Joint Manipulation Under Anesthesia for Arthrofibrosis After Hallux Valgus Surgery.

Arthrofibrosis is a known complication of hallux valgus surgery. Joint manipulation under anesthesia has been studied for adhesive capsulitis of the shoulder; however, a paucity of published data exists on the use of this modality in the foot and ankle. The purpose of the present study was to investigate the outcomes of first metatarsophalangeal joint manipulation for arthrofibrosis that occurred as a complication of bunion surgery. The study population consisted of patients attending a single foot and ankle specialty clinic who were evaluated for arthrofibrosis after bunion surgery. Patients who underwent joint manipulation under anesthesia were asked to complete a research visit in which a clinical examination was performed and the presence and severity of joint pain were assessed. A total of 38 patients (34 females, 4 males, 53 feet), with a mean age of 55.7 ± 11.8 (range 30 to 83) years, agreed to participate. The mean follow-up period was 6.5 ± 3.4 (range 1 to 17) years. The visual analog scale scores improved significantly from baseline to the final follow-up visit (baseline 6.5 ± 1.5, range 2 to 10; final follow-up visit 2.3 ± 1.5, range 0 to 6; p < .001). Furthermore, joint motion had increased significantly (p < .001) for both dorsiflexion and plantarflexion at the final follow-up examination. The final range of motion (dorsiflexion, r = -0.431, p = .002; plantarflexion, r = -0.494, p < .001) correlated highly with patient self-reported pain in the first metatarsophalangeal joint. Our findings suggest that joint manipulation could be a useful modality for increasing first metatarsophalangeal joint mobility and alleviating pain in patients who experience arthrofibrosis after surgical correction of hallux valgus.

Ultrasound diagnosis and evaluation of plantar heel pain.

BACKGROUND: One of the most common causes of heel pain is plantar fasciitis; however, there are other pathologic disorders that can mimic the symptoms and clinical presentation of this disorder. The purpose of this study was to retrospectively review the prevalence of various pathologic disorders on ultrasound in patients with proximal plantar heel pain. METHODS: The medical records and diagnostic ultrasound reports of patients presenting with plantar heel pain between March 1, 2006, and March 31, 2007, were reviewed retrospectively, and the prevalence of various etiologies was collected. The inclusion criteria were based on their clinical presentation of plantar fasciitis or previous diagnosis of plantar fasciitis from an unknown source. Ultrasound evaluation was then performed to confirm the clinical diagnosis. RESULTS: We examined 175 feet of 143 patients (62 males and 81 females; age range, 16-79 years). Plantar fibromas were present in 90 feet (51%). Plantar fasciitis was diagnosed in 128 feet (73%). Coexistent plantar fibroma and plantar fascial thickening was found in 63 feet (36%). Of the 47 feet that were negative for plantar fasciitis on ultrasound, 27 (57%) revealed the presence of plantar fibroma. CONCLUSIONS: Diagnostic ultrasound can effectively and safely identify the prevalence of various etiologies of heel pain. The high prevalence of plantar fibromas and plantar fascial tears cannot be determined by clinical examination alone, and, therefore, ultrasound evaluation should be performed for confirmation of diagnosis.

The radiographic effects of the scarf bunionectomy on rearfoot alignment.

STATEMENT OF PURPOSE: Excessive pronation of the rearfoot has been implicated as a destabilizing force in the progression of hallux abducto valgus. Although the scarf bunionectomy has been shown to effectively correct the intermetatarsal angle associated with hallux valgus deformity, its effect on the rearfoot has yet to be established. The purpose of this case series is to demonstrate the effect of the scarf bunionectomy on rearfoot alignment. METHODOLOGY: Medical records were reviewed to isolate patients who underwent unilateral or bilateral scarf bunionectomies (with or without akin osteotomy) who had complete medical records, follow-up of at least 12 months, and met the inclusion/exclusion criteria. Preoperative and postoperative radiographic measurements were analyzed at various postoperative time intervals. Standard deviations and statistical significance was obtained. RESULTS: One hundred feet (71 patients) were included in this analysis. The long-term results of this study highlighted the scarf osteotomy's ability to affect the medial longitudinal arch by decreasing the intermetatarsal angle and lateral talar-first metatarsal angle. The talar declination and calcaneal inclination angle were not significantly altered with the scarf bunionectomy. CONCLUSION: This case series demonstrates that the scarf bunionectomy had significant effect on radiographic alignment of the bunion deformity and medial longitudinal arch over time. However, its effect on the rearfoot position was not statistically significant. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case Series.

Static Versus Dynamic Musculoskeletal Ultrasound for Detection of Plantar Plate Pathology.

Musculoskeletal ultrasound (US) is a common modality used to examine plantar plate pathology. Comparison of the diagnostic accuracy of static versus dynamic ultrasound has not been previously published. The objective of this study was to prospectively compare the value of using preoperative static and dynamic ultrasound findings to diagnose plantar plate pathology using intraoperative inspection as the standard of reference. Patients attending a single foot and ankle specialty clinic from August 2012 to June 2013 with clinically suspected plantar plate pathology that was unresponsive to conservative care served as the study population. Static and dynamic ultrasound exams were performed by a single experienced rater and compared to intraoperative findings. The overall accuracy, sensitivity, specificity, positive predictive value and negative predictive value were determined for static and dynamic ultrasound exams. Thirty-six patients (45 lesser metatarsophalangeal joints) were included in this analysis. Of the 36 patients, 29 were females and 7 were males with average age of 57.9 ± 7.8 years (range, 38-73). There were 38 plantar plate tears (84.4%) noted on intraoperative examination. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for the static US exam were 80.0%, 81.6%, 71.4%, 93.9%, and 41.7%, respectively. The same values for the dynamic US exam were 88.9%, 100%, 28.6%, 88.3%, and 100%, respectively. Static and dynamic ultrasound techniques are each highly sensitive methods for assessing plantar plate pathology. However, the sensitivity and accuracy of the exam is best when dynamic assessment of the plantar plate is employed. Caution should be used when relying solely on static images to diagnose subtle injuries in this area of the foot. LEVELS OF EVIDENCE: Diagnostic Level II, Prospective.

Subungual melanoma of the great toe in a Hispanic male with Down syndrome: a case report and review of the literature.

Solid mass tumors are not as common as leukemia in individuals with Down syndrome. In this report, we describe the rare case of an adult Hispanic male with Down syndrome who developed advanced subungual melanoma in the hallux. We also describe the course of treatment, which involved hallux amputation along with metastatic work-up and sentinel lymph node biopsy with eventual resection.