Z-bunionectomy: retrospective long-term study.

Long-term patient satisfaction and objective clinical and radiographic examinations of patients who had undergone the Z-bunionectomy at the University of Chicago Medical Center were evaluated. Fifty-six surgeries were performed on 31 patients, with a follow-up range of 5 to 9 years. The University of Maryland 100-Point Painful Foot Center Scoring System was modified to be more specific to bunion surgery, and we used this modification to measure patient satisfaction. Patient satisfaction was rated good to excellent by 90% of the patients. Radiographic findings included: intermetatarsal angle-mean, 7.1 degrees; hallux abductus angle-mean, 8.96 degrees; tibial sesamoid position-mean, 2.8. The mean protrusion was -1.64 mm. Radiographic findings consistent with osteonecrosis were noted of one patient, one foot, although the patient was clinically asymptomatic. The objective findings were as follows: dorsiflexion, mean, 60 degrees; plantarflexion, mean, 14 degrees. No patients had pain or crepitus, nor were they tract-bound in their first metatarsophalangeal joint range of motion. In addition, stance dorsiflexion had a mean of 21 degrees, and the purchase power was 88% good to excellent on plantar paper pull-out testing. First ray motion qualitatively demonstrated 1 1/2 to 2 times dorsiflexion to plantarflexion. There were no subsecond metatarsal head keratoses. Generalized ligamentous laxity was not seen. For the resting calcaneal stance position the mean was 3.5 degrees everted, with 24% of the patients maximally pronated in this position. We were unable to correlate any structural and functional postoperative features with patient satisfaction.

Subcutaneous phaeohypomycosis caused by Scytalidium dimidiatum in the foot of an immunosuppressed host.

The authors present a case report of a subcutaneous phaeohypomycosis of the foot in an immuno-suppressed patient. The lesion was caused by Scytalidium dimidiatum, a dematiaceous fungus, which has only been reported to cause three previous similar lesions. To our knowledge, this is the first reported case of this fungus causing a deep-seated mycoses in the United States. A review of the literature concerning this organism is also presented.

The use of ultrasonography for the detection of retained wooden foreign bodies in the foot.

The efficacy of ultrasonography for the detection of wooden foreign bodies in the foot was analyzed retrospectively. Twenty patients underwent real-time, high-resolution ultrasound studies (7.5 or 10 MHz, linear array transducers) to rule out the presence of a wooden foreign body in their feet. Ten out of the 20 patients had positive ultrasound findings for a wooden foreign body. With the aid of the ultrasound study and preoperative markings, the subsequent mean surgical time was 20.8 minutes, with a 100% retrieval rate of the foreign body. Ultrasound was found to be 100% sensitive in the detection of wooden foreign bodies in the soft tissues of the foot. Ultrasonography should be considered an important diagnostic modality in the foot and ankle surgeon's armamentarium for the detection of retained wooden foreign bodies.

Complications of foot surgery. Nonunions and related disorders.

Management of malunions, delayed unions, and nonunions is a complex task that initially requires appropriate diagnosis and classification. Diagnostic modalities currently used include radiography, fluoroscopy, tomography, computed tomography, and radionucleotide evaluations. Based on these evaluations, nonunions may be classified as hypervascular or avascular in nature. Determining the presence of a synovial pseudoarthrosis or infection is also vital to nonunion management. Current treatment regimens available include combinations of cast immobilization, electrical stimulation, and surgical repair with and without bone graft. Internal and external fixation also provide rigid stability to promote healing of nonunion sites. Infected nonunions should be managed with appropriate surgical debridement and antibiotics. Internal fixation in the presence of infection may not necessarily need to be removed. There is no single best method for treatment of nonunions. Therapy must be tailored to each individual to provide a cure.

Z-bunionectomy with internal screw fixation.

A new procedure for the correction of hallux valgus was performed on 39 patients (66 feet). The follow-up period averaged 29 months, with a range of 24 to 32 months. The new procedure is a horizontally directed displacement Z-osteotomy in the head and shaft region of the first metatarsal. Rigid internal fixation is obtained with 3.5 or 2.7-mm bone screws. The surgeons' satisfaction rate of 79% compares favorably with the patients' complete satisfaction rate of 85%.

Retrospective analysis of surgical treatment of hallux rigidus/limitus: clinical and radiographic follow-up of hinged, silastic implant arthroplasty and cheilectomy.

Many authors have hypothesized on the etiology of hallux limitus and have proposed grading systems for classifying the degree of first metatarsophalangeal joint derangement and dysfunction. Several opinions exist regarding surgical treatment, should a patient fail with conservative therapy. Hinged, Silastic implant arthroplasty and cheilectomy account for a significant proportion of procedures accomplished. However, little follow-up documents and critically analyzes the long-term results of these procedures. This study analyzes, retrospectively, the results of these procedures with a minimum follow-up of 46 months. Hinged, Silastic implant arthroplasty appears to be a safe, technically easy, efficacious procedure in the grade II to III lesion in patients of 60 years or older, in whom an active life-style is desired. Cheilectomy appears to be indicated in the patient with a classic grade I lesion, while its use in grade II lesions, especially in the presence of sesamoid disease, requires further investigation.

