Mediciones de imágenes fotográficas del pie como una metodología no invasiva y válida en la exploración clínica / Photographic imaging measurements of the foot as a non-invasive and valid methodology for clinical examination

Introducción: La evaluación anatómica musculoesquelética por imagen en la exploración clínica del pie es la fotografía digital que evalúa la morfología superficial. Objetivos: Validar la obtención de las imágenes fotográficas del pie, calcular las mediciones longitudinales, angulares y el índice del arco plantar de las imágenes mencionadas usando un podoscopio y fotogrametría en sujetos sanos y categorizar la normalidad de las mediciones. Métodos: Este estudio fue exploratorio y se realizó utilizando un prototipo de cámaras alrededor de un podoscopio y un software de análisis de imágenes. La imagen fotográfica fue evaluada por mediciones longitudinales, angulares y el índice plantar. Resultados: Los 30 sujetos sanos evaluados tenían una edad media de 25,06 ± 11,95 años, predominaban las mujeres con un 53,3 por ciento. La longitud total del pie, anchura del metatarso y altura del empeine media para el lado derecho en 226,55 ± 36,49mm, 98,99 ± 22,71 mm, y 36,32 ± 4,07 mm respectivamente; y para el lado izquierdo en 229,81 ± 42,25 mm, 104,49 ± 16,84mm y 36,31 ± 3,32 mm, respectivamente. El ángulo intermetatarsal del 1-2 rayo, ángulo intermetatarsal del 4-5 rayo y ángulo del retropié para el lado derecho fueron 14 ± 4º, 11 ± 3º y 2 ± 2º respectivamente, para el lado Izquierdo 14 ± 3º, 9 ± 3º y 2 ± 2º respectivamente y el índice plantar del arco derecho e izquierdo fueron 0,23 ± 0,2 y 0,22 ± 0,1, respectivamente. La variabilidad solo se presentó en el antepié en 20 por ciento. Conclusiones: La obtención de las imágenes fotográficas del pie fueron válidas, las mediciones fueron menores o similares a otros estudios. La variabilidad de normalidad solo se presentó en antepié(AU)

Introduction: Musculoskeletal anatomical assessment by imaging in clinical examination of the foot is digital photography assessing surface morphology. Objectives: To validate the acquisition of photographic images of the foot, to calculate the longitudinal, angular and plantar arch index measurements of the above images using a podoscope and photogrammetry in healthy subjects and to categorize the normality of the measurements. Methods: This study was exploratory and was performed using a prototype camera around a podoscope and image analysis software. The photographic image was evaluated by longitudinal, angular and plantar index measurements. Results: The 30 healthy subjects evaluated had a mean age of 25.06 ± 11.95 years, females predominated with 53.3 percent. The mean total foot length, metatarsal width and instep height for the right side at 226 55 ± 36.49mm, 98.99 ± 22.71 mm, and 36.32 ± 4.07 mm respectively; and for the left side at 229.81 ± 42.25 mm, 104.49 ± 16.84mm and 36.31 ± 3.32mm respectively. The 1-2 ray intermetatarsal angle, 4-5 ray intermetatarsal angle and rearfoot angle for the right side were 14 ± 4º, 11 ± 3º and 2 ± 2º respectively; for the Left side 14 ± 3º, 9 ± 3º and 2 ± 2º respectively and the plantar index of the right and left arch were 0.23 ± 0.2 and 0.22 ± 0.1 respectively. Variability was only present in the forefoot at 20 percent. Conclusions: The photographic images of the foot were valid, the measurements were lower or similar to other studies. The variability of normality was only present in the forefoot(AU)

Actinomicosis ósea del antepié izquierdo. Presentación de un caso / Bone actinomycosis of the left forefoot. Presentation of a case

RESUMEN Se presentó el caso de una actinomicosis ósea, que se manifestó como una lesión de la piel en la zona correspondiente al segundo metatarsiano izquierdo. Por el antecedente de ser la paciente operada de un tumor de células gigantes, se pensó en una recidiva tumoral. Fue intervenida quirúrgicamente y se realizó exéresis del segundo metatarsiano y de la piel afectada. La biopsia informó actinomicosis. Se trató a la paciente con amoxicilina; evolucionando satisfactoriamente, y dando seguimiento en consulta (AU).

ABSTRACT The authors presented the case of a bone actinomycosis expressed as a skin lesion in the area of the second left metatarsals. Due to the antecedent of having undergone a surgery of a giant cell tumor, a tumor recurrence was thought. Surgical intervention was performed and the excision of the second metatarsals and affected skin was performed. The biopsy reported Actinomycosis. The patient was treated with amoxicillin. She had a satisfactory evolution and is still followed up in consultation (AU).

