Complex regional pain syndrome: a report of two cases recalcitrant to usual treatment protocols.

In this report the authors present a review of complex regional pain syndrome and two case reports of complex regional pain syndrome that were recalcitrant to the usual treatments. The first case presented is a middle-aged female who developed signs and symptoms of post-traumatic complex regional pain syndrome. The second case is a woman with a pre-existing history of complex regional pain syndrome whose condition worsened after surgery despite appropriate perioperative precautions. These cases are unique because in both cases an early diagnosis of complex regional pain syndrome was established, yet they were both resistant to the usual treatment protocols.

Tibiotalocalcaneal arthrodesis with intramedullary interlocking nail fixation.

The use of intramedullary rod fixation for tibiotalocalcaneal fusion is gaining popularity. Many methods of fixation have been employed in the past, but intramedullary fixation has been shown to achieve higher fusion rates, provide fixation along the weight-bearing axis, and control rotational deformities. The authors describe the history, indications, technical considerations, and postoperative care of patients treated with fixation using an intramedullary rod with interlocking screws.

The use of the hybrid external fixator system in the foot and ankle.

The proper techniques of external fixation are demanding regardless of the type of external fixator used. Attention to detail, including preoperative planning and strict postoperative care, is essential to maximize the advantages and minimize the disadvantages associated with external fixation.

The crescentic first metatarsal basilar osteotomy for correction of metatarsus primus varus.

The crescentic basilar first metatarsal osteotomy has been largely abandoned by the podiatric community in recent years in favor of proximal wedge-type osteotomies for the correction of metatarsus primus varus with large intermetatarsal angles. In most cases, this was due to the inherent instability of the osteotomy and difficulties with fixation. However, the crescentic osteotomy has the ability to correct in all three planes with less shortening than the wedge-type osteotomies. New fixation techniques, such as the small cannulated screw systems, have allowed for less technical difficulty in obtaining rigid internal fixation. In this article, the authors describe the results in 29 feet (27 patients) where the crescentic osteotomy was performed along with a metatarsaphalangeal joint procedure ranging from a McBride (with or without lateral sesamoidectomy) to a phalangeal osteotomy. Preoperative intermetatarsal angles ranged from 11 degrees to 22 degrees, with an average of 18.6 degrees. Postoperative intermetatarsal angles ranged from 2.6 degrees to 8.2 degrees with an average of 5.1 degrees. The preoperative hallux abductovalgus angles ranged from 25 degrees to 38 degrees, with an average of 33.6 degrees. The postoperative hallux abductovalgus angles ranged from 4 degrees to 18 degrees with an average of 11 degrees. Complications included one hallux varus, one delayed union, and three cases of superficial cellulitis that resolved with oral antibiotic therapy.

Treatment of brachymetatarsia by the callus distraction method.

Brachymetatarsia is not an uncommon congenital foot disorder that is due to a premature closure of the ephiphyseal plate. The literature has numerous surgical procedures for the correction of this problem. In recent years, the callus distraction technique described by ilizarov has been utilized for this problem. This is a retrospective study of the use of the callus distraction technique for the correction of congenitally short metatarsal. This series included six feet in six female patients, all with a short fourth metatarsal. Preoperative complaints were metatarsalgia and/or cosmesis. A noncircular, uniplanar axial fixation device was utilized for fixation and distraction. The fixator was put in place prior to the metatarsal osteotomy. Static fixation was for a period of 5-7 days before distraction was begun. The metatarsal was lengthened 0.5 mm two times a day, or 1 mm per day. The time to end point ranged from 45 to 70 days, followed by another 6-8 weeks of static immobilization. The preoperative metatarsal length ranged from 3.5 to 4.2 cm. The end stage metatarsal length ranged from 4.7 to 6.3 cm, with an average increase in length of 1.68 cm. As compared to other techniques described in the medical literature, the callus distraction technique has its own unique set of advantages and disadvantages.

Acute hematogenous osteomyelitis in intravenous drug users.

The authors report a case of acute hematogenous osteomyelitis in a closed metatarsal fracture of an adult intravenous drug user. A transient Staphylococcus aureus bacteremia documented by blood cultures was sustained that presumably seeded the existing fracture. Osteomyelitis was documented by intraoperative cultures that matched the blood cultures and a Technetium-HMPAO-labeled leukocyte scan. Reliance on a noncompliant patient for information may have been a factor that resulted in significant morbidity in this case. Although the patient managed to do well after surgical intervention, osteomyelitis may have been avoidable. Treatment and a self-critical review of the approach to this patient population and decisions made in this case are also discussed.

