Previously unreported X-ray findings associated with distal toe pain in children

While children undergo skeletal maturation, it is difficult to distinguish between normal variants and abnormalities of the epiphysis and acrophysis on radiological images. Abnormalities in the epiphysis and acrophysis of the toe phalanx have not been reported yet. Here, we describe a series of abnormalities in the epiphysis and acrophysis of the fourth and fifth toe phalanges, including an investigation of their pathogenesis. We evaluated patients suspected of having bone tumors at a local orthopedic clinic because of abnormal findings of the toe phalanx between the distal and middle phalanx on plain radiographs. The site of the lesion, duration of pain until the hospital visit, history of trauma and sports, treatment, and clinical course were investigated. A total of seven patients (five boys and two girls) with a mean age of 10 years (range 9-16) were included. In all cases, a circular erosive radiolucent image was present between the distal and middle phalanx. In two cases, the fourth toe was affected, and in five cases, the fifth toe was affected. Six patients showed improvements with conservative treatment using shoe insoles. In one case, surgical treatment was performed for persistent pain. Histological examination of the fibrous tissue collected from the circular erosive radiolucent area revealed normal bone and slightly degenerated hyaline cartilage. This is the first report on the abnormalities of the epiphysis and acrophysis of the toe phalanx, which is termed as Shintaniwakino disease. A better understanding of this disease may aid in the avoidance of unnecessary treatment.

The impact of associated tenotomies on the outcome of incomplete phalangeal osteotomies for lesser toe deformities

BACKGROUND

Partial or incomplete osteotomy (IO) of the phalanx is recently described in the literature. However, the clinical outcome and the rate of complications when applied to lesser toe deformities (LTD) have been never addressed. This study aims to find out if the association of tenotomies to incomplete or partial phalanx osteotomies has a significant impact on the clinical outcomes, the occurrence of complications, and the recovery time after surgery.

METHODS

A retrospective review of two cohorts of cases operated in our institution for hallux abductus valgus (HAV) and associated LTD from 2008 to 2014 was carried out. The surgical correction of both HAV and the associated LTD was always performed by minimally invasive techniques. The study included a total of 223 patients (723 IO in 556 toes). In 129 cases, the IO for LTD correction was performed without tenotomies, and in 94, the procedure was combined with flexor and/or extensor tenotomies. Patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire before surgery and at 6- and 12-month follow-up.

RESULTS

The mean preoperative AOFAS score before surgery was similar in both cohorts. At 12-month follow-up, the cohort without tenotomies showed better recovery (95.7 ± 2.8 versus 92.5 ± 6.8; p < 0.01). AOFAS scores decreased as the number of associated LTD increased (r = - 0.814; p < 0.001). Cases operated on by PO + tenotomy showed a high rate of complications such as delayed union of the osteotomy (p < 0.01), hypertrophic callus (p < 0.01), phalangeal fracture at the osteotomy site (p < 0.01), and lack of correction (p < 0.05). The overall occurrence of adverse events was 38.6% in cases operated by PO + tenotomy and 13.9% in cases receiving PO alone (p < 0.0001). Cases operated on without tenotomy showed a shorter time to complete recovery for daily life activities (37.4 ± 2.3 versus 43.0 ± 1.7 days; p < 0.01).

CONCLUSION

The performance of associated tenotomies to incomplete phalanx osteotomies provides worse clinical outcomes, higher complication rates, and longer recovery time as compared to similar forefoot surgeries without tenotomies.

TRIAL REGISTRATION

The study was based on retrospectively registered data starting on May 24, 2008.

A new surgical procedure for hallux limitus treatment: Double-V osteotomy on the base of the proximal phalanx of the hallux

The purpose of this study was to evaluate the effectiveness of the new Double-V osteotomy of the first metatarsophalangeal joint (1MPJ) in patients with hallux limitus (HL).A study of 66 patients was performed, 33 patients were treated Cheilectomy and 33 were treated Double-V. All patients underwent an assessment of the passive mobility of the 1MPJ before the procedure, reevaluated 12 months later evaluating dorsiflexion, plantarflexion, and patients status using both the American Orthopaedic Foot and Ankle Society (AOFAS) for Hallux Metatarsophalangeal-Interphalangeal Scale.In comparing the improvement achieved regarding the increase of mobility obtained with surgical treatment, the feet operated with procedure Double-V gained significant degrees of movement increased in all analyzed parameters (P < .05). We achieved 13.33° more than average in dorsiflexion motion and 2.12° more than average in plantarflexion with regard to the feet that were operated with Cheilectomy procedure. Double-V scores on the AOFAS scale improved significantly (P = .000) 91.48 points postoperative, while with the following Cheilectomy only 79.30 points.This new surgical technique, easy to perform and with low complexity in surgical execution and a minimum of complications, produces better clinical and functional results that Cheilectomy alone.

