Painful sesamoid of the great toe

The painful sesamoid can be a chronic and disabling problem and isolating the cause can be far from straightforward. There are a number of forefoot pathologies that can present similarly to sesmoid pathologies and likewise identifying the particular cause of sesamoid pain can be challenging. Modern imaging techniques can be helpful. This article reviews the anatomy, development and morphological variability present in the sesamoids of the great toe. We review evidence on approach to history, diagnosis and investigation of sesamoid pain. Differential diagnoses and management strategies, including conservative and operative are outlined. Our recommendations are that early consideration of magnetic resonance imaging and discussion with a specialist musculoskeletal radiologist may help to identify a cause of pain accurately and quickly. Conservative measures should be first line in most cases. Where fracture and avascular necrosis can be ruled out, injection under fluoroscopic guidance may help to avoid operative intervention.     

隐神经营养血管蒂逆行岛状皮瓣修复前足软组织缺损17例临床报告

目的:探讨隐神经营养血管蒂逆行岛状皮瓣修复前足软组织缺损的可行性及临床疗效。方法:2005年2月~2009年12月,对17例前足部软组织缺损患者行隐神经营养血管蒂逆行岛状皮瓣修复术,其中5例将隐神经断端与创面内皮神经相吻合。结果:皮瓣切取面积最大为9cm×11cm,最小为5cm×7cm,平均平均7.2cm×9.2cm;蒂长10~14cm。15例皮瓣全部成活,2例皮缘发生浅表性坏死。经6个月~3年随访,皮瓣外形满意、富有弹性、耐磨;所有患足步态正常,无继发性溃疡形成。5例行神经吻合皮瓣,两点辨别觉达8~12mm,恢复保护性感觉。结论:隐神经营养血管蒂逆行岛状皮瓣取材方便,血供可靠,不牺牲主要动脉,是修复前足部软组织缺损的一种良好方法。     

Outcomes of modified metatarsal shortening offset osteotomy for forefoot deformity in patients with rheumatoid arthritis: Short to mid-term follow-up

Objectives: Advances in drug therapy for rheumatoid arthritis (RA) have been encouraging us to preserve the metatarsopharangeal (MTP) joint in correction of forefoot deformities, and original metatarsal shortening offset osteotomy was recommended as one of the conventional surgical options for forefoot deformities in RA cases. The objective of this study was to evaluate short- to mid-term outcomes of modified metatarsal shortening offset osteotomy.

Methods: A retrospective observational study was completed for 80 RA cases (mean follow-up period: 3.2 years) who underwent modified metatarsal shortening offset osteotomy. Both lesser toe scales and RA foot ankle scales were administered using the Japanese Society for Surgery of the Foot (JSSF) standard rating system, and a postoperative self-administered foot evaluation questionnaire (SAFE-Q) at final follow-up was also checked to evaluate clinical outcomes.

Results: This procedure significantly improved clinical scores of both the JSSF [lesser toes and RA foot and ankle] scales. Of 80 feet, 24 (30%) showed recurrence of MTP joint subluxation/dislocation. Furthermore, the feet in the recurrence group showed significant varus hindfoot. On the other hand, valgus foot in the recurrence group more frequently included midfoot bony ankyloses. All of the affected feet showed the limitation of MTP joints (<70°) after surgery.

Conclusions: Modified metatarsal shortening offset osteotomy was recommended for RA forefoot disorders as one of the joint preservation surgeries in short- to mid-term follow-up. However, some modifications to avoid limitation of ROM in the MTP joint are required. It must be borne in mind that varus hindfoot and/or bony ankyloses in the mid-hindfoot can cause recurrence of dorsal dislocation/subluxation of the lesser toe MTP joint.     

低旋转点的隐神经营养血管远端蒂皮瓣修复前足背侧缺损创面

目的 探讨低旋转点隐神经营养血管远端蒂皮瓣修复前足背侧缺损创面的术式,并总结其临床效果.方法 2005年1月-2007年8月,应用低旋转点的隐神经营养血管远端蒂皮瓣修复前足背侧皮肤软组织缺损创面6例.男4例,女2例;年龄28～53岁.左足2例,右足4例.蓖物压砸伤5例,车祸伤1例.患足均伴肌腱、骨外露或坏死皮肤软组织切除后肌腱、骨外露.急诊手术2例,择期手术4例.清创后创面缺损为7.0 cm×5.0 cm～9.0 cm ×5.5 cm.皮瓣旋转点位于内踝上1～3 cm处,切取皮瓣人小为8.0 cm × 6.0 cm～13.0 cm × 6.5 cm.其中2例将皮瓣内隐神经近断端和创面内足背内侧皮神经残端吻合.供区创面中厚皮片植皮修复.结果 4例术后皮瓣顺利成活;2例术后2 d皮瓣远端出现肿胀、水疱,经对症处理后愈合.供区植皮全部成活.6例患者均获随访,随访时间6～18个月.皮瓣厚薄、颜色及质地接近受区.术中吻合神经的2例皮瓣痛、温觉恢复,两点辨别觉分别为8 mm和9 mm;未吻合神经的4例皮瓣恢复保护性感觉.患足负重行走正常,皮瓣无皮肤破溃. 结论 低旋转点的隐神经营养血管远端蒂皮瓣血供可靠,足修复前足背侧缺损创面的一种较好方法.     

Changes in gluteal muscle forces with alteration of footstrike pattern during running

Gait retraining is a common form of treatment for running related injuries. Proximal factors at the hip have been postulated as having a role in the development of running related injuries. How altering footstrike affects hip muscles forces and kinematics has not been described. Thus, we aimed to quantify differences in hip muscle forces and hip kinematics that may occur when healthy runners are instructed to alter their foot strike pattern from their habitual rear-foot strike to a forefoot strike. This may gain insight on the potential etiology and treatment methods of running related lower extremity injury. Twenty-five healthy female runners completed a minimum of 10 running trials in a controlled laboratory setting under rear-foot strike and instructed forefoot strike conditions. Kinetic and kinematic data were used in an inverse dynamic based static optimization to estimate individual muscle forces during running. Within subject differences were investigated using a repeated measures multi-variate analysis of variance. Peak gluteus medius and minimus and hamstring forces were reduced while peak gluteus maximus force was increased when running with an instructed forefoot strike pattern. Peak hip adduction, hip internal rotation, and heel-COM distance were also reduced. Therefore, instructing habitual rearfoot strike runners to run with a forefoot strike pattern resulted in changes in peak gluteal and hamstring muscle forces and hip kinematics. These changes may be beneficial to the development and treatment of running related lower extremity injury.     

Surgical corrections of the foot following posttraumatic ischaemic contractures

Surgical Principles Correction of pes equinus adductus by a wedge shaped resection of the Chopart joint, the basis of the wedge facing dorsolateral. If a pes varus also exists a cuneiform resection of the subtalar joint is performed, the basis of the wedge facing lateral [7, 8, 13] (Fig. 1a to 1f). In the presence of a tarsal tunnel syndrome decompression of n. tibialis splitting of the retinaculum musculi flexorum is added. For correction of claw toes resection of the distal part of the proximal phalanx according to Hohmann; in flexed distal interphalangeal joints resection of the distal part of the middle phalanx. (These techniques will not be described in this article.)