Outcomes Following Excision of Toe Glomus Tumors

BACKGROUND

Glomus tumors are uncommon tumors and their occurrence in the foot is even less common. Glomus tumors of the toes are often missed, causing delays in diagnosis and treatment. We report an ambispective observational study of glomus tumors of the toes that were treated at our institution.

METHODS

We reviewed the records of all the patients who underwent excision of toe glomus tumors in our department from January 2010 to September 2022. The follow-up data were collected from the outpatient records and by telephonic interview. Single Assessment Numeric Evaluation (SANE) score, Foot and Ankle Outcome Score (FAOS), and the Foot Function Index (FFI) were collected.

RESULTS

Out of all the patients treated for glomus tumors, we found that 7 patients had glomus tumors of the toes. Of the 7 patients, 6 were women and 1 was a male. The mean follow-up of our patients was 66.4 months (range, 7-109 months). Of the 7 patients, 1 presented with recurrent glomus tumor 30 months following the primary operation, for which she underwent excision again, after which she was symptom free. Another patient who developed recurrent symptoms on telephonic interview refused any further treatment. Among the 6 patients who were symptom-free at follow-up (including the patient who underwent excision for the recurrent tumor), the median SANE score, and FFI were 99.5 (IQR, 96-100) and 0.5 (IQR, 0-2) respectively. The mean FAOS was 96 (SD, 3.3).

CONCLUSION

Surgical excision of the subungual toe glomus tumors can be curative. Recurrence of toe glomus tumors was noted in 2 patients (29%), one of whom refused further surgery. Re-excision in the other patient resulted in complete resolution of symptoms.

LEVEL OF EVIDENCE

Level III, ambispective observational study.

The Reliability of Common Radiographic Measurements Used to Describe Foot Deformities

Radiographic measurements are frequently used to classify deformity and determine treatment options. Correlation coefficients can be used to determine inter- and intrarater reliability. Reliability is a required feature of any measurement if the measurement is to provide valid information. We calculated correlation coefficients for standard radiographic measurements used to categorize foot deformities: this was done for 52 sets of radiographs assessed by 5 raters. We aimed for generalizability, and kept rater instructions to match what was originally published for each measurement of interest with schematic illustration. Overall, our results mostly showed a lack of inter-rater reliability (correlation coefficients <0.4), and strong intrarater reliability (correlation coefficients >0.6), for 12 forefoot and 12 rearfoot radiographic measurements that are commonly used. The results of this investigation bring into question the routine use of radiographic measurements to categorize deformity, select treatments, and measure surgical outcomes, between surgeons, because the validity of these measurements appears to be threatened by weak inter-rater reliability. In order for these measurements to be considered useful, it may be necessary for surgeons to more rigorously define and practice making standard radiographic measurements.

Disposable Barrel Used for Easy and Fast Toe Space Examination

Chronic candidiasis with bacterial infection is common infection in the toe web which is is not inspected and treated well in early stage, and it is now the cause of cellulitis in the leg in a number of cases. To examine the narrow space of the toe web and to treat and to reduce the complication, we described the use a disposable syringe barrel.

Extraskeletal Myxoid Chondrosarcoma Identified in a Traumatic Fracture of the Toe: A Case Report

Introduction

Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft-tissue sarcoma that typically presents in the proximal lower extremity and limb-girdle. It can be easily misdiagnosed, especially when located in atypical locations like the foot.

Case Report

We present the case of an 80-year-old Caucasian female with a left 3rd toe pain and swelling that was initially misdiagnosed as a traumatic fracture on radiographs but later determined to be an indolent EMC based on histology. She was successfully treated with amputation of the toe.

Conclusion

EMC should be considered in the differential of osseous and soft-tissue abnormalities on radiographic imaging of the extremities. As reported in the literature, it can present in atypical locations with minimal symptoms and successful treatments include resection. Future cases presenting similarly should be evaluated for EMC and, if present, reported along with their applied treatment protocols to allow for further assessment of current therapeutic guidelines.

Osteoid Osteoma of the Toe: A Rare Presentation with Diagnostic Challenges

Teaching Point: Osteoid osteoma is one of the most frequent benign bone tumors; however, when found in the toes it usually presents atypical clinical and radiological features including soft tissue swelling that can lead to misdiagnosis.

Comparative Study of Digital Squamous Cell Carcinoma in Giant, Standard, and Miniature Schnauzers

In schnauzers, a breed predisposition to squamous cell carcinoma of the digit (dSCC) is well known. The aim of this study was to compare the clinical and macroscopic findings of dSCCs in giant (GSs), standard (SSs), and miniature schnauzers (MSs).

METHODS

Pathology reports of 478 dSCCs from 417 schnauzers (227 GSs, 174 SSs, and 16 MSs) were retrospectively evaluated.

RESULTS

The MSs were older than the SSs and GSs (p ≤ 0.01). The male GSs were predisposed to dSCC (p < 0.05). In the GSs, the nodular dSCCs were larger than in the MSs (p ≤ 0.05) and SSs (p ≤ 0.001). The digital SCCs were mostly diagnosed at the forelimbs, especially at digits 1, 2, and 5. At the hindlimbs, the affected toes differed between the GSs and SSs. Multiple dSCCs were more common in SSs than in GSs (p = 0.003). If dSCC was the cause of death, the survival time was shorter than in dogs dying from other diseases (p = 0.004). Metastases occurred in 20% of the cases and led to a significantly shorter survival time in both the GSs and SSs (p < 0.001).

CONCLUSIONS

The results showed various differences in the dSCC depending on the size variant of the schnauzer.

Immunohistochemical and Molecular Genetic Analysis of Canine Digital Mast Cell Tumours

Grading, immunohistochemistry and c-kit mutation status are criteria for assessing the prognosis and therapeutic options of canine cutaneous mast cell tumours (MCTs). As a subset, canine digital MCTs have rarely been explored in this context. Therefore, in this retrospective study, 68 paraffin-embedded canine digital MCTs were analysed, and histological grading was assessed according to Patnaik and Kiupel. The immunohistochemical markers KIT and Ki67 were used, as well as polymerase chain reaction (PCR) for mutational screening in c-kit exons 8, 9, 11 and 14. Patnaik grading resulted in 22.1% grade I, 67.6% grade II and 10.3% grade III tumours. Some 86.8% of the digital MCTs were Kiupel low-grade. Aberrant KIT staining patterns II and III were found in 58.8%, and a count of more than 23 Ki67-positive cells in 52.3% of the cases. Both parameters were significantly associated with an internal tandem duplication (ITD) in c-kit exon 11 (12.7%). French Bulldogs, which tend to form well-differentiated cutaneous MCTs, had a higher proportion of digital high-grade MCTs and ITD in c-kit exon 11 compared with mongrels. Due to its retrospective nature, this study did not allow for an analysis of survival data. Nevertheless, it may contribute to the targeted characterisation of digital MCTs.

