Determination of light pressing pressure for improving foot skin blood flow in type 2 diabetic patients.

OBJECTIVE: Traditional Thai massage is one of the alternative treatments for diabetic feet. However, the specific amount of pressing pressure applied to the foot during Thai foot massage is unknown. This study aimed to evaluate the effect of light pressing pressure on foot skin blood flow in type 2 diabetic patients. METHODES: A single-arm repeated measures was conducted. Forty-three participants were recruited via the subjective examination and screening using the Michigan Neuropathy Screening Instrument. To obtain foot skin blood flow by laser doppler blood flowmetry, a probe was pasted on the 1st distal phalange of the big toe. Light pressure at a single point was applied on the plantar skin fold between the bases of the second and third toes by using the digital algometer. The pressure was applied gently, then increased slightly until the participant started to feel some minor discomfort. Patients were asked to rate their pain intensity using the visual analogue scale. RESULTS: The average pressing pressure without discomfort was 3.55 ± 1.04 kg/cm2. The foot skin blood flow increased significantly immediately after the pressing pressure, and this increase represented about 1.9 times when compared with the baseline (p < 0.001). CONCLUSION: The application of light pressing pressure could be used as a basic standard criterion for massage to improve the foot skin blood flow in type 2 diabetic patients.

[Effect of moxibustion on AMPK/ULK1 signaling pathway in synovium tissue of toes in rats with rheumatoid arthritis].

OBJECTIVE: To observe the effect of moxibustion on AMP-activated protein kinase (AMPK)/UNC-51-like kinase 1 (ULK1) signaling pathway in the synovial tissue of toes in rheumatoid arthritis rats, so as to explore the mechanism of mo-xibustion in the treatment of rheumatoid arthritis (RA). METHODS: A total of 45 SD rats were randomly divided into blank, model， moxibustion, methotrexate and rapamycin groups, with 9 rats in each group. RA rat model was established by injection of Freund's complete adjuvant. Moxibustion was applied to "Zusanli" (ST36) and "Guanyuan" (CV4) for 20 min, once a day for 3 weeks. Methotrexate group was given methotrexate (0.35 mg/kg) by gavage, twice a week for 3 weeks. Rapamycin group was intraperitoneally injected with rapamycin (1 mg/kg)，once every other day for 3 weeks. The toe volume of the left hind limb of rats was measured by the toe volume measuring instrument. The content of AMP in toe synovium was detected by ELISA. The expression of AMPK and VPS34 protein in toe synovium was detected by Western blot.The expression of ULK1 and Atg13 mRNA in toe synovium was detected by RT-PCR. RESULTS: Compared with the blank group, the volume of toe in the model group was increased (P<0.01)，while the content of AMP, the expression of AMPK and VPS34 proteins, the expression of ULK1 and Atg13 mRNAs were significantly decreased(P<0.01).Compared with the model group, the volume of toe in the moxibustion，methotre-xate and rapamycin groups was decreased (P<0.05); the content of AMP, the expression of AMPK and VPS34 proteins, the expression of ULK1 and Atg13 mRNAs were significantly increased(P<0.05) in the moxibustion group; the content of AMP, the expression of VPS34 protein, the expression of Atg13 mRNA were significantly increased(P<0.05) in the methotrexate group; the expression of AMPK and VPS34 proteins, the expression of ULK1 and Atg13 mRNAs were significantly increased (P<0.05, P<0.01) in the rapamycin group. Compared with the moxibustion group, the expression of AMPK protein in the methotrexate group and the content of AMP in the rapamycin group were significantly decreased (P<0.05). CONCLUSION: Moxibustion can improve joint swelling in RA rats, and the mechanism may be related to promoting the activity of AMPK/ULK1 signaling pathway.

Green pharmacy at the tips of your toes: medicinal plants used by Setos and Russians of Pechorsky District, Pskov Oblast (NW Russia).

