"Coxa pedis" today.

UNLABELLED: Coxa pedis is the talocalcaneonavicular joint and is the distal enarthrosis of the lower limb. It is defined coxa because of: (1) the enarthrosic meaning from an anatomical point of view, (2) the analogy to the hip. The stabilising devices are structural, passive and active; the corresponding pathology is the "Coxa pedis destabilising syndrome". During walking, release and stiffening of the foot are related to the opening and closure of the kinetic chain of the coxa pedis: it is mutually reversible, while opening is a passive event, closure is an active one. Considering the importance of the flexor digitorum longus muscle in stabilising the coxa pedis, is it logical transferring it in the tibialis posterior disfunction? During walking, opening and closure of the kinetic chain of the coxa pedis intervene in the opening and closure of the kinetic chain of the entire lower limb. The kinetic chain closes starting from the bottom and moving upwards in the foot-knee-hip progression, and opens starting from the top and moving downwards. Even rotations along the orthogonal plane of the segmental axes of the limb contribute to the closure of the kinetic chain, coxa pedis dysmorphism (cavovalgus foot: false flat foot) can cause, during growth, dysmorphism of the hip (residual anteversion) and of the knee (condyles or tibial tuberosity) instead of the reverse. ISSUES: subtalar joint; anomalous subtalar pronation syndrome; flexor digitorum longum transfer pro tibialis posterior tendon; coxa pedis actor or participant in the functional integration of the lower limb; anterior knee pain syndrome.

An unusual case of fibular (postaxial) polydactyly: extrametatarsal head with fused duplication of the proximal phalanx.

Polydactyly of the foot is a congenital anomaly characterized by the appearance of all or part of 1 or more additional rays. A number of morphologically and anatomically based classifications exist. We present an unusual case of fibular (postaxial) polydactyly characterized by an extrametatarsal head with fused duplication of the proximal phalanx. We describe the method of surgical correction and emphasize the need for careful preoperative planning to achieve a good functional and cosmetic outcome.

The nosology of Richieri-Costa/Guion-Almeida syndrome(s).

Richieri-Costa/Guion-Almeida syndrome type 1 (RCGAS1) is a rare MR/MCA syndrome comprising developmental and growth delay, microcephaly, prominent supraorbital ridges, asymmetric ptosis and eyebrows, esotropia, nystagmus, eye colobomas, and cleft lip/palate. It was originally described in three brothers and an additional sporadic male. The same authors also described a further family with a partially overlapping condition in two sisters (Richieri-Costa/Guion-Almeida syndrome type 2, RCGAS2). We report on a sporadic, mentally retarded patient strongly resembling those of the original report of RCGAS1, but lacking some manifestations such as short stature and, possibly, some ocular changes. Results of 200 kb CGH-array study were normal. By comparing the present and previously reported patients with RCGAS1 and 2, we tried to contribute to syndrome delineation and to separate them from conditions with similar facial anomalies.

The spectrum of preaxial polydactyly of the foot.