The collisional geometry of economical walking predicts human leg and foot segment proportions

Human walking appears complicated, with many muscles and joints performing rapidly varying roles over the stride. However, the function of walking is simple: to support body weight as it translates economically. Here, a scenario is proposed for the sequence of joint and muscle actions that achieves this function, with the timing of muscle loading and unloading driven by simple changes in geometry over stance. In the scenario, joints of the legs and feet are sequentially locked, resulting in a vaulting stance phase and three or five rapid 'mini-vaults' over a series of 'virtual legs' during the step-to-step transition. Collision mechanics indicate that the mechanical work demand is minimized if the changes in the centre-of-mass trajectory over the step-to-step transition are evenly spaced, predicting an even spacing of the virtual legs. The scenario provides a simple account for the work-minimizing mechanisms of joints and muscles in walking, and collision geometry allows leg and foot proportions to be predicted, accounting for the location of the knee halfway down the leg, and the relatively stiff, plantigrade, asymmetric, short-toed human foot.

KITLG Copy Number Germline Variations in Schnauzer Breeds and Their Relevance in Digital Squamous Cell Carcinoma in Black Giant Schnauzers

Copy number variations (CNVs) of the KITLG gene seem to be involved in the oncogenesis of digital squamous cell carcinoma (dSCC). The aims of this study were (1) to investigate KITLG CNV in giant (GS), standard (SS), and miniature (MS) schnauzers and (2) to compare KITLG CNV between black GS with and without dSCC. Blood samples from black GS (22 with and 17 without dSCC), black SS (18 with and 4 without dSSC; 5 unknown), and 50 MS (unknown dSSC status and coat colour) were analysed by digital droplet PCR. The results are that (1) most dogs had a copy number (CN) value > 4 (range 2.5-7.6) with no significant differences between GS, SS, and MS, and (2) the CN value in black GS with dSCC was significantly higher than in those without dSCC (p = 0.02). CN values > 5.8 indicate a significantly increased risk for dSCC, while CN values < 4.7 suggest a reduced risk for dSCC (grey area: 4.7-5.8). Diagnostic testing for KITLG CNV may sensitise owners to the individual risk of their black GS for dSCC. Further studies should investigate the relevance of KITLG CNV in SS and the protective effects in MS, who rarely suffer from dSCC.

Subungual Osteochondromas of the Toe: Two Case Reports for Diagnosis and Treatment

Benign cartilaginous tumors, known as chondrogenic tumors, show cartilage components in the microscopic diagnosis. We present two clinical cases with cartilaginous tumors of the toes showing distinctive clinical manifestations. Two juvenile patients visited our outpatient clinic due to tumors with toenail deformities. A 10-year-old girl presented with a palpable mass with a nail deformity on the left third toe. The initial pathology report was soft tissue chondroma until complete resection. Another 15-year-old male patient visited the dermatology department with a toenail deformity and underwent a punch biopsy. The pathology report was fibrosis with myxoid degeneration. Excisional biopsies were performed for both patients. In the operative field, we observed exophytic tumors connected to the distal phalangeal bones. The final pathology reports were subungual osteochondroma on both patients. The specimen exhibited mature bone trabeculae with a focal cartilaginous cap. Benign cartilaginous tumors have a slow, progressive course and do not show significant symptoms. However, tumors in subungual areas are accompanied by toenail deformities and they can cause pain. Their clinical characteristics lead to a delayed diagnosis. Surgeons can be confused between soft tissue and chondrogenic tumors. When they conduct physical examinations, these categories should be considered in the differential diagnosis.

Evaluating the Histologic Grade of Digital Squamous Cell Carcinomas in Dogs and Copy Number Variation of KIT Ligand-A Correlation Study

Dark-haired dogs are predisposed to the development of digital squamous cell carcinoma (DSCC). This may potentially suggest an underlying genetic predisposition not yet completely elucidated. Some authors have suggested a potential correlation between the number of copies KIT Ligand (KITLG) and the predisposition of dogs to DSCC, containing a higher number of copies in those affected by the neoplasm. In this study, the aim was to evaluate a potential correlation between the number of copies of the KITLG and the histological grade of malignancy in dogs with DSCC. For this, 72 paraffin-embedded DSCCs with paired whole blood samples of 70 different dogs were included and grouped according to their haircoat color as follow: Group 0/unknown haircoat color (n = 11); Group 1.a/black non-Schnauzers (n = 15); group 1.b/black Schnauzers (n = 33); group 1.c/black and tan dogs (n = 7); group 2/tan animals (n = 4). The DSCCs were histologically graded. Additionally, KITLG Copy Number Variation (CNV) was determined by ddPCR. A significant correlation was observed between KITLG copy number and the histological grade and score value. This finding may suggest a possible factor for the development of canine DSCC, thus potentially having an impact on personalized veterinary oncological strategies and breeding programs.

Toe Acrometastasis as an Initial Sign of Metastasis in a Patient With a Large Cell Lung Carcinoma

Acrometastases are rare lesions that originate most commonly from the primary lung cancer. They can mislead the diagnosis and the treatment, since they often appear as an osteomyelitis of the affected area. The presence of these metastases is a sign of poor prognosis, with a life expectancy of few months. We report a case of a 78-year-old male with an acrometastasis to the distal phalanx of the right fourth toe. It was the first sign that his previously diagnosed large cell lung carcinoma had reached a metastatic stage. Amputation of the toe was considered in this case where the intense pain of his acrometastasis could not be managed even with strong analgesics.

Quantitative Evaluation and Midterm Progress of Reconstructed Toe Thickness in Lateral Ray Polydactyly of the Foot

In lateral ray polydactyly, the reconstructed toe often tends to become thicker, but no standard evaluation criteria for this thickness are available. 57 patients (68 toes) with Hirai-Togashi classification type II, III, or IV whom we were able to follow-up for more than 6 months after the operation were underwent measurement of the "Reconstructed toe width to Third toe width ratio." In addition, 16 patients who could be followed up for 3 years through the mid-term course were evaluated for mid-term progress. At 6 months after surgery, the mean R/T ratio was 1.246. In patients who could be followed up for 3 years after surgery, the mean R/T ratios at 6 months after surgery and at 3 years were significantly decreased. This result suggests that the thickness of the reconstructed toe may become relatively thin in the long term.

Subtalar Fusion for Correction of Forefoot Abduction in Stage II Adult-Acquired Flatfoot Deformity

BACKGROUND

Correction of talonavicular uncoverage (TNU) in adult-acquired flatfoot deformities (AAFD) can be a challenge. Lateral column lengthening (LCL) traditionally is utilized to address this. The primary study objective is examining stage II AAFD patients and determining if correction can be achieved with subtalar fusion (STF) comparable to LCL.

