SUBCUTANEOUS EXOSTOSIS OF THE TOES IN CHILDREN AND ADOLESCENTS TREATMENT EXPERIENCE.

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Relevance. In 1817, French surgeon Guillaume Dupuytren described a pathology: bone-cartilaginous growth in the area of the nail phalanx of the toe, which injures soft tissues, causes painful sensations and makes it difficult for the nail plate to grow. In this connection, this pathology is called "Dupuytren's exostosis" or "Subungual exostosis" (PNE). [1]
Currently, Osteochondroma is commonly referred to as osteochondroma. Osteochondroma is a benign cartilage-forming tumor that arises from aberrant subperiosteal cartilage that grows and matures in accordance with normal enchondral ossification. At the same time, the formation contains bone marrow spaces communicating with the bone, and is covered with a layer of mature hyaline cartilage. Osteochondromas can be either single formations or multiple formations. Polyossal forms of exostatic chondrodysplasia are described as genetic syndromes. [2]
In the international classification of bone and cartilaginous neoplasms, subungual exostosis occupies a separate group, which is called Subungual exostosis. [3]
Orthopedists and surgeons are most often found with Dupuytren's exostosis.
According to literature data, as well as analyzing outpatient patient records at the prehospital stage, it is noteworthy that most often PNE is mistaken for an ingrown toenail, especially with the localization of 1 toe. Due to the routine of "frequent surgical pathology" such as ingrown toenail, colleagues do not always suspect a possible pathology of the nail phalanx. Thus, patients often undergo several surgical procedures and medical manipulations before the true cause of the patient's suffering is established – subcutaneous exostosis. Even with the verification of the diagnosis of subcutaneous exostosis, it is not always possible to eliminate it during a single operation; according to the literature, recurrence of PNE was noted in 10% after surgical treatment and is associated with incomplete removal of the formation. [4]
Onychocryptosis or ingrown toenail (unguis incarnates, ingrown toenail) is one of the most common reasons for seeking surgical help. The prevalence of pathology among the population is 3.4%. Pathology that occurs in all age groups from newborns to the elderly. According to literature data, HC is from 0.5 to 10% in the structure of outpatient surgical care.  The etiopathogenesis of VN is based on a genetic predisposition - a violation of the normal growth of the nail plate, an anatomical disparity between the nail plate, the nail bed and the surrounding soft tissues. Additional factors contributing to ingrowth of the nail plate are: deformity of the feet and toes, irrational footwear, hygienic factors, including improper circumcision of the nail plate. [5, 6].  Analyzing clinical cases, we believe that the ingrown toenail pathology is the most often competing in establishing the correct diagnosis – subungual exostosis.
In 2023-2024 in ************* 14 pediatric and adolescent patients with osteocartilaginous formations of the subcutaneous plate of the toes were treated. Before going to the hospital, patients were observed in other medical institutions, where they received treatment, including surgical treatment for the disease - ingrown toenail.
The aim of the study was to improve the treatment results of patients with subungual exostosis of the toes.
Research objectives:
1. Assessment of the diagnosis and treatment results of patients with subungual exostosis of the toes.
2. Definition of criteria for the diagnosis of osteochondromas with subungual localization in children and adolescents.
3. Determination of criteria for differential diagnosis with other lesions of the nail phalanges of the toes.
Materials and methods: clinical examination, medical history, X-ray, histological examination, statistical.
For the period 2023-2024 *********** 14 patients underwent surgery for PNE of the toes. Gender distribution of boys - 4, girls - 10, minimum age – 3 years, maximum 17 years, average age — 13.3 years.
By localization: right foot, I finger - 6 cases, III finger - 1 case; left foot: I finger – 4 cases, II finger - 1 case, IV finger - 2 cases.
The age distribution of patients according to the location of PNE I toes: the minimum age is 12 years, the maximum age is 17 years, the average age is 14.6 years
Other toes (II-IV): minimum age 3g, maximum age 17, average age 10.25 years.
Inclusion criteria: children and adolescents with lesions of the nail phalanges of the toes of the foot – morphologically confirmed as osteochondromas.
Non-inclusion criteria: children and adolescents with lesions of the proximal, middle phalanges of the toes or other upper and lower extremities.
Exclusion criteria: children and adolescents with other benign lesions of the toes.
In the preoperative period, clinical examination of all patients Fig.1 (photo of the foot with PNE)

 

Fig.1 (photo of the foot from the PE)

It was supplemented with radiographs of the pathology area in 2 projections Fig.2 (radiographs),

  
Fig.2 (X-ray images)

 

in case of "doubts" about the true limits of the PHE, the examination was supplemented with computed tomography or cone beam tomography. Fig. 3 (CT)

Fig. 3 (CT)

After routine preoperative preparation, all patients underwent surgical treatment in full - complete removal of the subcutaneous exostosis.