Bilateral phalangeal fillet technique for metacarpal pad reconstruction in a dog

Loss of the metacarpal or metatarsal pad requires reconstruction with other pad tissue to allow functional weight-bearing on the limb. This report describes the use of a bilateral phalangeal fillet technique to reconstruct a weight-bearing surface in a dog following complete excision of its right metacarpal pad for malignant melanoma. This resulted in a functional weight-bearing limb.

Percutaneous forefoot surgery

Percutaneous methods can be used to perform many surgical procedures on the soft tissues and bones of the forefoot, thereby providing treatment options for all the disorders and deformities seen at this site. Theoretical advantages of percutaneous surgery include lower morbidity rates and faster recovery with immediate weight bearing. Disadvantages are the requirement for specific equipment, specific requirements for post-operative management, and lengthy learning curve. At present, percutaneous hallux valgus correction is mainly achieved with chevron osteotomy of the first metatarsal, for which internal fixation and a minimally invasive approach (2 cm incision) seem reliable and reproducible. This procedure is currently the focus of research and evaluation. Percutaneous surgery for hallux rigidus is simple and provides similar outcomes to those of open surgery. Lateral metatarsal malalignment and toe deformities are good indications for percutaneous treatment, which produces results similar to those of conventional surgery with lower morbidity rates. Finally, fifth ray abnormalities are currently the ideal indication for percutaneous surgery, given the simplicity of the procedure and post-operative course, high reliability, and very low rate of iatrogenic complications. The most commonly performed percutaneous techniques are described herein, with their current indications, main outcomes, and recent developments.

[Diaphysectomy of the proximal phalanx in quintus varus supraductus and hammer toe in children]

The most frequent foot and ankle anatomical alterations in the pediatric population are found in the little toes. Several treatments are proposed for these conditions, ranging from total phalangeal resections, phalangeal osteotomies, osteosynthesis, and soft tissue management. We propose a surgical technique based on the diaphysectomy of the proximal phalanx and the release of soft tissues that are under tension. The purpose is to assess the functional foot results after surgical treatment consisting of proximal phalanx diaphysectomy and soft tissue release using the functional AOFAS scale in pediatric patients. A prospective, longitudinal, descriptive, non-comparative clinical study was conducted from March 2008 to December 2010, with a follow-up of up to six months. Twenty patients (35 toes) were included; 15 females and five males, with a mean age of 14.65 years. Fifteen (30 toes) had bilateral involvement; 88.56% had greater involvement of the fifth toe. The surgical indication was determined based on the degree of functional disability for gait and the type of footwear. The functional assessment was conducted using the AOFAS criteria and a subjective assessment scale with a total score of 100 to assess the metatarsophalangeal and the interphalangeal joints of the smallest toes. Scores were as follows: < 50 points, poor; 51-70 points, fair; 71-90, good, and > 91, excellent. The assessment was done preoperatively and at postoperative month six. The mean preoperative score was 73.55 and the mean postoperative score was 85.75, with a 12.2 point difference (p > 0.5). Results were: 11 excellent, seven good and two fair. There were four relapses, so a salvage procedure was performed with the Ruiz-Mora technique; excellent results were obtained in all four. One case had soft tissue infection. Proximal phalanx diaphysectomy and soft tissue release provides appropriate alignment of the affected toes and relief of soft tissues under tension, thus avoiding broad resections leading to both esthetic and functional alterations. This is a simple and effective technique for the treatment of little toe deformities as it improves function and alignment.