METHODS

Following institutional review board approval, retrospective chart review performed identifying patients meeting criteria for stage IIB AAFD who underwent either STF with concomitant flatfoot procedures (but not LCL) to correct TNU, or who underwent LCL as part of their flatfoot reconstruction. Patients indicated for STF had one or more of the following: higher body mass index (BMI), were older, had greater deformity, lateral impingement pain, intraoperative spring ligament hyperlaxity. Patients without 1-year follow-up or compete records were excluded. All other patients were included. A total of 27 isolated STFs identified, along with 143 who underwent LCL. Pre-/postoperative radiographic parameters obtained as well as PROMIS (Patient-Reported Outcomes Measurement Information System) and FAOS (Foot and Ankle Outcome Score) scores. Radiographic and patient reported outcomes both preoperatively and at 1-year follow-up evaluated for both groups.

RESULTS

STF patients were older (P < .05), with higher BMIs (P < .004). STF had significantly worse TNU (P < .001) than LCL patients, and average change in STF TNU was larger than LCL change postoperatively (P = .006), after adjusting for age, BMI, gender. PROMIS STF improvement reached statistical significance in Physical Function (P 0.011), for FAOS Pain (P 0.025) and Function (P = 0.04).

CONCLUSIONS

STF can be used in appropriately indicated patients to correct flatfoot deformity without compromising radiographic or clinical, correcting not only hindfoot valgus, but also talonavicular uncoverage (TNU) and corresponding medial arch collapse.

LEVELS OF EVIDENCE

Level III: Retrospective chart review comparison study (case control).

Digit melanomas are associated with poor prognostic factors and unfavorable survivals

BACKGROUND

The anatomic location of primary melanoma is significantly associated with outcome.

OBJECTIVE

To evaluate the prognostic factors and survival outcomes associated with melanomas on hand and foot digits.

METHODS

The data of 106 patients with digit melanomas were analyzed retrospectively.

RESULTS

Median age of patients was 55 years, and male-to-female ratio was one. Majority of the patients had skin melanomas (74.5%); and 25.5% of them had ungual melanomas. The lesions slightly more frequently affected toes (53.8%) and thumbs (55.9%); and 57.4% of the lesions were right-sided. Acral lentiginous melanoma was the major histological subtype (67.5%). Digit melanomas were associated with aggressive histological features, such as high Clark level (75%), thick Breslow depth (72.3%), presence of ulceration (74.3%), and high mitotic rate (58.3%). At admission, the rates of stage I-II, stage III, and stage IV diseases were 57.6%, 33%, and 9.4%, respectively. The recurrence and mortality rates were 41.7% and 46.2%, respectively. The 5-year RFS and OS rates were similar: 47%. Melanoma origins (skin vs. ungual), locations (finger vs. toe; first digit vs. others; and right vs. left), and histological subtypes (acral lentiginous melanoma vs. others) had no impact on survivals. The known poor prognostic histological factors, such as Clark level, Breslow thickness, mitotic rate, ulceration, and neurotropism, were found to be associated with both RFS and OS.

CONCLUSION

Digit melanomas are associated with poor clinicopathological prognostic features, and they might predict unfavorable survivals.

Reliability of the Radiographic Measurement of the Hallux Interphalangeal Angle

BACKGROUND

The hallux valgus interphalangeus (HVI) deformity has a common association with hallux valgus and hallux rigidus. The HVI is formed by the angle between the long axes of the proximal and distal phalanges. The normal value for this angular deformity in the coronal plane is less than 10°. The aim of this study was to analyze the intra- and inter-observer reliability of measuring the interphalangeal angle by orthopaedic surgeons. This study is the first study to evaluate specifically the reliability and reproducibility of measuring the HVI angle.

METHODS

Twenty-one X-ray prints of weightbearing feet constituted a set. Sixteen qualified orthopaedic surgeons were asked to measure the HVI angle of all 21 X-ray images in the set. Three randomized sets were sent to each evaluator at 4-week intervals. After all 3 sets were measured, data were retrieved and statistically analyzed to determine the inter- and intraobserver variability and reliability in the measurement of the HVI angle. Reproducibility of the HVI measurement was assessed using 3 categories, which included the ability to measure the same angle 3 times and achieve: 3° or less, 5° or less, and more than 5° variation.

RESULTS

The intraobserver reliability was found to be 5° or less in 85.2% of participants and the interobserver reliability was 81.2%. The researcher did not find significant correlation between the surgeons' level of experience with regard to the reliability of measuring the HVI angle.

CONCLUSION

The inter- and intraobserver reliabilities of measuring the HVI angle is 81.2% and 85.2%, respectively. The level of experience of the surgeon does not improve this reliability.

LEVELS OF EVIDENCE

Level II.

Temporary Screw Lateral Hemiepiphysiodesis of the First Metatarsal for Juvenile Hallux Valgus Deformity: A Case Series of 23 Feet

Juvenile hallux valgus (JHV) can limit the quality of life of the affected children. This study aims to evaluate the outcomes of temporary screw lateral hemiepiphysiodesis of the base of the first metatarsal. A chart review of patients who underwent temporary screw lateral hemiepiphysiodesis of the first metatarsal at a tertiary care pediatric orthopedic center was done. A total of 23 feet of 14 patients were included. The mean age of the patients was 10.6 ± 1.8 years, while the bone age was 11.1 ± 1.8 years. The mean follow-up duration was 24.7 ± 13.4 months (range: 12-60 months). The hallux valgus angle (HVA) improved from a mean of 30.9° ± 6.7° to a mean of 27.6° ± 8.2° (p = .001), while the intermetatarsal angle (IMA) improved from a mean of 14.6° ± 2.3° to a mean of 12.5° ± 3.0° (p < .001). Revision surgery was done for 5 (21.7%) feet of 3 patients for symptomatic uncorrected deformity (4 feet) or screw migration due to bone growth (1 foot). The mean HVA correction was 5.00° ± 3.7° in patients with bone age of 12 years or less compared to 1.50° ± 4.6° in patients with bone age of more than 12 years (p = .060). The radiological outcomes of temporary screw lateral hemiepiphysiodesis of the first metatarsal for JHV deformity correction are promising, especially in children with lesser bone age. The procedure was technically simple to perform and had minor complications.

An Intradermal Spindle Cell Lipoma on the Plantar Hallux in a Patient With Scleroderma and Ehlers-Danlos Syndrome: A Case Report

Spindle cell lipoma (SCL) is a rare variant of lipomas, which predominantly occurs in the regions of shoulder and posterior neck but rarely on the toes. Epidemiological studies have demonstrated increased incidence of cancers in patients with scleroderma. A 28-year-old female with scleroderma and Ehlers-Danlos syndrome developed a painful, skin colored, raised, polypoid lesion on the plantar side of the left hallux for several years. The lesion was surgically excised. Pathological evaluation showed intradermal bland spindle cells associated with delicate ropey/refractile collagen bundles with strong and diffuse cytoplasmic expression of CD34 but negative expression of Rb and S-100, which are consistent with SCL. We report a first case of SCL on the plantar hallux in a young female patient with scleroderma and Ehlers-Danlos disease with clinical presentations, histopathology, and treatment to raise awareness of clinicians to this rare variant of lipomas.

