Anatomic Limitations of the Transmetatarsal Amputation With Consideration of the Deep Plantar Perforating Branch of the Dorsalis Pedis Artery.

The transmetatarsal amputation is considered a durable procedure with respect to limb salvage when managing the consequences of diabetic foot disease. The success of the procedure is, in part, determined by the preoperative appreciation of arterial and functional status. The objectives of the present investigation were to determine the length of the remaining first metatarsal required during transmetatarsal amputation to preserve the anastomotic connection of the deep plantar perforating artery and subsequent "vascular arch" of the foot and the insertion of the tibialis anterior tendon. The primary outcome measure of our investigation was a measurement of the distance between the first metatarsal-medial cuneiform articulation and the distal extent of the deep plantar perforating artery in 85 embalmed lower limbs. As a secondary outcome measure, the insertion of the tibialis anterior tendon was evaluated relative to the deep plantar perforating artery. The most distal extent of the deep plantar perforating artery was observed at a mean ± standard deviation of 15.62 ± 3.74 (range 6.0 to 28.28) mm from the first metatarsal-medial cuneiform articulation. Most (89.41%) of the arteries were found within 20 mm of the first metatarsal-medial cuneiform articulation. The insertion of the tibialis anterior tendon was found to be proximal to the deep plantar perforating artery in all specimens (100.0%). In conclusion, 2.0 cm of remnant first metatarsal might represent an anatomic definition of how "short" a transmetatarsal amputation can safely be performed in most patients when considering the vascular and biomechanical anatomy.

Anatomic basis and clinical application of the distally based medialis pedis flaps.

BACKGROUND: Soft-tissue defects of the forefoot are difficult to cover adequately, particularly, although multiple options for reconstruction are available. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels to medialis pedis flap viability. METHODS: Thirty cadavers were available for this anatomical study. Microdissection was conducted under a microscope, and details of the course and distribution and the communication of the first plantar metatarsal artery with the fascial vascular network of the medial side of the foot were recorded. Clinically, six cases of soft-tissue defects at the forefoot region were reconstructed with distally based medialis pedis flap. RESULTS: The perforator of the first plantar metatarsal artery pierces in the superficial fascia of the medial aspect of the foot 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, vascularize the skin of the medial plantar region. The anatomical study showed that the vasculature pattern could roughly be classified into two types. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft. CONCLUSION: The perforators of the medialis pedis flap are presented constant. The forefoot region can be repaired by the distally based medialis pedis flap on the perforator of the medial plantar artery of the hallux or the first plantar metatarsal artery perforator with medial plantar vein, medial plantar cutaneous nerve and nutrient vessels.

[Minor amputations - a maxi task. Part 1: From the principles to transmetatarsal amputation]. / Minor-Amputationen - eine "Maxi-Aufgabe". Teil 1: Von den Grundlagen bis zur transmetatarsalen Amputation.

A threatening major amputation represents a fateful turning point for diabetics. This occurs in 50% of cases of amputations in diabetics. This increases the demand for another therapeutic route not only because of the limitations in quality of life but also due to substantially higher mortality. Even if an osteomyelitic ischemic situation is often present specialized centers have succeeded in substantially reducing the rate of major amputations in such patients. The term "minor amputation" commonly used in vascular surgery is not uniformly understood. Following the "vascular surgery working model" developed by Rümenapf, the significance of "minor amputations" for retention of extremities and the associated controversies have been shown. "Minor amputations" therefore represent a maxi-task if patients undergoing such a procedure are to be timely and competently treated. The necessary interdisciplinary cooperation with other specialists should in the future also include orthopedic surgeons.

In vitro evaluation of a single injection technique for diagnostic analgesia of the proximal suspensory ligament of the equine pelvic limb.

