Black Bone Disease of the Foot: A Two-Year Follow-Up Case Study.

"Black bone disease" is a term commonly used to describe a condition characterized by a blue/green/brown discoloration to the bone that often resembles infracted or necrotic bone. The chronic use of minocycline or tetracycline has been reported in previous data as a cause of this discoloration to the skin, bone, and teeth. However, the occurrence in bone is rare, with few studies reported regarding the discoloration. We previously presented a case of this condition encountered during cheilectomy of the first metatarsophalangeal joint in a patient who had had long-term usage of minocycline for adult acne. Two years after the initial case, the patient returned for correction of a hammertoe deformity on the second left proximal phalanx of the same foot. We present the findings and photographs from the second surgery. In addition, we have provided the relevant case data and figures from the first case for ease of comparison.

Jones Tendon Transfer.

Hallux malleus is a deformity of the great toe. There is a dorsiflexion contracture at the metatarsophalangeal joint and plantar flexion of the interphalangeal joint. The deformity is commonly attributed to muscular imbalances of the various structures acting on the great toe. Jones tendon transfer is a procedure used to remove the deforming force to the clawed hallux. It is most often performed in conjunction with a hallux interphalangeal joint fusion. Typically there is a neurologic component causing a deformity to the entire foot, necessitating adjunct procedures. The Jones tendon transfer has shown to have reproducible results.

Alteraciones óseas en la mucolipidosis III / Skeletal deformities in mucolipidosis III

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Foot disorders, foot posture, and foot function: the Framingham foot study.

INTRODUCTION: Foot disorders are common among older adults and may lead to outcomes such as falls and functional limitation. However, the associations of foot posture and foot function to specific foot disorders at the population level remain poorly understood. The purpose of this study was to assess the relation between specific foot disorders, foot posture, and foot function. METHODS: Participants were from the population-based Framingham Foot Study. Quintiles of the modified arch index and center of pressure excursion index from plantar pressure scans were used to create foot posture and function subgroups. Adjusted odds ratios of having each specific disorder were calculated for foot posture and function subgroups relative to a referent 3 quintiles. RESULTS: Pes planus foot posture was associated with increased odds of hammer toes and overlapping toes. Cavus foot posture was not associated with the foot disorders evaluated. Odds of having hallux valgus and overlapping toes were significantly increased in those with pronated foot function, while odds of hallux valgus and hallux rigidus were significantly decreased in those with supinated function. CONCLUSIONS: Foot posture and foot function were associated with the presence of specific foot disorders.

High heritability of hallux valgus and lesser toe deformities in adult men and women.

OBJECTIVE: To estimate the heritability of 3 common disorders affecting the forefoot, i.e., hallux valgus, lesser toe deformities, and plantar forefoot soft tissue atrophy, in white adult men and women. METHODS: Between 2002 and 2008, a trained examiner used a validated foot examination to document the presence of hallux valgus, lesser toe deformities, and plantar soft tissue atrophy in 2,446 adults from the Framingham Foot Study. Among these, 1,370 participants with an available pedigree structure were included. Heritability was estimated using pedigree structures by the Sequential Oligogenic Linkage Analysis Routines package. Results were adjusted for age, sex, and body mass index. RESULTS: The mean age of the participants was 66 years (range 39-99 years) and 57% were women. The prevalence of hallux valgus, lesser toe deformities, and plantar soft tissue atrophy was 31%, 29.6%, and 28.4%, respectively. Significant heritability was found for hallux valgus (range 0.29-0.89, depending on age and sex) and lesser toe deformity (range 0.49-0.90, depending on age and sex). The heritability for lesser toe deformity in men and women ages >70 years was 0.65 (P = 9 × 10(-7)). Significant heritability was found for plantar soft tissue atrophy in men and women ages >70 years (H(2) = 0.37, P = 3.8 × 10(-3)). CONCLUSION: To our knowledge, these are the first findings of heritability of foot disorders in humans, and they confirm the widely-held view that hallux valgus and lesser toe deformities are highly heritable in white men and women of European descent, underscoring the importance of future work to identify genetic determinants of the underlying genetic susceptibility to these common foot disorders.

Costs and benefits of routine histopathological examination of hammertoe specimens.

