Management of acute lesser toe pain.

Patients with foot pain commonly present to their primary care physicians for their initial management and treatment. These patients and their respective foot or lesser toe pain can present the physician with a complex problem with a long differential list. Depending on the timing of the pain and underlying pathology, these differentials can be divided into acute and acute exacerbation of chronic conditions. This review categorizes the history, physical exam, radiological findings, conservative treatment, and surgical management for each major cause of lesser toe pain, whether acute or chronic. The acute conditions surrounding lesser toe pain in the adult population discussed are toe fractures, toe dislocations, and metatarsal head and neck fractures. The chronic pathologies surrounding lesser toe pain in the adult population evaluated in this review include metatarsalgia, Morton's neuroma, Freiberg infraction, brachymetatarsia, bunionettes, and lesser toe disorders.

High field magnetic resonance imaging contributes to diagnosis of equine distal tarsus and proximal metatarsus lesions: 103 horses.

Injury of the distal tarsus and proximal metatarsus commonly causes lameness. Magnetic resonance imaging (MRI) allows concurrent assessment of both the distal tarsal joints and suspensory ligament origin, and aids identification of lesions that may otherwise go undetected by other modalities. In this retrospective observational study, the medical records of a veterinary imaging center were searched for MRI exams of the distal tarsus and proximal metatarsus for the years 2012 through 2014. Studies for 125 limbs of 103 horses were identified and retrospectively evaluated by two board-certified veterinary radiologists. Soft tissue and osseous changes were characterized and graded by degree of severity. The patients' signalment, lameness severity, and results of diagnostic analgesia were recorded. Osteoarthritic changes of the distal intertarsal and tarsometatarsal joints were the most common findings. Other findings included bone marrow lesions, degenerative changes of the small cuboidal bones, subchondral cystic lesions, and intertarsal desmopathy. Suspensory ligament desmopathy was found in 53% of limbs. Fourty-seven percent of limbs that responded to analgesia of the proximal suspensory ligament had more severe lesions in the distal tarsus. Bone marrow lesions of the third tarsal bone were the only MRI finding that correlated with grade of lameness in patients for which lameness grade was reported. The grade of lameness has a poor correlation with the severity of lesions found on MRI. The findings support the use of MRI for simultaneous evaluation of the proximal metatarsus and distal tarsus, particularly given the difficulty of lesion localization with diagnostic analgesia.

Comparison of Pedal Soft Tissue Thickness Between Those With and Without Diabetes.

Ulceration is a serious consequence of diabetes that can lead to disability in patients with diabetes. One of the risk factors for ulceration is high foot pressure. The thickness of the pedal soft tissue is important because it has a cushioning effect. Soft tissue atrophy causes elevation in the plantar pressure, which, in turn, causes ischemia. Therefore, we investigated the severity of pedal soft tissue atrophy caused by diabetes and aging. From February 2009 to February 2016, we examined the feet of 261 patients treated in our hospital using magnetic resonance imaging. We divided the patients enrolled in the study into 2 groups. The first group included 52 patients with diabetes but without peripheral arterial disease and the second group included 47 patients without diabetes. We measured the vertical distances under all patients' metatarsal heads using T1-weighted magnetic resonance imaging and measured the pedal soft tissue thickness using the PACS workstation (m-view). We compared the soft tissue thicknesses of the 2 groups and performed statistical analyses of the relationships between these data and other parameters using 2-way analysis of variance. The soft tissue under the first to fourth metatarsal heads was thinner in the diabetic patients than in the nondiabetic patients (first metatarsal, 6.4 versus 8.69; second metatarsal, 8.85 versus 10.64; third metatarsal, 8.15 versus 9.21; fourth metatarsal, 7.38 versus 8.54; p < .05). Aging had no effect on pedal soft tissue atrophy in either group. In conclusion, our study confirmed that diabetic patients experience more severe plantar soft tissue atrophy than nondiabetic patients. We have developed a standard procedure to enable the prediction of pedal soft tissue atrophy severity in diabetic patients.

Fully automated determination of arch angle on weight-bearing foot radiograph.

