A prospective cohort study examining the association of claw anatomy and sole temperature with the development of claw horn disruption lesions in dairy cattle

Foot characteristics have been linked to the development of sole lesions (sole hemorrhage and sole ulcers) and white line lesions, also known as claw horn disruption lesions (CHDL). The objective of this study was to examine the association of claw anatomy and sole temperature with the development of CHDL. A cohort of 2,352 cows was prospectively enrolled from 4 UK farms and assessed at 3 time points: before calving (T1-precalving), immediately after calving (T2-calving), and in early lactation. At each time point body condition score was recorded, a thermography image of each foot was taken for sole temperature measurement, the presence of CHDL was assessed by veterinary surgeons, and an ultrasound image was taken to retrospectively measure the digital cushion and sole horn thickness. Additionally, at the postcalving time point, foot angle and heel depth were recorded. Four multivariable logistic regression models were fit to separately examine the relationship of precalving and postcalving explanatory variables with the development of either white line lesions or sole lesions. Explanatory variables tested included digital cushion thickness, sole horn thickness, sole temperature, foot angle, and heel depth. Farm, parity, body condition score, and presence of lesion at the time of measurement were also included in the models. A thicker digital cushion shortly after calving was associated with decreased odds of cows developing sole lesions during early lactation (odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.65-0.84). No association was found between digital cushion thickness and development of white line lesions. Sole temperature after calving was associated with increased odds of the development of sole lesions (OR: 1.03, 95% CI: 1.02-1.05), and sole temperature before and after calving was associated with the development of white line lesions (T1-precalving OR: 1.04, 95% CI: 1.01-1.07; T2-calving OR: 0.96, 95% CI: 0.93-0.99). Neither foot angle nor heel depth was associated with the development of either lesion type. However, an increased sole horn thickness after calving reduced the odds of cows developing sole lesions during early lactation (OR: 0.88, 95% CI: 0.83-0.93), highlighting the importance of maintaining adequate sole horn when foot trimming. Before calving, animals with a lesion at the time of measurement and a thicker sole were more likely to develop a sole lesion (OR: 1.23, 95% CI: 1.09-1.40), compared with those without a sole lesion. The results presented here suggest that white line and sole lesions may have differing etiopathogenesis. Results also confirm the association between the thickness of the digital cushion and the development of sole lesions, highlight the association between sole horn thickness and sole lesions, and challenge the potential importance of foot angle and heel depth in the development of CHDL.

An abattoir study of the prevalence of foot lesions and claw measurements in water buffalo in Egypt

BACKGROUND

Lameness has been associated with compromised animal welfare and reduced productivity in dairy cattle herds worldwide. However, little is known about the prevalence of claw lesions in the dairy buffalo population in Egypt. Furthermore, the optimum measurements for claw trimming in buffalo are unknown. A cross-sectional cadaver study was conducted where 135 pair buffalo hind feet were collected from 4 slaughterhouses and examined for the presence of claw lesions. The proportion and associated 95% confidence interval (CI) of each type of lesion were calculated. A separate set of healthy claws (n = 26) underwent ultrasonography (US) and computed tomography (CT). The agreement between US and CT measurements was assessed using Passing-Bablok regression and intraclass correlation coefficient. The CT measurements were used to calculate trimming recommendations.

RESULTS

At least one lesion was identified in 242 claws (89.6%, 95% CI = 85.4-93.0). In healthy claws, poor to moderate agreement was identified between US and CT measurements which could be due a sample size of the study. The average ± standard deviation (SD) minimum recommended external wall length of the lateral and medial claws in heifers was 7.1 ± 0.36 cm and 7.5 ± 0.35 cm, respectively. The average ± SD minimum recommended external wall length in buffaloes over five years of age was 8.2 ± 0.27 cm and 8.4 ± 0.39 cm for the lateral and medial claws, respectively.

CONCLUSIONS

The study found a high prevalence of claw lesions in buffalo in Egypt, the clinical significance of which requires further elucidation. Recommended measurements will help guide claw trimming in buffalo to minimise lesions.

Radiological features of arterial channels in the equine third phalanx measured using a novel customized software represent changes of laminitis

OBJECTIVE

To identify and measure radiolucencies at the solear margin of the distal phalanx in radiographs of healthy and laminitic hooves.

SAMPLE

Clinical records and dorsoproximal-palmarodistal radiographs of equine forelimbs with radiological diagnoses of either laminitis (n = 40, L) or navicular syndrome (n = 40, NS).

METHODS

Outlines of the radiolucent structures at the solar margin were drawn in ImageJ, and a customized novel plugin "Arteries Analyzer/ImageJ" was used for measurements. The diverging radiolucencies outside the terminal arc of the distal phalanx were differentiated as arterial channels (open at the solear margin) and ellipses (closed at the solear margin). Comparisons between L and NS, between distal phalanges with and without ellipses, and of arterial channels and ellipses in areas were compared using Wilcoxon and the Mann-Whitney U tests, respectively. The reliability and repeatability of the method were tested using Friedman's test.

RESULTS

Fewer arterial channels but more ellipses were identified in L than in NS. In phalanges with ellipses (n = 47), the number of ellipses and the number of arterial channels were negatively correlated (PCC -0.181, P = .224). The number of ellipses correlated positively with the severity of laminitis (PCC 0.495, P < .001; n = 80) and with the degree of rotation of the distal phalanx (PCC 0.392, P < .001; n = 80).

CLINICAL RELEVANCE

The software tool successfully measured arterial channels and ellipses outlined by the evaluators. Results indicate that healthy arteries develop into pathological ellipses in laminitic feet. This may be used to complement the interpretation of radiographs and support clinical decision-making.

Radiographic analysis of the dorsal hoof wall thickness in clinically normal draft horses

OBJECTIVE

To evaluate the radiographic thickness of the dorsal hoof wall in normal draft horse feet.

ANIMALS

33 adult draft horses with no history of laminitis, no clinically obvious lameness, and visibly unremarkable front feet were included.

