How to increase the accuracy of the diagnosis of the accessory bone of the foot?

PURPOSE: The study was conducted to search for confident radiological signs in symptomatic cases of accessory bones. A normal accessory bone appearance on X-ray does not exclude that the accessory bone is the source of the discomfort; because of this, MRI examination can later be applied as part of the diagnosis. METHODS: We retrospectively analysed cases of 64 patients with recognized 70 symptomatic accessory bones of the foot. The average age was 29.2 (range 8-42) years. We included only patients with X-ray and MRI examinations. We investigated the following radiological features of the bone (structural and signal) in relation to soft tissue. RESULTS: The most constant symptoms identified in our study were bone marrow oedema (93%) and soft tissue oedema (77%). Changes in structures in which accessory bones were located or in adjacent structures to accessory bone were identified: tendon changes 51%, fluid adjacent to bone 51% and tenosynovitis 46%. MRI revealed changes in bone structure that are not seen on X-ray, including changes in contour (28%), sclerosis (3%) or osteonecrosis (3%). CONCLUSIONS: MRI plays an important role in determining whether accessory bones cause symptoms because it shows specific and accurate changes in accessory bone and/or in adjacent soft tissue.

Arthritic lesions and congenital fusion in foot bones of Panochthus sp. (Xenarthra, Cingulata).

A set of lesions are re-described and new pathological findings in foot bones of Panochthus sp. (Xenarthra, Cingulata) are presented. The material reexamined in fact presents enthesiophytes instead of osteoartrithis, as previously interpreted. Furthermore, Calcium Pyrophosphate Deposition Disease (CPPD) was observed, a lesion absent in previous report. CPPD also was found in another set of foot bones and it was associated with a congenital fusion of two sesamoids. The material studied were collected in two natural tank deposits, one in Paraíba (material reexamined) and other in Rio Grande do Norte (new pathological findings) State.

[Visualization of local cortical defects in Charcot foot using microcomputed tomography]. / Visualisierung lokaler kortikaler Defekte im Charcot-Fuß mittels Mikrocomputertomographie.

BACKGROUND: In the pathogenesis of diabetic neuropathic osteoarthropathy (Charcot's foot) fractures cause chronic destruction of soft tissue and bone structure. To improve an early diagnosis of Charcot foot, modern diagnostic imaging is mainly based on magnetic resonance imaging (MRI), for example in relation to the detection of cortical bone fractures. OBJECTIVES: In this study we investigated the cortical microstructure in cases of Charcot foot with respect to fractures and porosity in order to visualize local cortical defects. This may substantiate recent efforts in a reclassification based on MRI. MATERIAL AND METHODS: Using microcomputed tomography (microCT) we investigated bone parameters, such as cortical thickness and porosity in order to quantify the local metatarsal microstructure in cases of Charcot foot. RESULTS: All bone samples showed a high degree of cortical porosity including pores that perforated the cortical bone. The data suggest that areas with reduced cortical thickness coincide with large cortical pores that may serve as initial points for fractures. Whether the detected microfractures are physiological or artefacts of preparation could not be determined. CONCLUSION: By means of microCT we were able to visualize and quantify the extent of cortical porosity for the first time in high resolution. The data suggest that both cortical fractures and cortical porosity play an important role in the pathogenesis in cases of Charcot foot.

[The painful os intermetatarseum]. / Das schmerzhafte Os intermetatarseum.

The os intermetatarseum is an uncommon accessory bone of the foot, usually found between the bases of the first and second metatarsal bones. Two cases of a painful os intermetatarseum in athletes are reported. Surgical excision of the os intermetatarseum relieved the pain in both patients. Case reports concerning athletes with a painful os intermetatarseum are rare. An os intermetatarseum should be taken under consideration when evaluating dorsal midfoot pain.

The role of ultrasound in clubfoot treatment: correlation with the Pirani score and assessment of the Ponseti method.