Fístula arteriovenosa como tratamento adjunto na revascularização arterial do membro em risco / Arteriovenous fistula as adjuvant treatment in arterial revascularization of an at-risk limb

Resumo A oclusão arterial aguda do membro inferior continua sendo um grande desafio para o cirurgião vascular. A abordagem cirúrgica depende principalmente da gravidade da lesão tecidual e da duração dos sintomas. Diversas técnicas estão disponíveis no arsenal terapêutico atual; porém, independentemente da técnica escolhida, fatores pós-operatórios, como o escoamento arterial limitado e o baixo fluxo nos substitutos arteriais, podem contribuir negativamente no resultado da revascularização. Descrevemos um caso de oclusão arterial aguda de membro inferior, no pós-operatório de uma derivação femorotibial, que se encontrava ocluída devido a limitação de escoamento e a alta resistência vascular periférica. Foi submetido a nova revascularização femorotibial, associada à confecção de uma fístula arteriovenosa, seguido de amputação de antepé e enxerto parcial de pele. O investimento enérgico no membro em risco possibilita reduzir os desfechos desfavoráveis, como amputação e óbito, e acelera a recuperação dos tecidos acometidos pela isquemia aguda.

Abstract Acute arterial occlusion remains a major challenge for the vascular surgeon. The therapeutic approach depends mostly upon the severity of the tissue injury and the duration of symptoms. Several techniques are available in the current therapeutic arsenal, however, regardless of the technique chosen, postoperative factors frequently observed, such as poor outflow status, or even low graft flow, can contribute negatively to the outcome of revascularization. We describe a case of acute limb ischemia, in the postoperative period of a femoral-tibial bypass, which was occluded due to outflow limitation and high peripheral vascular resistance. The patient underwent a second tibial revascularization combined with construction of an arteriovenous fistula, followed by forefoot amputation and partial skin graft. An energetic approach to the at-risk limb makes it possible to reduce unfavorable outcomes, such as amputation and death, and accelerates recovery of tissues affected by acute ischemia.

Weightbearing Forefoot Axial Radiography - Technical Description and Reproducibility Evaluation / Radiografia axial do antepé com carga - Descrição da técnica e avaliação da reprodutibilidade

Abstract Objective The present study aims to describe a new weightbearing radiographic method to visualize the heads of the five metatarsals on the coronal plane, evaluating their accuracy through intraclass correlation coefficients. Methods The subjects were evaluated, with weightbearing, with the ankle at 20 degrees of plantar flexion and the metatarsophalangeal joints at 10 degrees of extension, positioned on a wooden device. Two independent foot and ankle surgeons evaluated the radiography, with one of them doing it twice, at different moments, achieving an inter and intraobserver correlation, with intraclass correlation coefficients. Results We radiographed 63 feet, achieving an interobserver correlation coefficient of the radiographic method for the metatarsal heads heights in the coronal plane of the 1st, 2nd, 3rd, 4th, and 5th metatarsals of, respectively, 0.90, 0.85, 0.86, 0.83, 0.89. The intraobserver correlation coefficient were, respectively, 0.95, 0.93, 0.93, 0.86, 0.92. Conclusion Those correlations demonstrate that the method is accurate and can be used to investigate metatarsal head misalignments in this plane.

Resumo Objetivo Este estudo tem como objetivo descrever um novo método radiográfico com carga fisiológica para visualizar as cabeças dos cinco metatarsos no plano coronal. Métodos Os indivíduos foram radiograficamente avaliados com carga, com o tornozelo a 20º de flexão plantar e as articulações metatarsofalângicas a 10º de extensão, posicionadas em um dispositivo de madeira. As medidas foram aferidas por dois avaliadores independentes, sendo que um deles mediu em dois momentos distintos, obtendo a correlação inter e intraobservador, com o coeficiente de correlação intraclasses. Resultados Examinamos 63 pés, obtendo um coeficiente de correlação interobservador do método radiográfico para as alturas das cabeças dos metatarsos no plano coronal do 1º, 2º, 3º, 4º e 5º metatarsos de, respectivamente, 0,90, 0,85, 0,86, 0,83, 0,89. O coeficiente de correlação intraobservador foi, respectivamente, 0,95, 0,93, 0,93, 0,86, 0,92. Conclusão Essas correlações demonstram que o método é preciso e pode ser usado para investigar os desalinhamentos de cabeça dos metatarsos nesse plano.