METHODS

This was a prospective, descriptive study of clinically normal draft horses' front feet. Lateromedial radiographs were acquired of the front feet. A ratio of the dorsal hoof wall thickness to the length of the distal phalanx (DHWP3 ratio) was calculated.

RESULTS

The dorsal hoof wall thickness to length of the distal phalanx was calculated as 0.33 ± 0.03 (range of 0.28 to 0.39) in this population of draft horses.

CLINICAL RELEVANCE

With very few exceptions, the heterogeneous population of draft horses evaluated in this study had a DHWP3 ratio greater than previously published values in lighter breeds (< 0.30).

Comparing Clinical Examination and Radiological Evaluation in the Preoperative Diagnosis and Location of Symptomatic Interdigital (Morton's) Neuroma

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected preoperative clinical findings, radiological investigations, and postoperative outcomes. Sensitivity and positive predictive values were calculated and Z-score for 2 populations proportions was performed. One hundred fourteen consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common preoperative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (p value: <.001 and p value: <.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (p value: .005). Preoperative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Preoperative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound.

Emerging role of bone scintigraphy single-photon emission computed tomography/computed tomography in foot pain management

Foot and ankle joints being weight-bearing joints are commonly subjected to wear and tear and are prone to traumatic and other pathologies. Most of these foot and ankle pathologies present with pain. The diagnosis of pathology and localization of pain generators is difficult owing to the complex anatomy of the foot and similar clinical presentation. This makes the management of foot pain clinically challenging. Conventional anatomical imaging modalities are commonly employed for evaluation of any anatomical defect; however, these modalities often fail to describe the functional significance of the anatomical lesions, especially in presence of multiple lesions which is common in ankle and foot; however, hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) by virtue of its dual modalities, that is, highly sensitive functional imaging and highly specific anatomical imaging can serve as a problem-solving tool in patient management. This review attempts to describe the role of hybrid SPECT/CT in overcoming the limitation of conventional imaging and describes its potential application in the management of foot and ankle pain.

[Application value of imaging examination in the diagnosis of Muller-Weiss disease]

OBJECTIVE

To analyze radiological characteristics of Muller-Weiss disease, evaluate the clinical value of the imaging examination in diagnosis of Muller-Weiss disease.

METHODS

The imaging data of 26 patients with Muller-Weiss disease were collected from September 2015 to August 2020, including 7 males and 19 females, aged 43 to 68 years old with an average of (52.7±4.6) years old. In the X-ray examination observed the shape and position of the navicular bone. The talar-first metatarsal angle(TFM) was measured on the weight-bearing anteroposterior radiograph. The arch angle and angle between mid-axis of talus and mid-axis of the first metatarsal(Meary angle) were measured on the weight-bearing lateral radiographs. The morphology, density, adjacent joint space and position of the navicular bone were evaluated by computed tomography(CT), and magnetic resonance imaging(MRI) was used to observe the shape, signal, cartilage and surrounding soft tissue changes of the navicular bone.

RESULTS

Among 26 patients, 21 cases were unilateral and 5 cases were bilateral;X-ray examination showed that the lateral part of navicular bone of foot was compressed and flattened, showing"comma like"or"drop like", navicular moved to the medial side, partial fragmentation of bone, peripheral articular hyperplasia, uneven density and narrowing of relationship gap. According to Meary angle and deformity degree of the affected foot on the lateral X-ray of the load-bearing foot, Maceira staging was performed. There were 0 cases in stageⅠ, 2 cases in stage Ⅱ, 11 cases in stage Ⅲ, 9 cases in stage Ⅳand 4 cases in stage Ⅴ. CT examination showed bone fragmentation, medial displacement of navicular bone and formation of the talocalcaneal joint. MRI examination showed the irregular shape and uneven signal of navicular bone, narrowing of joint space, talocalcaneal joint surface hyperplasia and cartilage destruction, tarsal joint effusion and swelling of surrounding soft tissue.

CONCLUSION

Muller-Weiss disease has specific imaging manifestation, and an accurate diagnosis can be made based on the patient's age, gender, and clinincal history. Preoperative imaging examination can stage the disease, help clinicians to formulate better surgical plans, and postoperative imaging examination can better evaluate the surgical effect.

Sinus Tarsi Syndrome on Bone Scintigraphy With SPECT/CT: Spectrum of Findings

ABSTRACT

Sinus tarsi syndrome is a common cause of hindfoot pain in adults; however, diagnosis on planar bone scintigraphy can be challenging. We present 3 cases of sinus tarsi syndrome, review the spectrum of imaging findings associated with sinus tarsi syndrome, and show the key role that SPECT/CT can play in its diagnosis.

The Utility of SPECT/CT in Diagnosing Haglund Syndrome With Bone Scintigraphy

Haglund syndrome-the combination of Haglund's deformity, retrocalcaneal bursitis, and achilles tendinopathy-is a common cause of hind foot pain in adults; however, diagnosis on planar scintigraphy can be challenging. We present a case of Haglund syndrome and show the key role that SPECT/CT can play in its diagnosis.

Comparison of outcomes of arthrodesis and reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (Kidner procedure) in type 2 accessory navicula

BACKGROUND

The therapeutic outcome of the local arthrodesis surgery for type 2 accessory navicula (AN) is rarely reported. This study aimed to compare the clinical outcomes between Kidner and arthrodesis procedures for type 2 AN.

METHODS

Sixteen patients (20 feet) with symptomatic type 2 AN receiving surgical treatment in our hospital between November 2013 and December 2015 were retrospectively included. Ten patients (13 feet) underwent the Kidner surgery (Kidner group) and 6 patients received local arthrodesis procedure (arthrodesis group). Radiographic indices before/after surgery were compared between the two groups. Patient's satisfaction with surgery outcome was evaluated by patient self-assessment questionnaire.