BACKGROUND: To evaluate neonates and infants with clubfoot, clinical and imaging modalities are required. Conventional radiography is of limited value because the studied bones are not fully ossified. QUESTIONS/PURPOSES: We attempted to (1) evaluate clinically and sonographically the reliability of the Ponseti method in correcting clubfeet; and (2) determine whether various ultrasound (US) variables correlated with each other and with the Pirani score before and after treatment. METHODS: We prospectively followed 17 infants (25 clubfeet) assessed using the Pirani score and US variables (medial malleolus navicular distance, navicular alignment in relation to the talar head, medial soft tissue thickness, talar length, and calcaneocuboid distance) and treated with the Ponseti method. The mean age of the patients at first casting was 30 days, and repeat assessment after treatment was performed at a mean age of 6.3 months. Patients were followed for a minimum of 0.75 months (mean, 14.1 months; range, 0.75-38 months). RESULTS: The Ponseti method corrected all feet. We found three clinical/US correlations. Before treatment, we observed a negative correlation between the clinical midfoot score and the sonographic medial malleolus navicular distance. After treatment we observed two negative correlations: one between the midfoot score and the sonographic talar length and the other between the hindfoot score and medial malleolus navicular distance. Four feet had recurrence of varus, two of which had an increased calcaneocuboid distance despite full restoration of navicular alignment in one foot. CONCLUSIONS: US can play a role in clubfoot assessment and may alert the surgeon to feet that may be prone to recurrence. LEVEL OF EVIDENCE: Level II, prospective study. See Guidelines for Authors for a complete description of levels of evidence.

A young patient with polyarthralgia and hearing loss: a case report of Muenke syndrome.

There are few reports of the typical radiographic findings in the hands and feet of patients with Muenke syndrome. We present a case report of a young girl with Muenke syndrome, whose diagnosis was made following the observation of coalitions and coned epiphyses on hand radiographs.

Structural factors associated with hallux limitus/rigidus: a systematic review of case control studies.

STUDY DESIGN: Systematic review of case control studies. OBJECTIVES: To identify and analyze demographic and structural factors associated with hallux limitus/rigidus. METHODS: A literature search was conducted across several electronic databases (Medline, EMBASE, CINAHL, and PubMed) using the following terms: hallux limitus, hallux rigidus, metatarsophalangeal joint, and big toe. Methodological quality of included studies was evaluated using the Quality Index. To evaluate the magnitude of differences between cases and controls, odds ratios were calculated for dichotomous variables and effect sizes (Cohen d) were calculated for continuous variables. RESULTS: The methodological quality of the 7 included studies was moderate, with Quality Index scores ranging from 6 to 11 out of a possible score of 14. The overall mean age for the case group was 44.8 years (mean range, 23.4-54.9 years) and for the control group was 39.6 years (mean range, 23.4-58.8 years). There was a similar distribution of males and females across case and control groups. All studies used plain film radiography to assess foot structure. Cases were found to have a dorsiflexed first metatarsal relative to the second metatarsal, a plantar flexed forefoot on the rearfoot, reduced first metatarsophalangeal joint range of motion, a longer proximal phalanx, distal phalanx, medial sesamoid, and lateral sesamoid, and a wider first metatarsal and proximal phalanx. Measures of foot posture and arch height were not found to substantially differ between cases and controls. CONCLUSIONS: This review of case control studies indicates that several variables pertaining to the structure of the first metatarsophalangeal joint may be associated with hallux limitus/rigidus. These findings have implications for the conservative and surgical treatment of the condition.

Coalitions of the Tarsal Bones.

Tarsal coalitions are the result of impaired mesenchymal separation of the tarsal bones. The most common types include calcaneonavicular or talocalcaneal coalitions. Subtalar stiffness results in pathologic kinematics with increased risk of ankle sprains, planovalgus foot deformity, and progressive joint degeneration. Resection of the coalition yields good results. Tissue interposition may reduce the risk of reossification, and concomitant deformity should be addressed in the same surgical setting.

Imaging of pediatric foot disorders.

Infants and children undergo imaging studies to evaluate a wide variety of congenital and acquired disorders. Imaging protocols have to consider the patient's comfort, level of anxiety, and smaller size. The first imaging study is usually made with plain radiographs. The routine radiographic examination of the foot includes the anteroposterior (AP), lateral, and oblique projections. Magnetic Resonance Imaging (RMI) provides excellent anatomic detail of cartilage, vasculature and soft tissue thanks to superior soft tissue contrast and spatial resolution, so is valuable in many cases. According to the clinical and objective signs, guided by the radiographs images, we can be oriented to perform Computed Tomography (CT), CT imaging or MRI imaging. CT imaging is useful to observe the bones but it has the disadvantage of using radiation and doesn't  adequately define the bone's non-ossified portions. On the contrary, MRI imaging is very useful in identifying the cartilaginous parts and vascular and soft tissues, thanks to its superior contrast and spatial resolution. Finally, it is important to orientate the diagnostic process keeping in mind the clinical sign of the patient and to use the most appropriate diagnostic technique.

[Congenital club foot: treatment in childhood, outcome and problems in adulthood]. / Le pied bot varus equin: traitement chez l'enfant et devenir a l'age adulte.

