[Sonographic monitoring of gout]

OBJECTIVE

To assess the role of grayscale and power Doppler sonography in short-term monitoring of acute gouty synovitis.

METHODS

Clinical and sonographic assessments were performed in a patient with gout. Clinical and sonographic evaluations were performed within the first day of the acute onset of synovitis of the first metatarsophalangeal joint of the left foot and 7 and 14 days after the baseline assessments. The patient was treated only with colchicine.

RESULTS

At baseline, both grayscale and power Doppler sonography revealed clearly evident findings of acute synovitis (joint cavity widening, thickening of periarticular soft tissues and power Doppler signal). After seven days, a complete clinical remission occurred. Ultrasound examination revealed marked improvement with respect to the basic findings, even if all the sonographic features of joint inflammation were still detectable. Two weeks after the onset of the acute attack, clinical remission was maintained and all the sonographic features of synovitis disappeared.

CONCLUSION

Sonography is a sensitive and reliable tool for assessing and short-term monitoring of acute gouty attack.

Die Weil-Osteotomie bei Metatarsalgie

AIM

The purpose of the prospective study is to evaluate the results of Weil osteotomy in painful overloaded central forefoot with dislocation of the MTP joint.

METHOD

19 left and 16 right feet underwent the Weil osteotomy. In 10 patients the procedure was performed on both feet. In 15 cases only one metatarsal was corrected (the 2 (nd) in 12 and the 3 (rd) in 3 cases), in 17 cases both the 2 (nd) and the 3 (rd) metatarsals and in 4 cases also with the 4 (th) one together. The simultaneous correction of hallux valgus was performed in 19 forefeet. The mean follow-up was 31 months (range, 19 to 41 months).

RESULTS

All patients were satisfied with the result of the operation. The results were excellent in 29 cases (83 %) and good in 6 cases (17 %). The plantar callus disappeared in 27 feet (77 %) and decreased in 8 feet (23 %). In one patient the new callus formed under the head of the neighbouring metatarsal bone. The sufficient MTP joint reduction was found in 31 cases (89 %).

CONCLUSION

It is possible with the Weil osteotomy to correct the metatarsal length accurately according to the preoperative planning. This results in the prevention of new callus formation under the neighbouring metatarsal head. Stable internal fixation allows the early mobilisation of the MTP joint.

Boxer knuckle (injury of the extensor hood with extensor tendon subluxation): diagnosis with dynamic US--report of three cases

The use of dynamic ultrasonography (US) in diagnosing traumatic and nontraumatic extensor tendon dislocations in fingers of three subjects is reported. Dynamic US of the clenched fist in two patients with traumatic injury revealed dislocated but grossly intact tendons surrounded by soft-tissue edema; magnetic resonance (MR) imaging in one patient indicated similar findings. Rupture in the sagittal band of the extensor hood mechanism in the two patients was confirmed at surgery. The third subject, an asymptomatic volunteer, had a congenital tendency toward dislocation. Dynamic US of the clenched fist is useful in diagnosing injuries of the extensor hood mechanism.

Relationship between clinically detected joint swelling and effusion diagnosed by ultrasonography in metatarsophalangeal and talocrural joints in patients with rheumatoid arthritis

OBJECTIVE

To assess the relationship between clinically detected swelling and effusion diagnosed by ultrasonography (US) in metatarsophalangeal (MTP) and talocrural (TC) joints in patients with rheumatoid arthritis (RA).

METHODS

Thirty consecutive patients with RA were studied. Altogether 288 MTP joints and 60 TC joints were evaluated. The clinical investigations were carried out by one doctor and the US investigations by another and they were blinded to each others' results.

RESULTS

The clinical examination and US gave similar results in 194 MTP joints, whereas they differed in the remaining 94 MTP joints, and correspondingly the results were similar in 34 TC joints and differed in 26 TC joints. The kappa coefficient between these investigations was 0.165 in MTP joints and 0.043 in TC joints, showing very poor agreement.

CONCLUSION

These preliminary results showed poor agreement between the clinical assessment of swelling and effusion detected by US in MTP and TC joints. Thus US may considerably improve the diagnosis of synovitis in patients with RA.

Arthrodesis in the treatment of hallux rigidus

We reviewed 34 patients (38 joints) with hallux rigidus treated from 1989 to 1999 with arthrodesis of the first metatarsophalangeal joint. Average patient age at time of surgery was 52 (24-71) years, and the mean follow-up was 54 (18-116) months. There were six superficial infections, and all arthrodeses united. There was a good functional result with a significant pain reduction. The mean postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 53 (5-84) points.