RESULTS

The calcaneal pitch angle was significantly increased after surgery in both groups (bothp<0.01), while the talocalcaneal coverage angle and lateral talo-first metatarsal angle were not significantly changed after surgery. There was no significant difference regarding the postoperative changes in the three radiographic indices between the two groups. In the arthrodesis group, 3 patients (4 feet) had an excellent outcome, 2 patients (2 feet) a good outcome, and 1 patient (1 foot) had a fair outcome. In the Kidner group, 6 patients (8 feet), 2 patients (3 feet), 1 patient (1 foot) and 1 patient (1 foot) had excellent, good, fair, and poor treatment outcomes, respectively. The rate of good-to-excellent outcomes was comparable between the arthrodesis group and Kidner group (83% vs. 80%, p=0.696).

CONCLUSION

Our results suggested that both the Kidner surgery and arthrodesis surgery were an effective treatment for symptomatic type 2 AN.

Ultrasonographic alterations of bovine claws sole soft tissues associated with claw horn disruption lesions, body condition score and locomotion score in Holstein dairy cows

Claw Horn Disruption Lesions (CHDL) negatively affect the sole soft tissue structures located beneath the sole horn. The aim of the present study was to investigate the effect of CHDL on sole soft tissues by ultrasound means, correlating Body condition score (BCS), locomotion score and CHDL with ultrasonography evaluations of sole soft tissues in Holstein dairy cows. 100 Holstein dairy cows were enrolled in the study. BCS and locomotion score were assessed and functional trimming was performed on all animals. 84 healthy claws and 174 claws with solely one CHDL per claw were evaluated both clinically and with ultrasound, and CHDL were identified and recorded. Sole soft tissues thickness (mm) and echogenicity was determined, and ultrasonographic alterations, related to CHDL presence, where measured long their vertical (L1) and horizontal (L2) axis. Statistically significant (P < .001) differences were found in echogenicity between healthy claws and all the affected ones, with the healthy ones being mainly anechoic. Statistically significant (P < .001) differences were found for vertical (L1) and horizontal (L2) axis measures between the diverse CHDL, confirming ultrasonography as a useful tool to distinguish lesions and their extension by measuring L1 and L2. BCS had an influence both on sole soft tissues ultrasonographic appearance and on CHDL insurgency. These results confirm ultrasonography as a reliable tool for detecting an increase in sole soft tissues echogenicity, that was seen to occur with CHDL insurgency, and in determining lesion extension.

Relationship Between Sever Disease and Skeletal Maturity

BACKGROUND

Sever disease is a common condition in active, growing children. This condition presents as pain in the heel and is thought to be an overuse condition of the calcaneal apophysis. There are currently no defined radiographic diagnostic criteria for evaluation of Sever disease, with radiographs generally showing normal appearance of the calcaneal apophysis. A better understanding of the relationship of Sever disease and skeletal maturity may allow for improved interpretation of radiographs when trying to diagnose this condition.

METHODS

ICD-9 code 732.5 was used to search for patients diagnosed with Sever disease from 2007 to 2015 at a single hospital. For every patient with Sever disease with available calcaneal imaging within 40 days of diagnosis, heel x-rays were staged for calcaneal maturity score using a previously described calcaneal skeletal maturity assessment system. Controls matched by age, race, and sex were evaluated for calcaneal stage to compare with the Sever patients.

RESULTS

The chart review yielded 78 patients diagnosed with Sever disease by the orthopaedic attending, 39 of which have x-rays around the time of diagnosis. Calcaneal scores averaged 2.2±0.8 for all patients, 2.1±0.9 for male individuals, and 2.3±0.8 for female individuals. The average age for male individuals was 10.4±1.9 years and for female individuals, 9.2±2.2 years. The ages of diagnosis were similar for patients with and without x-rays. Twenty-two of 39 patients with Sever disease were calcaneal stage 2, and 37 of 39 were stages 1, 2, or 3. We calculated the absolute difference from stage 2 for the Sever and control groups. Mean difference from stage 2 was 0.51±0.68 for the Sever patients and 0.95±0.79 for control patients (P=0.01).

CONCLUSION

Sever disease occurs in a very narrow range of skeletal maturity, as measured by the calcaneal skeletal maturity assessment system and our observations with chronological age. When compared with age-matched and race-matched controls, stage 2 was seen more frequently in the Sever patients. If a child is not within calcaneal stages 1, 2, or 3, then a different diagnosis should be considered.

LEVEL OF EVIDENCE

Level III-retrospective case-control study.

Characterization of Foot Mycetoma Using Sonography and Color Doppler Imaging

BACKGROUND AND OBJECTIVE

Mycetoma of the foot, commonly referred to as Madura foot, is a chronic granulomatous infection, which impacts vascularization of the affected region. This study aimed to evaluate foot mycetoma using Doppler and sonography techniques to identify the principle sonographic features and blood flow patterns associated with the condition.

MATERIALS AND METHODS

This was a cross-sectional prospective single-center study conducted at the Mycetoma Research Center (MCR) in Khartoum State, Sudan. Sixty patients with Madura foot were examined using a Duplex ultrasound machine with a 7-10 MHZ linear probe. Data was analyzed using SPSS software. The distribution of demographic data was evaluated by simple descriptive statistics. Statistical tests was performed using Student's independent t-tests to compare different forms of mycetoma and Chi-square tests to examine differences in blood flow patterns between fungal (eumycetoma) and bacterial (actinomycetoma) forms of the infection.

RESULTS

The presence of multiple cavities and aggregated grains were more common in eumycetoma than in actinomycetoma. The echotexture was significantly more heterogeneous in eumycetoma than in actinomycetoma (p = 0.03). Eumycetoma had higher vascularity than actinomycetoma.

CONCLUSION

Mycetoma has characteristic sonographic features and patterns of vascularity, which are essential to differentiate between the fungal and bacterial forms of mycetoma.

Palmoplantar epidermoid cysts: two cases and brief review of the literature

Palmoplantar epidermoid cysts can range in clinical presentation from an asymptomatic slowly enlarging mass to a painful nodule. We report two cases: an epidermoid cyst on the sole and another on the palm. This article reviews the possible etiology, diagnosis, and prognosis of palmoplantar epidermoid cysts.