PURPOSE OF THE SYMPOSIUM: Treatment of idiopathic talipes varus, or congenital clubfoot, is designed to re-align the foot to alleviate pain and allow plantigrade weight bearing with adequate joint motion despite the subnormal radiographic presentation. This symposium was held to review current management practices for congenital clubfoot in children and to analyze outcome in adults in order to propose the most appropriate therapeutic solutions. MANAGEMENT OF CONGENITAL CLUBFOOT IN CHILDREN: Idiopathic talipes varus can be suspected from the fetal ultrasound. Parents should be given precise information concerning proposed treatment after birth. Deviations must be assessed in the newborn then revised regularly using objective scales during and after the end of treatment. This enables a better apprehension of the evolution in comparison with the severity of the initial deformation. Conservative treatment is proposed by many teams: a functional approach (rehabilitation and minimal use of orthetic material) or the Ponseti method (progressive correction using casts associated with percutaneous tenotomy of the calcaneal tendon) are currently preferred. If such methods are insufficient or unsuccessful, surgery may be performed as needed at about 8 to 11 months to achieve posteromedial release. Good results are obtained in 80% of patients who generally present minimal residual deformations (adduction of the forefoot, minimal calcaneal varus, residual medial rotation, limitation of dorsal flexion), which must be followed regularly through growth. The difficulty is to distinguish acceptable from non-acceptable deformation. At the end of the growth phase, severe articular sequelae are rare (stiff joint, recurrence of initial deformation, overcorrection) but difficult to correct surgically: osteotomy, tendon transfer, double arthrodesis, Ilizarov fixator. Gait analysis is essential to quantify function and obtain an objective assessment of the impact on higher joints, providing valuable guidance for surgical correction. OUTCOME IN ADULTHOOD: There have been very few studies evaluating the long-term functional outcome after treatment during childhood. According to two studies presented at this symposium (Brussels, Lausanne), results have been generally good but with subnormal radiographs irrespective of the type of treatment or how early treatment started in childhood. Hypoplasia of the talar dome is a constant finding and is correlated with limitation of dorsal flexion of the ankle joint. A small degree under-correction is often observed but well tolerated while overcorrection is generally less well tolerated. Functional outcome depends highly on preservation of subtalar joint motion. There have been no reports on the results of treatment of sequelae in adults. Most problems (pain, stiffness, osteoarthritis) are observed in the mid or rear foot. Indications for conservative surgery (osteotomy) of the mid or rear foot are rare compared with indications for combined arthrodesis. Talocrural decompensation is a turning point observed in the adult. Management at this point is difficult: fusion of the ankle worsens the situation by increasing the stress on the forefoot and aggravating the disability; implantation of an ankle prosthesis is technically difficult and remains to be fully developed. Treatment of the dorsal bunion of the great toe may require tendon transfer and/or fusion. CONCLUSION: A child born with clubfoot will never have a normal foot in adulthood. Sequelae present at the end of growth will intensify during adult life; under-correction is easier to treat in adulthood than overcorrection. The most difficult problems in adulthood are: neglected clubfoot, over correction, and degradation of the talocrural joint.

Pedal symphalangism in modern American and Japanese skeletons.

Pedal symphalangism is a surprisingly common heritable trait of the human foot. In individuals exhibiting the trait, the joint between the intermediate and distal phalanges of one or more lateral toes never develops, resulting in toes with two phalanges rather than three. This study was undertaken to explore variation in the frequency of pedal symphalangism among groups with widely different geographic ancestry, and to consider the applicability of this trait to skeletal biological distance studies. A total of 460 Euro-American, 191 African-American and 99 Japanese skeletons were examined for presence of pedal symphalangism. The American individuals date to the first half of the 20th c, while the Japanese individuals date to the late 19th and early 20th c. Although the country of ancestry is unknown for most of the American individuals, the Euro-Americans appear to be largely northern European, with roots in Germany, Ireland and Scandinavia, while the African-Americans are primarily descendants of slaves with roots in west African countries such as Nigeria, Benin, Togo, Ghana and Sierra Leone. Frequencies of fifth toe pedal symphalangism were calculated and compared among all three samples and found to be significantly higher in modern Japanese (83.7%) than in either Euro-Americans (46.4%) or African-Americans (44.0%). The Euro- and African-American frequencies were statistically indistinguishable for symphalangism of the fifth toe. In the fourth toe, however, the opposite result was found. The African-American frequency (7.9%) was significantly higher than the Euro-American frequency (2.6%), while no difference was found between the African-Americans and Japanese (11.7%). Since fourth toe pedal symphalangism has never been observed in the absence of fifth toe involvement, some of the same genes are clearly involved in producing the trait in both toes. However, differences in the pattern of fourth and fifth toe expression among the three groups identified in this study suggest that additional genetic or developmental factors may play a role in expression of pedal symphalangism in each of the toes.

