The plantarward oblique Chevron osteotomy: an optional method to treat hallux valgus with painful plantar callosities.

Hallux valgus (HV) is a foot deformity that can be treated with Chevron osteotomy, and a modified plantarward oblique osteotomy has been proposed in recent years. However, no research has focused on the correctional power of the osteotomy. The aim of this study was to examine the character of this plantarward oblique Chevron osteotomy (POCO) and to determine the rationale of this method.Radiographs and clinical data from 65 HV patients (77 feet) with painful callosities were evaluated. The intermetatarsal angle, hallux valgus angle, and relative height of the second metatarsal were measured, and a valid width of the first metatarsal was proposed. A visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society hallux-metatarsophalangeal interphalangeal scale (AOFAS) were used to evaluate the patients' clinical results.There were significant differences in the HVA and IMA. The decline in the height of the second metatarsal was positively related to the decline in the height of the first metatarsal, but the changes were smaller for the first metatarsal. Painful callosities disappeared in 77 feet, 4 (5.1%) patients had no pain but a remaining plantar callosity, and 2 (2.6%) patient had relieved pain with a plantar callosity after follow-up. The VAS scores improved from 8.58 ± 0.50 to 1.96 ± 0.75 points after the operation (p < 0.001). Significant differences were demonstrated in the AOFAS scores (65.81 ± 4.05 vs 87.88 ± 3.41, p < 0.001). The modified POCO prevents the dorsal migration of the metatarsal head, preserves other lesser metatarsals and provides an opportunity for patients who may possibly need additional future deformity correction. Therefore, POCO is a safe and effective method to treat hallux valgus and offers the superior potential benefits of correction and transfer metatarsalgia.

Efficacy of intralesional bleomycin for the treatment of plantar hard corns.

BACKGROUND: Intralesional bleomycin is effective for the treatment of various dermatologic conditions. However, the efficacy of intralesional bleomycin for the treatment of corns has not been established. METHODS: A total of 50 patients with plantar corns were recruited and equally divided between groups A and B. Groups A and B were then treated with intralesional bleomycin (1 mg/ml) after paring the hyperkeratotic tissue and simple paring, respectively. The patients visited our clinic at 3-week intervals and were treated for a maximum of 10 sessions. RESULTS: Patients in groups A and B were treated for 35 and 29 corns, respectively. The curative rates of the patients in groups A and B were 37% (13 of 35) and 7% (three of 29), respectively. The proportions of lesions in groups A and B that demonstrated a decrease in size by >50% were 80% (28 of 35) and 38% (11 of 29), respectively. The total number of patients that demonstrated excellent symptomatic improvement in group A was 15 of 22. Excellent responses were achieved within a small number of treatment sessions, ranging from one to four sessions (average: 2.6). Statistical differences in terms of the degree of size reduction and pain relief were noted between the two groups. CONCLUSIONS: This study provides evidence that intralesional bleomycin (1 mg/ml) injection could be one of the ideal treatments for corn. Intralesional bleomycin is particularly useful for reducing lesional pain and size within a short period.

Debridement of painful forefoot plantar callosities in rheumatoid arthritis: the CARROT randomised controlled trial.

The objective of this study was to evaluate the long-term benefits of sharp scalpel debridement of painful forefoot plantar callosities in rheumatoid arthritis (RA). The null hypothesis: sharp scalpel debridement would offer no additional long-term advantage in terms of pain and function. Sixty-five people with RA were randomised to receive regular sharp scalpel debridement of painful forefoot plantar callosities in conjunction with a combined therapeutic approach or a combined therapeutic approach alone. The primary outcome measure was change at 18 months in participant-reported forefoot plantar pain measured by a 100-mm visual analogue scale (VAS). Secondary outcome measures were recorded at baseline and study exit and included revised Foot Function Index, Health Assessment Questionnaire, Foot Impact Scale and gait parameters. At 18 months, there were no differences between groups for the primary outcome VAS-measured forefoot plantar pain (left foot (F = 0.23, p = 0.635), right foot (F = 2.14, p = 0.148)). Within-group changes were highly significant (treatment arm, difference = 16.9 (95 % confidence interval (CI) 9.4, 24.4), t = 4.6, p < 0.0001; control arm, difference = 17.5 (95 % CI 9.4, 25.5), t = 4.4, p < 0.0001). There was little change in scores of overall function and foot impact in either group and there were no significant changes in gait parameters noted. The long-term effects of sharp scalpel debridement of painful forefoot plantar callosities in people with RA, when used in conjunction with a combined therapeutic approach, produced no additional benefit over the combined therapeutic approach alone. Trial registration http://www.controlled-trials.com/ISRCTN05190231.

