Description of the surgical technique for condylectomy with minimally invasive surgery to treat interdigital helomas on the lesser toes: a Delphi study.

BACKGROUND: Descriptions of the techniques for condylectomies via minimally invasive surgery (MIS) to treat interdigital helomas of the lesser toes are scarce in the literature. This study aimed to define and describe this surgical technique. METHODS: This observational study was performed using the Delphi method. We collected the anonymous opinions of a multidisciplinary international panel of ten experts by answering a 43-items questionnaire via e-mail. Statements with an average score ≥ 3 were included in the next round, as were those in which none of the three statements reached the minimum score of 3 within the same item. RESULTS: Response rate: 90%. Three rounds were needed to reach consensus on proposed items. A new statement that combined two statements was proposed in round 3. Eleven recommendations regarding the incision and instruments used to perform this surgical technique were obtained based on the expert consensus. CONCLUSIONS: A longitudinal incision to the distal pulp of the toe or an incision to the centre of the plantar aspect of the head of the proximal phalanx should be performed according to the affectation, and a Beaver 64 scalpel blade, a blunt elevator and a Shannon-Isham burr are the most acceptable tools for this kind of surgery.

Colgajo de avance y rotación celuloadiposo de pulpejo para reconstrucción de lecho ungueal / Cell adipose finger pad advancement and rotation flap for nail bed reconstruction

Introducción y Objetivo. Las lesiones de punta de dedo, y en especial de lecho ungueal, son de las más frecuentes en el trauma de mano, generalmente asociadas a traumatismo por agresión y accidentes laborales, con una incidencia y prevalencia elevada en nuestro medio. Presentamos la experiencia con nuestra técnica quirúrgica para reconstrucción de lecho ungueal consiste en el avance y rotación de un colgajo celuloadiposo de pulpejo de dedo basando su vascularización en las arterias palmares ascendentes. Material y Método. La técnica consiste en elevar un colgajo de tejido celuloadiposo del pulpejo desde la falange distal de acuerdo con el tamaño del defecto tisular a nivel del lecho ungueal, realizando una rotación, si se requiere, y un avance, brindando una completa y adecuada cobertura. Hay que destacar que con esta técnica se preservan los tabiques fibrosos favoreciendo la vascularización del colgajo y como ventaja adicional no deja cicatriz en el pulpejo. Resultados. Hemos llevado a cabo la técnica descrita en un total de 120 pacientes (70% hombres, 26% mujeres y 4% niños) con una edad media de 36.5 años, siendo la principal causa traumatismo en accidente laboral: 110 fueron exitosos, 3 se perdieron sufriendo necrosis total, y 7 presentaron sufrimiento inicial sin pérdida. Conclusiones. Esta técnica constituye una herramienta práctica, segura y eficiente como alternativa para la reconstrucción del lecho ungueal, brindado resultados óptimos para este tipo de lesiones (AU)

Background and Objective. Fingertip injuries and nail bed lesions are associated with trauma aggression and work accidents with a high incidence and prevalence in our environment. We present the experience with our surgical technique for reconstruction of nail bed with the advancement and rotation of a cell adipose flap of finger pad, basing its vascularization in the palmar arteries. Methods. The technique consists on lifting the flap (cell adipose finger pad tissue) from the distal phalange according to the size of the tissue defect at the level of the nail bed, performing a rotation, if required, and an advance flap, providing a complete and adequate coverage. It is necessary to emphasize that with this technique the fibrous bands are preserved favoring flap vascularization and, as an additional advantage, does not leave scar in the finger pad. Results. The technique was performed in a total of 120 patients (70% men, 26% women and 4% children) with a mean age of 36.5 years, being the main cause a work-related injury: 110 were successful, 3 were lost suffering total necrosis, and 7 presented suffer without loss. Conclusions. This technique is a practical, safe and efficient tool and an alternative for nail bed reconstruction, providing optimal results for this type of injury (AU)

A diabetic foot ulcer treated with hydrogel and hyperbaric oxygen therapy: a case study.