Partially thrombosed aneurysm of the medial marginal vein

Lower extremity superficial venous aneurysms are occasionally encountered by clinicians and are almost always located above the knee. Very few cases of aneurysm of the medial marginal vein in the most distal part, near the origin of the great saphenous vein, have been reported. We present a case of partially thrombosed aneurysm of the medial marginal vein, and briefly review the imaging characteristics and treatment options of this entity. Being aware of the existence of superficial venous aneurysms may help clinicians in their differential diagnosis of foot masses and choice of appropriate treatment.

The relationship of MRI findings and clinical features in symptomatic and asymptomatic os naviculare

AIM

To investigate the relationship between magnetic resonance imaging (MRI) findings and clinical features in patients with os naviculare.

MATERIALS AND METHODS

All patients with a foot or ankle MRI study showing an os naviculare were identified from a specialist orthopaedic hospital between 2014 and 2017. A total of 110 patients with 133 os naviculare were included. The MRI features were recorded, as well as the presence or absence of medial foot pain and/or tenderness over the navicular tuberosity. Fisher's exact test was used for categorical data and unpaired t-tests for continuous data. Specificity and sensitivity were calculated for MRI features.

RESULTS

There were 80 female and 30 male patients with a mean age of 46±1.7 years at time of MRI (range 11-90.6 years). There was a significant correlation between os naviculare oedema (p=0.008) and navicular tuberosity oedema (p=0.001) with a history of medial foot pain. There were significant associations between mean age (p=0.003), type of os naviculare (p=0.004), os naviculare oedema (p<0.001), navicular tuberosity oedema (p=0.001), and soft tissue oedema (p=0.01) with examination findings of tenderness over the navicular tubercle. Oedema of the os naviculare, navicular tuberosity, or soft tissues were found to have a high specificity but low sensitivity for medial foot pain and tenderness.

CONCLUSION

When present, certain MRI findings indicate that an os naviculare is likely to be a cause of patient symptoms, but when absent they do not exclude the possibility of it causing symptoms.

Effectiveness of Nonoperative Treatment of the Symptomatic Accessory Navicular in Pediatric Patients

BACKGROUND

Initial management of symptomatic accessory navicular in pediatric patients is nonoperative. However, efficacy of nonoperative treatment has not been studied or established. If nonoperative treatment is frequently unsuccessful or does not give lasting pain relief, surgery could be offered as first line treatment. This study retrospectively reviewed outcomes of pediatric patients treated nonoperatively for symptomatic accessory naviculae in an effort to provide clinicians success rates for their discussion of treatment options with patients and their families.

METHODS

A retrospective analysis of pediatric patients diagnosed and treated nonoperatively for a symptomatic accessory navicular bone at Cincinnati Children's Hospital Medical Center between dates August 1^st, 2006 and August 24^th, 2016 was performed. Outcome measures consisted of complete pain relief, partial relief without operative intervention, or need for operative intervention. Radiographic imaging for each patient was also used to identify the type of accessory navicular and presence of concurrent pes planus.

RESULTS

A total of 169 patients were included, with 226 symptomatic accessory naviculae. Average age at diagnosis was 11.8 years, with majority females (78%). Type 2 accessory naviculae were most frequent (72.7%), with Type 1 and Type 3 in 9.7% and 17.4%, respectively. Average number of nonoperative trials was 2.1, with 28% experiencing complete pain relief, 30% requiring surgical intervention, and 41% that experienced partial pain relief and did not require surgical intervention, and were recommended as needed (PRN) follow-up based on clinical improvement. Of those that achieved complete pain relief, the average length of non-operative treatment was 8.0 months.

CONCLUSIONS

The results of this study can be used by clinicians to frame discussions surrounding treatment options for symptomatic accessory navicular bones with both patients and their families.Level of Evidence: III.

Maximum standardized uptake value of foot SPECT/CT using Tc-99m HDP in patients with accessory navicular bone as a predictor of surgical treatment

Quantitative bone SPECT/CT (single-photon emission computed tomography/computed tomography) using Tc-99m hydroxymethylene diphosphonate is emerging as a useful imaging modality for skeletal diseases. Accessory navicular bone (ANB) has been evaluated by bone scintigraphy only qualitatively and semiquantitatively. However, a truly objective quantitative assessment of ANB is lacking. Here, we measured the maximum standardized uptake value (SUVmax) of the ANB and investigated its usefulness as an imaging biomarker for ANB.Consecutive quantitative bone SPECT/CT studies that had been performed on the foot were retrospectively analyzed. One hundred five patients (male:female = 44:61; median age = 32.0 [range, 11-81] years old; 31 negative controls without ANB and 74 patients with ANB [7 unilateral and 67 bilateral]) and their 210 feet were investigated. The ANBs were classified into types I, II, III (Geist classification), and 0 (contralateral navicular of unilateral ANB). Type II ANBs were subclassified into II-1 (with bony abnormality) or II-0 (without bony abnormality). The treatment modality was observation, conservative treatment, or surgical removal. The associations between the SUVmax and clinical findings, including surgery, were investigated.Patients with type II-1 ANB had the highest SUVmax among all ANB types (P < .001). The SUVmax of symptomatic ANB was greater than that for asymptomatic ANB (P < .001), and the SUVmax for the surgically resected ANB group was also significantly higher than that for the observation only or conservative treatment group (P < .001). Subtype II-1 had a significantly higher SUVmax compared with subtype II-0 (P < .001). Logistic regression analyses in type II ANB showed that young age (P = .020) and SUVmax (P = .031) were significant predictors for surgery. Receiver operating characteristic curve and survival analyses revealed an optimal SUVmax cutoff of 5.27 g/mL for predicting final surgical treatment.SUVmax derived from quantitative bone SPECT/CT was strongly associated with symptom, surgical treatment, and a known high-risk type of ANB. Risk stratification for final surgical treatment of ANB can be achieved using the SUVmax from quantitative bone SPECT/CT.