Avaliação do alinhamento de joelhos e retropés em mulheres com e sem dor patelofemoral durante o exercício de agachamento / Knee and rearfoot alignment´s assessment in womans with and without patellofemoral pain during squat exercise

O agachamento, considerado um movimento biomecânico complexo em função de exigir alinhamento dinâmico, é um exercício frequentemente praticado. Se executado de forma errada, pode tornar-se fator de risco para lesões osteomioarticulares, como a dor patelofemoral. Objetivo: Avaliar o alinhamento dos joelhos e do retropé durante o exercício de agachamento em mulheres com e sem dor patelofemoral. Método: Foram selecionadas 25 mulheres, com idade entre 19 e 37 anos, praticantes de musculação há no mínimo seis meses, que referissem dor no joelho durante atividades funcionais. A amostra foi recrutada em quatro academias do Vale do Taquari. Após a aplicação de um Questionário, que abordou intensidade e comportamento da dor patelofemoral, as voluntárias foram divididas em dois grupos: 14 com dor patelofemoral e 11 sem dor patelofemoral. Foi filmada a execução do exercício de agachamento e do Step Down Test, para avaliar o alinhamento dos joelhos e retropé nestas atividades funcionais. Resultados: Os dados foram analisados por meio de estatística descritiva, teste t Student e Correlação de Pearson, com um nível de significância de p < 0,05. Não houve diferença entre as variáveis, comparando-se o grupo com e sem dor patelofemoral. As participantes com maiores valores angulares de valgismo estático tendem a apresentar a mesma característica durante o teste Step Down. Conclusão: É necessária uma abordagem avaliativa individualizada, com a divisão em subgrupos, de acordo com a etiologia da dor. Questiona-se a classificação das alterações biomecânicas como causa ou efeito da dor patelofemoral e das compensações realizadas.

The Squatting, considered a complex biomechanical movement due to requiring dynamic alignment, is a frequently practiced exercise. If performed in the wrong way, it can become a risk rese for osteomioarticular lesions, such as patellofemoral pain. Objective: The objective of this study was to evaluate the alignment of the knees and the rearfoot during the squatting exercise in women with and without patellofemoral pain. Method: Twenty-five women, aged between 19 and 37 years, were trained for at least six months, who reported knee pain during functional activities. The sample was recruited in four academies of the Taquari Valley. After the application of a Questionnaire, which addressed the intensity and behavior of patellofemoral pain, the volunteers were divided into two groups: 14 with patellofemoral pain and 11 without patellofemoral pain. The execution of the squat exercise and the Step Down Test were recorded to evaluate the alignment of the knees and rearfoot in these functional activities. Results: The data were analyzed using descriptive statistics, Student's t-test and Pearson's correlation, with a significance level of p <0.05. There was no difference between the variables, comparing the group with and without patellofemoral pain. The participants with higher angular values of static valgus tend to resente the same characteristic during the Step Down test. Conclusion: An individualized evaluation approach is necessary, with the subgrouping according to the pain's etiology. It is questioned the classification of biomechanical alterations as cause or effect of patellofemoral pain and compensations performed.

Baropodometric analyses of patients before and after bariatric surgery

OBJECTIVE: The aim of this study was to evaluate the vertical component of the ground reaction force, plantar pressure, contact area of the feet and double-support time using static and dynamic (gait) baropodometry before and after bariatric surgery. METHODS: Sixteen individuals with a body mass index of between 35 and 55 were evaluated before and after bariatric surgery. Thirteen patients (81.3%) were female and three (18.8%) male and their average age was 46±10 (21-60) years. An FSCAN system (version 3848) was used for baropodometric analyses (1 km/h and 3 km/h). The peak plantar pressure and ground reaction force were measured for the rear foot and forefoot. The double-support time and foot contact area were measured during gait. RESULTS: There were reductions in the ground reaction force in the forefoot and rear foot and in the foot contact area in all evaluations and of the double-support time at 3 km/h, as well as a significant reduction in the body mass index at six months post-surgery. The peak pressure did not vary at 1 km/h and at 3 km/h, reductions in peak pressure were observed in the left and right rear feet and left forefoot. CONCLUSIONS: Weight loss after bariatric surgery resulted in decreases in the ground reaction force and contact area of the foot. Plantar pressure was decreased at 3 km/h, especially in the forefoot. There was an increase in rhythm because of a reduction in the double-support time at 3 km/h.

Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure / Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure

Introduction: Although diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF. Objective: The aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure. Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome. Results: A total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): −2.65 to −0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = −0.25 mg/dL; 95% CI: −0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64–1.56; p = 0.993). Conclusion: Compared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality ...

Introdução: Embora os diuréticos sejam utilizados como o principal tratamento na insuficiência cardíaca aguda descompensada, sua significativa taxa de complicações e respostas inadequadas levou ao uso de ultrafiltração extracorpórea como uma alternativa. Objetivo: Realizar uma meta-análise de estudos de ultrafiltração venosa extracorpórea e diuréticos no tratamento de sobrecarga hídrica na insuficiência cardíaca aguda descompensada. Métodos: MEDLINE, EMBASE e o banco de dados do Cochrane Central Register of Controlled Trials foram pesquisados sistematicamente usando um critério pré-estabelecido. Estimativas combinadas para os resultados na alteração de peso em 48 horas, creatinina sérica e mortalidade por todas as causas foram calculados utilizando modelos de efeitos aleatórios. As diferenças entre as médias ponderadas combinadas foram calculadas para a perda de peso e alteração nos níveis de creatinina e relação risco partilhado foi utilizada para o resultado binário de todas as causas de mortalidade. Resultados: Nove estudos foram considerados elegíveis para a análise, com inclusão de 613 pacientes. Pacientes submetidos a ultrafiltração perderam em média 1,78kg (intervalo de confiança [IC] 95% -2,65 a 0,91kg, p < 0,001) quando comparados com pacientes submetidos à terapia diurética padrão. Os níveis de creatinina pós-intervenção, no entanto, não diferiram entre os grupos (diferença média de -0,25 mg/dL CI 95% -0,56 a 0,06mg/dL p = 0,112). Não observamos evidências de redução de risco de mortalidade por todas as causas em pacientes submetidos à UF quando comparados àqueles tratados com terapia diurética padrão (RR combinado = 1,00 CI 95% 0,64 1,56, p = 0,993). Conclusão: Quando comparado à terapia diurética padrão, o uso de UF no tratamento de sobrecarga hídrica em ICAD resultou em uma redução significativa de peso em 48 horas. No entanto, não foi observada melhoria significativa na redução dos níveis de creatinina ou na taxa de ...

Osteomalacia oncogénica: Presentación de dos casos

La osteomalacia oncogénica es una enfermedad rara. Existen descriptos alrededor de 337 casos. Es ocasionada por un tumor productor del factor de crecimiento fibroblástico 23 (FGF-23), hormona que disminuye la reabsorción tubular de fosfatos y altera la hidroxilación renal de la vitamina D, con hipofosfatemia, hiperfosfaturia y niveles bajos de calcitriol. Se presentan dos pacientes de 44 y 70 años, que consultaron por dolores óseos generalizados de aproximadamente un año de evolución en los que se hallaron alteraciones bioquímicas compatibles con osteomalacia hipofosfatémica. En el primer caso se realizó la resección de una tumoración en tejido celular subcutáneo del pie derecho, un año después del diagnóstico clínico. Luego de la exéresis, se disminuyó el aporte de fosfatos que recibía el paciente, pero reaparecieron los dolores al intentar suspenderlos. Ocho años más tarde, hubo recidiva local de la tumoración por lo que se efectuó resección completa. Después de la misma, se logró suspender el aporte de fosfatos. En el segundo caso, el paciente se estudió con tomografía por emisión de positrones con 18F-fluorodesoxiglucosa, hallando formación nodular hipermetabólica en partes blandas de antepie derecho, de 2.26 cm de diámetro. Luego de su escisión se pudo suspender el aporte de fosfatos. Ambos pacientes se encuentran asintomáticos con indicadores de metabolismo fosfocálcico normales. El diagnóstico anatomopatológico en ambos fue un tumor mesenquimático fosfatúrico, variante mixta del tejido conectivo, la entidad más frecuentemente asociada a la osteomalacia oncogénica.