This study reports on the case of an elderly patient, with diabetes, and a bullous wound on the left big toe that led to an amputation of the first and second left toes. The amputation was because of deep injury as it was not able to heal with a conventional treatment. After completing the normal treatment and the removal of a bacterial infection in the lesion, the patient underwent a treatment that was based on a hydrogel gel (0.9% saline solution) and hyperbaric oxygen therapy (HBOT). After 60 sessions of the therapy, almost complete closure of the wound was observed. There were no reports of discomfort or infection during the treatment. After seven months of treatment almost complete healing was observed with no infection. This treatment appears to be effective and should be recommended for the treatment of DFUs.

Rupture of the Extensor Hallucis Longus Muscle Secondary to Repetitive Overuse in a Taekwondo AthleteA Case Report.

Closed rupture of the extensor hallucis longus (EHL) tendon is rare, with most cases caused by either direct penetrating trauma or predisposing factors such as corticosteroid injection and iatrogenic trauma incidences. Almost all of the previous case reports have reported on rupture of the EHL tendon rather than the EHL muscle. In this report, we highlight an unusual clinical presentation of a rupture of the EHL muscle and discuss its predisposing factors. This patient was a taekwondo athlete with EHL muscle rupture secondary to repetitive overuse without any underlying systemic or local predisposing factors or direct trauma. Fifteen months after successful surgical treatment, he became fully functional again as an elite taekwondo athlete.

Delayed treatment of frostbite with hyperbaric oxygen: a report of two cases.

Frostbite is an injury caused by the freezing of tissue, causing varied levels of tissue damage and necrosis. Case reports have shown a positive effect of hyperbaric oxygen (HBO2) in such injuries, in acute cases as well as delayed (up to 21 days) presentation with complications. In this case report we present the course of hyperbaric treatment of two patients (a brother and sister, age 58 and 62) who sustained frostbite injuries to both feet 28 days earlier while hiking in the Himalayas. They were initially treated in Nepal following local protocol; afterward their primary care in the Netherlands was managed by the Burn Centre at Maasstad Hospital in Rotterdam. Both patients were treated with daily sessions of in total 80 minutes of 100% oxygen at 2.5 atmospheres absolute. The female patient (age 62) received 25 sessions and showed a remarkable preservation of tissue and quick demarcation. Only partial surgical amputation of the second toe on the right was needed. In the male patient (age 58) both front feet were already mummified to a larger extent before start of treatment. During hyperbaric oxygen therapy 30 sessions) demarcation progressed quickly, resulting in early surgical amputation. Both patients experienced no side effects of HBO2 treatment. Given that both patients showed a quick progress and demarcation of their wounds, with remarkable tissue preservation in the female patient, we suggest that hyperbaric oxygen therapy should be considered in treating frostbite injuries, in acute as well as delayed cases, even four weeks after initial injury.

Analgesic effect of perineural magnesium sulphate for sciatic nerve block for diabetic toe amputation: A randomized trial.

