Pediatric Traumatology, Orthopaedics and Reconstructive Surgery

BACKGROUND: Achilloplasty is one of the most common procedures in the reconstruction of various foot deformities. Achilles tendon lengthening is often used in most reconstructive interventions in patients with flatfeet. Literature data reflecting the dynamics of foot dorsiflexion after percutaneous achilloplasty are limited.

AIM: This study aimed to determine the foot dorsiflexion dynamics in children with flatfeet at different time points after foot reconstruction in combination with percutaneous Achilles tendon lengthening.

MATERIALS AND METHODS: The study included the observation results of 159 children (260 feet) aged 12 (9–17) years having flatfeet with Achilles tendon shortening after flatfoot reconstruction and percutaneous Achilles tendon lengthening. Dynamic follow-up was performed for 3 years after foot reconstruction. The obtained data were analyzed statistically by nonparametric one-factor analysis of variance, Kruskal–Wallis and post hoc test, pairwise comparisons, and Dwass–Steel–Critchlow–Fligner test.

RESULTS: At follow-up after Achilles tendon lengthening, significant differences were obtained in the magnitude of the initial foot dorsiflexion up to 2 years after surgery, and other indicators were not significantly different. Foot dorsiflexion with tarsal joint stabilization was significantly different at all stages of follow-up compared with baseline. Foot dorsiflexion tended to decrease throughout the follow-up period.

CONCLUSIONS: After reconstructive interventions on the feet in combination with percutaneous Achilles tendon lengthening, the dorsiflexion of the feet decreased over time. At 2 and 3 years after Achilles surgery, dorsiflexion was not significantly different from baseline. The angle of dorsiflexion of the feet with the tarsal joint stabilization 3 years after Achilles tendon lengthening was significantly different from the initial level, but throughout the follow-up there was also a tendency to its gradual decrease.

BACKGROUND: Congenital giant melanocytic nevi (CMN) occur approximately in 1 of 250,000–500,000 newborns. According to foreign literature, the risk of malignancy of a melanocytic nevus varies widely within 5%–42%.

AIM: This study aimed to identify possible risk factors for CMN in children and determine the most common location and actual list of examination.

MATERIALS AND METHODS: The study enrolled 104 mother–child pairs, where the children had CMN. The control group included 60 mother–child pairs, in which the children had no CMN.

RESULTS: CMN were located on the head in 42.4% of cases, which was the most frequent localization. The most frequent localizations also included the trunk and simultaneous location of nevi on several body segments. Abnormalities in thyroid hormone levels were noted in 12.5% of the mothers. The frequency of large nevi in the grandparents of children with CMN (13.5%) was significantly higher than that in their parents (mother, 1.9%; father, 2.9%). In addition, 19.2% of the children were examined by an oncologist or are on a dispensary register with an oncologist. Moreover, 4.8% of the patients were observed by a neurologist. Magnetic resonance imaging was performed once in 19.2% of the children, who underwent genetic testing. No foci of melaniform cell accumulation in the nervous tissue were detected in any examined child.

CONCLUSIONS: The most common location of CMN is the head and torso – areas of risk of damage to the central nervous system by melanoform cells. The survey results of parents of the main group identified the following as risk factors for CMN development in children: a history of miscarriage or frozen pregnancy, thyroid hormone abnormalities, CMN in grandparents, ARVI during pregnancy, particularly in the first trimester, and visiting a solarium and using long-lasting gel polishes during pregnancy.

BACKGROUND: Diseases of the musculoskeletal system in children and their dynamics and structure are urgent health problems and have important scientific and practical significance. The epidemiological features of the detectability of pathology in different regions are of interest for detailed consideration.

AIM: This study aimed to conduct a comparative characterization of the primary morbidity of children with diseases of the musculoskeletal system in St. Petersburg in the 2017–2022 period.

MATERIALS AND METHODS: Official collections of statistical reports of the Central Research Institute of Organization and Informatization of Healthcare from 2017 to 2022 were analyzed. Indicators of diseases of the musculoskeletal system and connective tissue in children were analyzed, and a comparative assessment of the ratio of the probabilities of detecting pathologies in general and for individual nosologies presented in the collections in St. Petersburg and the Russian Federation was performed. Digital analysis was performed in Microsoft Office 2010 programs (Word and Excel).

