Operative Management of Y-Shaped Metatarsal with Biphalangeal Sixth Toe.

BACKGROUND: In the literature, there is no consensus regarding the surgical management of postaxial polydactyly, and few cases of polymetatarsia with polydactyly have been reported. Treatment of the complete deformity will prevent further foot and gait disorders. OBJECTIVE: To identify literature relevant to the operative management of Y-shaped metatarsal with biphalangeal sixth toe and related skin and wound care to improve surgical treatment protocols from a clinical experience perspective. DATA SOURCES: The authors searched several electronic databases in December 2022 for articles related to postaxial polysyndactyly in the feet and polymetatarsia. Databases searched included PubMed, SciELO, ScienceDirect, Cochrane Database of Systematic Reviews, and Google Scholar gray literature. STUDY SELECTION: Two independent researchers conducted the searches and read the article titles and abstracts. Studies were included if they were narrative reviews, case studies, or observational studies; written in English or Spanish; and published between 2012 and 2022. Nonhuman studies were excluded. Studies that met the inclusion criteria were fully evaluated. Disagreements between reviewers were resolved by consensus, and when there was no consensus, a senior researcher was consulted. DATA EXTRACTION: The following data were extracted from the included studies using a standardized form: author and year of publication, study type, number of participants, sex, polydactyly location, polymetatarsia, type of polydactyly, participants' history of hereditary associated diseases or malformations, treatment, removal criteria, and timing of surgery. DATA SYNTHESIS: Authors evaluated 11 studies of postaxial polydactyly that included a total of 153 participants (64 men, 89 women). They also document their clinical experience with a surgical technique used in cases of bilateral postaxial polydactyly of the foot with a Y-shaped metatarsal with biphalangeal sixth toe. CONCLUSIONS: Surgical correction with lateral removal of the sixth toe is a resolutive treatment to improve the functionality of the foot, its aesthetic appearance, and the patient's quality of life. Case-specific treatment should be applied and tailored to meet the individual needs. The biomechanics of gait and shoe problems in these patients improve with surgical treatment, without presenting secondary aesthetic problems in skin care.

Digital Gangrene as a Paraneoplastic Manifestation of Peripheral T-cell Lymphoma Not Otherwise Specified Type.

BACKGROUND: Peripheral T cell lymphoma (PTCL), not otherwise specified (NOS) is a heterogenous group of predominantly nodal T cell lymphomas that generally presents with lymphadenopathy with or without extra nodal involvement. Acral vascular syndrome clinically presents as digital ischemia with Raynaud's phenomenon and acral cyanosis. Although, this condition is commonly associated with connective tissue disorder, smoking and vasculitis, its association with lymphoid malignancy is very rare. Here, we present a case report of a patient with digital gangrene of all toes and fingers as a presenting symptom of PTCL-NOS. CASE DESCRIPTION: A 62 year old male presented with digital ischemia associated with pain, low grade fever, loss of appetite and significant weight loss of 6 kilograms over a period of 3 months. On examination, he was found to have bilateral inguinal and axillary lymph nodes with gangrenous changes over toes and fingers but peripheral pulses were palpable. On evaluation he had anemia, elevated ESR and CRP. CT angiogram revealed thinned out digital arteries with multifocal areas of narrowing. Patient was screened for other causes of digital gangrene and was tested negative for ANCA, ANA, cryoglobulins and viral markers. Lymph node biopsy with IHC was suggestive of peripheral T-cell lymphoma-NOS and was started on CHOP regimen. Lymph nodes size decreased and gangrenous changes resolved. CONCLUSION: Though digital ischemia is a rare paraneoplastic presentation of lymphoma, it should be considered if there is a rapid progression of gangrene. Early initiation of chemotherapy may result in the reduction of further progression of digital gangrene and thus prevent permanent disability. In our patient, progression of gangrene was prevented even though it was an aggressive variant of T cell lymphoma.

Subungual Osteochondroma of the Great Toe: A Case Report.

Bony outgrowths of the distal phalanx of the great toe have been described in the literature but rarely. These subungual bony outgrowths can be caused by subungual exostosis or subungual osteochondromas. Both of these abnormalities are bony outgrowths with differences in the cartilage cap wherein the exostoses have fibrocartilage, and osteochondromas have hyaline cartilage. The subungual exostosis and osteochondroma that are protruding present symptoms of pain, redness, and deformed nail bed, whereas the nonprotruding osteochondromas have only a lump as the presenting symptom. In both conditions, excision of the lesion and curettage of the base helps prevent a recurrence. Curettage at the end of the excision of the bony outgrowth is required to avoid recurrence. After excision, the specimen should be sent for histopathologic examination to differentiate between the exostosis and osteochondromas, which are underreported in subungual locations, and to rule out malignant transformation. We present a 13-year-old girl with an isolated subungual nonprotruding exostosis of the great toe that was treated by excisional biopsy. The histopathologic examination confirmed it as osteochondroma, which is underreported.

