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).

Does Hallux Valgus Correction Reduce the Width of the Forefoot?

Background: Hallux valgus has been associated with a widened forefoot. Most surgical procedures for the correction of hallux valgus have the potential to reduce forefoot width. Success after hallux valgus surgery is correlated with relief of toe pain in conventional shoes and improvement in the appearance of the foot. Therefore, reduction in forefoot width, referred to as metatarsal span (MS), likely correlates with both criteria and may be a reliable radiographic indicator of success after hallux valgus surgery. Methods: Preoperative and postoperative radiographs of 52 patients who underwent correction of hallux valgus with a distal Chevron osteotomy and Akin osteotomy were evaluated by 4 observers. The observers measured the hallux valgus angle (HVA), the intermetatarsal first and second angle (IMA), and the MS. Results: Preoperative HVA ranged from 14° to 48°, IMA ranged from 6° to 25°, and MS ranged from 74.2 to 110.6 mm. The average HVA improvement was 19.4°, IMA improvement was 6.7°, and MS reduction was 8.7 mm. No correlation was identified with regard to correction of the HVA or IMA to MS. Conclusion: Digital radiographic linear measurements were easily and reliably made. Therefore, linear measurements as described in this article can be used as a tool to evaluate if clinical outcomes correlate with reduction of MS. A distal Chevron with an Akin osteotomy has the potential to reduce forefoot width. Levels of Evidence: Level IV: Case series.

Maximally Disfiguring Surgery for Forefoot Osteomyelitis: Time for a Rethink?

The treatment of choice for diabetic foot osteomyelitis is surgical debridement and targeted antibiotics with or without revascularization, depending on vascular status. In our society, debridement is done by either a vascular or orthopedic surgeon, and the common teaching is that generous amputation of bone with the accompanying soft tissue envelope is essential for adequate source control and to prevent recurrence (which remains as high as 30% even with this approach). Most of our patients undergo formal ray amputation through the metatarsal neck, while a few get digital amputations through the interphalangeal joints. Many of the resultant wounds cannot be closed and are left to heal by secondary intention. These amputations invariably alter the biomechanics of the foot and leave large and slow-healing open wounds, which have associated adverse psychosocial impacts. We describe 2 cases of patients who had osteomyelitis in the region of the forefoot who underwent complete bony resections of the osteomyelitis but with sparing of the soft tissue envelopes with good outcomes, and we challenge the dogma that maximal debridement of soft tissue must accompany debridement of necrotic and infected bone.

Solid-Cystic Hidradenoma: A Dorsal Foot Presentation.

Solid-cystic hidradenoma is a benign cutaneous tumor with eccrine sweat gland origins that is most commonly found in the head, neck, trunk, and upper extremity regions of patients in the middle to older age groups. These lesions are generally asymptomatic, slow-growing, solitary, and nonulcerative in presentation. Degenerative malignant transformation of this tumor is very rare. In this case report, the authors describe the marginal surgical excision and subsequent microscopic pathologic diagnosis of a moderate sized solid-cystic hidradenoma of the dorsolateral forefoot in a middle-aged male patient.

Forefoot Reconstruction Following Metatarsal Head Resection Arthroplasty With a Plantar Approach-A 20-Year Follow-Up.

BACKGROUND: Rheumatoid arthritis (RA) can cause significant forefoot disorders. If forefoot deformity and pain are severe, surgical treatment can be considered. The aim of this study was to analyze the long-term outcomes of surgical forefoot correction per Tillmann, which involves resection of the metatarsal heads through a transverse plantar approach for the lesser toes and a dorsomedial approach to the great toe. METHODS: This retrospective study used patient-based questionnaires to analyze the revision rate, pain, use of orthoses, walking ability, forefoot function, and patient satisfaction of patients with RA who had undergone a complete forefoot correction of metatarsophalangeal (MTP) I to V. The study only included participants with RA before the era of biological agents and who were at least 20 years postoperatively. A total of 60 patients who had undergone 100 complete forefoot operations according to Tillmann 24.6 ± 3.5 years ago were included in this study. RESULTS: The data collected showed that 35 reoperations were performed on 26 of the patients. Deformity relapses were often documented for the hallux valgus. More than 60% of the patients were able to wear conventional shoes. The distances the participants were able to walk were significantly increased by wearing shoes when compared with walking barefoot (P < .01). CONCLUSION: While forefoot function remained difficult to assess, the majority of patients were able to use conventional shoes. This long-term follow-up study of patient-reported questionnaires completed more than 20 years after the Tillmann procedure showed that more than 80% of the patients remained satisfied with the outcome. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

