Foot biomechanics in patients with advanced subtalar- and mid-tarsal joint osteoarthritis and poorly responding to conservative treatment

BACKGROUND

A comprehensive insight into the effects of subtalar- and mid-tarsal joint osteoarthritis on lower limb's biomechanical characteristics during walking is lacking. Our goal was to assess joint kinematics and kinetics and compensatory mechanisms in patients with subtalar and mid-tarsal joint osteoarthritis.

METHODS

Patients with symptomatic and radiographically confirmed osteoarthritis of the subtalar and mid-tarsal (n = 10) and an asymptomatic control group (n = 10) were compared. Foot joint kinematics and kinetics during the stance phase of walking were quantified using a four-segment foot model.

RESULTS

During pre-swing phase, the tibio-talar range of motion in the sagittal plane of the patient group decreased significantly (P = 0.001), whereas the tarso-metatarsal joint range of motion in the sagittal plane was greater in the pre-swing phase (P = 0.003). The mid-tarsal joint showed lower transverse plane range of motion in the patient group during the loading response and pre-swing phase (P < 0.001 resp. P = 0.002). The patient group showed a lower Tibio-talar joint peak plantarflexion moment (P = 0.004), peak plantarflexion velocity (P < 0.001) and peak power generation in the sagittal plane (P < 0.001), and a lower mid-tarsal joint peak adduction and abduction velocity (P < 0.001 resp. P < 0.001) and peak power absorption (P < 0.001).

CONCLUSIONS

These findings suggest that patients with subtalar and mid-tarsal joint osteoarthritis adopt a cautious walking strategy potentially dictated by pain, muscle weakness, kinesiophobia and stiffness. Since this poorly responding population faces surgical intervention on the short term, we recommend careful follow-up after fusion surgery since biomechanical outcome measures associated to this post-surgical stage is lacking.

Quantifying increased lateral column instability in Adult Acquired Flatfoot Deformity (AAFD)

AAFD comprises ligamentous failure and tendon overload, mainly focused on the symptomatic posterior tibial tendon and the spring ligament. Increased lateral column (LC) instability arising in AAFD is not defined or quantified. This study aims to quantify the increased LC motion in unilateral symptomatic planus feet, using the contralateral unaffected asymptomatic foot as an internal control. In this case matched analysis, 15 patients with unilateral stage 2 AAFD foot and an unaffected contralateral foot were included. Lateral foot translation was measured as a guide to spring ligament competency. Medial and LC dorsal sagittal instability were assessed by direct measurement of dorsal 1st and 4th/5th metatarsal head motion and further video analysis. The mean increase in dorsal LC sagittal motion (between affected vs unaffected foot) was 5.6 mm (95% CI [4.63-6.55], p < 0.001). The mean increase in the lateral translation score was 42.8 mm (95% CI [37.48-48.03], p < 0.001). The mean increase in medial column dorsal sagittal motion was 6.8 mm (95% CI [5.7-7.8], p < 0.001). Video analysis also showed a statistically significant increase in LC dorsal sagittal motion between affected and unaffected sides (p < 0.001). This is the first study that quantifies a statistically significant increased LC dorsal motion in feet with AAFD. Understanding its pathogenesis and its link to talonavicular/spring ligament laxity improves foot assessment and may allow the development of future preventative treatment strategies.

Synovial Sarcoma of the Foot as an Atypical Cause of Persistent Metatarsalgia: A Report of 3 Cases

CASE

Three cases of atypical metatarsalgia are presented, all diagnosed with foot synovial sarcomas (SSs) at different stages of evolution, after a year of medical consultations. One case was treated with marginal excision without requiring bone excision; the second patient required amputation of the first ray; and the third patient, with advanced disease, required amputation through Chopart's joint.

CONCLUSION

Metatarsalgia is a recurrent reason for consultation in orthopaedics. Even so, patients with persistent symptoms should be studied further in depth. Computed tomography or magnetic resonance imaging can detect tumor pathology, such as SS, of insidious development.

[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.

Two stage surgical treatment of cuboid osteomyelitis. A case report and review of the literature

Isolated osteomyelitis of the cuboid bone is an extremely rare condition. A 32 year old man was evaluated for a painful and swollen right foot after a penetrating trauma and the presence of a sinus in the lateral aspect the midfoot. MRI findings were consistent with the presence of cuboid osteomyelitis. The patient underwent a two stage procedure which included partial excision of the cuboid bone, the use of a cemented spacer for lateral column length preservation, followed by arthrodesis of the calcaneocuboid joint with a tricortical autologous bone graft harvested from the ilium and preservation of the cuboid-metatarsal joints. At 4 years follow up, the patient is asymptomatic. Diagnosis of isolated cuboid osteomyelitis requires high clinical suspicion and a two stage procedure is an effective approach for symptomatic patients who do not respond to conservative treatment. LEVEL OF CLINICAL EVIDENCE: IV.

Charcot Arthropathy of Foot and Ankle: Radiographic and Clinical Patterns with Related Outcomes

PURPOSE

Our aim is to retrospectively review and evaluate the patterns of affection of Charcot arthropathy of foot and ankle.

METHODS

Two hundred twenty-eight patients (235 feet) with post-acute Charcot were reviewed and classified anatomically through plain radiographs into type I and type II based on single or multiple regions affected, respectively. Type I included ankle, Lisfranc (tarsometatarsal), naviculocuneiform, forefoot, and hindfoot which includes one of the following: talonavicular joint, calcaneocuboid joint, or calcaneus. Type II included peritalar, perinavicular, mid-tarsal Charcot, or any other combination. Both types were further classified into four stages (A, stable with no deformity; B, stable with deformity; C, unstable; and D, deformity/instability with associated mechanical ulcers).

RESULTS

The most common type was type IIC (27.2%) followed by type IID (18.3%), while types IA and IIA represented the least common types (3.4% and 3.8%, respectively). Types IA and IIA were managed conservatively. All patients in types IC, ID, IIB, IIC, and IID and the majority of type IB received fusion surgery to achieve stability and correction of deformity. Type II D had the highest complication rate (30%). Five patients ended up with amputation, and all were stage IID.