Magnetic resonance imaging of the fifth metatarsophalangeal joint compared with conventional radiography in patients with early rheumatoid arthritis

OBJECTIVE

To evaluate if magnetic resonance imaging (MRI) is superior to conventional radiography for detection of erosions in the fifth metatarsophalangeal (MTP5) joint.

METHODS

Within one year from the onset of rheumatoid arthritis (RA) (baseline), one and three years thereafter MRI and conventional radiographs of the MTP5 joint were performed in 23 patients.

RESULTS

MRI revealed erosions in 10 patients at baseline, in 15 after one year and in 15 patients after 3 years. On conventional radiography, there were erosions in 10 patients at baseline, 16 after one year as well as after 3 years. The agreement between the two imaging methods was fair to good at baseline and after one and three years (kappa 0,65, 0,51 and 0,51 respectively). The number of patients with clinical evidence of synovitis decreased considerably over time although the number of patients with MRI-synovitis was unchanged and the number of patients with erosions increased.

CONCLUSIONS

MRI was not superior to conventional radiography in detecting erosions in MTP5 joints in patients with early RA. Most erosions developed during the first year of observation. Synovitis on MRI may be a marker of future development of erosions in the MTP5 joint.

Traumatic dislocation of the fourth metatarsophalangeal joint

A32-year-old man presented to the accident and emergency department 2 hours after twisting his ankle. He had been running down stairs, barefoot, and missed a step, inverting his left ankle and landing on the lateral aspect of his left foot before falling to the ground. He was weight-bearing on his left heel, but complaining of intense pain over the lateral aspect of his forefoot. He mentioned that his wife had noticed a dimple on the sole of his foot. Besides the dimple on the plantar aspect of the left foot, about 2 cm proximal to the base of the fourth toe, no other deformity, swelling or bruising was evident. The patient was markedly tender over the dorsum of the foot over the area of the fourth metatarsophalangeal joint and over the dimple, which marked the same place on the plantar surface. Distal sensation and capillary refill were normal.

A combined proximal and distal dislocation of two adjacent metatarsals: double floating metatarsal bones (second-third)

A rare foot injury consisting of an irreducible, closed combined distal and proximal articulation dislocation of two adjacent metatarsals (second and third), called a "double floating metatarsal," was encountered in a 29-year-old man. The anatomy, mechanism of injury, and sequence of the surgical procedure are presented and discussed.

Rheumatoid forefoot deformity: a comparison study of 2 functional methods of reconstruction

OBJECTIVE

To compare the functional, radiographic, and pedobarographic results of different reconstructive methods for severe rheumatoid forefoot deformities.

METHODS

A total of 138 feet in 79 patients with RA forefoot reconstructions between 1978 and 1997 were reviewed through a detailed questionnaire, clinical examination, standardized radiographs, and pedobarographic analysis. Five subgroups based on procedure to the 1st ray were identified, then divided into 2 functional categories: Group 1: stable 1st ray by means of arthrodesis or no surgery; and Group 2: a resection procedure to 1st metatarsophalangeal (MTP) joint.

RESULTS

Sixty-one patients (106 feet) attended clinical review; 18 returned the questionnaire. There were 65 women and 14 men, with a mean age of 59 years (range 24-80): with 52 feet in Group 1 and 86 feet in Group 2. Mean age at surgery for both groups was 52 years (range 23-79). Mean age at the time of review was 55 years (Group 1) and 60.5 years (Group 2). Length of followup was significantly different: Group 1 averaged 36 months; Group 2, 102 months (p < 0.001). At review, no significant difference was noted in SF-36, comorbidities, WOMAC, or Foot Function Index. The disability score as defined by the American Rheumatological Society was significantly different: Group 1, 2.1 +/- 0.5; and Group 2, 2.4 +/- 0.6 (p = 0.006). Group 1 did significantly better in terms of walking distance, satisfaction with postoperative appearance of foot, relief of plantar pain, less plantar calluses, and higher AOFAS HMIP and LMIP scores. Postoperative complications occurred in 16 feet (11%); 15 feet required reoperation (10.6%). Major resection of the 1st MTP joint was associated with a significant increase in the 1st and 2nd intermetatarsal angle on radiographic review. The pattern of pressure distribution on the plantar aspect was similar regardless of the surgical procedure. The maximum contact area, maximum peak pressure, and maximum pressure time integral were located under the region of the 1st metatarsal, with a progressive decrease in values under the more lateral rays and under the lesser toes. Significantly higher pressures were seen under the 1st, 2nd, and 3rd metatarsal regions in Group 2 (1st MTP joint resection). Toe function was absent or minimal in the majority of Group 2.

CONCLUSION

Forefoot arthroplasty by means of a resection or stabilization provides significant pain relief. Maintenance of a stable 1st MTP joint and resection of the lesser metatarsal heads with K-wire stabilization will result in a more cosmetic forefoot, more even distribution of forefoot pressures, and more satisfied patients.