The Influence of Fat Grafting on Skin Quality in Cosmetic Foot Grafting: A Randomized, Cross-Over Clinical Trial.

BACKGROUND: Pedal fat grafting is a cosmetic procedure to treat the functional and aesthetic sequelae of pedal fat pad atrophy. Fat grafting has been found to mitigate these symptoms, but the exact mechanism is unknown. OBJECTIVES: The authors hypothesized that pedal fat grafting may improve skin quality, accounting for prolonged symptomatic improvement despite loss of grafted fat. METHODS: Patients with pedal atrophy were enrolled in a randomized crossover clinical trial. Group 1 underwent fat grafting upon enrollment with 2-year follow-up. Group 2 was managed conservatively for 1 year then placed into the fat grafting group with 1-year follow-up. Patients underwent pedal ultrasounds to determine thicknesses of the fat pad and dermis, and photographs were taken to assess skin quality. RESULTS: Three men and 20 women with an average age of 63 ± 6 years and an average BMI of 26.0 ± 4.6 kg/m2 were enrolled in the study. Twenty-six feet were injected in Group 1 and 17 were injected in Group 2. Group 1 dermal thickness increased at 6 months post-injection (P < 0.05). This increase persisted through 24 months. Group 2 dermal thickness decreased prior to injection (P < 0.05) but returned to baseline after injection and through 12-month follow-up (P < 0.05). Fat pad thickness returned to baseline by study completion in both groups (P < 0.05). CONCLUSIONS: Pedal fat grafting yielded a significant, sustained increase in dermal thickness, though grafted fat was not retained. Fat grafting may improve skin quality, which could contribute to improved clinical outcomes despite loss of grafted fat.

Fat Grafting for Pedal Fat Pad Atrophy in a 2-Year, Prospective, Randomized, Crossover, Single-Center Clinical Trial.

BACKGROUND: By age 60, 30 percent of Americans suffer from fat pad atrophy of the foot. Forefoot fat pad atrophy results from long-term aggressive activity, genetically dictated foot type, multiple forefoot steroid injections, surgery, and foot trauma. METHODS: The authors present data from a 2-year, prospective, randomized crossover study performed to assess pain and disability indexes, fat pad thickness, forces, and pressures of stance and gait. Group 1 underwent fat grafting with 2 years of follow-up, and group 2 underwent conservative management for 1 year, then underwent fat grafting with 1 year of follow-up. RESULTS: Eighteen subjects (14 women and four men) constituted group 1. Thirteen subjects (nine women and four men) constituted group 2. Group 1 reported the worst pain at baseline and group 2 experienced the worst pain at 6- and 12-month standard-of-care visits; pain for both groups improved immediately following fat grafting and lasted through study follow-up (p < 0.05). Group 1 demonstrated functional improvements at 12, 18, and 24 months postoperatively (p < 0.05), whereas group 2 demonstrated the highest function at 12 months postoperatively (p < 0.05). Pedal fat pad thickness of subjects in group 1 increased postoperatively and returned to baseline thickness at 2 months postoperatively; subjects in group 2 experienced return to baseline thickness at 6 months postoperatively (p < 0.01). Forces and pressures of stance and gait increased over the 2 years of follow-up for group 1 (p < 0.05). CONCLUSION: Pedal fat grafting provides long-lasting improvements in pain and function, and prevents against worsening from conservative management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Culture of Bone Biopsy Specimens Overestimates Rate of Residual Osteomyelitis After Toe or Forefoot Amputation.

