Pes Cavus Deformity: Anatomic, Functional Considerations, and Surgical Implications.

Pes cavus is a complicated, multiplanar deformity that requires a thorough understanding in order to provide the appropriate level of care. The foot and ankle surgeon should perform a comprehensive examination, including a neurologic evaluation, in the workup of this patient population. Understanding the cause of the patient's deformity is a critical step in predicting the disease course as well as the most acceptable form of treatment. The surgical correlation with the patient's pathologic anatomy requires an in-depth clinical evaluation, in addition to the radiographic findings, as the radiographic findings do not necessarily correlate with the patient's discomfort.

The perils of dressings: a cautionary tale of ischaemia.

A cohort of patients presented to Queen Victoria Hospital, UK, with iatrogenic toe ischaemia following application of a different, newly available post-procedure dressing with different properties to those usually used. This resulted in ischaemia with extensive skin and soft tissue damage, requiring debridement surgery and, in some cases, skin grafting. We aim to highlight the risk of morbidity from dressing application to the digits. This is a key learning skill for anyone who may either perform dressings or evaluate dressings on digits in the community and across multiple specialties in hospital. This article follows a thorough root cause analysis and addresses other possible causes of an acutely painful erythematous toe post-Zadek's procedure.

Identification of a novel pathogenic variant in CKAP2L and literature review in a child with Filippi syndrome and congenital talipes equinovarus.

Filippi syndrome (MIM #272440), one of the craniodigital syndromes, is a rare genetic entity with autosomal recessive inheritance and characterized by pre- and postnatal growth retardation, microcephaly, distinctive facial appearance, developmental delay/intellectual disability, and variable syndactylies of the fingers and toes. In this report, a further female patient of Filippi syndrome who additionally had a unilateral congenital talipes equinovarus (CTEV), a feature not previously recorded, is described. Genetic testing revealed a novel homozygous frameshift pathogenic variant (c.552_555delCAAA, p.Asn184Lysfs*8) in CKAP2L and thus confirmed the diagnosis of Filippi syndrome. We hope that the newly recognized feature (CTEV) will contribute to expand the clinical spectrum of this extremely rare condition. In view of the paucity of reported cases, the full spectrum of clinical findings of Filippi syndrome necessitates obviously further affected individuals/pedigrees delineation in order to elucidate the etiological and phenotypic aspects of this orphan disease appropriately.

Chilblain-Like Lesions (CLL) Associated With COVID-19 ("COVID Toes"): A Systematic Review.

Reports of chilblain-like lesions (CLL) coinciding with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been described in the literature, but this phenomenon has not been critically summarized. The aim of this paper is to summarize reports of CLL coinciding with SARS-CoV-2 infection to clarify the prevalence, clinical relevance, and prognostic value of these lesions. A literature search was conducted using the Embase, Pubmed, and Scopus databases from December 2019 to June 16, 2020 using the search terms ("COVID-19" OR "coronavirus" OR "2019-nCoV" OR "SARS-CoV-2") AND ("chilblain-like" OR "COVID toes" OR "acral"). Papers that described skin changes in patients with suspected or confirmed COVID-19 were included. A total of 31 papers were summarized, representing 813 cases of CLL. Available data suggests an equal gender distribution, mean age of 21 years, and median age of 14 years. Mild extracutaneous symptoms were reported in 53% of cases and 47% were asymptomatic. CLL occurred an average of 16 days after extracutaneous symptoms. Patients with CLL were positive for SARS-CoV-2 in 15% of cases. Lesions were mainly described as asymptomatic and/or pruritic erythematous to violaceous acral macules and plaques. Partial or complete resolution occurred in 85% of cases in a mean of 13 days. The most common histologic findings were perivascular and perieccrine superficial and deep lymphocytic infiltrates. Although a causal relationship between CLL and SARS-CoV-2 has not been confirmed, the temporal association and 15% positive SARS-CoV-2 rate in affected individuals should not be ignored.

Differences in toe flexor strength and foot morphology between wheelchair dependent and ambulant older people in long-term care: a cross-sectional study.