BACKGROUND: Polydactyly is a common congenital anomaly of the foot classified as preaxial, central, or postaxial depending on the location of the duplication. Approximately 15% of all duplications of the toes are preaxial. The purpose of this study is to report our experience in the management of preaxial polydactyly of the foot over a period of 30 years at a single institution. PATIENTS AND METHODS: This is a retrospective institutional review board-approved descriptive case series of 21 children representing 28 feet with preaxial foot polydactyly seen at our institution from 1977 to 2009. All subjects were analyzed in terms of sex, laterality, anatomic patterns of polydactyly, associated anomalies, family history, clinical features, surgical indications, details of surgical procedures, and outcomes after surgical interventions, using data collected from medical records, radiographs, and clinical photographs. Clinical outcomes were evaluated at the most recent examination, according to the format published by Phelps and Grogan. RESULTS: There were 21 patients (28 feet) including 11 male and 10 female subjects. Duplications were bilateral in 7 patients and unilateral in 14. The average age at surgery was 1.8 years (range: 0.8 to 4.6 y). The average follow-up was 81.7 months (range: 5 to 180 mo). According to the Watanabey classification, the distal phalangeal type occurred in 4 feet, the proximal phalangeal type in 10 feet, the metatarsal type in 10 feet, the tarsal type in 2 feet, a combined tarsal and metatarsal type in 1 foot, and a mirror type in 1 foot. All patients had associated anomalies in the affected feet. Congenital hallux varus was the most common associated anomaly (20 feet). A longitudinal epiphyseal bracket was observed in 4 feet. Clinical outcomes after the initial surgery were excellent in 8 feet, good in 15 feet, and poor in 5 feet. The 5 feet rated as poor were because of residual deformities and required additional surgery. Good results were subsequently obtained at final follow-up in all 5 feet. CONCLUSIONS: In our opinion, the Watanabe classification is more useful than the Venn-Watson for surgical planning. However, we have added an additional type, representing a mirror foot which we feel is within the overall spectrum of preaxial polydactyly. Good or better results were obtained in all feet at final follow-up. Early detection and adequate excision of the longitudinal bracket affecting the phalanges or metatarsal can reduce residual deformity and the need for revision surgery.

Congenital cleft foot deformity.

Cleft foot or ectrodactyly is a rare congenital anomaly. It is often associated with cleft hands. Most early authors advised non-operative treatment but more recently surgical treatment has been advised. However the last two decades have seen a trend towards surgical management of these deformities. Most authors agree that whilst cosmesis is an important consideration, the main aim of correction is to provide feet which could fit into normal shoes and to provide or maintain a normal functional foot. We describe our experience with five feet in three patients treated surgically as a one step procedure as opposed to a staged approach.

Elements of morphology: standard terminology for the hands and feet.

An international group of clinicians working in the field of dysmorphology has initiated the standardization of terms used to describe human morphology. The goals are to standardize these terms and reach consensus regarding their definitions. In this way, we will increase the utility of descriptions of the human phenotype and facilitate reliable comparisons of findings among patients. Discussions with other workers in dysmorphology and related fields, such as developmental biology and molecular genetics, will become more precise. Here we introduce the anatomy of the hands and feet and define and illustrate the terms that describe the major characteristics of the hands and feet.

Foot problems in children presented to the family physician: a comparison between 1987 and 2001.

BACKGROUND: In recent decades, studies on the management of common foot problems in children have suggested that in many cases, there is no indication for treatment. It is not known whether these studies have changed daily practice. OBJECTIVE: Our aim was to establish and compare incidence and referral rates for foot problems in children in 1987 and 2001. METHODS: A comparison was made of two large consecutive surveys in Dutch general practice performed in 1987 (86 577 children aged 0-17 years) and 2001 (87 952 children aged 0-17 years), which were carried out by The Netherlands Institute for Health Services Research. Both surveys included a representative sample of the Dutch population. Incidence and referral rates were calculated and, data were stratified for age group and gender. RESULTS: Compared to 1987, in 2001 the overall incidence rate of foot problems presented to the family physician (FP) decreased substantially from 80.0 [95% confidence interval (CI) 77.0-84.7] to 17.4 (95% CI 16.5-18.3) per 1000 person-years (P < 0.0001). The incidence rate of flat feet decreased from 4.9 (95% CI 4.0-5.9) per 1000 person-years in 1987 to 3.4 (95% CI 3.0-3.8) per 1000 person-years in 2001 (P = 0.001). The distribution of referrals to other primary health care professionals and medical specialists has almost reversed in favour of primary health care professionals. CONCLUSION: Total incidence rate of musculoskeletal foot problems seen by the FP has decreased substantially, between 1987 and 2001.

Central ray deficiency with extensive syndactyly: a dilemma for classification.