Fibro-Osseous Pseudotumor Arising From Nail Bed of the Great Toe: A Rare Case of Recurrence

A fibro-osseous pseudotumor (FOPT) is a rare, rapidly enlarging, benign soft-tissue neoplasm that presents with localized pain, swelling, and redness. It typically presents in the hands and much less frequently in the feet. FOPT is characterized histologically by foci of osseous differentiation within the proliferated fibroblasts. This must be differentiated from other benign and malignant lesions. FOPT of the toes has been described in a few reports, but recurrence, following surgical excision, is extremely rare. Here we report a young, healthy female patient who presented with a rapidly growing FOPT of the left great toe. This unusual case had recurred twice following surgical excision, all within a 2-month period of time. The lesion was again completely excised, with no recurrences at follow-ups of 18 and 36 months. In conclusion, FOPT is a rare soft tissue lesion of the toes. It features fibroblastic proliferation and osseous differentiation, which needs to be differentiated from other benign and malignant tumors. The standard treatment is complete surgical excision with an excellent prognosis.

Nonincisional Osteotomy for Gradual Lengthening by Callus Distraction for Congenital Brachymetatarsia

Gradual lengthening by distraction osteogenesis is widely used for congenital brachymetatarsia. The usual presenting complaint is the patient's cosmetic appearance. Osteotomy is an integral element. A nonincisional surgical approach for osteotomy can reduce dorsal longitudinal scarring and help preserve the periosteal blood supply to the bone during surgical dissection. Between June 2003 and January 2019, we performed gradual lengthening by callus distraction with nonincisional osteotomy for congenital brachymetatarsia on 13 digits in 5 patients. All 5 patients were female, and their average age was 18 years old. The lengthened bones involved 3 first metatarsals, 2 third metatarsal, and 8 fourth metatarsal bones. The mean gain in length was 15.2 mm (10-21 mm). The mean duration of distraction was 36.2 days (30-48 days). The mean duration of consolidation was 62.8 days (28-103 days). The lengthened segment consolidated in all cases. One patient had early consolidation and did not wish to undergo further surgery. There were no cases of trouble due to drilling for osteotomy. All patients had a normal gait and were satisfied with the cosmetic results.

Development of an Effective Treatment Algorithm for the Stubbed Great Toe

While toe fractures are the most common fractures of the foot in the pediatric population, the majority of these injuries do not require aggressive treatment. However, the mechanism of stubbing the great toe with bleeding at the base of the nail, a laceration proximal to the nail fold, or signs of a displaced fracture through the physis of the distal phalanx signal a likely open fracture involving the distal phalanx of the great toe. Unrecognized open fractures can lead to mistreatment and consequently osteomyelitis or growth disturbances. We report a case of a patient who required open reduction and Kirschner wire (K-wire) stabilization of a Salter-Harris I fracture involving the distal phalanx of the great toe after delayed recognition of the initial injury and subsequent failure to obtain closed reduction with a digital block in the clinic setting. We present this case to demonstrate the importance of vigilance in the evaluation of stubbed great toe injuries and propose an algorithm to guide the management of these injuries.

Verruciform Acral-Associated (Vacas) Xanthoma: Case Report and Review

Verrucous xanthoma is a benign histiocytic lesion of macrophage derivation. We describe a woman with a non-mucosal verruciform xanthoma located on her right thumb and review the features of patients with verruciform acral-associated xanthoma. A 69-year-old woman presented with a lesion on her right thumb of eight years duration that had been previously treated with liquid nitrogen cryotherapy without resolution. An initial biopsy was consistent with the surface of a callous. A second biopsy demonstrated a verruciform xanthoma. The patient elected to apply lactic acid 12% twice daily and pare the lesion with a pumice stone once weekly; this resulted in flattening of the xanthoma-associated hyperkeratosis. Acral verruciform xanthoma has, albeit rarely, been described on the hands and feet of individuals. Including the patient in this report, six individuals have been reported with verrucous xanthoma on the hands and 12 individuals have been reported with a verrucous xanthoma on the feet. Verruciform xanthoma most commonly occurs on the oral mucosa. Genital lesions are also a frequent site. Acral-distributed verruciform xanthoma is rare; we propose that a verruciform xanthoma that occurs on acral sites be referred to as a verruciform acral-associated (Vacas) xanthoma.

Digital Lesions in Dogs: A Statistical Breed Analysis of 2912 Cases

Breed predispositions to canine digital neoplasms are well known. However, there is currently no statistical analysis identifying the least affected breeds. To this end, 2912 canine amputated digits submitted from 2014–2019 to the Laboklin GmbH & Co. KG for routine diagnostics were statistically analyzed. The study population consisted of 155 different breeds (most common: 634 Mongrels, 411 Schnauzers, 197 Labrador Retrievers, 93 Golden Retrievers). Non-neoplastic processes were present in 1246 (43%), tumor-like lesions in 138 (5%), and neoplasms in 1528 cases (52%). Benign tumors (n = 335) were characterized by 217 subungual keratoacanthomas, 36 histiocytomas, 35 plasmacytomas, 16 papillomas, 12 melanocytomas, 9 sebaceous gland tumors, 6 lipomas, and 4 bone tumors. Malignant neoplasms (n = 1193) included 758 squamous cell carcinomas (SCC), 196 malignant melanomas (MM), 76 soft tissue sarcomas, 52 mast cell tumors, 37 non-specified sarcomas, 29 anaplastic neoplasms, 24 carcinomas, 20 bone tumors, and 1 histiocytic sarcoma. Predisposed breeds for SCC included the Schnauzer (log OR = 2.61), Briard (log OR = 1.78), Rottweiler (log OR = 1.54), Poodle (log OR = 1.40), and Dachshund (log OR = 1.30). Jack Russell Terriers (log OR = −2.95) were significantly less affected by SCC than Mongrels. Acral MM were significantly more frequent in Rottweilers (log OR = 1.88) and Labrador Retrievers (log OR = 1.09). In contrast, Dachshunds (log OR = −2.17), Jack Russell Terriers (log OR = −1.88), and Rhodesian Ridgebacks (log OR = −1.88) were rarely affected. This contrasted with the well-known predisposition of Dachshunds and Rhodesian Ridgebacks to oral and cutaneous melanocytic neoplasms. Further studies are needed to explain the underlying reasons for breed predisposition or “resistance” to the development of specific acral tumors and/or other sites.

Endoscopic Resection of a Toe Web Fibroma That Was Mimicking a Morton's Neuroma

Fibroma of tendon sheath is a rare benign tumor originating in the tendon or tendon sheath. It most commonly occurs in upper extremity and rarely presents in the foot. In this report, a case of fibroma of tendon sheath in the web space with Morton's neuroma-like symptoms was presented. The tumor was resected endoscopically with preservation of the interdigital nerve. Post-operatively, the symptoms were subsided and the toe sensation was preserved. There was no sign of recurrence of the tumor at the end of 3-year-period of follow-up.