BACKGROUND: The purpose of this study was to evaluate the cost and benefit of routinely submitting hammertoe specimens for histopathological examination. We hypothesized that such examination rarely shows a new diagnosis and seldom alters postoperative care. MATERIALS AND METHODS: Three hundred and fourteen proximal interphalangeal (PIP) joint and 37 extensor tendon specimens from 187 consecutive hammertoe correction surgeries were submitted by 2 surgeons for histopathological examination between January 2009 and December 2011. Each patient's chart was reviewed to determine whether the histopathological examination revealed a diagnosis other than degenerative joint or degenerative tendon and whether subsequent patient management was altered. The total reimbursements for professional charges were calculated using the average reimbursement from common insurance providers for two Current Procedural Terminology (CPT) codes: 88304 (soft tissue examination) and 88311 (decalcification). RESULTS: Almost all of the specimens were diagnosed as degenerative: 97.5% (307/314) of the PIP specimens and all (37/37) of the tendon specimens. Seven PIP specimens (2.2%, 7/314) from 5 patients (2.7%, 5/187) and no tendon specimens had other diagnoses. These diagnoses were rheumatoid arthritis (5/314, 1.6%), osteomyelitis (1/314, 0.3%), and pigmented villonodular synovitis (PVNS) (1/314, 0.3%). Only the PVNS was a new diagnosis. A total of $56,750 was spent to determine 1 new diagnosis. CONCLUSION: The routine submission of hammertoe specimens for pathological evaluation was not cost-efficient. Our analysis showed that new diagnoses were rarely found and patient management was not affected.

Hammertoe surgery: arthroplasty, arthrodesis or plantar plate repair?

In cases of painful complex hammertoe deformity, there is no single approach that can be used in all circumstances. If conservative care fails, surgical management may include interphalangeal joint arthroplasty, arthrodesis, and/or plantar plate repair. The best and most pragmatic surgical plan must be patient-centered, taking the age, activity level, expectations of the patient, and precise etiology of the hammertoe deformity into account.

Effective zone of botulinum toxin a injections in hallux claw toe syndrome: an anatomical study.

INTRODUCTION: The aim of this study was to determine the anatomical location of the motor points of the flexor hallucis longus (FHL) and brevis (FHB) muscles for an effective motor point block. METHODS: Twenty cadavers were used for this study. For the FHL, we identified the line between the medial and lateral epicondyle of the femur and the line joining the prominent point on the surface of the medial malleolus of the tibia and the lateral malleolus of the fibula. For the FHB, we identified the line between the middle-lowest point of the great toe and the middle-lowest point of the sole of the foot. RESULTS: The dense area of the motor points was located at 40-70% for the FHL and 50-70% for the FHB. CONCLUSION: An injection area of 50-60% on the reference line for the FHL and FHB is suggested.

Mallet toe deformity.

Mallet toe is one of the most common deformities encountered by orthopedic surgeons. Care needs to be taken to ascertain whether it is a primary condition or secondary to a systemic disease, especially if multiple deformities are present. There are numerous operative strategies available, but each has its specific indications. If the indications are followed, highly successful outcomes may be achieved.

Hammertoes and clawtoes: proximal interphalangeal joint correction.

Hammertoe and clawtoe deformities are common forefoot problems. The deformity exists owing to the underlying pathoanatomy. Hallux valgus, longer metatarsals, and intrinsic imbalance are the most common etiologies. Understanding the cause of the deformity is important to be able to successfully treat the condition, whether nonoperative or with operative intervention. When nonoperative measures fail, PIP correction is best obtained through arthroplasty or arthrodesis. The key to successful PIP correction is obtaining a well-aligned toe and reducing pain as demonstrated by Coughlin and Mann.15 When choosing a technique, the author prefers PIP joint arthrodesis because it has several advantages, including a decreased risk of recurrence and a more predictable toe posture. The authors prefers an intramedullary device to avoid the well-known complications of K-wires. The best surgical correction and fixation techniques are still to be determined. Each patient much be evaluated thoroughly and treatment should be tailored to the patient's deformity, comorbidities, expectations and surgeon's experience.

Modified plantar plate tenodesis for correction of claw toe deformity.

