[Reverse second dorsal metatarsal artery island flap for repairing the soft tissue defect at toes]

OBJECTIVE

To report the application of reverse second dorsal metatarsal artery island flap for From May 2005 to September 2008, 5 cases with soft tissue repairing the soft tissue defect at toes.

METHODS

defects at toes were treated with reverse second dorsal metatarsal artery island flaps. The flaps size ranged from 2 cm x 3 cm to 5 cm x 6 cm.

RESULTS

All the 5 flaps survived completely. The patients could walk 1-2 months after operation. The patients were followed up for 5-7 months with good appearance, texture and sensation of toes.

CONCLUSION

The reverse second dorsal metatarsal artery island flap has a reliable blood supply and good tissue texture. It is a practical method for repairing the soft tissue defect at toes.

[Patient's comfort during cicatrization and wound protection process due to the use of Nobecutan plastic dressing administered by an aerosol]

This report received the 2009 Nobecutan Nursing Prize. Born to Protect. This is a study which proposes to evaluate the comfort level patients perceive when they apply the Nobecutan transparent dressing administered by an aerosol. Dressing composition: plastic composed by a 4% acrylic co-polymer, 42.98% ethyl acetate, Tetramethylthiuram disulfide 0,02% and dimethyl 53%. Characteristics: *Micro-porous, prevents maceration of the skin. *Impervious to water and micro-organisms. *Easy to use as a aerosol which upon spraying an area, forms a thin film which permits transparency over a wound and therefore constant visual control; plus this film prevents allergic reactions.

Boutonniere deformity of the second toe after planter dislocation of proximal interphalangeal joint: a case report

The boutonniere deformity is a well-known deformity in the fingers, however, its appearance on a lessor toe is extremely rare. In the present case, the deformity resulted from a rupture of the central slip of the extensor tendon and the shift of the lateral bands to the planter side after reduction of a traumatic planter dislocation of the PIP joint of the second toe. Surgical repair of the extensor mechanism brought good results.

One case of big-toe re-plantation: a 13-year follow-up and a literature review

In this case of a 3-year-old patient who had a left big-toe amputation through the proximal phalange, re-plantation was performed successfully. Big-toe amputations are not frequent entities, but it should always be re-planted to avoid unsatisfactory aesthetic and functional outcomes. There are just a few reports in literature and their follow-up is very brief compared with our report.

[The polyurethane shoe -- a new possibility in the treatment of the toe and metatarsal fractures (author's transl)]

The problem of supporting casts in the treatment of metatarsal and toe fractures is discussed. A therapeutic enrichment is given by a new polyurethane cast, the so-called PU-shoe, which can even be worn in a little wider than normal ready-made shoe. The proedure is demonstrated with some clinical examples.

[Preventing effect of TGF-beta1 antibody compounded with fibrin glue on postoperative adhesions of flexor tendon]

OBJECTIVE

To explore the preventing effects of TGF-beta1 antibody (TGF-beta1Ab) compounded with fibrin glue (FG) on postoperative adhesions of flexor tendon.

METHODS

Seventy-two Leghorn chickens were randomly divided into 4 groups (groups A, B, C and D), 18 chickens for each group, and the long flexor tendons of the 3rd and 4th toes in zone II of all chickens were transversed and sutured with the 4-strand cruciate repair technique to make defect models. In group A, 0.2 mL TGF-beta1 Ab was applied at repair site. In group B, 0.2 mL FG was applied at repair site. In group C, 0.2 mL TGF-beta1Ab and FG was applied at repair site. In group D, 0.2 mL normal sodium was applied at repair site. At 1, 3 and 8 weeks after operation, the tendons of 6 chickens in each group were harvested for morphological and histological evaluation. Six specimens of each group were obtained for biomechanical test at 3 and 8 weeks.