OBJECTIVE: To examine the anatomic relationship of the deep branch of the lateral plantar nerve (DBLPN) with structures of the proximal metatarsal region, and to define the anatomic location of a solution injected using a single injection technique for diagnostic analgesia of the proximal suspensory ligament (PSL). STUDY DESIGN: Descriptive study. ANIMALS: Cadaveric equine pelvic limbs (n=29). METHODS: The proximal metatarsal region of both pelvic limbs (n=5 horses, 10 limbs) was dissected and measurements were made of anatomic structures relative to the head of the 4th metatarsal bone (HMT4). A single injection technique was used to inject dye 15 mm distal to the HMT4, axial to the MT4 at a depth of 25 mm in each limb from 10 equine cadavers (19 limbs). Hindlimbs were dissected and the position of the dye was recorded. RESULTS: DBLPN branched from the lateral plantar nerve (LPN) at a mean distance of 30 mm proximal to the HMT4 and entered the PSL at a mean distance of 17 mm distal to the HMT4. A 2nd DBLPN was observed in 1 of 10 dissected limbs. Blue dye surrounded the DBLPN in 18 limbs (95%). CONCLUSIONS: A single injection technique was likely to have resulted in desensitization of the DBLPN in 18 of 19 limbs (95%). CLINICAL RELEVANCE: This technique provides a reliable method using a single needle puncture for perineural analgesia of the DBLPN for diagnosis of proximal suspensory desmitis of the pelvic limb with a minimal risk of inadvertently desensitizing structures within the tarsal sheath and the tarsometatarsal joint.

[Morton disease].

The author presents a review of 17 Russian and foreign sourses dedicated to Morton's disease and describes a clinical case.

Anatomical study of the communicating branches between the medial and lateral plantar nerves.

The plantar areas of the foot have specific biomechanical characteristics and play a distinct role in balance and standing. For the forefoot surgeon, knowledge of the variations in the anatomy of communicating branches is important for plantar reconstruction, local injection therapy and an excision of interdigital neuroma. The anatomy of the communicating branches of the plantar nerves between the fourth and third common plantar digital nerves in the foot were studied in 50 adult men cadaveric feet. A communicating branch was present between the third and fourth intermetatarsal spaces nerves in all eight left feet and in six right feet (overall, 28%), and absent in 36 (72%). A communicating branch was found in 14 ft. Ten of the 14 communications were from the lateral to the medial plantar nerve. The length of the communicating branch ranged from 8 to 56 mm (average 16.4 mm) and its diameter was 0.2-0.6 times of the fourth common plantar digital nerve. The angle of the communicating branch with the common plantar digital nerve from which it originated was less than 30 degrees in 11 ft, 30-59 degrees in 27 ft, 60-80 degrees in 8 ft, and more than 80 degrees in 4 ft. Classification of the branch is based on the branching pattern of the communicating branch and explains variations in plantar sensory innervations. We think that the perpendicular coursing communicating branch is at higher risk to be severed during surgery.

[Surgical treatment of Morton's neuroma]. / Operativ behandling av Mortons nevrom.

BACKGROUND: We have resected the nerve when surgery is indicated for Morton's neuroma and wanted to compare our results with results reported after decompression. MATERIAL AND METHODS: 33 patients with 37 operated feet filled in a questionnaire 17 (8-27) months after surgery. They were asked to indicate their pain on a visual analogue scale (VAS: 0 = no pain, 100 = worst imaginable pain). RESULTS: Patients' mean age was 44 (17-76) at the time of operation. The average VAS score for pain was 81 (35-100) before operation and 7 (0-52) at review. 28 said the pain had disappeared (VAS 0). CONCLUSION: Three quarters of our patients had no pain at review. This is comparable to reported results after decompression.

Adjacent interdigital nerve irritation: single incision surgical treatment.

Twenty-three patients with clinical signs of adjacent intermetatarsal nerve irritation who underwent adjacent nerve release with single-nerve excision through one incision were studied. Mean follow-up was 11 months. Of 21 patients interviewed, 19 (90%) had resolution of all or most of their pain, 20 (95%) had no or only minimal activity limitation, and 20 (95%) were completely satisfied with their outcome. Of 19 patients examined, none had pain with compression of the interspace of the excised nerve, although two (11%) had discomfort with compression of the interspace of the nerve that was only released. Protective sensation was present postoperatively in all patients except one who had preoperative neuropathy.

Extensor digitorum brevis muscle flap: new refinements.