Oncogenic osteomalacia is a rare disease. It is caused by a tumor that produces fibroblast growth factor 23, a hormone that decreases the tubular phosphate reabsorption and impairs renal hydroxylation of vitamin D. This leads to hyperphosphaturia with hypophosphatemia and low calcitriol levels. About 337 cases have been reported and we studied two cases; 44 and 70 year-old men who sought medical attention complaining of suffering diffuse bone pain over a period of approximately one year. In both cases, a laboratory test showed biochemical alterations compatible with a hypophosphatemic osteomalacia. In the first case, a soft tissue tumor of the right foot was removed, one year after the diagnosis. The patient was allowed to diminish the phosphate intake, but symptoms reappeared at this time. Eight years later, a local recurrence of the tumor was noted. A complete excision was now performed. The patient was able to finally interrupt the phosphate intake. In the second case, an F-18 fluorodeoxyglucose positron emission tomography, with computed tomography revealed a 2.26 cm diameter hypermetabolic nodule in the soft tissue of the right forefoot. After its removal, the patient discontinued the phosphate intake. Both patients are asymptomatic and show a regular phosphocalcic laboratory evaluation. The histopathological diagnosis was, in both cases, a phosphaturic mesenchymal tumor, a mixed connective tissue variant. This is the prototypical variant of these tumors.

The anatomy and clinical application of reverse saphenous nerve neurocutaneous flaps for reparing skin defects of forefoot / 中华整形外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of reverse saphenous nerve neurocutaneous flaps for skin defects of forefoot.</p><p><b>METHODS</b>In the anatomic study, 50 cadaveric feet were injected with red latex and the anastomosis, distribution and external diameters of medialtarsal artery, medial anterior malleolus artery, medial plantar artery, the superficial branch of the medial basal hallucal artery and saphenousnerve nutritional vessels were observed. Based on anatomic research results, we designed the reverse saphenous nerve neurocutaneous flaps for repairing skin defects of forefoot.</p><p><b>RESULTS</b>The blood supply of reverse saphenous nerve neurocutaneous flaps were based on the vasoganglion, which consist of arterial arch at the superior border of abductor hallucis and arterial network on the surface of abductor hallucis around the saphenous nerve and medial pedis flap. From Oct. 2006 to Oct. 2011, the reverse saphenous nerve neurocutaneous flaps were used to repair skin defects of forefoot in 11 cases. The flap size ranged from 2.5 cm x 3.5 cm to 7.5 cm x 8.5 cm. The wounds at donor site were covered with full-thickness skin graft. All flaps survived completely with no ulcer at the donor site. 11 cases were followed up for 6 to 18 months( mean, 10 months). The skin color and texture were satisfactory. The patients could walk very well.</p><p><b>CONCLUSIONS</b>It is reliable to repair the skin defects of forefoot with reverse saphenous nerve neurocutaneous flaps. It is easily performed with less morbidity. This flap should be considered as a preferential way to reconstruct skin defects of forefoot.</p>

Clinical application of venous nutrition flap pedicled by medial plantar artery of the hallux on the medical aspect of the foot / 中华整形外科杂志

<p><b>OBJECTIVE</b>To introduce the clinical application of venous nutrition flap pedicled by medial plantar artery of the hallux on the medical aspect of the foot.</p><p><b>METHODS</b>Based on the anastomoses between the medial plantar artery of the hallux and the nutritional vein, the flap was designed with the perforator of medial plantar artery adjacent to the first metatarsal bone as the rotation point. The flap axis was along the vein at the medial aspect of the foot between rotation point and medial malleolus.</p><p><b>RESULTS</b>5 cases were treated with primary healing and complete survival flaps. The patients were followed up for 1-12 months with good match of texture and color.</p><p><b>CONCLUSIONS</b>The venous nutrition flap pedicled by medial plantar artery of the hallux on the medical aspect of the foot can be transpositioned to repair the defect at forefoot.</p>

Forefoot plantar pressure changes of the first tarsometatarsal joint fracture-dislocation fixation by different internal fixations / 中国骨伤

<p><b>OBJECTIVE</b>To measure the changes of plantar pressure of the first tarsometatarsal joint fracture and dislocation by three different implants to provide experimental reference in selecting implants.</p><p><b>METHODS</b>Eight fresh foot specimens were made into the models of the first tarsometatarsal joint fracture and dislocation, which were fixed with 3.5 mm cortical screw, 1/4 tubular plate and compressive staple in turn. After the loading of 600 N, the changes of the plantar pressure in forefoot were measured by the method of the F-scan plantar pressure system.</p><p><b>RESULTS</b>After first tarsometatarsal joint fracture and dislocation, the peak pressure under the first metatarsal head would decrease, while the pressure under the second metatarsal head would increased,whose differences were statistically significant (P<0.05). When the first tarsometatarsal joint was fixed with screw or plate respectively; the peak pressure under the two metatarsal heads would tend to be normal. However,the staple fixation showed the statistical significant difference compared with normal state, although the peak pressure under the first and second metatarsal heads were recovered in some extent(P<0.05).</p><p><b>CONCLUSION</b>After the first tarsometatarsal joint fracture-dislocation, the plantar pressure might be compensated partly by the adjacent metatarsal heads according to the regulation of the load transfer mechanism. While the first tarsometatarsal joint fracture-dislocation was fixated by screw or plate, the plantar pressure of the forefoot would return to the normal state. However,if the joint was fixated by the staple, it would still be difficult to return the plantar pressure to be normal.</p>