BACKGROUND: Guidelines recommend both histological analysis and culture for definite diagnosis of osteomyelitis. It is not clear if histological and culture criteria can be used interchangeably in the clinical scenario of toe amputation. We therefore prospectively compared the results of intraoperative culture and those of histological examination in this setting. METHODS: Consecutive patients requiring toe or forefoot amputation at the University Hospital Basel during a 2-year period were included in the study. Biopsy specimens from the residual bone were cultured according to microbiological standards. Histological analysis was performed using standardized criteria for osteomyelitis. Clinical outcomes were assessed retrospectively via chart review. RESULTS: Of 51 patients included in the study, 33 (65%) had a positive culture of residual bone and 14 (27%) showed histological signs of osteomyelitis. A negative histological result but a positive culture was found for 21 (41%) of the patients, suggesting that culture has a high false-positive rate if histological analysis is used as the reference to rule out osteomyelitis. The recommended criteria of both positive histological findings and positive culture were fulfilled by 12 (24%) of the 51 patients. CONCLUSIONS: Positive cultures of residual bone after forefoot or toe amputation overestimate the true rate of osteomyelitis as defined by histological analysis, presumably because of contamination from soft tissue at the time of surgery. Additional studies are needed to evaluate the indications for, and the duration of, antibiotic treatment according to these findings. CLINICAL RELEVANCE: Our results cast doubt on the strategy of relying solely on culture of bone biopsy specimens when deciding whether antibiotic treatment for osteomyelitis is necessary after toe or forefoot amputation.

Reconstruction of the Heel, Middle Foot Sole, and Plantar Forefoot with the Medial Plantar Artery Perforator Flap: Clinical Experience with 28 Cases.

BACKGROUND: Defects in the weight-bearing region of the foot sole can represent a substantial restriction in quality of life and pose a challenge for reconstructive plastic surgery. The purpose of this article is to report the authors' experience with the use of the medial plantar artery perforator flap for reconstruction of defects of the foot sole in three different regions: heel, middle foot sole, and plantar forefoot. METHODS: From January of 2003 to May of 2016, 28 patients (13 male and 15 female patients) with an average age of 54 years (range, 12 to 84 years) underwent reconstruction with 28 medial plantar artery perforator flaps. Twenty-six flaps were harvested as pedicle perforator flaps and two as free perforator flaps. All flaps were raised from the ipsilateral instep area. The defect locations included the heel (20 cases), middle foot sole (four cases), and forefoot (four cases). The causes of reconstruction were tumors in 18 patients, decubitus in eight patients, and trauma in two patients. RESULTS: The flap sizes varied from 2.5 × 2.5 cm to 5.5 × 9.5 cm. All of the flaps survived completely after surgery, apart from one. The donor sites were all covered with a split-thickness skin graft. Follow-up observations were conducted for 4 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results. CONCLUSION: The medial plantar artery perforator flap can be considered an optimal method of foot sole reconstruction not only for covering the weight-bearing area of the heel but also for the middle and forefoot plantar region. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evidencia científica del tratamiento ortopodológico en pie afectado por artritis reumatoide / Evidence of orthopodiatric treatment affected by rheumatoid arthritis on foot