RESULTS: The indicators of primary morbidity in St. Petersburg from 2017 to 2022 exceeded the national and regional averages and had a negative upward trend. In all age groups, over 6 years, the odds ratio in favor of St. Petersburg increased with arthropathies in general and deforming dorsopathies and decreased with spondylopathies and systemic connective tissue lesions. Moreover, in children aged 0–14 years, the chances of detection in St. Petersburg increased with respect to reactive arthropathies and fell with juvenile arthritis, whereas in adolescents the increase concerned juvenile arthritis and the decrease in reactive arthropathies. In rheumatoid arthritis, a transition was noted – the probabilities of detection have become lower in favor of the regions in Russia.

CONCLUSIONS: In St. Petersburg, an unfavorable trend in the probabilities of detecting diseases of the musculoskeletal system and connective tissue was registered among children. A two-stage increase in indicators was found in 2017–2019 and 2020–2022, and the rate of increase in the detectability of most nosologies during the COVID-19 pandemic exceeded the prepandemic values, indicating the conjugacy of the studied group of diseases with organizational limitations in the outpatient unit, quality and specificity of differential diagnosis, and viral component. The identified features indicate the need for a reassessment of organizational measures and management decisions.

BACKGROUND: In children, progressive congenital deformities of the thoracic spine combined with thoracic anomalies require surgical intervention to correct the curvature and prevent further progression during the child’s growth. Surgical correction of congenital deformity caused by segmentation disorders of the lateral surfaces of the vertebral bodies with unilateral rib synostosis aims at full correction of the existing curvature using the transpedicular spinal system and is an effective and reliable treatment option for these patients. However, this technology requires precise and correct installation of the supporting elements of the metal structure to exclude possible irreversible complications. A solution is the use of template guides in the installation of the support elements of the spinal metal structure.

AIM: This study aimed to conduct a comparative analysis of the results of using template guides for the placement of transpedicular screws with the free-hand method in children during surgical correction of congenital spinal deformities combined with thoracic anomalies.

MATERIALS AND METHODS: The results of surgical treatment of 20 patients, aged 3–9 years, were analyzed retrospectively to compare the time and accuracy of spinal metal support element placement with and without the use of template guides. The data collected included demographic information, time of bone canal formation, accuracy of spinal transpedicular screw placement, and various complications.

RESULTS: Compared with the free-hand method, the use of template guides in the surgical correction of congenital spinal deformities combined with thoracic anomalies in children reduces the time of bone canal formation and increases the accuracy of metal screw placement. These results confirm the efficacy and safety of using template guides during spinal surgery in children with these congenital malformations.

CONCLUSIONS: The use of template guides is an effective and reliable method of inserting transpedicular metal screws in the correction of congenital spinal deformities combined with thoracic anomalies in children, which increases the accuracy of implantation of support elements and reduces the surgical time. These results confirm the necessity of using template guides in the correction of congenital spinal deformities in children.

BACKGROUND: Nail–patella syndrome is an autosomal dominant disease caused by LMX1B mutations, characterized by a combination of dermatological and musculoskeletal abnormalities. The classic tetrad of the nail–patella syndrome includes hypoplasia of the nail plates, absence or hypoplasia of the patella, elbow joint contractures, often accompanied by posterior subluxation of the radial head, presence of “iliac horns” on radiographs of the pelvic bones, and renal changes. However, its diagnosis and treatment are not described in sufficient detail in domestic and foreign literature.

AIM: This study aimed to analyze the variability of clinical and radiological manifestations in children with nail–patella syndrome.

MATERIALS AND METHODS: Nine patients with nail–patella syndrome were examined and treated (aged 4 months to 14 years). All children presented to the H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery with a diagnosis of congenital multiple arthrogryposis. The examination results excluded this diagnosis. The diagnosis of nail–patella syndrome has been verified.

