MRI of the Spine in Patients who Toe Walk: Is There a Role?

BACKGROUND

Little is known about the prevalence of intraspinal pathology in children who toe walk, but magnetic resonance imaging (MRI) may be part of the diagnostic workup. The purpose of this study was to examine the role of MRI for children who toe walk with a focus on the rate of positive findings and associated neurosurgical interventions performed for children with said MRI findings.

METHODS

A single-center tertiary hospital database was queried to identify a cohort of 118 subjects with a diagnosis of toe walking who underwent spinal MRI during a 5-year period. Patient and MRI characteristics were summarized and compared between subjects with a major abnormality, minor abnormality, or no abnormality on MRI using multivariable logistic regression. Major MRI abnormalities included those with a clear spinal etiology, such as fatty filum, tethered cord, syrinx, and Chiari malformation, while minor abnormalities had unclear associations with toe walking.

RESULTS

The most common primary indications for MRI were failure to improve with conservative treatment, severe contracture, and abnormal reflexes. The prevalence of major MRI abnormalities was 25% (30/118), minor MRI abnormalities was 19% (22/118), and normal MRI was 56% (66/118). Patients with delayed onset of toe walking were significantly more likely to have a major abnormality on MRI ( P =0.009). The presence of abnormal reflexes, severe contracture, back pain, bladder incontinence, and failure to improve with conservative treatment were not significantly associated with an increased likelihood of major abnormality on MRI. Twenty-nine (25%) subjects underwent tendon lengthening, and 5 (4%) underwent neurosurgical intervention, the most frequent of which was detethering and sectioning of fatty filum.

CONCLUSIONS

Spinal MRI in patients who toe walk has a high rate of major positive findings, some of which require neurosurgical intervention. The most significant predictor of intraspinal pathology was the late onset of toe walking after the child had initiated walking. MRI of the spine should be considered by pediatric orthopedic surgeons in patients with toe walking who present late with an abnormal clinical course.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

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.

Morphologic Changes in Postaxial Polydactyly of the Foot: A Standardized Quantitative Analysis Using the Watanabe-Fujita Classification

BACKGROUND

Postaxial polydactyly of the foot is one of the most common congenital abnormalities. A wide forefoot, short toe, and lateral joint deviation are associated with aesthetic and functional outcomes. This study used the Watanabe-Fujita classification to characterize the preoperative and postoperative skeletal morphology of postaxial polydactyly of the foot.

METHODS

This retrospective study included 42 patients (51 feet) with postaxial polydactyly treated at age 1 year. Radiographs taken at ages 0 and 3 to 4 years were used for morphologic analysis. The length of the reconstructed toe, the distance between the fourth and fifth metatarsals, and joint deviation angles were measured. The length measures were standardized using the length of the third metatarsal. Morphologic characteristics were compared based on the Watanabe-Fujita classification at ages 0 and 3 to 4 years. Long-term outcomes were also evaluated in patients followed up for longer than 6 years.

RESULTS

The fifth-ray proximal phalangeal subtype had the shortest toe length both at ages 0 and 3 to 4 years. Proximal phalangeal joint lateral deviation improved postoperatively in 78% of patients with the fifth-ray middle phalangeal subtype, regardless of reconstruction type. There was no significant change in proximal phalangeal joint deviation between ages 3 to 4 years and 7 years or older. A residual metatarsal was associated with lateral metatarsophalangeal joint deviation and a wide intermetatarsal distance, and required revision surgery.

CONCLUSIONS

Morphologic changes of postaxial polydactyly of the foot were successfully characterized using the Watanabe-Fujita classification. This classification could be useful for planning surgical strategies and anticipating morphologic outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Comparative Radiographic Analysis of the Width of the Lesser Digit Proximal Phalangeal Heads

BACKGROUND

Digital deformities represent a common presenting abnormality and target for surgical intervention in podiatric medicine and surgery. The objective of this investigation was to compare the radiographic width of the heads of the lesser digit proximal phalanges.

METHODS

One hundred fifty consecutive feet with a diagnosis of digital deformity and performance of weightbearing radiographs were analyzed. The maximum width of the heads of the lesser digit proximal phalanges were recorded from the radiographs using computerized digital software.