Antecedentes: La artritis reumatoide afecta más a mujeres. La prevalencia en nuestro país es de 0.5%. Se debe abordar mediante un equipo multidisciplinar. Los signos característicos en el pie son sinovitis de las articulaciones, entesitis, nódulos reumatoides y vasculitis. Las modalidades de tratamiento conservador son: ortesis, calzado, estiramientos, terapia manual e incluso ejercicios terapéuticos mediante Tai-chi. Objetivos: Valorar la evidencia científica sobre el tratamiento conservador del pie reumático mediante ortesis plantares y calzado terapéutico. Conocer los últimos avances y que opción es la más indicada para tratar esta patología que afecta al pie. Material y métodos: Se ha realizado una revisión bibliográfica de los últimos 15 años en Pubmed. Resultados: Se ha encontrado relación entre el dolor de antepié, subluxación metatarsofalángica y erosión del cartílago articular con el aumento de presión a nivel metatarsal plantar lo que justifica la realización de tratamiento ortopodológico encaminado a reducir la misma. El tratamiento conservador está enfocado a la utilización de ortesis y de zapato terapéutico para mejorar el dolor, la marcha y la funcionalidad. Hay evidencia científica para tratar la metatarsalgia con diferentes tipos de ortesis, que no solo ayudan a mejorar el dolor sino que además reducen el nº de articulaciones inflamadas. La combinación con zapato terapéutico con o sin modificaciones externas produce mejores resultados. Conclusión: Existe escasa evidencia científica sobre el uso de tratamiento ortopodológico para el pie reumático pero se han encontrado algunos artículos que avalan su eficacia, por lo que es imprescindible realizar estudios en este campo (AU)

Background: Rheumatoid arthritis affects more women. The prevalence in our country is 0.5%. It should be approached by a multidisciplinary team. Characteristic foot signs' are synovitis of joints, enthesitis, rheumatoid nodules and vasculitis. The conservative treatment modalities are: orthotics, footwear, stretching, manual therapy and therapeutic exercises even by Tai-chi. Objectives: To evaluate the scientific evidence on the conservative treatment of rheumatoid foot with orthotics and therapeutic footwear. Aware of progress and that is the most suitable option for treating this disease that affects the feet. Material and methods: We carried out a literature review of the past 15 years in Pubmed. Results: We found the relationship between pain forefoot metatarsophalangeal subluxation and erosion of articular cartilage with increasing pressure to plantar metatarsal level which justifies conducting orthosis treatment aimed at reducing it. Conservative treatment is aimed at the use of orthoses and shoe therapy to improve pain, gait and functionality. There is scientific evidence for treating metatarsalgia with different types of orthotics that not only help improve the pain but also reduce the number of swollen joints. The combination with therapeutic shoe with or without external changes produces better results. Conclusion: There is little scientific evidence on the use of orthosis treatment for rheumatoid foot but found some articles that support its effectiveness, so it is essential to carry out studies in this field (AU)

Leishmaniasis of the Feet Sole: A Case Report.

Here we report the case of a patient with cutaneous leishmaniasis, who was referred to our clinic in Yazd, Iran. On examining the patient, who was a housekeeper, we found a small plaque in the palmoplantar region due to cutaneous leishmaniasis. She had not any history from an identical case in this patient. After treatment, the lesions improved.

Recurrent and other new foot ulcers after healed plantar forefoot diabetic ulcer.

Diabetic foot ulcer is a serious complication in patients with diabetes. In most outcome studies of this condition, there is a combination of various types of ulcer and ulcer locations. Plantar ulcers are usually localized to the forefoot, and constitute a quarter of all diabetic foot ulcers. There are a limited number of studies regarding development of new ulcers following healing of a plantar forefoot ulcer, and there are no uniform definitions of recurrent and other new ulcers. The aim of this study was to evaluate the outcome of a large cohort of consecutively treated patients with diabetes mellitus and a healed planter forefoot ulcer (n = 617) with regard to development, characteristics, and outcome of recurrent and other new ulcers. Patients were followed consecutively and prospectively with a 2-year follow-up, according to a preset protocol. Out of 617 patients, 250 (41%) did not develop any new ulcer, 262 (42%) developed a new ulcer, 87 (14%) died and 18 (3%) were lost at 2 years following healing of a plantar forefoot ulcer. Thirty-four percent developed other new ulcers (112 on the same foot and 99 on the contralateral foot), whereas 51 patients (8%) developed a recurrent ulcer (at the same site and foot). Of the patients who died within 2 years, 30 patients had developed other new ulcers. The risk of a recurrent ulcer in patients with diabetes and a healed plantar forefoot ulcer was only 8% within 2 years, whereas other new ulcers, on the same foot or on the contralateral foot, was seen in 4 out of 10 patients indicating the need for further preventive measures and surveillance in these patients. We suggest a concise definition for new ulcer to be used in future research.

