Imaging of Müller-Weiss Disease.

Müller-Weiss disease (MWD) is the result of a dysplasia of the tarsal navicular bone. Over the adult years, the dysplastic bone leads to the development of an asymmetric talonavicular arthritis with the talar head shifting laterally and plantarly, thus driving the subtalar joint into varus. From a diagnostic point of view, the condition may be difficult to differentiate from an avascular necrosis or even a stress fracture of the navicular, but fragmentation is the result of a mechanical impairment rather than a biological dysfunction.Standardized weight-bearing radiographs (anteroposterior and lateral views) of both feet are usually enough to diagnose MWD. Other imaging modalities such as multi-detector computed tomography and magnetic resonance imaging in early cases for the differential diagnosis can add additional details on the amount of cartilage affected, bone stock, fragmentation, and associated soft tissue injuries. Failure to identify patients with paradoxical flatfeet varus may lead to an incorrect diagnosis and management. Conservative treatment with the use of rigid insoles is effective in most patients. A calcaneal osteotomy seems to be a satisfactory treatment for patients who fail to respond to conservative measures and a good alternative to the different types of peri-navicular fusions. Weight-bearing radiographs are also useful to identify postoperative changes.

Navicular Fracture.

The tarsal navicular is an essential component of the Chopart joint and crucial for most of hindfoot motion. Most fractures are low-energy dorsal avulsions that may be treated nonoperatively. Displaced comminuted fractures require open reduction and internal fixation, sometimes with external fixation, bridge plating, and bone grafting. Diagnosis of stress fractures is commonly delayed. Conservative treatment is associated with good results, but surgery allows for quicker return-to-play in athletes. Nonunion in acute and stress fractures needs open debridement, grafting, and stable fixation. Müller-Weiss disease may present with a fragmented navicular and mimic an acute or a stress fracture.

Progressive Collapsing Foot Deformity. Is There Really a Johnson and Strom Stage I?

Johnson and Strom stage I posterior tibialis tendon dysfunction presents with pain and swelling but preserved function and no deformity. Diagnosis is clinical. Pathomechanics explains the overloading of the tendon that may be worsened by a tight gastrocnemius, but systemic inflammatory disease may also be responsible for a stage I condition. Medial heel wedged orthoses are effective in most patients. Surgery usually consists of an open/endoscopic tenosynovectomy. In cases of complete tendon rupture, flexor digitorum longus tendon transfer may be considered. Stage I patients with a higher risk of progression-inflammatory conditions, excessive laxity, obese-may benefit from a "prophylactic" medializing calcaneal osteotomy.

Management of Complications After Hallux Valgus Reconstruction.

Complications following hallux valgus (HV) reconstruction will have an expected incidence of between 10% and 55% of cases. The more commonly reported complications include undercorrection/recurrence, overcorrection (hallux varus), transfer metatarsalgia, nonunion, malunion, avascular necrosis, arthritis, hardware removal, nerve injury, and ultimately patient dissatisfaction. The presence of arthritis will be an indication for fusion, whereas osteotomies will be the procedure of choice if the first metatarsophalangeal joint is healthy. Wide experience in primary HV surgery is advised before dealing with complex cases of failed HV surgery.

Management of Müller-Weiss Disease.

Müller-Weiss disease (MWD) is a dysplasia of the tarsal navicular. The shifting of the talar head laterally over the calcaneus drives the subtalar joint into varus. Failure to identify patients with paradoxic flatfoot varus may lead to the incorrect diagnosis and management. Conservative treatment with the use of rigid insoles with medial arch support and a lateral heel wedge is effective in most patients. Dwyer calcaneal osteotomy combined with lateral displacement seems to be a satisfactory treatment for patients who had failed to respond to conservative measures and a good alternative to the different types of perinavicular fusions.

Efficacy of Calcaneus Osteotomy for Treatment of Symptomatic Müller-Weiss Disease.