BACKGROUND: The purpose of the study was to evaluate the efficacy and safety of the modified plantar plate tenodesis for correction of claw toe deformity. MATERIALS AND METHODS: Modified plantar plate tenodesis was performed in ten fresh frozen cadaveric feet with claw toe deformity of the second toe. The plantar plate of the second metatarsophalangeal joint was anchored to the extensor digitorum longus tendon by a figure-of-eight suture. The figure-of-eight construct and the relationship of the digital nerve and the suture were studied. A clinical study was conducted to study the operative times, degree of correction and the improvement of AOFAS score between groups with the original plantar plate tenodesis (Group 1) and modified technique (Group 2). Any neural injury if present was also noted. RESULT: In the cadaveric study, the claw toe deformity was corrected and no nerve injury occurred in any specimen. There was flexor tendon tethering by the suture in 2 specimens. In the clinical study, the average operative time was 51 minutes for Group 1 and 31 minutes for Group 2. The improvement in AOFAS score averaged 44 in Group 1 and 43 in Group 2. The corrective power of the sagittal plane deformity at the metatarsophalangeal joint averaged 25 degrees in Group 1 and 23 degrees in Group 2. CONCLUSION: Plantar plate tenodesis was effective in correction of flexible claw second toe deformity by stabilization of the attenuated plantar plate. The modified technique allowed easier retrieval of the suture and shorter operative time. However, it may result in tethering of the flexor tendon.

Advantages and drawbacks of proximal interphalangeal joint fusion versus flexor tendon transfer in the correction of hammer and claw toe deformity. A finite-element study.

Correction of claw or hammer toe deformity can be achieved using various techniques, including proximal interphalangeal joint arthrodesis (PIPJA), flexor digitorum longus tendon transfer (FDLT), and flexor digitorum brevis transfer. PIPJA is the oldest technique, but is associated with significant complications (infection, fracture, delayed union, and nonunion). FDLT eliminates the deformity, but leads to loss of stability during gait. Flexor digitorum brevis tendon transfer (FDBT) seems to be the best surgical alternative, but it is a recent technique with still limited results. In this work, these three techniques have been analyzed by means of the finite-element method and a comparative analysis was done with the aim of extracting advantages and drawbacks. The results show that the best technique for reducing dorsal displacement of the proximal phalanx is PIPJA (2.28 mm versus 2.73 mm for FDLT, and 3.31 mm for FDBT). However, the best technique for reducing stresses on phalanges is FDLT or FDBT (a reduction of approximately 35% regarding the pathologic case versus the increase of 7% for the PIPJA in tensile stresses, and a reduction of approximately 40% versus 25% for the PIPJA in compression stresses). Moreover, the distribution of stresses in the entire phalanx is different for the PIPJA case. These facts could cause problems for patients, in particular, those with pain in the surgical toe.

Role of intrinsic muscle atrophy in the etiology of claw toe deformity in diabetic neuropathy may not be as straightforward as widely believed.

OBJECTIVE: Clawing of the toes in the diabetic neuropathic foot is believed to be caused by muscle imbalance resulting from intrinsic muscle atrophy. However, experimental data that support this mechanism are lacking. The aim of this study was to evaluate this hypothesis using magnetic resonance imaging (MRI). RESEARCH DESIGN AND METHODS: In 20 neuropathic diabetic patients, 10 with claw toe deformity and 10 with normally aligned toes, multiple plane images of the foot and lower leg were acquired using T1-weighted spin-echo MRI. Atrophy of the intrinsic and extrinsic muscles controlling the toes was assessed using a semiquantitative 5-point atrophy scale. An intrinsic-to-extrinsic foot muscle imbalance score was derived from these atrophy scores, and correlation coefficients were established. RESULTS: The mean +/- SD intrinsic muscle atrophy score was 3.1 +/- 1.1 for the toe deformity group and 2.6 +/- 1.2 for the non-deformity group (not significantly different). The intrinsic muscle atrophy score was not significantly correlated with degree of toe deformity (r = -0.18). The muscle imbalance score was not significantly different between study groups and was not significantly correlated with degree of toe deformity (r = -0.14). CONCLUSIONS: Neither intrinsic muscle atrophy nor muscle imbalance discriminated between neuropathic patients with or without claw toe deformity, suggesting that the role of these muscle factors in claw toe development may not be primary or as straightforward as previously believed. These findings shed new light on the etiology of foot deformity in diabetes and suggest a more complex nature of development, potentially involving anatomical and physiological predisposing factors.

Foot structure and footwear prescription in diabetes mellitus.