Accessory navicular syndrome as a cause of foot pain during stroke rehabilitation

Although usually asymptomatic, an accessory navicular bone can lead to medial foot pain, especially in younger people engaged in high impact sports. In many such cases, the tendon of posterior tibialis (which inverts and plantarflexes the foot) inserts onto the accessory bone resulting in greater strain on the tendon. In the present case, pain due to an accessory navicular bone first developed during stroke rehabilitation in a 69-year-old man. The relative overactivity of posterior tibialis in strokes involving the leg and overuse due to active rehabilitation were likely contributors. An accessory navicular syndrome should be considered as a cause of medial foot pain in patients following a stroke. As in our case, conservative management with rest, ice and elevation is usually successful.

Extra-tunnel Compression Mimicking Tarsal Tunnel Syndrome: Ultrasound Imaging for a Plantar Ganglion Cyst

We reported a 43-year-old man with right-foot numbness under the tentative diagnosis of tarsal tunnel syndrome. The initial ultrasound examination did not identify any remarkable findings at the level of the medial malleolus. Owing to the failure of conservative treatments, he was referred for US-guided injection of the tibial nerve. When tracking the entire course of the nerve, a ganglion cyst was observed on top of the tibial nerve, in proximity to the medial and lateral plantar branches. The symptom disappeared after surgical excision. The present case highlights the importance of sonoantomy and tracking of the entire course of affected nerve in peripheral nerve disorders and scout scanning prior to any perineural injections.

Spontaneous distal rupture of the plantar fascia

Spontaneous ruptures of the plantar fascia are uncommon injuries. They typically occur at its calcaneal insertion and usually represent a complication of plantar fasciitis and local treatment with steroid injections. In contrast, distal ruptures commonly result from traumatic injuries. We describe the case of a spontaneous distal rupture of the plantar fascia in a 48-year-old woman with a low level of physical activity and no history of direct injury to the foot, plantar fasciitis, or steroid injections.

Distal Tibia and Foot Involvement in a Patient With Waldenstrom's Macroglobulinemia

Bone lesions are a rare presentation in Waldenstrom's macroglobulinemia patients. Although lytic bone lesions and generalized osteoporosis have been described variably in literature on Waldenstrom's macroglobulinemia patients, distal long bone and foot involvement has not been described to our knowledge. We report a patient with Waldenstrom's macroglobulinemia with IgM monoclonal spike, plasmacytic infiltration of bone marrow, and symptoms of foot pain, and found to have distal tibia and foot involvement. The symptoms of bone lesions in our patient were significantly improved with radiation treatment. The possibility of distal involvement of long bones in a clinically relevant presentation should be kept in mind in these patients.

Plantar Fibromatosis and Other Fibroblastic and Fibrohistiocytic Soft Tissue Tumors of the Foot

Plantar fibromatosis, also known as Ledderhose's disease, is a benign fibroblastic disorder of plantar aponeurosis, more specifically the medial side of the foot arch. Magnetic resonance imaging (MRI) has an important role in the diagnosis, staging, and determining the deep extension found in advanced, aggressive forms of plantar fibromatosis, thereby guiding appropriate clinical and surgical management. This case report aims to provide radiologists and clinicians with simple guidelines for the differential diagnosis of the fibroblastic and fibrohistiocytic soft tissue tumors of the foot with the emphasis on the MRI findings. (Journal of Surgical Orthopaedic Advances 26(4):266-270, 2017).

Epithelioid sarcoma of the plantar fascia mimicking Morbus Ledderhose - A severe pitfall for clinical and histopathological misinterpretation

Plantar fibromatosis, also known as Morbus Ledderhose, is a well known and frequently encountered disorder of the planta pedis. When conservative treatment fails, surgical therapy with complete resection is the therapeutical procedure of choice. Soft tissue sarcoma is a heterogeneous and rare malignant disease of the musculoskeletal system with over 50 histopathological subtypes which can potentially arise in any localization but is most commonly found at the extremities. Here, we report the case of an epithelioid sarcoma of the sole of the foot which was initially and repeatedly clinically and histopathologically misinterpreted as plantar fibromatosis, receiving insufficient resection and subsequently ending in amputation of the lower leg.

The potential of ultrasonography in the evaluation of foot orthotics therapy

Foot orthotics prescription is based on the foot functioning paradigms with tissue stress theory being in avant-garde. The main goal of orthotic therapy is to reduce the internal tissue's pathological stresses in the foot structures. Traditionally, ultrasound scanning technique depicts anatomic related data of both common and uncommon pathology encountered in the clinical practice, helping in diagnosing, treating and evaluating, which are equally important for the practitioners. Its accessibility, compared to biomechanical modelling, makes this technique a valuable tool in the field of foot and ankle disorders. Despite its user-dependent limitation, the ongoing technical progress improves the ability of ultrasonography as a highly advanced procedure in musculoskeletal imaging, being also a valuable searching tool for musculotendinous mechanics or morphological changes as a result of a conservative intervention. The aim of the present work was to perform a review of the state of the art concerning the usefulness of ultrasonography in the study of foot orthotic therapy and to analyze its effectiveness.

Heel Pad Stiffness in Plantar Heel Pain by Shear Wave Elastography

The goal of the study was to evaluate the reliability of supersonic shear wave elastography in measuring heel pad stiffness and the change in heel pad stiffness in patients with plantar heel pain. In the reliability test involving 12 normal participants, each heel pad was tested six times in succession, and adequate reliability was reflected in the intraclass correlation coefficients (0.95, 0.93 and 0.96 for the microchambers, macrochambers and bulk heel pad, respectively). In the clinical assessment involving 20 normal participants and 16 unilateral plantar heel pain patients, diseased heel pads (86.8 ± 22.9, 36.8 ± 7.7 and 46.6 ± 10.9 kPa for the microchambers, macrochambers and bulk heel pad, respectively) were significantly stiffer than unaffected heel pads (66.8 ± 14.1, 25.2 ± 5.7, 34.2 ± 6.6 kPa) and those of normal participants (60.9 ± 11.4, 26.3 ± 6.1, 31.8 ± 6.3 kPa), suggesting that the heel pad with plantar heel pain was associated with loss of elasticity.