RESULTS

The gross-observation showed that the differences in grading of tendon adhesion were not significant among 4 groups at 1 week after operation (P > 0.05), but the differences were significant between groups A, B, D and group C at 3 and 8 weeks after operation (P < 0.05). Histological observation showed that collagen fibers arranged irregularly in groups A, B and D, but arranged regularly in group C at 3 and 8 weeks' after operation. At 3 weeks after operation the gliding excursion ratio of the tendon in groups A, B, C and D were 0.45 +/- 0.05, 0.40 +/- 0.10, 0.79 +/- 0.09 and 0.25 +/- 0.07 respectively; the simulated active flexion ratio were 0.61 +/- 0.02, 0.67 +/- 0.03, 0.91 +/- 0.03 and 0.53 +/- 0.04 respectively; the work of flexion were (18.00 +/- 0.77), (17.80 +/- 1.13), (27.60 +/- 1.73) and (15.60 +/- 1.27) degrees/N respectively. There were significant differences between group C and other three groups (P < 0.05). The tendon anastomosis breaking strength were (14.2 +/- 1.9), (15.2 +/- 2.2), (16.0 +/- 2.2) and (14.7 +/- 2.7) N, showing no significant differences among 4 groups (P > 0.05). At 8 weeks after operation, the gliding excursion ratio of the tendon in groups A, B, C and D were 0.45 +/- 0.07, 0.43 +/- 0.08, 0.80 +/- 0.09 and 0.29 +/- 0.05 respectively; the simulated active flexion ratio were 0.61 +/- 0.02, 0.63 +/- 0.03, 0.92 +/- 0.03 and 0.53 +/- 0.03 respectively, the work of flexion were (18.30 +/- 0.84), (18.60 +/- 0.80), (27.90 +/- 1.24) and (15.30 +/- 0.75) degrees/N respectively. There were significant differences between group C and other three groups (P < 0.05). The tendon anastomosis breaking strength were(51.9 +/- 3.0), (51.4 +/- 1.4), (53.3 +/- 1.3) and (52.3 +/- 2.2) N, showing no significant differences among 4 groups (P > 0.05).

CONCLUSION

TGF-beta1Ab compounded with FG could significantly prohibit the formation of fibrous adhesions without interfering with the healing process.

Toe bandaging to prevent and manage oedema

Toe oedema is more commonly associated with lymphoedema but is frequently seen in patients with venous hypertension. In the long-term it leads to toe deformity and it is essential that the problem is managed. Brenda King outlines how to apply toe bandages and the long-term management once the problem is resolved.

[An effect of 5-fluorouracil on tendon adhesion formation after flexor tendon repair in chickens]

OBJECTIVE

To assess an effect of 5-fluorouracil (5-FU) applied topically on the tendon adhesion and the healing process after the flexor tendon repair in Leghorn chickens.

METHODS

Thirty-two white Leghorn chickens, aged 4 months and weighing 1.5-1.7 kg, were randomly divided into 2 groups: Group A and Group B, with 16 chickens in each group. The flexor digitorum profundus tendons of the 2nd, 3rd and 4th toes were transected and repaired. The repair site in Group A was given 5-FU in a concentration of 25 mg/ml with a soaked sponge that was cut into pieces 7 mm X 20 mm x 1 mm in size, and the synovial sheath of the repair site was wrapped with the 5-FU-soaked sponge for 1 min for 4 times. The repair site in Group B was served as a control, with no 5-FU but with the sterile normal saline. At 3 and 6 weeks postoperatively, the repaired tendons and the tendon adhesion formation were examined macroscopically and histologically, and the repaired tendons were tested biomechanically. The tissue blocks from the tendon repair site were examined under the transmission electron microscope.