Refinement of Surgery for Postaxial Polysyndactyly of the Toes: Esthetic Outcome in Japanese Feet.

PURPOSE: Treatment for polysyndactyly of the toes aims at cosmetic improvement but the lateroplantar rotation of the new fifth toe remains challenging. This study evaluated our novel surgical procedure for postaxial polysyndactyly of the toes. MATERIALS AND METHODS: Patients with postaxial polysyndactyly involving the fourth, fifth, and sixth toes treated in 2007 to 2017 with a minimum follow-up duration of 1 year were retrospectively investigated. Our aims of surgery for this condition were to avoid excessive lateroplantar rotation of the new fifth toe by using a proximally elongated plantar "shark-fin flap" and to make the tip of this toe appear to be naturally pointing inward by using the dog-ear component of the flap on the tip of the toe. The excess skin of the shark-fin flap was grafted onto the lateral surface of the fourth toe. Lateroplantar rotation of the fifth toe in these patients was compared with that in photographs of the feet of 96 normal 4-year-old children. RESULTS: A total of 11 feet in 10 patients (6 male, 4 female; mean age 1.3 years) were analyzed. Syndactyly between the fourth and fifth toes was complete in 3 feet, incomplete at the level of the distal interphalangeal joint of the fifth toe in 5, and incomplete at the level of the proximal interphalangeal joint of the fifth toe in 3. Lateroplantar rotation of the fifth toe, evaluated by the mean angle between 2 intersecting lines extending from the proximal nail fold of the third and fifth toes, was 25 ± 10° in normal feet and 0 ± 12° in operated feet with polysyndactyly. The absolute left-right difference in this angle was 7 ± 5° in normal children and 22 ± 12° in patients with polysyndactyly. Valgus deformity of the new fifth toe improved in all patients during a mean postoperative follow-up of 3.8 years. CONCLUSIONS: Using our procedure, no excessive lateroplantar rotation has been observed when the tip of the fifth toe is inclined inward using a dog-ear flap component. This procedure could be useful in patients in whom the cosmetic outcome is a priority.

Effects of walking speeds on lower extremity kinematic synergy in toe vertical position control: An experimental study.

BACKGROUND: This study aimed to investigate whether lower limb joints mutually compensate for each other, resulting in motor synergy that suppresses toe vertical position fluctuation, and whether walking speeds affect lower limb synergy. METHODS: Seventeen male university students walked at slow (0.85 ±â€…0.04 m/s), medium (1.43 ±â€…0.05 m/s) and fast (1.99 ±â€…0.06 m/s) speeds on a 15-m walkway while lower limb kinematic data were collected. Uncontrolled manifold analysis was used to quantify the strength of synergy. Two-way (speed × phase) repeated-measures analysis of variance was used to analyze all dependent variables. RESULTS: A significant speed-by-phase interaction was observed in the synergy index (SI) (P  < .001). At slow walking speeds, subjects had greater SI during mid-swing (P  < .001), while at fast walking speeds, they had greater SI during early-swing (P  < .001). During the entire swing phase, fast walking exhibited lower SI values than medium (P  = .005) and slow walking (P  = .027). CONCLUSION: Kinematic synergy plays a crucial role in controlling toe vertical position during the swing phase, and fast walking exhibits less synergy than medium and slow walking. These findings contribute to a better understanding of the role of kinematic synergy in gait stability and have implications for the development of interventions aimed at improving gait stability and reducing the risk of falls.

Navigating diagnostic challenges-distinguishing malignant melanoma and clear cell sarcoma of soft tissues: a case report and review of the literature.

