A nonclassified and unusual polydactyly of the foot

A rare polydactyly of the foot, mixed central and pre-axial type, is described; no other dysmorphic features were present. Early surgery was performed with good results.

Interstitial deletion of 13q22-->q31: case report and review of the literature

In the present study we describe a patient with characteristic brachydactily, developmental delay and interstitial del 13q22-->q31. After the review of the literature, few cases sharing similar chromosomal deletions were found and they displayed little resemblance with our patient. We discuss the phenotype correlation among the deleted regions in such cases.

Carcinome cuniculatum : un diagnostic difficile, à évoquer devant une ostéite chronique d'évolution défavorable sous traitement

INTRODUCTION

The clinical and histological features of cuniculatum carcinoma (CC) are often misleading.

CASE REPORT

We report a case of CC of the foot, which was misdiagnosed as osteomyelitis for a two year period and which relapsed 2 months after complete resection.

DISCUSSION

The CC has to be evoked in patients with chronic osteomyelitis and torpid wound. The anatomopathologist needs to be aware of the suspected diagnosis.

Secondary centers of ossification of the human toes: exceptional polymorphism and evolutionary perspectives

As great morphological variability characterizes the phalanges of the human toes in adults, we hypothesized for a possible variability in the presence or absence of their secondary (= epiphyseal) centers of ossification linked to the unique morphology of the human foot within primates. The aim of this study was thus to provide original and detailed data on the occurrence of these centers. Classically, the big toe or hallux (I) presents two secondary centers and the lateral toes (II-V) three centers, and consequently the five toes present a total of 14 secondary centers. The material studied consisted of 261 foot radiographs from 261 young individuals of European origin (202 males and 59 females; 6-16 years). The presence (or absence) of the secondary centers of the phalanges of the toes was assessed for each foot. Feet presenting a biphalangeal variant in one or more lateral toes were studied separately. The theoretical possibilities of association of the three secondary centers in a given lateral toe (II-V) are eight in number; these eight patterns were studied and coded in the present study by types A-H. An exceptional variability in the occurrence of the secondary centers in lateral toes (II-V) was observed, and the classic pattern of phalangeal ossification was never observed. The absence of one or more secondary centers seems to be observed only in the human species, and we suggest that this could be a derived pattern specific to the human species, i.e., autapomorphic pattern. These results are of interest in the characterization and understanding of the reduction in size of the lateral toes which characterizes the specific evolution of the human foot.

Jaw fixation as the key to diagnosis of fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva is a very rare and disabling hereditary disorder of connective tissue characterised by symmetric congenital anomalies of the great toes and thumbs and by progressive heterotopic ossification of tendons, ligaments, fasciae and striated muscles. In this case we report a 17-year-old boy who presented with a painful swelling of the right mandibula with trismus. Multiple heterotopic soft tissue calcifications, severe scoliosis and typical anomalies of toes and thumbs on the radiographs were pathognomonic for fibrodysplasia ossificans progressiva.

Chronic inflammatory joint disease revealing borderline leprosy

Musculoskeletal symptoms are not infrequent in leprosy and, when inaugural, may be difficult to differentiate from other conditions, most notably rheumatoid arthritis. We report the case of a 24 year-old man with a 5 year history of intermittent inflammatory arthritis and fever. Physical findings and radiographs were normal initially. Several years later, he had severe wasting of the hand muscles, stocking-glove sensory loss, burn scars on the hands, and plantar ulcers. Electrophysiological test results indicated sensory-motor neuropathy with predominant demyelination. Laboratory tests showed inflammation without immunological abnormalities. A prominent endoneurial inflammatory infiltrate composed of mononuclear cells was seen on a nerve biopsy specimen, suggesting leprosy. A family study then revealed that the patient's aunt had been diagnosed with leprosy. Dapsone, clofazimine, and rifampin were given. The joint manifestations and laboratory tests for inflammation improved. However, no changes were noted in the neurological symptoms.