RESULTS

The mean ± standard deviation of the head of the second digit proximal phalanx was 9.74 ± 0.87 mm (range, 7.94-11.78 mm); the head of the third digit proximal phalanx, 9.00 ± 0.91 mm (range,7.27-10.94 mm); the head of the fourth digit proximal phalanx, 8.49 ± 1.01 mm (range, 5.57-10.73 mm); and the head of the fifth digit proximal phalanx, 8.67 ± 0.89 mm (range, 6.50-11.75 mm). The width of the head of the proximal phalanx decreased from the second digit to the third digit (P < .001), decreased from the third digit to the fourth digit (P < .001), and then increased from the fourth digit to the fifth digit (P = .032).

CONCLUSIONS

The results of this investigation provide evidence in support of an anatomical and structural contribution to digital deformities. The width of the heads of the lesser digit proximal phalanges decreased from the second to the third to the fourth toes, and then subsequently increased with the fifth proximal phalangeal head.

A Novel Radiographic Measurement Method for the Evaluation of Metatarsophalangeal Joint Dislocation of the Lesser Toe in Patients with Rheumatoid Arthritis

Dorsal dislocation of metatarsophalangeal (MTP) joints of the lesser toe frequently occurs in patients with rheumatoid arthritis (RA), and may cause painful and uncomfortable plantar callosities and ulceration. The current study examined the reliability and clinical relevance of a novel radiographic parameter (the MTP overlap distance [MOD]) in evaluating the severity of MTP joint dislocation. The subjects of the current study were 147 RA patients (276 feet; 1104 toes). MOD, defined as the overlap distance of the metatarsal head and the proximal end of the phalanx, was measured on plain radiographs. The relationship between the MOD and clinical complaints (forefoot pain and/or callosity formation) was analyzed to create a severity grading system. As a result, toes with callosities had a significantly larger MOD. ROC analysis revealed that the MOD had a high AUC for predicting an asymptomatic foot (−0.70) and callosities (0.89). MOD grades were defined as follows: grade 1, 0 ≤ MOD < 5 mm; grade 2, 5 ≤ MOD < 10 mm; and grade 3, MOD ≥ 10 mm. The intra- and inter-observer reliability of the MOD grade had high reproducibility. Furthermore, the MOD and MOD grade improved significantly after joint-preserving surgeries for lesser toe deformities. Our results suggest that MOD and MOD grade might be useful tools for the evaluation of deformities of the lesser toe and the effect of surgical intervention for MTP joints in patients with RA.

Impact of intertendinous connections between the flexor digitorum brevis and longus on percutaneous tenotomy for the treatment of claw toes: an anatomic and ultrasound study

PURPOSE

Selective percutaneous tenotomy of the flexor digitorum longus (FDL) is a treatment for claw toes that gives astonishingly good functional results despite tendon sacrifice. However, the involution of the FDL tendon stump after tenotomy is unknown. The aim of our study was to assess the involution of the tendon stump after selective percutaneous tenotomy of the FDL.

METHODS

The study included two parts. In the clinical part, an ultrasound analysis of 15 FDL tenotomies in 7 patients was carried out 3 months post-surgery. In the anatomic part, the feet of 10 bodies donated to science were dissected and examined anatomically.

RESULTS

The proximal stump of the FDL was located near the base of the proximal phalanx and moved synchronously with the flexor digitorum brevis (FDB).Separating the FDB and FDL revealed a large tissue connection between the plantar surface of the tendinous chiasm of the FDB and the dorsal part of the FDL. These connections had significant resistance ranging from 2 to 9 Newtons depending on the toe. Tenotomy of the FDL followed by proximal traction of it led to retraction of the stump up to the base of the proximal phalanx and transfer of its action to the FDB by tensioning the intertendinous structure. Histologically, these structures were mostly comprised of tendon connective tissue. Their vascular component was small.

CONCLUSION

The presence of this intertendinous connection leads, in the case of isolated tenotomy of the FDL, to equivalent transfer of the latter to the FDB.

Minimally invasive correction for symptomatic, fixed curly toe deformity

BACKGROUND

Curly toe deformity is a relatively common deformity that generally occurs at the 4th and 5th proximal and/or middle phalanges but rarely presents with symptoms. Although numerous open operative techniques have been introduced, there is no established treatment yet. We report the results of minimally invasive correction for symptomatic, fixed curly toe deformity.

METHODS

Between 2016 and 2018, 25 consecutive percutaneous dorsolateral closing wedge-shaped osteotomies with Shannon burrs at the proximal and/or middle phalanx were performed. We assessed the postoperative clinical and radiological changes at a mean of 22.51 months of follow-up.