Parrot Beak Nail: Case Report and Review of Parrot Beak Nail Dystrophy

Parrot beak nail dystrophy is an excessive forward curvature of the nail plate that can affect both fingernails and toenails. Few cases have been reported since its original description in 1971; however, the incidence is estimated to be 2.5% in healthy individuals. Although the pathogenesis has not yet been established, parrot beak nail has been associated with chronic crack cocaine use, congenital bone or soft tissue abnormalities, other nail dystrophies, peripheral neuropathy, systemic sclerosis, and trauma to the nail. We describe an 86-year-old man with dementia and neuropathy who presented with an unperceived parrot beak nail of his left fourth toenail and concurrent onycholysis of his left great toenail. He had stopped visits with his podiatrist for nail care, which fostered the growth of these nail dystrophies. Our patient's parrot beak nail was successfully treated with nail clipping and regular nail maintenance to prevent its recurrence. The associated conditions, etiologies, and treatment of parrot beak nails are discussed.

Missed Fracture Dislocation of the Fifth Toe in a Two-Year-Old Child: A Case Report

Fracture dislocation injuries of the toes are rare among pediatric population. These injuries when acute are mostly treated conservatively and a good reduction must be ensured. We present the case of a 2-year-old girl who presented with missed chronic fracture dislocation of the proximal interphalangeal joint of the fifth toe, which was managed by open reduction and internal fixation and had a good outcome at over 1 year of follow up. We believe that this is the first case of this injury to be published in the peer-reviewed literature.

Early Results of a Novel Intramedullary Fixation Device for Proximal Fifth Metatarsal Fractures

BACKGROUND

Proximal fifth metatarsal fractures are commonly treated surgically due to their poor healing capacity. While intramedullary screws may be the most popular operative treatment choice, newer fixation methods continue to develop. We present a case series utilizing a novel intramedullary fixation device for proximal fifth metatarsal fractures. To our knowledge, no other study in the literature has assessed the safety and efficacy of this fixation method.

METHODS

A retrospective analysis was performed for 16 patients with proximal fifth metatarsal fractures who underwent fixation with the same novel intramedullary device. Patient charts were reviewed for fracture union, plantar fracture gapping, time to weight-bearing, refracture, perioperative complications, and secondary surgeries.

RESULTS

Sixteen patients with an average age of 43.3 years underwent fixation with this novel device from 2015 to 2020. Mean follow-up was 32.4 weeks. Fifteen of the 16 patients achieved radiographic union at a mean of 8.9 weeks. One patient suffered a nonunion. Mean time to full weight-bearing in, and out of, a walking boot was 6.4 and 9.8 weeks, respectively, for healed fractures. Mean plantar fracture gap improved from 1.22 mm to 0.88 mm following surgery. There were zero infections, refractures, or hardware complications. Three patients suffered iatrogenic fracture during implant insertion.

CONCLUSION

To our knowledge, this is the first report of early results for this novel intramedullary device. Excellent union rates, acceptable time to weight-bearing, and a low complication profile can be achieved. Based on our findings, we propose a safe and effective treatment option for proximal fifth metatarsal fractures.

LEVELS OF EVIDENCE

Level IV: Clinical case series.

Pilomatrixcarcinoma of the Foot: A New Localization of an Extremely Rare Adnexal Tumour

Pilomatrixcarcinoma is a very rare follicular neoplasm that shows matrical differentiation. The majority of these lesions originate de novo, while only a few cases of transformation of pilomatricoma (calcifying epithelioma of Malherbe) have been described in the literature. The neoplasm affects mostly middle-aged males with a male-to-female ratio of 3-4:1. The most common localizations are the face, head, trunk and extremites, though there are a few reports of pilomatrixcarcinoma of the eyelid, eyebrow, axilla and clitorid. Here, we describe the first case of a pilomatrixcarcinoma on the anterolateral surface of the first toe of the left foot of an 83-year-old patient, which developed in less than six months and led to amputation of the distal phalanx. We report a brief review of the current literature with particular emphasis on histopathological features useful for diagnosis.

Shortening Scarf Osteotomy for Macrodactyly and Valgus of the Hallux in Acrodysostosis Lesser Toes Brachydactyly

Level V: Case report.

A Demonstration of Long-Term Outcomes in a Case of Toe to Thumb Transfer Following Traumatic Amputation

The thumb is pivotal to many functions of the hand. Loss or absence of the thumb can be catastrophic to a patient’s functioning. Different methods can be employed to surgically fashion a new thumb. This case report aims to demonstrate one patient’s 34-year experience, reporting objective measures for a toe to thumb transfer, and documenting aesthetic outcomes. A semi-structured interview was conducted to gain insight into the patient's personal experiences. Validated assessment tools were used to assess range of movement and power, including Kapandji test, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Cochin Hand Function Scale, Qingfeng Hand Dynamometer, Self-Administered Foot Evaluation Questionnaire (SAFE-Q). A physical examination on the neothumb was performed, along with photography to document aesthetic outcome. A 55-year-old white British male injured his right thumb whilst on a placement year in a sugar refinery in the Netherlands. The thumb was traumatically amputated proximal to the metacarpophalangeal joint. The patient lived for a year without a thumb on his dominant hand, which had a huge effect on his functioning, with extensive input from physiotherapists to help increase his handgrip strength. He then underwent a transfer operation, with the removal of the second toe which was transferred to create a right neothumb. The patient has high physical functioning of his neothumb, however, he is still mildly limited due to pain 34 years post-operation. The objective assessment tools demonstrate a high functioning of the neothumb, with only mild deficits in the dexterity and the physical functioning of the right hand. He experiences mild pain and reduced function of the donor foot. Light touch was found to be absent on the right thumb, but present on the left. Two-point discrimination was 7 mm on the right thumb, and 0.5 mm on the left. In this case, we present a toe to thumb transfer that had very good outcomes after 34 years with few complications. This case demonstrates that great adaptation can occur over long periods of time, restoring near-normal function. Measures of functional outcomes were generally high, with main deficiencies in fine motor skills such as picking up a penny from a flat surface and undoing small buttons. Additionally, there can be good long term outcomes from toe to thumb transfer despite moderate impairment of function. There is hope that this can be used to encourage and reassure patients and surgeons alike that the neothumb is likely to give good outcomes both functionally and aesthetically for many years. 

Susceptibility Factors for Early Reamputation in Diabetic Great Toe Gangrene

INTRODUCTION

The effectiveness of the treatment has long been significant in diabetes and its complications, especially in developing countries. Prolonged hospitalization and repeated surgery should be avoided due to clinical and economic reasons. Wound breakdowns or necrosis can occur after amputation procedures, and subsequently will require reamputation. This study analyzed susceptibility factors in diabetic foot patients undergoing prior high toe amputation that are thought to be related to early reamputation.

METHODS

We performed a retrospective analysis in 107 patients that have undergone amputation for great toe gangrene, during May 2014-April 2019. Demographic data, clinical features, laboratory results and treatment modality, were documented and statistically analyzed by simple and multiple logistic regression methods.