Surgical treatment: Operations were performed under anesthesia. Additionally, local anesthesia was performed according to the Oberst–Lukashevich method. The nail plate was completely removed, which in some cases made it possible to fully visualize the formation and, depending on the location of the PNE, skin accesses were performed.  Fig. 4 (intraoperative photo)
 

Fig. 4. (View of the PE after removal of the nail plate)

Only with full visualization of the PHE was performed: resection of the pathological formation within healthy tissues – "minus tissue". In the case of skin incisions, stitches were applied to the skin. The operation was completed with the application of an aseptic dressing with antiseptic, ointment with antimicrobial composition. All the removed formations were sent for histological examination. In all 14 cases, the pathomorphological conclusion is "osteochondroma".
On the 2nd day after the operation, the patients were discharged for outpatient follow-up.
Results. In the postoperative period, patients were observed in catamnesis for up to 2 years. It was noted that there were no complaints, including pain, the shape of the distal phalanx of the toe was not cosmetically affected, the nail plate was completely restored, and there were no cases of recurrence of PNE.
Discussion: In our study, there were no patients with a polyossal form of exostous chondrodysplasia, PNE was represented by a single formation, although we assume that with a polyossal form of exostous chondrodysplasia, the nail phalanges of the toes may also be affected. [4]
Most often, PNE should be differentiated from the pathology of ingrown toenail.
Hospital's versatility ************ and the possibility of joint discussion and management of patients jointly by orthopaedists and general surgeons allows us to summarize the clinic's material. The Department of Surgery provided data on the number of operated patients for ingrown toenail pathology in 2023-2024, as well as its clinical observations. The clinical picture of LV consists of signs of local inflammation (hyperemia, edema, increased local temperature, pain, impaired function) of varying severity, as the skin is hyperemic, the lateral rollers thicken and build up on the nail plate, causing inflammation with secretions, including pus from the wound, the growth of granulation tissue in the area of the nail roller, ingrown part the nail plate feels like a foreign body. Chronic injury and infection exacerbate the development of persistent chronic inflammation. Figure 5.

 
Figure 5. Ingrown toenail

266 patients with HC pathology were operated on in 2023, and 259 children and adolescents in 2024. Thus, having compared and analyzed data on patients with ingrown toenail and PNE pathology, we want to share our observations with colleagues. Tab1/Table 1
Table 1/Table 1 clinical signs
    Subcutaneous exostosis Ingrown toenail
The periarticular roller does not grow on the nail plate, the lateral rollers thicken
and grow on the nail plate,
The deformation of the nail plate and or the distal phalanx of the toe is primary and depends on the location and size of the PNE.    It is possible. It is secondary against the background of an active inflammatory process.
The symptoms of inflammation are absent or secondary against the background of traumatization of the adjacent tissues by PE and shoes, the manifestation of HF disease along with pain syndrome.
Pain syndrome is a variable sign.    The constant sign of intensity depends on the intensity of inflammatory phenomena.
X-ray Reveals osteochondroma.    There is no additional bone shadow.

The frequency and routine of pathology – ingrown toenail do not allow us to insist on X-rays during the examination and treatment of the pathology of VN. At the same time, if HF recurs after surgical treatment or when additional bone and cartilage structures are visualized during the surgical treatment of an ingrown toenail, the appointment of radiographs of the toes will be quite appropriate and possibly key in verifying the pathology.
The pathogenesis of PNE is currently not fully defined. The clinical manifestations of PNE of the nail phalanx of the II, II, IV toes are manifested in children at an earlier age than the clinical manifestations of PNE of the nail phalanx of the I toes, which indicates not the traumatic pathogenesis of PNE, but the growth of osteochondroma.  [4]
This assumption is confirmed by the conclusions of morphological studies of all removed osteochondromes. 
It is also an interesting observation that we have not had any patients with PNE of the 5th toe, although theoretically it should be injured at least as often as the 1st toe. [1]

About the authors

Sergey Транковский

Children s State Hospital of St. Vladimir;
Academy of Postgraduate Education Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical
Technologies of the Federal Medical Biological Agency, Moscow, Russian Federation

Author for correspondence.
Email: doctseort@yandex.ru
ORCID iD: 0000-0002-5077-2186
SPIN-code: 5017-4839
Россия

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