A neglected case of macrodystrophia lipomatosa of the foot in an elderly man

Macrodystrophia lipomatosa is a rare disorder characterized by three-dimensional enlargement of one or more fingers or toes with predominantly fibroadipose tissue. Radiographically, it appears as hypertrophy of soft tissues and bones. The pathologic findings are infiltration and hypertrophy of adipose tissue in subcutaneous tissue, nerve sheaths, and periosteum. Macrodystrophia lipomatosa is usually diagnosed during childhood. The case presented here involves the most elderly patient with the condition ever reported, to our knowledge. As such, it may advance current knowledge of macrodystrophia lipomatosa. Special emphasis is given to the unique "bridge" formation seen radiographically in this case.

Foot polydactyly and polysyndactyly: genetic implications in two families

The purpose of this study was to determine the genetic characteristics of foot polydactyly and identify its inheritance pattern by analyzing familial pedigree. Five cases from 2 Korean families were studied: 1 is a family whose members have been affected for 4 generations and the other for 2 generations. Using peripheral blood samples, we performed chromosomal analysis using the banding technique with Giemsa stain and karyotyping. We investigated the shape and structure of 46 chromosomes, looking for translation, deletion, inversion, ring chromosome, and isochromosome abnormalities. All peripheral blood samples demonstrated no chromosomal abnormalities, though the genetic nature of foot polydactyly and a new genetic locus was identified recently by other studies. Familial pedigree analysis suggested that polydactyly was inherited as an autosomal dominant trait in the first family. The mode of inheritance for the second family could not be determined due to an insufficient number of family members. The result of this study brought us to the conclusion that, while genetic factors play a major role in polydactyly, other factors may contribute to its occurrence.

Clinical correlates of filarial infection in Haitian children: an association with interdigital lesions

To assess clinical findings associated with Wuchereria bancrofti infection, 192 school children in a filariasis-endemic area of Haiti underwent physical and ultrasonographic examinations and testing for circulating filarial antigen (CFA). The CFA-positive children were more likely than CFA-negative children to have severe interdigital lesions (> or = 1 macerated lesion with involvement of > or = 4 toe web spaces) (P < 0.0001) and inguinal (P = 0.003) or crural (P = 0.004) lymph node pathology. In multivariate analysis, CFA positivity remained a significant predictor for severe interdigital lesions (P = 0.006) and inguinal lymph node pathology (P = 0.05). Ultrasound detected adult worms and lymphangectasia (diameter = 2.0-4.0 mm) in 11 (10.8%) CFA-positive children. Among CFA-positive children, ultrasonographic detection of adult worms was associated with inguinal (P = 0.01) and crural (P = 0.004) lymph node pathology and advanced pubertal stage (sexual maturity rating = 3-5) (P = 0.02). This is the first study to associate interdigital lesions with filarial infection in children.

A case of toe macrodactyly treated by application of a vascularised nail graft

Macrodactyly is a relatively rare congenital abnormality of the fingers and toes and is difficult to treat. We report a new method for treating toe macrodactyly in which a nail with a vascularised pedicle is raised, the toe is shortened to an appropriate length, and the nail transferred to an aesthetically appropriate proximal site. Although this technique is of a higher level of difficulty than conventional procedures involving pedicled nail flaps, allows aesthetically more favourable nail reconstruction by single-stage operation.

The effect of first metatarsophalangeal arthrodesis on transverse plane deviation of the second toe: a retrospective radiographic study

