Selective atrophy of the abductor digiti quinti: an MRI study.

OBJECTIVE: Entrapment of the first branch of the lateral plantar nerve is a well-recognized but diagnostically elusive cause of heel pain. The MR finding of selective atrophy of the abductor digiti quinti (ADQ) muscle has been reported as a marker of such entrapment. We performed a prospective study of consecutive patients undergoing foot and ankle MRI to determine the prevalence of ADQ atrophy and to examine the clinical symptoms of patients found to have ADQ atrophy. SUBJECTS AND METHODS: A prospective study of all patients referred for ankle and foot MRI examinations was performed. Six hundred two patients were included in the study: 387 females and 215 males. All images were evaluated for the presence of selective fatty atrophy of the ADQ muscle. The clinical notes on all patients with findings of ADQ atrophy were analyzed for descriptions of symptoms leading to the MR examination, the presence of symptoms that might be related to nerve entrapment, and the influence on clinical management related to the MR finding of ADQ atrophy. RESULTS: Thirty-eight of the 602 patients had selective fatty atrophy of the ADQ, 29 females and nine males. Only one patient had a clinical diagnosis of possible nerve entrapment before MR examination. MRI findings of ADQ atrophy altered clinical management in only one patient. CONCLUSION: Selective fatty atrophy of the ADQ is not a rare finding on MR examination of the foot and ankle, being seen in 6.3% of all studies and in 7.5% of all studies in females. The clinical relevance of selective ADQ atrophy seen on MRI is uncertain.

Effect of pilot-hole size on the pullout strength of flexor digitorum longus transfer fixed with a bioabsorbable screw.

BACKGROUND: Fixation of tendon transfers with a bioabsorbable interference-fit screw has several advantages over other fixation methods: decreased dissection, operative time, and blood loss; preservation of tendon length; no interference with radiographic studies; no need for implant removal; and no barrier to revision surgery. Whether strength of fixation is affected by the size of the pilot hole has not been established. The purpose of this study was to determine the effect of pilot hole size on the pullout strength of a flexor digitorum longus (FDL) tendon secured into a bone analog using a 5.5-mm bioabsorbable screw. METHODS: Thirty FDL tendons were harvested from 15 cadaver specimens and secured into predrilled 4 x 4 x 4 cm bone cubes with a 5.5-mm Arthrex bioabsorbable screw (Arthrex, Naples, FL). The use of bone analog foam cubes ensured consistent porosity at the insertion site, eliminating the variations associated with varying bone densities of cadaver specimens. Pilot hole sizes studied were 5.0 mm, 5.5 mm, and 6.0 mm. Pullout tests were done with an servohydraulic testing frame (MTS, Eden Prairie, MN). RESULTS: There was no significant difference (p = 0.4) between the pullout forces and stresses among the three pilot hole sizes. All specimens failed at the interface between the FDL and the bioabsorbable screw. In the 6.0-mm pilot hole group, there was a trend for increased pullout strength with increased tendon size. CONCLUSIONS: With a bioabsorbable 5.5-mm screw used for FDL transfer, a pilot hole the same size or a half millimeter larger or smaller than the screw had no statistically significant effect on the strength of the construct, even with tendons of different sizes.

The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study.

BACKGROUND: Plantar fasciitis frequently responds to a broad range of conservative therapies, and there is no single universally accepted way of treating this condition. Modalities commonly used include rest, ice massage, stretching of the Achilles tendon and plantar fascia, nonsteroidal anti-inflammatory medications (NSAIDs), corticosteroid injections, foot padding, taping, shoe modifications (steel shank and anterior rocker bottom), arch supports, heel cups, custom foot orthoses, night splints, ultrasound, and casting. To our knowledge, no prospective, randomized, placebo controlled double-blind study has evaluated the efficacy of oral NSAIDs in the treatment of plantar fasciitis. METHODS: Twenty-nine patients with the diagnosis of plantar fasciitis were treated with a conservative regimen that included heel-cord stretching, viscoelastic heel cups, and night splinting. They were randomly assigned to either a placebo group or an NSAID group. In the NSAID group, celecoxib was added to the treatment regimen. RESULTS: Pain and disability mean scores improved significantly over time in both groups, although there was no statistical significance between the placebo and NSAID groups at 1, 2, or 6 months. There was a trend towards improved pain relief and disability in the NSAID group, especially in the interval between the 2 and 6-month followup. Pain improved from baseline to 6 months by a factor of 5.2 and disability by 3.8 in the NSAID group compared to 3.6 and 3.5, respectively, in the placebo group. Even though at baseline the pain and disability scores were higher in the NSAID group, the final pain and disability scores were subjectively lower in the NSAID group than in the placebo group (1.43 for pain and 1.16 for disability in the NSAID group, compared to 1.86 and 1.49, respectively, in the placebo group). CONCLUSIONS: These results provide some evidence that the use of an NSAID may increase pain relief and decrease disability in patients with plantar fasciitis when used with a conservative treatment regimen.

