RESUMO
No consensus exists regarding operative treatment of Müller-Weiss disease (MWD). Its only classification is based solely on Méary's angle and serves neither as guide to management nor prognosis. We report on 33 feet that underwent surgery following failed conservative management. Treatment was directed towards joint(s) involved, as determined by clinical examination, plain radiography and SPECT-CT. Thus, surgery consisted of isolated talonavicular in 6 feet, triple in 8, subtalar and talonavicular in 7, talonaviculocuneiform in 4, talonaviculocuneiform with interpositional tricortical iliac crest graft in 6 and pantalar arthrodesis in 2. PROMIS scores for pain interference and depression decreased significantly (p < .001) with significant accompanying increase in physical function (p = .003). Union occurred in 31 of 33 feet (94%) with complete resolution of pain at an average follow-up of 84 months. Of the 2 nonunions, 1 had fracture through the lateral navicular, and the other marked sclerosis and avascularity of the lateral navicular. We describe our pathways for selecting arthrodesis based on the joints affected. Isolated talonavicular arthrodesis was performed in early stages of MWD, which begins at the talonavicular articulation. When disease extended to both sides of the navicular, we performed talonaviculocuneiform arthrodesis. When considering isolated talonavicular, double medial or triple arthrodesis, there should be adequate cancellous bone stock remaining in the lateral part of the navicular, as determined on medial oblique radiographs and CT scan. In case of inadequate bone stock or fracture through the lateral navicular, talonaviculocuneiform arthrodesis with interpositional iliac crest bone graft is recommended.
Assuntos
Doenças Ósseas , Doenças do Pé , Ossos do Tarso , Articulações Tarsianas , Humanos , Ossos do Tarso/diagnóstico por imagem , Ossos do Tarso/cirurgia , Doenças do Pé/cirurgia , Resultado do Tratamento , Articulações Tarsianas/diagnóstico por imagem , Articulações Tarsianas/cirurgia , Artrodese , DorRESUMO
BACKGROUND: The single existing classification of Müller-Weiss Disease (MWD), based solely upon Méary's angle, serves neither as guide for prognosis nor treatment. This accounts for lack of gold standard in its management. METHODS: Navicular compression, medial extrusion, metatarsal lengths, Kite's, lateral and dorsoplantar talo-first metatarsal angles were measured in 95 feet with MWD. Joints involved, presence and location of navicular fracture were recorded. RESULTS: Group 1 "early-onset" MWD feet (n = 11) had greatest compression and medial extrusion, and lowest Kite's angles. All except 1 were index minus and had lateral navicular fracture. Only 1 had moderate degeneration at the talonavicular joint (TNJ) with none requiring surgery yet. Group 2 "Müller-Weissoid" feet (n = 23) had radiologically normal navicular in their fifties and developed MWD on average 5 years later. They had the lowest compression and extrusion, and highest Kite's angles. None had complete fracture. All had TNJ arthritis, with early changes at lateral naviculocuneiform joint (NCJ) in 43%. Group 3 "late-onset" MWD presented in the sixth decade. Only TNJ was involved in Group 3 A (n = 16). Group 3B (n = 20) affected TNJ more than NCJ and had the greatest number of Maceira stage V disease. Group 3 C "reverse Müller-Weiss disease", which affected NCJ more than TNJ (n = 25), had greatest midfoot abduction and overlength of the second metatarsal. No fracture occurred in group 3 A compared to 65% and 32% in groups 3B and 3 C, respectively. CONCLUSIONS: With need to compare like-for-like pathology, the proposed classification provides a common platform for reporting outcomes of different treatments. We theorize pathogenetic pathways in the various groups.
Assuntos
Artrite , Doenças Ósseas , Doenças do Pé , Fraturas Ósseas , Ossos do Tarso , Humanos , Artrodese , Ossos do Tarso/diagnóstico por imagem , Ossos do Tarso/cirurgia , Pé , Doenças do Pé/cirurgiaRESUMO
CASES: Two women presented with newly growing callosities beneath the first and second metatarsal heads, initially believed to reflect gastrocnemius tightness and plantar plate pathology. In another man, swelling at the posterolateral aspect of the heel was mistaken for a Haglund deformity. Subsequent imaging of each patient led to delayed diagnosis of extraskeletal osteochondroma (ESO). Surgical excision resolved symptoms in all 3 with no recurrence over 12 months later. CONCLUSIONS: Whenever bony prominences newly develop in soft tissues of the foot, ESO should be suspected and appropriate imaging obtained. We describe physical features to help differentiate ESO from other common causes of foot overload.