BACKGROUND AND OBJECTIVES: High concentrations of local anesthetics may be neurotoxic for diabetic patients. Additive perineural administration of magnesium was reported to decrease the consumption of local anesthetics for nerve block. It was hypothesized that MgSO4 added to dilute ropivacaine was equianalgesic to more concentrated ropivacaine for toe amputations in diabetic patients. METHODS: Seventy diabetic patients were allocated into 3 groups: 1) perineural 200 mg MgSO4 added to 0.25% ropivacaine, 2) 0.25% ropivacaine alone, and 3) 0.375% ropivacaine alone. All patients underwent popliteal sciatic nerve block that was guided by ultrasonography using the respective regimens. Time of onset, duration of motor and sensory block were recorded. Spontaneous and evoked pain score, worst pain score, additional analgesic consumption, satisfaction score and initial time of analgesic requirement of each patient were documented up to 48 hours postoperatively. RESULTS: In comparison with 0.25% ropivacaine alone, magnesium supplement prolonged the duration of sensory block (p = 0.001), as well as better evoked pain score at 6 hour postoperatively (p = 0.001). In comparison with evoked pain score (1.6/10) in group of 0.375% ropivacaine, magnesium plus 0.25% ropivacaine presented a little higher score (2.5/10) at 6 hour postoperatively (p = 0.001), while lower worst pain score (p = 0.001) and less postoperative total analgesic consumption (p = 0.002). CONCLUSIONS: The regimen of adding 200mg MgSO4 to 0.25% ropivacaine for sciatic nerve block yields equal analgesic effect in comparison with 0.375% ropivacaine. These findings have suggested that supplemental MgSO4 could not improve analgesic quality except reducing the total amount of local anesthetics requirement in diabetic toe amputations with sciatic nerve blocks.

[Diaphysectomy of the proximal phalanx in quintus varus supraductus and hammer toe in children]. / Diafisectomía de la falange proximal en el quinto dedo supraducto y dedo en martillo en niños.

The most frequent foot and ankle anatomical alterations in the pediatric population are found in the little toes. Several treatments are proposed for these conditions, ranging from total phalangeal resections, phalangeal osteotomies, osteosynthesis, and soft tissue management. We propose a surgical technique based on the diaphysectomy of the proximal phalanx and the release of soft tissues that are under tension. The purpose is to assess the functional foot results after surgical treatment consisting of proximal phalanx diaphysectomy and soft tissue release using the functional AOFAS scale in pediatric patients. A prospective, longitudinal, descriptive, non-comparative clinical study was conducted from March 2008 to December 2010, with a follow-up of up to six months. Twenty patients (35 toes) were included; 15 females and five males, with a mean age of 14.65 years. Fifteen (30 toes) had bilateral involvement; 88.56% had greater involvement of the fifth toe. The surgical indication was determined based on the degree of functional disability for gait and the type of footwear. The functional assessment was conducted using the AOFAS criteria and a subjective assessment scale with a total score of 100 to assess the metatarsophalangeal and the interphalangeal joints of the smallest toes. Scores were as follows: < 50 points, poor; 51-70 points, fair; 71-90, good, and > 91, excellent. The assessment was done preoperatively and at postoperative month six. The mean preoperative score was 73.55 and the mean postoperative score was 85.75, with a 12.2 point difference (p > 0.5). Results were: 11 excellent, seven good and two fair. There were four relapses, so a salvage procedure was performed with the Ruiz-Mora technique; excellent results were obtained in all four. One case had soft tissue infection. Proximal phalanx diaphysectomy and soft tissue release provides appropriate alignment of the affected toes and relief of soft tissues under tension, thus avoiding broad resections leading to both esthetic and functional alterations. This is a simple and effective technique for the treatment of little toe deformities as it improves function and alignment.

Boutonniere deformity of the second toe after planter dislocation of proximal interphalangeal joint: a case report.

The boutonniere deformity is a well-known deformity in the fingers, however, its appearance on a lessor toe is extremely rare. In the present case, the deformity resulted from a rupture of the central slip of the extensor tendon and the shift of the lateral bands to the planter side after reduction of a traumatic planter dislocation of the PIP joint of the second toe. Surgical repair of the extensor mechanism brought good results.

Multiple digital grengrene arising from traditional therapy: a case report.

