Lethal hydrops fetalis due to congenital dyserythropoietic anemia in a newborn: association of a new skeletal abnormality

Congenital dyserythropoietic anemias (CDAs) are a group of hereditary refractory anemias characterized by ineffective erythropoiesis, typical morphological abnormalities of erythroblasts, a low or no reticulocyte response, hyperbilirubinemia, and splenomegaly. A massive hydropic newborn born with a very severe anemia (Hb 4.8 g/dL), diffuse edema, hepatosplenomegaly, ascites, pulmonary edema and respiratory distress, and shortness and hallux varus deformity of the great toe of the right foot was diagnosed to have congenital dyserythropoietic anemia on the basis of the hematological (macrocytosis, anisopoikilocytosis, fragmented red cells and erythroblastosis in the peripheral blood, and erythroid hyperplasia with erythroblastosis and erythroblasts with double nuclei and thin chromatin bridges connecting these nuclei in the bone marrow) and serological (negative acidified serum lysis test and no agglutination with anti-i antibodies) findings. In this article the seventh case of neonatal congenital dyserythropoietic anemia presenting with a very severe (lethal) form of hydrops fetalis and a new (hallux varus) deformity of the great toe of the right foot is presented. Congenital dyserythropoietic anemia should be considered in the differential diagnosis of hydrops fetalis presenting with a very severe anemia and a skeletal abnormality of the great toe.

Complications after surgery of the hallux

The great toe is affected by many congenital and acquired conditions including arthritis, hallux valgus, and hallux rigidus and disease of the hallucal sesamoids. Many surgical procedures have been described for the treatment of these conditions. With the increased popularity of forefoot surgery comes the potential for complications even when the surgery is done meticulously by an experienced surgeon under well-planned conditions. When a complication occurs, it can present difficult and challenging problems. It is, therefore, important to recognize a complication early so it may be analyzed and treated successfully. When recognized, a plan should be developed to identify, quantify, control, and resolve the problem. The current review defines some common complications and treatment options. Several problems may exist at the same time. A solution addressing all aspects of the problem must be designed so as not to augment the presenting complications. Salvage operations and long-term treatment are included to provide a perspective on treatment of residual deformity. It is important to realize that there often are several solutions to a difficult problem. Many factors influence the surgeon's choice and implementation of a solution, but the ultimate outcome always depends on a well thought out plan.

A new syndrome with craniofacial and skeletal dysmorphisms and developmental delay

We report a 16-year-old boy with multiple craniofacial and skeletal dysmorphic features including brachycephaly, acrocephaly, hypertelorism, wide palpebral fissures, broad nose, anteverted nares, broad columella, long and smooth philtrum, thin upper lip, macrostomia, carp-like mouth, micrognathia, low-set and posteriorly angulated ears with small and abnormal pinnae, a low posterior hairline, a short neck, hypoplastic and widely-spaced nipples, multiple severe pterygia, an umbilical hernia, metatarsus varus, low implantation of the halluces, and delayed motor and language development. An MRI of the head showed bilateral frontal pachygyria but no sign of heterotopia. The unique features of our patient suggest that he represents a new syndrome.

Anterolateral tibial bowing and duplication of the hallux: a rare but distinct entity with good prognosis

Congenital anterolateral bowing of the lower leg usually is a symptom of (impending) fracture because of congenital pseudarthrosis. This article reports a case of anterolateral bowing of the lower leg that is characterized by spontaneous correction and combination with duplication of the hallux. A review of the literature showed 10 comparable cases. This article is the first report on the magnetic imaging of this entity and describes its differentiation from congenital pseudarthrosis.

Congenital hypertrophy of the lateral nail folds of the hallux: clinical features and follow-up of seven cases

Congenital hypertrophy of the nail folds of the hallux describes an abnormality of the periungual soft tissues of the big toe characterized by hypertrophy of the nail fold which partially covers the nail plate and is frequently associated with inflammation and pain due to an ingrowing nail. We describe the clinical picture and follow-up of seven patients with this abnormality. In three patients the affected toe showed an asymptomatic, dome-shaped, hypertrophic lip that partially covered the nail plate. Four patients had acute inflammatory changes due to toenail ingrowth, with considerable swelling and reddening of the hypertrophic lip that was painful on pressure. Topical treatment with steroids was useful to reduce inflammation and produced persistent remission in two patients. Follow-up showed a spontaneous disappearance of the hypertrophic nail fold in one of the seven patients. In two patients the hypertrophic lip partially regressed, but remained clearly visible, while in two patients it remained unchanged. In two patients surgical correction of the soft tissue abnormality was necessary due to painful nail ingrowth unresponsive to topical treatment.