BACKGROUND: Within the spectrum of melanocytic-differentiated tumors, the challenge faced by pathologists is discerning accurate diagnoses, with clear cell sarcoma of soft tissues standing out as a rare and aggressive neoplasm originating from the neural crest. Accounting for 1% of all soft tissue sarcomas, clear cell sarcoma of soft tissues poses diagnostic complexities, often misidentified owing to its phenotypic resemblance to malignant melanoma. This chapter delves into the intricacies of clear cell sarcoma of soft tissues, its epidemiology, characteristic manifestations, and the imperative need for a comprehensive diagnostic approach involving immunohistochemical and molecular analyses. CASE PRESENTATION: A compelling case unfolds as a 25-year-old male from Morocco, initially misdiagnosed with malignant melanoma, experiences tumor recurrence on the second toe. With no history of trauma or familial neoplasia, the patient's clinical journey is explored, emphasizing the importance of detailed clinical examinations and radiological assessments. The chapter elucidates the histopathological findings, immunohistochemical spectrum, and the correlation between clinical parameters and diagnostic inference, ultimately leading to metatarsal amputation. This clinical vignette highlights the multidimensional diagnostic process in soft tissue neoplasms, emphasizing the synergistic role of clinical, radiological, and histopathological insights. CONCLUSION: The diagnostic challenges inherent in melanocytic-differentiated tumors, exemplified by the rarity of soft tissue clear cell sarcoma, underscore the essential role of an integrated diagnostic approach. This concluding chapter emphasizes the perpetual collaboration required across pathology, clinical medicine, and radiology for nuanced diagnostic precision and tailored therapeutic strategies. The rarity of these soft tissue malignancies necessitates ongoing interdisciplinary engagement, ensuring the optimization of prognosis and treatment modalities through a comprehensive understanding of the diagnostic intricacies presented by clear cell sarcoma of soft tissues.

Prolonged Union in Conservative Treatment of Symphalangeal Toe Fractures: Case Series.

Background: Toe symphalangism is characterized by a fusion of the interphalangeal joint between the middle and distal phalanges. While typical lesser toe fractures heal well with conservative treatment, in our clinical experience, we encountered patients with symphalangeal toe fractures who experienced long-lasting pain and delayed radiographic union. Therefore, this study aimed to report radiographic outcomes following conservative treatment of symphalangeal fractures of the lesser toes. Methods: We retrospectively reviewed 14 patients with symphalangeal lesser toe fractures who were treated conservatively. We investigated the mechanism of injury and measured the time from the initial injury date to the complete radiographic union. The fracture gap distance was measured on an initial lateral radiograph. Results: Symphalangeal fractures involved the fourth toe in 4 patients (28.5%) and the fifth toe in 10 patients (71.4%). Regarding the mechanism of injury, 6 patients (42.9%) were injured by stubbing or bumping into the door, 5 patients (35.7%) were injured by tripping, 2 patients (14.3%) were injured by heavy objects falling directly on their toes, and 1 patient (2.3%) complained of pain after wearing pointed shoes for half a day. The mean time to complete union was 9.1 months, and the median period was 5.5 months (range, 0.8-29 months). The initial gap of the fracture was 0.60 mm (range, 0.30-1.04 mm). Conclusions: The results of our case series may help counsel patients in the outpatient clinic that prolonged healing time may be required for the union of symphalangeal toe fractures.

The association between tobacco smoking and systolic toe pressures in active foot ulceration.

Smoking may increase the risk of diabetic foot disease and ulceration. It does so by impairing glycaemic control and promoting the formation of advanced glycated end-products. Additionally, smoking is known to delay surgical wound healing and accelerate peripheral arterial disease. We aimed to determine whether toe pressures differed in smokers with a foot ulcer, when compared to non-smokers and ex-smokers, as well as ulcer outcomes at 12 months, among patients attending Blacktown Hospital High Risk Foot Service (HRFS). This study is a retrospective analysis of our prospectively collected clinic database. Eligible participants were adults attending the HRFS between June 2020 and April 2022. Participants were included if they had an ulcer, at least one systolic toe pressure reading completed at their initial visit and attended at least one follow-up visit. Participants were followed until healing, loss to follow-up or a minimum of 12 months. A total of 195 participants were included; 36 smokers, 82 ex-smokers, and 77 controls who had never smoked. Smoking status was by self-report. Current smokers were significantly younger at initial presentation (p = .002) and tended towards lower socioeconomic status (p = .067). Current smokers were significantly more likely to have ischaemic grade 3 toe pressures (< 30 mmHg) of their left foot (p = .027), suggestive of reduced perfusion. At the end of follow up period, smokers had the numerically highest rates of minor amputations. In conclusion, smokers ulcerate younger and are more likely to have grade 3 ischaemia. Collecting information about the brachial artery pressures and the time since the last cigarette may clarify any relationship between smoking and toe pressures.Trial registration: WSLHD HREC ethics approval 2111-02 and ANZCTR registration 382470. Registered on 15/09/2021.

Association between postoperative fall history and toe grip strength in patients after total knee arthroplasty: A prospective observational study.