The purpose of this retrospective, radiographic study was to examine the effect of first metatarsophalangeal arthrodesis on the transverse plane deviation of the second metatarsophalangeal joint. Sixty-nine patients (76 feet) were separated into 3 groups based on preoperative diagnosis: group 1, hallux valgus; group 2, hallux rigidus; and group 3, rheumatoid forefoot deformity with concomitant lesser metatarsal head resection. Intermetatarsal, hallux abduction, and second metatarsophalangeal angles were measured on preoperative and follow-up anteroposterior radiographs. Multivariate analysis found a significant postoperative change (P < .001) in both the intermetatarsal and hallux abduction angles for all groups, but no significant change in the second metatarsophalangeal angle for any group. There was also no significant difference in the number of patients with medial versus lateral second toe deviation in each group. The addition of a second ray procedure, such as a digital arthrodesis or second metatarsal decompression osteotomy, in groups 1 and 2 did not correlate to the amount of change in second metatarsophalangeal deviation. However, there was a significant correlation (r = .330; P = .004) between the amount of change in the hallux abduction angle and the amount of change in the second metatarsophalangeal angle. A lack of change in the second metatarsophalangeal angle in patients with hallux valgus and hallux rigidus suggests that the creation of a stable medial buttress may protect the lesser digits. However, in patients with rheumatoid, this lack of change denotes a postoperative recurrence of lateral deviation of the second toe despite lesser metatarsal head resection and stabilization of the hallux.

Premature osteoarthritis of the knee associated with cartilage hypertrophy and phalangeal dysgenesis

A woman presented with premature knee osteoarthritis associated with marked femoral cartilage hypertrophy. She also exhibited phalangeal dysgenesis, suggesting this may be an unrecognised syndrome that may predispose to knee osteoarthritis.

Congenital macrodactyly: a clinical study

Congenital macrodactyly is a rare congenital malformation characterised by progressive enlargement of all mesenchymal elements of a digit. The present study is an attempt to draw the attention towards the similarities and differences between macrodactyly of the hand and foot. Radiographical, operative findings and histopathological examination of five cases are included in the present study. Emphasis was given to know the possible basic lesion. Radiographic findings, which differentiate this entity from other forms of local gigantism, were also analysed. The most characteristic finding noted was excessive overgrowth of fibro-fatty tissue with unusually large fatty lobules, apparently fixed by a mesh of dense fibrous tissue. Hypertrophy and tortuosity of the digital nerve, a striking feature in macrodactyly of the hand, was notably absent in cases affecting the foot. None of the patients had any other associated congenital anomalies. Neither the patients nor any of their family members had any stigmata of neurofibromatosis. Chromosomal study was normal in all of them. We conclude that in macrodactyly of the foot, excessive proliferation and accumulation of adipose tissue was the basic lesion, whereas involvement of the nerve might be the fundamental lesion in gigantism of the hand. Furthermore, whatever be the basic lesion, the final pathway must be either the local deficiency of a growth inhibiting factor or local expression of a basic intrinsic factor, leading to excessive growth of all elements of the digit.

Bizarre parosteal osteochondromatous proliferation with a t(1;17) translocation

Bizarre parosteal osteochondromatous proliferation (BPOP) is a benign lesion that tends to recur repeatedly. Histologically, BPOP contains three components (cartilage, bone, and spindle cells) in differing amounts. The histological findings of BPOP are similar to those of florid reactive periostitis (FRP) and subungual (Dupuytren's) exostosis. Some authors have postulated that all of these conditions are reactive proliferative lesions representing different phases of reactive processes. Whether BPOP is a reactive proliferative lesion or a neoplastic lesion, however, remains controversial. Recently, a t(1;17)(q32;q21) translocation in BPOP was detected using chromosome banding and fluorescence in situ hybridization (FISH) analyses. Here, we describe a 39-year-old Japanese female with BPOP arising in the proximal phalanx of her third toe. A cytogenetic analysis revealed a t(1;17)(q 42;q23) translocation. The breakpoints in this case are located close to those of previously reported cases. These results suggest that t(1;17) is a distinct translocation of BPOP and that BPOP is a neoplastic lesion, rather than a reactive proliferative process.

A variant of Cenani-Lenz syndactyly (CLS): review of the literature and attempt of classification

An oligodactylous variant of Cenani-Lenz syndactyly and its surgical treatment is presented. The deformity is believed to be of autosomal recessive inheritance and caused by a disordered axial and longitudinal differentiation of the upper and lower extremities. The classical form is mainly characterised by a complete syndactyly of the hands. Malformations may also affect the bones of the forearm and, to a lesser extent, the lower limbs. We analysed clinical features and compared them with those previously described. According to our research of literature and our clinical findings there seem to exist two grossly different clinical phenotypes: spoon hand type and oligodactyly type. Typical constant clinical features such as carpal, metacarpal and digital synostoses, disorganisation of carpal bones, reduction of digital rays and syndactyly of toes are found in the reported cases. Inconstant features such as radio-ulnar synostosis, brachymesomelia, metatarsal synostoses and reduction of metatarsal rays may be present. In our case, successful bilateral digital ray individualisation and tendon transfers were performed to construct a grip function of the grossly deformed hands.

