Sesamoid problems.

The understanding of the pathology and treatment of hallux sesamoid disorders has improved considerably over the last few decades. It is interesting to speculate what further improvements are on the horizon. Newer imaging methods and possibly an increased use of small joint arthroscopy may make it possible to better diagnose and treat conditions of these two small bones and to develop better biologic and artificial methods of surface replacement. In the meantime clinicians should only excise sesamoids if it is really essential.

The surgical management of the rheumatoid foot.

After cancer and heart disease, arthritis is the third most common health problem in the UK and Europe. Patients with rheumatoid arthritis require more medical care then those with osteoarthritis because rheumatoid patients have multiple joint involvement. Some patients require surgery for successful treatment of their painful joints. This article outlines the surgical procedures most commonly undertaken for reconstruction of the rheumatoid foot, and summarizes the indications for these procedures and the causes of failure.

Double-stem silicone implant arthroplasty of all metatarsophalangeal joints in patients with rheumatoid arthritis.

Double-stem silicone implants have been used to reconstruct destroyed hallux metatarsophalangeal joints (MTPJ) for many years. When smaller implants became available, they were used to reconstruct the lateral four MTPJ. An arthroplasty of all MTPJ was performed using these implants in 44 patients (72 feet) with rheumatoid arthritis (RA). The mean age of patients was 46 years (range, 21 to 66) and 84% were female. Previous surgery had been performed on 28% of the feet. All patients were followed prospectively for an average of 67 months (range, 36 to 111). The patients were evaluated clinically and radiographically; results were recorded on a standardized foot form that allowed computer analysis of the data. The results showed improvement in the hallux valgus angle from 41.6 degrees to 16.1 degrees postoperatively, with no loss of correction over time. Similarly, other forefoot deformities, such as plantar callus and lateral toe abnormalities, all improved both clinically and radiographically. The pain, walking, and function scores all improved, with the greatest improvement being pain relief. Radiographic analysis showed some evidence of fracture in seven hallux (9.7%) and nine lateral toe (3%) implants. Only three toes with implant fracture had some pain at follow-up examination. Three other lateral toe implants were removed for pain. There was no evidence of deep infection or silicone synovitis. Other complications included superficial infection, delayed wound healing, and second surgery for heterotopic bone excision.(ABSTRACT TRUNCATED AT 250 WORDS)

Metatarsal osteotomies: which operation?

Surgical correction of hallux valgus by metatarsal osteotomy should aim to restore normal foot anatomy. The operation selected, therefore, needs to be a compromise between biologic and biomechanical considerations. Particular attention should be addressed to the preoperative length and direction of the first metatarsal, as well as the alignment of the first metatarsophalangeal joint. Reducing an already short first metatarsal should be avoided. Realignment of a subluxed first metatarsophalangeal joint requires medial capsular plication, and marked metatarsus primus varus warrants a basal osteotomy.

The effect of early weight-bearing in total knee arthroplasty.

Patients undergoing bilateral simultaneous total knee arthroplasty experienced early supported-weight-bearing on both knees. They were compared with two similar groups of patients whose postoperative weight-bearing on the operated extremity was markedly restricted. The clinical results and incidence of complications were similar in the three groups. There were no significant differences in the incidence of radiolucent lines at follow-up examination two to five years later. Bilateral simultaneous total knee arthroplasty is an effective and safe method of managing patients with arthritic knees where both require replacement. Early supported bilateral weight-bearing does not appear to have any deleterious effects on the bone-cement interface that can be detected on clinical or radiographic analysis. However, all patients should not be considered for bilateral prosthetic knee arthroplasty simply because they have arthritic changes in both knees and the procedure is efficacious. Frequently, only one knee is significantly painful or deformed, and its correction may relieve the opposite knee for an extended period. Bilateral operations are indicated when the pain and deformity of an unoperated knee will significantly retard the reconstructed knee, as in severe flexion contractures or malalignment.

A method of evaluating the results of forefoot surgery.

Clinical evaluation of the foot is complicated because of the large number of structures, most of which are difficult to record or measure. A standardized system of evaluation is needed to assess the ever-increasing methods of treating foot abnormalities. An evaluation form for recording clinical information on forefoot operations has been designed and can be specifically used for computerized data retrieval. In designing the form, an attempt has been made to standardize methods of clinical examination (mainly on the forefoot) and enable accurate comparisons of data from similar studies in the literature. Two hundred thirty-two specific items are included in the form. More data are available on the forefoot because this part of the foot can be more readily evaluated clinically. Also, it is usually the area of the more extreme pathologic changes and largest number of procedures. Specific entries cover details of the history, physical signs, diagnosis, pain assessment, shoes, walking, function, general and surgical treatment, and complications. The form is applicable to computer methods or data retrieval.

Lateral ankle ligament injuries. Inversion and anterior stress radiography.

Known anatomic lesions of the ankle ligaments were correlated with stress radiographic measurements on both anteroposterior and lateral projections, and the effect of foot position during stress radiography was determined. In autopsy specimens ankle ligaments were surgically divided to produce various single and combined lesions. The resulting instability was then assessed by stress radiography in two planes. Talar tilt and anterior displacement of the talus were related to the lesions present. Talar tilt did not normally exceed 4 degrees, and significant tilt occurred only when more than one component of the lateral ligament had been divided. Anterior displacement of the talus did not normally exceed 6 mm when measurement was made from the posterior lip of the tibia to the nearest part of the talar dome. Up to 14 mm of displacement was observed when the anterior talofibular ligament was divided alone or in combination with other ligaments with the foot plantigrade. The anterior stress radiograph should be obtained with the foot in this position. Both inversion and anterior stress radiographs are of value in demonstrating ankle instability and may help in the diagnosis of specific lesions.

Traumatic correction of Dupuytren's contracture.

Two cases are described where a Dupuytren's contracture has been released by injury.

Traumatic dislocation of the hip in adolescence with separation of the capital epiphysis. Two case reports.

Fracture separation of the capital femoral epiphysis occurring during attempted closed reduction of a traumatic dislocation of the hip is described in two adolescents. Although this complication is extremely rare, the prognosis of fracture separation with dislocation of the epiphysis is known to be poor. Avascular necrosis subsequently developed in both cases. The importance of gentle manipulative reduction under general anaesthesia with complete muscle relaxation is emphasised.

Irreducible fracture-separations of the distal tibial epiphysis.

Three cases of a rare complication of Salter Type II fracture-separations of the distal tibial epiphysis are described. Interposition of the anterior tibial neurovascular bundle between the displaced epiphysis and the lower tibia prevented reduction and, in two patients, the blood supply to the foot was compromised. Open reduction and internal fixation resulted in a satisfactory outcome in each case.