BACKGROUND: While the hybridization of ecological knowledge has attracted substantial attention from researchers, the coexistence of local and allopathic medicinal traditions in literate societies widely exposed to centralized schooling and medical services has not yet been investigated. To this end, we studied the current and remembered local ethnomedical practices of Setos and neighboring Russians at the border with Estonia. METHODS: During 2018-2019, we carried out 62 semi-structured interviews in the Pechorsky District of Pskov Oblast, NW Russia. For cross-border comparison, we utilized the data from 71 interviews carried out at the same time among Setos in Estonia. The Jaccard Similarity Index and qualitative comparison were used to analyze the data. RESULTS: The study participants mentioned 819 uses of 112 taxa belonging to 54 families. More than two-thirds of the uses (565) were quoted by 36 Russian interviewees, while the remaining third (254) were quoted by 26 Seto interviewees, with the top 3 in both groups being Viburnum opulus, Rubus idaeus, and Plantago major. The Seto intraethnic similarity index was lower (0.43) than the interethnic similarity in Estonia (0.52) and comparable to the interethnic similarity in Russia (0.43). Setos in Russia and local Russians rely more on wild plants (86% and 80% of medicinal plants, respectively), while Setos in Estonia and Estonians show less preference to them (63% and 61%, respectively). Nevertheless, Setos tend to source wild plants available in their gardens (33% of plants for Setos in Estonia and 38% in Russia), while Russians prefer to source them in the wild (38%). CONCLUSIONS: The preference of both groups in Russia for wild plants over cultivated and purchased plants was inspired by the overall plant literacy, access to nature, and one-to-many knowledge transfer favoring wild plants. Setos in Russia reported a narrower and more homogenous set of plants transferred vertically. However, due to atomization and the erosion of horizontal connections, there are singular plant uses among Setos that overlap with the local Russian set of medicinal plants and differ qualitatively from that of Setos in Estonia.

Clinical utilization of a sous vide device in the acute rewarming of frostbitten extremities.

The current standard of care for acute frostbite rewarming is the use of a circulating warm water bath at a temperature of 37 °C to 39 °C. There is no standardized method to achieve this. Manual management of a warm water bath can be inefficient and time consuming. This case describes the clinical use of a sous vide cooking device to create and maintain a circulating warm water bath to rewarm acute frostbite. A 34 year-old male presented to the emergency department with acute frostbite. Each of the patient's feet were placed in a water bath with a sous vide device attached to the side of the basin and set to 38 °C. Temperatures were recorded every 2 m from 2 thermometers. Once target temperature was achieved, the extremities were rewarmed for 30 m. The water baths required an average of 25 m to reach target temperature and maintained the target temperature within ±1 °C for the duration of the rewarming. The extremities were clinically thawed in one session and there were no adverse events. The patient was seen by plastic and vascular surgery and admitted to the hospital for conservative management. He was discharged on hospital day 3 and did not require any amputations. A sous vide device can be used clinically to heat and maintain a water bath and successfully rewarm frostbitten extremities in one 30 m cycle. No adverse events were reported and providers rated this as a convenient method of water bath management.

Local Anesthesia Alone for Postaxial Polydactyly Surgery in Infants.

BACKGROUND: Surgical excision for postaxial polydactyly type B is advocated to avoid long-term complications. Excision with local anesthesia (LA) in infancy represents a safe and effective treatment for this condition, although general anesthesia (GA) is employed by many surgeons. We present a comparison of surgical outcomes, cost, and time between LA and GA to support widespread change in management. METHODS: A retrospective review of patients under 12 months of age undergoing surgical polydactyly excision by a single surgeon was performed. Anesthesia type, patient demographics, and complications were recorded. Comparisons were made between LA and GA groups on procedure cost, operating time, length of stay (LOS), and time from procedure end to discharge. Stepwise forward regression was used to identify the best model for predicting total costs. RESULTS: Ninety-one infants with a mean age of 3 months (±1.9) were examined; 51 (56%) underwent LA alone, 40 (44%) underwent GA. Mean operating time was 11.53 ± 4.36 minutes, with no difference observed between anesthesia groups (P = .39). LA infants had a significantly shorter LOS (2.5 vs 3.5 hours; P < .05), quicker postoperative discharge (32 vs 65 minutes, P < .05), and fewer overall expenses, 2803 vs 6067 U.S. dollars (USD), P < .05. Two minor surgical complications (1 in each group) were reported. CONCLUSIONS: This study demonstrates significantly decreased cost, LOS, and time to discharge using LA alone for surgical excision of postaxial polydactyly type B. Results suggest the approach is quick, economical, and avoids the risks of GA in early infancy.

