The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections

The cause of intermetatarsal neuromas or intermetatarsal neuritis is unclear; however, the most likely pathogenesis is either a mechanically induced degenerative neuropathy or entrapment of the intermetatarsal nerve as it passes under the transverse intermetatarsal ligament. Treatment of intermetatarsal neuromas includes the very simple method of changing shoe styles, more complex conservative treatments with functional orthotic devices, oral anti-inflammatory medications and cortisone injections, and surgical intervention. In this study, 100 adult patients with previously untreated intermetatarsal neuromas received three to seven injections of a 4% alcohol sclerosing solution every 5-10 days. No additional treatment was provided during the visits. The use of 4% alcohol sclerosing solution showed an 89% success rate. Of the 89 patients who were improved, 82 had complete resolution of symptoms. Eleven patients showed no improvement. The results of this prospective study indicate that the alcohol sclerosis treatment of intermetatarsal neuromas is a viable alternative to serial steroid injections or surgery for persistent symptoms.

Surgical treatment of mycotic toenails

The authors present several options for the surgical treatment of painful and dystrophic mycotic toenails. The procedures include total and partial nail avulsion as well as chemical and excisional matrixectomies, both partial and total. Adjunctive treatment with topical and oral antifungal agents is also discussed.

The Romano drill: a new surgical curved drill system

A new surgical curved drill system that drills curved holes into bone is presented, along with several examples of its use in foot and ankle surgery. The technical information involving soft tissue fixation, wiring, or suturing around a bone bridge, by drilling a curved tunnel for tendon, capsule, and ligament reconstruction is also reviewed.

Symptomatic juvenile flatfoot condition: surgical treatment

This article presents the clinical findings of a particular form of flatfoot described as the "symptomatic flexible juvenile pes planovalgus" condition. A review and postoperative follow-up of the results from surgical treatment of symptomatic juvenile flatfoot condition is presented for 32 children (59 feet), ranging from 7 to 15 years of age. The author describes the indications and justifications of the procedures involved and reviews the long-term results obtained with this combined surgical approach.

Hypertrophic and keloid scars

Scar formation is discussed along with definitions of the three most common types of scars: normal, hypertrophic, and keloid. Several current forms of therapy designed to reduce or eliminate scars are presented. The use of silicone gel sheeting is reviewed as a newer solution for the treatment of many types of lower extremity scars.

V-Y plasty and its variants

The authors present an overview of the V-Y plasty technique with a discussion of the basic underlying principles and a description of the surgical technique. The variations available and the direct application of this procedure are discussed with reference to the foot and ankle. Consideration is given for design, location, survival, and postoperative care of the V-Y plasty.

Use of Z-skin plasty in scar revisions and skin contractures of the lower extremity

A discussion of the design and use of the Z-skin plasty to revise scars and lengthen skin contractures of the lower extremities is presented. One of the most commonly used rotational flaps to alter scar direction or relieve tension on the existing scar or skin, the Z-plasty can also be the most difficult to perform and carries a high risk of flap loss if inaccurately planned or poorly placed. Several variations of the standard procedure and examples of common usage are presented.

Single-lobe rotation flaps

The basic principles of a single-lobe flap are discussed along with the description of a modified slide-swing rotational flap. This rotation flap is called the Schrudde flap, and it has many applications in the treatment of skin defects of the foot and ankle. This rotation skin flap procedure provides excellent end results with high patient acceptance.

Adhesive lesions of the talocrural joint

Iatrogenic and posttraumatic adhesive lesions of the ankle joint are rather common, although infrequently reported, clinical entities. Ankle arthroscopy has proved to be a valuable asset in the assessment and treatment of recalcitrant symptomatic cases of both localized adhesions and adhesive capsulitis. This article intends to broaden the reader's understanding of the clinical presentation and intra-articular derangements of these lesions.

An autogenous free graft technique for lateral ankle stabilization

A recent advancement in the surgical treatment of chronic lateral ankle instability is presented. The authors have collected data from 401 surgical stabilizations of the lateral ankle performed at the Waldo Podiatric Residency Program. A data summary is presented to provide the reader an appreciation of the evolution in treatment of ankle instability at this institution. The free tendon graft method of lateral ankle ligament reconstruction is also presented as performed on 37 patients with chronic unstable ankles.