Clinical and functional evaluation of forefoot reconstruction in patients with rheumatoid arthritis / Avaliação clínico-funcional da reconstrução do antepé nos pacientes portadores de artrite reumatoide

OBJECTIVE: to evaluate the long-term results from reconstruction of the forefoot in patients with rheumatoid arthritis who underwent arthrodesis of the metatarsophalangeal joint of the hallux, resection arthroplasty of the heads of the lateral metatarsals and correction of the deformities of the smaller toes through arthrodesis of the proximal interphalangeal joint or closed manipulation. METHODS: seventeen patients (27 feet) who underwent forefoot reconstruction surgery by means of arthrodesis of the first metatarsophalangeal joint, resection of the heads of the lateral metatarsals and correction of the deformities of the smaller toes, were studied retrospectively. The mean follow-up was 68 months (12-148 months); the mean age was 52 years (range: 20-75 months); and four patients were male and 13 were female. RESULTS: the results were classified as excellent in 17 feet, good in two, fair in four and poor in two. The mean score on the AOFAS scale was 70 points; 21 feet (78%) were found to be asymptomatic; and six feet (22%) presented some type of symptom. Three feet presented pseudarthrosis, and one of these successfully underwent revision of the arthrodesis. There was no significant difference in scoring on the AOFAS scale or in the consolidation rate, between using a plate and screws and using Kirschner wires for fixation of the arthrodesis. CONCLUSION: arthrodesis of the first metatarsophalangeal joint with resection arthroplasty on the heads of the lateral metatarsals and correction of the deformities of the smaller toes, which was used in forefoot reconstruction in rheumatoid patients, showed good long-term results with a high satisfaction rate among the patients and clinical-functional improvement...

OBJETIVO: avaliar os resultados em longo prazo da reconstrução do antepé nos pacientes com artrite reumatoide submetidos à artrodese da articulação metatarsofalângica (MTF) do hálux, artroplastia de ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores por meio de artrodese da articulação interfalângica proximal (IFP) ou manipulação fechada. MÉTODOS: foram estudados retrospectivamente 17 pacientes (27 pés) submetidos à cirurgia de reconstrução do antepé com artrodese da primeira articulação MTF, ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores. O seguimento médio foi de 68 meses (12 a 148), a média de idade foi de 52 anos (20 a 75 meses) e quatro pacientes eram do sexo masculino e 13 do feminino. RESULTADOS: os resultados foram classificados como excelente em 17 pés, bom em dois, regular em quatro e ruim em dois. A pontuação média da escala Aofas (American Orthopaedic Foot and Ankle Society) foi de 70 pontos, 21 pés (78%) encontravam-se assintomáticos e seis (22%) apresentavam algum tipo de sintoma. Três pés apresentaram pseudoartrose. Um deles foi submetido à revisão da artrodese com sucesso. Não houve diferença significativa na pontuação da escala Aofas e nos índices de consolidação com o uso de placa e parafusos ou fios de Kirschner na fixação da artrodese. CONCLUSÃO: a artrodese da primeira articulação MTF com artroplastia de ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores, usada na reconstrução do antepé dos pacientes reumatoides, demonstrou bons resultados em longo prazo, com elevado...

Free perforating flap of peroneal artery for repairing the forefoot skin defects / 中国骨伤

<p><b>OBJECTIVE</b>To explore the clinical techniques and effects of repairing skin defects of the forefoot by free perforating flap nourished by peroneal artery.</p><p><b>METHODS</b>From June 2007 to June 2011, 11 patients with skin and soft tissue defects of the forefoot were repaired by free peroneal artery perforating flap in emergent or subemergent. There were 10 males and 1 female with an average age of 28.6 years old ranging from 23 to 46 years old. Among them, 4 cases injured for traffic accidents, 3 for crush and 4 for machine strangulation. In all cases, the defect area of forefoot tissue varied from 2.0 cm x 4.0 cm to 4.0 cm x 8.5 cm,and the adopted area varied from 2.5 cm x 4.5 cm to 4.0 cm x 9.0 cm. The operation time was from 6 to 96 h (averaged 31.8 h). The blood vessels were anastomosed end-to-end.</p><p><b>RESULTS</b>All of the transferred free flaps survived uneventfully. Nine of them were successfully followed up from 6 to 24 months. The appearance, elasticity and functions of flaps were satisfied accompanied with slight damage of donor site although seemed bloated. The smaller donor site could be intimately seamed if necessary.</p><p><b>CONCLUSION</b>The vessels anatomy of knee with antegrade extended peroneal artery was relative constant with a moderate thickness and simple operation, is useful to repair small or middle areas of skin defects in forefoot.</p>