RESULTS

The locations of osteotomy were at the middle phalanx in 10 cases, proximal phalanx in 13 cases, and both in one case. The mean amount of corrections of varus inclination and shortening were 16.54° and 2.24 mm, respectively. The Foot and Ankle Ability Measure Activities of Daily Living scores significantly improved from 59.09 preoperatively to 74.55 at the last follow-up. There was one case of pin site infection and one case of incision site numbness due to digital nerve injury.

CONCLUSIONS

Minimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.

Isolated hexadactylia: A rare case of central polydactyly of the foot

BACKGROUND

Central polydactyly of foot is uncommon form of polydactyly but it usually causes intermetatarsal widening because of metatarsal bifurcation. Central polydactyly associated with T shaped bifurcation of metatarsal in vertical plane has not been reported yet.

CASE

We present a 4 year male child with extra toe on the dorsal aspect of right foot with complains of difficulty in wearing footwear and poor cosmesis. The extra digit was fully developed with bifurcation of 2^nd metatarsal bone proximal to the head without any intermetatarsal widening. The angular deviation was 45° to the longitudinal axis of foot and in a plane vertical to the transverse arch of foot. The child was operated with excision of extra toe without any residual bony deformity.

CONCLUSION

The central polydactyly is rare type of polydactyly of foot. Central polydactyly with metatarsal extension causing intermetatarsal widening has been well described entity. But the previous classifications need to be modified to include central polydactyly with vertical oriented T bifurcation of metatarsal bone without intermetatarsal widening.

Does timing of surgery influence the long-term results of foot polydactyly treatment?

BACKGROUND

There is an evident lack of research on timing of polydactyly surgery and its effects on treatment results.

METHODS

Retrospective comparative study on foot polydactyly patients treated at our department from 1995 to 2009. Patients were divided into 2 groups, group A - under the age of 5 at surgery, and group B - 5 years and older.

RESULTS

There were 24 patients (8 male, 16 female), 30 feet. Median age at surgery was 1 year (range, 9 months-4.5 years) for group A, and 8.5 years (range, 6-37 years) for group B. Median follow-up was 16.2 years (range, 7-21 years). There were 16 postaxial and 8 preaxial cases. At the last follow-up 12 patients' feet were "excellent" and 12 "good". No significant differences were identified between the two groups at final follow-up.

CONCLUSIONS

Timing of surgery for foot polydactyly is not crucial for final results.

Non-Vascularized Free Toe Phalanx Transfers in Congenital Hand Deformities – the Great Ormond Street Experience

Many options of varying complexity are available for the management of congenital short digits resulting from aphalangia in symbrachydactyly and constriction ring syndrome. We have used non-vascularized free toe phalanx transfers for these children when a vascularized toe transfer has been contraindicated. We describe our technique and experience with 22 children who underwent a total of 64 transfers of the proximal (35) or middle (29) toe phalanges (average 3 per child). The mean age at initial surgery was 15 months, and the mean follow-up was 5 years. Duration of time until epiphyseal closure could not be determined accurately, but total digital elongation averaged 6 mm. Complications of this technique include joint instability, premature epiphyseal closure and, in one patient, infection and graft loss. Donor site deformity was determined according to measured growth deficit and toe function. This technique is a simple option for digital elongation and, if performed in the appropriate age group in short fingered and monodactylous subtypes of symbrachydactyly, has the potential to allow growth and function with minimal donor site deficit.

Macrodystrophia lipomatosa of foot involving great toe

Macrodystrophia lipomatosa is a rare form of congenital disorder in which there is localized gigantism characterized by progressive overgrowth of all mesenchymal elements with a disproportionate increase in the fibroadipose tissues. The adipose tissue infiltration involves subcutaneous tissue, periosteum, nerves and bone marrow. Most of the cases reported have hand or foot involvement. Patient seeks medical help for improving cosmesis or to get the size of the involved part reduced in order to reduce mechanical problems. We report a case of macrodystrophia lipomatosa involving medial side of foot with significant enlargement of great toe causing concern for cosmesis and inconvenience due to mechanical problems. The X-rays showed increased soft tissue with more of adipose tissue and increased size of involved digits with widening of ends. Since the patient's mother did not want any surgical intervention he was educated about foot care and proper footwear design was suggested.