BACKGROUND: Hallux valgus, lesser toe deformity, and muscle weakness of the toe flexors contribute to falls in older people. This study aimed to examine the differences in toe flexor strength and foot morphology in older people requiring long-term care due to changes in the way they mobilize in everyday life. METHODS: This study included 84 people aged ≥70 years without motor paralysis who underwent rehabilitation. They were divided into those who could mobilize without a wheelchair (walking group, n = 54) and those who used a wheelchair to mobilize (wheelchair group, n = 30). The presence or absence of diseases was confirmed, and hand grip strength, toe flexor strength, and foot morphology using the foot printer were measured. The presence of diseases, hand grip strength, toe flexor strength, and foot morphology were compared between the two groups. Multiple logistic analysis was performed with wheelchair dependence as the dichotomous outcome variable, and the percentages of each strength measure observed in the wheelchair group to the average hand grip and toe flexor strength measures in the walking group were compared. RESULTS: No significant between-group difference in foot morphology was found. The factors related to the differences in ways of ambulating in daily life were history of fracture, heart disease, and toe flexor strength. After comparing the muscle strength of the wheelchair group with the mean values of the walking group, we found that the toe flexor strength was significantly lower than the hand grip strength. CONCLUSIONS: Older people who used a wheelchair to mobilize have significantly less toe flexor strength than those who do not despite no significant difference in foot morphology. Use of a wheelchair is associated with a reduction in toe flexor strength.

Effects of Norepinephrine Infusion on Cutaneous Surface Temperatures of the Distal Extremities.

OBJECTIVES: The etiology of vasopressor-induced digital necrosis is poorly understood, but the skin changes resemble those of frostbite, and it is known from experience that patients taking vasopressors have decreased digital temperatures. We aimed to examine the effects of norepinephrine use on surface temperatures of the distal extremities because there have been no studies examining this relation. METHODS: Surface temperatures of all digits, palms, and soles were measured using an infrared thermometer in patients receiving different rates of norepinephrine infusion in the intensive care unit and compared with those not receiving any vasopressors. RESULTS: A total of 101 measurements from 41 unique individuals were obtained. Temperature gradients between the core and the fingertips were consistently more pronounced in those receiving norepinephrine compared with those not receiving norepinephrine and increased with increasing rates of norepinephrine infusion, except with high-dose norepinephrine. Temperature gradients were more pronounced in the toes. CONCLUSIONS: Norepinephrine use was associated with greater core-to-fingertip temperature gradients and were more pronounced in the toes compared with the fingers.

Bardet-Biedl syndrome presenting with laryngeal web and bifid epiglottis.

Bardet-Biedl syndrome (BBS) is a rare autosomal recessive ciliopathy characterised by rod-cone dystrophy, obesity, postaxial polydactyly, cognitive impairment, hypogonadism, renal abnormalities, and rarely, laryngeal webs or bifid epiglottis. Most patients present with obesity. Multiple genes are involved in causation of BBS and there is also evidence of triallelic inheritance. We herein report an Asian boy who had weak cry and stridor since birth, and on evaluation was found to have both laryngeal web and bifid epiglottis. Mutation analysis revealed a homozygous variant in BBS10 gene.

Toe gaps and their assessment in footwear for people with diabetes: a narrative review.

BACKGROUND: Adequate footwear fit is critical in preventing diabetes-related foot ulcers. One important element is the toe gap, the difference between foot length and internal footwear length available to the foot. We summarised the literature on toe gaps in studies assessing footwear worn by people with diabetes, the methods used to measure both foot length and internal footwear length and identify ambiguities which may impact on toe gap assessment in clinical practice, and suggest pragmatic solutions. METHODS: The Google Scholar database was searched to April 2020 for peer-reviewed studies using keywords related to incorrectly fitting or ill-fitting and diabetes, foot and ulcer which returned 979 results. Included studies within this narrative review encompassed toe gap measurement to assess footwear worn by people with diabetes. RESULTS: A total of eight studies were included after full paper review. Toe gap ranges as used in assessments of footwear worn by people with diabetes vary, with a minimum of 1.0-1.6 cm and a maximum of 1.5-2.0 cm, as do methods of measuring internal footwear length. Only three published studies suggested possible measuring devices. CONCLUSIONS: Toe gap ranged as used when assessing footwear fit in people with diabetes vary and a gold standard device for internal footwear length measurement has yet to emerge. International guidelines provide welcome standardisation, but further research is needed to evaluate both the effect of toe gap ranges upon pressure, plantar stress response and ulceration and available measuring devices to facilitate development of toe gap measurement protocols that may further enhance consistency in practical assessments.