Reconstruction of hind foot defects; a simplified workable solution

Reconstruction of traumatic as well as non-traumatic hind foot defects is always a challenging task. We share here a simple and practical protocol [working solution] to select the most suitable method for soft tissue coverage of hind foot defects, customizable for every patient. We carried out this study, in our department on 75 cases from March 2009 to May 2012. All cases with wound/defect in hind foot area were included. Majority of cases were traumatic rest included cases of malignancy, Trophic ulcers, infection. Patient's data including age, sex, site of injury, mode of injury, extent of injury [isolated or combined], if combined structures involved, type of wound, management of wound, wound healing time and complications were noted. Once optimal wound conditions were achieved the best possible reconstructive option was selected. The various reconstructive options include VAC therapy, Skin graft, local transposition flap, perforator based flapspedicled faciocutaneous/ muscle flaps, intrinsic foot muscles, Medial plantar artery flap and distant flaps like cross leg flap and micro vascular free flaps. All patients had satisfactory and stable reconstruction. They were ambulating freely by 4-6 weeks post operatively. There were few complications like patchy graft loss, peripheral flap necrosis, flap congestion, but none was serious and did not require repeat surgery. The simplified protocol followed by us is a practical customizable solution for difficult task of hind foot reconstruction. The choice of one or multiple techniques will vary from time to time from one surgeon to another depending upon his or her experience and liking

Análise baropodométrica dos corredores de rua na cidade de Fortaleza/CE / Baropodometric analysis of street runners in city of Fortaleza/CE

Este estudo objetiva analisar as pressões plantares dos corredores de rua de uma praça na cidade de Fortaleza/ CE. Estudo exploratório-descritivo analisou as pressões plantares e tipo de pé de corredores de rua na cidade de Fortaleza/CE. Amostra de 13 indivíduos, ambos os sexos, com mais de um ano de treinamento. A avaliação ocorreu entre agosto e novembro de 2007 através de plataforma de força no modo estático e plantigrama. Os corredores apresentaram média de pressão plantar em antepé de 55,15% (±2,56) e de retropé 44,84% (±2,56) e tipo de pé plano (38,46%) e 42,30% pé cavo. Há uma inversão das pressões plantares, sendo sugerido que a deformidade dos arcos plantares e a inversão representem um fator de aumento para as lesões nesses corredores.

Clinical result of forefoot correction by the first ray stabilization combined with resection of the lesser metatarsal head procedure for patient with rheumatoid arthritis / 中国骨伤

<p><b>OBJECTIVE</b>To introduce the procedure of the 1st ray stabilization combined with resection of the lesser metatarsal heads for patient with severe forefoot deformity caused by rheumatoid arthritis (RA) and evaluate the short to mid-term clinical results.</p><p><b>METHODS</b>From Oct. 2006 to Aug. 2010,97 patients (129 feet) aged from 36 to 67 years (average 54), with forefoot deformity caused by rheumatoid arthritis were reviwed. There were 88 males and 9 females,65 single lateral involved and 32 bilateral involved, the average duration of disease was 17 years (6 to 32 years). The 1st ray instability and lesser metatarsophalangeal (MTP) joint stiff dislocation were found in all cases. The first ray stabilization combined with resection of the lesser metatarsal head procedure were performed for all cases. The radiographic Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measurde and the JSSF (Japanese Society for Surgery of the Foot) score were evaluated before operation and every follow up.</p><p><b>RESULTS</b>The average followed-up was 37 months (6 to 52 months) for all patients except 5 (7 feet) and 1 died for acute cardiac infarction 1 year after operation. The average JSSF score improved from (33.2 +/- 8.2) points preoperative to (67.3 +/- 3.1) points at final followed-up (P < 0.01); the average HVA was corrected from (50.0 +/- 11.8) degrees preoperative to (21.2 +/- 3.2) degrees at final follow up (P < 0.01); the average IMA was corrected from (15.5 +/- 3.6) degrees preoperative to (9.7 +/- 6.6) degrees at final follow up (P < 0.01). MTP joint nonunion was found in 4 feet. A radiographic high density mass was found in the 1st cuneiform bone during 8 to 11 months followed-up in 3 feet; delayed wound healing was happened in 9 feet; MTP joint infection was happened in 2 feet; tarsometatarsal joint infection was happened in 1 foot; lesser MTP joints deformity recurrence were found in 16 feet.</p><p><b>CONCLUSION</b>The characters of forefoot with RA in later stage are the 1st ray deformity and instability compound with the lesser toes deformity. The 1st ray stability procedure which include the 1st MTP arthrodesis and the Lapidus procedure can correct the 1st ray deformities and rebuilt its stability. The lesser toes metatarsal head resection is effective in correct their deformity. This combined procedure is reliable. It is suitable for patients with severe Hallux valgus, increased IMA, tarsometatarsal joint instability and the lesser MTP joint stiff dislocation.</p>