Two original operative techniques of raising the extensor digitorum brevis muscle flap are presented. These methods allow for covering distal foot defects that are difficult to cover by other reconstructive means. In the first technique, the flap is based on an extended distal pedicle supplied by the dorsal interosseous artery of the first intermetatarsal space. In the second technique, the flap receives its vascular supply from the medial tarsal artery; this procedure may be valuable when the vascular supply of the dorsalis pedis pedicle has been disrupted. To confirm the availability of these vascular pedicles, cadaver dissections were performed and proved that the extended pedicle dissection enhances the rotation arc of the flap. Four selective clinical cases, in which the flap was successfully used, are discussed. Advantages of these techniques, in reconstructing large defects in the distal foot, are delineated.

Postoperative analgesia after peripheral nerve block for podiatric surgery: clinical efficacy and chemical stability of lidocaine alone versus lidocaine plus clonidine.

Postoperative analgesia may be prolonged by the addition of clonidine to local anesthetic solutions used for regional anesthesia. The purpose of this study was to test this hypothesis in a clinical trial of patients undergoing podiatric surgery. The study design was prospective, double-blinded, and randomized. Ninety ASA physical status I or II patients scheduled for bunionectomy or hammer toe repair were randomized to receive ankle or metatarsal blocks with plain 1.73% lidocaine (Group L), 1.73% lidocaine with 10 micrograms/mL of clonidine added (Group C10), or 1.73% lidocaine with 20 micrograms/mL clonidine (Group C20). Time from the performance of the block to 1) loss of sensation to pinprick, 2) return of sensation to pinprick, 3) onset of postsurgical pain, and 4) time of first oral pain medication intake were recorded. Beginning at 1 h after the completion of the block, visual analog scale (VAS) and verbal pain scores were recorded every 30 min. Additional postoperative oral pain medication required in the first 9 h after the block was also recorded. Analysis of variance (ANOVA) was used to analyze intergroup differences in the VAS and verbal pain scores, the time to first reported pain, the time to first oral pain medication, and the total amount of oral pain medications required. Repeated-measures ANOVA was used to analyze the VAS and verbal pain scores overall and integrated assessment of pain scores and rescue medication was per-formed. Adverse events were also recorded for each group. There were no differences among the three groups with regard to overall VAS pain scores although Group C10 had significantly better verbal pain scores after the first 3 h (P < 0.05). There was also no difference in time to loss or return of pinprick sensation. Group C10 had a longer time to first reported pain (P < 0.01), a longer time to first oral pain medication (P < 0.01), a lower average total dose of oral pain medication required (P < 0.05), and a lower integrated assessment of pain and medication (P < 0.01) than Group L. More patients in Group C10 reported no pain postoperatively (P < 0.01) and no pain medication taken (P < 0.01) than Group L. Group C20 results suggested no statistically significant improvement over plain lidocaine. One patient in Group C20 experienced significant hypotension postoperatively. pH determinations and chemical analysis by capillary electrophoresis showed no significant change in composition of the solutions when clonidine was mixed with lidocaine and stored at 4 degrees C for 1 wk. Compared to 1.73% lidocaine, combining clonidine (10 micrograms/mL) with lidocaine for local anesthetic block for foot surgery significantly increases the duration and quality of postoperative analgesia.

[Osteotomy of the smaller metatarsals]. / Die Osteotomie der kleinen Metatarsalia.

A simple, oblique osteotomy at the distal third of the metatarsal shaft is described. It is a method of relieving the pain of prolapsed metatarsal heads incarcerated in the sole and often adherent to plantar skin. The procedure has a high success rate and has stood the test of time (over a quarter of a century).

[Pathologic study of Morton's neuroma]. / Etude pathologique du névrôme de Morton.

The clinical syndrome of Morton's neuroma [correction of nephroma] was described over a century ago, but its etiopathology remains unknown. Recent studies suggest that it may be induced by compression neuropathy. Histologic changes in digital nerves resected for therapeutic purposes were compared with histologic findings of digital nerves sampled at autopsy of asymptomatic subjects. Results show that approximately one-third of resected "diseased" digital nerves were histologically normal. The authors question the therapeutic approach, which consists of resecting the nerves.