Spondyloperipheral dysplasia is caused by truncating mutations in the C-propeptide of COL2A1

The term "spondyloperipheral dysplasia" (SPD) has been applied to the unusual combination of platyspondyly and brachydactyly as observed in a small number of individuals. The reported cases show wide clinical variability and the nosologic status and spectrum of this condition are still ill defined. Zabel et al. [1996: Am J Med Genet 63(1):123-128] reported an individual with short stature and SPD who was heterozygous for a frameshift mutation in the C-propeptide domain of COL2A1. To explain the additional finding of brachydactyly that is not an usual feature of the type II collagenopathies, it was postulated that the nature of the mutation induced precocious calcification and premature fusion of metacarpal and phalangeal growth plates. The C-propeptide of collagen II had previously been found to promote calcification ("chondrocalcin"). We have ascertained two further individuals with clinical and radiological findings of a type II collagenopathy in infancy who developed brachydactyly type E like changes of fingers and toes in childhood. In both individuals, heterozygosity for novel, distinct mutations in the C-propeptide coding region of COL2A1 were found. Although all three mutations (the one previously reported and the two novel ones) predict premature termination, their location close to the 3'-end of the mRNA probably protects them from nonsense-mediated decay and allows for synthesis of mutant procollagen chains. However, loss of crucial cysteine residues or other sequences essential for trimerization prevents these chains from associating and participating in procollagen helix formation, and thus leads to accumulation in the ER-consistent with EM findings. The mechanism leading to precocious fusion of phalangeal epiphyses remains to be explored. The consistency of clinical, radiographic, and molecular findings in these three unrelated individuals confirms SPD as a distinct nosologic entity. The diagnosis of SPD is suggested by the appearance of brachydactyly in a child who has clinical and radiographic features of a collagen II disorder.

Involvement of the foot in patients with psoriatic arthritis. A review of 26 cases

OBJECTIVE

To describe the clinical and radiological features of foot involvement in patients with psoriatic arthritis.

METHODS

We retrospectively reviewed the medical records of patients admitted between 1972 and 1999 for psoriatic arthritis with involvement of the foot. We included all patients who had peripheral and/or axial, asymmetric, chronic inflammatory joint disease meeting or not Avila's radiological criteria for psoriatic arthritis, with or without other imaging findings suggestive of psoriatic arthritis and with or without psoriasis.

RESULTS

Twenty-six patients were included. Inflammatory heel pain was reported by 14 patients, whereas forefoot involvement was found in only seven patients. Sausage toe was present in two patients. None of the patients had Bauer's toe (combining arthritis and psoriatic skin and/or nail changes) or psoriatic onychopachydermoperiostitis of the great toe. Radiological abnormalities were found in 20 patients. Half the patients had calcaneal changes. Osteoperiostitis of the great toe was noted in two patients and mushrooming in five.

DISCUSSION

The features of psoriatic arthritis in Morocco seem similar to those in other countries. Hindfoot involvement was present in 53% of patients. Involvement of the forefoot was rarely recorded in the charts, suggesting missed cases because of insufficient attention to the forefoot during the physical examination and availability of anteroposterior radiographs only. Oblique views (Hirtz and Chaumet) should be obtained because they give a clearer image of the distal part of the toes, which is often difficult to analyze on anteroposterior films.

Imaging of the nail unit and toes-a pictorial review. Illuminating newer techniques by looking "back to the future"

Despite a number of multimodality options now available when imaging the distal digits for potential pathology, the plain radiograph remains the everyday "workhorse" in podiatric medical practice. This section will illustrate how looking back to simple basics can provide new pathways to future practice.