Epithelioid sarcoma: an unusual presentation in the distal phalanx of the toe

Epithelioid sarcoma is rare soft tissue sarcoma first described by Enzinger in 1970. The classic variant often occurs in the deep or superficial soft tissue of the distal upper extremities of individuals between the ages of 10 and 35. Due to the tumor's benign clinical presentation, infrequent occurrence, and histological similarities with other disease processes, diagnosing epithelioid sarcoma in its early stages has become extremely difficult. We report a rare case of epithelioid sarcoma of the toe with bone metastasis, as well as the clinical, pathological, and radiological difficulties in correctly diagnosing epithelioid sarcoma.

[Elongation with callotaxis for congenital brachymetatarsia]

OBJECTIVE

To present 10 cases of congenital brachymetatarsia treated with elongation by means of callotaxis with external minifixators.

INTRODUCTION

Brachymetatarsia of one or more of the matatarsals involving one or both extremities is a congenital condition, more frequent in the right foot, with the 4th metatarsal most commonly affected.

MATERIAL AND METHODS

From May 2007 to September 2008, 7 patients with congenital brachymetatarsia, ages 8 to 15 years, were operated on. Two metatarsals were involved in 3 of them and thus the series included 10 procedures. All of them underwent lengthening through callotaxis with a monoaxial external mini-fixator.

RESULTS

Mean lengthening was 21.1 mm, with a range of 17 to 25 mm. The complications included two cases of lengthening regression of 5 mm each. Delayed healing was reported in one of these two cases, and healing occurred spontaneously at 6 months. Nine metatarsals healed without any problems; no infections or material intolerance occurred.

CONCLUSION

Lengthening of metatarsals through callotaxis with external mini-fixators is an appropriate procedure for pediatric and adolescent patients with congenital brachymetatarsia.

[Clinical course of the quintus varus supraductus osteotomy in postoperative patients subjected to the LP-INR surgical approach]

OBJECTIVE

To evaluate the clinical course of patients subjected to the osteotomy designed at the National Rehabilitation Institute (LP-INR) with a memory staple to treat the congenital quintus varus supraductus deformity, from December 2002 to August 2009. Moreover, to show that the LP-INR osteotomy decreases weight bearing under the 5th metatarsal head, descends the phalanx, spares the metatarsophalangeal joint, and prevents relapses and pain.

MATERIAL AND METHODS

The study was conducted from December 2002 to August 2009 and included 51 patients with quintus varus supra-ductus deformity and 78 feet; 33 patients were males (64.7%) and 18 were females (35.2%), the Maryland clinical scale was applied at postoperative month six. The AOFAS scale was applied in the preoperative and postoperative periods to assess pain, gait and alignment.

RESULTS

The Maryland scale showed excellent results in 42 patients (84.3%), good results in 3 patients (5.8%), fair in 3 patients (5.8%) with a score of 75 to 50, and poor in 3 patients (5.8%). The AOFAS scale score for the forefoot was 55 + 8 preoperatively and 90 + 5 postoperatively. The Student t test was statistically significant in the preoperative and postoperative periods < 0.05.

DISCUSSION

The LP-INR osteotomy for the treatment of the congenital quintus varus supraductus deformity provides appropriate alignment of the 5th toe with decreased load on the 5th metatarsal head and avoids broad resections that result in both cosmetic and functional alterations.

Intraosseous and extraosseous attachments of flexor tendon to bone: a biomechanical in vivo study in rabbits

There are 2 popular methods of repairing flexor tendons to the distal phalanx and attaching a free tendon graft to bone: intraosseous, by implanting the tendon into a bony tunnel, and extraosseous, by suturing the tendon to the cortical surface after elevating the periosteum. An in vivo study was designed to determine whether one method is stronger than the other. The profundus flexor of the third and fourth toes of the hind paw of adult rabbits was divided and reattached to the middle phalanx using either an intraosseous tunnel or an extraosseous suture. Half the rabbits were killed after 3 weeks, the other half after 8 weeks. Repairs were then tested to failure, using an Instron device, and compared with the same tendons in the nonoperated limbs. The repaired tendons demonstrated similar strength 3 weeks and 8 weeks after surgery but were significantly weaker than the nonoperated tendons. The importance of this study is that it gives equal credence to these usual methods of tendon attachment.