First metatarsal-cuneiform dorsal exostosis: its anatomical relation with the medial dorsal cutaneous nerve.

The results of the cadaver dissection show the importance of identifying the proper digital nerve at the time of surgery. In all 20 cadaver dissections, the nerve crossed the first cuneometatarsal joint. Identification of this nerve, along with meticulous dissection may help prevent the formation of postoperative neuroma.

[True neurolysis in the treatment of Morton's neuroma]. / La neurolyse vraie dans le traitement du névrome de Morton.

The authors consider Morton's neuroma as a tunnel syndrome, the most likely etiology being the compression of the nerve by the intermetatarsal ligament. Therefore, they have treated Morton's disease by decompression of the intermetatarsal nerve via a dorsal approach. They operated 45 patients, 82% of whom were women. In 85% of the cases, a large neuroma was found and they did not find the theoretical predominance of the 3rd intermetatarsal space; 9 times in 10, the treatment consisted in epineural dissection of the nerve and its collaterals at the bifurcation. In 84% out of the cases, the result was satisfactory; associated pathology was treated at the same time. The authors discuss the results and emphasize that, in case of failure, a simple neurectomy may be used.

[Could biomechanical factors affect the etiology of Morton's neuralgia?]. / Des facteurs biomécaniques peuvent-ils influencer la genèse de la névralgie de Morton?

In the literature mechanical factors are considered as the most frequent etiology of Morton's disease. The pathology is a classical progressive fibrosis with rupture of nerve "fascicules" and/of arterioli, without nerve proliferation and without specific inflammatory factors. The deep intermetatarsal ligament and the bursae between the metatarsal heads are probably the most important factors in nerve irritation. In the literature there are few precise descriptions of the mechanism of irritation of the nerve, either by the bursae between the metatarsal heads, by the deep intermetatarsal ligament, or by the tendons of the lumbrical muscles which are close to the nerve. The aim of this study is an analysis of the mobility of these structures in both planes, by radiological evaluation in the erect position, after implantation of radiopaque pellets. The authors also present an hypothesis on the mechanism of the lesion.

Longitudinal bone growth after sciatic denervation in rats.

The right sciatic nerve of 50 one-month-old male rats was cut under general anaesthesia. Groups of animals were sacrificed at intervals of up to 12 weeks after operation and the length of the femora, tibiae and first and fifth metatarsals were measured with a caliper accurate to 0.05 mm. From the first week, both metatarsals were between 3% and 5% shorter on the denervated side, but there was no further increase of the discrepancy. The femora were less than 1% longer in the denervated limb at the second and eighth week. No difference was found between the lengths of the tibiae. The various factors which could possibly be responsible for these findings are discussed.

Morton's metatarsalgia. Clinical, electrophysiological and histological observations.

In an attempt to improve the accuracy of diagnosis, 16 patients suffering from Morton's metatarsalgia were investigated clinically and electrophysiologically. The histological findings were related to these observations. The precise aetiology of Morton's metatarsalgia remains obscure, but the findings are compatible with an entrapment syndrome. Nerve conduction studies have a place in the investigation of patients with atypical presentation of pain in the foot. Further refinement of the electrophysiological technique should be possible.

Sensory conduction velocity of plantar digital nerves in Morton's metatarsalgia.

The orthodromic sensory conduction velocity of the plantar interdigital nerves were measured with needle electrodes in 28 healthy subjects. The stimulating needle electrodes were placed close to the shaft of the proximal phalanx of the toe, and the recording needle electrode was placed behind the medial malleolus. We examined six subjects with clinical symptoms of entrapment of the common plantar digital nerve (Morton's metatarsalgia). Five of the subjects later had surgery. The conduction velocities of the affected interdigital nerves were abnormally slow. The method is technically simple, but more painful than conventional conduction studies.

Post-traumatic reflex sympathetic dystrophy.

This report presents a brief review and an illustrative case summary of post-traumatic reflex sympathetic dystrophy. The manuscript is concerned with reviewing updated methods of properly diagnosing and treating such a complex condition. The case presented involves a young, healthy male patient, who after undergoing foot surgery, developed signs and symptoms of post-traumatic reflex sympathetic dystrophy.