First metatarsal bone: an anatomic study.

BACKGROUND: The purpose of this study was to establish the range of anatomic variations of the first metatarsal bone, including both the angulations of the articular surfaces and the dimensions of the bone in a large sample. METHODS: Four hundred and seventy-eight first metatarsal bones of 239 cadaver specimens were studied. The following parameters were recorded: the distal metatarsal articular angle (DMAA), distal metatarsal articular surface shape, proximal metatarsal articular angle (PMAA), the first metatarsal bone length and width at the mid-region of the shaft, and the existence of a joint between the bases of the first and second metatarsals. These parameters were correlated to the specimen's age, sex, race, height, and weight. The DMAA and PMAA were measured from a digital picture of the first metatarsal bone by a specially designed computer analysis program. RESULTS: Males and African-American race had a longer and wider metatarsal. The joint between the first and second bases was present in 25% of the population. The DMAA ranged from -14 degrees of medial deviation to 30 degrees of lateral deviation with an overall average of 8.21 degrees. The DMAA increased 1 to 3 degrees with every 10 years in age for both right and left bones with a p value of < 0.01 and < 0.001, respectively, and the average increase from 20 to 60 years of age was 4.5 degrees. The PMAA ranged from -13.8 degrees of lateral deviation to 12.7 degrees of medial deviation with an overall average of -1 degrees. PMAA significantly deviated laterally in the presence of a joint between the bases of the first and second metatarsals (p < 0.001). The male and female means for the DMAA and PMAA were nearly equal. CONCLUSIONS: The DMAA had a wider range than reported in the literature, and it increased with age. The first-second metatarsal joint was accompanied by lateral deviation of the PMAA. CLINICAL RELEVANCE: Laterally deviated PMAA could predispose to a varus deformity of the first metatarsal.

Diabetes mellitus--overview.

DM increases the risk of multiple complications including retinography, nephropathy, and atherosclerotic disease. Management strategies include management of the associated metabolic risk factors such has hyperglycemia, dyslipidemia, and hypertension. Additional management strategies include laser therapy for retinopathy and appropriate footwear to reduce the risk of lower extremity amputations.

Hypermobility of the first tarsometatarsal joint.

This article discusses hypermobility of the first tarsometatarsal joint.

Arthrodesis after workplace injuries.

Many foot and ankle injuries are incurred in the workplace. Despite steel-toed shoes, metatarsal bars, and ankle-high boots, fractures which require arthrodesis procedures can occur. The area of the foot and ankle involved, any pre-existing conditions, and the patient's occupational requirements must be taken into account. When an employer is flexible, the patient can often return to a sit down job during the postoperative recovery, if intermittent elevation of the extremity is permitted and hours are gradually increased. Alternatively, manual laborers who operate heavy machinery or work on ladders or elevated surfaces will require a prolonged recovery period before being able to return to the workplace. Algorithms with return to work dates may be helpful, but because so many factors exist, a functional capacity evaluation is often necessary to determine what, if any, permanent restrictions will be required.

The medical management of chronic pain.

Pain is defined by the International Association for Study of Pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage." This article reviews the medical management of chronic pain.

Complications of missed or untreated Lisfranc injuries.

Injuries to the Lisfranc complex are fairly common. Delayed treatment or missed diagnosis of these injuries can lead to significant complications. Non-operative treatment and salvage surgery can help to relieve sequelae that are associated with tarsometatarsal arthritis following traumatic injury.