Congenital absence of the lateral metatarso-phalangeal sesamoid bone of the human hallux: a case report

A case of congenital absence of the lateral metatarsophalangeal sesamoid bone of the hallux is reported, in a 47-year-old woman. The lateral sesamoid bone was absent on the right hallux, and extremely reduced on the left hallux. The normal intersesamoidean crest and both sesamoidean grooves of the metatarsal head were absent. Physical examination was normal, and no functional disturbance resulted from this variant. Only two previous cases have been found in the literature. It must be distinguished from a total resorption due to an infectious process, or from an absence due to surgical excision. This absence can be related to the general tendency of disappearance of the sesamoid bones within hominoid primates.

Thumb/hallux duplication and preaxial polydactyly type I

It was recently shown that hand postaxial polydactyly differed from foot postaxial polydactyly. The aim of this work was to test whether thumb and hallux duplication also had different clinical and epidemiological characteristics, depending on limb involvement. We studied 920 newborn infants with first digit duplication, ascertained among 3,444,374 births by the Latin-American Collaborative Study of Congenital Malformations (ECLAMC), from 1967 to 1995. Since biphalangeal thumb duplication or hallux duplication can occur in families with triphalangeal thumb or polysyndactylous propositi, these groups were also analyzed. The 715 isolated (nonsyndromal) cases (prevalence 2.08 per 10,000) were subdivided into five groups: thumb duplication (N = 568; prevalence: 1.65/10,000); hallux duplication (N = 82; prevalence: 0.24); thumb and/or hallux duplication plus syndactyly (polysyndactyly) (N = 37; prevalence: 0.11); triphalangeal thumb (N = 24; prevalence: 0.07), and thumb duplication plus hallux duplication (N = 4; prevalence: 0.01). Both thumb and hallux duplication groups showed a significant excess of males, and right sidedness was also more frequent in both of them, though without statistical significance for hallux duplication. Thumb duplication was more often unilateral (94.7% versus hallux duplication of 81.5%), and its prevalence was higher in Bolivia (3.37/10,000) than in the other 10 Latin-American countries included (1.62/10,000). In a subseries of 405 preaxial polydactylies with matched controls, a logistic regression analysis showed that birth weight and gestational age had an effect on the calculated risk of having an infant with thumb duplication, while first trimester vaginal bleeding had only a borderline effect. None of the polydactyly groups showed abnormal values for twinning, perinatal mortality, ethnicity, maternal education, parental ages, parity, parental subfertility, or consanguinity. There were 70/405 familial cases. Their pedigrees were compatible with autosomal dominant inheritance with a 9% penetrance for thumb duplication and hallux duplication and a 70% penetrance for triphalangeal thumb and polysyndactyly. Inheritance of thumb duplication and probably the untested inheritance of hallux duplication were also compatible with a four-locus multiplicative model. The observed differences in laterality, geographical distribution, birth weight, gestational age, and first trimester vaginal bleeding between thumb duplication and hallux duplication groups suggested that apparent preaxial polydactyly type 1 is a causally heterogeneous group.

Blepharophimosis, hypoplastic radius, hypoplastic left heart, telecanthus, hydronephrosis, fused metacarpals, and "prehensile" halluces: a new syndrome?

We report on the prenatal ultrasound and postnatal findings in an infant born to a healthy, nonconsanguineous couple. The infant had microcephaly, telecanthus, blepharophimosis, cleft palate, micrognathia, abnormally modeled ears, hypoplastic left heart, hypoplastic radii and ulnae with radial subluxation, pseudoarthrotic distal humeri, fused metacarpals, tibial bowing, unusual feet with long halluces, hydronephrosis, patent urachus, abnormal electroencephalogram, and normal karyotype. To our knowledge, this combination of anomalies has not been recognized previously and may represent a new condition.

[Hallux varus congenitus]

INTRODUCTION

The congenital hallux varus is a rare hereditary deformity of the big toe, which often is combined either with polydactylia or with systemic deformities of the skeleton. The congenital hallux varus can be easily diagnosed clinically. The X-ray shows the ossified bony elements and provides information about the shape and number of the digits as well as their axial deviation. An operative treatment is required. So far a standardized surgical technique has not been accepted for all types of hallux varus.

METHODS

The correction of the bony structures and soft tissues is planned by means of preoperative scetches. The amount of correction depends on the degree of the deformity. As consequence of the reorientation of the first ray a soft tissue flap has to be planned and prepared for wound closure which otherwise would need larger grafts.