Chiropractic management of toe-walking in an eight-year-old male diagnosed with autism spectrum disorder utilizing a functional approach: A case study.

OBJECTIVE: The objective of this paper is to discuss the treatment of idiopathic toe-walking utilizing cognitive-motor dual-tasking and primitive reflex integration exercises. METHODS: An eight-year-old child with the previous diagnosis of autism spectrum disorder and idiopathic toe-walking presents for chiropractic care. The patient had previously received eight months of physical therapy in which his results plateaued after three months of care. RESULTS: On the initial visit, the child was evaluated for primitive reflexes. The patient retained the asymmetrical tonic neck reflex and palmer grasp. He was prescribed exercises to integrate these reflexes. In the second visit and onwards, the patient was tasked with walking while performing a cognitive or motor task. The patient's performance of primitive reflex attenuation exercises significantly improved in form and timing, and the patient achieved proper gait mechanics with most interventions used. CONCLUSION: Due to the limited number of visits, the patient was prescribed a cognitive task to help facilitate the retention of proper gait mechanics; however, these findings suggest that chiropractic management may prove useful in children who toe walk and that further investigation into treatment utilizing primitive reflex integration exercises for children with psychomotor delays is warranted. We suggest that the integration of primitive reflex testing for the chiropractor can yield many answers and serve as a valuable rehabilitation approach.

Effects of proprioceptive neuromuscular facilitation stretching at low-intensities with standing toe touch on developing and maintaining hamstring flexibility.

BACKGROUND: Proprioceptive neuromuscular facilitation (PNF) stretching at low intensities has been rarely investigated. Previous studies have shown that hamstring flexibility after stretching is only temporary. OBJECTIVE: The aim of this study was to assess the effect of low intensities (40% and 10% of maximum voluntary isometric contraction, MVIC) of PNF stretching on hamstring muscles and to assess the effect of standing toe touch on the duration of hamstring flexibility. METHODS: This was a single-blind randomized controlled trial. Sixty-four healthy adults (age, 22.67 ± 1.73 years) were selected and divided into four groups: 40% intensity PNF stretching (P40), 10% intensity PNF stretching (P10), 40% intensity PNF stretching with toe touch (P40 with TT), and 10% intensity PNF stretching with toe touch (P10 with TT). Hamstring flexibility was measured using the active knee extension test (pre-stretching, post-stretching, and 3, 6, 9, 12, and 15 min after PNF stretching). RESULTS: In the P40, P40 with TT, and P10 with TT groups, significant changes were observed at all time points after stretching (p < 0.05). In the P10 group, significant changes were only observed immediately post stretching (p = 0.006) and at 3 min (p = 0.029) after stretching. In terms of maintaining the duration of flexibility, the P40 with TT and P10 with TT groups were superior to the P40 and P10 groups. CONCLUSION: PNF stretching at low intensity, approaching 40% of MVIC, led to more flexibility than 10% MVIC. Additionally, standing toe touch after PNF stretching is recommended to develop and maintain hamstring flexibility.

Intrinsic foot muscle strengthening exercises with electromyographic biofeedback achieve increased toe flexor strength in older adults: A pilot randomized controlled trial.

BACKGROUND: Toe flexor strength is important for preventing older adults from falling. Although intrinsic foot muscles are the main determinants of toe flexor strength, exercises for strengthening these muscles are difficult for older adults. This study therefore aimed to determine whether the use of electromyographic biofeedback helps older adults to perform intrinsic foot muscle strengthening exercises. METHODS: This randomized controlled trial had two parallel arms. Participants were randomly allocated to the control group or the electromyographic biofeedback group. Control participants performed two progressive intrinsic foot muscle strengthening exercises twice a week for 6 weeks. Participants in the other group performed these exercises assisted by electromyographic biofeedback. Primary outcome measures were changes in toe flexor strength and the timed up-and-go and functional reach tests (the latter two being balance tests). FINDINGS: Altogether, 23 older adults were randomized to the control group (n = 12) or the electromyographic biofeedback group (n = 11). After the 6-week intervention, toe flexor strength on the dominant side increased in both groups (P < 0.017). However, toe flexor strength on the nondominant side increased only in the electromyographic biofeedback group (P < 0.017), with a large effect size of 1.5. There were no changes in the two balance tests. Three of the control group and two of the electromyographic biofeedback group were lost to follow- up. INTERPRETATION: Our results indicate that, the use of electromyographic biofeedback can enhance the effect of intrinsic foot muscle strengthening exercises on the nondominant side in older adults. CLINICAL TRIAL REGISTRATION NUMBER: UMIN000036521.