Foot structure abnormalities such as foot deformity and limited joint mobility are common and well established components of the diabetic foot which are associated with increased levels of mechanical stress on the foot and the development of ulcers. Our understanding of foot structure abnormality in diabetes has improved recently, mainly through the findings from in vivo imaging studies. Several examples will be discussed in this review. A limited understanding, however, still exists about several aspects related to the assessment, etiology, and consequences of change in foot structure in diabetes. Knowledge on these matters is needed if we are to better deal with the implications of foot structure change in diabetes. Diabetic patients with neuropathy and foot deformity are commonly prescribed with custom footwear, in particular after ulcer healing. The goal of this footwear is to redistribute and reduce plantar foot pressures, and to prevent ulcer recurrence. However, the available evidence for the effectiveness of custom footwear in secondary ulcer prevention is not yet strong. This may be associated with several factors, including a lack of standardized or systematic approach (a set of guidelines) in footwear prescription and evaluation or with the significant variability that exists across patients in the offloading effect of different footwear interventions, which increases the difficulty of predicting what works for a given patient. Objective evaluation tools such as in-shoe plantar pressure analysis can be helpful in this regard in order to ensure efficacy of an intervention. This provides a more optimal footwear solution that may lower the risk for ulceration.

Plantar pressure distribution analysis in normal weight young women and men with normal and claw feet: a cross-sectional study.

We analyzed the plantar support in 72 normal-weight young voluntaries (46 women, 26 men), by a baropodometric platform. We considered subjects with claw foot (CFS) and subjects with normal foot (NFS). We found a significant reduction of total plantar support surface in the CFS (P < 0.0001 for women, P < 0.001 for men), due to the reduction of the forefoot and rear foot areas of both plantar imprints. Indeed, CFS of both sexes exhibited higher values of both plantar pressure and peak pressure, compared to the NFS. Moreover, the load per units of plantar surface increased in CFS compared to the NFS. In conclusion, the reduction of plantar support surfaces in CFS of both sexes was associated to a major load per units of plantar surface in the forefoot and rear foot areas, and this may be a risk factor to lower extremity overuse injuries.

Ectopic dermal ridge configurations on the interdigital webbings of Hammertoe mutant mice (Hm): another possible role of programmed cell death in limb development.

BACKGROUND: The mechanism underlying the development of aberrant phalangeal pads and dermal ridge configurations in malformed limbs is not well understood. The forelimbs of Hammertoe (Hm) mutant mouse fetuses were examined sequentially to clarify the relationship between the occurrence of abnormal programmed cell death (PCD) and the formation of phalangeal pads and dermal ridge patterns. METHODS: Relevant morphological features, with special emphasis on pads and dermal ridge configurations, were inspected on the exposed dermal surface of the forelimbs of adult Hm mutant mice. The forelimbs of Hm mutant mouse fetuses (GD13-18) and newborns were examined histologically. The forelimbs of GD13 fetuses were subjected to Nile blue (NB) vital staining for in situ labeling of PCD. RESULTS: In the forelimbs of +/+ mice, the formation of dermal ridges was confined to pads, while in Hm/+ and Hm/Hm animals, which have interdigital webbing involving digits II-V, dermal ridges were formed also on the ventral side of the webbing, specifically on its lateral margins between the neighboring digits and on the medial margin of the webbing extending toward the palmar pad. PCD was decreased in the interdigital zones II-IV in GD13 Hm/+ and Hm/Hm fetuses. CONCLUSIONS: Reduced PCD interdigital tissue of Hm/+ and Hm/Hm fetuses may result in the failure of physiological elimination of interdigital cells and in the persistence of soft tissue webbing between digits. The failure of PCD to occur may also interrupt the interdigital surviving cells to reach the neighboring digits and the distal area of the palm, thereby producing ectopic dermal ridges. It seems that interdigital PCD contributes not only to digit separation but also to the development of digital and palmar pads.

Second metatarsophalangeal joint fusion: a new technique for crossover hammertoe deformity. A preliminary report.

The author reports on second metatarsophalangeal joint arthrodesis for the severe crossover hammertoe deformity. Eleven patients underwent an arthrodesis of the second metatarsophalangeal joint with a.062 Kirschner wire intramedullary fixation and a dorsal small bone staple and resection of the proximal phalangeal head of the second digit. Outcomes were retrospectively reviewed at average follow-up time of 19 months. A subjective patient satisfaction survey along with a clinical and radiographic evaluation was undertaken in the postoperative period. Ten of 11 patients scored good to excellent results based on the patient subjective survey at final follow-up. Ten of 11 patients obtained primary arthrodesis. One patient experienced an asymptomatic nonunion. This new technique appears to be reliable for the maintenance of long-term correction of a crossover second toe with arthrodesis of the second metatarsophalangeal joint.