Effect of toe exercises and toe grip strength on the treatment of primary metatarsalgia.

BACKGROUND: The relationship of metatarsalgia and toe function is poorly understood. We investigated the efficacy of toe exercises for the treatment of metatarsalgia. METHODS: Forty-one (56 feet) metatarsalgia patients (mean age ± SD: 63.4 ± 10.6) underwent toe strength measurement. We recorded pre- and post-treatment VAS score, AOFAS score, marble pickup, single-leg standing time (SLST), and compared in two subgroups to evaluate impact of disease duration on treatment outcome. RESULTS: Post treatment, toe plantarflexion strength improved (all p < 0.01); VAS scores decreased (p < 0.01); AOFAS scores, marble pickup, and SLST improved (all p < 0.01). Patients symptomatic for > 1 year had significantly lower changes in VAS scores (p < 0.01). Multivariate analysis showed patients with longer disease duration, and larger body mass index had significantly lower improvement in VAS scores (p = 0.029 and p = 0.036, respectively). Device consistency assessed by ICC was excellent (0.89-0.97). CONCLUSION: Toe function and metatarsalgia are improved by toe exercises, suggesting that they are closely related.

A 47-Year-Old Hispanic Man Who Developed Cutaneous Vasculitic Lesions and Gangrene of the Toes Following Admission to Hospital with COVID-19 Pneumonia.

BACKGROUND Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in Wuhan, China, in late 2019 and has led to an ongoing pandemic. COVID-19 typically affects the respiratory tract and mucous membranes, leading to pathological involvement of various organ systems. Although patients usually present with fever, cough, and fatigue, less common manifestations have been reported including symptoms arising from thrombosis and thromboembolism. A spectrum of dermatologic changes is becoming recognized in patients with COVID-19 who initially present with respiratory symptoms. The mechanism behind these manifestations remains unclear. This report presents the case of a 47-year-old Hispanic man who developed cutaneous vasculitic lesions and gangrene of the toes following admission to hospital with COVID-19 pneumonia. CASE REPORT COVID-19 has been associated with cardiovascular disease entities including stroke, acute coronary syndrome, venous thromboembolism, and peripheral vascular disease. We present a case in which a 47-year-old Hispanic man arrived at the Emergency Department with COVID-19 and was admitted for respiratory failure. Despite anticoagulation initiated on admission in the presence of an elevated D-dimer, the patient developed gangrene of all his toes, which required bilateral transmetatarsal amputation. CONCLUSIONS This case shows that dermatologic manifestations may develop in patients who initially present with COVID-19 pneumonia. These symptoms may be due to venous thrombosis following SARS-CoV-2 vasculitis, leading to challenging decisions regarding anticoagulation therapy. Randomized controlled trials are needed to evaluate the efficacy of anticoagulation, to choose appropriate anticoagulants and dosing, and to assess bleeding risk.

Toe walking in children with cerebral palsy: a possible functional role for the plantar flexors.