RESULTS

At 3 and 6 weeks postoperatively, the macroscopic and histological observation showed that the peritendinous adhesions in Group A were looser when compared with those in Group B. The length of the tendon gliding and the extent of yieldance to exercise were found to be 4.85+/-1.31 mm, 0.67+/-0.42 mm and 5.74+/-1.61 mm, 1.55+/-0.35 mm respectively at 3 and 6 weeks after operation in Group A,but 2. 99+/-0.51 mm,0.24+/-0.14 mm and 3.65+/-0.54 mm, 1.22+/-0.16 mm in Group B. Group A was significantly greater in the above-mentioned parameters than Group B (P<0.05). At 3 weeks after operation, the ultimate breaking strength was 20.28 +/- 4.92 N in Group A and 21.29 +/- 4.88 N in Group B, with no statistically significant difference found between the two groups (P>0.05). At 6 weeks, the ultimate breaking strength was 47.12+/-6.76 N in Group A but 39. 31 +/- 7.20 N in Group B, with a significant difference between the two groups (P < 0.05).

CONCLUSION

5-fuorouracil, when applied topically, can reduce the tendon adhesion, with no inhibition of the intrinsic healing mechanism. It is an ideal treatment strategy to prevent peritendinous adhesion.

Evaluation of transfixation casting for treatment of third metacarpal, third metatarsal, and phalangeal fractures in horses: 37 cases (1994-2004)

OBJECTIVE

To evaluate clinical findings, complications, and outcome of horses and foals with third metacarpal, third metatarsal, or phalangeal fractures that were treated with transfixation casting.

DESIGN

Retrospective case series. Animals-29 adult horses and 8 foals with fractures of the third metacarpal or metatarsal bone or the proximal or middle phalanx.

PROCEDURES

Medical records were reviewed, and follow-up information was obtained. Data were analyzed by use of logistic regression models for survival, fracture healing, return to intended use, pin loosening, pin hole lysis, and complications associated with pins.

RESULTS

In 27 of 35 (77%) horses, the fracture healed and the horse survived, including 10 of 15 third metacarpal or metatarsal bone fractures, 11 of 12 proximal phalanx fractures, and 6 of 8 middle phalanx fractures. Four adult horses sustained a fracture through a pin hole. One horse sustained a pathologic unicortical fracture secondary to a pin hole infec-tion. Increasing body weight, fracture involving 2 joints, nondiaphyseal fracture location, and increasing duration until radiographic union were associated with horses not returning to their intended use. After adjusting for body weight, pin loosening was associated with di-aphyseal pin location, pin hole lysis was associated with number of days with a transfixation cast, and pin complications were associated with hand insertion of pins.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that transfixation casting can be successful in managing fractures distal to the carpus or tarsus in horses. This technique is most suitable for comminuted fractures of the proximal phalanx but can be used for third metacarpal, third metatarsal, or middle phalanx fractures, with or without internal fixation.

Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis

Hair-thread tourniquet syndrome is a rare condition where appendages are strangulated by an encircling strand of hair, a thread, or a fiber. The condition usually occurs in very young patients in the first few months of life. We present a unique case of a 3-month-old baby girl with hair-thread tourniquet syndrome in whom a hair cheese-wired through the skin and soft tissue of the toe and caused bony erosion of the underlying phalanx. An extensive literature review and meta-analysis of the topic are also presented.

Ingrown toenails

Ingrown toenails are common, especially in young patients. Several predisposing factors contribute to the formation of an irregular sharp edge (spicule) of the lateral nail plate that penetrates and injures the soft tissue of the lateral nail fold. Depending on the severity of the disease, treatment varies from simple disembedding of the spicule to phenolization of the lateral nail matrix. This article provides a step-by-step guide to the management of patients with ingrown toenails.

Undiagnosed fracture in a common foot variant: the biphalangeal little toe

The biphalangeal little toe is an anatomical anomaly that has been previously well described in the early anatomical literature. But, as is the case with many anomalies, there is a lack of awareness of it amongst current clinicians. We report the case of a fracture through the distal phalanx of the little toe, with a delay in the diagnosis due to confusion over the X-ray findings. X-rays revealed a biphalangeal toe with a fracture through the distal phalanx, which mimicked the usual triphalangeal toe. This is the first reported case of clinical confusion over this anatomical variation. A review of 102 human skeletal feet at the Department of Anatomy, University of Melbourne, was performed to evaluate the frequency of the biphalangeal little toe variant, revealing an incidence of 26%.