BACKGROUND AND OBJECTIVE: Flatfeet can be evaluated by measuring the calcaneal-fifth metatarsal angle on a weight-bearing lateral foot radiograph. This study aimed to develop an automated method for determining the calcaneal-fifth metatarsal angle on weight-bearing lateral foot radiograph. METHOD: The proposed method comprises four processing steps: (1) identification of the regions including the calcaneus and fifth metatarsal bones in a foot image; (2) delineation of the contours of the calcaneus and the fifth metatarsal; (3) determination of the tangential lines of the two bones from the contours; and (4) determination of the calcaneal-fifth metatarsal angle between the two tangential lines as arch angle. RESULTS: The proposed method was evaluated using 300 weight-bearing lateral foot radiographs. The arch angles determined by the proposed method were compared with those measured by a radiologist, and the errors between the automatically and manually determined angles were used to evaluate the precision of the method. The average error in the proposed method was found to be 1.12°â€¯±â€¯1.57° In the study, in 73.33% of the cases, the arch angles could be determined automatically without redrawing any tangential lines; in 23.00% of the cases, the angles would be correctly determined by redrawing one of the tangential lines; further, in only 3.67% of the cases, both the calcaneal and fifth metatarsal tangential lines needed to be redrawn to determine the arch angles. CONCLUSION: The results revealed that the proposed method has potential for assisting doctors in measuring the arch angles on weight-bearing lateral foot radiographs more efficiently.

[Amputation of the forefoot in a 14-year-old boy due to infiltrative glomus tumour].

Glomus tumours are rare dermal tumours, which very seldom can be seen viscerally. The majority is benign small tumours of the skin. Malignancy has been reported in very few cases worldwide. The diagnosis is made clinically supported by MRI-scans and biopsy of the lesion. We present a case story of a 14-year-old boy, who had an infiltrative glomus tumour of the foot. The tumour met the criteria for malignancy and was operated radically by amputation of the forefoot. The post-operative period was uncomplicated and no metastases were observed neither clinically nor by PET-CT scans.

[Skin pigmentation induced by meropenem and levofloxacin]. / Hyperpigmentation cutanée induite par le méropénème et la lévofloxacine.

BACKGROUND: Various cutaneous side-effects, including, exanthema, pruritus, urticaria and Lyell or Stevens-Johnson syndrome, have been reported with meropenem (carbapenem), a rarely-prescribed antibiotic. Levofloxacin (fluoroquinolone), a more frequently prescribed antibiotic, has similar cutaneous side-effects, as well as photosensitivity. We report a case of cutaneous hyperpigmentation induced by meropenem and levofloxacin. PATIENTS AND METHODS: A 67-year-old male was treated with meropenem (1g×4 daily), levofloxacin (500mg twice daily) and amikacin (500mg daily) for 2 weeks, followed by meropenem, levofloxacin and rifampicin (600mg twice daily) for 4 weeks for osteitis of the fifth metatarsal. Three weeks after initiation of antibiotic therapy, dark hyperpigmentation appeared on the lower limbs, predominantly on the anterior aspects of the legs. Histology revealed dark, perivascular and interstitial deposits throughout the dermis, which stained with both Fontana-Masson and Perls stains. Infrared microspectroscopy revealed meropenem in the dermis of involved skin. After withdrawal of the antibiotics, the pigmentation subsided slowly. DISCUSSION: Similar cases of cutaneous hyperpigmentation have been reported after use of minocycline. In these cases, histological examination also showed iron and/or melanin deposits within the dermis, but the nature of the causative pigment remains unclear. In our case, infrared spectroscopy enabled us to identify meropenem in the dermis. Two cases of cutaneous hyperpigmentation have been reported following use of levofloxacin, and the results of histological examination were similar. This is the first case of cutaneous hyperpigmentation induced by meropenem.

Osteoclasis for the Treatment of Recalcitrant Diabetic Forefoot Ulceration: A Case Study.