RESULTS

Of all 107 patients, 17 patients had to undergo early reamputation. Limited dorsiflexion, level of amputation, and sepsis condition is shown to be significantly associated with first amputation. Multiple logistic regression analysis confirmed a significant association of early reamputation with amputation or disarticulation at the level of the metatarsophalangeal joint.

CONCLUSION

While limited ankle dorsiflexion and sepsis conditions need to be addressed comprehensively, from the surgical options point of view, we suggest ray amputation to be preferred over metatarsophalangeal joint disarticulation to prevent early reamputation.

Evaluating the Histologic Grade of Digital Squamous Cell Carcinomas in Dogs with Dark and Light Haircoat-A Comparative Study of the Invasive Front and Tumor Cell Budding Systems

Simple Summary

This study compares two different adapted grading systems for Canine digital squamous cells carcinomas, taking into account the animals’ haircoat color and focusing on the tumor’s invasive front. In general, dark-haired breeds develop more poorly differentiated DSCC than their light-haired counterparts. Additionally, both grading systems challenged are in agreement when grading well differentiated CDSCC in both populations but are discordant when assessing tumors with poorly differentiated features. To our knowledge, this is the first study comparing CDSCC in dogs by two histological grading systems, taking into account their phenotypical and presumed genotypical haircoat color and demonstrating that digital squamous carcinomas are not only more common in dark-haired dogs, but potentially more aggressive.

Abstract

Canine digital squamous cell carcinomas (CDSCC) are particularly aggressive when compared to their occurrence in other locations. Although these neoplasms are more frequently seen in dark-haired dogs, such as Giant Schnauzers, there are no data checking whether these tumors are histologically different between breeds. We histologically evaluated DSCC from 94 dogs. These were divided into two groups, namely, (1) dark-haired (N = 76) and (2) light-haired breeds (N = 18), further subdividing Group 1 into three subgroups, (1a) black breeds (n = 11), (1b) Schnauzers (n = 34) and (1c) black & tan breeds (n = 31). Adaptations from two different squamous cell carcinomas grading schemes from human and veterinary literature were used. Both systems showed significant differences when compared to Groups 1 and 2 in terms of final grade, invasive front keratinization, degree of invasion, nuclear pleomorphism, tumor cell budding, smallest tumor nest size and amount of tumor stroma. Group 2 was consistently better differentiated CDSCC than Group 1. However, there were no significant differences among the dark-haired breeds in any of the features evaluated. This study represents the first attempt to grade CDSCC while taking into account both phenotypical and presumptive genotypical haircoat color. In conclusion, CDSCC are not only more common in dark-haired dogs, they are also histologically more aggressive.

The skin of birds' feet: Morphological adaptations of the plantar surface

The skin of the foot provides the interface between the bird and the substrate. The foot morphology involves the bone shape and the integument that is in contact with the substrate. The podotheca is a layer of keratinized epidermis forming scales that extends from the tarsometatarsus to the toe extremities. It varies in size, shape, amount of overlap and interacts with the degree of fusion of the toes (syndactyly). A study of toe shape and the podotheca provides insights on the adaptations of perching birds. Our analysis is based on micro-CT scans and scanning electron microscopy images of 21 species from 17 families, and includes examples with different orientations of the toes: zygodactyl (toes II and III forward), anisodactyl (toes II, III, and IV forward), and heterodactyl (toes III and IV forward). We show that in these three groups, the skin forms part of a perching adaptation that involves syndactyly to different degrees. However, syndactyly does not occur in Psittacidae that use their toes also for food manipulation. The syndactyly increases the sole surface and may reinforce adherence with the substrate. Scale shape and toe orientation are involved in functional adaptations to perch. Thus, both bone and skin features combine to form a pincer-like foot.

Electron beam radiotherapy for Kaposi's sarcoma of the toe and web

Kaposi's sarcoma (KS) is an uncommon neoplastic vascular disease. The standard treatment for localized classic KS lesions is surgical excision or radiation. Superficial skin lesions are generally treated with electrons or low-energy photon fields using boluses. Radiotherapy (RT) can be used for poor surgical candidates or when surgery is expected to result in a poor cosmetic or functional outcome. This study is the first to describe a case of KS of the toe and web treated with electron RT, which precisely targeted the irregular skin lesion with a markedly higher presided effective treatment. An electron field is often limited in its effectiveness to deliver a homogeneous dose in cases with irregular contours. Here, we report our successful experience using low-energy electron beam radiation to treat KS of the toe and web. The patient was a 78-year-old woman who was diagnosed with KS located on the first and second toe and web, based on radiology, pathology, and immunohistochemical examinations. KS was located on the left foot and measured more than 2.5 cm. No regional nodal or distant organ metastasis was observed. She was medically inoperable. RT was performed using a 6-MeV electron with a 0.5-cm bolus and a dose of 50 Gy delivered in 25 fractions. Follow-up computed tomography 2 months after RT revealed a complete tumor response. Toxicity was limited to mild skin desquamation during treatment. The patient remains alive and has shown no evidence of disease for 2 years. This study suggests that electron RT is a safe and effective treatment option for skin lesions located on the toe and web.

Outcomes Study of an Innovative Method of Direct Repair of Metatarsophalangeal Joint Instability With an Angiocatheter Needle

Plantar plate tears are a common cause of forefoot pain and digital deformity. Repair of the plantar plate has been described from both a dorsal and plantar approach, each with its own benefits and drawbacks. Many of the approaches use costly devices. Our innovative repair method uses low-cost materials available in most operating room settings. We undertook a retrospective case series study to evaluate outcomes in patients who had undergone plantar plate repair with our method of repair. A review was performed to identify patients with plantar plate disruptions treated with this approach by a single surgeon. Clinical position and patient satisfaction of the involved joints were evaluated. Six patients (9 joints) underwent plantar plate repair using this innovative method and were evaluated at a median follow-up time of 19 (range 19 to 39) months. The mean visual analog scale pain score at final follow up was 0.8 ± 2.0. The median sagittal plane position of the toe was 2 mm (range 0 to 6) from the plantar skin of the digit to the ground. Five of the 6 patients (83%) stated that they would have the procedure again. We were able to obtain satisfactory outcomes with good alignment by repairing the plantar plate with this innovative method. Our data suggest that the described method of plantar plate repair can be used as an effective way to treat metatarsal phalangeal joint instability.

[Ultrasound of the Foot (Adapted According to SGUM Guidelines)]

Ultrasound of the Foot (Adapted According to SGUM Guidelines) Abstract. This review paper explains the simplified ultrasound anatomy of the foot including the ankle, midfoot and the toes. The adapted basic standard planes are described in detail according to SGUM guidelines and illustrated with a selection of high-resolution ultrasound images. A profound knowledge of the sonographic anatomy is essential for the detection of pathologies.