Use of transfixation pin casts to treat adult horses with comminuted phalangeal fractures: 20 cases (1993–2003)

OBJECTIVE

To determine the clinical applications, short and long-term survival, and complications of using transfixation pin casts for treatment of comminuted phalangeal fractures in adult horses.

DESIGN

Retrospective case series.

ANIMALS

20 horses.

PROCEDURES

Medical records were reviewed to obtain information regarding signalment, fracture location, treatment methods, complications, and short-term survival (discharge from hospital). Long-term follow-up information was obtained via contact with owners or trainers.

RESULTS

12 fractures were in a hind limb, and 8 were in a forelimb. Fourteen fractures occurred in a middle phalanx, and 6 occurred in a proximal phalanx. Eleven fractures were treated with internal fixation combined with transfixation pin casts, and 9 fractures were treated with transfixation pin casts alone. Transfixation pin casts were maintained for a mean of 52 days (median, 49 days; range, 1 to 131 days). Fourteen (70%) horses were discharged from the hospital, whereas 6 (30%) were euthanized during the treatment period. Reasons for euthanasia included secondary fracture of the third metacarpal or metatarsal bone, avascularity of the distal aspect of the limb associated with an open fracture, and displacement of the fracture after transfixation pin cast removal. A significantly greater number of horses was discharged from the hospital when the transfixation pin cast was maintained for > 40 days, compared with those in which the transfixation pin cast was maintained for < 40 days.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that horses should be maintained in a transfixation pin cast for a minimum of 40 days, as this was associated with an increase in short-term survival without an increased risk of catastrophic failure.

[Pasteurella dagmatis spondylodiscitis in a diabetic patient]

INTRODUCTION

Healthy pets contact are able to induce unusual and severe diseases.

CLINICAL CASE

This case reports the medical history of a dorsal spondylodiscitis in a diabetic patient admitted for a chronic wound of his toes. He had a long-standing history of regular consumption of alcohol and tobacco. Blood bottles and biopsy of intervertebral disc infected discovered Pasteurella dagmatis, commonly colonizing the oropharynx of healthy dogs and cats. In this case, licking of his injured toe by his dog was the likely source of entry of the organism.

DISCUSSION

We found no identical cases in the medical literature. Diabetes mellitus and other immunocompromised disorders justify to change behaviours toward domestic animals.

Reverse First Dorsal Metatarsal Artery Flap for Reconstruction of Traumatic Defects of Dorsal Great Toe

BACKGROUND

Soft-tissue defects of the great toe that include exposed tendon and bone present a reconstructive challenge for plastic surgeons. This study investigates the feasibility and reliability of reverse first dorsal metatarsal artery flap (FDMA) for reconstruction of the dorsal great toe soft-tissue defects.

METHODS

Six male patients with dorsal great toe defects (mean 2.2 x 4.7 cm) underwent reconstruction using the reverse FDMA flap. Preoperative angiography was performed to confirm the existence and patency of the distal communicating artery between the FDMA and plantar metatarsal artery. The flap was raised by dividing the dorsalis pedis artery and proximal communicating arteries and rotated 180 degrees to cover the defect.

RESULTS

All flaps survived completely. Mean follow-up time was 3.3 months. Painless full range of motion was recovered and the contour of the flap was satisfactory. All patients returned to their normal walking and running activities and none necessitated special footwear. No donor-site morbidity was encountered.

CONCLUSION

Reverse FDMA flap presents a viable alternative for reconstruction of soft-tissue defects of dorsal great toe when local flap coverage is required. Because of anatomic variations, preoperative angiography is necessary for successful reconstruction, especially in patients with comorbidities affecting patency of their vasculature.