BACKGROUND: Traditional medicine has being advocated as an alternative to Orthodox medicine in Nigeria despite, its reported adverse effects. OBJECTIVE: To report an unusual complication of traditional therapy. METHODS: A 20-year-old house-wife who was bitten by a crawling insect presented to a hospital with complaints of swollen body and pain in three digits. After clinical evaluation and investigations, she had both medical and surgical intervention. RESULTS: Two weeks following an insect bite, the patient noticed periorbital and bilateral leg swellings. She sought help from a traditional medicine practitioner who incised and tied the affected digits for three days. He repeated the cycle thrice. She had generalized oedema, massive proteinuria, hypoalbuminaemia, hypercholesterolaemia features consistent with a diagnosis of nephritic syndrome. There was gangrene of the left middle finger and both index toes. Oedema responded to diuretics, lisinopril and low salt diet. She had surgery for the gangrenous digits. CONCLUSION: Development of gangrene is an unusual finding in nephrotic syndrome. It occurred in this case as an aftermath of traditional medical intervention. This report reiterates the danger of this form of medical practice and the need for measures to protect the populace to be put in place.

Multiple digital gangrene arising from traditional therapy: a case report.

BACKGROUND: Traditional medicine has being advocated as an alternative to Orthodox medicine in Nigeria despite, its reported adverse effects. OBJECTIVE: To report an unusual complication of traditional therapy. METHODS: A 20-year-old house-wife who was bitten by a crawling insect presented to a hospital with complaints of swollen body and pain in three digits. After clinical evaluation and investigations, she had both medical and surgical intervention. RESULTS: Two weeks following an insect bite, the patient noticed periorbital and bilateral leg swellings. She sought help from a traditional medicine practitioner who incised and tied the affected digits for three days. He repeated the cycle thrice. She had generalized oedema, massive proteinuria, hypoalbuminaemia, hypercholesterolaemia features consistent with a diagnosis of nephritic syndrome. There was gangrene of the left middle finger and both index toes. Oedema responded to diuretics, lisinopril and low salt diet. She had surgery for the gangrenous digits. CONCLUSION: Development of gangrene is an unusual finding in nephrotic syndrome. It occurred in this case as an aftermath of traditional medical intervention. This report reiterates the danger of this form of medical practice and the need for measures to protect the populace to be put in place.

Primary stent-supported angioplasty for treatment of below-knee critical limb ischemia and severe claudication: early and one-year outcomes.

OBJECTIVES: The objective of this study was an investigation of the safety and efficacy of primary below-knee stent-supported angioplasty (BKSSA) for restoring straight inline arterial flow in patients with critical limb ischemia (CLI) or lifestyle-limiting claudication (LLC). BACKGROUND: Surgical tibial bypass for CLI and severe LLC is associated with significant morbidity, mortality, and graft failure, whereas percutaneous angioplasty is suboptimal. METHODS: Below-knee stent-supported angioplasty was attempted in 82 patients (92 limbs) with either CLI (68%) or severe LLC (32%). Patients received daily aspirin, thienopyridine, and glycoprotein IIb/IIIa agents during the procedure. One-month major adverse events (MAEs) were defined as death, myocardial infarction, major unplanned amputation, need for surgical revascularization, or major bleeding. Clinical success was defined as improved resting ankle brachial index by > or =0.10, relief of resting pain, healing of ulceration or amputation, and improvement of claudication. RESULTS: Mean age of patients was 74 +/- 17 years. In 86 limbs, straight inline flow was restored to at least one tibial vessel. Technical success was 94% for de novo lesions and there were no MAEs. Ankle brachial indexes increased for all groups (CLI = 0.32 +/- 0.13 to 0.9 +/- 0.14 and LLC = 0.65 +/- 0.09 to 0.95 +/- 0.12; p < or = 0.0001, pre vs. post). Relief of rest pain and healing of ulcerations and amputations were seen in 96% (47 of 49) of patients with CLI who underwent successful intervention. CONCLUSIONS: Below-knee stent-supported angioplasty for CLI and LLC improves ankle brachial indexes comparable to tibial bypass, heals amputations and ulcerations, relieves rest pain, and improves ambulation. Because BKSSA is associated with minimal MAE, it may hold promise as an alternative therapy for patients with CLI and LLC.

[Treatment of ingrown toenails. What is an "Emmert plasty"?]. / Zur Behandlung des eingewachsenen Zehennagels. Was ist eine "Emmert-Plastik"?