Radiation synovectomy with holmium-166 ferric hydroxide macroaggregate in equine metacarpophalangeal and metatarsophalangeal joints

OBJECTIVES

To evaluate the effects of radiation synovectomy (RSYN) with holmium-166 ferric hydroxide macroaggregate (Ho-166 FHMA) on synovium and synovial fluid in normal metacarpo- and metatarsophalangeal joints of horses and to determine intraarticular distribution of radioactivity after Ho-166 FHMA treatment.

STUDY DESIGN

Either Ho-166 FHMA or nonradioactive Ho-165 FHMA was injected into metacarpo- or metatarsophalangeal joints.

ANIMALS

Six adult mixed-breed horses without any clinical evidence of metacarpo- or metatarsophalangeal joint disease.

METHODS

Joints were injected with a single high dose of Ho-166 FHMA (mean, 1,000 MBq/joint) or a nonradioactive Ho-165 FHMA preparation (controls). Clinical examination, arthroscopy, synovial fluid analyses, and histologic studies were performed to detect effects of RSYN. Scintigraphy was used to localize intraarticular distribution of Ho-166 FHMA.

RESULTS

Ho-166 FHMA treatment induced joint inflammation leading to regional edema, effusion, and scar tissue formation. Scintigraphy revealed the highest intensity of radioactivity in the proximal plantar joint pouch, at which the Ho-166 FHMA treatment caused multifocal necrosis. In the dorsal joint pouch, however, arthroscopic study and histologic analysis showed very little effect of RSYN. There was no regeneration of synovium evident within 2 months. Synovial fluid protein concentration was significantly (P <.01) elevated, and some residual radioactivity remained for 5 days after Ho-166 FHMA injection.

CONCLUSIONS

Injection of a single high dose of Ho-166 FHMA caused multifocal necrosis of synovium and deep, soft-tissue injury in equine fetlock joints.

CLINICAL RELEVANCE

Inflamed equine joints with synovial lining hyperplasia could benefit from Ho-166 FHMA-induced radiation synovectomy if excessive scar tissue formation can be avoided.

[Hidden bone erosions]

The aim of this pictorial essay was to demonstrate the diagnostic efficacy of high-resolution sonography in detecting bone erosions in a patient with rheumatoid arthritis. Standard X-Ray of the feet did not reveal clearly evident erosions. Ultrasonography was able to detect the presence of bone erosions of the metatarsal heads of both the first toes and of the V toe of the left foot. Because the appearance of bone erosions on radiographs of a patient with a recent onset arthritis indicates a poor prognosis, the possibility of demonstrating small hidden erosions at the level of the early targets of the disease is of relevant practical value.

The floating metatarsal. A rare traumatic injury

The authors report a case of concomitant plantar Lisfranc dislocation and plantar metatarsophalangeal dislocation of the hallux. This is the second case of floating metatarsal described in the literature. When examining patients with Lisfranc joint injuries, one should explore carefully the metatarsophalangeal joints. It is also imperative to adapt the order of reductions to the presumed tension on the plantar fascia. Open reduction on the proximal side and closed reduction on the distal side, in addition to internal fixation proximally and distally, gave good results in this case.

[Functional CT imaging: Load-dependent visualization of the subchondral mineralization by means of CT osteoabsorptiometry (CT-OAM)]

PURPOSE

Functional computed tomography for visualization and quantification of subchondral bone mineralization using CT osteoabsorptiometry (CT-OAM).

MATERIALS AND METHODS

Tarsometatarsal (TMT) and metatarsophalangeal (MTP) joints of 46 human hallux valgus (HV) specimens were examined (sagittal 1/1/1 mm) on a single slice CT scanner SCT (Somatom Plus 4, Siemens AG). Subchondral bone pixels were segmented and assigned to 10 density value groups (Delta 100 HU, range 200 - 1200 HU) the pixels using volume rendering technique (VRT). The data analysis considered the severity of HV as determined by the radiographically measured HV-angle (a. p. projection).

RESULTS

CT-OAM could generate reproducible densitograms of the distribution pattern of the subchondral bone density for all four joint surfaces (TMT and MTP joints). The bone density localization enables the assignment to different groups, showing a characteristic HV-angle-dependent distribution of the maximum bone mineralization of the load-dependent densitogram (p < 0.001).

CONCLUSION

CT-OAM is a functional CT technique for visualizing and quantifying the distribution of the subchondral bone density, enabling a noninvasive load-dependent assessment of the joint surfaces. Load-dependent densitograms of hallux valgus specimens show a characteristic correlation with an increase of the HV-angle.