Recurrence after diabetic foot ulceration is a common occurrence after healing. Curative surgery has been suggested to reduce the incidence of recurrent ulcerations. Osteoclasis is a simple procedure used to fracture the metatarsal head in attempt to reduce pressure under the affected metatarsal without transferring excessive pressure to adjacent metatarsals. We present a case study of a 65-year-old diabetic male with multiple attempts to heal and maintain a healed ulceration who underwent an osteoclasis procedure. Following this patient for 3 years (until time of death), no recurrent or new ulcerations had occurred. Further studies should be conducted to identify if this result is reproducible prior to widespread use.

The role of fasciae in Civinini-Morton's syndrome.

This study evaluates the pathogenetic role of the perineural connective tissue and foot fasciae in Civinini-Morton's neuroma. Eleven feet (seven male, four female; mean age: 70.9 years) were dissected to analyse the anatomy of inter-metatarsal space, particularly the dorsal and plantar fasciae and metatarsal transverse ligament (DMTL). The macrosections were prepared for microscopic analysis. Ten Civinini-Morton neuromas obtained from surgery were also analysed. Magnetic resonance images (MRIs) from 40 patients and 29 controls were compared. Dissections showed that the width of the inter-metatarsal space is established by two fibrous structures: the dorsal foot fascia and the DMTL, which, together, connect the metatarsal bones and resist their splaying. Interosseous muscles spread out into the dorsal fascia of the foot, defining its basal tension. The common digital plantar nerve (CDPN) is encased in concentric layers of fibrous and loose connective tissue, continuous with the vascular sheath and deep foot fascia. Outside this sheath, fibroelastic septa, from DMTL to plantar fascia, and little fat lobules are present, further protecting the nerve against compressive stress. The MRI study revealed high inter-individual variability in the forefoot structures, although only the thickness of the dorsal fascia represented a statistically significant difference between cases and controls. It was hypothesized that alterations in foot support and altered biomechanics act on the interosseous muscles, increasing the stiffness of the dorsal fascia, particularly at the points where these muscles are inserted. Chronic rigidity of this fascia increases the stiffness of the inter-metatarsal space, leading to entrapment of the CDPN.

Focal metatarsal fistulae syndrome affecting a greyhound dog successfully treated with topical 0.1% tacrolimus ointment.

Metatarsal fistulation is an uncommon cutaneous condition reported almost exclusively in German shepherd dogs and their cross-breeds. To the best of the authors' knowledge this is the first reported case of focal metatarsal fistulae syndrome affecting a greyhound. Remission was obtained within 6 weeks of commencing treatment using compounded 0.1% tacrolimus ointment twice daily and the dog remained stable for another 6 months with twice weekly application before treatment was discontinued. The dog remained in remission at the time of writing, which is 1 year after treatment withdrawal.

Gorham-Stout's disease in the metatarsus: a case report.

Gorham-Stout disease (GSD) is a rare disease occurring in the bone tissue and is characterized by spontaneous, progressive resorption. The etiology and treatment of the disease remains unclear. This article presents a 53-year-old male patient diagnosed with GSD in the 3rd and 4th metatarsal of his right foot.

Is anaesthesia of the deep branch of the lateral plantar nerve specific for the diagnosis of proximal metatarsal pain in the horse?

OBJECTIVES: To investigate the specificity of anaesthesia of the deep branch of the lateral plantar nerve (DB-LPN). METHODS: Twenty horses had DB-LPN anaesthesia performed by a single injection technique as part of a lameness investigation. The mechanical nociceptive threshold (NT) was measured using a handheld force meter at six points on the lateral aspect of the limb: before diagnostic anaesthesia (T0), and at 15 (T15) and 30 (T30) minutes post anaesthesia. Paired t-tests were performed and significance was set at p <0.05. In addition, ten cadaveric limbs were injected with 2.5 ml new methylene blue solution using a single injection technique to evaluate the extent of dye diffusion within the proximal metatarsal region. RESULTS: Compared with T0, there was a significant decrease in NT for all points combined at T15 (p = 0.008) and also at T30 (p = 0.007). There was a significant decrease in NT at T15 on the lateral third metatarsal bone (p = 0.012). At T30 there was a significant decrease in NT at the lateral sesamoid (p = 0.007), lateral third metatarsal bone (p = 0.031), and mid metatarsus (p = 0.033). Four out of 20 horses had a NT greater than 10 N at the lateral heel bulb at T30. In the cadaveric limbs, the total diffusion distance for all limbs (mean ± SD) was 70.4 ± 20.5 mm. Dye surrounded the DB-LPN in all limbs and the lateral plantar nerve (LPN) in nine out of 10 limbs. CLINICAL SIGNIFICANCE: Concurrent anaesthesia of the LPN is likely to occur when DB-LPN anaesthesia is performed using a single injection technique.