Melorheostosis in a pediatric patient.

Melorheostosis is a nonhereditary and uncommon condition that can affect both adults and children. It can appear on radiographs as increased sclerosis on bones of the upper and lower extremities and may mimic other bony conditions such as osteopoikilosis, osteopetrosis, arthrogryposis multiplex congenita, and osteopathia striata. The sclerotic appearance can differ greatly between adults and children. The skin and subcutaneous tissues may be affected by fibrosis, resulting in contractures of joints and limbs that lead to deformities and limb-length discrepancies. This article reviews the literature on melorheostosis and describes a case in a 10-year-old boy.

Macrodactyly of the foot.

BACKGROUND: The purpose of this study was to focus on the problems associated with macrodactyly of the foot and to formulate guidelines for optimum treatment. METHODS: Seventeen feet (fifteen patients) with macrodactyly formed the basis of this retrospective review. The feet were classified into one of two groups, depending on whether the macrodactyly involved only the lesser toes (group A) or involved the great toe with or without involvement of the lesser toes (group B). Toe amputation or ray resection was usually done to reduce the length and width of the foot in group A, whereas the length of the first ray was reduced by epiphysiodesis or amputation of the phalanx in four of the five feet in group B. In both groups, soft-tissue debulking was an integral part of the treatment. The severity of the macrodactyly and the effect of treatment were documented radiographically by measurement of the so-called metatarsal spread angle. At the latest follow-up evaluation, each foot was graded with regard to pain and shoe wear. RESULTS: Toe amputation was performed in six of the twelve feet in group A and toe shortening was performed in two, but only three of those procedures had a good result. Ray resection was performed in five feet (as an initial or secondary procedure) in Group A, and all had a good result. The mean reduction of the metatarsal spread angle was 10.0 degrees following resection of a single ray in Group A. In Group B, four of the five feet were rated as having only a fair result because shortening alone did not effectively reduce the size of the great toe. The macrodactyly of the great toe was not treated in the fifth foot, which also had a fair result. CONCLUSIONS: Toe amputation, which is cosmetically unappealing, is not effective for treating macrodactyly of the lesser toes and does not address the enlargement of the forefoot. Ray resection results in the best cosmetic and functional outcomes in feet with involvement of the lesser toes. When the great toe is involved, the result is often only fair, and repeated soft-tissue debulking may be necessary.

Coexistence of oto-palato-digital syndrome type II and Arnold-Chiari I malformation in an infant.

A Taiwanese infant with clinically apparent oto-palato-digital syndrome type II had Arnold-Chiari I malformation. Arnold-Chiari I malformation has not been reported previously to occur in association with oto-palato-digital type II syndrome. The pathogenesis of both conditions has remain unclear although the Arnold-Cliari I malformation is most likely due to a developmental abnormality of improperly times or incomplete closure of the neural tube. We propose the physician who care for children with OPD type II must be aware of one more condition.

MR imaging and CT in the assessment of osseous abnormalities of the ankle and foot.

This article focuses on the contributions of MR imaging and CT toward the evaluation of painful osseous abnormalities of the foot and ankle. Inconclusive findings on conventional radiographs often mandate further work up with the more advanced cross-sectional imaging techniques. Often, however, the radiologist remains unsure, which modality, CT or MR imaging, should be used. Based on our experience, CT and MR imaging play a complementary role in the assessment of these disorders.

MR imaging of pediatric abnormalities in the ankle and foot.

MR imaging plays a valuable role in the evaluation of foot and ankle in infants and children. In young children with nonossified bones, MR imaging offers the advantage of effectively demonstrating the cartilaginous anlage in addition to soft tissue and bone marrow. The MR imaging examination is tailored to the clinical question, the child's age, foot size, and ability to cooperate. This article reviews the MR imaging of a number of familiar and uncommon disorders of the pediatric foot and ankle.

"Os post peronei" and the posterolateral nutcracker impingement syndrome.

Impingement syndromes have been described in relation to accessory or anomalous bony additions to the foot skeleton. We describe a hitherto undescribed accessory bone in the hindfoot causing posterolateral impingement in a 28-year-old woman.

Congenital absence of the hallux fibular sesamoid: a case report and review of the literature.

Congenital absence of the fibular sesamoid of the hallux is an extremely rare condition. We could find only one previously reported case in the literature. The authors present a second case of congenital absence of the fibular sesamoid and a review of the literature regarding the clinical significance of this anomaly.