Assuntos
Neoplasias Ósseas , Condroma , Osteocondroma , Neoplasias de Tecidos Moles , Erros de Diagnóstico , Feminino , Pé/patologia , Humanos , Masculino , Osteocondroma/diagnóstico por imagem , Osteocondroma/cirurgia , Neoplasias de Tecidos Moles/patologiaRESUMO
CASE: Lesions, which commonly grow and protrude beneath the distal end of a toe nail and present to the podiatrist or foot and ankle surgeon, include subungual exostosis or enchondroma and a Nora lesion. Neurothekeoma is a benign dermal tumour of the peripheral nerve sheath that usually affects the skin of the head, neck, shoulders and arms. It occurs less commonly in the lower limbs and has only been reported twice in a subungual location. A case of subungual neurothekeoma that recurred twice due to inadequate margins of resection is presented. CONCLUSION: Although rare, neurothekeoma should be included in the differential diagnosis of a subungual lesion. Histopathological diagnosis is reached by differential immunostaining. Adequate clear margins of resection are recommended to prevent recurrence.
Assuntos
Exostose , Doenças da Unha , Neurotecoma , Neoplasias Cutâneas , Diagnóstico Diferencial , Exostose/diagnóstico , Humanos , Doenças da Unha/diagnóstico , Doenças da Unha/cirurgia , Recidiva Local de Neoplasia , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/cirurgiaRESUMO
BACKGROUND: The only classification of Müller-Weiss disease (MWD) is based primarily on Méary's talo-first metatarsal angle. It describes increasing sag of the medial longitudinal arch with greater degrees of compression and fragmentation of the navicular. Purportedly, the talar head pushes the subtalar joint into varus and drives the medial pole of the navicular medially, as it protrudes inferiorly and laterally. Its authors stipulated heel varus as a pre-requisite, coining the term 'paradoxical pes planus varus' to define heel varus and flatfoot as hallmark deformities of the condition. METHODS: We measured Méary's and Kite's talocalcaneal angles, heel offset, anteroposterior thickness of the navicular at each naviculocuneiform (NC) joint, medial extrusion of the navicular and calculated percentage compression at each NC joint in 68 consecutive feet presenting with MWD. Morphology and activity at the various peri-navicular joints were studied using SPECT-CT in 45 feet. RESULTS: Inverse relationships between Méary's angle and degree of navicular compression reach statistical significance at NC2 but not at NC3. Strong correlation exists between medial extrusion and percentage compression at NC2 and NC3. Medial extrusion is significantly greater on the affected side in unilateral cases and on the more compressed side in bilateral cases. Significant inverse relationships exist between Kite's angle and percentage compression at both NC2 and NC3 and degree of medial extrusion of the navicular. No correlation was detected between Kite's angle and either heel offset or Méary's angle. Varus heel offset was present in only 33% of cases. The combination of heel varus and negative Méary's angle was present in just 26% of cases, the commonest combination being heel valgus with sagging at 56%. CONCLUSION: Our findings confirm part of Maceira's hypothesized pathomechanism of MWD. Reductions in Kite's talocalcaneal angle confirm that lateral and inferior protrusion of the talar head causes increasing compression and medial extrusion of the navicular. However, such shift of the talar head does not always lead to heel varus. As such, we caution against universal advocacy of lateral displacement calcaneal osteotomy, as the heel is not always in varus in MWD.
Assuntos
Doenças Ósseas/diagnóstico por imagem , Pé Chato/diagnóstico por imagem , Doenças do Pé/diagnóstico por imagem , Ossos do Metatarso/diagnóstico por imagem , Tomografia Computadorizada com Tomografia Computadorizada de Emissão de Fóton Único/métodos , Articulação Talocalcânea/diagnóstico por imagem , Ossos do Tarso/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Ósseas/cirurgia , Feminino , Pé Chato/cirurgia , Seguimentos , Pé/diagnóstico por imagem , Doenças do Pé/cirurgia , Humanos , Masculino , Ossos do Metatarso/cirurgia , Pessoa de Meia-Idade , Osteotomia , Estudos Retrospectivos , Articulação Talocalcânea/cirurgia , Ossos do Tarso/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: We describe a previously unreported presentation of the hallucal interphalangeal joint sesamoid (HIPJS) following arthrodesis of the first metatarsophalangeal joint (MTP1). METHODS: Of 438 MTP1 arthrodeses performed over a 13-year period, 12 feet returned with a painful keratoma beneath a gradually hyperextending interphalangeal joint of the great toe (IPJ1) from unexcised, unrecognized or recognized HIPJS. We identified another 7 feet with HIPJS, which did not develop symptoms after MTP1 arthrodesis. Angles at which arthrodesis had been performed were measured. RESULTS: All big toes had been arthrodesed in good position, clinically and radiologically, with no difference between the two groups in angles subtended by the proximal phalanx of the arthrodesed big toe with the ground. Good outcomes followed surgical excision of the symptomatic HIPJS. CONCLUSIONS: The presence of a HIPJS should be excluded in the differential diagnosis of IPJ1 symptoms developing after MTP1 arthrodesis. Furthermore, one should look out for and consider prophylactic excision of a HIPJS at time of MTP1 arthrodesis.