Cytologic findings from a benign giant cell tumor of the tendon sheath in a dog.

A 6-year-old male neutered Australian Shepherd dog was presented for evaluation of a subcutaneous mass on the plantar aspect of the proximal left metatarsus. Fine-needle aspirate smears contained numerous plump spindle cells and large multinucleated cells amongst a considerable amount of pink extracellular matrix. Histopathologic diagnosis of the tissue obtained during initial biopsy and eventual surgical cytoreduction of the mass was a benign giant cell tumor of the tendon sheath (GCTTS). Immunohistochemically, the synovioblastic neoplastic cells were diffusely strongly positive for vimentin and S-100, were multifocally moderately positive for cytokeratin AE1/3, and were negative for CD18, muscle-specific actin (MSA), and melanoma-associated antigen (mutated) 1 (MUM-1). The dog recovered from surgery and underwent definitive radiation therapy to treat the local residual disease. Eight months later, the mass had not recurred. The diagnosis of GCTTS in this case supports previously published reports describing GCTTS as a relevant disease entity in dogs, and provides the first documentation of cytologic findings with this tumor. Further investigation is needed to correlate pathologic features with clinical behavior and response to therapy in dogs.

Clear Cell Sarcoma Of Metatarsus.

We report a case of clear cell sarcoma in the third metatarsus of the right foot. This type of tumor is very rare and scantily reported in literature. A 42-year-old Caucasian male presented with a nodular ulcerated mass on the dorsal side of the left foot. X-rays demonstrated a nodular solid lesion which dislodged the third metatarsus. A biopsy revealed a neoplastic proliferation with a sarcoma clear cell profile; because of the aggressive nature of this type of neoplasm, we performed a trans-tibial amputation according to Bugess to achieve a better functionality for the patient. The present study underlines clinical, morphological, as well as imaging and therapeutic aspects of a rare neoplasm such as clear cell sarcoma. The location site is also quite unusual - the metatarsus of the foot. The histological and immunohistochemical data were suggestive of the diagnosis of clear cell sarcoma of metatarsus. After MRI and a bone scan, the surgical treatment suggested the extension over the forefoot and the ankle and therefore a trans-tibial amputation was made.

Correlation between broiler lameness and anatomical measurements of bone using radiographical projections with assessments of consistency across and within radiographs.

Lameness represents a major welfare and production issue in the poultry industry with a recent survey estimating 27% of birds lame and 3% unable to walk by 40 d of age. A variety of factors may induce lameness and are typically grouped into 2 broad classes on the basis of being infectious or skeletal in nature with the latter accounting for the majority of cases. The current work sought to build upon a large body of literature assessing the anatomical properties of bone in lame birds. Our specific objectives sought to identify relationships between relevant anatomical properties of the tibia and metatarsus using digital quantification from radiographs of legs and a measure of walking difficulty. Resulting output was statistically analyzed to assess 1) observer reliability for consistency in placing the leg during the radiograph procedure and quantification of the various measures within a radiograph, 2) the relationship between the various measurements of anatomical bone properties and sex, bird mass, and gait score, and 3) the relationship between each measurement and leg symmetry. Our anatomical bone measures were found to be reliable (intra-rater and test-retest reliabilities < 0.75) within radiograph for all measures and 8 of the 10 measures across radiographs. Several measures of bone properties in the tibia correlated to difficulty walking as measured by gait score (P < 0.05), indicating greater angulations with increasing lameness. Of the measures that manifested a gait score × bird mass interaction, heavier birds appeared to exhibit less angulation with increasing difficulty walking with lighter birds the opposite. These interactions suggest possibilities for influencing effects of activity or feed intake on bone mineralization with the bone angulation observed. Our efforts agree with that of others and indicate that angulation of the tibia may be related to lameness, though subsequent efforts involving comprehensive measures of bird activity, growth rates, and internal bone structure will be needed if the validity of the measures are to be accepted.