Split Hand Foot Malformation (SHFM) (cleft hand/foot, central ray deficiency) is a complex, highly variable anomaly involving the hands and/or feet. A clinical epidemiologic study of split hand/foot (central ray deficiency) of the Manitoba population identified a subset of patients who did not present with either typical or atypical split hand. Clinically, some patients presented with "mitten hand" syndactyly; the deficiency was not recognized before imaging. In this paper, we identify additional similarly affected literature cases, review existing classifications of split hand and syndactyly and attempt to classify these patients. This group presents a challenge for classification and genetic counseling. General classifications permit inclusion of patients with diverse phenotypes; however, details are overlooked. Osseous fusions and disorganization of osseous components complicate classification. Many of these patients had findings that overlapped different subtypes within existing classifications. This cohort highlights the importance of imaging patients with distal limb anomalies. An effective classification scheme should include relevant clinical and radiographic findings in order to assist clinicians following these patients.

[Results of surgical treatment of congenital convex pes valgus (10 non-idiopathic feet)]. / Résultats du traitement chirurgical du pied convexe congénital.

PURPOSE OF THE STUDY: Congenital pes valgus is a rare and complex deformity of the foot raising serious diagnostic and therapeutic challenges. The purpose of our work was to present the surgical procedures used in our series and to analyze outcome. MATERIAL AND METHODS: Ten feet presenting congenital convex valgus treated surgically over a six-year period using the same operative technique were reviewed at minimum five years follow-up. Idiopathic deformities were excluded from this series. Deformities were secondary to arthrogryposis in five feet, a multiple malformative syndrome in four and diastematomyelia in one. The surgical technique used two approaches: a posteromedial incision to release the dorsal flexors, disinsert the tibialis posterior, open the talonavicular joint, release the Achilles tendon and release the posterior tibiotalar capsule; a lateral incision to lengthen the fibular tendons and perform an osteotomy of the anterior process of the calcaneum. A talonavicular pin and a calcaneocuboid pin maintained the correction. The tibialis posterior tendon was reinserted on the anterior aspect of the talonavicular capsule after incision of the dislocation chamber. RESULTS: Outcome was considered good in five cases and fair in five. Outcome was fair in the arthrogyrposis feet. Undercorrection was observed in two feet and valgus flatfoot in three. Talar necrosis occurred in one foot and navicular necrosis in two. DISCUSSION: Simultaneous correction of the different anomalies observed in the congenital convex foot was achieved in this series. The anatomic and functional results were satisfactory. We recommend avoiding overly extensive release in order to decrease the risk of talar and navicular necrosis. It is also important to check the reduction radiographically during the operation. Patients should use an orthesis several months postoperatively to avoid recurrence.

Classification of postaxial polydactyly of the foot.

BACKGROUND: The origins and shapes of accessory digits in postaxial polydactyly of the foot were analyzed morphologically and radiographically, and their characteristics were determined. A simple classification method was then devised to assist in determining the most appropriate treatment options. METHODS: We evaluated 113 feet of 95 patients who had surgery for the treatment of postaxial polydactyly between 1998 and 2002. Based on the morphologic, radiographic, and operative findings, the cases were classified according to the origin of the accessory digit: middle phalangeal, proximal phalangeal, floating, fifth metatarsal, or fourth metatarsal. The proximal phalangeal type was further divided into three subtypes: proximal phalangeal lateral type, proximal phalangeal medial, and proximal phalangeal head. RESULTS: Of the 113 feet, 36 were middle phalangeal type, 45 were proximal phalangeal type, 5 were floating type, 15 were fifth metatarsal type, and 12 were fourth metatarsal type. Of the proximal phalangeal types, 15 were laterally duplicated supernumerary sixth digits, and 17 were medially duplicated supernumerary fifth digits. The duplicated digits of the remaining 13 originated at the distal portion of the proximal phalanx. In the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, and fourth metatarsal types, the medial accessory fifth digit was an abnormally duplicated digit, which was excised. In the proximal phalangeal lateral, floating, and fifth metatarsal types, the lat eral accessory sixth digit was excised. For the children in this study, we did not perform reconstruction of the deep transverse metatarsal ligament or collateral ligament. Also, we did not use longitudinal pin fixation. Skin necrosis occurred in 10 feet that resolved, and in five of the 15 feet of the 5th metatarsal medial deviation occurred. CONCLUSIONS: Based on the morphologic, radiographic, and operative findings, we suggest a classification method of postaxial polydactyly of the foot. We believe this is a straightforward and useful method for the treatment of postaxial polydactyly.