CONCLUSION

Affection of single region has better prognosis than affection of two or more regions. Stage A has the best prognosis and can be managed conservatively provided good diabetes control. Surgery is indicated in all cases of types IC, ID, IIB, IIC, and IID to achieve stability and correction of deformity and prevent complications. Mechanical ulcer (stage D) carries the worst prognosis and highest complication rate.

Giant Cell Tumor of Tendon Sheath with Tarsal Bones and Intertarsal Joint Invasion: A Case Report

The giant cell tumor of tendon sheath (GCTTS) is a benign lesion most commonly attached to the tendons and bones of the fingers, hands, and wrists. The involvement of GCTTS to the foot is uncommon. The GCTTS invading tarsal bones and intertarsal joints is not described yet, and the appropriate diagnosis and treatment remain unclear. We report a case of GCTTS with the involvement of tarsal bones and intertarsal joint. Computed tomography scan and magnetic resonance imaging were used to further diagnose and evaluate the quality and range of tumor. The patient was treated with surgical excision of the tumor without application of bone graft. After adequate clearance of the tumor, the patient returned to an asymptomatic walk in 3 months. No malfunction, fracture, or tumor recurrence was found in 2-years follow-up. This report includes clinical, radiologic, histologic diagnostic, and surgical challenges in an unexpected lesion and a review of the literature.

Clinical findings and diagnostic test results for calves with septic arthritis: 64 cases (2009-2014)

OBJECTIVE To describe clinical findings and diagnostic test results and identify potential prognostic indicators for calves with septic arthritis. DESIGN Retrospective case series. ANIMALS 64 calves with septic arthritis. PROCEDURES The medical record database for a veterinary teaching hospital was searched to identify calves ≤ 6 months old that were treated for septic arthritis between 2009 and 2014. Data evaluated included signalment, history, physical examination and diagnostic test results, treatment, and outcome. Descriptive data were generated, and calves were assigned to 2 groups (neonatal [≤ 28 days old] or postneonatal [29 to 180 days old]) on the basis of age at hospital admission for comparison purposes. RESULTS 64 calves had 92 infected joints; 17 calves had polyarthritis. Carpal joints were most frequently affected followed by the stifle and tarsal joints. Forty-nine bacterial isolates were identified from synovial specimens for 38 calves, and the most commonly identified isolates were catalase-negative Streptococcus spp (n = 14) and Mycoplasma bovis (9). Calves in the neonatal group had a shorter interval between onset of clinical signs and hospitalization and were more likely to have an infected carpal joint than calves in the postneonatal group. Outcome was positive for 35 calves. Synovial fluid total nucleated cell count was positively associated with a positive outcome. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that empirical antimicrobial treatment for calves with septic arthritis should target gram-positive catalase-negative cocci and M bovis and that synovial fluid total nucleated cell count might be a useful prognostic indicator.

Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot: a systematic review

BACKGROUND

Ankle arthrodesis traditionally has been regarded as the treatment of choice for many patients with end-stage ankle arthritis. However, a major reported risk of ankle arthrodesis is adjacent-joint degeneration. There are conflicting views in the literature as to the causative link between ankle arthrodesis and progression to adjacent-joint arthritis. Recent studies have challenged the causative link between arthrodesis and adjacent-joint arthritis, purporting that preexisting adjacent-joint arthritis is present in many patients. The aim of the present study was to systematically review the available literature to determine if there is sufficient evidence to support either hypothesis.

METHODS

A literature search of the EMBASE and PubMed/MEDLINE databases (1974 to present) was performed. A total of twenty-four studies were included for review. The studies were reviewed, and the relevant information was extracted, including research methodology, postoperative outcomes in the adjacent joints of the foot, and whether pre-arthrodesis radiographs and medical records were available for analysis.

RESULTS

The twenty-four manuscripts included eighteen clinical studies, five biomechanical studies, and one gait-analysis study. The majority of biomechanical studies showed altered biomechanics in the fused ankle; however, there was no clear consensus as to whether these findings were causes of adjacent-joint arthritis. In studies assessing clinical outcomes, the reported prevalence of subtalar joint arthritis ranged from 24% to 100% and the prevalence of talonavicular and calcaneocuboid arthritis ranged from 18% to 77%. Correlation between imaging findings of arthritis in adjacent joints and patient symptoms was not established in a number of the clinical studies reviewed.

CONCLUSIONS

There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. Similarly, a correlation between postoperative imaging findings and clinical presentation in this cohort of patients has not been conclusively demonstrated.

Isolated tuberculous osteomyelitis of the talonavicular joint without pulmonary involvement-a rare case report

Tuberculosis is one of the leading causes of death worldwide amongst curable diseases. It is estimated that one-third of the world's population has been diagnosed with tuberculosis infection [1]. The prevalence is on the rise with an estimated 9.4 million new cases per year worldwide [1]. Tuberculosis most commonly presents with pulmonary involvement. However, approximately 23-30% of patients found to be infected with tuberculosis have extrapulmonary symptoms [2]. Of those, only 1-3% have been found to have osseous disease. Skeletal involvement with a primary focus of tuberculosis usually affects major weight-bearing joints such as the hip and knee. Tuberculosis infections of the foot and ankle are very rare, accounting for 1% of all tuberculosis infections [2-4]. Difficulties arise in the timing of diagnosis, patient compliance of therapy and awareness of the less obvious presenting symptoms. Musculoskeletal tuberculosis, although rare, can be a problem. Its uncommon site, non-specific presenting symptoms and its ability to mimic numerous disorders make it more difficult to formulate a definitive diagnosis and, in turn, leads to therapeutic delays [5-7]. It is for this reason that we report this case in an effort to promote awareness.