Second metatarsophalangeal joint pathology and freiberg disease.

Pain in the second metatarsophalangeal joint (MTPJ) is a complaint frequently encountered by foot and ankle specialists. The pathology associated with this joint is often painful and debilitating for the patient. In the past, typical treatment protocols for second MTPJ pathology were aimed at relief of patient symptoms. Conservative treatment and offloading devices have historically dominated treatment options for the clinician. However, recent surgical techniques and procedures have been developed to correct the mechanical and structural defects that can affect this joint. The aim of this review was to outline recent developments and treatment options for common second MTPJ pathologies.

Impact of Charcot neuroarthropathy on metatarsal bone mineral density and geometric strength indices.

Charcot neuroarthropathy (CN), an inflammatory condition characterized by rapid and progressive destruction of pedal bones and joints, often leads to deformity and ulceration in individuals with diabetes mellitus (DM) and peripheral neuropathy (PN). Repetitive, unperceived joint trauma may trigger initial CN damage, causing a proinflammatory cascade that can result in osteolysis and contribute to subsequent neuropathic fracture. We aimed to characterize osteolytic changes related to development and progression of CN by measuring bone mineral density (BMD) and geometric strength indices using volumetric quantitative computed tomography. Twenty individuals with DM+PN were compared to twenty age-, sex-, and race-matched individuals with DM+PN and acute CN. We hypothesized that individuals with acute CN would have decreased BMD and decreased total area, cortical area, minimum section modulus, and cortical thickness in the diaphysis of the second and fifth metatarsals. Results showed BMD was lower in both involved and uninvolved feet of CN participants compared to DM+PN participants, with greater reductions in involved CN feet compared to uninvolved CN feet. There was a non-significant increase in total area and cortical area in the CN metatarsals, which helps explain the finding of similar minimum section modulus in DM+PN and CN subjects despite the CN group's significantly lower BMD. Larger cortical area and section modulus are typically considered signs of greater bone strength due to higher resistance to compressive and bending loads, respectively. In CN metatarsals, however, these findings may reflect periosteal woven bone apposition, i.e., a hypertrophic response to injury rather than increased fracture resistance. Future research using these techniques will aid further understanding of the inflammation-mediated bony changes associated with development and progression of CN and other diseases.

Modified Weil osteotomy for the treatment of Freiberg's disease.

BACKGROUND: Numerous metatarsal osteotomies have been developed for the treatment of Freiberg's disease. The purpose of this study was to evaluate the clinical outcomes of modified Weil osteotomy in the treatment of Freiberg's disease. METHODS: From November 2001 to July 2008, nineteen patients (twenty feet), treated surgically for Freiberg's disease, were included in this study. The average age of the patients was 33.6 years (range, 17 to 62 years), the mean follow-up period was 71.6 months (range, 41 to 121 months). Clinical outcomes were evaluated according to visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the patients' subjective satisfaction and range of motion (ROM) of metatarsophalangeal (MTP) joint. In the radiologic evaluation, initial metatarsal shortening by Freiberg's disease compared to opposite site, metatarsal shortening after modified Weil osteotomy compared with preoperative radiography and term for radiologic union were observed. RESULTS: VAS showed improvement from 6.2 ± 1.4 to 1.4 ± 1.5 at last follow-up (p < 0.0001). Points of AOFAS score increased from 63.3 ± 14.9 to 80.4 ± 5.6 (p < 0.0001). ROM of MTP joints also improved from 31.3 ± 10.1 to 48.3 ± 13.0 degrees at last follow-up (p < 0.0001). According to Smillie's classification system, there was no significant improvement of VAS, AOFAS score and ROM between early stages (stage I, II, and III) and late stages (stage IV and V). Out of twenty cases, nineteen (95%) were satisfied, reporting excellent or good results. CONCLUSIONS: Modified Weil osteotomy is believed to be a useful method for the treatment of Freiberg's disease, not only in the early stages but also in the late stages. It relieves pain and improves function via shortening of metatarsals and restoration of MTP joint congruency.