The role of the width of the forefoot in the development of Morton's neuroma.

AIMS: Morton's neuroma is common condition of the forefoot, but its aetiology remains unclear. Our aim was to evaluate the relationship between the width of the forefoot and the development of a Morton's neuroma. PATIENTS AND METHODS: Between January 2013 and May 2016, a total of 84 consecutive patients (17 men, 67 women) with a unilateral Morton's neuroma were enrolled into the study. The involved and uninvolved feet of each patient were compared. A control group of patients with symptoms from the foot, but without a neuroma who were matched for age, gender, affected side, and web space location, were enrolled. The first to fifth intermetatarsal distance, intermetatarsal angle and intermetatarsal distance of involved web space on standing radiographs were assessed. RESULTS: The inter- and intra-observer reliability was excellent. The three parameters did not differ significantly between the involved and uninvolved feet. Neither did they differ significantly between the patients and the controls. CONCLUSION: We conclude that there is no significant relationship between the width of the forefoot and the development of a Morton's neuroma. Cite this article: Bone Joint J 2017;99-B:365-8.

Severe forefoot infection complicated by Fusobacterium russii.

We present the first case of a complicated foot infection caused by Fusobacterium russii in Austria. F. russii is highly associated with mammals such as cats and dogs. Our case underlines the difficulties in isolation and identification of anaerobes and the pitfalls in antimicrobial treatment of polymicrobial infections.

Autologous Fat Grafting for Pedal Fat Pad Atrophy: A Prospective Randomized Clinical Trial.

BACKGROUND: Pedal fat pad atrophy is associated with pain, decreased tissue thickness, and increased foot pressures. To date, no objective studies investigating the use of fat grafting to the forefoot have been performed. The authors hypothesize that pedal fat grafting can reduce pain, increase tissue thickness, and decrease pedal pressures. METHODS: A prospective randomized study was performed to assess tissue thickness, pain, and foot pressures. Group 1 underwent fat grafting immediately with 1-year follow-up, and group 2 underwent conservative management for 1 year. RESULTS: Thirteen patients (two men and 11 women) constituted group 1 and 12 patients (four men and eight women) constituted group 2. Ten patients in group 1 underwent bilateral injections with a mean volume of 4.8 cc per foot. Mean follow-up time was 11.1 ± 5.4 months for group 1 and 13.8 ± 4.2 months for group 2. At 1 year, group 1 demonstrated improved foot function (p = 0.022), pain (p = 0.022), and work/leisure activities (p = 0.021). Group 1 had no change in tissue thickness, whereas in group 2, the right third metatarsal tissue thickness decreased significantly (p = 0.036). Foot pressures in group 1 did not improve; however, group 2 had a significant increase in left foot pressure (p = 0.011). When comparing the groups at 1 year, group 2 had significantly higher foot pressures and forces than group 1 (p < 0.05). CONCLUSIONS: Pedal fat grafting significantly improves pain and disability outcomes, and prevents against worsening foot pressures. Future analysis will reveal whether fat grafting has lasting efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

MRI assessment of regional differences in phosphorus-31 metabolism and morphological abnormalities of the foot muscles in diabetes.