[A boy with a wart-like lesion of the toe]

A 10-year-old boy consulted a dermatologist with a painful, subungual tumour on one of his toes. X-ray showed an outgrowth of the distal phalanx and histopathological investigation showed osteochondromatous proliferation. The patient was diagnosed with exostosis. Subungual exostoses are benign osteocartilaginous tumours that occur beneath the nail bed. Excision was performed, the patient recovered well.

[Amputation level after frostbite: role of bone scan. A case report]

BACKGROUND

frostbite is defined as the damage sustained by tissues while subject to temperatures below their freezing point. The severity of tissue damage is variable, but frequently can result in amputation. Early surgical debridement is contraindicated in almost all patients because it can take weeks for definitive demarcation of non-viable tissues to occur. Bone scan is indicted in the evaluation of frostbite injuries and helps to establish the prognosis early.

CLINICAL CASE

a 42 year old man suffered frostbite injury in the fingers and toes after more than 24 hours at 8,000 meters of altitude. The patient was treated with anticoagulant therapy and topical cures for six weeks. During this period, we performed two consecutive bone scan studies showing no changes in the level of vascularization. However, clinical improvement was important, devitalized tissues delimited to the level marked by the bone scan study, so amputation was performed.

CONCLUSION

Because the bone scan remained invariable, we believe that could help us to determine the amputation level early without delaying surgery.

The psoriatic great toe or the psoriatic onycho-pachydermo-periostitis of great toe (OP3gt)

The onycho-pachydermo-periostitis of the great toe is a characteristic feature of psoriatic arthritis first described by Fournié in 1980. In the affected patients, the great toe involvement is characterised by a relevant osteo-periostitis of the distal phalanx, a thickening of the distal soft tissues associated with a psoriatic onychopathy. In most cases, the distal interphalangeal joint is spared. Radiographic and scintigraphic osteo-periostitis of distal phalanx of the great toe are frequent, being found in about 44% of patients with psoriatic arthritis. However, clinical manifestations, with inflammatory inflammation of the great toe, are rare.

Superficial acral fibromyxoma: a clinicopathological and immunohistochemical analysis of 12 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes

AIM

Superficial acral fibromyxoma (SAFM) is a rare soft tissue tumor, recently delineated and documentated as a separate entity. We report 12 cases of SAFM observed in our department from June 2004 to June 2010 and highlight pathological features and differential diagnosis.

METHODS

Radiographic examination of the affected digit was performed in all patients. All the tumors were surgically excised under local anesthesia. Follow-up was made every 6-8 months for a maximum period of five years.

RESULTS

The patients consisted of 8 men and 4 women, age range 28-76 years (mean 51), presenting with a solitary mass or nodule located in the toes and fingers. Histologically the lesions were well circumscribed dermal nodules composed of stellate and spindle cells, arranged in a myxoid matrix. Very low grade atypia and a few mitotic figures were found in only one case. Neoplastic cells showed immunoreactivity for CD34 (12 patients). In contrast focally positive or negative staining was shown for the epithelial membrane antigen (EMA) and CD 99. Actin, S100 protein, HMB45 and cytokeratin were negative. In three cases marked hyperkeratosis and acanthosis of the epidermis was present. Pathological analysis confirmed the diagnosis of superficial acral fibromyxoma. No recurrences were observed even in a long term, 2-5 year follow-up.

CONCLUSION

Complete surgical excision of the tumors and a careful follow-up is suggested, despite the benign course previously reported.

Chronic interdigital dermatophytic infection: a common lesion associated with potentially severe consequences

Interdigital intertrigo and onychomycosis has the potential cause of severe bacterial infectious complications with pain, mobility problems, abscess, erysipelas, cellulitis, fasciitis and osteomyelitis. In another hand, diabetic neuropathy, which affects 60-70% of those with diabetes mellitus, is one of the most troubling complications for persons with diabetes. These people are high suspecting to be infected by dermatophytic infections in interdigital spaces or onychomycosis witch are frequently induce damage to the stratum corneum, leading to bacterial proliferation and secondary infection. A patient presented with an asymptomatic warm, painless, erythematous swelling of the second left toe, which had been present for a few weeks. Clinically, the lesion was categorized as erysipelas upon an insidious abscess formation. Further investigation was undertaken to confirm the presence of diabetes. Leg erysipelas is a common affection which, according to various studies, has both local concomitants (interdigital intertrigo, lymphoedema, surgical antecedents) and/or general causes (immune suppression, diabetes, alcoholism, etc). Interdigital intertrigo, tinea pedis, and onychomycosis present as public health problems that could trigger serious deterioration in patient quality of life, due to complications induced by secondary bacterial infections.