Imaging of injuries to the tarsometatarsal joint complex.

Injuries to the tarsometatarsal joint complex, or Lisfranc's joint, are intricate, subtle, difficult to diagnose, and potentially devastating. The identification of these injuries is based upon an understanding of the normal clinical and radiographic anatomy of the area. The authors discuss several imaging techniques useful in documenting these injuries.

Recurring desmoid tumor of the foot: a case study.

The desmoid tumor is benign, uncommon, and frequently recurs after excision. It can be confusing in terms of diagnosis and treatment due to its ability to achieve large size, causing functional limitation and/or pain. Its overall clinical characteristics can mimic those of its malignant counterparts. Because of its high rate of recurrence, surgical treatment should include a wide excision around the margins.

Intraosseous lipoma of the fifth metatarsal.

Intraosseous lipoma is a very rare bony tumor. Most of the documented reports are isolated cases, and in the foot all are limited to the calcaneus. This manuscript presents a case of an intraosseous lipoma of the fifth metatarsal. The radiologic and pathologic features of the lesion are described.

Hematogenous osteomyelitis of the calcaneus.

A case report of hematogenous calcaneal osteomyelitis has been presented along with a brief review. Hematogenous osteomyelitis of the foot is an uncommon but potentially devastating disease that can result in severe long-term sequelae. An index of suspicion in cases such as these can help the physician prevent unnecessary delay in treatment. In pediatric hematogenous osteomyelitis, oral antibiotics can often be sufficient for long-term therapy, provided sufficient surgical decompression is performed.

Tc-99m-HMPAO leukocyte scintigraphy for the diagnosis of osteomyelitis in diabetic foot infections.

The diagnosis of osteomyelitis in the presence of soft tissue infection and neuropathic bone changes is often difficult in the diabetic foot. Previous attempts at scintigraphic diagnosis included Tc-99m methylene diphosphonate, Gallium-67 citrate and Indium-111 autologous leukocytes (WBCs). A new agent recently available, Technetium-99m-HMPAO labeled white blood cells, shows promise as a scintigraphic agent superior to other agents for this purpose. The authors discuss this agent and present a case report as a preliminary study.

The offset V modification of the Chevron bunionectomy: a retrospective study.

This is a retrospective study of two different types of fixation for the offset-V modification of the Chevron (Austin) bunionectomy for correction of hallux abducto valgus deformity. Both screw fixation and Kirschner wire fixation were evaluated radiographically for hallux abductus angle, intermetatarsal angle, proximal articular set angle, tibial sesamoid position, and first metatarsal length. In addition, charts were reviewed for complications selective to each type of fixation. Radiographically, there was no apparent difference in preoperative and postoperative measurements between the two types of fixation. However, chart review led the authors to conclude certain advantages to screw fixation, in terms of clinical results and patient satisfaction.

Osteomyelitis of the distal phalanx following trauma to the nail. A case report.

A case in which inadequate treatment of a nail plate injury resulted in chronic osteomyelitis has been described. Because of its distinct anatomy, trauma to the nail and its associated structures should not be summarily dismissed as an innocuous injury but should be thoroughly examined for phalangeal fracture and laceration of the nail bed.

Use of indium-111-labeled white blood cells in the diagnosis of diabetic foot infections.

The diagnosis of bone infection in the patient with nonvirgin bone is a diagnostic dilemma. This is especially true in the diabetic patient with a soft tissue infection and an underlying osteoarthropathy. The authors present a retrospective study using the new scintigraphic technique of indium-111-labeled white blood cells as a method of attempting to solve this diagnostic dilemma.

Lesser metatarsophalangeal joint implants.

A double-stemmed MTP joint silastic implant has been described that acts as a flexible spacer for a number of pathologic conditions that affect the lesser metatarsophalangeal joints. Preliminary results suggest that this is a feasible alternative to joint destructive procedures with advantages over previously described implants.

Transchondral fractures of the dome of the talus.

Osteochondritis dissecans of the talus is a well documented entity, defined as a transchondral fracture of the dome of the talus. As a fracture, it should heal with immobilization; however, this lesion often causes severe disability and, more often than not, the fragment will not unite with conservative treatment. There is much debate concerning operative versus nonoperative treatment, and the purpose of this paper is to discuss the salient points of the controversy, review literature on the subject, and present a case with a follow-up of 4.5 years.