RESULTS

Based on this series the clinical and radiological appearance of the congenital hallux varus are discussed. The operative treatment is explained step by step illustrated by photographs as well as planing scetches. Our procedures are compared to other operative methods reported in the literature.

CONCLUSIONS

There are no diagnostic problems with the hallux varus deformity. For therapy surgery is mandatory and recommended between 9 and 24 months of age. For microsurgical preparation and correction of the deformity planning of all surgical steps and alternatives is advocated, this allows for good functional and cosmetic results.

Lengthening of short great toes by callus distraction

We lengthened seven first metatarsals in four patients with short great toes by callus distraction using an external fixator. Good clinical and cosmetic results were obtained. Bone lengthening is effective in patients with short great toes not only for cosmesis, but also to relieve pain and callosities on the plantar aspect of the second and third metatarsal heads. Excessive lengthening of the first metatarsal resulted in limitation of the range of movement of the metatarsophalangeal joint of the great toe. To prevent this the amount of lengthening should not exceed 40% of the preoperative length of the metatarsal.

HOX gene links limb, genital defects

The HOX gene family has helped to unlock the intricacies of development in animals from flies to mammals, but its role in humans has been a mystery. Now the second human HOX gene mutation has been found in a Michigan family. It causes abnormalities in both limbs and genitals—and raises some intriguing evolutionary ideas.

Concomitant syndactyly and polydactyly in a pediatric foot

Syndactyly and polydactyly in a child may warrant surgical treatment to avert resultant emotional and psychologic problems. The authors present a unique case report of a bilateral polydactyly of the hallux and bilateral syndactyly of the second and third toes in a normal 6-year-old Hispanic female. The article will discuss the surgical management of these problems, using the skin harvested from resection of the extra hallux for the adjacent side of the lesser toes after desyndactyly.

Multiple lower limb osteophytosis with macrodactyly: a case report

A 39-year-old woman with restriction of movement and macrodactyly of the great toes was found to have severe juxta-articular multiple osteophytosis of the lower limbs. The pathogenesis of this unusual condition is unknown. It may be a variant of diffuse idiopathic skeletal hyperostosis.

Use of titanium grommets in silicone implant arthroplasty of the hallux metatarsophalangeal joint

Double-stem silicone implants protected by titanium grommets were placed in the hallux metatarsophalangeal joints of 32 patients (47 feet). All patients had a painful destroyed joint and most were women. Three patients (six feet) were lost to follow-up. Nineteen patients had a diagnosis of rheumatoid arthritis (25 feet) and 10 had degenerative joint disease (16 feet). The average age for the group was 57 years and the average follow-up was 51 months (range, 34-76 months). Twenty patients (30 feet) were completely satisfied with their result. Eight patients (10 feet), all with rheumatoid arthritis, had some minor postoperative complaints, usually involving the lateral toes. Two patients (three feet) in this group had no pain, but would have preferred more hallux motion. One patient with rheumatoid arthritis (one foot) had a poor result due to implant removal for deep sepsis. Radiographic analysis of these patients showed no evidence of implant fracture and the implant composite appeared to be well tolerated by the surrounding bone in which it was placed. When compared with another, similar group of patients in whom grommets were not used, this implant appeared to be much more stable, as there was significantly less evidence of radiolucency seen around those implants protected by the grommets. It appears that the titanium grommets may protect the silicone implant and may help provide a longer life for the silicone implant.

Biomechanical assessment of a new tenodesis for correction of hallux varus

Each of six below-the-knee amputation specimens were transfixed to a wooden block and mounted to a jig on an amputee testing device preloaded with 5 N applied to the proximal phalanx and displaced at a constant rate of 2 mm/min. Load displacement curves were generated for the intact joint and after sequential incisions of the lateral capsule, the adductor hallucis, and the lateral slip of the flexor hallucis brevis tendon, which caused varus dislocation of the hallux. An extensor hallucis brevis tenodesis was performed after the varus dislocation. Division of the lateral capsule, the adductor, and the flexor brevis reduced the force required to displace the hallux by 42.2%, an additional 25.2%, and a further 14.2%, respectively. Use of the extensor hallucis brevis tenodesis restored the load displacement curves to that of the normal joint. We conclude that the extensor hallucis brevis tendon may be useful as a tenodesis for reconstructing the deformity of acquired hallux varus.