Radiographic characterization of ossification of the ungular cartilages in horses: 271 cases (2005-2012)

OBJECTIVE

To describe in detail the radiographic appearance of ossified ungular cartilages in horses and to evaluate the usefulness of a flexed dorsolateral-palmaromedial oblique (flexed oblique) radiographic view in evaluating the ungular cartilages.

DESIGN

Retrospective case series. Sample-Radiographs of 1,255 front feet of horses.

PROCEDURES

Ossification of the ungular cartilages was graded during evaluation of radiographs on a scale from 0 to 5; feet with cartilages with an ossification grade ≥ 2 were included (386 feet [271 horses]). The shape (straight, curved outward or inward, and dorsopalmar extension of ossification) was determined. The view on which abnormalities were best identified was documented. Abnormalities of the compact bone, radiopacity, trabecular architecture, compactospongious demarcation, and presence of radiolucent lines were recorded; grouped as modeling, adaptive changes, or both; compared with ossification grade, separate centers of ossification, mediolateral symmetry of ossification, shape, cartilage (medial or lateral), and foot (left or right); and tested for significant associations.

RESULTS

Fractures (n = 35) were most common in feet with cartilages with an ossification grade of 4 (18) or 5 (17) and were best identified in flexed oblique images, compared with more commonly recommended images. Multivariable logistic regression showed a significant positive association of ossification grade with modeling or adaptive changes; feet with cartilages with an ossification grade of 4 (OR, 11.59; 95% CI, 6.52 to 20.60) or 5 (OR, 72.90; 95% CI, 25.32 to 209.90) were more likely than those with an ossification grade of 2 or 3 to have modeling or adaptive changes. Abnormally shaped cartilages were more likely to have modeling or adaptive changes, compared with normally shaped cartilages (OR, 4.90; 95% CI, 1.94 to 12.42).

CONCLUSIONS AND CLINICAL RELEVANCE

Extensive ossification and the presence of inward or outward curvature as well as palmar curvature or a bulbous shape were significant risk factors for modelling and adaptive changes. Flexed oblique images provided clinically useful information, including detection of abnormal shape and fractures, that may not be evident on other currently recommended images. Such images are recommended for complete radiographic appraisal of ossified ungular cartilages of the foot in horses.

Distribution of technetium-99m PEG-liposomes during oligofructose-induced laminitis development in horses

Liposomes are phospholipid nanoparticles used for targeted drug delivery. This study aimed to determine whether intravenous liposomes accumulate in lamellar tissue during laminitis development in horses so as to assess their potential for targeted lamellar drug delivery. Polyethylene-glycol (PEG) coated liposomes were prepared according to the film hydration method and labelled using (99m)Tc-hexamethyl-propylene-amine-oxime. Six horses received 10 g/kg oligofructose via nasogastric tube to induce laminitis, and four control horses received water via nasogastric tube. All horses received 300 µmol (99m)Tc-PEG-liposomes (5.5 GBq) plus 5.5 µmol/kg PEG-liposomes by slow intravenous infusion. Scintigraphic imaging was performed at 0, 6 and 12 h post-infusion. Technetium-99m liposome uptake was measured in regions of interest over the hoof, fetlock and metacarpus. At the study end-point horses were euthanased, tissue samples collected and tissue liposome levels were calculated as the percentage of the injected dose of (99m)Tc-liposomes per kilogram of tissue. Data were analysed non-parametrically. All horses receiving oligofructose developed clinical and histological signs of laminitis. Technetium-99m liposome uptake in the hoof increased with time in laminitis horses (P = 0.04), but decreased with time in control horses (P = 0.01). Technetium-99m liposome levels in lamellar tissue from laminitis horses were 3.2-fold higher than controls (P = 0.02) and were also higher in laminitis vs. control skin, muscle, jejunum, colon, and kidney (P < 0.05). Liposomes accumulated in lamellar tissue during oligofructose-induced laminitis development and demonstrated potential for targeted lamellar drug delivery in acute laminitis. This study provides further evidence that lamellar inflammation occurs during laminitis development. Liposome accumulation also occurred in the skin, muscle, jejunum, colon and kidneys, suggesting systemic inflammation in this model.

[Arthrodesis for patients with rheumatic arthritis of the ankle and hindfoot. A reasonable option?]

BACKGROUND

Ankle and hindfoot deformities as well as degenerative changes are often found in patients with rheumatological diseases. They often suffer from severe pain and complain of increasing immobility. Corrective procedures with ankle or hindfoot arthrodesis are promising options.

OBJECTIVES

This article presents epidemiological data and describes the clinical aspects, diagnostics and treatment options for patients with ankle and hindfoot osteoarthritis.

MATERIALS AND METHODS

The retrospective results of 56 patients after ankle or hindfoot arthrodesis are presented.

RESULTS

After an average follow-up of 52 months the majority of results were good or excellent with relief of pain and reconstruction of the function of the foot.

CONCLUSION

Ankle or hindfoot arthrodesis represents a promising option for patients with severe osteoarthritis and can safeguard patients from increasing immobility.

Enthesopathy of the lateral cord of the plantar fascia

The objective of this study was to raise awareness of the diagnosis of enthesopathy of the lateral cord of the plantar fascia (LCPF) and describe its sonographic findings. We conducted a retrospective case series of 13 sonographic examinations with the diagnosis of LCPF enthesopathy. Two cadaver dissections of the plantar foot were performed for anatomic correlation. Sonographic findings of LCPF enthesopathy included generalized or focal hypoechoic thickening, loss of the normal fibrillar echo texture, cortical irregularity of the fifth metatarsal tuberosity, and vascularity on color Doppler imaging. Anatomic dissections of the plantar foot detailed the course of the LCPF and served as a guide for optimal sonographic imaging. Enthesopathy of the LCPF is an important etiology of nontraumatic pain at the base of the fifth metatarsal. Sonographic evaluation can readily show the characteristic findings of LCPF enthesopathy.