Diabetic gangrene in multiple fingers and toes after a dog bite in an elderly patient with type 2 diabetes

A 78-year-old diabetic woman experienced multiple sites of gangrene not only in fingers that were directly bitten by a dog but also in fingers and toes that had not beenbitten. Her glycemic control was fair and microvascular complications were mild. There were no clinical findings related to angitis, collagenosis or severe infection. The fingers and toes with gangrene were amputated. The pathological diagnosis was diabetic gangrene. This report presents a case of multiple sites of gangrene of the fingers and toes after a dog bite in an elderly patient with type 2 diabetes.

The translating Weil osteotomy in the treatment of an overriding second toe: a report of 25 cases

We present a retrospective study of 25 feet operated for an overriding second toe deformity, whether or not associated with hallux valgus deformity and metatarsalgia. The surgical technique of a medial sliding and decompressive Weil osteotomy is described. All patients, operated between January 2002 and December 2007 for this condition in our institution, were reviewed clinically and radiologically. The mean AOFAS score improved with 47.6 points from 45.9 to 93.5. The theoretical advantages of such a translation Weil osteotomy are discussed trying to clarify the previously described pathologic anatomy of this condition.

Diagnosis, management, and complications of glomus tumours of the digits in neurofibromatosis type 1

BACKGROUND

Glomus tumours are benign painful tumours of the glomus body, a thermoregulatory shunt in the digits. Glomus tumours of the fingers and toes are associated with the monogenic disorder neurofibromatosis type 1 (NF1) and are recently recognised as part of the NF1 phenotype.

METHODS AND RESULTS

A multi-institutional experience with 15 individuals with NF1 and glomus tumours of the fingers or toes is reported. The majority of individuals presented with at least two of the symptoms in the classic triad of localised tenderness, severe paroxysmal pain, and sensitivity to cold. Appearance of the nail and finger or toe is often normal. Women are affected more often than men. Multifocal tumours are common. There is often a delay in diagnosis of many years and clinical suspicion is key to diagnosis, although magnetic resonance imaging may be useful in some scenarios. Surgical extirpation can be curative; however, local tumour recurrence and metachronous tumours are common. Three of our patients developed signs and symptoms of the complex regional pain syndrome.

CONCLUSIONS

Glomus tumours in NF1 are more common than previously recognised and NF1 patients should be specifically queried about fingertip or toe pain.

Dactylitis, a term for different digit diseases

Dorland's Illustrated Medical Dictionary gives the following definition of dactylitis (deltaalphachitauupsilonlambdaomicronsigma = digit): 'inflammation of a finger or toe'. Although any inflammatory process involving the fingers or toes may be called dactylitis, the term has entered in current use only in some well-defined entities. These differ in the involved tissue of the digit and in the type of involvement. Tuberculous dactylitis is the variant of tuberculous osteomyelitis affecting the short tubular bone of the hands and feet. Radiographs typically show a central, lytic, cystic, and expansive lesion known as spina ventosa. Syphilitic dactylitis is a manifestation of congenital syphilis. Radiological findings mimic those of tuberculous dactylitis but the involvement is bilateral and symmetric. Sarcoid dactylitis is due to typical non-caseating granulomas invading the phalanges and the adjacent soft tissue. Blistering distal dactylitis is an infection of the anterior fat pad on the volar surface of the distal portion of a single finger or more rarely a toe, mostly caused by group A beta-haemolytic streptococci. Sickle cell dactylitis, also known as 'hand-foot syndrome', is due to localized bone marrow infarction of the carpal and tarsal bones and phalanges. Spondyloarthritis dactylitis, also called 'sausage-like' digit, is a diffuse painful swelling of the fingers and toes. Recent ultrasonography (US) and magnetic resonance imaging (MRI) studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and that the enlargement of the joint capsule is not an indispensable condition for the 'sausage-like' feature. There is no evidence of enthesitis of flexor digitorum tendons and joint capsule.

One case of big-toe re-plantation: a 13-year follow-up and a literature review

In this case of a 3-year-old patient who had a left big-toe amputation through the proximal phalange, re-plantation was performed successfully. Big-toe amputations are not frequent entities, but it should always be re-planted to avoid unsatisfactory aesthetic and functional outcomes. There are just a few reports in literature and their follow-up is very brief compared with our report.