[Oberst's block anesthesia]. / Leitungsanästhesie nach Oberst.

OBJECTIVE: Complete anesthesia of the phalanges of the fingers and toes. INDICATIONS: All lesions distal to the metacarpophalangeal/metatarsophalangeal joint. CONTRAINDICATIONS: Local infections at the injection site. Lesions proximal to the metacarpophalangeal/metatarsophalangeal joint. TECHNIQUE: A subcutaneous deposit of a 0.5-2% local anesthetic is administered dorsoradially and dorsoulnarly at the base of the metacarpophalangeal/metatarsophalangeal joint. With the cannula advanced to palmar, an additional 0.5-1.5 ml is then administered to achieve complete anesthesia. POSTOPERATIVE MANAGEMENT: The effect of the local anesthesia is self-limiting. RESULTS: The Oberst block results in reliable anesthesia of the finger and toe. All surgical procedures distal to the metacarpophalangeal/metatarsophalangeal joint can be performed without pain.

Different lasers reveal different skin microcirculatory flowmotion - data from the wavelet transform analysis of human hindlimb perfusion.

Laser Doppler flowmetry (LDF) and reflection photoplethysmography (PPG) are standard technologies to access microcirculatory function in vivo. However, different light frequencies mean different interaction with tissues, such that LDF and PPG flowmotion curves might have distinct meanings, particularly during adaptative (homeostatic) processes. Therefore, we analyzed LDF and PPG perfusion signals obtained in response to opposite challenges. Young healthy volunteers, both sexes, were assigned to Group 1 (n = 29), submitted to a normalized Swedish massage procedure in one lower limb, increasing perfusion, or Group 2 (n = 14), submitted to a hyperoxia challenge test, decreasing perfusion. LDF (Periflux 5000) and PPG (PLUX-Biosignals) green light sensors applied distally on both lower limbs recorded perfusion changes for each experimental protocol. Both techniques detected the perfusion increase with massage, and the perfusion decrease with hyperoxia, in both limbs. Further analysis with the wavelet transform (WT) revealed better depth-related discriminative ability for PPG (more superficial, less blood sampling) compared with LDF in both challenges. Spectral amplitude profiles consistently demonstrated better sensitivity for LDF, especially regarding the lowest frequency components. Strong correlations between components were not found. Therefore, LDF and PPG flowmotion curves are not equivalent, a relevant finding to better study microcirculatory physiology.

Early treatment of frostbite with hyperbaric oxygen and pentoxifylline: a case report.

While several published cases have reported tissue preservation with hyperbaric oxygen (HBO2) after frostbite, its routine use is not endorsed by expert consensus. We report a case of possible frostbite injury to the toes of both feet and the plantar surface of the left foot in a 17-year-old male patient. The exposure history included two episodes of rewarming followed by refreezing in the field during a hike through knee-deep snow without adequate clothing. The patient also sustained full-thickness ice abrasions to both anterior shins. The patient was evaluated within 60 minutes after self-rewarming. He was treated with 400 mg oral pentoxifylline three times a day and HBO2 at 2.4 atmospheres absolute for 90 minutes twice a day for a total of 13 treatments. Therapy was initiated approximately two hours from the estimated time of rewarming. Both feet recovered full sensation, and the patient had no tissue loss on his feet and and no functional impairment. The patient was followed for 12 months from injury. This case report highlights the difficulty health care providers face to accurately diagnose frostbite within the first 24 hours of injury, prior to development of more definitive signs and symptoms. Early treatment during this critical period may preserve tissue and function.