The association between teat end hyperkeratosis and teat canal microbial load in lactating dairy cattle.

Most pathogens that cause bovine mastitis invade the udder lumen through the teat canal. Amino acids and intercellular lipids may support microbial colonisation of the teat canal epithelium by pathogenic microorganisms. The aim of this study was to investigate the association between teat end hyperkeratosis, which is induced by machine milking, and teat canal microbial load. Contralateral teats, which differed in teat end hyperkeratosis scores, were identified in a split-udder experiment. The teat canal's microbial load was evaluated using the wet and dry swab technique. Staphylococcus (S.) aureus, Streptococcus (Sc.) uberis, Escherichia (E.) coli and other coliforms were detected by agar plate cultures. The positive detection of E. coli and the log(10)-transformed E. coli load of a teat canal were significantly associated with the teat end hyperkeratosis score (P<0.05). There were significant differences with respect to positive findings for E. coli, as well as the microbial load of E. coli and Sc. uberis, between the less-calloused and the more-calloused teat of a pair. For S. aureus, no significant associations between hyperkeratosis score and teat canal microbial load were detected. In general, a teat with a highly calloused teat end had an increased teat canal microbial load compared with the contralateral teat, characterised by a lower callosity. The results of the present study indicate that the environmental pathogen load is associated with teat end hyperkeratosis. Further research is needed to identify factors that may affect teat canal microbial load in lactating dairy cattle.

Xerosis and callus formation as a key to the diabetic foot syndrome: dermatologic view of the problem and its management.

The diabetic foot syndrome is a major complication of diabetes mellitus. The two most important pathophysiologic factors are peripheral arterial occlusion and peripheral neuropathy. The cutaneous lesion is a plantar ulcer, often accompanied by soft tissue and bone infections which can require amputation. Triggers include poorly fitting shoes, poor foot care, or overlooked foreign bodies, often coupled with a structural foot deformity. Increased plantar pressure, especially beneath the metatarsal heads, and the resultant callus play an important role. The patients often already have xerosis of the plantar skin with scales, fissures, erosions and impaired barrier function, complicating the situation. Prompt neurologic and vascular diagnostic studies, coupled with routine examination of the feet and primary prophylactic measures are most important. The most important therapeutic goals are optimal control of the diabetes mellitus, relieving pressure points and avoiding or reducing callus formation.

Osteosíntesis de fracturas del fémur distal con placas LISS / Distal femoral fractures; treatment with less invasive stabilitation system (L. I. S. S.)

Las fracturas del fémur distal son complejas en su tratamiento y asocian múltiples complicaciones evolutivas com pseudoartrosis, callos viciosos, gonartrosis o infección secundaria a cirugía abierta agresiva, por lo que han surgido las osteosíntesis mínimamente invasivas dentro de las cuales se sitúa la placa LISS. Analizamos los resultados tras 10 meses de seguimiento de 14 pacientes con fractura del fémur distal tratados con placa LISS. Los tiempos de consolidación no fueron muy divergentes respecto a series mayores, la incidencia de retrasos de consolidación y callos viciosos, baja. No hubo pseudoartrosis, fracasos del material, aflojamientos, infecciones, tromboembolismos ni algodistrofias. Por ello, consideramos que los resultados obtenidos con este implante son satisfactorios

The treatment of the distal femoral fractures is difficult in order to the surgery and múltiple complications, like pseudoartrosis,c allus vicious, gonartrosis or infection because open surgery. So that it has arised the minimun invasive system of osteosynthesis like LISS plate. We have assessed outcomes in 14 patients with distal femoral fractures treated with that implant. The mean follow up was 10 months. The times of consolidation was similar than other bigger series of patients and low incidence of delayed consolidation and callus vicious. There has not been any case of pseudoartrosis, failure of implant, loosenin, infections, tromboembolism or algodystrophia, so that considered that we has obtained good results

Debridement of plantar callosities in rheumatoid arthritis: a randomized controlled trial.