Rectal carcinoma metastasizing to a toe

We report on a 63-year-old patient with rectal carcinoma that metastasized to a toe. Although bone metastases from malignant tumors are common, metastatic lesions of the small bones of extremities are very rare. We have found in the literature only 29 cases of carcinoma which have metastasized to the small bones of the feet. Twenty of these cases are verified histologically. The differential diagnosis includes osteomyelitis, gout, and Reiter's disease. The roentgenographic features and the possible pathogenetic mechanisms of peripheral metastases are discussed.

Prenatal diagnosis of isolated macrodactyly

Congenital enlargement of one or several digits of the hands or feet, known as macrodactyly, is a rare malformation. True macrodactyly, characterized by overgrowth of all mesenchymal elements, must be differentiated from that due to tumorous enlargement of a single element, as in hemangioma, lymphangioma or enchondroma. Furthermore, macrodactyly may be isolated, but it can also be associated with several syndromes. Here we present a case of prenatally diagnosed isolated true macrodactyly of the second toe of the left foot at 24 weeks of gestation, and discuss the key points in its differential diagnosis and management.

Enhancing limb salvage by non-mobilized peripheral blood angiogenic cell precursors therapy in patients with critical limb ischemia

BACKGROUND

Stem cell therapy has been proposed to enhance the salvage of critically ischemic limbs.

OBJECTIVE

Assess the efficacy and safety of the implantation of non-mobilized peripheral blood angiogenic cell precursors (NMPB-ACPs) in patients with critical limb ischemia (CLI) who were poor candidates for standard revascularization treatment options.

MATERIAL AND METHOD

Six patients with CLI due to the infrapopliteal artery occlusive disease were included in the present study. Intramuscular injections of NMPB-ACPs were administered in the ischemic limbs. The efficacy was evaluated by clinical outcomes, ankle brachial index, toe brachial index, and computerized tomographic angiography.

RESULTS

There was no evidence of local or systemic complication related to the procedure. Five patients (83.3%) had clinically significant improvement of adequate circulation at the distal limb for the complete healing. Four of them had complete healing of ischemic ulcers and stumps of toe amputation. However one patient with adequate granulation tissue at the stump of the left first toe amputation subsequently suffered from severe foot infection originating from the other toes and eventually underwent below knee amputation. There was no improvement of circulation at the distal limb after the administration of NMPB-ACPs in one patient (16.7%) who eventually underwent major amputation.

CONCLUSION

The preliminary result of NMPB-ACPs therapy may be safe and provide benefits in the improvement of circulation in patients with CLI. A larger controlled trial is required to ascertain these preliminary results.

[Fibular dimelia]

It is presented an extremely rare condition characterised by total absence of tibia and fibular dimelia. Only few patients were presented till now. Our patient was observed and treated for 19 years. He was born with normal forearms (radiologically ulna and radius were present), syndactyly of hands, mirror feet and extremely equinus. The knees were normal in flexion and dislocated in extension. Radiologically there was total absent of tibia and duplication of fibula; moreover there was duplication of toes (right foot--9, left foot--10 toes), metatarsal bones, cuneiform, cuboid and calcaneal bone. Although the unstable knees and equinus feet deformities he was able to walk indenpendently.

Brachydactyly

Brachydactyly ("short digits") is a general term that refers to disproportionately short fingers and toes, and forms part of the group of limb malformations characterized by bone dysostosis. The various types of isolated brachydactyly are rare, except for types A3 and D. Brachydactyly can occur either as an isolated malformation or as a part of a complex malformation syndrome. To date, many different forms of brachydactyly have been identified. Some forms also result in short stature. In isolated brachydactyly, subtle changes elsewhere may be present. Brachydactyly may also be accompanied by other hand malformations, such as syndactyly, polydactyly, reduction defects, or symphalangism. For the majority of isolated brachydactylies and some syndromic forms of brachydactyly, the causative gene defect has been identified. In isolated brachydactyly, the inheritance is mostly autosomal dominant with variable expressivity and penetrtance. Diagnosis is clinical, anthropometric and radiological. Prenatal diagnosis is usually not indicated for isolated forms of brachydactyly, but may be appropriate in syndromic forms. Molecular studies of chorionic villus samples at 11 weeks of gestation and by amniocentesis after the 14th week of gestation can provide antenatal diagnosis if the causative mutation in the family is known. The nature of genetic counseling depends both on the pattern of inheritance of the type of brachydactyly present in the family and on the presence or absence of accompanying symptoms. There is no specific management or treatment that is applicable to all forms of brachydactyly. Plastic surgery is only indicated if the brachydactyly affects hand function or for cosmetic reasons, but is typically not needed. Physical therapy and ergotherapy may ameliorate hand function. Prognosis for the brachydactylies is strongly dependent on the nature of the brachydactyly, and may vary from excellent to severely influencing hand function. If brachydactyly forms part of a syndromic entity, prognosis often depends on the nature of the associated anomalies.