Focused Ultrasound PC-6 Stimulation Effects on Blood Flow Volume, Skin Temperature, and Coldness of the Finger and Toe.

INTRODUCTION: Focused ultrasound can stimulate a specific point of tissue and can be a noninvasive method for acupoint stimulation. The aim of this study was to clarify the effects of acupoint stimulation by focused ultrasound on blood flow volume and coldness of the fingers and toes. MATERIALS AND METHODS: Forty healthy volunteers were included in this experiment. The blood flow volume and the skin temperature of a finger and toe were measured before and after stimulation of the pericardium 6 acupuncture point (PC-6) by focused ultrasound. Subjective coldness of the fingers and toes was also assessed using a visual analog scale (VAS) before and after stimulation. RESULTS: The maximum blood flow volumes of the finger and toe were significantly larger (p < 0.01) than those before stimulation. The maximum skin surface temperatures of the fingers were significantly higher (p < 0.01) than those before stimulation. The VAS scores for subjective coldness of the toes after stimulation were significantly higher (p < 0.01). CONCLUSION: The blood flow volume and skin temperature tended to increase after PC-6 stimulation. The VAS scores also indicated a tendency toward a warmer sensation in the toes after stimulation.

A Randomized, Double-Blind, Controlled Trial Evaluating the Efficacy of Nd:YAG 1064 nm Short-Pulse Laser Compared With Placebo in the Treatment of Toenail Onychomycosis.

INTRODUCTION: Laser and light-based therapies have emerged as interesting treatment options with minimal side effects or contraindications to treat onychomycosis. Although increasing reports of successful treatment exist, few randomized, controlled, prospective studies have evaluated their true efficacy. We conducted a prospective, randomized, double-blind, controlled trial to evaluate the cure rate of onychomycosis treated by laser. METHODS: Fifty-one patients were randomized to receive 3 treatments (0, 12, 24 weeks) of 1064 Nd:YAG short-pulse (Cutera GenesisPlus) laser or placebo sham laser. The primary efficacy end point is the proportion of patients with a complete cure rate of the target great toenail at week 52. The secondary efficacy end points, at week 52, were treatment success defined as almost clear nail (≤ 10%) and negative mycology, completely or almost clear nail of the great toenail, negative mycology, improvement from one OSI severity class to another of the target toenail, and the difference in proximal nail plate clearance between baseline and week 52. RESULTS: No patient (0%) in the laser group and 2 patients (7.7%) in the placebo group reached the primary outcome. One patient (4.8%) in the laser group reached treatment success vs 2 (7.7%) in the placebo group. Only 6 patients (33%) had negative cultures in the laser group vs 11 (50%) in the placebo group. None of the secondary end points were met. CONCLUSIONS: This study demonstrated that 3 treatments of Nd:YAG 1064 nm laser at 3-month intervals were not effective to treat onychomycosis.

Real-time foot clearance biofeedback to assist gait rehabilitation following stroke: a randomized controlled trial protocol.

BACKGROUND: The risk of falling is significantly higher in people with chronic stroke and it is, therefore, important to design interventions to improve mobility and decrease falls risk. Minimum toe clearance (MTC) is the key gait cycle event for predicting tripping-falls because it occurs mid-swing during the walking cycle where forward velocity of the foot is maximum. High forward velocity coupled with low MTC increases the probability of unanticipated foot-ground contacts. Training procedures to increase toe-ground clearance (MTC) have potential, therefore, as a falls-prevention intervention. The aim of this project is to determine whether augmented sensory information via real-time visual biofeedback during gait training can increase MTC. METHODS: Participants will be aged > 18 years, have sustained a single stroke (ischemic or hemorrhagic) at least six months previously, able to walk 50 m independently, and capable of informed consent. Using a secure web-based application (REDCap), 150 participants will be randomly assigned to either no-feedback (Control) or feedback (Experimental) groups; all will receive 10 sessions of treadmill training for up to 10 min at a self-selected speed over 5-6 weeks. The intervention group will receive real-time, visual biofeedback of MTC during training and will be asked to modify their gait pattern to match a required "target" criterion. Biofeedback is continuous for the first six sessions then progressively reduced (faded) across the remaining four sessions. Control participants will walk on the treadmill without biofeedback. Gait assessments are conducted at baseline, immediately following the final training session and then during follow-up, at one, three, and six months. The primary outcome measure is MTC. Monthly falls calendars will also be collected for 12 months from enrolment. DISCUSSION: The project will contribute to understanding how stroke-related changes to sensory and motor processes influence gait biomechanics and associated tripping risk. The research findings will guide our work in gait rehabilitation following stroke and may reduce falls rates. Treadmill training procedures incorporating continuous real-time feedback may need to be modified to accommodate stroke patients who have greater difficulties with treadmill walking. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry, ACTRN12617000250336 . Registered on 17 February 2017.