Complications following traumatic incidents with STA-peg procedures

The authors describe use of a Silastic plug to limit subtalar joint motion in symptomatic pediatric flatfeet. Three patients sustained postoperative injury resulting in pedal complications. Successful resolution of these cases is discussed.

Bovine tendon lateral ankle stabilization procedure: xenograft bioprosthesis model GR 6 mm

A surgical technique utilizing a bovine xenograft bioprosthesis has been developed for stabilizing a chronically unstable lateral ankle. With this new technique, minimal dissection of adjacent soft tissue is required, and the method allows for tissue ingrowth for strength and anastomosis to bone. However, a longer period of non-weightbearing is required to prevent inadequate incorporation of the graft.

Intralesional injections

Several types of agents used for intradermal and intralesional injection have been presented along with general discussion of technique and principles of use. We have a great deal of respect for the effectiveness of properly utilized injections in the treatment of various conditions, and we also know that if used improperly, these agents can do more harm than good. For this reason, we caution practitioners to use common sense and to refer to product information and specific sources for additional information before using any of the medications or drugs discussed here. Special attention should be given to systemic absorption and the use of these drugs in infants and children, pregnant and nursing females, and in patients with systemic illness. Each of the agents presented must be evaluated independently and information and experience gathered will aid in the longterm results of their use. We hope this report helps to describe intralesional injections for treatment of some of the more common lesions and that your patients will benefit from this technique.

Flap classification and survival factors. Current concepts

Flap survival variables are different for each type of flap and for each anatomic location. One must have sound knowledge concerning tissue survivability for all types of flaps. Otherwise, a high rate of failure may be experienced. A thorough knowledge of blood flow patterns of the foot and leg is paramount, as well as insight to the basic fundamental concepts concerning flap mechanics. These fundamentals include delay phenomenon, designing flaps, length-to-width ratios, and evaluation of flap vascularity. Successful and appropriate use of flaps in the lower extremity can be rewarding and provide the surgeon with a powerful tool to use in reconstructive procedures. Inappropriate or poorly performed flap procedures often create situations that are more difficult to manage than the original problem. According to Hoopes, "flaps are vicarious, mischievous, and frequently insubordinate reconstructive agents. They demand thorough understanding and meticulous attention for successful employment." Therefore, judicial use of these procedures is recommended.

Dermatology flow sheet

This article presents an organized and relatively easy mechanism for the diagnosis of dermatologic problems by using an algorithmic flow sheet. Once this technique is understood, the practitioner may find it much easier to categorize, diagnose, and manage skin conditions of the lower extremities.

Vasospastic diseases. Diagnosis and management

Vasospastic disease represents a group of diseases in which the common link is spasm. The causes of the individual disorders may differ slightly but a history of exacerbation of the symptoms by cold, emotional stimuli, or caffeine usually will be elicited. Ulceration and gangrene do not usually occur. Treatment involves patient education, reassurance, and the use of oral vasodilating agents.

Contact dermatitis. A review

Contact dermatitis of the lower extremity is reviewed in regard to symptoms, clinical manifestations, etiologic agents, and treatment. Examples of some of the clinical manifestations are presented pictorially.

Principles and descriptions of design of skin flaps for use on the lower extremity

Distinction must be made between tissue movability and tissue elasticity when considering tissue movement with the hope of predicting good results. Tissue movability is either inherent, as on the back of the thigh, or is created by undermining, back-cutting, or cutting out Bürow's triangles. The elasticity of skin is inherent everywhere and is difficult to accurately predict. Elastic tissue will gape when cut, whereas inelastic tissue will not. Finally, elastic tissue will rotate with little puckering but inelastic tissue will form large dog-ears when rotated. For these reasons, as soon as the decision has been made to use a flap it is important to "prethink" the dynamics of flap movement and decide which type of flap to use and what is to be accomplished. If consideration is given to which flap will best allow proper transfer of tissue and at the same time give the best cosmetic result, the task is usually simpler. By further considering the secondary movement of surrounding tissues (as well as the primary movement), the number of potential techniques and designs are greatly increased.