Sesamoid and toe fractures

Injuries of the toes and sesamoids of the first metatarsophalangeal joint comprise a wide spectrum of traumatic entities. Despite the fact that a majority of lesions may well respond to nonsurgical treatment and exhibit an excellent prognosis, appropriate clinical and imaging analysis is mandatory to select those injuries that require specific therapeutic and surgical measures to avoid long-term sequelae of functional disability.

Congenital curly toe of the fetus

OBJECTIVES

To assess the prevalence, prenatal detection rate, and associated anomalies of congenital curly toe in an unselected obstetric population.

METHODS

Between September 2001 and July 2002, 1167 singleton fetuses in the second and third trimesters underwent routine prenatal ultrasound at our hospital. Congenital curly toe was diagnosed when the fourth or fifth toe was not fully delineated on the axial image with medial and plantar flexion on the coronal image. All neonates underwent a physical examination within 3 days after delivery. Radiography was performed on those infants with curly toe. We assessed the prevalence, prenatal detection rate, and associated anomalies of the condition.

RESULTS

There were 38 congenital curly toes among the 1167 neonates, yielding a total prevalence of 32.6 per 1000. In 26 of the 38 the fourth toe was curly and in 12 the fifth toe was curly. Of those in which the fourth toe was curly, 26.9% involved the right toe, 65.4% the left, and 7.7% involved both toes. For a curly fifth toe, these values were 25.0%, 16.7% and 58.3%, respectively. There was no associated structural anomaly, chromosomal abnormality, or syndrome in any case. Sixteen of the 38 curly toes were detected on prenatal ultrasound, including 13 of 26 with the fourth toe being curly and three of 12 with the fifth being curly.

CONCLUSIONS

Congenital curly toe is not an uncommon condition, and can be detected on the prenatal ultrasound. Although it usually appears as an isolated finding without clinical significance, thorough ultrasound examination of the fetus should be recommended.

Hallux rigidus – Ein globales Problem?

Der Begriff «Hallux rigidus» steht für eine Bewegungseinschränkung der Großzehe, die insbesondere beim Abrollen während des Gehens Schmerzen verursacht. In der Regel besteht eine Arthrose des Metatarsophalangealgelenks. Im Frühstadium ist das Röntgenbild normal, später bildet sich eine Arthrose zunächst im dorsalen Anteil des Gelenks. Im Vordergrund der konservativen Therapie stehen die Entzündungshemmung am Metatarsophalangealgelenk und eine Entlastung des Gelenks durch orthopädietechnische Maßnahmen. Bei Fortschreiten der Arthrose kommen gelenkerhaltende Operationstechniken wie die Cheilektomie zur Anwendung, bei der der degenerierte dorsale Anteil der Metatasale I-Gelenkfläche reseziert, wird. Im späten Stadium ist bei den überwiegend körperlich aktiven und jüngeren Patienten mit einem Hallux rigidus die Arthrodese des Metatarsophalangealgelenks die Therapie der Wahl. Nur beim Patienten im fortgeschrittenen Lebensalter und mit deutlich verminderter allgemeiner Körperaktivität kommt die Resektionsarthroplastik als relativ einfaches Operationsverfahren in Betracht. Endoprothesen des Metatarsophalangealgelenks führen im Vergleich zu den genannten alternativen Verfahren zu schlechteren Ergebnissen.

An Unusual and Nonclassified Central Polydactyly of the Foot

Central-type, 8-toed polydactyly is a distinctly rare congenital foot anomaly. In this report, a new subtype of the metatarsal type of the central ray polydactyly of the foot is presented. This includes a triplication, one of which is Y-shaped of the second metatarsal and 8 toes. In the literature, polydactyly of the foot has been usually operated during childhood after walking age. We performed the surgery at 6 months of age. After ray amputation of the extra toes, we reapproximated the muscle pieces that remained on the original first and second metatarsals and repaired the transverse metatarsal ligament. Despite the early surgery, we did not encounter any problems intraoperatively and postoperatively.