Surgical Fixation and Inter-phalangeal Arthrodesis of Symptomatic Non-union of Fracture of a Lesser Toe Distal Phalanx: A Case Report

Distal phalanx fractures of the toes are common injuries. The majority of them are treated conservatively with good outcome. We present the case of a painful non-union fracture of the distal phalanx of the 4th toe in a 60-year-old female patient with symphalangism of the 4th and 5th toes. She underwent surgical fixation of the fracture with concomitant inter-phalangeal joint (IPJ) arthrodesis for better stability. A transverse dorsal incision was made just distal to the IPJ to allow preparation of both the fracture site and IPJ. Fibrous tissue at the fracture non-union site was removed and the opposing surfaces drilled with a 0.88mm K-wire. Cartilaginous tissue at the IPJ was removed and similarly drilled with the 0.88mm K-wire. Stabilisation was achieved with a percutaneous headless compression screw. Radiographic union was achieved and the patient had resolution of symptoms 16 weeks after the surgery. The patient continued to be symptom-free at one year follow-up. This is the first case report of a surgically treated symptomatic non-union of distal phalanx fracture of a lesser toe in the literature.

Beach Feet: A Sand-associated Thermal Injury to the Soles of the Feet and the Plantar Aspect of the Toes

Athletes may develop sports-related dermatoses. Indeed, participants of aquatic-associated sports can experience dermatologic conditions that affect their feet when they play barefooted on the beach. These disorders are variable in etiology and include traumatic injury to the unprotected feet and toes, penetration of organisms (such as hookworm larva and schistosomiasis cercaria) into the feet and toes, and ultraviolet radiation-related maladies such as an acute phototoxic reaction (sunburn) and thermal injury from contact with hot sand. Indeed, exposure to hot sand can result in first-degree, second-degree or rarely third-degree burns. A 27-year-old man developed painful erythematous patches on the plantar feet and toes after running barefoot on the sand during a hot August afternoon on a dog beach in Del Mar, California. To emphasize both the injury-causing environment and the affected location, beach sand-associated thermal injury to the soles of the feet and the plantar aspects of the toes is referred to as beach feet.

Tarsal Tunnel Syndrome Secondary to Accessory Musculature: A Case Report

Tarsal tunnel syndrome (TTS) is a relatively uncommon compression neuropathy caused by impingement of the tibial nerve or one of the terminal branches. The presence of accessory musculature at the posteromedial aspect of the ankle has been identified as a rare cause of this condition. Despite the rarity of this condition, it must be considered in patients with refractory symptoms consistent with tibial nerve dysfunction. The accurate diagnosis of this condition relies heavily on a detailed history and physical examination, adequate imaging read by both surgeon and trained musculoskeletal radiologist, as well as a high level of suspicion for such pathology. In this case report, we describe a 46-year-old male with history, examination, and imaging all consistent with TTS secondary to accessory musculature. Following excision of an accessory soleus and flexor digitorum accessorius longus, as well as simultaneous tarsal tunnel release, the patient experienced full resolution of his symptoms. This highlights the importance of considering accessory musculature as a potential cause of TTS in patients presenting with tibial compression neuropathy. Levels of Evidence: Level V: Case Report.

Middle Phalangectomy for the Correction of Toe Clinodactyly With Longitudinal Epiphyseal Bracket in Young Children

Toe clinodactyly is often owed to the presence of a longitudinal epiphyseal bracket. We developed middle phalangectomy as a simple surgical solution for correction of toe clinodactyly because of longitudinal epiphyseal bracket in childhood. Ten children (ages 1-5 years) were operated on by the same surgeon between October 2007 and May 2012 (n = 15 feet). The same surgical technique was used in all the cases. A clinical evaluation included the appearance of the foot, the parents' level of satisfaction, and the presence or absence of bothersome symptoms (such as pain and discomfort when wearing footwear). A radiological evaluation under weight-bearing conditions enabled us to 1) rate the achievement of a natural-looking toe parabola and 2) detect the recurrence of clinodactyly (defined as an angle of >40° between 2 adjacent phalanges). The mean follow-up period was 5.4 (range 3.3 to 8.1) years. Nine sets of parents (90%) were satisfied with the results of the procedure. None had difficulties wearing boots, and only 1 child (10%) had residual pain during sports activities. Clinodactyly recurred in 3 feet in 3 patients (20% of feet, 30% of patients). Two (20%) of the latter patients underwent repeat surgery and achieved a lasting, satisfactory outcome. Middle phalangectomy is an appropriate procedure for the treatment of toe clinodactyly because of longitudinal epiphyseal bracket in young children. However, the patients' long-term outcomes (notably once bone growth has ended) must be assessed.

One-Stage Metatarsal Interposition Lengthening With an Autologous Fibula Graft for Treatment of Brachymetatarsia

Objective: Brachymetatarsia is defined as the pathological shortening of a metatarsal bone, which can cause cosmetic problems and pain in the forefoot. The main surgical treatment options are: extension osteotomy, interposition of a bone graft, and callus distraction. Usually, a bone graft from the iliac crest is used for the interposition osteotomy. The operative technique of graft extraction from the fibula has not been described in the literature yet. Methods: Eight feet with brachymetatarsia in 5 patients were evaluated retrospectively. The minimum follow-up period was 2 years. Via a dorsal V/Y skin incision, a central osteotomy on the metatarsal bone was done. A graft was obtained from the anterior fibula. The graft was inserted and fixed by a locking plate. Additional soft tissue procedures were done. Results: We had bony consolidation in all cases. The mean extension was 9.01 mm (5.49 to 12.54 mm). This corresponded to a mean 20.3% extension of the entire metatarsal. High patient satisfaction as well as high satisfaction regarding the cosmetic results were achieved. There were no postoperative complications. The range of motion of the metatarsal-phalangeal joint IV was 20% less preoperative in terms of plantar flexion. Standing up on tiptoes was possible in all patients postoperatively. One patient reported mild symptoms after sports activities. Conclusions: Because of its anatomy the graft adapts to the metatarsal IV bone. As our study showed, harvesting from the distal fibula causes no functional restriction. In terms of wound and bone healing as well as pain symptoms, this method should be considered as an alternative to the standard iliac graft.

Pediatric Acral Angioleiomyoma: Report of an Unusual Case and Review of the Literature

BACKGROUND

Angioleiomyoma is a classic painful cutaneous tumor of the limbs of middle aged adults. They are usually a straight-forward histologic diagnosis, being well-circumscribed or encapsulated lesions with both smooth muscle and vascular components.

CASE REPORT

We report the case of an angioleiomyoma on the toe of an 8-year-old girl which displayed an unusual plexiform growth pattern. It was treated successfully with surgical excision, with no recurrence at one month.

CONCLUSIONS

Angioleiomyoma is uncommon in children, particularly at acral sites. We describe the first such lesion to display a plexiform growth pattern.

