Staging of Charcot neuroarthropathy along the medial column of the foot in the diabetic patient.

Diabetes mellitus is the leading cause of Charcot neuroarthropathy. The most common location is along the medial column of the foot. Over a 2-year period, the process can result in a severely deformed foot, which is highly prone to ulcers, infection, and subsequent amputation. To help identify the early stages of the disease process, the histories, physical examinations, and radiographs of 40 patients with 51 neuropathic feet were evaluated. We were able to identify five stages of Charcot deformities. Stage 0 is a clinical stage in which the patient presents with a locally swollen, warm, and often painful foot. Radiographs are negative and technetium 99 bone scan is markedly positive. Indium and gallium scans are normal. Stage 1, in addition to the clinical findings, demonstrates periarticular cysts, erosions, localized osteopenia, and sometimes diastases. Stage 2 is marked by joint subluxations, usually starting between the second cuneiform and the base of the second metatarsal and spreading laterally. Stage 3 is identified by joint dislocation and arch collapse. Stage 4 is the healed and stable end result of the process. Clinically, there is no temperature gradient between the two feet. Radiographically, there is bony trabeculation across joint spaces indicative of mature fusion. Treatment of stage 0 consists of limited weightbearing and close observation while the diagnosis becomes clear. Stage 1 is treated with casting followed by a University of California Biomechanics Lab orthosis (UCBL), to maintain the arch while allowing limited weightbearing. In stage 2, a partial weightbearing total contact cast followed by a Charcot restraint orthotic walker (CROW) is used. Surgery may be needed at this stage, while the joints are still reducible. Arthrodesis with rigid fixation is recommended. Stage 3 is treated with casting for the acute phase, then with a patellar-tendon-bearing ankle-foot orthosis, CROW, or caliper orthosis. If ulcers are present, they are treated with weekly local debridement, antibiotics, and total contact casting. Occasionally decompressive ostectomy is required. Stage 4 may need surgical removal of the bony prominences causing the nonhealing ulcers. Extra-depth shoes and pressure-relieving orthoses are also used. Twenty-five percent of our patients diagnosed and treated in the early stages (stages 0, 1 and 2) did not develop deformity. Surgery to prevent deformity is recommended early, before the destructive stage (stage 3). Close follow-up, especially in a noncompliant population is necessary.

MR imaging of anterosuperior calcaneal process fractures.

OBJECTIVE: Fractures of the anterosuperior calcaneal process can be both clinically and radiographically difficult to detect yet, if not recognized and immobilized early, may result in painful nonunion. The purpose of this study was to show that MR imaging is sensitive in the detection of such subtle or radiographically occult fractures, that the pattern of marrow edema corresponds to the two known mechanisms of injury, and that MR imaging can document both healing and nonunion of these fractures. CONCLUSION: MR imaging can reveal subtle or nondisplaced fractures of the anterosuperior calcaneal process. Also, MR imaging can be used to document healing. The pattern of marrow edema limited to the anterosuperior calcaneal process corresponds to the bifurcate ligament avulsion mechanism of injury. Edema in both the anterosuperior calcaneal process and the cuboid is caused by the impaction mechanism of injury.

Haglund's syndrome.

Haglund's syndrome is a painful condition of the heel caused by mechanically induced inflammation of the retrocalcaneal bursa, supracalcaneal bursa, and Achilles tendon. Surgical management has included calcaneal osteotomy, but results have been unpredictable because of the inability to measure accurately bone removal. A method was devised in this study to accurately determine radiographically the amount of bone removal necessary. Sixteen heels in 13 patients underwent surgery after failing 21 months of conservative treatment. The desired osteotomy angle (preop x-rays) was compared to the actual angle obtained at surgery. A patient questionnaire, developed by the Outcome Study Committee of the AOFAS, was used to assess results. There were 13 good results and 3 failures. The average actual angle of the good results was 49 degrees and that of the poor results was 61 degrees. These results were statistically significant to a p = .0012. The average score obtained by the good results was 87 points, while that of the failures was 25 points. Follow-up was 42 months. The authors recommend that the osteotomy be made in such a way as to remove not only the superolateral deformity, but also to decompress the retrocalcaneal bursa and to remove the calcaneal step. In order to do so, an osteotomy angle of 49 degrees should be achieved.

Noncompressive spinal radiculitis.