In Germany,"Emmert plasty" is one of the terms most frequently used in daily surgical practice. It describes the wedge excision of nail fold, nail edge, and corresponding matrix for advanced stages of ingrown toenail in most standard textbooks of surgery but without direct reference to Emmert. The method, however,was apparently first described by the French military surgeon Baudens in 1850 and was strongly opposed by Emmert himself who propagated a pure soft tissue resection. This text gives a short historical review of the various treatment methods of ingrown toenails.

Forefoot narrowing with external fixation for problem cleft wounds.

Healing of forefoot cleft wounds can be a difficult management problem in patients with peripheral vascular disease, diabetes or both. This is a prospective review of 15 patients with these conditions with nonhealing middle-ray cleft wounds managed with a temporary mini-external fixator to close the cleft wound. Fourteen (93%) of the 15 patients had a successful obliteration of the cleft and skin coverage. Twelve (80%) of 15 were able to resume their previous level of activity with the reconstructed, mechanically sound forefoot. Fourteen (93%) of the 15 patients received hyperbaric oxygen treatments as an adjunct to wound healing. All patients avoided a transmetatarsal or higher amputation.

Changes in the organization of the ventroposterior lateral thalamic nucleus after digit removal in adult raccoon.

The ventroposterior lateral nucleus of the thalamus was studied in seven raccoons that had undergone amputation of the fourth digit between 2 and 5 months previously. Extracellular recordings were made in a series of closely spaced penetrations through the thalamus in chloralose anesthetized animals. The responses to cutaneous stimulation of the forepaw were used to reconstruct the somatotopic organization of the thalamus and to identify recording sites believed to be located in the digit zone that had lost its peripheral input. Twelve penetrations that passed through both of the adjacent fifth and third digit regions were analyzed in detail to delineate this deafferented region. None of the recording sites in this region were completely silent, indicating that the deafferented thalamus had undergone significant reorganization of its inputs. At most sites, the neurons had receptive fields on the skin surrounding the amputation wound and including one of the adjacent digits. Approximately half of the sites had low thresholds in the range of normal thalamic neurons. These results indicate that the ventroposterior thalamus is capable of substantial reorganization, which may account for much of the reorganization seen in somatosensory cortex.

Asymptomatic large hypothalamic hamartoma associated with polydactyly in an adult.

A hypothalamic hamartoma is a congenital tumor-like neural malformation. It is usually seen in children and is associated with neuroendocrinological symptoms, seizures, or psychological impairments. An asymptomatic hypothalamic hamartoma in an adult is extremely rare. This report describes an asymptomatic adult with a large hypothalamic hamartoma associated with polydactyly in his feet. Both polydactyly and hamartoma are rare lesions; therefore, this may not be a coincidental presentation. It is thought to have occurred in the embryonic period presumably between 37 and 40 gestational days.

Phalangeal set.

A summary of the phalangeal set procedure has been given with indications, significance of the correction, contraindications, biomechanical factors, operative procedure, and the acceptance in many podiatric and orthopedic surgery circles. This is an ambulatory procedure for toe deformities which allows for release of toe contractures, reduction of superimposition of phalanges, increased joint space, and correction of malalignment.

Restoration of toe function with minimal traumatic procedures including advanced diaphysectomy.

Minimal traumatic surgery is considered the preferred treatment for painful digital deformities including hammertoes, overlapping toes, mallet toes, underlapping toes, and painful corns. With the introduction of technology such as intraoperative x-ray monitoring, these procedures can be performed more efficiently, safely, and without unnecessary hospitalization in most cases. Mobility is kept to a minimum, yet the patients can be comfortably mobile while they are recovering.

Tenotomy, tenectomy, and capsulotomy for the lesser toes.

Indications and contraindications for tenotomy, tenectomy, and capsulotomy have been cited and surgical procedures outlined. The importance of possible supplemental surgery and biomechanical follow-up have also been stressed.