Calcaneocuboid joint dislocation: a case report

Tarsal bone dislocation is a rare entity. It is usually undiagnosed in the emergency department. We present the case of a 44-year-old man who was diagnosed as having calcaneocuboid joint dislocation in the emergency department. The dislocation was reduced in the emergency department, and a below-the-knee cast was applied. Successful clinical and radiologic results were obtained during follow-up. In this case, unlike the previous reports in the literature, conservative management succeeded in the treatment of calcaneocuboid joint dislocation.

An unusual manifestation of osteoarticular tuberculosis: case report

Although osteoarticular tuberculosis is usually presented as monoarthritis of the large, weight-bearing joints (predominantly hip, knee or ankle joint), or in the form of spinal disease, it is rarely seen as oligoarthritis. In this article, we present case history of a female patient with tuberculous oligoarthritis of the right talocruraljoint and left talocalcaneal joint. A 77-year-old female patient was admitted to our department due to the symptoms of painful and swollen right talocrural joint and left talocalcaneal joint accompanied with fever, general weakness and night sweating. Laboratory findings, including erythrocyte sedimentation rate, whole blood count, liver and kidney functional tests showed no significant changes. Plain x-rays and magnetic resonance imaging of the affected joints showed demineralization, significant narrowing of joint space, erosions of articular surfaces, numerous calcifications, and ankylosis of both right talocrural and left talocalcaneal joint. Synovial biopsy confirmed the diagnosis of tuberculous arthritis. Our patient underwent triple tuberculostatic therapy with rifampicin, isoniazid and pyrazinamide, which resulted in the resolution of arthritis.

Charcot neuroarthropathy triggered and complicated by osteomyelitis. How limb salvage can be achieved

BACKGROUND

Charcot neuroarthropathy is a severe complication in the feet of patients with diabetes, which can lead to a major amputation. Osteomyelitis and surgery for osteomyelitis have been reported as trigger mechanisms of developing Charcot neuroarthropathy. However, the development of acute Charcot neuroarthropathy triggered by osteomyelitis during conservative antibiotic treatment is not well outlined in the medical literature.

CASE REPORTS

Two patients apparently developed mid and rear foot Charcot neuroarthropathy, which was clinically suspected while being treated with antibiotics for osteomyelitis. One of them presented osteomyelitis of the navicular bone and subsequently developed acute Charcot neuroarthropathy of the tarsometatarsal joints. The other presented calcaneal osteomyelitis with pathological fracture and developed Charcot neuroarthropathy of the transverse tarsal joint. No offloading had been implemented in either case. A major amputation had been indicated in both cases in their teaching hospitals. Limb salvage was achieved in both cases by means of surgery, culture-guided post-operative antibiotics, intraosseus instillation of super-oxidized solution, bed rest before placing a total contact cast and stabilization of the unstable foot with a total contact cast with an opening for checking the healing course and to detect any complications. The mechanisms of the development of acute Charcot neuroarthropathy in a patient with osteomyelitis are discussed.

CONCLUSIONS

Osteomyelitis in the feet of patients with diabetes and neuropathy may trigger the development of acute Charcot neuroarthropathy. Fractures and dislocated joints may subsequently become infected from the index focus, producing a severe infected and unstable foot that may require a major amputation. Limb salvage can be achieved in specialized departments.

Chopart fractures and dislocations

Fractures and dislocations of the midfoot and Chopart complex are among the most difficult foot injuries to manage. The treating surgeon is faced with a wide array of treatment challenges. Plain radiographs often grossly underestimate the extent of injury. The anatomy in this region of the foot is quite intricate with numerous articulations. Fractures can occur in isolation or as part of a more complex injury pattern. Misdiagnosis and under treatment can lead to severe alterations of both normal anatomy and function. This article discusses the rationales and techniques for treating these difficult injuries.

Lisfranc joint displacement following sequential ligament sectioning

BACKGROUND

There are two primary radiographic patterns of Lisfranc instability, transverse and longitudinal. There is no single diagnostic method with which to consistently confirm the diagnosis of an unstable injury. Our purpose was to define which ligament disruptions produce these two injury patterns and to compare the utility of weight-bearing and stress radiographs for detecting each pattern of instability.

METHODS

Ten fresh-frozen cadaveric lower extremities were dissected to expose the dorsal aspect of the midfoot. Radiographic markers were placed at the base of the second metatarsal and the distal borders of the first and second cuneiforms. The specimens underwent sectioning of the interosseous first cuneiform-second metatarsal (Lisfranc) ligament and were then divided into two groups. The transverse group underwent sectioning of the plantar ligament between the first cuneiform and the second and third metatarsals at the plantar aspect of the second cuneiform-second metatarsal joint, whereas the longitudinal group underwent sectioning of the interosseous ligament between the first and second cuneiforms. Weight-bearing, adduction, and abduction stress radiographs were made before and after each ligament was sectioned. The radiographs were digitized, and displacement was recorded. Instability was defined as >or=2 mm of displacement.

RESULTS

Weight-bearing radiographs made after the Lisfranc (first cuneiform-second metatarsal) ligament alone was sectioned were diagnostic (showed instability) for one of ten specimens. Abduction stress radiographs were diagnostic for two of five specimens, and adduction stress radiographs were diagnostic for zero of five specimens. In the transverse group (sectioning of the plantar ligament between the first cuneiform and the second and third metatarsals), weight-bearing radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens but were not diagnostic on the basis of second cuneiform-second metatarsal displacement for any of five specimens. Abduction stress radiographs were diagnostic on the basis of displacement of both the first cuneiform-second metatarsal and the second cuneiform-second metatarsal joints for five of five specimens. In the longitudinal group (sectioning of the interosseous ligament between the first and second cuneiforms), weight-bearing radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens and were diagnostic on the basis of displacement between the first and second cuneiforms for one of five specimens. Adduction stress radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens and were diagnostic on the basis of displacement between the first and second cuneiforms for four of five specimens.