BACKGROUND: Factors associated with falls after total knee arthroplasty (TKA) have been rarely reported. The aim of this study was to identify factors that influence the incidence of falls after TKA, focusing on toe grip strength (TGS) in particular, which has been associated with falls in older adults. METHODS: 217 patients who underwent TKA were included and followed up for 1 year. Main study outcome measures were the presence or absence of falls within 1 year after TKA. Multiple logistic regression analysis was used with postoperative falls as the dependent variable and preoperative falls and postoperative TGS on the affected sides as independent variables. RESULTS: 170 (43 and 127 in the fall and non-fall groups) patients were included in the analysis. The presence of a preoperative falls history before TKA and a weak postoperative affected TGS indicated an increased susceptibility of the patient to fall postoperatively. CONCLUSIONS: Results of the current study revealed the association between postoperative TGS and postoperative falls. We highlight the importance of preoperative fall monitoring and postoperative TGS evaluation to prevent falls after TKA.

[Preliminary application of antibiotic bone cement directly inducing skin regeneration technology in repairing of wound in lateral toe flap donor area].

Objective: To investigate the feasibility and effectiveness of antibiotic bone cement directly inducing skin regeneration technology in the repairing of wound in the lateral toe flap donor area. Methods: Between June 2020 and February 2023, antibiotic bone cement directly inducing skin regeneration technology was used to repair lateral toe flap donor area in 10 patients with a total of 11 wounds, including 7 males and 3 females. The patients' age ranged from 21 to 63 years, with an average of 40.6 years. There were 3 cases of the distal segment of the thumb, 2 cases of the distal segment of the index finger, 1 case of the middle segment of the index and middle fingers, 1 case of the distal segment of the middle finger, and 3 cases of the distal segment of the ring finger. The size of the skin defect of the hand ranged from 2.4 cm×1.8 cm to 4.3 cm×3.4 cm. The disease duration ranged from 1 to 15 days, with an average of 6.9 days. The flap donor sites were located at fibular side of the great toe in 5 sites, tibial side of the second toe in 5 sites, and tibial side of the third toe in 1 site. The skin flap donor site wounds could not be directly sutured, with 2 cases having exposed tendons, all of which were covered with antibiotic bone cement. Results: All patients were followed up 6 months to 2 years, with an average of 14.7 months. All the 11 flaps survived and had good appearance. The wound healing time was 40-72 days, with an average of 51.7 days. There was no hypertrophic scar in the donor site, which was similar to the color of the surrounding normal skin; the appearance of the foot was good, and wearing shoes and walking of the donor foot were not affected. Conclusion: It is a feasible method to repair the wound in the lateral foot flap donor area with the antibiotic bone cement directly inducing skin regeneration technology. The wound heals spontaneously, the operation is simple, and there is no second donor site injury.

Relationship between the strength of the ankle and toe muscles and functional stability in young, healthy adults.

This study investigates the relationship between ankle and toe strength and functional stability in young adults, with a sample comprising sixteen females and fourteen males. The research employed force platform data to determine the center of foot pressure (COP) and calculated the forward functional stability index (FFSI) through foot anthropometric measurements. Strength measurements of toe and ankle muscles, during maximal isometric flexion and extension, were conducted using force transducers. Notable positive correlations were found between toe flexor strength and FFSI (left flexor: r = 0.4, right flexor: r = 0.38, p < 0.05), not influenced by foot anthropometry. Contrarily, no significant correlation was observed between ankle muscle strength and FFSI, despite a positive correlation with the COP range. The moderate correlation coefficients suggest that while toe flexor strength is a contributing factor to functional stability, it does not solely determine functional stability. These findings highlight the critical role of muscle strength in maintaining functional stability, particularly during forward movements and emphasize the utility of FFSI alongside traditional COP measures in balance assessment. It is recommended to employ a multifaceted approach is required in balance training programs.

Temporal changes in toe-brachial index results in haemodialysis patients.