[Breast cancer metastasis in distal phalanx of the big toe. Case report]

Breast cancer represents the most prevalent malignancies in women and bone is the first site of metastasis in 26-50% of cases. Usually metastasis involve limbs in 16%. We present a rare case of 47-year-old woman, who underwent to monolateral mastectomy for lobular cancer. After 8 years from surgery, she presented pain, swelling and functional limitations, gradually increasing, to the left big toe. X-rays and MRI showed a lucent area of bone destruction on the shaft of the distal phalanx of the left big toe. Surgical biopsy on the excised bone assessed for breast cancer metastasis.

Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement

AIMS/HYPOTHESIS

We analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of foot-sparing surgery and avoidance of amputation.

METHODS

A consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death.

RESULTS

Probing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as 'other'. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection.

CONCLUSIONS/INTERPRETATION

Conservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.

[Complications of first ray osteotomies: a consecutive series of 475 feet with first metatarsal Scarf osteotomy and first phalanx osteotomy]

PURPOSE OF THE STUDY

Available studies on Scarf osteotomies of the first metatarsal (M1) and first phalange (P1) shortening and varus displacement have reported good results, but have have not focused on complications. We reviewed a consecutive series of 475 feet operated on over a five year period. Our goal was to determine the incidence of complications and to compare our data with reports in the literature. We wanted to know if association with Weil osteotomy on the lateral metatarsals affects the rate of complications.

MATERIAL AND METHODS

We used the following inclusion criteria: hallux valgus>35 degrees, adult subject, with or without impact on the lateral ray, no prior foot surgery, no systemic disease, no other co-morbid condition. We distinguished two groups: group 1 with isolated first ray disease, and group 2 with hallux valgus and lateral metatarsalgia requiring surgery.

RESULTS

We determined the incidence of each complication. Metatarso-phalangeal joint (MTP1) stiffness was the most frequent complication: incidence declined with postoperative time: 41.7% at day 35, 5.7% at day 120. The joint was very stiff with defective pulp weight-bearing in 1.3% of the feet at 12 months. Late wound healing was observed in 5.7% of feet and secondary osteotomy displacement in 1%. Incidence of other complications, including operative site infection, was less than 1%. General complications were: reflex dystrophy (1.3%) and deep vein thrombosis (0.6%). Excepting a longer period of postoperative stiffness, we were unable to identify any change in the rate of postoperative complications in feet with an associated Weil osteotomy of the first ray.

DISCUSSION

Our findings confirm that Scarf M1 osteotomies with varus shortening of P1 generates fewer complications than the techniques used earlier. Certain complications have disappeared: nonunion after M1 and P1 osteotomy, great toe claw, symptomatic iatrogenic hallux valgus. Complications with a very low incidence in all series are: operative site infection, osteonecrosis of the M1 head, fracture of M1 at weight bearing. Notching of the two osteotomy pieces with elevation of the metatarsal head and transfer metatarsalgia has been reported by authors using short diaphyseal osteotomies. A stiff MTP1 remains the most frequent complication. Overtly stiff joints (30% loss of range of motion) were observed in 4.6% of our patients at 12 months; 1.3% had major stiffness (20 degrees extension, 0 degrees plantar flexion). This stiffness has been reported by others using the same technique but the risk factors have not been identified.

CONCLUSION

This prospective work enabled us to establish the rate of secondary complications of first ray surgery for M1 Scarf osteo-tomy and P1 osteotomy. Complications are rare, a further argument favoring use of these osteotomies. This statistical study enables us discuss the risk of complications at the preoperative interview, keeping in mind the specific elements inherent in each particular situation.

Blood supply to the first metatarsal head and vessels at risk with a chevron osteotomy

BACKGROUND

Chevron osteotomy, a commonly performed procedure for the treatment of hallux valgus, results in osteonecrosis of the first metatarsal head in 0% to 20% of cases. The aim of this study was to map out the arrangement of the vascular supply to the first metatarsal head and its relationship to the limbs of the chevron osteotomy.

METHODS

Ten cadaveric lower limbs were injected with an India ink-latex mixture, and the feet were dissected to assess the blood supply to the first metatarsal head. The dissection was carried out by tracing the branches of the dorsalis pedis and posterior tibial vessels. A distal chevron osteotomy was mapped, with the limbs of the osteotomy set at an angle of 60 degrees from the geometric center of the first metatarsal head. The relationship of the limbs of the osteotomy to the blood vessels was recorded.