Assuntos
Artrodese/métodos , Placas Ósseas , Parafusos Ósseos , Hallux Valgus/cirurgia , Hallux/cirurgia , Articulação Metatarsofalângica/cirurgia , Idoso , Feminino , Seguimentos , Hallux/diagnóstico por imagem , Hallux Valgus/diagnóstico , Humanos , Articulação Metatarsofalângica/diagnóstico por imagem , Pessoa de Meia-Idade , Radiografia , Estudos RetrospectivosRESUMO
BACKGROUND: This study analyzes position of the peroneal tendons and status of the superior peroneal retinaculum (SPR) whenever a lateral malleolar bony flake fracture occurs. METHODS: Twenty-four patients had a lateral malleolar bony fleck on anteroposterior ankle radiographs, either in isolation or associated with other hindfoot injuries. We studied size of the bony flecks, presence or absence of peroneal tendon dislocation and pathoanatomy on CT scans. RESULTS: In 11 patients, a small bony fleck lies within the superior peroneal retinaculum and contiguous periosteum, which are stripped off the lateral fibula (Class II lesions). Tendons dislocate into the subperiosteal pouch thus formed, resembling Class I lesions without associated bony avulsion. Treatment for Class II is same as for Class I injuries. In 8 patients with a big bony fleck, tendons dislocate into the fracture site and SPR is intact (Class III lesions). In Class IV lesions, observed in 5 patients with 2-part calcaneal fracture/dislocation, SPR remains intact and peroneal tendons are not dislocated. The invariably large fleck results from the displacing lateral calcaneal fragment abutting against the fibula, whereas the dislocating tendons cause the bony avulsions in Classes II and III. CONCLUSIONS: Due to pathoanatomical differences, surgical approach and natural history of neglected lesions differ depending on size of the bony fleck. The SPR must not be incised in case of big Class III flecks.
Assuntos
Fraturas do Tornozelo/classificação , Traumatismos do Tornozelo/classificação , Traumatismos dos Tendões/classificação , Adulto , Idoso , Fraturas do Tornozelo/diagnóstico por imagem , Traumatismos do Tornozelo/diagnóstico por imagem , Calcâneo/diagnóstico por imagem , Calcâneo/lesões , Feminino , Fíbula/diagnóstico por imagem , Fíbula/lesões , Fratura-Luxação/classificação , Fratura-Luxação/diagnóstico por imagem , Humanos , Luxações Articulares/classificação , Luxações Articulares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Tálus/diagnóstico por imagem , Tálus/lesões , Traumatismos dos Tendões/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
We present a rare case of interposition of the flexor hallucis longus (FHL) tendon blocking percutaneous closed reduction of a displaced tongue-type calcaneal fracture, and necessitating open repositioning of the tendon and internal fixation through a single extensile lateral approach. Although not recognized until during surgery, with a high index of suspicion, preoperative diagnosis of this injury combination should be possible on high resolution CT, thus enabling better planning of the procedure. The presence of a small sustentacular fragment, especially if markedly displaced or rotated, should further alert the physician as to increased likelihood of such tendon entrapment within the fracture. In the literature, fracture fixation and extrication of the FHL tendon have been performed via either or both lateral and medial approaches. A medial approach may prove necessary when there is severe displacement or rotation of the sustentacular fragment. Arthroscopically assisted surgery may aid in disengaging the tendon from within the fracture site.
Assuntos
Calcâneo/lesões , Redução Fechada/efeitos adversos , Fraturas Ósseas/complicações , Encarceramento do Tendão/etiologia , Adulto , Calcâneo/cirurgia , Fixação Interna de Fraturas , Fraturas Ósseas/cirurgia , Humanos , Masculino , Encarceramento do Tendão/diagnóstico por imagem , Encarceramento do Tendão/cirurgiaRESUMO
BACKGROUND: Questions abound regarding natural history and medicolegal implications of untreated peroneal tendon dislocation (PTD) associated with calcaneal fractures. METHODS: We retrospectively analyzed CT scans and anteroposterior ankle radiographs of 79 consecutive calcaneal fractures presenting over 4 years at a single institution. RESULTS: Nineteen patients (24%) had associated PTD, which was initially missed in 10 (53%). Bony fleck was present in 11 (13.75%). Soft tissue swelling at lateral malleolar level, present on radiographs of 18 tendon dislocators (95%), raises likelihood of PTD with increasing specificity the greater the swelling. In 6 patients, surgeons failed to identify on CT spontaneously relocated tendons that then peeped around the posterolateral fibula, a finding not appreciable on 3-dimensional volume-rendering. CONCLUSIONS: Despite a significant association of PTD with calcaneal fractures, it still passes unrecognized all too frequently. Anatomical fracture fixation does not guarantee stable tendon reposition. Further studies are required to elucidate functional outcome of untreated PTD.
