Use of desmopressin in a patient with von Willebrand's disease undergoing podiatric surgery.

This patient required reconstructive surgery for a productive life, free of pain. The use of desmopressin provided effective hemostasis and avoided the transfusion of potentially hazardous blood products.

Squamous cell carcinoma: an unusual early complication of postoperative osteomyelitis.

Review of the world biomedical literature noted only scant attention to the rare variant of squamous cell carcinoma which can develop in traumatic lesions. Squamous cell carcinoma developed 10 months after a patient was treated for multiple injuries including bilateral ankle and foot trauma. After surgery, attention to the clinical signs of neoplastic transformation is important, even when treating lesions of less than 1 year's duration. When clinical signs and symptoms indicate possible squamous cell carcinoma, a biopsy must be done. Once the diagnosis is confirmed, definitive surgery is mandatory because recurrence and metastatic disease have a low 5-year survival rate.

Retrospective study of fifth metatarsal fractures.

On the basis of the authors' results in treating avulsion fractures of the tuberosity, immobilization in a short leg weightbearing cast for 4 weeks is the preferred treatment. If still symptomatic at 4 weeks, some patients may require further immobilization for an additional 1 to 3 weeks. Rarely do these patients require surgery. In patients with these types of fractures, no angulation or displacement deformity was seen on x-rays, so open reduction was not warranted. Although the study does not strongly support the view that delayed healing of Jones fractures is associated with weightbearing cast treatment, the authors still tend to recommend treatment with a short leg nonweightbearing plaster cast for 6 weeks. Patients may not tolerate such treatment for this amount of time. To encourage better patient compliance, a minimum of 3 to 4 weeks in a nonweightbearing cast followed by 3 weeks in a weightbearing cast is recommended. Although open reduction was indicated in a few cases, all patients with Jones fractures, aged 20, 22, 24, 24, and 27 years, declined that option. Specifically, one patient had a delayed union of the Jones-type fracture (Fig. 4). In spite of being young and athletic, and thus at high risk for refracture, he decided against open reduction internal fixation and opted for prolonged casting.

Ciprofloxacin in the treatment of Mycobacterium fortuitum infection of the peroneal tendons. A case report.

In the case reported, M. fortuitum was sensitive in vitro to amikacin, erythromycin, tobramycin, and ciprofloxacin. Because the patient did not respond to long-term therapy with amikacin and erythromycin, an experimental antibiotic, ciprofloxacin, was tried. Only after extensive surgical debridement and 2 1/2 months of oral ciprofloxacin therapy was the infection eradicated and wound healing obtained. The authors conclude that a wound that has reopened, but remains indolent, exudes a clear, serous drainage and responds poorly to antibiotics should suggest a possible mycobacterial infection. Combination antibiotic therapy is recommended because of the high rate of relapse and development of resistance to drugs. Extensive surgical debridement of all infected tissue remains the primary treatment. The therapeutic value of ciprofloxacin and other newer antibiotics in the treatment of mycobacterial infection is promising.

Lateral subtalar dislocation. A literature review and unusual case report.

An unusual case of suspected lateral subtalar joint dislocation was reported. A review of the literature found that medial dislocations were reported four times more frequently than lateral dislocations. Half of the cases of subtalar dislocation reviewed here described associated fractures, the incidence of which was higher in lateral dislocations. In both types of dislocations examined, almost half were reduced nonoperatively. In most cases, long-term results of repair of these injuries were considered favorable.

Lisfranc's fracture-dislocation. A review of the literature and case reports.

The authors present an in-depth discussion of Lisfranc's fracture-dislocations, including classifications, mechanisms of injury, radiographic evaluation, and a literature review. Four cases are presented for review. Lisfranc's fracture-dislocation is a rare injury that can lead to prolonged disability if undiagnosed or if there is a delay in treatment.

Power staple fixation in hallux valgus surgery: a preliminary report.

The authors describe a relatively new power staple device for foot surgery. Their preliminary review has been very favorable, as studied in 40 cases of hallux valgus repair. Their discussion includes the indications, contraindications, and potential for future use in the foot.

Intra-articular fractures of the calcaneus: a review.

Intra-articular fractures of the calcaneus can result in prolonged or permanent disability. The systematic approach to analysis based on anatomy, mechanism of injury, and x-ray films allows determination of the various elements of the lesion. Management is difficult because treatment is not standardized, and, even when good reduction has been achieved, long-term complications are commonplace. The authors review different types of intra-articular calcaneal fractures, various methods of treatment, and examples of possible complications.