RESULTS

The first metatarsal head was found to be supplied by branches from the first dorsal metatarsal, first plantar metatarsal, and medial plantar arteries. The first dorsal metatarsal artery was the dominant vessel among the three arteries in eight specimens. All of the vessels formed a plexus at the plantar-lateral aspect of the metatarsal neck, just proximal to the capsular attachment, with a varying number of branches from the plexus then entering the metatarsal head. The plantar limb of the proposed chevron cuts exited through this plexus of vessels in all specimens. Contrary to the widely held view, only minor vascular branches could be found entering the dorsal aspect of the neck.

CONCLUSIONS

The identification of the plantar-lateral corner of the metatarsal neck as the major site of vascular ingress into the first metatarsal head suggests that constructing the chevron osteotomy with a long plantar limb exiting well proximal to the capsular attachment may decrease the postoperative prevalence of osteonecrosis of the first metatarsal head.

Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint

BACKGROUND

Currently, arthrodesis is the most commonly performed surgical procedure for the treatment of severe arthritis of the first metatarsophalangeal joint. The objective of this study was to compare the long-term clinical and radiographic outcomes of a metallic hemiarthroplasty with those of arthrodesis for the treatment of this condition.

METHODS

A series of patients with osteoarthritis of the first metatarsophalangeal joint were treated with either a metallic hemiarthroplasty or an arthrodesis between 1999 and 2005. Postoperative satisfaction and function were graded with use of the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) scoring system, and pain was scored with use of a visual analogue scale.

RESULTS

Twenty-one hemiarthroplasties and twenty-seven arthrodeses were performed in forty-six patients. Five (24%) of the hemiarthroplasties failed; one of them was revised, and four were converted to an arthrodesis. Eight of the feet in which the hemiprosthesis had survived had evidence of plantar cutout of the prosthetic stem on the final follow-up radiographs. At the time of final follow-up (at a mean of 79.4 months), the satisfaction ratings in the hemiarthroplasty group were good or excellent for twelve feet, fair for two, and poor or a failure for seven. The mean pain score was 2.4 of 10. All twenty-seven of the arthrodeses achieved fusion, and no revisions were required. At the time of final follow-up (at a mean of thirty months), the satisfaction ratings in this group were good or excellent for twenty-two feet, fair for four, and poor for one. The mean pain score was 0.7 of 10. Two patients required hardware removal, which was performed as an office procedure with the use of local anesthesia. The AOFAS-HMI and visual analogue pain scores and satisfaction were significantly better in the arthrodesis group.

CONCLUSIONS

Arthrodesis is more predictable than a metallic hemiarthroplasty for alleviating symptoms and restoring function in patients with severe osteoarthritis of the first metatarsophalangeal joint.

Segmental bony defect of the proximal phalanx in the great toe reconstructed by free vascularized bone graft from the supracondylar region of the femur: a case report

We report the case of a 24-year-old man with a segmental bone defect of the proximal phalanx of the great toe that was successfully reconstructed by free vascularized bone graft (FVBG) from the supracondylar region of the femur after initial stabilization with external fixation and temporary antibiotic-impregnated bone cement. His functional outcome at 22 months follow-up was excellent. On the basis of this experience, FVBG from the supracondylar region of the femur can be used as an option for treating segmental bone defects of the great toe.

Evaluation of transfixation casting for treatment of third metacarpal, third metatarsal, and phalangeal fractures in horses: 37 cases (1994-2004)

OBJECTIVE

To evaluate clinical findings, complications, and outcome of horses and foals with third metacarpal, third metatarsal, or phalangeal fractures that were treated with transfixation casting.

DESIGN

Retrospective case series. Animals-29 adult horses and 8 foals with fractures of the third metacarpal or metatarsal bone or the proximal or middle phalanx.

PROCEDURES

Medical records were reviewed, and follow-up information was obtained. Data were analyzed by use of logistic regression models for survival, fracture healing, return to intended use, pin loosening, pin hole lysis, and complications associated with pins.