Tratamento cirúrgico das fraturas dos metatársicos laterais com técnica percutânea anterógrada: descrição técnica e resultados clínicos / Anterograde percutaneous treatment of lesser metatarsal fractures: technical description and clinical results

OBJETIVO: O objetivo deste trabalho é avaliar os resultados obtidos com a técnica de fixação anterógrada percutânea para o tratamento das fraturas do colo e diáfise dos metatársicos laterais. MÉTODOS: Realizamos avaliação prospectiva de 14 pacientes operados no período de 2003 a 2008, em que foram levados em consideração a topografia das fraturas, o mecanismo de trauma, as comorbidades associadas e o escore AOFAS para o antepé. RESULTADOS: A região anatômica mais atingida foi o colo dos metatársicos (79%); o acometimento de múltiplos metatársicos ( 53%) foi mais comum que o acometimento isolado (47%); o trauma de baixa energia (79%) foi mais frequente do que o de alta energia (21%); pacientes do sexo feminino com diabetes mellitus apresentaram os piores resultados funcionais pós-operatórios. Não foram encontradas complicações pós-operatórias relacionadas com o tipo de tratamento instituído. CONCLUSÕES: A técnica cirúrgica apresentada demonstrou ser eficiente para o tratamento das fraturas dos metatarsos laterais com menor índice de complicações do que as técnicas já existentes na literatura.

OBJECTIVE: The aim of this study was to evaluate the results obtained using the anterograde percutaneous fixation technique for treating shaft and neck fractures of the lesser metatarsals. METHODS: We prospectively evaluated 14 patients between 2003 and 2008, taking into consideration the topography of the fracture, trauma mechanism, associated comorbidities and AOFAS score for the forefoot. RESULTS: The anatomical region most affected was the metatarsal neck (79%). Involvement of multiple metatarsals (53%) was more common than isolated fractures (47%). Low-energy trauma (79%) was more frequent than high-energy trauma (21%). Female patients with diabetes had the worst postoperative functional results. There were no postoperative complications relating to the type of treatment instituted. CONCLUSIONS: The surgical technique presented was efficient for treating fractures of the lesser metatarsals, with a lower complication rate than shown by other established techniques in the literature .

Digital gigantism of the foot: a clinical study of 12 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the clinical characteristic and outcome of digital gigantism of the foot.</p><p><b>METHODS</b>Retrospectively analyze the clinical documents of cases of digital gigantism of the foot. Twelve 12 cases with 13 feet in this study included 8 male and 4 female with an average 4.6-years-old. All the deformities were found at birth. Multiple toes involved were more than single toe, and tibial toe involved more than fibular. Forefoot was enlarged. All the phalanges involved and partial metatarsal bones were enlarged. Marked increase in subcutaneous fat was found in all cases in the operation which infiltrated interossei and articular capsules. The appearance of the nerves and its branches in the foot were normal and fat infiltrating was not discovered. The operation types included debulking, epiphyseal arrest, amputation, nerve stripping and anastomosis.</p><p><b>RESULTS</b>Seven cases were followed up with mean periods 25.6 months. Functional evaluation according to a criterion formulated by author revealed a result of 2 excellent, 2 good and 3 fair.</p><p><b>CONCLUSIONS</b>Digital gigantism of the foot is an uncommon congenital deformity of the foot characterized by overgrowth of both the soft-tissue and the osseous elements of the enlarged toe and forefoot. Surgical treatment is the unique method, and the goal is to reduce the size of the foot to allow fitting regular shoes and walking readily. There are several types of operations which to be chosen. The indication, the timing of operative intervention and the selection of operation type should be paid more attention.</p>