Herpetic whitlow of the toe presenting with severe viral cellulitis

Herpetic whitlow of the toe is a common infection in an uncommon location, leading it to be frequently misdiagnosed; however, as the virus responds well to conservative management or antivirals alone, proper identification is necessary to prevent unnecessary interventions. We present a case of herpetic whitlow of the toe with an unusually ominous appearance in a previously healthy and otherwise well-appearing child. This case illustrates the spectrum of herpetic whitlow's clinical presentations and enourages consideration of the disease even for atypical location and severity.

Surgical Treatment of Mild to Severe Hallux Valgus Deformities With a Percutaneous Subcapital Osteotomy Combined With a Lateral Soft Tissue Procedure

Distal metatarsal (MT) osteotomies have been used in mild or moderate cases of hallux valgus (HV) and proximal MT osteotomy has been considered the treatment of choice for severe deformities. A distal osteotomy could achieve a greater degree of correction by the addition of a distal soft-tissue procedure and be used to treat also severe deformity. Limited evidence about the use of the percutaneous subcapital osteotomy (SCOT); a type of MT osteotomy, in combination of a soft tissue procedure, is available. We evaluated this procedure routinely used in our clinic. A total of 30 consecutive patients treated in our hospital from September 2012 to April 2015 with SCOT combined with lateral soft tissue release were included in this retrospective review. Outcomes assessed included radiological parameters: HV angle (HVA) and intermetatarsal angle (IMA), clinical evaluation using the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complication rate. In 12 of the 30 patients included, the pathology was bilateral, comprising a total of 42 cases. The overall correction of the angles was statistically significant (P < .001), changing from a HVA of 28.2° and IMA of 13.5° preoperatively to 8.0° and 6.0° postoperatively, respectively. The cases were divided into mild-moderate (34/42) and severe (8/42). Both groups showed a statistically significant correction in the angles, 3 months after surgery (P < .001). The AOFAS score showed a median of 49 points (n = 24) preoperatively and of 95 points (n = 40) at the end of follow-up. The complication rate at end of follow-up was 19% (8/42). After a minimum follow-up of 1 year, our technique for HV correction results in a clinically relevant improvement of the radiological parameters and AOFAS score in mild to severe deformities. Combination with lateral release could be a meaningful surgical alternative for the treatment of severe cases to help decrease the risk of recurrence. Levels of Evidence: Level IV.

Lesser Metatarsophalangeal Joint Pathology Addressed With Arthrodesis: A Case Series

Lesser metatarsophalangeal joint pathology is a common condition facing the foot and ankle surgeon, often beginning as a mild subluxation of the toe and progressing to a full dislocation of the metatarsophalangeal joint. In severe or recalcitrant deformities, traditional conservative and surgical methods can fail to resolve the issue. We report on 4 patients with 5 severely dislocated lesser metatarsophalangeal joints with varied etiologies and comorbidities who underwent arthrodesis of these joints using screw and plate fixation. All patients achieved radiographic and clinical signs of union at an average of 16.4 weeks.

Outcomes of Noninvasively Treated Idiopathic Toe Walkers

Idiopathic toe walking (ITW) causes a common problem in pediatric orthopaedics. In the literature, numerous treatment options have been reported, but consensus about the management of ITW is still missing. The aim of the current study was to evaluate conservative treatment with pyramidal insoles. A total of 193 patients underwent conservative treatment between January 2010 and June 2013. Mean age at the beginning of the treatment was 7.75 ± 0.23 years (range 2.0-17.0 years). For all patients, demographic data, comorbid diseases, passive range of motion (ROM), persistent toe walking, and performed operations were retrospectively evaluated. Following operative treatment was defined failure. Eight (4.15%) patients underwent Achilles tendon lengthening operation after mean therapy time of 2.72 years (range 0.1-7.0 years), 174 cases were treated successfully (90.16%). In 50 cases, toe walking suspended completely after mean therapy time of 2.83 years. In cases of failure, patients were older at diagnosis and at the beginning of the treatment. Mean passive ROM increased over the time. In cases of failure, ROM decreased from the first to the second examination. Conservative treatment of ITW using pyramidal insoles can be effective. Ankle dorsiflexion significantly improved in the patients who were successfully treated. Therapy should start early. A decrease of ROM under therapy should lead to critical revisal of individual therapy. Levels of Evidence: Therapeutic, level IV: Case series.

Transplantation of a Free Vascularized Joint Flap from the Second Toe for the Acute Reconstruction of Defects in the Thumb and other Fingers

BACKGROUND

This study aimed to evaluate a novel surgical method for the acute reconstruction of defects in the thumb and other fingers by transplanting a free vascularized joint flap from the second toe and to determine its clinical curative effects.

MATERIALS AND METHODS

A free vascularized joint flap from the second toe was transplanted to reconstruct a complete defect of the thumb and other fingers accompanied by the loss of the proximal finger in 10 patients. Of these patients, three had their thumbs reconstructed with a free vascularized joint flap from the second toe and with the proximal interphalangeal joint flap, one had a thumb reconstructed with a free vascularized joint flap from the second toe, and six had their finger defects reconstructed with the proximal interphalangeal joint flap. The toes of the metatarsophalangeal joint were amputated at the foot donor site. All patients underwent one-stage emergency surgery.

RESULTS

The composite tissue flaps, replanted thumbs, and fingers survived well in all 10 cases. Follow-up visits were conducted for 6-28 months, with an average of 9 months of follow-up. The transplanted bone joints healed over a period of 6-16 weeks. Bone nonunions and refractures did not occur, and the walking function of the foot donor site was not visibly affected.

CONCLUSION

A free vascularized joint flap from the second toe can be transplanted to repair defects in the thumb and other fingers. This technique can be applied to recover the appearance and function of fingers.

Use of Metatarsophalangeal Joint Dorsal Subluxation in the Diagnosis of Plantar Plate Rupture

A dorsal drawer exam, also known as a modified Lachman's test, is a common clinical test for plantar plate insufficiency. This disorder presents as a dislocated metatarsophalangeal joint. The aim of this cadaveric case study was to quantify the degree of the plantar plate pathology necessary to correlate with a positive Lachman's test. The second metatarsophalangeal joint was tested on 18 cadaveric lower extremities. Limbs with previous digital surgery or with an obvious digital deformity were excluded from this study. A plantar linear incision over the plantar aspect of the second metatarsophalangeal joint was performed, and the flexor tendons were retracted to expose the plantar plate. After evaluating the plantar plate's integrity and measuring its width, a Lachman's test was then performed under fluoroscopy. The plantar plate was subsequently severed in a serial manner in 2-mm increments. A modified Lachman's test was performed with the different levels of rupture to assess the degree of dislocation. We found that a tear as small as 2 mm, detected in 12 (66.7%) of 18 specimens, produced gross instability in the second metatarsophalangeal joint. We also showed that a simulated plantar plate tear ≥4 mm but <6 mm resulted in joint subluxation (positive modified Lachman's test) with a sensitivity of 90.3%. This study reinforces the finding that a modified Lachman's test is a clinical exam that demonstrates high sensitivity in diagnosing plantar plate insufficiency.