Atherosclerotic coronary plaque in subjects with diabetic neuropathy: the prognostic cardiovascular role of Charcot neuroarthropathy--a case-control study

The aim of this study was to investigate the severity of coronary artery disease (CAD) and the plaque composition in neuropathic type 2 diabetic subjects with and without Charcot neuroarthropathy (CN) undergoing multidetector computed tomography coronary angiography (MDCT-CA). The study was a single-center, observational, with unmatched case-control design. We selected 17 CN patients and 18 patients with diabetic neuropathy (DN) without CN. In all the patients, multidetector computed tomography was performed to assess the coronary artery calcium score (CACS) and degree of coronary artery stenosis. Patients were classified as positive in the presence of significant CAD if there was at least one stenosis >50 % on MDCT-CA. The invasive coronary angiography was performed in case of significant stenosis detected with MDCT-CA, both as reference to standard and eventually as treatment. Groups were matched for age, sex, and traditional CAD risk factors. As compared to DN individuals, CN exhibited higher rates of significant coronary stenoses (p = 0.027; OR 7.7 [1.3-43.5]). However, no significant differences were observed in the CACS, which reflects plaque burden, in the two groups (p = 0.759). No significant differences were observed comparing CACS distribution in all subjects for stenosis higher/equal or lower than 50 % (p = 0.320). Finally, no significant differences were observed comparing CACS distribution in CN and DN subjects for coronary stenoses higher/equal or lower than 50 %. Our results suggest that CN patients have a higher prevalence of severe coronary plaques compared to DN patients. Nevertheless, coronary plaques in CN patients did not exhibit an increased degree of calcification.

Surgical treatment of symptomatic accessory navicular in children and adolescents

Although an accessory navicular (AN) is present in approximately 10% of the population, it rarely is symptomatic, and few cases necessitate operative intervention. When symptoms require surgical treatment, excision of the AN, with or without advancement of the posterior tibial tendon, usually is successful. We reviewed our records to evaluate the outcomes and complications of surgical treatment of AN. Retrospective chart review identified patients younger than 18 who were treated surgically for a painful AN between 1991 and 2012. Medical records and digital images were reviewed to determine demographic information, duration of symptoms before surgery, type of AN, presence of flatfoot deformity, type of surgery, length of follow-up, outcomes, and complications. Twenty-seven patients (32 feet) had either isolated excision (14 feet) or excision plus tendon advancement (18 feet). Overall, 28 (87.5%) of feet had excellent or good functional outcomes. There was no significant difference in outcomes between the 2 procedures, though there was a trend toward more complications and more reoperations after tendon advancement.

Sonographic evaluation of plantar hindfoot and midfoot pain

Plantar hindfoot and midfoot pain is a common orthopedic condition. Plantar fasciopathy is the most common cause of plantar foot pain, and sonographic evaluation can easily show the characteristic pathologic changes. In addition, sonography is well suited to evaluate other potential causes of plantar foot pain. We present a review of the sonographic findings of plantar fasciopathy and other potential causes of plantar hindfoot and midfoot pain.

Osteoarthritis of the foot: a review of the current state of knowledge

Foot osteoarthritis(OA)is very common disease that mainly affects older people deeply influencing their quality of life.The join most frequently involved in the articular degenerative process is the first metatarsophalangeal joint. Its severe impairment may lead to a specific clinical pattern known as hallux rigidus that often requires surgical treatment.Currently conventional radiograms of feet associated with an accurate clinical examination should be performed in order to diagnose foot OA.However, new imaging modalities as ultrasonography and magnetic resonance imaging are emerging as valuable tools to assess foot OA.Therapeutic options for foot OA consist of conservative strategies, including life-style modification and pharmacological treatment, options that are usually adopted in early-stage disease and in invasive surgical procedures reserved to late-stage conditions. At the present time there is a lack of evidence in international literature specifically dealing with foot OA, so further investigation on this topic is required to clarify its pathogenesis, the diagnostic pathway and the best clinical management.

[Excision of accessory navicular with reconstruction of posterior tibial tendon insertion on navicular for treatment of flatfoot related with accessory navicular]

OBJECTIVE

To analyze the excision of accessory navicular with reconstruction of posterior tibial tendon insertion on navicular for the treatment of flatfoot related with accessory navicular and to evaluate its effectiveness.

METHODS

Between May 2006 and June 2011, 33 patients (40 feet) with flatfoot related with accessory navicular were treated. There were 14 males (17 feet) and 19 females (23 feet) with an average age of 30.1 years (range, 16-56 years). All patients had bilateral accessory navicular; 26 had unilateral flatfoot and 7 had bilateral flatfeet. The disease duration ranged from 7 months to 9 years (median, 24 months). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-midfoot score was 47.9 +/- 7.3. The X-ray films showed type II accessory navicular, the arch height loss, and heel valgus in all patients. All of them received excision of accessory navicular and reconstruction of posterior tibial tendon insertion on navicular with anchor.

RESULTS

All patients got primary wound healing without any complication. Thirty patients (36 feet) were followed up 6-54 months with an average of 23 months. All patients achieved complete pain relief at 6 months after surgery and had good appearance of the feet. The AOFAS ankle-midfoot score was 90.4 +/- 2.0 at last follow-up, showing significant difference when compared with preoperative score (t=29.73, P=0.00). X-ray films showed that no screw loosening or breakage was observed. There were significant differences in the arch height, calcaneus inclination angle, talocalcaneal angle, and talar-first metatarsal angle between pre-operation and last follow-up (P < 0.01).

CONCLUSION

The excision of accessory navicular with reconstruction of posterior tibial tendon insertion on navicular is a good choice for the treatment of flatfoot related with accessory navicular, with correction of deformity, excellent effectiveness, and less complications.