Two Cases of Big-Toe Replantation: A Ten-Year Follow-Up

It is rare for traumatic amputation of the big toe to occur as a single injury. This trauma is especially significant in children for influencing foot development and for possible psychological impact. Two cases of successful replantation of completely amputated big toes in two girls, 2 years 7 months and 5 years 2 months old, are presented. Follow-up was 10 years. In the younger child, the replanted big toe was 49.2 percent shorter compared to the contralateral side, because growth was limited by the affected growth zone in the proximal phalanx. In the older child, the growth zone of the bone was intact, with consequent bone growth unimpaired, and an initial shortage of 10.4 percent was reduced to 2 percent compared to the contralateral side.

[Treatment of freezing injury]

Report on therapeutic procedures in patients with second and third degree congelations (frostbite) on the feet. Two mechanisms of tissue damage caused by exposure to cold temperature will be discussed pathophysiologically: direct freezing injuries and cell death through intra and extracellular ice crystal formation as well as transient and finally irreversible tissue damage due to decreased perfusion. The condition of decreased perfusion results from persistent vaso-constriction induced by cold temperature, increased blood viscosity, sludge phenomenon and occlusion by platelet thrombi in the microvasculature. Frostbite beyond the erythematous stage should be treated primarily with a parenteral therapy in order to improve the hemorrheologic parameters, in particular within the micro-vascular compartment. Colloidal plasma volume expander such as 10% dextran solution is used to increase the intravascular volume. This solution (with its coating effect) and pentoxifyllin lowers the aggregation of erythrocytes and platelets. The latter will also be favourably influenced by the use of iloprost or acetylsalicylic acid. Iloprost as a stable metabolite of prostacyclin is a powerful vasodilator which attenuates the peripheral vascular resistance and activates fribrinolysis. Pentoxifyllin is considered to lower pathologically increased levels of fibrinogen. Both drugs may protect against damage of the vascular endothelium. Based on their pharmacological effects the above-mentioned drugs may improve tissue perfusion and therefore tissue damage caused by frostbite can be limited. However, an important factor is to strictly avoid bacterial infections in the cold-damaged tissue.

Digital amputations

Digital amputations may be indicated for trauma, tumor, transplantation, infection, peripheral vascular disease, congenital deformities, and chronic pain. This article reviews indications, general principles of amputation, surgical procedures, complications, postoperative course and rehabilitation, and clinical cases.

Modifications of the great toe fibular flap for diabetic forefoot and toe reconstruction

Diabetic forefoot and toe wounds are difficult to heal in a timely fashion. Despite proper continued offloading and protective shoe-gear techniques, these wounds are frequently complicated by recurrent breakdown and adjacent toe deformities. When properly performed, pedicle flaps from the fibular border of the great toe represent viable and cost-effective means of providing early and durable soft tissue coverage and osseous reconstruction of diabetic forefoot and lesser toe wounds. Two modifications of the traditional great toe fibular flap are described: the great toe fibular adipofascio-cutaneous flap and the great toe fibular osteo-cutaneous flap, useful for providing forefoot and toe reconstruction, respectively. Understanding the surgical aspects of the treatment provides insights into overall care for these challenging wounds. Long-term outcomes studies involving these toe reconstruction techniques are needed to fully evaluate their success in preventing recurrent toe deformity and forefoot ulceration.

Coverage of Big Toe Defects After Wrap-Around Flap Transfer with a Free Soleus Perforator Flap

In thumb reconstruction, a wrap-around flap transfer from the big toe gives excellent results aesthetically and functionally; however, there may be some problems at the donor site, such as delayed wound healing and skin ulceration. In 10 patients, a free soleus perforator flap was used for immediate coverage of defects of the big toe with wrap-around flap procedures. Eight flaps survived completely, and the time required for wound healing was less than 1 month. Two flaps developed partial necrosis and required additional skin grafts. The average follow-up period was 46 months. There were no patients requiring defatting of the flaps. There were no patient complaints, such as postoperative skin erosion or ulceration. All patients were satisfied with the outcome. A free soleus perforator flap is an available method for covering defects of the big toe after wrap-around flap transfer.