Equinus and toe walking are common locomotor disorders in children with cerebral palsy (CP) walking barefoot or with normal shoes. We hypothesized that, regardless of the type of footwear, the plantar flexors do not cause early equinus upon initial foot contact but decelerate ankle dorsiflexion during weight acceptance (WA). This latter action promoted by early flat-foot contact is hypothesized to be functional. Hence, we performed an instrumented gait analysis of 12 children with CP (Gross Motor Function Classification System class: I or II; mean age: 7.2 yr) and 11 age-matched typically developing children. The participants walked either barefoot, with unmodified footwear (4° positive-heel shoes), or with 10° negative-heel shoes (NHSs). In both groups, wearing NHSs was associated with greater ankle dorsiflexion upon initial foot contact, and greater tibialis anterior activity (but no difference in soleus activity) during the swing phase. However, the footwear condition did not influence the direction and amplitude of the first ankle movement during WA and the associated peak negative ankle power. Regardless of the footwear condition, the CP group displayed 1) early flattening of the foot and ample dorsiflexion (decelerated by the plantar flexors) during WA and 2) low tibialis anterior and soleus activities during the second half of the swing phase (contributing to passive equinus upon foot strike). In children with CP, the early action of plantar flexors (which typically decelerate the forward progression of the center of mass) may be a compensatory mechanism that contributes to the WA's role in controlling balance during gait.NEW & NOTEWORTHY Adaptation to walking in negative-heel shoes was similar in typically developing children and children with cerebral palsy: it featured ankle dorsiflexion upon initial contact, even though (in the latter group) the soleus was always spastic in a clinical examination. Hence, in children with cerebral palsy, the early deceleration of ankle dorsiflexion by the plantar flexors (promoted by early flattening of the foot, and regardless of the type of footwear) may have a functional role.

The evidence for improving balance by strengthening the toe flexor muscles: A systematic review.

BACKGROUND: Poor postural balance in the upright position is strongly correlated to morbidities, such as falls in older adult populations and to lower limb injuries in the younger populations. Good postural balance depends on muscular strength and the integration of neurological and muscular feedback mechanisms throughout the body. Since the interface with the ground is the plantar surface of each foot, an improved understanding of the role of foot muscles in postural balance is warranted. RESEARCH QUESTION: Does improved toe flexor strength result in better postural balance, across the lifespan? METHODS: A systematic review was conducted of papers from 1900 to 2019 inclusive, from five databases. Inclusion and exclusion criteria were established prior to selection. Inclusion criteria were: observational and longitudinal studies, healthy subjects, at least one balance and one toe flexor strength test conducted. Exclusion criteria were: subjects with a pathology/disability, case study, systematic or literature review. Two examiners assessed a study's suitability for inclusion in this review, based on the above criteria. Study quality was assessed using the Critical Appraisal Skills Program Tools. The type of studies and methodological heterogeneity precluded the feasibility of conducting a meta-analysis. RESULTS: Nine studies were included. In each study, participants were over sixty years of age, and over 73 % of them were female. No study was found for a younger population group. There were seven cross-sectional studies, two randomized control trials and there was one case-control study. All studies provided evidence of directly proportional, clinically significant correlations between toe flexor strength and postural balance. SIGNIFICANCE: Toe flexor strength contributes to improved postural balance for people over the age of 60. Research is needed to establish the relationship between foot muscle strength and balance in younger adults and children.

Correlation between functional ability, toe flexor strength, and plantar pressure of hallux valgus in young female adults: a cross-sectional study.

BACKGROUND: The prevalence of hallux valgus (HV) increases with age in females. Several studies have investigated the relationship between foot problems, including HV, and falls in older individuals. This study aimed to examine whether HV causes a decline in functional activity in young females and also evaluate the relationship between HV angle, functional activity, toe flexor strength, and plantar pressure. METHODS: We assessed 94 females (mean age, 19.6 ± 1.3 years; mean body mass index, 21.2 ± 2.0 kg/m2) not currently receiving treatment for lower limb disease. HV angle was determined using their footprint. Functional reach (FR) and maximum step length (MSL), toe flexor strength, and plantar pressure were measured. Plantar pressure was measured during walking. We also calculated FR and the pressure in eight regions (first toe, second through fifth toes, first metatarsal, second through fourth metatarsals, fifth metatarsal, midfoot, medial heel, and lateral heel). RESULTS: There were 39 and 55 participants in the HV and no HV groups, respectively. FR and MSL did not differ significantly between the HV and no HV groups. Toe flexor strength was significantly different between the HV and no HV groups (26.69 ± 9.68 vs. 32.19 ± 8.55, respectively) (p = 0.002, ß = 0.206). During walking, plantar pressure was significantly lower in the second through fifth toes in the HV group (p = 0.005, ß = 0.187). During FR, plantar pressure was significantly greater in the first metatarsal in the HV group (p = 0.016, ß = 0.338). HV angle was negatively correlated with toe flexor strength (r = - 0.315, p = 0.002, ß = 0.121) and plantar pressure during walking in the second through fifth toes (r = - 0.362, p < 0.001, ß = 0.047), and positively correlated with plantar pressure during FR in the first metatarsal (r = 0.308, p = 0.002, ß = 0.137). Toe flexor strength was negatively correlated with plantar pressure during FR in the second through fourth metatarsals (r = - 0.318, p = 0.002, ß = 0.115), and there was a positive correlation with MSL (r = 0.330, p = 0.001, ß = 0.092). CONCLUSIONS: This study confirmed that HV reduces toe flexor strength and affects forefoot pressure during walking and FR in young females. Moreover, the toe flexor strength affects MSL. Efforts to prevent the onset and deterioration of HV from a young age might help reduce the risk of falling when older.