CONCLUSIONS

Transverse instability required sectioning of both the interosseous first cuneiform-second metatarsal ligament and the plantar ligament between the first cuneiform and the second and third metatarsals. Longitudinal instability required sectioning of both the interosseous first cuneiform-second metatarsal ligament and the interosseous ligament between the first and second cuneiforms. Compared with weight-bearing radiographs, injury-specific manual stress radiographs showed qualitatively greater displacement when used to evaluate both patterns of instability.

Résultats à long terme du traitement du pied plat valgus de l’adulte par arthrodèse médiotarsienne

PURPOSE OF THE STUDY

Arthrodesis proposed for the surgical treatment of reducible pes planovalgus (flatfoot) in adults is designed to relieve pain and correct the deformity. The purpose of this work was to present the radiological and clinical results obtained with midtarsal arthrodesis performed in 22 cases of pes planovalgus.

MATERIAL AND METHODS

This study concerned 22 cases of reducible flatfoot (Johnson grade 2) in 19 patients (11 males, 8 females, mean age 43 years, age range 15-75 years). Clinical outcome was assessed in terms of pain, function and motion using the AOFAS and Mann classifications. Radiological assessment (loaded anteroposterior and lateral views with Méary cerclage) noted the Djian angle, talometatarsal alignment, talar slope, calcaneal slope, calcaneal valgus, and osteoarthritis stage in adjacent joints.

RESULTS

Mean follow-up was 7 years 4 months (range 6 months-20 years 3 months). Two nonunions resolved favorable after cancellous grafting. The Kitaoka score was 73.5/100 points (range 53-94). Pain and function improved from 2.8 to 1.1 points (/4 points) and from 3.45 to 1.6 points (/4) on the Mann scale. Flexion-extension remained unchanged. The foot was aligned correctly in 68% of cases. The mean talar slope and the talocalcaneal divergence were normal at last follow-up but there was a persistent undercorrection of the Djian angle in 68% of the feet and a break in the Méary line in 41%. Calcaneal valgus was reduced 6.6 degrees (16.6 to 10 degrees ) but the podoscope footprint was still the flatfoot type in 86% of the feet. For 50%, the neighboring joints presented progressive osteoarthritic degeneration. Subjectively the patients were very satisfied or satisfied with minor reservations for 73%. None of the patients was disappointed with the results. The objective outcome was excellent or good in 68% of the feet.

DISCUSSION AND CONCLUSION

The results in terms of pain relief, function, motion, complications, and rate of satisfaction were comparable with results presented in the literature. Midtarsal arthrodesis provides effective pain relief and satisfactory functional recovery without creating any morbidity greater than simple talonavicular fusion. Nevertheless, it was noted that while correct alignment is achieved in the majority of cases, the clinical and radiological restoration of plantar cavum is limited. Furthermore compensatory hypermobility of the adjacent joints leads to the development of moderate osteoarthritic remodeling which remains asymptomatic more than seven years after the operation.

Arthrotomy and arthrodesis in the treatment of complicated arthritis of the fetlock joint in adult cattle

One Galloway bull and three German Holstein-Friesian cows aged between three and five years with complicated arthritis of the fetlock joint were treated by arthrotomy (on the bull and two of the cows) or by arthrodesis (on the other cow). Arthrotomy involved four vertical dorsolateral/dorsomedial and palmolateral/palmomedial incisions 5 cm long to give access to the joint cavities and allow fibrin, debris and necrotic tissue to be removed. Arthrodesis consisted of lateral and medial (abaxial) horizontal 5 cm incisions along the joint space. After debridement, the joint surfaces (cartilage and superficial bone tissue) of the metacarpus and first phalanx were completely abraded with a high-speed surgical drill. The interdigital region, palmar and dorsal tendons, vessels and nerves were conserved during both arthrotomy and arthrodesis, and the pouches were flushed during the surgery. The incisions were sutured and a casting tape was applied. Six weeks later, the cast was removed and a supporting bandage was applied. Each animal received 10 mg/kg ampicillin subcutaneously twice a day from one day before surgery until a mean (sd) of 23 (4) days after the arthrotomies and 36 days after the arthrodesis. After a recovery period of at least one year, all the animals could be used without restrictions.

Rat hindlimb joint immobilization with acrylic resin orthoses

The objective of the present study was to propose an orthosis of light material that would be functional for the animal and that would maintain only the ankle joint immobilized. Male Wistar rats (3 to 4 months old, 250-300 g) were divided into 2 groups (N = 6): control and immobilized for 7 days. Rats were anesthetized with sodium pentobarbital (40 mg/kg weight) and the left hindlimb was immobilized with the orthoses composed of acrylic resin model, abdominal belt and lateral supports. The following analyses were performed: glycogen content of the soleus, extensor digitorum longus, white gastrocnemius, red gastrocnemius, and tibialis anterior muscles by the phenol sulfuric method, and the weight, fiber area and intramuscular connective tissue of the soleus by the planimetric system. Data were analyzed statistically by the Kolmogorov-Smirnov, Student t and Wilcoxon tests. Immobilization decreased glycogen in all muscles (P < 0.05; soleus: 31.6%, white gastrocnemius: 56.6%, red gastrocnemius: 39%, extensor digitorum longus: 41.7%, tibialis anterior: 45.2%) in addition to reducing soleus weight by 34% (P < 0.05). Furthermore, immobilization promoted reduction of the fiber area (43%, P < 0.05) and increased the connective tissue (200%, P < 0.05). The orthosis model was efficient comparing with another alternative immobilization model, like plaster casts, in promoting skeletal muscle alterations, indicating that it could be used as a new model in other studies related to muscle disuse.

Conservative Chiropractic Management of Recalcitrant Foot Pain After Fasciotomy: A Retrospective Case Review

OBJECTIVE

The objective of this study was to describe the safety and potential therapeutic benefit of joint mobilization and manipulation in the conservative management of patients with recalcitrant foot pain after plantar fasciotomy.