Sciatica can be caused by a herniated disc (compressive neuropathy) or by the process of disc degeneration (noncompressive neuropathy). Laminectomy and discectomy usually produce a good result in compressive neuropathy, whereas surgery for noncompressive neuropathy, if necessary, consists of complete excision of the disc and anterior interbody fusion, posterior fusion, or both. Noncompressive spinal radiculitis is a biochemical, not a biomechanical, problem. Phospholipase A2, substance P, and increased fibrinolytic activity have been implicated in the process.

Duration of symptoms and disc configuration in chemonucleolysis.

Previous studies have compared the effectiveness of chemonucleolysis with surgery, but currently, no objective criteria have been correlated with the clinical outcome. The authors reviewed 28 cases where the patients had undergone chymopapain injection to determine the significance of disc herniation size, disc space height reduction, and the duration of symptoms on clinical outcome. All patients had a complete history, physical examination, and discogram, and most had pre- and post-injection computerized tomography (CT) or myelogram. Nine of the 28 patients were considered clinical failures. Seven underwent laminectomy and discectomy and were improved markedly. Two patients were advised to have surgery but refused and were considered clinical failures. The causes of failure were unknown in three patients, free fragment in two patients, and diabetic neuropathy in one. Only two patients who did well showed complete resolution of the disc deformity on repeat CT scan. The remainder still had evidence of an avascular deformity that persisted although reduced in size. The failures showed no changes in disc size. The height of the disc space was too variable to be correlated with clinical outcome. Patients who failed had a longer duration of symptoms than the ones who did well (15.1 months for failures vs. 5 months). Therefore, some reduction of disc deformity size, but not necessarily complete reduction, is necessary for a good result, and the enzyme is not as effective in patients with long-standing symptoms.

Biomechanics of the accessory navicular synchondrosis.

The accessory navicular is commonly considered an asymptomatic variant, but when traumatized, it can become the source of clinical symptoms. The accessory naviculars were divided into Types I, IIa and b, and III based on their appearance and location with relationship to their parent navicular. Only Type IIa and b accessory naviculars have a synchondrosis. The synchondrosis of Type IIa and b can undergo tension, shear, and compression forces causing avulsion or a painful pseudarthrosis to develop.

The accessory navicular synchondrosis.

The accessory navicular, which is considered an anatomic variant, may be the source of pain in athletes. There are three types of accessory naviculars: Type I is an ossicle in the substance of the posterior tibial tendon; Type II forms a synchondrosis with the navicular; and Type III, "the cornuate navicular," represents the possible end stage of Type II. Nine feet had Type II accessory naviculars. The pull of the posterior tibial tendon, the degree of foot pronation, and the location of the accessory navicular in relation to the undersurface of the navicular are factors that produce tension, shear, and/or compression forces on the synchondrosis of Type II accessory naviculars and cause microscopic changes of injury and repair similar to those observed with a physeal fracture. Such alterations are not always visible on roentgenograms but are usually detected by 99mTc methylene diphosphonate (99mTcMDP) scans. Initially, nonsurgical treatment with orthotics or casts should be attempted, but if this is unsuccessful, surgical treatment is recommended. Surgical treatment consists of excision of the accessory navicular with its synchondrosis, without transposition of the posterior tibial tendon.

Occult injuries of the talus diagnosed by bone scan and tomography.

Five patients, four women and one man, were found to have an osteochondral lesion of one of the talar joints. All patients had normal plain radiographs of the ankle and foot and were referred to us as a second or third consultation for undiagnosed ankle and hindfoot pain. Bone scans of the tali demonstrated the specific talar joint that was injured, and tomography confirmed the presence of an osteochondral lesion. The average delay in the diagnosis between the onset of symptoms and the initiation of treatment was over 10 months. Bone scanning is an effective diagnostic tool in locating injuries of the talus not appreciated on routine x-ray.

An office-based orthotic system in treatment of the arthritic foot.

Patients with inflammatory arthritic disease of the feet invariably require conservative office management. The simplest method of obtaining relief has been to use commercially available extra-depth shoes combined with custommade, removable, closed-celled polyethylene foam arch supports. These supports are soft, light, and can be accurately adjusted to each patient's pathology. The technique and modifications used for relieving the commonest problems, such as anterior metatarsalgia and plantar heel pain, are discussed.