Unilateral duplication of the great toe with anterolateral tibial bowing

A syndrome consisting of unilateral duplication of the great toe in association with anterolateral bowing of the tibia is described. Patients with this syndrome have significant pedal difficulties after surgical management, but the tibial bowing spontaneously resolves without treatment. Tibial shortening is noted relative to the fibula. Associated clinodactyly and dysharmonic maturation of carpals and metacarpals are also seen. Current data are most consistent with a developmental rather than a genetic etiology.

Results of hallux varus correction using an extensor hallucis brevis tenodesis

We have used an extensor hallucis brevis tenodesis procedure to treat symptomatic hallux varus in six patients (five women and one man). Indications for this procedure include the presence of flexible metatarsophalangeal and interphalangeal joints and the absence of arthritis. In this group (mean age, 47 years; range, 18-65 years), hallux varus followed correction of hallux valgus deformity in five patients and traumatic dislocation of the hallux in one patient. Excellent correction was noted and maintained in all patients at a mean interval of 28 months (range, 24-32 months) after surgery. Despite a slight decrease in dorsiflexion following surgery (average, 10 degrees), there were no additional complications noted, and the mean American Orthopaedic Foot and Ankle Society rating score improved from 61 to 85 after surgery.

A large Turkish kindred with syndactyly type II (synpolydactyly). 1. Field investigation, clinical and pedigree data

A very large Turkish family with syndactyly type II (synpolydactyly (SPD)) is described, which originated from and is mainly concentrated in the village of Derbent, Afyon. The kindred consists of 425 subjects over seven generations, of whom 182 are affected. It appears that a founder effect in this village has led to this extensive kindred. This condition is inherited as an autosomal dominant trait with variable expressivity and an estimated penetrance of 96%. Penetrance is different between the upper (96%) and lower (69.5%) extremities. No excess of affected males or females or other associated features were documented in this condition. Variations in the involvement of one or both hands, upper or lower extremities, bone and soft tissue, as well as variation in the affected subjects of two successive generations were documented. We also noted that metacarpal and metatarsal involvement and middle phalangeal hypoplasia of the feet are the consistent features of SPD and, therefore, should be considered as characteristic of this phenotype. We observed four different phenotypes in various branches of the Derbent kindred: (1) subjects presenting typical features of SPD; (2) subjects exhibiting both pre- and post-axial polydactyly simultaneously; (3) persons manifesting postaxial polydactyly type A; and (4) subjects born to two affected parents with severe hand and foot deformities that have not been previously described in any other SPD families (that is, homozygotes). A total of 27 affected offspring were born to two such affected parents, of whom seven are expected to be homozygous for the SPD gene. This group is presented in an accompanying paper in this issue of the Journal. A molecular study is currently under way to identify the chromosomal location of the defective gene.

A metallic hemiarthroplasty resurfacing prosthesis for the hallux metatarsophalangeal joint

Two-hundred seventy-nine arthritic hallux metatarsophalangeal joints treated surgically with a metallic resurfacing hemiarthroplasty over a 40-year period were reviewed. The implant, which is made available in three evenly graded sizes, is designed to replace only the articular surface of the proximal phalanx, with minimal resection of bone stock. The pathologic indications for surgery included classical hallux rigidus, rheumatoid arthritis, and degenerative changes associated with hallux valgus and bunion deformity. Follow-up at 8 months to 33 years after surgery revealed good or excellent clinical results in 95%. The time to follow-up was in excess of 5 years in 101 (36%) of the procedures, beyond 10 years in 62 (22%), and longer than 20 years in 23 (8%). Unlike other available surgical options for this debilitating condition, biomechanics of the hallux metatarsophalangeal joint remained unaffected and problems associated with prosthetic wear or mechanical failure were not encountered.

Preaxial brachydactyly with abduction of thumbs and hallux varus: a distinct entity

We describe a father and his daughter who had a unique pattern of preaxial brachydactyly, and unusual facial appearance. Both had short broad abducted thumbs and halluces. The second digits of both hands were also short and broad and those of feet were medially angulated. The radiographic findings were short first metacarpals and first metatarsals and hypoplastic phalanges of first two digits of hands and feet. A similar pattern of brachydactyly was described by Christian et al. [1972: Am J Hum Genet 24:694-701] and Mononen et al. [1992: Am J Med Genet 42: 706-713]. Our patients differ from those described by Christian et al. in that they did not have any mental retardation and from those of Mononen et al. by the absence of short stature and epiphyseal and metaphyseal changes. The heterogeneity of this new type of brachydactyly remains to be resolved.