[Clinical signs and diagnosis of hallux valgus]. / Klinische Untersuchung + Röntgenbild. So funktioniert die Hallux-valgus-Diagnostik.

The hallux valgus deformity (fibular deviation of the big toe) is one of the most common deformities affecting lower limbs. If the hallux crosses over the second toe, the condition may be termed hallux valgus superductus, if it moves under the second toe, the term hallux valgus subductus applies. Mechanical pressure on the pseudoexostosis results in a bunion and possibly fistulization. Hallux valgus is often combined with a splay foot. Overloading of the second to fourth metatarsal heads may cause midfoot pain. As a result of the increased load, the second to fifth toes may deform into hammer or claw toes. Therefore hallux valgus should usually not be considered in its own. Apart from the anamnesis and clinical examination, X-ray diagnosis is very important for the treatment planning. A.p. and lateral X-rays should be obtained of the entire foot in the standing patient, as also an oblique view. While the latter permits evaluation of the extent of an arthrosis of the metatarsophalangeal joint of the big toe, the lateral films allow the longitudinal arch and the stability of the first tarsometatarsal articulation to be assessed. On the a.p. film the hallux valgus angle and the intermetatarsal (rays 1/2) angle can be determined.

The newborn foot: diagnosis and management of common conditions.

An assessment of the foot should be a part of every newborn physical examination. The newborn foot, although complex in structure, can be examined quickly in any office setting. Many foot deformities are diagnosed immediately after birth, allowing for earlier and often more successful treatment. A neonate with a foot deformity can be a source of anxiety to parents. Adequate knowledge of commonly encountered neonatal foot problems enables the nurse to give appropriate anticipatory guidance to the parents. Foot abnormalities usually occur as isolated findings in an otherwise healthy newborn. However, these deformities can also be seen in newborns with underlying neuromuscular disorders and syndromic conditions. Common newborn foot abnormalities include equinovarus deformity (clubfoot), metatarsus adductus, calcaneovalgus, congenital vertical talus, polydactyly (supernumerary digits), and syndactyly (webbed toes). These common foot disorders, their treatment, and their prognosis are discussed. This article also discusses fundamental nursing implications needed to care for these young patients and their families.

Foot deformities in diastrophic dysplasia. An analysis of 102 patients.

The exceptionally high prevalence of diastrophic dysplasia in Finland has enabled us to analyse the foot deformities of 102 patients at their first orthopaedic evaluation and classify 204 feet into five categories. The most common finding (43%) was a foot with tarsal valgus deformity and metatarsus adductus; 37% showed either equinovarus adductus (29%) or equinus (8%) deformities. At the first examination 13% showed metatarsus adductus deformity alone, and 7% were clinically normal. The expression 'club foot', generally used for the foot deformity in diastrophic dysplasia is a misnomer. There is a wide spectrum of deformities, some of them specific for the condition.

Polydactyly of the foot: an analysis of 265 cases and a morphological classification.

Three hundred and thirty feet in 265 patients with polydactyly of the foot were classified on the basis of ray involvement and the level of duplication. Anatomic differences in bony structures according to x-ray and operative findings, external appearance of involved digits, associated anomalies, and familial incidence were studied. In medial-ray polydactyly, bilateral occurrence was common, and a higher frequency of associated anomalies was detected. Each involved foot with even the same level of duplication usually had a different morphologic pattern. In central-ray polydactyly, all patients except one had duplications of the second toe, commonly with unilateral involvement. Both components were underdeveloped, with delay in appearance of ossification areas. In two patients, each member of duplication had syndactyly with the neighboring toe, resembling the pattern of polysyndactyly-cleft hand complex. Lateral-ray polydactyl was classified into two new major groups based on ossification pattern and bony alignment: (1) fifty-ray duplication, referring to the medially duplicated supernumerary fifth toe, and (2) sixth-ray duplication, referring to the laterally duplicated supernumerary sixth toe. Fifth-ray duplication was much more frequent than sixth-ray duplication in the Japanese population. Many differences were noted between the two groups of lateral polydactyly. Syndactyly between the fourth and fifth toes was associated only with fifty-ray duplication. Ulnar polydactyly was associated only with sixth-ray duplication. In lateral polydactyly, every patient with bilaterally involved feet had similar groups of polydactyly bilaterally. All the patients in the same family also had similar groups of anomalies. These facts suggest independent etiologic mechanisms for each.