A case of symptomatic tumoral calcinosis on the great toe and review of the literature

A 67-year-old woman with no specific medical history showed a hard mass on her great toe for several years. The lesion was elastic, round, and had good mobility. An X-ray showed the lesion to be a calcified "chicken wire" lesion; CT and MRI findings indicated it as a benign subcutaneous calcified tumor. Therefore, a resection biopsy was performed. The mass was a 20 x 20 mm calcified tumor diagnosed as tumoral calcinosis. Pathological findings showed that the calcified lesion lay in fibrous connective tissue and characteristic cells were seen around the calcification site. In this case, the lesion was mature and surgical resection was successful. The patient showed no symptoms or recurrence 3 years after the surgery.

Isolated dextrocardia with bilateral undescended testis and bilateral polydactyl of the hands and feet: a case report

The incidence of dextrocardia with or without situs inversus is rare though the true incidence in Nigeria is not known. Plain films are the preliminary investigations of choice in diagnosis of situs anomalies. The aim of this case report is to emphasise the importance of recognition of the spectrum of situs anomalies, because the altered anatomy associated with these anomalies may result in confusing imaging findings, misdiagnosis and difficulties with treatment when seen in conjunction with acquired abnormalities of the chest and abdomen. This study also aim to emphasise the need for accurate placement of radiographic markers by the radiographers before exposure of the films as the key for identification of situs anomalies. The case of dextrocardia without situs inversus diagnosed in a 4-month old baby boy who also had bilateral undescended testis and bilateral polydactyl of hands and feet is presented. The imaging modalities for assessment of situs anomalies are discussed.

Chondrolipoma of the toe

Chondrolipoma is a rare benign mesenchymoma composed of mature cartilage and adipose tissue. We present a 71-year-old man with a chondrolipoma of the great toe. On histological examination, the tumor contained both mature fat cells and chondrocytes. To our knowledge, this is the first report of a chondrolipoma on the toe. This case contributes to better awareness of an extremely rare lesion of the distal lower limb.

Craniodigital syndrome of Scott: clinical and neuroradiological features of a new case

We report on a girl presenting with mental retardation, craniofacial dysmorphisms, and syndactyly. The child's mother and maternal grandfather presented bilateral syndactyly of toes 2 and 3. These manifestations, falling within the ambit of what has been termed the craniodigital syndromes, were first reported by Scott et al (1971) in 3 brothers.

Real-time 3D computed tomographic reconstruction using commodity graphics hardware

The recent emergence of various types of flat-panel x-ray detectors and C-arm gantries now enables the construction of novel imaging platforms for a wide variety of clinical applications. Many of these applications require interactive 3D image generation, which cannot be satisfied with inexpensive PC-based solutions using the CPU. We present a solution based on commodity graphics hardware (GPUs) to provide these capabilities. While GPUs have been employed for CT reconstruction before, our approach provides significant speedups by exploiting the various built-in hardwired graphics pipeline components for the most expensive CT reconstruction task, backprojection. We show that the timings so achieved are superior to those obtained when using the GPU merely as a multi-processor, without a drop in reconstruction quality. In addition, we also show how the data flow across the graphics pipeline can be optimized, by balancing the load among the pipeline components. The result is a novel streaming CT framework that conceptualizes the reconstruction process as a steady flow of data across a computing pipeline, updating the reconstruction result immediately after the projections have been acquired. Using a single PC equipped with a single high-end commodity graphics board (the Nvidia 8800 GTX), our system is able to process clinically-sized projection data at speeds meeting and exceeding the typical flat-panel detector data production rates, enabling throughput rates of 40-50 projections s(-1) for the reconstruction of 512(3) volumes.