Perioperative management of the infant and child

The perioperative management of children is important and the concepts should be reviewed regularly by all surgeons. This article emphasizes the overall aspects of physical and psychological care which begins at the first office visit and continues through the postoperative period. The podiatrist must assess the child's growth and development, emotional status, psychological needs, and the requirements of anesthesia and surgery.

Congenital metatarsal synostosis

The authors discuss congenital synostoses in a 28-year-old patient. They emphasize the importance of early correction to prevent alteration of foot function and development of early deformities.

The resistant, painful, plantar lesion: a surgical approach

Osteotomies designed to lift the metatarsal head dorsally on the sagittal plane are performed to alleviate painful plantar lesions beneath the metatarsal head. Correcting the position of the bone reduces the plantar pressure and stresses that are believed to cause the painful lesions. The authors found that resistant plantar lesions secondary to a plantarly depressed or long lesser metatarsal responded to a combination of plantar excision and modified cartilaginous articulation preservation osteotomy procedure.

Strain Injury to the Flexor Hallucis Longus and Flexor Hallucis Brevis

Overstretching by forceful and excessive dorsiflexion of the hallux can cause strain injury to the muscles that flex the big toe. Five patients learned this the hard way.

Giant keratoacanthoma of the plantar foot: a report of two cases

KA develops from a rapidly growing, firm, smooth nodule into a mature dome-shaped lesion with a central core filled with keratin that usually degenerates into an involuting keratinous mass. KAs must be differentiated from squamous cell carcinoma. Classically, KA is a benign tumor that is self-limiting. However, there is controversy concerning the aggressiveness of the tumor. Some authors believe there is no way to determine the aggressiveness of the tumors and they should be classified as low grade squamous cell carcinomas (3). Others feel that the risk of malignant transformation is not a serious consideration but misdiagnosis is, due to the histopathologic similarities (31, 33). Overall, the literature shows that solitary and giant lesions should be excised. Excisional biopsy yields a more cosmetic scar and increases the chance for an accurate biopsy diagnosis. Multiple and multinodular lesions should be excised if they have the potential for causing a mutilating deformity but are otherwise treated systematically. If a solitary or multiple lesion which is left to spontaneously resolve shows signs of aggressiveness, even with a biopsy indicating that it is a KA, it should be immediately excised. Solitary and giant KA are usually not considered to be located on the palms and soles. However, with the cases presented here, there are now a total of 4 cases in the literature. Therefore, KA should be included in the differential diagnosis when dealing with rapidly growing tumors on the plantar aspect of the foot.

Treatment of hypertrophic and keloid scars with SILASTIC Gel Sheeting

An evaluation of the results of treatment of both fresh and long-standing hypertrophic and keloid scars on the lower extremities using topical SILASTIC Gel Sheeting was performed in 94 patients ranging in age from 11 to 73 years. In the total of 94 patients, there were 80 with true hypertrophic scars. Of this group, 74 patients (92.5%) were greatly improved with treatment, five patients (6.25%) were somewhat improved, and one patient (1.25%) was not improved. The remaining 14 patients in the study had true keloid scars, and their results were poorer with five patients (35.7%) greatly improved, five patients (35.7%) somewhat improved, and four patients (28.6%) showing no improvement. When all patients were totalled together, there were 79 patients (84%) greatly improved, 10 patients (11%) somewhat improved, and only five patients (5%) with no improvements. Overall, the success rate (somewhat improved to greatly improved) for the treatment of hypertrophic and keloid scars is high (95%).

Diagnosis and treatment of digital mucoid cysts

An analysis of treatment options and the results of various treatments is presented for the lower extremity digital mucoid cyst. The author reviews the retrospective results of 25 consecutive Schrudde rotation flap procedures which were performed on 24 patients with digital mucoid cysts. The long-term results (greater than one year) revealed a 94% success rate with this treatment option.