BACKGROUND: Various methods of midfoot and hindfoot arthrodesis for treating symptomatic Müller-Weiss disease (MWD) have been reported in the literature. In this study, we present the results of a previously unreported method of treatment using a calcaneal osteotomy incorporating a wedge and lateral translation. METHODS: Thirteen patients (14 feet) with MWD were treated with a calcaneal osteotomy and retrospectively reviewed. These included 7 females and 6 males, with an average age of 56 years (33-79 years), and an average symptoms duration of 10.6 years (1-16 years). The disease was staged according to Maceira, which included 5 feet in stage II, 4 feet in stage III, 4 feet in stage IV, and 1 foot in stage V. Pre- and postoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS), radiologic examination, and patients' satisfaction rate of the surgery were evaluated at an average of 3.7 years (range, 1-8.5 years) following surgery. RESULTS: The final follow-up visit showed satisfactory outcomes, with VAS score reducing from the preoperative 8 (7-9) to postoperative 2 (0-4), whereas the AOFAS score improved from the preoperative 29 (20-44) to the postoperative 79 (70-88). The patient's subjective ratings showed excellent results in 4 feet, good results in 8 feet, and fair outcomes in 2 feet. The hindfoot range of motion remained unchanged, as did the extent of the navicular complex arthritis, and no patient required an arthrodesis since surgery. CONCLUSION: A calcaneal osteotomy can be used as an alternative treatment option for selected MWD patients regardless of the radiologic stage of the disease. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Posterior tibial tendoscopy.

The posterior tibial tendon (PTT) helps the triceps surae to work more efficiently during ambulation. Disorders of the PTT include tenosynovitis, acute rupture, degenerative tears, dislocation, instability, enthesopathies, and chronic tendinopathy with dysfunction and flat foot deformity. Open surgery of the PTT has been the conventional approach to deal with these disorders. However, tendoscopy has become a useful technique to diagnose and treat PTT disorders. This article focuses on PTT tendoscopy and tries to provide an understanding of the pathomechanics of the tendon, indications for surgery, surgical technique, advantages, complications, and limitations of this procedure.

Transfer metatarsalgia post hallux valgus surgery.

Metatarsalgia, pain around the metatarsophalangeal joints, may arise from mechanical causes spontaneously or iatrogenically. Nonunion or malunion of the first metatarsal can transfer weight-bearing forces and overload the lesser metatarsals. Transfer metatarsalgia after failed hallux valgus surgery is troublesome and more prevalent than would be expected. Clinical examination of the patient allows identifying the type of transfer metatarsalgia and pathomechanics involved. This review focuses on transfer metatarsalgia after hallux valgus surgery and provides a basic understanding of the pathomechanics, clinical examination, and image studies. It also addresses the options for both conservative and surgical treatment of this challenging condition.

Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession.

PURPOSE: The purpose of this study was to compare results of partial proximal fasciotomy (PPF) with proximal medial gastrocnemius release (PMGR) in the treatment of chronic plantar fasciitis (CPF). METHOD: This retrospective study compares 30 patients with CPF that underwent PPF with 30 that underwent isolated PMGR. Both groups were matched in terms of previous treatments and time from onset of symptoms to surgery. Different standardised evaluation scales (VAS, Likert, AOFASh) were used to evaluate results. RESULTS: Plantar fasciotomy had satisfactory results in just 60 % of patients, with an average ten weeks needed to resume work and sports. Patient satisfaction in the PMGR group reached 95 %, being back to work and sports at three weeks on average. Functional and pain scores were considerably better for PMGR and fewer complications registered. CONCLUSION: In our series, isolated PMGR is a simple and reliable procedure to treat patients with CPF. It provides far better results than conventional fasciotomy with less morbidity and better patient satisfaction, and thus has become our surgical procedure of choice in recalcitrant CPF.

Correlation between immature platelet fraction and reticulated platelets. Usefulness in the etiology diagnosis of thrombocytopenia.

