Osteonecrosis in the foot

Osteonecrosis, also referred to as avascular necrosis, refers to the death of cells within bone caused by a lack of circulation. It has been documented in bones throughout the body. In the foot, osteonecrosis is most commonly seen in the talus, the first and second metatarsals, and the navicular. Although uncommon, osteonecrosis has been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating both adult and pediatric foot pain. Osteonecrosis is associated with many foot problems, including fractures of the talar neck and navicular as well as Kohler's disease and Freiberg's disease. Orthopaedists who manage foot disorders will at some point likely be faced with the challenges associated with patients with osteonecrosis of the foot. Because this disease can masquerade as many other pathologies, physicians should be aware of the etiology, presentation, and treatment options for osteonecrosis in the foot.     

Development of the foot in prenatal life in relation to idiopathic club foot

The development of the human foot from the eighth to the twenty-first intrauterine week was studied in 147 specimens. The results documented a stage of "physiologic club foot" characterized by a medial deviation and plantigrade orientation of talar neck and head during the ninth week. At the same time, the calcaneus assumes a position of varus with the forefoot in adduction. By the eleventh week, the foot assumes a normal position. All findings during the stage of physiologic club foot closely resemble those of the intrinsic type of club foot.     

Reconstructive foot surgery following complex trauma of the foot

Compound post-traumatic foot deformity may follow indirect, direct, or combined trauma. This is demonstrated by a number of case reports. Particularly during adolescence, primary injuries to the soft tissue, with neurovascular injury or compartment syndrome, and post-traumatic skin contractures can cause severe growth deformity at the site of the injury and distal to it. Compression screw arthrodesis, using the 6.5-mm cancellous screw with the triple arthrodesis and the 3.5-mm cortical screw with the Lisfranc arthrodesis, has particular significance. It is stable, it allows functional treatment later, and bone union takes place rapidly. The most important surgical principles in post-traumatic foot surgery are: precise reconstruction of the foot axes, the medial and lateral foot length, and the longitudinal and transverse arches, i.e., restitution of the normal foot anatomy.     

Amputations in the diabetic foot

This article presents an overview of the pathogenesis of diabetic foot lesions that lead to lower extremity amputation surgery. The magnitude of this problem is presented together with a brief historical perspective. Indications for "local amputation" of the foot are discussed as well as preoperative noninvasive hemodynamic evaluation of the patient, with determination of level of amputation. Surgical management is covered in detail, with discussion of factors important for amputation wound healing, selection of anesthesia and operative technique, use of tourniquet, and antibiotic considerations.     

Macrodystrophia lipomatosis in the foot

Summary A rare case of macrodystrophia lipomatosis in the foot is reported. The literature is reviewed and the different presentations of macrodactyly are discussed.     

Rheumatoid changes in the foot

The clinical importance, incidence and clinical appearance of foot deformities as a result of rheumatism are described. The pathomechanics of rheumatic deformities and the connection with inflammatory changes in the anterior and posterior parts of the foot are described. The possible types of conservative treatment are introduced briefly. The operative form of therapy is presented in detail and subdivided according to preventive and reconstructive measures in various parts of the foot. The peculiarities and subsequent requirements of the therapeutic procedure are addressed.     

Neuroarthropathy of the foot in leprosy

Among 449 patients with leprosy, 40 had clinical and radiographic evidence of neuroarthropathy in 50 feet. These changes were classified into four types according to the joints first involved by major lesions: ankle (25 feet), midtarsal (15 feet), tarsometatarsal (7 feet) and subtalar (3 feet). The progression of joint destruction was different in each type, but despite the severe destructive changes seen in radiographs, the patients had relatively few complaints. The muscles innervated by the peroneal nerve were severely paralysed in ankle and midtarsal types and it seems that, over a long term, repeated trauma and/or abnormal stress may lead to these types of neuroarthropathy. Neuropathy was less severe in the tarsometatarsal type of joint degeneration; the pathogenesis in this type seemed to be mainly direct trauma to the forefoot.     

Synovial sarcoma in the foot

Synovial sarcoma is a rare malignancy that occurs most frequently in the extremities. Its onset and associated symptoms are often insidious and therefore can be misleading. The authors review this primary malignancy and offer a case report to illustrate the importance of including such entities in the differential diagnosis and subsequent treatment of soft tissue masses found in the foot.     

Microsurgery in the diabetic foot

The treatment of serious tissue defects on the diabetic foot is complicated and tedious because of a combination of pathogenetic mechanisms that influence healing. Diabetic neuropathies (sensory, motor, vegetative), ischaemia and microangiopathies contribute in varying degrees to the adverse healing. The submitted three-year prospective study was focused on an analysis of the pathogenetic factors with the objective of defining the indications for one of three types of microsurgical transfer: 1. a free flap sutured directly to the vessels at the site of the defect (in predominantly neuropathic defects); 2. a free flap sutured to a politeopedal bypass (in predominantly ischaemic defects); 3. a "nourishing" flap sutured by means of a long venous graft to vessels of the medial and upper leg (in patients in whom an inadequate outflow tract does not make revascularisation possible). In the first year of the investigation, thirteen patients were operated on by means of a free muscle flap incl. three "nourishing" and ten sutured at the site of the defect. Twelve flaps were flaped healed; one patient died from myocardial infarction on the second day after surgery.     

Infection in the neuroischemic foot

Infection in the neuroischemic foot can lead to cellulitis, which often progresses to necrosis as a result of septic vasculitis. Therefore, it is important to diagnose infection early. However, the signs and symptoms of infection are diminished in the neuroischemic foot. Microbiological investigation is essential. Severe infection needs intravenous antibiotic therapy and urgent assessment of the need for surgical drainage and debridement. Infected neuroischemic feet need vascular assessment and intervention where appropriate. It is important to maintain strict metabolic control and optimize cardiovascular function. Recent modern approaches based on multi-disciplinary clinics have resulted in improved results in the management of infection in the ischemic diabetic foot.     

Osteonecrosis in the foot.

Osteonecrosis is a pathologic condition that affects bones in the lower extremity. Circulatory impairment, forces of weightbearing, and increased intraosseous bone marrow pressure can interact to create this malady. Radiologic identification is paramount to accurate diagnosis. The authors present various examples of this condition in the foot.     

Leiomyosarcoma of the foot

The author describes a middle-aged female who sustained a leiomyosarcoma on the outer aspect of her right ankle. He reviews the different diagnostic aids in achieving the diagnosis, and analyzes various microscopic characteristics. The lesion is extremely rare in the foot and ankle.