RESULTS

In 27 of 35 (77%) horses, the fracture healed and the horse survived, including 10 of 15 third metacarpal or metatarsal bone fractures, 11 of 12 proximal phalanx fractures, and 6 of 8 middle phalanx fractures. Four adult horses sustained a fracture through a pin hole. One horse sustained a pathologic unicortical fracture secondary to a pin hole infec-tion. Increasing body weight, fracture involving 2 joints, nondiaphyseal fracture location, and increasing duration until radiographic union were associated with horses not returning to their intended use. After adjusting for body weight, pin loosening was associated with di-aphyseal pin location, pin hole lysis was associated with number of days with a transfixation cast, and pin complications were associated with hand insertion of pins.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that transfixation casting can be successful in managing fractures distal to the carpus or tarsus in horses. This technique is most suitable for comminuted fractures of the proximal phalanx but can be used for third metacarpal, third metatarsal, or middle phalanx fractures, with or without internal fixation.

Turret exostosis of the hallux

A 22-year-old woman presented with pain on the dorsum of her left big toe. The patient had had an accident 1 year previously, when a heavy object fell on her left big toe. She experienced no pain in the hallux before the injury. Radiographic evaluation revealed a well-circumscribed osseous mass, in close relationship to the underlying dorsal cortex of the proximal phalanx. A 2 x 1.5 x 0.7 cm mass was resected. No communication was found between the undersurface of the bony mass and the medullar space of the phalanx. The histology report confirmed diagnosis of acquired osteochondroma. Removal of the bony mass resulted in disappearance of symptoms without any sign of recurrence 10 months later.

Shoe adaptation after amputation of the II - V phalangeal bones of the foot

In The Netherlands, about 50% of all amputations of the lower limb are toes and forefoot amputations. Traumata of toes and mid-foot are rare. Preservation of the foot is the primary goal for treatment. Crush injuries of the foot may be associated with prolonged morbidity. This case study presents an insole solution for the solitary first phalangeal bone after amputation of the phalangeal bones II - V. The normal adaptation for forefoot amputations is stiffening of the sole of the shoe and a rocker bar to improve the toe off phase with load reduction of the forefoot. Because the patient had to do excessive stair climbing during work another solution was chosen. As a foot orthosis, a metal soleplate was made in order to have free movement during loading and toe-off during walking. The soleplate gives safety and provides self-adjusting properties after toe off. This enables the shoe technician to make a shoe without a rocker bar or an extra stiff insole. The 0.5 mm custom-made spring-steel plate is also used as a protective in industrial safety shoes. To improve shoe adaptation more research and case reports have to be published in order to inform doctors and shoe technicians about everyday solutions to partial foot amputations.

Oral antimicrobial therapy for diabetic foot osteomyelitis

BACKGROUND

Osteomyelitis in the foot of a diabetic individual is a common complication of peripheral neuropathy, peripheral vascular disease, and infection. Operative facilities and home intravenous antibiotic therapy programs may not be available in remote or rural communities. Limited data are available regarding the treatment results of oral antimicrobial therapy, with or without limited office debridement for diabetic foot osteomyelitis.

METHODS

This retrospective medical record review of 325 consecutive diabetic patients who were evaluated at a multidisciplinary foot clinic identified 94 (29%) patients with 117 episodes of osteomyelitis. The most common group of organisms isolated were aerobic gram-positive cocci, and the single most frequent organism was Staphylococcus aureus. A mean of 1.6 +/- 0.8 (range 1 to 4) pathogens were recovered per episode of osteomyelitis. Therapy was guided by culture results. There were 93 episodes of osteomyelitis (79 patients) that were treated with a mean of 3 +/- 1 oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents) and had adequate followup to evaluate outcome of treatment; office treatment included bone debridement in 26 (28%) and toe amputation in nine (10%) of the 93 episodes (79 patients).

RESULTS

Of the 93 episodes treated with oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents), 75 (80.5%) episodes were put into remission. Mean duration of oral antimicrobial therapy was 40 +/- 30 weeks. Mean relapse-free followup duration was 50 +/- 50 weeks.

CONCLUSIONS

Diabetic foot osteomyelitis was effectively managed with oral antimicrobial therapy with or without limited office debridement in most patients. This regimen may be especially useful in communities where infectious disease specialists and operative resources are limited.

