Lesser metatarsal osteotomies. A biomechanical approach to metatarsalgia.

As with most other orthopedic conditions, a firm understanding of the normal and pathologic biomechanics of the lesser metatarsals is essential when contemplating treatment of metatarsalgia. Despite its prevalence, metatarsalgia remains a technically demanding surgical challenge. Some of the difficulty with treatment of this problem arises because of some of the controversies discussed previously. Many lesser metatarsal osteotomies have been described, and their success depends on many factors. Alleviating the correct amount of pressure underneath the metatarsal head without adversely affecting the biomechanics of the region demands an exacting osteotomy that is stable and readily heals. Much of the research done to date has not proved which procedure can achieve these goals reproducibly for patients. It is hoped that future investigations will guide treatment choices and allow patients to obtain relief from this difficult problem with greater success.

Foot and ankle infections after surgery.

Infection after foot and ankle surgery or trauma can range from the common superficial cellulitis to the less common deep soft tissue or bone infections that can have disastrous consequences. The emergence of antibiotic-resistant organisms has made treatment of infection more difficult, even though promising new antibiotics are being developed. Prevention of infection, through proper patient selection and meticulous surgical technique, is essential to satisfactory outcomes.

Orthotic and prosthetic devices in partial foot amputations.

With advanced surgical techniques and orthotic, as well as prosthetic devices, partial foot amputations have become a viable alternative. Orthotics can help restore stability, maintain support, and protect function of the residual limb. The authors discuss orthotic and prosthetic management of patients who have undergone toe amputations; ray amputations; transmetatarsal, Lisfranc-, or Chopart-level amputations.

Magnetic resonance imaging of the foot and ankle.

Magnetic resonance (MR) imaging of the foot and ankle is playing an increasingly important role in the diagnosis of a wide range of foot and ankle abnormalities, as well as in planning for their surgical treatment. For an optimal MR study of the foot and ankle, it is necessary to obtain high-resolution, small-field-of-view images using a variety of pulse sequences. The most common indication for MR imaging of the foot and ankle is for the evaluation of tendon and bone abnormalities, such as osteomyelitis, occult fractures, and partial and complete tears of the Achilles, tibialis posterior, and peroneal tendons. Magnetic resonance imaging has also been shown to be helpful in the diagnosis of several soft-tissue abnormalities that are unique to the foot and ankle, such as plantar fasciitis, plantar fibromatosis, interdigital neuromas, and tarsal tunnel syndrome.

Percutaneous CT guided resection of osteoid osteoma of the tibial plafond.

Osteoid osteomas of the foot and ankle are relatively rare and notoriously difficult to diagnose. Juxta-articular osteoid osteomas are more difficult to treat and often have a significant delay in diagnosis. We report a case of a juxta-articular osteoid osteoma of the tibial plafond. Once the diagnosis was made, excisional biopsy was performed percutaneously under computed tomography (CT) guidance as an outpatient in the radiology suite. The patient had complete resolution of symptoms and remains pain free at two years follow-up. CT guided resection can be a lower morbidity and more cost effective technique to treat this lesion than traditional methods.

Evaluation and management of common running injuries.

Adults who run for sport or for pleasure often present to their primary care physician with musculoskeletal complaints. Rapid diagnosis and conservative management of common running injuries and referral of patients with injuries that have a propensity for morbidity, such as femoral neck stress fractures, are reviewed. Careful evaluation of the patient's running program and physical therapy are important components of management.

Diagnosing and treating plantar fasciitis: a conservative approach to plantar heel pain.

Plantar fasciitis is the most common cause of pain at the weight-bearing surface of the heel, and may coexist with other sources of heel pain. This has led to a confusing array of treatment strategies, including surgery. We offer a simple, effective diagnostic and treatment algorithm that emphasizes nonsurgical treatment options for this often frustrating condition.

Risk of sural nerve injury with intramedullary screw fixation of fifth metatarsal fractures: a cadaver study.