Tratamiento del Hallux Rigidus. A propósito de un caso / Treatment of Hallux rigidus. A propos of a case

En este artículo se describió la definición, la anatomía, la etiología, la clínica, el diagnóstico y las estrategias terapéuticas utilizadas en la actualidad, ya sean conservadoras o quirúrgicas, del Hallux Rígidus. En él se presentó la resolución de un caso clínico atendido en nuestra consulta donde la paciente presentaba dolor unilateral en el recorrido del Músculo Tibial Posterior de un año de evolución y ausencia total de la movilidad de la primera articulación metatarso-falángica del pie izquierdo. Se le diagnosticó de Hiperpronación de Retropié Bilateral y de Hallux Rígidus secundario del pie izquierdo. El objetivo principal fue reducir la sintomatología que presentaba la paciente, a su vez, conseguir disminuir la hiperpronación del retropié y favorecer una mayor funcionalidad en el primer segmento dígito-metatarsal(AU)

This article describes the definition, anatomy,etymology, clinical, diagnostic and the therapeutic strategies currently used, both chirurgic and palliative, for Hallux Rigidus. The methodology used to describe all of the above terms was the resolution of a real clinical case at the University of Barcelona Podiatrist Hospital during my last year of studies forthe degree of Podiatry at the same University. The patient who agreed to be part of the study suffered from unilateral pain in posterior tibial muscle and total lack of mobility of the first articulation metatarsal-phalanges of the left foot. The symptoms appeared a year before this study was conducted. The diagnosis of the patient was bilateralr-pronation of the bilateral and with secondary Hallux Rigidus in the left foot. The main objective of the study was to reduce the symptoms suffered by the patient; the secondary objective was to find an appropriate treatment that would reduce the patient’s overpronation to gain some functionality of the first segment(AU)

Freiberg's disease: quantitative assessment of osteonecrosis on three-dimensional CT.

BACKGROUND: The extent of necrosis is the main determining factor in the outcome of osteonecrosis. There is no method for measuring the extent of osteonecrosis of the metatarsal head in Freiberg's disease. The purpose of this study was to determine the reliability and prognostic ability of a new method for measurement of the extent of osteonecrosis in Freiberg's disease on three-dimensional computed tomography. METHODS: A retrospective review of 11 cases with symptomatic Freiberg's disease in ten patients (5 males and 5 females; mean age, 27 years) undergoing computed tomography between July 2005 and September 2007 was performed. Two investigators (K.A.C. and H.K.O.) used a new method to measure the necrotic extent of the metatarsal head: the necrotic angle ratio of necrotic arc angle to normal arc angle of the articular surface on the sagittal reconstruction image of computed tomography. The interobserver reliability was determined for computed tomography measurement. Correlation between the Smillie staging using radiographs and the necrotic angle ratio on computed tomography was also evaluated. RESULTS: One patient presented with stage I disease (Smillie staging), one with stage II, two with stage III, five with stage IV, and two with stage V, respectively. The necrotic angle ratio of the metatarsal head was 14% in stage I, 21% in stage II, 34% in stage III, 43% in stage IV, and 53% in stage V. The interobserver reliability for computed tomography measurement was high (Cronbach α=0.96). We found the increase of the necrotic extent in proportion to the Smillie stage. The Smillie staging using radiographs and the necrotic angle ratio on computed tomography were significantly correlated. (P<0.05) CONCLUSIONS: Three-dimensional computed tomography measurement of the necrotic extent of the metatarsal head is a reliable and useful method in evaluating the staging of Freiberg's disease and may eventually help to optimize treatment.