Subungual osteochondroma: a diagnostic dilemma

Osteochondroma is the most common skeletal neoplasm of all benign bone tumors. However, it rarely occurs subungually. In this location, the lesion may penetrate the skin, causing nail deformity, and can easily be misdiagnosed. We report two cases of subungual osteochondroma of the distal phalanges of the first toes with cutaneous penetration and discuss the clinical, histologic, and radiographic features and the treatment options.

Bizarre parosteal osteochondromatous proliferation of the little toe

A 19-year-old woman presented with pain at the lateral side of the fifth toe of her left foot, which was separated from the adjacent toe. Initial examination suggested dislocation of the fifth metatarsophalangeal joint due to a past fracture. Radiographs showed a mass arising from the proximal phalanx of the little toe, with no medullary and cortical continuity. Excisional biopsy of the mass was performed, and a histologic diagnosis of bizarre parosteal osteochondromatous proliferation of bone (Nora's lesion) was made.

Hemiphalangectomy and syndactylization for treatment of osteoarthritis and dislocation of the second metatarsal phalangeal joint: an outcome study

End-stage osteoarthritis or severe dislocation at the second metatarsophalangeal joint typically presents with chronic pain and is often unrelieved by conservative treatment. The aim of this article is to review the preliminary outcomes of surgery involving resection of the base of the second proximal phalanx with syndactylization to the third toe for stability. Thirteen patients (13 feet) with second metatarsophalangeal osteoarthritis and 15 patients (15 feet) with a dislocated second toe underwent the procedure and were reviewed after a mean 12.4 months (range, 5-25 months). Patients were evaluated preoperatively and postoperatively with the American Orthopedic Foot and Ankle Society's scoring system and clinical review. A patient questionnaire was devised to yield information regarding toe alignment, cosmesis, and reflection on the procedure. Pain and activities were significantly improved in both subgroups (P < .01). Eighty-two percent were very satisfied or satisfied with the reduction in symptoms, with 11% satisfied with reservations and 7% not satisfied. Seventy-nine percent were very satisfied or satisfied with the appearance. Thirty-nine percent stated the outcome was better than expected, 14% as expected, and 14% felt the result was worse than expected. Twenty-three patients (82%) had no postoperative cosmetic concerns, and 7 patients (25%) felt there was a moderate or severe difference in the alignment with respect to the other toes. In conclusion, syndactylization can significantly improve pain and activity levels and was found to be cosmetically acceptable.

Contemporary approaches to stage II and III hallux rigidus: the role of metallic hemiarthroplasty of the proximal phalanx

Metallic proximal phalangeal hemiarthroplasty has been described for the surgical treatment of moderate to severe hallux rigidus. This long-term follow-up of an extended case series of 37 patients who underwent the index operation demonstrated a high rate (93%) of patient satisfaction, and significant improvement in Foot Function Index scores.

The effect of temperature elevation during discontinuous use of rotatory burrs in the correction of hallux valgus

The purpose of this study was 2-fold: to measure temperature elevation during exostectomy and osteotomies of the metatarsal head and the proximal phalanx in 78 patients (94 feet) with hallux valgus undergoing distal first metatarsal and proximal phalangeal osteotomies by minimal incision surgery; and to assess whether there was a relationship between working temperatures at operation and the overall thickness of the forefoot. The procedure included the use of rotary wedge burrs in discontinuous cutting bursts of less than 20 seconds for removal of the exostois, and the use of rotary triflute burrs used in discontinuous cutting bursts of less than 10 seconds for each osteotomy. The temperature of the bone surface was measured with a thermocouple and, when 38 degrees C was exceeded, the field was irrigated with saline solution. The temperature generated during the procedure was found to be significantly associated with the amount of bone removed from the metatarsal (Pearson's correlation coefficient, r = -0.101, P = .05). At the 6-week visit, thickness of the first metatarsal was greater in the group with temperature elevations > or =47 degrees C compared with the group with temperatures <47 degrees C. The Reverdin-Isham procedure by minimal incision surgery using rotatory triflute burs in discontinuous cutting bursts is an effective, reliable, and technically simple procedure for treating hallux valgus deformity. At follow-up, thickness of the foot at the level of the head of the first metatarsal was associated with heat generated during the use of rotary burs.