METHODS

The study design was a retrospective review of outcomes of 15 patients seen in a multidisciplinary office setting. All patients had undergone plantar fasciotomy within the 9 months before their admission and had developed lateral foot pain after operation. Each patient had exhibited suboptimal improvement with at least a 4- to 6-week trial of nonsteroidal anti-inflammatory drugs, shoe padding, and rest as prescribed by the attending podiatric surgeon. Manual therapy consisted of either grade III or grade IV joint mobilization and/or high-velocity, low-amplitude chiropractic manipulation to the affected joints in the foot and ankle, and home-based exercise. Outcome criteria were empirically defined as significant improvement, moderate improvement, or no change as assessed by each patient based on a verbal rating scale.

RESULTS

There was no long-lasting complication associated with any of the procedures, although a common pattern of transient pain migration over the dorsum of the foot into the ankle was noted in some patients; this resolved by the time of discharge. Of the patients with pain in the calcaneocuboid and/or fifth tarsometatarsal articulation, 11 noted significant improvement, 3 experienced moderate improvement, and 1 reported no change. Patients who complied with home care instructions responded better to therapy in most instances.

CONCLUSIONS

These preliminary findings suggest that joint mobilization and manipulation are safe conservative procedures to use in the treatment of patients with lateral column foot pain in status post plantar fasciotomy.

Die Korrekturarthrodese des Lisfranc-Gelenks nach fehlverheilten Luxationsfrakturen

Malunited fracture dislocations at the tarsometatarsal (Lisfranc's) joint regularly lead to painful deformities with severe functional impairment for the affected patients. Malunions result from initially overlooked injuries as well as from misjudged and inadequately treated injuries. Depending on the nature of the primary dislocation, either abduction or adduction of the forefoot will result, accompanied by a planus or cavus deformity. Corrective arthrodesis aims at axial realignment at the tarsometatarsal junction, and elimination of residual instabilities especially after pure ligamentous injuries. Fusion should be limited to the medial metatarsocuneiform joints if full realignment of all five metatarsals can be achieved with this procedure. A review of the literature revealed that corrective tarsometatarsal arthrodesis reproducibly leads to considerable pain reduction and functional improvement with patient satisfaction between 69% and 100%. Favourable prognostic factors are anatomic realignment and limited fusion of the first to third metatarsocuneiform joints.

Dorsal foot pain due to compression of the deep peroneal nerve by exostosis of the metatarsocuneiform joint

Podiatric physicians often encounter patients with dorsal foot pain related to either an exostosis or a ganglion arising at the junction of the first metatarsal and the cuneiform. Removal of the exostosis or ganglion is routine but may not relieve the pain. Exostosis surgery can result in worsening of pain owing to injury of the deep peroneal nerve. In this retrospective series, ten patients with dorsal foot pain-related exostosis or ganglion underwent measurement of the cutaneous pressure threshold of the skin of the dorsal first web space to determine whether compression of the deep peroneal nerve was related to their symptoms. The Pressure-Specified Sensory Device (Sensory Management Services LLC, Baltimore, Maryland) was used for this measurement bilaterally, and the results were compared with age-related normative data. Ninety percent of the patients had abnormal sensibility in the first dorsal web space. During surgery, each patient was noted to have a site of compression of the deep peroneal nerve by the extensor hallucis brevis tendon at the metatarsocuneiform exostosis. Patients with compression of the deep peroneal nerve had pain relief in the immediate postoperative period and have remained pain-free for a mean of 14 months (range, 1-22 months). Neurosensory testing can identify pain related to the deep peroneal nerve in patients with a dorsal exostosis or ganglion in this region.

Chemical arthrodesis of the distal tarsal joints using sodium monoiodoacetate in 104 horses

OBJECTIVE

To evaluate chemical arthrodesis using sodium monoiodoacetate for treatment of degenerative joint disease of the tarsometatarsal and distal intertarsal joints.

DESIGN

Retrospective clinical study.

METHOD

Horses were diagnosed with degenerative joint disease of one or more of the tarsometatarsal or distal intertarsal joints based on history, lameness examination, radiographic findings and, in some cases, response to intra-articular anaesthesia or medication. Intra-articular injections of sodium monoiodoacetate were performed using 23 gauge needles in the sedated, standing horse. Positive contrast arthrography of the distal intertarsal joint was performed in all horses to evaluate needle placement and the presence or absence of communication with other synovial structures. The mean intra-articular dose of sodium monoiodoacetate was 192 mg. Horses were subject to a graded exercise program commencing 7 to 10 days after treatment. Where possible, follow up lameness examination and radiography was performed at 3, 6, 12 and 24 months after treatment.

RESULTS

At 3, 6, 12 and 24 months after treatment, respectively, 0/57, 14/55, 41/50, and 29/34 of horses were sound. At 3, 6, 12 and 24 months after treatment, respectively, 5/55, 24/38, 26/30 and 18/18 of horses had radiographic evidence of ankylosis of treated joints. Post injection pain was marked in 6.7% of horses and significant complications requiring further treatment occurred in 3.8% of horses.

CONCLUSIONS

Chemical arthrodesis using sodium monoiodoacetate was an effective treatment method for degenerative joint disease of the distal tarsal joints. The technique was performed in the sedated standing horse and required minimal equipment. Results were comparable to those achieved following surgical arthrodesis. The risk of significant complications was minimised through good technique using an appropriate injection volume and concentration.

[Operative treatment of displaced talar neck fractures with absorbable lag screw]

OBJECTIVE

To study a new kind of operation for displaced talar neck fractures.

METHODS

From April 1996 to March 2001, 9 talar neck fractures were treated by internal fixation of absorbable lag screw with a medial approach and cut of medial malleolus to expose the fractures. A non-weight-bearing below-knee cast was applied for 6 to 12 weeks after operation. Once union of the fracture site is apparent, the patient should remain non-weight bearing in a removable short-leg and keep exercise every day.