An Open Label Study of an Occlusive Heat Patch in the Treatment of Warts

Background: Local hyperthermia has been demonstrated to be a safe and efficacious treatment for warts. Objective: We aimed to evaluate the safety and efficacy of an epicutaneous heat patch to induce local hyperthermia for the treatment of warts. Methods: We performed an uncontrolled, proof of concept study by applying a novel, reproducible, epicutaneous heat patch to a target wart for 2 hours per day for 12 weeks. There were 15 evaluable participants. An untreated wart was also observed and measured. Wart measurements included the diameter in two dimensions, an investigator global assessment (IGA) score, wart clearance, and monitoring for adverse events as endpoints at week 12 (end of treatment) and week 24 (end of study). Results: No major adverse events were observed. 6.7% of participants reported minor cutaneous events. At week 24, 46.7% of participants achieved complete clearance of both warts. Limitations: The small sample size and lack of independent control in each participant were the main limiting factors. Conclusion: Local hyperthermia delivered by epicutaneous heat patches was well-tolerated, safe, and achieved complete clearance in both treated as well untreated warts in 46.7% of participants at week 24 after 12 weeks of daily use. Clinicaltrials.gov: NCT01746056 J Drugs Dermatol. 2019;18(4):368-373.

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.

Toe Flexor Muscle Strength and Morphological Characteristics of the Foot in Judo Athletes.

Whether practicing in judo influences the muscle strength and morphological characteristics of the foot is unknown. The purpose of this study was to determine the toe flexor muscle strength and morphological characteristics of the foot in judo athletes. Judo athletes (JUDO, men=24) and age-, gender- and body mass-matched physically active healthy subjects (CON, men=24) were recruited, and their toe flexor strength and morphological characteristics of the foot were compared. The maximum isometric toe flexor strength and foot intrinsic muscle thicknesses were measured using a toe grip dynamometer and a B-mode ultrasound, respectively. Foot arch height was assessed as the distance between the navicular tuberosity of the foot and the floor in the sitting and standing positions. JUDO showed a significantly lower foot arch height and smaller foot arch index than CON, whereas foot length and muscle thickness did not significantly differ between groups. The toe flexor strength relative to total muscle thickness was significantly larger in JUDO than CON. The foot arch dynamics was significantly larger in JUDO than CON. This study suggests that exercise training specific to judo may affect the force-generating capacity, morphological structure and arch function of the foot.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients.

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

Onset Time of Local Anesthesia After Single Injection in Toe Nerve Blocks: A Randomized Double-Blind Trial.

PURPOSE: The study was conducted to investigate the onset time and safety profile of four different local anesthetic solutions. DESIGN: Randomized controlled clinical trial study. METHODS: One hundred twelve healthy volunteers were assigned to receive digital block on their second toe. Individuals were randomly assigned to one of the following groups: lidocaine 2%, lidocaine 2% with epinephrine, bupivacaine 0.5%, or bupivacaine 0.5% with epinephrine. Onset time was measured until detecting the absence of pinprick sensation. Oxygen saturation was measured in the infiltrated toe up to 60 minutes. FINDINGS: The subjects in the groups of anesthetics with epinephrine had a significantly lower mean onset time. There were no significant differences regarding oxygen saturation between the groups and no adverse effects were recorded. CONCLUSIONS: The use of anesthetics with epinephrine can be an effective form of local anesthetic for digital blocks when a rapid onset of action, prolonged duration of anesthesia, and vasoconstrictive action are required.