Prophylactic surgery in the diabetic foot.

Prophylactic surgery in the diabetic foot is often fraught with complications, according to a five-year retrospective study at the University of Chicago Hospitals and Clinics. The findings indicate that seven major areas need be addressed in order to properly evaluate the potential diabetic surgical patient. These include careful evaluation of preoperative nutritional status, vascular status, neurologic status, bacteriologic culture status, deformity status, radiologic status, and surgical predictive index.

Retrospective analysis of intermetatarsal neuroma excision with preservation of the transverse metatarsal ligament.

The authors present a retrospective analysis of intermetatarsal neuroma excision with preservation of the transverse metatarsal ligament. They reviewed a series of 43 patients who had undergone a total of 59 such surgical resections. No other surgical procedures were performed on the foot. The patients included 36 women, and 7 men. Follow-up ranged from 1 year and 5 months to 6 years and 3 months with an average of 4 years and 3 months. Fifty-one of the neuromas removed were in the third interspace, three in the second interspace, and five in the fourth interspace. The surgical excision was performed in standard fashion except for the major modification of preservation of the transverse metatarsal ligament. There were 47 excellent or good results and, thus, the overall success rate was 79%. Seven patients had fair results and five had poor results. The results compare favorably with those reported by other authors who advocate transecting the transverse metatarsal ligament. The authors conclude that their approach to surgical excision of intermetatarsal neuromas is valid while preservation of the normal ligamentous anatomy is maintained.

Sports-related tendon injuries of the foot and ankle.

Treatment of major tendon injuries is a complex and challenging subject. It is necessary to have a thorough understanding of the mechanism of injury to successfully treat these soft tissue injuries of the foot and ankle.

Posterior tibial tendon rupture in a world class runner.

Complete rupture of the posterior tibial tendon occurs infrequently. It can be caused by a variety of factors, including repeated steroid injections, chronic tenosynovitis, and decreased blood supply to the tendon. The authors report a world class runner who sustained a rupture requiring surgical intervention.

Foot trauma in a rural hospital.

The authors made a survey of a rural hospital emergency room to determine the types of foot injuries seen and the frequency of foot injuries in relation to total emergency room visits. The study showed that foot fractures made up a significant portion of emergency room admissions.

Percutaneous transluminal angioplasty in the treatment of ischemic disease of the lower extremity.

Symptoms of severe peripheral vascular disease in the lower extremity necessitate attempts to revascularize the limb. Patients refusing or unable to undergo direct arterial surgery may be candidates for percutaneous transluminal angioplasty. Combined with realistic goals regarding foot salvage, careful selection of patients for angioplasty may prevent unnecessary amputations and permit local surgical care of the foot. Restoration of pain-free ambulation can follow the procedure. The coordinated efforts of various specialists can now be directed toward treatment of previously unmanageable ischemic complications in the foot.

The effect of a thigh tourniquet on the incidence of deep venous thrombosis after operations on the fore part of the foot.

We performed a prospective randomized clinical study to determine whether use of a thigh tourniquet influences the incidence of deep venous thrombosis. The lower limbs of patients who were scheduled for elective surgery on the fore part of the foot were randomized and assigned to one of three treatment categories: Group I, no tourniquet; Group II, exsanguination by an Esmarch bandage before tourniquet application; and Group III, exsanguination by elevation of the extremity prior to application of a tourniquet. The 117 limbs of seventy-one patients included in this study were evaluated preoperatively and twenty-four and seventy-two hours postoperatively with 125I-labeled fibrinogen, and preoperatively and seventy-two hours postoperatively with Doppler ultrasound studies and phleborheography. The findings in all of the Doppler ultrasound studies and all of the phleborheograms were normal. Two of the 125I-fibrinogen studies were positive, but subsequent contrast venography revealed that these were false-positive findings. We therefore concluded that the use of a thigh tourniquet does not increase the risk of deep venous thrombosis in patients who have had an operation on the fore part of the foot.

Peroneus longus tendinitis: a possible biomechanical etiology.

Tendinitis of the foot and ankle is becoming increasingly common, or at least more commonly recognized, with the recent widespread interest in running. In runners seen in our clinics we have encountered several cases of peroneus longus tendinitis. The authors present a case report and possible biomechanical etiology for peroneus longus tendinitis.

Subacute anterior tibial compartment syndrome.

Although acute anterior tibial compartment syndrome has been discussed frequently in the literature, there are few reports on the subacute or chronic syndrome. This problem may result from running or strenuous exercise, or even from walking. Additional demands are placed on the muscles of the anterior compartment by exercise, and this may result in varying degrees of symptomatology. Rest, elevation of the limb, and ice packs should be included in the treatment of this condition.

Acute gouty arthritis in a first metatarsophalangeal joint replaced with a flexible-hinge implant: a case report.

Use of the flexible-hinge, double-stemmed implant has eliminated many of the complications that followed correction of an arthritic first metatarsophalangeal joint caused by hallux valgus. There were no reports in the literature of acute gout after this type of correction. The authors present such a case in a patient with a history of gout, and they suggest that, when a synovectomy is performed in a patient with gouty arthritis, the joint should be freed of synovial tissue in which a uric acid crystal-induced synovitis could occur.