INTRODUCTION: Toe brachial index (TBI), the ratio of toe pressure to systolic blood pressure (SBP), helps predict peripheral arterial disease. In patients with kidney failure this may be performed during haemodialysis for convenience. Until recently there has been little evaluation of the impact of haemodialysis in limb and systemic perfusion on these values. We aimed to determine if the values of TBI would change during and after dialysis compared to pre-dialysis assessments. METHODS: Using a repeated measures study, TBIs and toe pressures were measured using the Hadeco Smartop Vascular Ultrasound Doppler in 31 patients undergoing haemodialysis. TBI assessments were completed pre-dialysis and compared to values obtained at 1 hour, 2 hours, 3 hours, and post-dialysis to monitor change in TBI results. Comparison of values for each patient were tested for differences using paired t-tests. Linear mixed-effects models were used to test for the effect of patient and clinical factors on change in outcome measures. RESULTS: Mean TBI decreased from pre-dialysis at 1 hour (0.72 to 0.63, p = 0.01) and remained lower at 2 hours and 3 hours, before returning to pre-dialysis levels at post-dialysis. Mean systolic blood pressure also declined during dialysis. Mean TBI results were lower in those with a history of lower limb ulceration and in females. Sixteen patients (51.6%) had a normal TBI at baseline, 14 (45.2%) had a mildly low TBI, and one (3.2%) had a severely low TBI. Between baseline and 1 h, five patient's results moved from normal to mildly abnormal and one from mildly abnormal to severely abnormal. As haemodialysis concluded (post-dialysis) there were 17 (56.7%) 'normal' TBIs, with no severely abnormal TBIs (p = 0.73). 0.30). CONCLUSION: TBI and toe pressures are impacted significantly by dialysis. TBI and toe pressure assessments should be conducted before haemodialysis begins, or between dialysis sessions to avoid variability.

The assessment and management of foot and toe oedema as part of holistic lower limb care.

Toe and foot swelling can manifest as lymphoedema or chronic oedema but can also be a complication of the treatment of these conditions. In this article, the authors discuss the assessment and treatment options for toe and foot swelling, highlighting the importance of prevention in the first instance.

A toe-inspired rigid-flexible coupling wheel design method for improving the terrain adaptability of a sewer robot.

The human toe, characterized by its rigid-flexible structure comprising hard bones and flexible joints, facilitates adaptive and stable movement across varied terrains. In this paper, we utilized a motion capture system to study the adaptive adjustments of toe joints when encountering obstacles. Inspired by the mechanics of toe joints, we proposed a novel design method for a rigid-flexible coupled wheel. The wheel comprises multiple elements: a rigid skeleton, supporting toes, connecting shafts, torsion springs, soft tendons, and damping pads. The torsion springs connect the rigid frame to the supporting toes, enabling them to adapt to uneven terrains and pipes with different diameters. The design was validated through kinematic and dynamic modeling, rigid-flexible coupled dynamics simulation, and stress analysis. Different stiffness coefficients of torsion springs were compared for optimal wheel design. Then, the wheel was applied to a sewer robot, and its performance was evaluated and compared with a pneumatic rubber tire in various experiments, including movement on flat surfaces, overcoming small obstacles, adaptability tests in different terrains, and active driving force tests in dry and wet pipelines. The results prove that the designed wheel showed better stability and anti-slip properties than conventional tires, making it suitable for diverse applications such as pipeline robots, desert vehicles, and lunar rovers.

Advances in Pediatric Toe Transfers.

Microsurgery is undoubtedly the pinnacle of hand surgery. Significant advancement in recent years has stretched the indications for toe-to-hand transfer in both acquired and congenital hand defects to restore function, esthetics, and motion, with minimal morbidity to the donor site. There is no one fixed microsurgical transfer technique but a surgeon's versatility and innovation in using what one could spare because each case is unique. Esthetic refinements and reducing donor site morbidities have taken a front seat in recent years. We present a few cases to put forward the senior author's preferred techniques with this objective in mind.

The Foot as a Donor Site for Reconstruction in the Hand.

The foot contains a unique collection of tissue types that can be used in the reconstruction of the hand. Numerous reconstructive options have been presented, some of which have been adopted, such as modifications to procedures that have been described in the past or even newly developed options for hand reconstruction. It is possible to reconstruct missing fingers and other hand structures using tissues taken from the foot rather than removing healthy tissue from a hand that has already been injured. This makes it possible to avoid having healthy tissue removed from an injured hand.

Midlateral Approach Replantation of a Distal Phalanx Second Toe Amputation in a 4-Year-Old Child: A Case Report.

CASE: A 4-year-old girl patient presented with complete amputation of the second toe close to the distal interphalangeal joint. Replantation was performed using a novel midlateral approach. The procedure used the dorsal subcutaneous vein on the foot as a graft for the artery. Four months postoperatively, the toe healed without any complication. The patient reported pain-free physical exercise without limitations in daily activity. CONCLUSION: This report demonstrates that this approach has the potential to provide a safe and viable alternative for treating toe amputations and offers advantages such as simplified artery identification, straightforward anastomosis, and improved vein graft harvesting.

Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers.

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.