Ultrasound of the ankle and foot in rheumatology

In the last years musculoskeletal ultrasound (US) has become a very useful imaging tool for the evaluation of rheumatic patients and a natural extension of the clinical examination of the ankle and foot. Musculoskeletal US allows the evaluation of the symptomatic and asymptomatic ankle and foot with a detailed analysis of a wide range of elementary lesions at the level of different anatomical structures and their distribution in early or long standing disease. In inflammatory pathology, it helps in the assessment of the disease activity and severity at the joint, tendon or entheseal level and in the detection of subclinical pathological features in early disease or residual activity after therapy. Moreover, US guided procedures allow accurate diagnostic and therapeutic interventions. It is a valuable imaging method that can be also used in the follow up of the treated patients (systemic and/ or local therapies or surgical procedures), being a patient friendly, non-invasive, and quick to perform method. The aim of this paper is to review the US technique of scanning and the indications of US in the analysis of the ankle and foot in rheumatic diseases.

Recurrent eccrine poroma with malignant transformation and bony involvement of the foot: a case report and review of the literature

OBJECTIVE

Eccrine poroma is a benign appendage tumor showing either eccrine or apocrine differentiation. However malignant transformation of this tumor is very rare. The present report demonstrated a case of the eccrine poroma with malignant transformation and its rarity in terms of its high degree of recurrences and its aggressiveness with bony invasion.

CASE REPORT

A 67-year old female had a mass on plantar surface of 4th-5th intermetatarsal area of her left foot for 10 years with three recurrent episodes following excisions at local hospital with no pathological report. She was referred to our institute. A recurrent tumor was removed again with pathological findings as eccrine poroma with incomplete excision; however; the patient had a failure to follow-up. Four years later; she was back in our center again with 5th episode of recurrent tumor which was marginally excised with pathological findings revealing a malignant transformation of eccrine poroma with close resected margins. Unfortunately, the patient failed to follow-up again. Eventually, four years later she returned to our institute with 6th recurrent episode of tumor. Incisional biopsy was performed with pathological findings as appendage tumor with eccrine differentiation. Wide resection including removal of 5th metatarsal head-and-neck was performed due to aggressive behaviors of this tumor; particularly; history of malignant findings and multiple recurrences, significantly bony invasion. Final pathologicalfindings were malignant eccrine poroma with close resected margin. There were no metastases in evidence from all investigations. Local irradiation with the aim of eradication of microscopically residual tumor was initiated.

CONCLUSION

Malignant transformation is a rare occurrence of eccrine poroma. It should be initially included in differential diagnoses, especially in a patient with long standing foot lesion or history of recurrent masses. Wide excision is recommended as basis treatment, especially in a patient with high likelihood of recurrences or positive malignant transformation.

Ultrasound imaging for the rheumatologist XXXVI. Sonographic assessment of the foot in gout patients

OBJECTIVES

This study aims to investigate the relationship between clinical and US findings together with the prevalence and distribution of US findings indicative of monosodium urate (MSU) crystal deposition within the foot in patients with gout.

METHODS

A total of 50 patients with gout attending the in-patient and the out-patient clinics of the Rheumatology Departments were prospectively enrolled in this multi-centre study. Multiplanar examination of the following 15 joints was performed: talo-navicular, navicular-cuneiform (medial, intermediate and lateral), calcaneo-cuboid, medial, intermediate and lateral cuneiform-metatarsal, cuboid-4th metatarsal, cuboid-5th metatarsal and all five metatarsophalangeal (MTP) joints.

RESULTS

The following US findings were indicative of gout: enhancement of the superficial margin of the hyaline cartilage, intra-articular tophus, and extraarticular tophus. In 46 patients, a total of 1380 foot joints were investigated. In 1309 joints that were not clinically involved, US detected signs indicative of joint inflammation in 9% (121/1309). Talo-navicular joint and the first MTP joint were the joints in which the highest number of US findings were found at mid-foot and fore-foot, respectively. At MTP joint level, dorsal scans allowed the detection of a higher number of US findings indicative of joint inflammation, and MSU crystal deposits rather than on the volar plane.

CONCLUSIONS

This study demonstrated that US detected a higher number of inflamed foot joints than clinical examination, and that the first MTP and the talo-navicular joints were the anatomic sites with the highest prevalence of US signs of MSU crystal aggregates.

Ultrasound imaging for the rheumatologist XXXV. Sonographic assessment of the foot in patients with osteoarthritis

OBJECTIVES

The aims of our study were to investigate the prevalence of ultrasound (US) abnormalities in the foot of patients with osteoarthritis (OA) and to compare them with clinical findings.

METHODS

Consecutive patients with foot OA were investigated by clinical and US examinations. Bilateral US of the midfoot and forefoot joints was performed by using a Logiq9 machine, equipped with a multi-frequency linear probe, operating at 14 MHz; in addition, power Doppler was applied (frequency 7.5 MHz; gain 50%; PRF 750 Hz). Clinical evaluation included the registration of demographic data, disease duration, current treatment undergone, joint swelling and tenderness. US study included the assessment of both inflammatory (joint effusion, synovial hypertrophy, local pathologic vascularisation at PD, big-toe bursitis) and structural (osteophytes, MTP joints subluxation) abnormalities.

RESULTS

One hundred patients were studied. At midfoot level, clinical examination demonstrated signs suggestive for joint inflammation (tenderness and/or swelling) in at least one joint in 43/200 feet (21.5%) of 23 patients; US showed inflammatory abnormalities in 87/200 feet (43.5%) of 63 patients and structural lesions in 100/200 feet (50%) of 70 patients. At forefoot level, clinical examination found inflammatory signs in at least one joint in 128 feet (64%) of 64 patients; US showed inflammatory abnormalities in at least one joint in 176 feet (88%) of 88 patients and structural lesions in 189 feet (86%) of 86 patients.

CONCLUSIONS

US is a useful imaging tool for analysing both inflammatory and structural damage lesions at foot joints level in OA. In addition, it demonstrated to be more sensitive than clinical examination in the detection of inflammatory abnormalities.