RESULTS

All the patients received follow-up from 15 to 60 months with an average of 28 months. The fractures healed from 20 to 42 weeks. The excellent and good rate of function was 77.8% (7/9) according to American Orthopedic Foot and Ankle Society Score(AOFAS). One case had the complication of superficial infection of wound and skin edge necrosis after operation, which was Hawkins type III. Late complication included two cases of avascular necrosis(AVN). Among them, one AVN of Hawkins type II was caused by early weight-bearing five weeks after operation and gained the fair score. The other AVN of Hawkins type III was inefficient to conservative therapy and proceeded ankle fusion in the end. The AOFAS of the patient was bad.

CONCLUSION

Treatment of talar neck fractures by internal fixation of absorbable lag screw with a medial approach is an ideal method. It can gain a satisfactory result by the operation, strict postoperative care and rehabilitation.

[Case report: MRI findings in gout]

MR imaging is not routinely used for the evaluation of tophaceous gout. However, gout may have atypical clinical and radiologic findings. It should be considered in the differential diagnosis when a mass reveals heterogeneous and low signal intensity on T2 weighted images. We present MR imaging characteristics of gout tophi and arthritis in two patients.

New aspects of the tolerance of the antiseptic povidone-iodine in different ex vivo models

Investigating new possibilities for the application of 1% (v/v) iodophors, povidone-iodine (PVP-I) was better tolerated in the HET-CAM or explant test than 1% (w/v) silver nitrate or tetracycline. After application to the eye, at least 2.6% of used iodine were adsorbed. Therefore PVP-I is more effective than silver nitrate or erythromycin, meaning a possible alternative for the prevention of ophthalmia neonatorum. PVP-I is more active against methicillin-resistant Staphylococcus aureus (MRSA) in a human ex vivo skin model, which results in a complete eradication of S. aureus in the nasal cavity of volunteers after 2 daily applications and will be better tolerated by human nasal cilial epithelium than chlorhexidine. Having the same clinical tolerance as mupirocin, PVP-I is a useful alternative for the antiseptic therapy of germ carriers of MRSA. The synthesis of proteoglycans in articular cartilage of bovine sesamoid bones was increased after application of 5% (v/v) PVP-I without any increase in catabolism revealing possibilities for the use as irrigation solution in the joint.

The adult acquired flatfoot and spring ligament complex. Pathology and implications for treatment

This article reviews the anatomy of the spring ligament complex, the extent of ligament involvement in addition to the spring ligament, and implications for clinical reconstruction.

Lymph draining from foot joints in rheumatoid arthritis provides insight into local cytokine and chemokine production and transport to lymph nodes

OBJECTIVE

Rheumatoid arthritis (RA) is characterized by inflammatory reactions in joints and adjacent tissues unaccompanied by clinically evident changes in lymphatics and lymph nodes draining the inflamed areas. The explanation for this phenomenon, which contrasts with infectious processes in joints and soft tissues that evoke major changes in the lymphatic system, is unclear. To determine which inflammatory factors produced in the joints of RA patients are transported in lymph to lymph nodes, we measured levels of immunoglobulins, cytokines, and chemokines in prenodal lymph from the foot joints of RA patients and quantified their rate of transport to regional lymph nodes.

METHODS

Lymph was collected from the cannulated lymphatics draining the foot joints, tendons, fascia, and skin of 20 RA patients. Lymph flow rate and concentrations of proteins and immunoglobulins were measured. Cytokine and chemokine levels were quantified by enzyme-linked immunosorbent assays. Results were compared with those obtained in 20 control subjects.

RESULTS

In the cannulated vessel, the mean +/- SEM lymph flow rate in RA patients was almost 2-fold that in control subjects (22.6 +/- 3.2 ml/24 hours versus 13.2 +/- 1.1 ml/24 hours; P < 0.01). Lymph concentrations of total protein, IgG, and IgM were 1.80 +/- 0.14 gm/dl, 384 +/- 45 mg/dl, and 32.0 +/- 1.5 mg/dl, respectively, in RA patients and 1.66 +/- 0.14 gm/dl, 238 +/- 32 mg/dl, and 15.0 +/- 1.3 mg/dl, respectively, in control subjects. The corresponding lymph:serum (L:S) ratios were 0.21 +/- 0.02, 0.22 +/- 0.02, and 0.15 +/- 0.02, respectively, in RA patients and 0.22 +/- 0.02, 0.19 +/- 0.02, and 0.11 +/- 0.02, respectively, in control subjects. The L:S ratios of <1 and the absence of significant differences between groups suggested a lack of local production of immunoglobulins. In RA patients, lymph concentrations (in pg/ml) were as follows: interleukin-1beta (IL-1beta) 14.8 +/- 3.9, IL-6 511 +/- 143, tumor necrosis factor alpha (TNFalpha) 9.9 +/- 1.1, IL-1 receptor antagonist (IL-1Ra) 4,274 +/- 737, IL-10 13.3 +/- 4.4, IL-8 846 +/- 174, IL-15 6.2 +/- 0.9, granulocyte-macrophage colony-stimulating factor (GM-CSF) 2.30 +/- 0.15, vascular endothelial growth factor (VEGF) 80.4 +/- 8.6, and macrophage inflammatory protein 1alpha (MIP-1alpha) 171 +/- 34. In control subjects, these values were as follows: IL-1beta 1.50 +/- 0.25, IL-6 79.0 +/- 14.6, TNFalpha 4.4 +/- 1.1, IL-1Ra 208 +/- 52, IL-10 0.0, IL-8 216 +/- 83, IL-15 5.00 +/- 0.45, GM-CSF 0.40 +/- 0.05, VEGF 42.0 +/- 2.4, and MIP-1alpha 3.4 +/- 1.7 (P < 0.05 versus RA patients for all except IL-15). The L:S ratio was >1 in all RA patient samples for IL-1beta, IL-6, IL-1Ra, IL-8, GM-CSF, IL-10, IL-15, TNFalpha, and MIP-1alpha, indicating local production of cytokines. Great variability in lymph cytokine concentrations, presumably reflecting differences in the intensity of local inflammation, was not reflected in serum cytokine concentrations. Intravenously infused methylprednisolone decreased lymph cytokine levels to normal within 12 hours. In contrast, their concentrations in serum showed little or no change.