PURPOSE: To assess differences in the phosphorus-31 (31 P) metabolism and morphology in multiple muscle regions in the forefoot of diabetic patients and normal subjects. MATERIALS AND METHODS: Fifteen diabetic patients and 15 normal subjects were assessed for muscle atrophy by 1 H magnetic resonance imaging (MRI) at 3T to grade the flexor hallucis, adductor hallucis, interosseous regions, and entire foot cross-section. Each region and the entire foot were also quantitatively evaluated for metabolic function using 31 P imaging for spatial mapping of the inorganic phosphate (Pi) to phosphocreatine (PCr) ratio (Pi/PCr). The ratio of viable muscle area to the predefined region areas (31 P/1 H) was calculated. The variability of each method was assessed by its coefficient of variation (CV). RESULTS: Muscle atrophy was significantly more severe in diabetic compared to normal subjects in all regions (P < 0.01). The 31 P/1 H area ratio was significantly larger in the adductor hallucis than in the other two regions (P < 0.05). The Pi/PCr ratio was significantly different between the two groups in the flexor hallucis and interosseous regions (P < 0.05) but not adductor hallucis region. The CV for Pi/PCr ranged from 10.13 to 55.84, while it ranged from 73.40 to 263.90 for qualitative grading. CONCLUSION: Changes in atrophy and metabolism appear to occur unequally between different regions of the forefoot in diabetes. The adductor hallucis region appears more capable of maintaining structural and metabolic integrity than the flexor hallucis or interosseous regions. The CV analysis suggests that the quantitative 31 P methods have less variability than the qualitative grading. J. Magn. Reson. Imaging 2016;44:1132-1142.

[APPLICATION OF ROTATIONAL FLAP, BASED ON LATERAL MARGINAL AND METATARSAL АRTERIES, ТHE DIGITI QUINTI TISSUES OF THE FOOT FOR THE NEUROTROPHIC ULCER OF THE SOLE].

The flap of anterior­lateral portion of the sole with inclusion of lateral plantar artery (a. plantaris lateralis digiti quinti­fibular plantar marginal artery) and variable aа. metatarseae plantares of the fourth intermetatarsal gap in conjunction with plasty, using the fifth toe soft tissues (fillet flap), was proposed and applied in clinical practice. The method permits to remove the sole defect, using a supporting flap, owing multiple axial blood supply and sensitive innervation. The flap was applied successfully for the tissues restoration in neurotrophic ulcer of the foot anterior portion.

Midfoot and Forefoot Injuries.

Sports injuries of the midfoot and forefoot encompass a spectrum of osseous and soft tissue trauma. Magnetic resonance imaging serves as a primary or important supplementary diagnostic modality in evaluation of various injuries, most important of which include Lisfranc complex injury, stress fractures, and injury to the first metatarsophalangeal joint, aka "turf toe." Current technical advances in magnetic resonance and improved knowledge of regional anatomy enable thorough evaluation of the complex anatomic structures of the foot and facilitate accurate diagnosis in the setting of trauma.

MR Imaging Evaluation of the Lisfranc Ligament in Cadaveric Feet and Patients With Acute to Chronic Lisfranc Injury.

BACKGROUND: Magnetic resonance (MR) imaging is known to be useful to demonstrate Lisfranc ligament injury. There are few studies that report differences in MR imaging findings of acute or chronic Lisfranc ligament injuries. We applied oblique MR imaging planes parallel to the Lisfranc ligament for better visualization of the entire course of the ligament and assessed the detailed MR imaging appearances of the Lisfranc ligament in cadavers and patients with presumed Lisfranc injuries. METHODS: Twelve preserved cadaveric feet were examined using a small-diameter surface coil. Long axis, oblique sagittal, and oblique short axis cross sections parallel to the Lisfranc ligament, dorsal ligament, and plantar ligament were obtained. Twenty-six MR examinations from 23 patients with suspected Lisfranc joint injuries were evaluated. RESULTS: In the cadaveric study, the Lisfranc ligament was satisfactorily visible along its entire course in a single slice on long axis and oblique sagittal MR images. The dorsal ligament and the plantar ligament were visible separately from the Lisfranc ligament in oblique sagittal and oblique short axis planes. In the patient study, 11 MR examinations led to diagnoses of complete tears of the Lisfranc ligament that were acute injuries (3-21 days after trauma) mostly associated with disruption of the dorsal and plantar ligaments. Nine studies led to diagnoses of incomplete tears of the Lisfranc ligament that were chronic injuries (2-14 months after trauma). Recovery of the continuity of the disrupted ligament was observed in 3 patients. CONCLUSION: MR imaging demonstrated the integrity of the ligaments and was useful for diagnosing an acute Lisfranc injury. Fibrous healing of the torn ligament was observed in a chronic injury.