The risk of injury to the sural nerve and its branches during operative procedures performed on the lateral foot and ankle is well recognized; however, there have been no anatomic studies demonstrating the proximity of the sural nerve branches to the head of an intramedullary screw used for fixation of fractures of the proximal fifth metatarsal. Dissection of 10 cadaver specimens, after insertion of 4.5-mm screws, demonstrated that the screw head was within 2 mm of the dorsolateral branch of the sural nerve in five specimens and within 3 mm of eight specimens. Irritation of or injury to the nerve during screw insertion may explain the persistence of pain after screw removal in some patients. Furthermore, patients could sustain injury to the sural nerve at the time of screw removal. Careful surgical technique, including the use of drill guides and tissue protectors, may help lessen the risk of sural nerve injury and subsequent neuroma formation.

Managing injuries of the great toe.

Most of the common great-toe injuries that affect active people are self-limiting and easily treated if detected early. Reviewed here are the causes, symptoms, diagnosis, and treatment of hallux valgus, turf toe, hallux rigidus, sesamoid dysfunction, nail abnormalities, dislocations and fractures, calluses, and blisters. Conservative treatment will usually enable patients to return to activity relatively quickly. Continued disability may require referral to an orthopedist.

Acquired hallux varus.

Acquired hallux varus most commonly occurs after hallux valgus surgery. Sagittal plane, coronal plane, and varus deformities are present at the metatarsophalangeal joint. Evaluation of both the metatarsophalangeal and interphalangeal joints for mobility is necessary in surgical decision making. Not all patients require surgery. The anatomy, incidence, pathogenesis, evaluation, classification, and treatment of acquired hallux varus are discussed in this review.

Diagnosing and treating hallux valgus: a conservative approach for a common problem.

For most patients with hallux valgus, the problem is caused by wearing shoes that are too tight, and conservative measures can help. We review how primary care physicians can evaluate and treat this problem, and when to refer to an orthopaedic surgeon.

Neural fibrolipoma of the foot: a case report.

Neural fibrolipoma is a benign mass of fibrofatty tissue intermixed with nerve tissue. It most commonly occurs in the upper extremity in infants and children, usually affecting the median nerve. This report describes surgical resection of a rare neural fibrolipoma of the foot in a 32-year-old woman.

Percutaneous intramedullary pinning of proximal humeral fractures.

Proximal humeral fractures can usually be treated closed. However, even with an adequate closed reduction, these fractures are occasionally unstable, fail to remain reduced, and require operative intervention. A percutaneous intramedullary pinning technique is effective in stabilizing these fractures. Two cases that illustrate the adult and pediatric techniques for pin placement/application are presented. In the pediatric population, however, large multiple pins often cannot be used due to the size of the intramedullary canal, and fewer or smaller diameter pins are used.

Arthrodesis of the knee with an intramedullary nail.

The cases of twenty patients who had an arthrodesis in which an intramedullary nail was used for stabilization were reviewed at an average follow-up of six years. The predominant indications were infection after total knee arthroplasty and post-traumatic pain and instability. Other indications included aseptic loosening of the components of a total knee arthroplasty, reconstruction after resection of a giant-cell tumor, non-union of a fracture of the distal part of the femur or the proximal part of the tibia, and failed external-compression arthrodesis. Success was achieved in seventeen patients (85 per cent), and functional stability immediately postoperatively was gained in all twenty. Of the three patients in whom the arthrodesis failed, all had sustained an intraoperative fracture, and infection eventually developed. Of the twelve nails that were secured to the greater trochanter with a loop of stainless-steel wire, none showed evidence of proximal migration. Of the eight nails that were not thus secured, two migrated proximally, necessitating removal of the nail. Two drawbacks to this operation are the long duration and the large amount of blood that is lost. The major advantage is that a high percentage of patients have progression to a stable fusion despite serious problems. Furthermore, all but seven patients (including the six who had a tumor or who had sustained an intraoperative fracture) were able to bear full weight by the second postoperative week. Only a few patients needed an external support for walking.