Minimum toe clearance and tripping probability in people with unilateral transtibial amputation walking on ramps with different prosthetic designs.

BACKGROUND: Minimum Toe Clearance (MTC) is defined as the minimum vertical distance between the lowest point under the front part of the foot and the ground, during mid-swing. Low values of MTC and walking on inclines are both related to higher probability of tripping and falling in lower limb amputees. New prosthetic designs aim at improving MTC, especially on ramps, however the real effect on MTC still needs investigation. The objective of this study was then to evaluate the effect of different prosthetic designs on MTC in inclined walking. METHODS: Thirteen transtibial amputees walked on a ramp using three different prostheses: non articulating ankle (NAA), articulating hydraulic ankle (AHA), and articulating hydraulic ankle with microprocessor (AHA-MP). Median MTC, coefficient of variation (CV), and tripping probability (TP) for obstacles of 10 and 15 mm were compared across ankle type in ascent and descent. FINDINGS: When using AHA-MP, larger MTC median values for ascending (P ≤ 0.001, W = 0.58) and descending the ramp (P = 0.003, W = 0.47) were found in the prosthetic limb. Also significantly lower CV was found on the prosthetic limb for both types of AHA feet when compared to NAA for descending the ramp (P = 0.014, W = 0.45). AHA-MP showed the lowest TP for the prosthetic leg in three conditions evaluated. On the sound limb results showed the median MTC was significantly larger (P = 0.009, W = 0.43) and CV significantly lower (P = 0.005, W = 0.41) when using an AHA in ascent. INTERPRETATION: Both AHA prosthetic designs help reduce the risk of tripping of the prosthetic limb by increasing the median MTC, lowering its variability and reducing TP for both legs when ascending and descending the ramp. For most of the conditions, AHA-MP showed the lowest TP values. Findings suggest that AHA prostheses, especially AHA-MP could reduce the risk of tripping on ramps in amputees.

Gait control in children with attention-deficit/hyperactivity disorder.

The current profile of gait control in children with ADHD is incomplete and predominately based on children walking forward at a self-selected pace. There are no studies of potential gait deficits in this clinical population when walking in different directions in combination with varying rates of stepping that are freely selected and entrained to an external stimulus. The purpose of the current study was to address this lack of information by assessing gait of children aged 7-17 years with (n = 17) and without (n = 26) ADHD. Participants walked forward and backward along an electronically instrumented carpet at a self-selected stepping rate and in synchrony to a metronome that dictated an increased and decreased stepping rate. Using repeated measures analysis of covariance (ANCOVA) to assess spatiotemporal gait parameters, results showed that children with ADHD exhibited a significantly exaggerated, toes 'turned out,' foot position for all walking conditions compared to typically developing children. When walking backward, children with ADHD produced an increased step width, higher stepping cadence, and increased velocity. Additionally, coefficient of variation ratios indicated that children with ADHD produced greater variability of velocity, cadence, and step time for all walking conditions, and greater variability for stride length when walking at an increased stepping rate. Results were interpreted in terms of clinical significance and practical ramifications that inform rehabilitation specialists in designing therapies that ameliorate the reported gait deficits.