OBJECTIVE: To compare forefoot pain, pressure and function before and after normal and sham callus treatment in rheumatoid arthritis (RA). PATIENTS AND METHODS: Thirty-eight RA patients were randomly assigned to normal (NCT group) or sham (SCT) scalpel debridement. The sham procedure comprised blunt-edged scalpel paring of the callus which delivered a physical stimulus but left the hyperkeratotic tissue intact, the procedure being partially obscured from the patient. Forefoot pain was assessed using a 100 mm visual analogue scale (VAS), pressure using a high-resolution foot pressure scanner and function using the spatial-temporal gait parameters measured on an instrumented walkway. Radiographic scores of joint erosion were obtained for metatarsophalangeal (MTP) joints with and without overlying callosities. The trial consisted of a randomized sham-controlled phase evaluating the immediate same-day treatment effect and an unblinded 4-week follow-up phase. RESULTS: During the sham-controlled phase, forefoot pain improved in both groups by only 3 points on a VAS and no statistically significant between-group difference was found (P = 0.48). When data were pooled during the unblinded phase, the improvement in forefoot pain reached a peak after 2 days and gradually lessened over the next 28 days. Following debridement, peak pressures at the callus sites decreased in the NCT group and increased in the SCT group, but there was no statistically significant between-group difference (P = 0.16). The area of and duration of contact of the callus site on the ground remained unchanged following treatment in both groups. Following debridement, walking speed was increased, the stride-length was longer and the double-support time shorter in both groups; however, between-group differences did not reach levels of statistical significance. MTP joints with overlying callus were significantly more eroded than those without (P = 0.02). CONCLUSIONS: Treatment of painful plantar callosities in RA using scalpel debridement lessened forefoot pain but the effect was no greater than sham treatment. Localized pressure or gait function was not significantly improved following treatment.

High plantar pressure and callus in diabetic adolescents. Incidence and treatment.

This study examined the incidence of high peak plantar pressure and plantar callus in 211 adolescents with diabetes mellitus and 57 nondiabetic controls. The percentage of subjects with these anomalies was the same in both groups. Although diabetic subjects were no more likely than nondiabetic controls to have high peak plantar pressure and callus, these anomalies place individuals with diabetes at greater risk of future foot problems. The effects of orthoses, cushioning, and both in combination were monitored in 17 diabetic subjects with high peak plantar pressure and in 17 diabetic subjects with plantar callus; reductions of up to 63% were achieved. Twelve-month follow-up of diabetic subjects fitted with orthoses showed a significant reduction in peak plantar pressure even when the orthoses were removed. The diabetic subjects who had not received any interventions during the same 12-month period showed no significant change in peak plantar pressure.

Operative repair of fourth and fifth toe corns.

METHODS: We report a retrospective review of 57 consecutive patients (72 feet) over a period of 20 years who had been treated operatively for either a lateral fifth toe corn or an interdigital corn of the fourth interdigital space more than two years previously. Of these, 51 patients (62 feet) returned for a follow-up evaluation at a minimum of two years (average of over seven years) which included a review of the interval history since the surgery, a physical examination, a radiographic evaluation, and assessment of the patient's satisfaction with the alignment and results of surgery. Treatment of 31 lateral fifth toe corns involved either a lateral condylectomy and flexor tenotomy or a complete condylectomy. Treatment of 31 interdigital corns comprised either a single condylectomy, double condylectomy of adjacent corns, or a complete condylectomy (hammertoe repair) of a symptomatic corn. Treatment in each case was dependent upon the severity of the deformity. RESULTS: There was found to be no significant difference in comparison of the two major groups (interdigital corns and lateral fifth toe corns) with the measurement of the relative length of the fourth and fifth metatarsals, toe malalignment, angulation of the fourth and fifth toes (MTP-4, MTP-5 angles), and the phalangeal-5 angle. Pain was relieved in 58 of 62 feet (93%) and subjective acceptable alignment was achieved in 54 of 62 feet (87%). At final follow-up 53 feet were rated by patients as excellent, seven as good, one as fair, and one as poor. Complications included numbness of the involved digit (six feet). There were two superficial infections. There were two cases of joint instability due to excessive bone resection. Joint stiffness was commonly observed (34/62 feet, 55%), but was not associated with diminished satisfaction at final follow-up. Mild asymptomatic recurrence of a callosity was noted in 10 feet and moderate or severe recurrence was noted in two feet. Dissatisfaction was associated with moderate or severe recurrence. CONCLUSION: In this retrospective study at an average of more than seven years, we achieved a high level of patient satisfaction treating both lateral fifth toe corns and interdigital corns with a partial and/or complete condylectomy, the choice depending upon the magnitude of the deformity and the callus, and the fixed nature of the lesser toe deformity.

