A rare combination of brachymetatarsia and congenital hallux varus: case report and review of the literature.

Hallux varus is defined as a medial deviation of the phalanx at the first metatarsophalangeal joint and can be congenital or acquired. Brachymetatarsia is defined as shortening of the metatarsal bones. A combination of hallux varus and brachymetatarsia is rare. A 15-year-old girl presented to our outpatient clinic complaining of problems with her feet. A distinctive hallux varus was present bilaterally combined with a brachymetatarsia of the first metatarsals. The patient reported discomfort. She was restricted in her activities and had severe psychological strain owing to the deformity. We decided on surgery. First, a Pennig MiniFixator for callus distraction of the first metatarsal bone was applied. Owing to the increased plantar subluxation of the phalanx during distraction, an extension of the external fixator was administered so that the hallux could be repositioned to a physiologically satisfying position. After sufficient callus formation, the hardware was removed 14 weeks after surgery. Thereafter, the phalanx moved back to the subluxed position. Finally, an arthrodesis of the first metatarsophalangeal joint was performed with a locking plate. Surgery should not be made only for cosmesis and associated psychological aspects; but, discomfort should be the deciding factor. The postoperative clinical and cosmetic results in our case were good, and the patient was quite satisfied. There was no longer any preoperative discomfort and pain.

Giant gouty tophi of the hand and wrist.

Gout is an inflammatory-rheumatic disease characterized by an elevated serum urate concentration and recurrent flares, including painful, hot, red, and swollen joints and surrounding tissue. Untreated gout often develops into a chronic disease with tophi and destruction of joint surfaces. Giant tophi are often resistant to medication and change in diet.This article presents a case of a 44-year-old man with giant gouty tophi at his hand and wrist. The last acute gout flare in his left wrist was approximately 3 years prior. For 2 years he had refused adequate nutrition, such as a low-purine diet, and had refused to take any preventive medication. Blood urate level was elevated to 8.7 mg/dL (normal range, 3.4-7.0 mg/dL). In time, the tophi led to a massive limitation of motion and use of especially the left wrist and thumb. Under the condition that the patient changed his diet and took the medication for his underlying disease, we surgically removed the almost skin-perforating tophi. Surgical debulking significantly improved joint function and cosmetic appearance.The best treatment for gouty tophi is prevention by ensuring adequate nutrition, treating the underlying causes, and taking effective medication. In the case of massive limitation of joint motion, skin breakdown with risk of infection, and compression of neurovascular structures, surgical debulking of the tophi should be considered.

Iliopsoas cyst causing persistent pain after total hip arthroplasty.

Persistent pain after total hip arthroplasty (THA) has many potential causes. The most common are aseptic loosening, infection, and heterotopic ossification. Irritation of the iliopsoas tendon due to the acetabular component is an underestimated cause of persistent groin pain and functional disability after THA with rare incidence. Pain specific to iliopsoas tendonitis includes activities such as hyperextension of the hip, forced flexion, and activities of daily living (eg, ascending stairs). This article presents a case of a 50-year old man with clinical and radiological signs of osteoarthritis of the right hip joint. A THA was performed. After a symptom-free interval of several weeks postoperatively, the patient reported pain projecting from the right groin and radiating ventromedially along the leg. Magnetic resonance imaging of the hip showed a fluid-filled cyst in anatomical proximity to the femoral nerve causing an iliopsoas tendonitis. The patient underwent surgical resection of the cyst was performed by an anterior approach; a conjunction to the hip joint was not present. The implanted components of the prosthesis showed good osseointegration with no signs of loosening. The cyst was removed and the iliopsoas tendon was released. A few weeks after the operation, the patient was pain free. At 17-month follow-up, no problems were reported. In cases such as this, finding the correct diagnosis may be difficult and misleading. Conservative and operative therapeutic options are discussed and compared with divergent findings in the literature.

Achilles tendon ossification after treatment with acitretin.

Achilles tendon ossifications are rare. Usually they develop after surgery or trauma. The present case report illustrates a severe and tender Achilles tendon ossification of 10 cm in length a few months after treatment with acitretin for lichen ruber. With discontinuation of acitretin therapy, regression of pain was achieved but the ossification was irreversible. This case should raise awareness for possible and severe calcifications in the use of retinoid therapy.

Distally based capsule-periosteum interpositional arthroplasty for hallux rigidus. Indications, operative technique, and short-term follow-up.

Twelve patients (15 feet) with severe hallux rigidus underwent distally based capsule-periosteum interpositional arthroplasty of the first metatarsophalangeal joint (mean +/- SD follow-up, 16.8 +/- 7.0 months). Subjective evaluation was based on a modified version of the American Orthopaedic Foot and Ankle Society's 100-point Hallux Metatarsophalangeal-Interphalangeal Joint Scale. Objective evaluation consisted of preoperative and postoperative physical examinations (first metatarsophalangeal joint range of motion and axial grind testing) and radiographic evaluations (joint space width). The short-term results of this novel procedure showed subjective patient improvement and satisfaction, increased first metatarsophalangeal joint dorsal range of motion, maintained hallux plantar range of motion and power, and improved joint space width on anteroposterior and lateral radiographs. None of the patients developed a hallux hammer toe or extensus deformity or lesser metatarsalgia, and none required further surgical intervention. After describing the indications of the procedure and the surgical technique, the authors compare the results with those of the various other procedures available for the surgical treatment of hallux rigidus.