of these high-energy injuries. A consecutive series of patients with OTF presenting to a major trauma centre at a children's hospital in Liverpool had age, gender, fracture pattern, mechanism, timing of the injury and their postcode of residence recorded. Those cases outside Liverpool, Sefton and Knowsley local authorities were excluded from incidence calculations. Postcodes were used to generate deprivation scores (Index of Multiple Deprivation, 2010) based on census data (2011). Cases were ranked and allocated to deprivation quintiles. A comparison to the normal population within Merseyside was undertaken using regression analysis. There were 71 cases over a 9-year period. Fifty cases resided within the geographical limits of Merseyside and were included in the incidence calculations. The annual incidence of paediatric OTF is 3.09 per 100 000 children (0-16 years). The median age at injury was 11 years (range 2-16) and this occurred most usually during term-time between 3 and 5 p.m. from road traffic collisions. Paediatric OTFs are strongly associated with socioeconomic deprivation. The association with deprivation reflects an exposure to unsafe roads in busy urban areas with limited access to safe playing spaces. Socioeconomically deprived men are most at risk from this injury. The links between deprivation and outcomes of treatment or long-term prospects are unclear.

Short-term outcome of surgical arthrodiastasis of the ankle with Ilizarov frame in a cohort of children and young people with juvenile idiopathic arthritis.

OBJECTIVES: Despite medical advances, life-changing articular damage may still occur in patients with JIA. We report a cohort with destructive arthropathy of the ankle treated by surgical arthrodiastasis. METHODS: Eight patients (nine ankles) received arthrodiastasis by means of an Ilizarov frame between 2009 and 2013. Patient- and clinician-reported outcome measures were collated prospectively, with retrospective analysis of demographics, disease and pre-surgical treatment. RESULTS: Pre-surgery, all patients received IA CS (mean 0.8 injections/year) and MTX (mean diagnosis to treatment 3.8 years; two of eight started within 3 months). Seven of eight patients received biologic drugs. Pain scores improved by 56 and 29% (P < 0.005) at 6 and 12 months post-frame removal. American Academy Orthopaedic Foot and Ankle Society ankle-hindfoot scale, Oxford Ankle Foot Questionnaire-Child and Oxford Ankle Foot Questionnaire-Parent scores improved by 171, 62 and 80%, respectively (P < 0.005) at 12 months post-frame removal. Patients remained satisfied with surgical treatment for a mean of 13.3 months. There was transient pin site infection in three patients, and all patients had radiological improvement in joint space. CONCLUSION: Arthrodiastasis with an Ilizarov frame is a safe, well-tolerated technique that should be considered as a short-term joint-preserving procedure to improve pain and function when damage has occurred. Delays to systemic medical treatment in this cohort would be considered out-with standard modern practice but, although less prevalent, destructive ankle arthropathy continues to occur in JIA, and we believe this study to be relevant. The ankle is particularly susceptible to damage and, even if localized, should be treated early and aggressively with DMARDs and rapid progression to biologic therapies. LEVELOF EVIDENCE: Level IV.

Elastic stable intramedullary nailing in paediatric forearm fractures: the rate of open reduction and complications.

The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.

Guided Growth of the Distal Posterior Tibial Physis and Short Term Results: A Potential Treatment Option for Children With Calcaneus Deformity.

BACKGROUND: We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity around the ankle. METHODS: Our study included 9 consecutive patients (11 ankles) with calcaneus deformity, over a period of 4 years. Surgical treatment with extra periosteal application of flexible 2 hole plate and screws on posterior aspect of distal tibial physis was carried out.The indications for treatment were residual clubfoot deformity in 9, posttraumatic in 1, and neurologic in 1. The average age of the patients was 10 years (range, 4 to 13 y). There were 7 males and 2 females.Serial preoperative and postoperative radiographs were used to measure deformity correction and anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA), and Screw Divergence Angle (angle subtended by lines passing through the screws) were measured. A 2-tailed student t test was used to determine statistical significance. RESULTS: The ADTA showed mean correction of 8.41 degrees (range, 3.1 to 16.6 degrees) this was statistically significant with P-value of 0.0003.The change in LDTA was not statistically significant (P-value=0.05) reinforcing the aptness of the procedure and that the procedure did not result in coronal plane deformities. Six ankles required revision of fixation: 4 due to metalwork reaching its maximum limit of divergence at an average of 1 year, 1 ankle had screw pull-out, and another ankle was revised due to technical error in screw selection. In our study there were no cases of infection. CONCLUSIONS: We report satisfactory short-term results of correction of calcaneus deformity using flexible tension band plates and screws. In our opinion this is an effective alternative providing gradual correction with easy and minimally invasive surgical technique. It does not violate the physis and is easy to remove and revise. It is safe and well tolerated and can be grouped with other procedures with ease. LEVEL OF EVIDENCE: Level IV­case series.