Cylindrical press-fit osteochondral allografts for resurfacing the equine metatarsophalangeal joint

OBJECTIVE

To investigate the feasibility of resurfacing the equine fetlock joint using cylindrical, orthotopic, press-fit, osteochondral allografts.

STUDY DESIGN

Experimental study.

ANIMALS

Ten mature, mixed-breed horses.

METHODS

Cylindrical, osteochondral grafts (6.5-mm diameter) were harvested aseptically from cadaveric equine metatarsophalangeal joints. Allografts were transplanted into 6 horses; 4 horses were sham operated. The surgical approach involved creation of a bone block at the origin of the medial collateral ligament and luxation of the metatarsophalangeal joint. Grafts were placed into the medial and lateral metatarsal condyles. Radiographs were taken at 8 and 25 weeks, and lameness was evaluated at 25 weeks. Horses were killed at 25 weeks. Analyses included gross evaluation, microradiography, paravital staining, light microscopy, and cartilage biochemistry.

RESULTS

No complications occurred that could be attributed to the surgical procedure. Graft congruency with the surrounding articular cartilage was fair to excellent. Two horses were sound at 25 weeks. Most grafts had more than 90% articular cartilage coverage, and histologic and microradiographic analysis revealed good graft incorporation and articular cartilage survival. Sulphated glycosaminoglycan concentration was decreased in grafted tissue.

CONCLUSIONS

We attribute the viability of osteochondral allografts in the equine fetlock to adequate congruency, stable graft fixation, and the use of orthotopic tissue. Host response to the allograft bone tissue did not affect cartilage viability.

CLINICAL RELEVANCE

Before clinical use, improvements to instrumentation are required that would decrease damage to grafts and minimize technique-associated incongruencies of the articular surface at the time of grafting. Larger grafts would also likely be required to resurface a greater surface area.

Concomitant plantar tarsometatarsal (Lisfranc) and metatarsophalangeal joint dislocations

We report an unusual case of concomitant plantar tarsometatarsal (Lisfranc) and 1st and 2nd metatarsophalangeal (MTP) joint dislocations and fracture of the neck of the third metatarsal bone which has never been reported before. The plantar dislocation of the Lisfranc joint was treated by open reduction and fixation with K-wires; the dislocations of the MTP joints and neck fracture of the third metatarsal bone were treated by closed reduction and percutaneous fixation with K-wires and immobilized with a plaster cast. At the 5 year follow-up examination, our patient had no complaints, but the radiograph showed degenerative changes of the Lisfranc and the 1st MTP joint.

Management of Lisfranc's fracture-dislocation

Lisfranc's joint injuries are rare and complex. A car driver who sustained a traffic accident, was admitted because of partial dorsolateral fracture-dislocation of the Lisfranc's joint. The diagnosis was made by physical examination and radiographs. Reduction and pin fixation were performed under general anesthesia. At the end of the ninth month, range of motion of the foot and ankle was full, with no pain on daily activities.

Lesser metatarsophalangeal joints: standard MR imaging, MR arthrography, and MR bursography--initial results in 48 cadaveric joints

PURPOSE

To delineate the normal magnetic resonance (MR) imaging anatomy of the lesser metatarsophalangeal (MTP) joints in a cadaveric model and compare the MR arthrographic and MR bursographic findings with the standard MR imaging findings.

MATERIALS AND METHODS

T1-weighted spin-echo MR imaging of 48 lesser MTP joints of 12 cadaveric feet was performed. The specimens were subsequently evaluated with MR arthrography, MR bursography, or both examinations. Musculoskeletal radiologists evaluated standard MR images to determine the normal appearances of the joint structures, especially the fibrous capsule, plantar plate, and collateral ligament complex (CLC). Signal intensity, morphology, joint thickness, relationships with adjacent structures, and best plane for analysis were analyzed. The contrast material-enhanced (ie, arthrographic and bursographic) MR imaging findings were compared with the standard MR imaging findings.

RESULTS

The coronal plane was best for simultaneous depiction of the fibrous capsule, plantar plate, and collateral ligament complex and for assessment of the relationship between the CLC and the plantar plate. The sagittal plane was best for analysis of the bone attachments of the plantar plate and the transverse plane for evaluation of the CLC attachment sites in the phalanges. MR arthrography enabled identification of the bare areas and recesses of the joints, better delineation of the plantar plate articular surface, and better evaluation of the integrity of the soft-tissue components of the joints. Compared with the other examinations, MR bursography did not help improve these evaluations.

CONCLUSION

MR imaging is an excellent examination for delineating the anatomy of the lesser MTP joints. Compared with standard MR imaging, only MR arthrography helps improve visualization of the fibrous capsule, plantar plate, and CLC of the lesser MTP joints.