RESULTS: Various variants of the nail–patella syndrome have been identified, with lesions to only the elbow joints (n = 3), damage to the upper and lower extremities (n = 5), and damage to only the lower extremities (n = 1). All patients had hypoplasia of fingernail plates. However, the pathognomonic sign – “iliac horns” on radiographs of the pelvic bones – was noted only in 33% of cases. Regarding functional disorders of the kidneys, proteinuria was observed in one patient, which appeared at the age of 15 years. In two cases, the parents suffered from this disease. A genetic examination was performed in three patients: a pathogenic variant in LMX1B was detected in a heterozygous state. All patients underwent conservative treatment for knee and elbow joint contractures and foot deformities. When casting, the presence of dislocation of the radial head or patella was considered. Surgical treatment was performed on five patients. The results of surgery on the lower extremities (knee contractures, foot deformities, and hip dislocation) were good in 87% of the cases. Recurrence of flexion contractures in the elbow joints was observed both after conservative and after surgical treatment in all cases; however, their severity varied.

CONCLUSIONS: Clinical observations were considered to attract the attention of doctors of different specialties to a rare pathology. Moreover, a molecular genetic study is recommended for the timely diagnosis of the nail–patella syndrome, determining the treatment techniques and disease prognosis.

BACKGROUND: Conservative treatment of children with carinatum is currently an urgent and unresolved problem despite the wide range of techniques available. Conservative treatment stops the progression of deformation and reduces the degree of deformation or eliminates it. Methods of evaluating treatment results include clinical (photo–video assessment, questionnaire survey, and chest measurements) and instrumental diagnostics (radiography, computed tomography [CT], and 3D scanning); however, no method of correction and orthosis that would consider all the tasks of conservative treatment, method of evaluating conservative treatment, and uniform protocol have been established.

AIM: This study aimed to analyze the literature containing information on the conservative treatment of patients with pectus carinatum.

MATERIALS AND METHODS: The study presents the results of a search in PubMed, Cochrane, and eLibrary using combinations of operators and keywords. A total of 54 foreign and domestic sources were extracted, and the search was not limited retrospectively.

RESULTS: Orthosis is effective and positively perceived by doctors and patients. The most modern designs in the treatment of carinatum included dynamic orthoses FMF-DCS and Braceworks (Calgary). Recent studies have reported a strong correlation between 3D scanning and CT to assess treatment outcomes. However, no single option for conservative correction of deformity allowed for achieving all treatment goals. The assessment of the effectiveness of orthosis using photos, videos, and questionnaire, and chest measurement is subjective.

CONCLUSIONS: The disadvantages of prosthetics determine the need to develop a clear treatment algorithm, methodology, and objective assessment of treatment outcomes, requiring further research.

BACKGROUND: Fractures of the distal metaepiphysis of the radius are among the most common injuries in pediatric patients. This results from the peculiarities of the anatomical structure and structure of the radial tissue in this area.

AIM: This study aimed to analyze the literature on the treatment of children with fractures of the distal metaepiphysis of the radius.

MATERIALS AND METHODS: Literatures on the treatment of children with fractures of the distal metaepiphysis of the radius were extracted from PubMed, eLibrary, and Google Scholar without language restrictions for the period from 1990 to 2024.

RESULTS: In fractures of the distal metaepiphysis of the radius without displacement, the limb is immobilized. Displaced fractures require closed reduction and/or surgical treatment. For the treatment of stable fractures, specialists adhere to conservative techniques. The method of choice for the surgical treatment of unstable fractures should be minimally invasive osteosynthesis. The current gold standard for the surgical treatment of fractures of the distal metaepiphysis of the radius in children is closed reduction and intramedullary metal osteosynthesis with Kirschner wires, followed by plaster cast application.

CONCLUSIONS: Currently, no consensus has been reached on the method of choice for the surgical treatment of fractures of the distal metaepiphysis of the radius in children. The results of treating children using the presented surgical techniques are contradictory, and high risks of developing intra- and postoperative complications are noted. Thus, conducting more research in this area and developing new and most effective surgical methods that can reduce the risk of complications and optimize the rehabilitation process for these patients remain relevant.

Valentin A. Neverov, Honored Physician of the Russian Federation, Doctor of Medical Sciences, Professor, celebrates his 80th birthday. V.A. Neverov is the president of the Russian Association of Traumatologists-Orthopedists of St. Petersburg and Leningrad Region, a member of the editorial board of the journals Grekov’s Bulletin of Surgery and Traumatology and Orthopedics of Russia, and a member of the dissertation council on traumatology and orthopedics. His main scientific research focuses on reconstructive and restorative surgery of the musculoskeletal system and hip arthroplasty.