PAPPI: Personalized analysis of plantar pressure images using statistical modelling and parametric mapping.

Quantitative analyses of plantar pressure images typically occur at the group level and under the assumption that individuals within each group display homogeneous pressure patterns. When this assumption does not hold, a personalized analysis technique is required. Yet, existing personalized plantar pressure analysis techniques work at the image level, leading to results that can be unintuitive and difficult to interpret. To address these limitations, we introduce PAPPI: the Personalized Analysis of Plantar Pressure Images. PAPPI is built around the statistical modelling of the relationship between plantar pressures in healthy controls and their demographic characteristics. This statistical model then serves as the healthy baseline to which an individual's real plantar pressures are compared using statistical parametric mapping. As a proof-of-concept, we evaluated PAPPI on a cohort of 50 hallux valgus patients. PAPPI showed that plantar pressures from hallux valgus patients did not have a single, homogeneous pattern, but instead, 5 abnormal pressure patterns were observed in sections of this population. When comparing these patterns to foot pain scores (i.e. Foot Function Index, Manchester-Oxford Foot Questionnaire) and radiographic hallux angle measurements, we observed that patients with increased pressure under metatarsal 1 reported less foot pain than other patients in the cohort, while patients with abnormal pressures in the heel showed more severe hallux valgus angles and more foot pain. Also, incidences of pes planus were higher in our hallux valgus cohort compared to the modelled healthy controls. PAPPI helped to clarify recent discrepancies in group-level plantar pressure studies and showed its unique ability to produce quantitative, interpretable, and personalized analyses for plantar pressure images.

Successful Fat Grafting in a Patient With Thromboangiitis Obliterans.

Thromboangiitis obliterans, or Buerger disease, is a rare nonatherosclerotic segmental inflammatory vasculitis that generally affects young tobacco smokers. Although no surgical treatment is available, the most effective way to halt the disease's progress is smoking cessation. In this case report, a 29-year-old smoker showed up to emergency department with gangrene of his fifth left toe and extensive plantar ulceration. After investigative angiography, he was diagnosed with Buerger disease. On November 2017, he underwent fifth left toe amputation and hyperbaric therapy. Five months after amputation, the patient was rehospitalized because of surgical wound dehiscence, wide ulceration, and pain. He was treated with lipofilling using the Coleman technique. Two weeks after the fat grafting procedure, the patient suspended pain control medication, and after 2 months, the surgical wound was almost healed. Fat grafting (lipofilling) is mostly used in plastic surgery; it offers regenerative effects, with minimal discomfort for the patient. This case report demonstrates a successful alternative use of lipofilling for this unique condition and opens up new options for use of this technique in other fields.

Quantitative assessment of cortical somatosensory digit representations after median and ulnar nerve injury in rats.

Incomplete recovery of sensory function is common after peripheral nerve injury (PNI). Despite reinnervation following injury, disorganized cortical representations persist and may contribute to functional deficits. There is a dearth of literature characterizing cortical responses after PNI in rodent models. Here we develop a quantitative electrophysiological method for mapping forepaw digit responses in primary somatosensory cortex (S1) of rats. We tested the hypothesis that PNI in the forelimb would generate significant, long lasting sensory deficits, and corresponding disorganization in S1. Rats underwent a transection of the proximal segment of the median and ulnar nerves in the forelimb followed by tubular repair. 4-12 months after nerve injury, we tested mechanosensory withdrawal thresholds and mapped S1 responses to mechanical stimulation of the digits. PNI produces persistent elevation of mechanical withdrawal thresholds, consistent with an impairment in sensory function. Assessment of cortical neurophysiology reveals a substantial disorganization of S1 somatotopy. Additionally, we document degraded timing and digit specificity of cortical responses. This quantitative measurement of long-term changes in S1 digit representations after forelimb nerve injury in rodents provides a framework for further studies focused on the development of therapeutic strategies to restore cortical and sensory function.