Polydactyly of the foot

Fifty-six patients with 72 duplicated toes were analysed. Postaxial duplication accounted for 79%, and the most common anatomical pattern was duplication of the proximal phalanx with a wide metatarsal head. Forty-two patients with 55 duplications were clinically and radiographically evaluated at long-term follow-up (mean 22.5 years). Results were satisfactory in 91% of the patients. Poor results were often associated with preaxial polydactyly because of persistent hallux varus. Surgical treatment is usually straightforward but must be individualized, and some anatomical and surgical details should be considered to obtain a better result.

Korrektur des rheumatischen Vorfußes

INTRODUCTION

Resection of the metatarsal heads is an established procedure for the therapy of rheumatic forefoot deformations. However, a recurrence of lateral deviation of the lesser toes and painful plantar keratosis remain a challenging problem for the treatment of these patients. The aim of this study was to evaluate our results in cases of rheumatoid forefoot deformities. We performed a resection of the metatarsal heads 2-5 in combination with an arthrodesis of the first toe and resection of keratosis by the plantar approach.

MATERIAL AND METHODS

Fifteen patients (20 feet) were followed-up clinically and radiologically using the American Orthopedic Foot and Ankle Society (AOFAS), Miehlke-, and Larsen scores.

RESULTS

Average follow-up time was 3.5 years (range: 1.5-7.5 years). An average AOFAS score of 81/90 was found for the hallux and 90/100 for the lesser toes. A total of 18 feet were rated as pain free, while two feet showed some residual pain. Every case showed an harmonic cascade of the resection. All patients stated that the operation had improved their quality of life and that they would consent to undergoing it again.

CONCLUSION

Our results after arthrodesis of MP-1 and resection of the metatarsal heads 2-5 using the plantar approach were good compared to the data published in the literature.

Computer based methods for measurement of joint space width: update of an ongoing OMERACT project

Computer-based methods of measuring joint space width (JSW) could potentially have advantages over scoring joint space narrowing, with regard to increased standardization, sensitivity, and reproducibility. In an early exercise, 4 different methods showed good agreement on measured change in JSW over time in the small joints of the hands and feet. Despite differences in measurement values between methods, measurement of within-joint change over time showed no systematic differences. The within-method variation was small, with intra-operator variation being smaller than inter-operator variation. Although this initial study was limited in terms of the number of patients and timepoints (total 10), the number of joints was relatively high (340 joints), so the results were considered strong evidence supporting the validity of computer-based JSW measurements to continue the study of the potential value of JSW by comparison of measurements to manual scoring of joint space narrowing using the COBRA trial images.

Multiple calcified subungual epidermoid inclusions

Subungual epidermoid inclusions (also known as subungual onycholemmal cysts) are an uncommon and distinctive nail abnormality occurring in the dermis of the nail bed. Clinically the nail plate may exhibit onychodystrophy, clubbing, ridging, thickening, pigmentation, or appear normal. We report the case of a patient with onychodystrophy of the right halux of 7 years' duration. This case is presented with serial pictures demonstrating the gradual development of nail plate thickening, yellow discoloration, and nail bed hyperkeratosis indicative of the disease. She had negative fungal cultures, poor response to topical and oral antifungal agents, and an initial nondiagnostic superficial biopsy. Repeat full-thickness nail bed biopsy results revealed multiple calcified subungual epidermoid inclusions epidermoid inclusions. Histologic features included characteristic elongation of the rete ridges with cyst formation and pinching off of the connection to the nail bed epithelium, forming free-lying cysts within the dermis of the nail bed. The cysts contained compact onycholemmal keratin and calcification. A granular layer was not present. This case reinforces the need to clinically reassess, possibly x-ray, and perform a sufficient biopsy for persistent undiagnosed nail unit disorders. Subungual calcified inclusions may be an underrecognized and more common entity than currently recognized.

A novel patient with Cooks syndrome supports splitting from “classic” brachydactyly type B

We report on a 2-year-old girl affected by an isolated form of brachydactyly type B (BDB)-like malformation of the limbs consistent with Cooks syndrome (CS). A literature review was carried out in an attempt to delineate the CS clinical spectrum and separate it from BDB. The two conditions can be differentiated on clinical, radiological, and genetic grounds. In particular, CS shows a characteristic pattern of ungueal and phalangeal anomalies. In the hands, all rays are involved to a similar extent with bulbous tips. The feet are generally more severely affected than the hands. Involvement of the nails appears to be a primary feature and not secondary to phalangeal hypo/aplasia. Also, radial and ulnar rays are similarly affected. The CS clinical spectrum is expanded to include ungueal tumor-like lesions, observed in the present patient.