Interventional modalities in the treatment of complex regional pain syndrome.

Complex regional pain syndrome (CRPS) applies to a variety of conditions in which symptoms such as allodynia and hyperalgesia predominate along with hyperpathia and vasomotor/sudomotor disturbances. The incidence of CRPS in the chronic pain population varies and is difficult to determine, though it appears to affect women more than men. Treatment is multidisciplinary, and recovery of function and the reduction of pain are the main goals of treatment;this article addresses some of the interventional modalities that are used.

The crossover toe and valgus toe deformity.

Second toe problems are among the most common of all forefoot complaints. Its proximity to the hallux combined with limited motion at the second tarsometatarsal joint likely contributes to the second MTP joint being the most common to experience both pain and deformity. Many causes have been linked to this problem, which has lead to many surgical techniques to correct this deformity. Although many techniques have been described, a systematic approach relying first on soft tissue releases and plication followed by osteotomies as necessary has lead to satisfactory outcomes in the treatment of this difficult problem.

Finite element modeling of the first ray of the foot: a tool for the design of interventions.

Disorders of the first ray of the foot (defined as the hard and soft tissues of the first metatarsal, the sesamoids, and the phalanges of the great toe) are common, and therapeutic interventions to address these problems range from alterations in footwear to orthopedic surgery. Experimental verification of these procedures is often lacking, and thus, a computational modeling approach could provide a means to explore different interventional strategies. A three-dimensional finite element model of the first ray was developed for this purpose. A hexahedral mesh was constructed from magnetic resonance images of the right foot of a male subject. The soft tissue was assumed to be incompressible and hyperelastic, and the bones were modeled as rigid. Contact with friction between the foot and the floor or footwear was defined, and forces were applied to the base of the first metatarsal. Vertical force was extracted from experimental data, and a posterior force of 0.18 times the vertical force was assumed to represent loading at peak forefoot force in the late-stance phase of walking. The orientation of the model and joint configuration at that instant were obtained by minimizing the difference between model predicted and experimentally measured barefoot plantar pressures. The model were then oriented in a series of postures representative of push-off, and forces and joint moments were decreased to zero simultaneously. The pressure distribution underneath the first ray was obtained for each posture to illustrate changes under three case studies representing hallux limitus, surgical arthrodesis of the first ray, and a footwear intervention. Hallux limitus simulations showed that restriction of metatarsophalangeal joint dorsiflexion was directly related to increase and early occurrence of hallux pressures with severe immobility increasing the hallux pressures by as much as 223%. Modeling arthrodesis illustrated elevated hallux pressures when compared to barefoot and was dependent on fixation angles. One degree change in dorsiflexion and valgus fixation angles introduced approximate changes in peak hallux pressure by 95 and 22 kPa, respectively. Footwear simulations using flat insoles showed that using the given set of materials, reductions of at least 18% and 43% under metatarsal head and hallux, respectively, were possible.

Lower-extremity amputations in patients with diabetes: pre- and post-surgical decisions related to successful rehabilitation.

BACKGROUND: Peripheral vascular disease and diabetes account for the majority of lower-extremity amputations in the adult population. Whenever a patient presents to a surgeon regarding a diseased limb, the initial basic decision is to determine whether to attempt limb salvage or proceed with an amputation. Unfortunately, limb salvage is not an option for many of these patients. Once amputation is chosen as a treatment option, the optimal level of amputation has to be determined by the surgeon, who is then faced with selecting the optimal level of amputation compatible with wound healing and subsequent prosthetic fitting. METHODS: Methods for objectively determining optimal amputation level include vascular evaluations, assessing the level of cellulites or osteomyelitis, or intra-operatively, by looking at the amount of bleeding in skin flaps. RESULTS: The net outcome is that there is currently no universally accepted method for determining the level of amputation for successful wound healing or for preventing subsequent higher amputations. CONCLUSIONS: What is generally recognized is that there are disparities in the rates of amputation for type 1 versus type 2 diabetic patients, for different ethnic groups and for patients with multiple co-morbidities. However, with advances in surgical techniques and with modern prosthetics, all categories of patients are benefiting from surgeries in which a longer residual limb can be kept (within surgical constraints related to proper wound healing), and where appropriate biomechanical considerations are taken into account.