Outpatient care and morbidity reduction in diabetic foot ulcers associated with chronic pressure callus.

In a retrospective review of 233 cases of diabetic foot ulceration preceded by minor trauma, 192 ulcerations exhibited focal pressure keratosis as the preceding traumatic event. The frequency of outpatient visits and other foot care interventions were correlated with the occurrence and severity of ulceration. Patients seen more frequently in an outpatient foot clinic had less severe ulcers and were less likely to undergo surgical treatment than those with less frequent visits.

Surgical treatment for hallux valgus with painful plantar callosities.

We retrospectively reviewed the results of a distal soft-tissue procedure and proximal crescentic osteotomy of the first metatarsal combined with a proximal shortening osteotomy of the second and/or third metatarsal. This was in patients who had hallux valgus with painful plantar callosities. The review covered seven years of procedures (1989-1996) in 12 patients (14 feet) averaging 53 years of age. Average follow-up was 52 months. All patients had pain at the first metatarsophalangeal joint and had metatarsalgia preoperatively. At follow-up, 11 feet had no pain at the first metatarsophalangeal joint, and three had some improvement of pain. Ten feet had no metatarsalgia, two had improvement of metatarsalgia, and two feet had transfer lesions postoperatively and required reoperation. The angle of hallux valgus averaged 40 degrees preoperatively and 13 degrees postoperatively. The intermetatarsal angle averaged 18 degrees preoperatively and 6 degrees postoperatively. Mean decreases in length of the second and third metatarsal after surgery were 5.4 mm and 4.8 mm, respectively. Our results suggested that this combined procedure for hallux valgus with painful plantar callosities may be successful, in carefully selected patients.

Relationship between teat-end callosity and occurrence of clinical mastitis.

A longitudinal study in 15 herds, with a total of 2157 cows, was conducted to examine the relationship between teat-end callosity (TEC) and the incidence of clinical mastitis. During the 1.5-yr study period, clinical mastitis was diagnosed by the farmers based on clinical signs. Teat-end callosity was scored every month according to a teat-end callosity classification system, which discriminates between teat-end callosity thickness (TECT) and roughness (TECR). Differences in TECT between healthy and clinical mastitis quarters within infected cows were small but significant 3 mo before (0.13 higher), in the month during which the clinical mastitis occurred (0.08 higher), and in the following 2 mo (0.06 and 0.05 higher). To compare TECT and TECR between cows with and without clinical mastitis, 199 cows with clinical mastitis were paired with control cows based on herd, days in milk, and parity. Clinical mastitis cows had more TEC than their healthy herd mates, particularly when clinical mastitis occurred between the second and fifth months of lactation. Clinical Escherichia coli mastitis in the second or third month of lactation occurred in cows with less TEC than in cows with clinical mastitis caused by other pathogens. Clinical culture-negative, yeast, Klebsiella pneumoniae, and Enterobacter aerogenes mastitis cows had more TECT and TECR than other cows with clinical mastitis in the same month of lactation. Pointed teat ends had higher TECT and TECR than flat or inverted teat ends. Teat-end callosity thickness increased with a higher milk yield at peak production.