The position of symbrachydactyly in the classification of congenital hand anomalies.

The clinical features of 53 cases of intercalated hypoplasia and 113 cases of distal aplasia are reviewed and compared with each other and with 129 cases of syndactyly. Tri-, di- and mono-phalangeal symbrachydactyly, and adactyly with nubbin digits are consecutive anomalies. Transverse deficiency may result if the mesenchyme is damaged severely, and if damage is mild and formation has continued, intercalated transverse deficiency may occur. Webbing in symbrachydactyly may result from failure of the apical ectodermal ridge under the influence of damaged mesenchyme.

Congenital vertical talus: a retrospective and critical review of 32 feet operated on by peritalar reduction.

Thirty-two feet in 23 children treated for congenital vertical talus by peritalar reduction have been evaluated. The age at operation ranged from 9 months to 8 years (mean 3.2 years). The follow-up ranged from 2.8 to 19.1 years (mean 9.2 years). In eight feet Green-Grice extraarticular subtalar arthrodesis was performed as part of a one-stage procedure. Eight of all operated feet required a second surgery 2.2 years after the first operation. In all the reoperated feet the Green-Grice arthrodesis was performed as well. Clinical examination found excellent results in five feet, good results in 12, fair results in nine, and poor results in six feet. The severe type of deformity, other abnormalities, and less extensive surgical procedures contributed to worse clinical results. Poor clinical results were associated with persistent equinus of the hindfoot, abduction of the forefoot, restriction of supination and eversion, and weakness of push-off power. X-ray examination showed excellent results in three feet, good in nine, fair in 13, and poor in seven feet. Poor radiological results were observed in children operated on after the fourth year of age. In most of the feet the navicular remained dislocated dorsally, dorsally and medially, and dorsally and laterally toward the head of the talus. A divergence between a relatively good appearance of the operated foot and a worse radiographic image has been observed. The Green-Grice extraarticular subtalar arthrodesis combined with the peritalar reduction method led to overcorrection in seven feet.

Postaxial polydactyly. A case report.

Polydactyly is a fairly common congenital foot deformity. Treatment may include simple shoe modification or surgical intervention. Careful preoperative planning must be undertaken with each patient because of the uniqueness of each individual case. A case of type A postaxial polydactyly was presented with a brief review of classification, etiology, and treatment.

Pedal polydactyly. A case report.

Polydactyly is a common pedal deformity with great variation in clinical presentation. There is a tendency toward a higher incidence in previously affected families, but the actual occurrence rate of the different forms of polydactyly has not been agreed upon in the literature to date. Most authors agree that the isolated deformity is an expression of an autosomal dominant gene with varied penetrance. Syndromatically associated polydactyly is inherited as an autosomal recessive trait. Surgical intervention should be attempted as early as possible. Correction should be undertaken only after a thorough clinical and radiographic evaluation has been performed. The patient's postoperative goals should always be considered. It is not necessary to remove the supernumerary digit if it does not interfere with the foot's function and comfort. Cosmesis should not be the chief consideration. The surgeon should strive to return the foot to a more normal contour while maintaining or improving foot function.

Accessory bone or unusual congenital anomaly.

This case study presents a congenital anomaly, diagnosed in a 23-year-old male, not found previously described in the medical literature. It also reviews the current classification systems used to describe congenital anomalies.