CONCLUSION

High lymph concentrations of cyto kines and chemokines, exceeding those in serum, were found in RA patients. The L:S concentration ratios of > 1 indicate the local production of these cytokines and chemokines in the inflamed tissues. High flow rates of lymph containing high cytokine concentrations through the regional lymph nodes are likely to affect node lymphocytes and dendritic cells. Analysis of cytokines in lymph should provide insight into events in inflamed tissues in RA and in regional lymph nodes.

Lateral premalleolar bursitis as a result of sitting on the foot

Lateral premalleolar bursitis develops on the dorsolateral aspect of the foot in people who sit on their feet for prolonged periods. Twenty-nine premalleolar bursae in 21 patients were diagnosed. The patients presented with one or more of the complaints of swelling, pain and difficulty in wearing shoes. One bursa was infected. Initial treatment was non-surgical. With avoidance of the sitting position, the problem resolved in eight of the sixteen patients who were followed. Four bursae were injected with cortisone, three without success. Six bursae were surgically excised, and four of them, with a minimum of one year follow-up were doing well.

[Congenital synostoses of the tarsus. Concept, classification, diagnosis and therapeutic approach]

The incidence of congenital tarsal coalition is about 1%. It is recognized as the main etiology of painful, rigid flatfoot in the pediatric population. Talonavicular (50%) and talocalcaneal (40%) coalition are the most common presentation. We must suspect a tarsal coalition in a child with mechanical pain and shoes deformity. Rigid and painful planovalgus deformity are found in physical exam which led to describe in the pass this entity as peroneal spastic flatfoot. Lateral and oblique (35 degrees-45 degrees) radiographs must be practice to observe the coalition. The presence of a beak in the head of the talus or a half moon condensation image as the result of the superposition of the talus over the calcaneus are commonly described. CT-scan is also useful to delineate the size of the coalition and its location. Resection of the bar is the surgical treatment of choice. Excision of the coalition and interposition of fat or a graft must be tried in young patients in order to preserve foot biomechanical properties and to avoid long term problems associated with arthrodesis. Triple arthrodesis or subtalar arthrodesis must be used in older patients with degenerative signs in radiographs or in those cases of multiple coalition or if resection has failed.

Articular cartilage. Anatomy, injury, and repair

Articular cartilage plays a vital role in joint morphology. An understanding of articular cartilage anatomy and physiology will enable the physician to more fully appreciate its function and necessity. Articular cartilage is made up of four basic biological layers or zones. Each zone possesses attributes necessary to make articular cartilage as a whole strong, durable, and more able to withstand shear and axial forces through a joint. Cartilage metabolism is relatively slow in comparison with other tissues; hence, it is much more difficult for defects in cartilage to heal spontaneously. There are many ways in which articular cartilage can incur damage. Mechanical injury, be it acute or insidious, causes cartilage to fissure and fracture. This results in painful and inflamed joints along with disruption of the cartilage. Metabolic diseases also can produce joint destruction, inflammation, and pain. The resultant defects fail to heal spontaneously because of slow metabolism of cartilage. These chondral defects eventually may penetrate subchondral bone. Disruption of the layers of cartilage eventually will cause collapse and loss of integrity of the entire joint apparatus as a whole. More than 250 years ago, Hunter stated, "Ulcerated cartilage is a troublesome thing--once [it is] destroyed it is not repaired." Articular cartilage defects are very difficult to repair effectively. Cartilage defects can heal spontaneously, if the defect extends to subchondral bone. The reparative substance, fibrocartilage, is less durable and much less smooth. There are many techniques and procedures in which chondral or osteochondral defects can be filled. Promoting subchondral bleeding is the method most commonly used clinically. This allows pleuripotent cells to fill the defect with eventual fibrocartilage. Implants are gaining favor as a method of inducing a more pure, hyaline-like cartilage into cartilage defects. Gene therapy and tissue engineering are at the forefront of cartilage research today. Cartilage injury and repair remains today a very difficult topic of study. Understanding the anatomy of articular cartilage, the pathomechanics of injury, and methods available for cartilage repair, will help the physician more adequately approach treatment options.

Charcot's foot

Charcot's foot used to be considered an unusual complication of diabetic peripheral neuropathy. With the current appreciation that approximately 25% of adult diabetics have an appreciable peripheral neuropathy, it is understandable that Charcot's neuro-osteoarthropathy has become recognized as a major problem for clinicians caring for diabetics. Differentiation from acute diabetic foot infection is the first challenge. Once Charcot's foot is identified, treatment generally involves immobilization during the acute inflammatory stage. When deformity develops, the orthopedic foot and ankle surgeon must decide whether accommodative care with a combination of inlay depth shoes, accommodative foot orthoses, and ankle-foot orthoses is adequate. If a plantigrade weight-bearing surface cannot be achieved, surgical stabilization or reconstruction requires rigid stabilization in a poor biomechanical environment using tools that are not designed for structures as small as the foot. The controversies presented to clinicians charged with care of this difficult patient population are as follows: 1. When to allow weight bearing in the acute phase of the disease process. 2. Whether prefabricated devices are as successful as the total contact cast in the acute phase. 3. Early surgical stabilization versus accommodation when deformity first develops. 4. Late reconstruction versus accommodation or amputation in the deformed late stages.