BACKGROUND: Reticulated platelets (RP) are a surrogate marker for megakaryocytic activity, but the limitation of this determination is the lack of standardization of methodology. The determination of the immature platelet fraction (IPF) is performed in a simple, automated, and reproducible way between laboratories. We analyzed the correlation between IPF and RP, and usefulness of IPF in patients with thrombocytopenia. METHODS: RP were determined by flow cytometry using double staining with thiazole orange and CD61 PerCP. IPF was performed with Sysmex XE2100 analyzer. We used a control group with normal platelets, and thrombocytopenic patients were classified into three groups: Group 1. Central thrombocytopenia, Group 2. Thrombocytopenia as a result of enhanced peripheral platelet destruction, and Group 3. Peripheral non-immune thrombocytopenia by abnormal distribution. RESULTS: Fourteen controls and 66 patients were analyzed. Group 1: 25 patients, they had mean and confidence interval 95% (95% CI) for IPF 8.67% (6.49-10.46%) and RP 4.08% (2.86-5.30%). Group 2: 20 patients, they had mean and 95%CI for IPF 16.80% (12.20-21.39%) and RP 16.14% (9.89-22.40%). Group 3: 21 patients, they had mean and 95% CI for IPF 9.04% (6.95-11.14%) and RP 5.23% (3.41-7.05%). The overall Pearson linear correlation between IPF and RP was r: 0.65. There were statistically significant differences in values of IPF and RP between Group 2 and the other two groups (P < 0.01). CONCLUSION: There is a good correlation between IPF and RP mainly in thrombocytopenia by peripheral destruction. Determination of IPF is an easy technique in their implementation, standardized and reproducible, so it could be a useful screening technique in patients with thrombocytopenia.

Effectiveness of rituximab in severe Wegener's granulomatosis: report of two cases and review of the literature.

We hereby describe the satisfactory evolution of rituximab treatment in two patients with Wegener's granulomatosis (WG). Rituximab was indicated for refractoriness to standard treatment in one case and life-threatening myelotoxicity due to alkylating agents in the other. A brief review of previous experience with the use of rituximab in the treatment of WG is presented.

[Relationship between reticulated platelets and megacaryocyte number in thrombocytopenic patients]. / Relación entre plaquetas reticuladas y número de megacariocitos en pacientes con trombocitopenia.

BACKGROUND AND INTRODUCTION: Marrow aspiration is a test that helps the pathogenic diagnosis of thrombocytopenia. Our goal was to analyze the correlation between reticulated platelets (RP) values in peripheral blood with megakaryocytic number in bone marrow in a group of thrombocytopenic patients. PATIENTS AND METHODS: Prospective observational study in thrombocytopenic patients, between June 2002 and June 2005. RP determination was performed by flow cytometry using whole blood. We used a monoclonal anti-glycoprotein-IIIa antibody (CD61PerCP) for platelet identification and orange thiazole (Retic-count) as platelet mRNA stain. Marrow study was conducted by marrow aspiration. RESULTS: RP were measured in 54 thrombocytopenic patients with bone marrow study. Three were excluded from the study. Thirty-two patients had central thrombocytopenia with diminished megakaryocytes (MK) and/or dysplasia, mean of RP 9.5% (CI 95%:5.6%-13.4%). Thirteen patients had high MK,mean of RP 25.7%(CI 95%:13.1%-38.3%). Six patients had normal MK, mean of RP 13.6% (CI 95%:0.6%-26.8%). There were differences between the group of increased MK and the group of central thrombocytopenias (p=0001). A value of RP>or=11% showed a sensitivity of 70% and specificity of 81% for the diagnosis of marrow aspirate with increased MK. CONCLUSIONS: RP are an indirect marker of megakaryocyte number in bone marrow. A value of RP>or=11% in patients with thrombocytopenia, especially with an acute onset, would indicate regenerative thrombocytopenia, while in the presence of low levels of RP a marrow aspiration should be performed.