Assuntos
Traumatismos do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/diagnóstico por imagem , Erros de Diagnóstico , Fraturas Ósseas/diagnóstico por imagem , Luxações Articulares/diagnóstico por imagem , Traumatismos dos Tendões/diagnóstico por imagem , Adulto , Idoso , Traumatismos do Tornozelo/cirurgia , Articulação do Tornozelo/cirurgia , Calcâneo/diagnóstico por imagem , Calcâneo/lesões , Calcâneo/cirurgia , Feminino , Fraturas Ósseas/cirurgia , Humanos , Incidência , Luxações Articulares/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos dos Tendões/cirurgia , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
A case of open traumatic lacerations of the anterior tibial tendon (ATT) and extensor hallucis longus (EHL) tendon that both healed in continuity but significantly elongated position following primary repair, resulting in foot drop and sagging of the great toe affecting gait and function, is presented. An adequate immobilization and protection in the early post-operative period is very important and a secure technique for reconstructing a healed elongated anterior tibial tendon is described.
Assuntos
Fazendeiros , Traumatismos Ocupacionais/cirurgia , Procedimentos de Cirurgia Plástica , Traumatismos dos Tendões/cirurgia , Humanos , Masculino , Adulto JovemRESUMO
BACKGROUND: Purpose of study was to compare nail alignment, incidence of stress riser and fracture with straight and curved nails of different lengths. METHODS: We conducted a retrospective review of consecutive, initially 13 straight and subsequently 15 curved nails implanted in 17 men and 11 women. Angles of incidence and reflection subtended by nail tip with inner tibial cortex were measured. Cortical hypertrophy was assessed on follow-up radiographs. RESULTS: Angles of incidence and reflection were greater with short straight nails, less with long straight nails and stayed close to zero with long curved nails. Stress fractures occurred in 2 patients with straight nails at the level of the proximalmost tibial screw. Cortical hypertrophy was present in 7 patients with straight nails and in only 1 patient with a curved nail (p=0.01). CONCLUSIONS: Both nail length and inbuilt valgus contribute to better central positioning within the tibia. However, cortical stress reactions occur less frequently with curved nails.
Assuntos
Articulação do Tornozelo , Artrodese/métodos , Pinos Ortopédicos , Fixação Intramedular de Fraturas/métodos , Artropatias/cirurgia , Articulação Talocalcânea , Adulto , Idoso , Idoso de 80 Anos ou mais , Artrodese/instrumentação , Desenho de Equipamento , Falha de Equipamento , Feminino , Fixação Intramedular de Fraturas/instrumentação , Humanos , Artropatias/diagnóstico , Artropatias/etiologia , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Müller-Weiss disease (MWD) is an uncommon condition of unclear etiology, characterized by compression of the lateral aspect of the tarsal navicular bone. It presents with chronic mid and hindfoot pain, mostly in middle-aged females. It does not represent persistence of Kohler's disease, which is self-limiting and resolves completely in childhood. METHODS: A total of 12 patients with 19 affected feet, seven of whom had bilateral involvement, presented to a single foot and ankle surgeon over a 10-year period. Diagnosis of MWD was based on radiographic appearances demonstrating compression of the lateral part of the navicular. Affected feet were graded using Maceira classification. RESULTS: The cohort comprised four males and eight females with a mean age of 57.9 years. Only one patient had previously been a manual worker. Mean duration of symptoms was 5.2 years. Of the seven patients who underwent surgery for symptoms related to MWD, five had a triple arthrodesis, one had triple arthrodesis combined with naviculo-cuneiform fusion, and one had a pantalar arthrodesis for associated varus ankle osteoarthritis. Solid union was achieved in all cases. CONCLUSION: We propose that MWD is much more common than previously reported and did not find conditions of extreme environmental stress or poverty in our patients. We advocate surgical management of the condition by triple arthrodesis and extend it to include a naviculocuneiform fusion whenever indicated according to CT findings.