Systemic therapy for squamous cell carcinoma of the skin in organ transplant recipients.

During the second half of the 20th century, organ transplantation saved thousands of lives. This, unfortunately, also led to unforeseen consequences that need to be addressed to help extend the lives of patients who require these life-saving procedures. Secondary malignancies have been recognized as a potential consequence for decades. One of these malignancies, squamous cell carcinoma of the skin, not only appears more frequently in organ transplant recipients than the general population, but also is more aggressive in organ transplant recipients. It also shows a high propensity to nodal spread and metastasis in transplant patients. Unfortunately, there are no clear guidelines for a chemotherapy in this population, who have an increased need for alternative therapies to surgery given the high recurrence and metastasis rate. In this review, we attempt to describe the characteristics of squamous cell carcinoma of the skin in transplant recipients and discuss what chemotherapeutic options can be used to treat this aggressive malignancy.

Congenital clavicular pseudarthrosis: comparison of two treatment methods.

BACKGROUND: Congenital pseudarthrosis of the clavicle is rare and popular surgical options include excision of the non-union, iliac crest bone grafting and stabilisation with either a fully threaded pin or stabilisation with a reconstruction plate. METHODS: Between 1995 and 2009, ten patients with congenital pseudarthrosis of the clavicle were retrospectively reviewed for outcome of two different forms of surgical management. Five patients had excision of the non-union, iliac crest bone grafting and stabilisation with a fully threaded pin (group A) and the other five patients had excision of the non-union, iliac crest bone grafting and stabilisation with a reconstruction plate (group B). One patient in the second group had bilateral pseudarthrosis. RESULTS: In group A, three patients achieved radiological union at a median of 6 months. Two patients failed to unite at the pseudarthrosis and one of them had further surgery with a reconstruction plate in order to achieve union. In group B, all five patients (six clavicles) achieved radiological union at a median of 3 months. All patients had painless full range of shoulder movement and were engaging in unrestricted activities. CONCLUSION: Excision of the pseudarthrosis, autogenous iliac bone grafting and stabilisation with plate achieves union quicker and with lower incidence of complications compared to excision of the pseudarthrosis, autogenous iliac bone grafting and stabilisation with fully threaded pins.

Lipoblastoma--an unfamiliar but important diagnosis. A case series and literature review.

Lipoblastoma and its infiltrative variant lipoblastomatosis are rare adipose tissue tumours seen in infants and children. Many surgeons are unfamiliar with these uncommon lesions and hence they are suboptimally treated. We report a case series of six patients in our tertiary paediatric hospital. Cases were reviewed retrospectively with reference to demographics, investigations, diagnosis and their management. Lipoblastomas are easily misdiagnosed and excision before proper investigations may result in incomplete resection, recurrence and further potentially mutilating surgery.

Epidemiology of acute haematogenous osteomyelitis in children--a single unit's experience over three different time-periods.

The epidemiology of paediatric osteomyelitis in a single health district in England from 2000 to 2005 was compared to that from two prior timeframes. Fifty-three children were diagnosed with acute haematological osteomyelitis (AHO) and were compared to 36 and 49 patients from 1982 to 1986 and 1947 to 1951 respectively. The annual incidence of AHO in the most recent period was 0.4 patients per 100 000 of the total population. The mean age of presentation was 40 months (ranging between 0.5 and 179). This was statistically significantly less than the two earlier timeframes. Staphylococcus species was the commonest isolated organism. Plain radiography had a pickup rate of 32.7%. Second line investigation of nuclear medicine and magnetic resonance imaging had greater sensitivities of 78.8% and 75% respectively. The rate of surgical intervention was halved comparing 2000-05 to 1947-51. We were unable to unequivocally demonstrate a decreased incidence AHO in our region. However the review does confirm that the clinical approach to diagnosing and treating AHO had changed over the years.