Fractures of the neck of the talus and the Blair fusion: a review of the literature and case report.

Historically, fractures of the neck of the talus have been serious injuries with sometimes devastating results. Several mechanisms have been reviewed to explain the types of injuries most commonly seen. Hawkin's classification of the types of talar neck fractures has been explained and used as a guideline in a review of treatment and results of talar neck fractures. Hawkin's group I fractures generally require only immobilization and are frequently without serious sequelae. Hawkin's group II fractures are more serious injuries, which may frequently be treated with closed reduction. Open reduction is occasionally necessary. Hawkin's group III fractures have the most potentially devastating results. These generally require open reduction with internal fixation or occasionally primary salvage procedures. Secondary salvage procedures are also sometimes necessary. Avascular necrosis of the talar body is reviewed in detail, including correlation with the type of fracture as well as diagnostic techniques and treatment. Other complications, including soft-tissue damage, osteomyelitis, malunion, and posttraumatic arthrosis, are discussed. The Blair tibiotalar arthrodiesis is reviewed in detail, with the consideration that it may be used as a primary or secondary salvage procedure with good results. Finally, a case in which the Blair fusion was used successfully is reported with 1-year follow-up.

The neuropathic joint in diabetes mellitus.

This article discusses the development and treatment of Charcot's joints in patients with diabetic peripheral neuropathy. Historical and clinical reviews are presented, as are case illustrations. This article provides the practitioner with a comprehensive review of diagnosis and treatment of this clinical entity.

Lesser digital arthrodesis.

Arthrodesis at the proximal interphalangeal joint is a surgical procedure useful when dealing with semireducible or nonreducible contractures of the lesser digits. When arthrodesis of the proximal interphalangeal joint is performed, there is conversion of the retrograde dorsal buckling force of the long extensor tendon to a plantargrade straightening force of the flexor tendon. This occurs as a result of the rigid strut created at the arthrodesis site. If metatarsal equinus is present, arthrodesis can help reduce this deformity and eliminate plantar pressure contributing to submetatarsal tyloma. An arthroplasty procedure does not resist deforming forces and is more useful in correcting painful deformities where flexibility is desired postoperatively. It is therefore important, even in "simple" digital surgery, to understand the etiology of the pathology and identify and structure the goals of the surgery. The end-to-end arthrodesis offers the advantage of being easy to perform, relatively free of complication, and able to maintain the length of the digit. A fixation device, such as a Kirschner wire or monofilament wire, may be needed to maintain the correction. Its inherent complications have been described. It can be relatively unstable. The peg in hole arthrodesis offers the advantage of better stability which does not necessarily require internal fixation. There is also rapid bone healing due to the side-to-side configuration of the arthrodesis site. The procedure is more complicated and time consuming to perform than an end-to-end procedure. There is more shortening in the peg in hole. Taking these factors into account, the surgeon should choose the procedure which best meets the preoperative criteria and expected postoperative results.

Calcaneal bone graft after enchondroma excision.

Enchondroma is a commonly encountered bone tumor in the foot, frequently necessitating excision. The calcaneus is a convenient source of bone for a bone graft, should that be required. The patient's own calcaneus offers the advantages of both cortical and cancellous bone, accessibility, dependable bone healing, and the superior osteogenic potential of autologous bone.

Fractures in children.

The unique structure and function of the pediatric patient lends them to patterns of osseous trauma not found in their adult counterparts. Epiphyseal anatomy, epidemiology, and classic fracture patterns are reviewed. Early restoration of joint and epiphyseal plate congruity is the objective with a goal of complete functional return and structural integrity at skeletal maturity.

Nonosseous considerations in trauma.

A description of the nonosseous considerations, both accidental and iatrogenic, in the evaluation and treatment of the traumatized foot has been presented. The brief description of the types of wounds encountered provided here should enable the reader to extrapolate the principles to be used in treating any type of pedal wound. A classification of wounds for better understanding of treatment alternatives is presented. Though it is obvious that classifying wounds may be simplistic, the myriad of treatment alternatives make the definitive treatment of the wounds a dynamic process. It is axiomatic that clean wounds can be closed and infected wounds cannot; however, clinicians are rarely presented with such clear-cut alternatives. The patient, the principles of wound healing, and the bacterial-host interface must all be considered in rendering an appropriate diagnosis and selecting the most effective treatment from the multiplicity of treatments available.