Current practice patterns in the treatment of Charcot foot

Treatment of Charcot foot osteoarthropathy has emerged as a major component of the American Orthopaedic Foot and Ankle Society (AOFAS) Diabetes 2000 Initiative. A two-part survey described treatment patterns and current footwear use of patients with Charcot osteoarthropathy of the foot and ankle. In the first part, 94 consecutive patients with a history of Charcot foot and ankle presenting for care were questioned on their foot-specific treatment and current footwear use. A history of diabetic foot ulcer was given by 39 (41%) patients, and an infection had been present in a foot of 20 (21%) patients. The initial treatment of the Charcot foot and ankle had been a total contact cast in 46 (49%) patients, and a pre-fabricated walking boot in 19 (20%). Charcot related surgery had consisted of 76 procedures in 46 (49%) patients. Sixty-three (67%) patients were currently using accommodative footwear (depth-inlay shoes in 46 [49%], custom shoes in 10 [11%], and CROW in 7 [7%] patients), and 72 (77%) were currently using custom accommodative foot orthoses. The second part of this study consisted of a questionnaire completed by 37 orthopaedic surgeons (members of AOFAS) interested in forming a Charcot Study Group. They treated an average of 11.8 patients having Charcot foot or ankle per month. Thirty (81%) used the Semmes-Weinstein 5.07 monofilament as a screening tool for peripheral neuropathy. For treatment of Eichenholtz Stage I, 29 (78%) used a total contact cast and 15 (41%) allowed weightbearing; for Stage II, 30 (81%) physicians used a total contact cast and 18 (49%) allowed weightbearing. Although the literature contains uniform recommendations for immobilization and non-weightbearing as treatment for the initial phases of Charcot arthropathy, the results of this benchmarking study reveal that currenl treatment is varied.

Clinical application of the modified medially-mounted motor-driven hip gear joint for paraplegics

PURPOSE

This paper describes a motor-driven orthosis for paraplegics which has been developed. This orthosis is composed of a medially-mounted motor-driven hip joint and bilateral knee-ankle-foot orthosis. With the gear mechanism, the virtual axis of the hip joint of this orthosis is almost as high as the anatomical hip joint.

METHOD

A paraplegic patient with an injury level of T10/11 walked using bilateral lofstrand crutches and this new orthosis with or without the motor system. The motor is initiated by pushing a button attached at the edge of the grab of the crutches.

RESULT

Faster cadence and speed and smaller rotation angle of the trunk was obtained in motor walking compared with non-motor walking. The patient did not feel fearful of falling.

CONCLUSION

The benefit of motor orthosis is that it can be used even in patients with lower motor lesions and that it provides stable regulation of hip flexion movement in spastic patients. In conclusion, this motor orthosis will enhance paraplegic walking.

[Injuries of the tibialis posterior tendon: diagnosis and therapy]

Complete traumatic rupture of the tibialis posterior tendon is absolutely rare. From the scarce case reports in the medical literature a extreme pronation-abduction or pronation-external rotation mechanism according to the Lauge-Hansen classification can be presumed, leading to a malleolar fracture because of forced pronation, external rotation and dorsiflexion of the foot. With primary suture the prognosis is favorable. Traumatic dislocations, mostly with luxatio pedis sub talo, are treated by atraumatic reduction and refixation of the retinaculum. Again, the prognosis is favorable. Incomplete traumatic rupture of the tibialis posterior tendon with development of posttraumatic pes plano valgus, according to case reports and our own experience result from severe pronation-external rotation-soft tissue injuries as well as with pronation-abduction or pronation-external rotation-type ankle fractures. In these cases no macroscopic rupture of the tendon is evident, however occult interstitial micro-ruptures can occur because of excessive stretching, which can be determined histologically. If conservative measures fail, a modified Evans osteotomy to lengthen the lateral foot column is indicated. Degenerative complete and incomplete ruptures of the tibialis posterior tendon are predominantly seen in women more than 42 years old. Staging of this entity can be achieved with clinical tests (muscular force, external rotation), ultrasound, weight-bearing x-rays, CT and MRT. According to the degree of decompensation of tendon function, treatment consists of augmentation, modified Evans procedure or triple arthrodesis of the hind-foot.

1999 Arthritis Survey. American Podiatric Medical Association

This report presents the results of analyses of statistical data from 1,114 members of the American Podiatric Medical Association (APMA) who responded to the 1999 Arthritis Survey, conducted from July through August 1999. The purpose of the survey was to determine the extent and methods of treatment of patients with arthritis of the foot or ankle by doctors of podiatric medicine.

The influence of birth weight, rate of weight gain and final achieved height and sex on the development of osteochondrotic lesions in a population of genetically predisposed Warmblood foals

The influence of inherent variables (sex, birth weight, final achieved height, monthly weight gain rates and osteochondrosis (OC) status of the parents) on the occurrence of osteochondrotic lesions in the femoropatellar and tarsocrural joints in a group of foals was investigated as part of a research project aimed at the study of the development of osteochondrosis and the influence of exercise on the development of the musculoskeletal system in Warmbloods. The foals were genetically predisposed to develop OC, being offspring of sires that all had radiographically proven OC in either the femoropatellar or the tarsocrural joint. In the mare population the incidence of femoropatellar OC was 16% and of OC in the tarsocrural joint 7%. Foals (n = 43) were weighed at birth, and thence every second week until euthanasia at 5 (n = 24) or 11 (n = 19) months. Height at the withers was taken twice, at birth and at euthanasia. Weight gain rates were calculated for months 1, 2, 3, 4, 5, 7, 9 and 11 and for the entire 5 or 11 month period. Osteochondrosis status of the parents in the 2 joints with respect to the distal tibial sagittal and lateral femoral trochlear ridges was determined radiographically. In all foals, radiographs were taken from the same sites prior to euthanasia. After euthanasia the joints were examined macroscopically and histologically for the presence of osteochondrotic lesions and classified as OC positive (OC+) or negative (OC-). No influence of sex on the prevalence of OC in either of the joints could be established. Also, no relationship between the prevalence of tarsocrural OC and any of the growth variables was found. Foals positive for femoropatellar OC had a significantly higher weight gain rate in the third and fifth month. Animals killed at 11 months that were OC+ in the femoropatellar joint had a significantly higher weight gain rate over the 11 month period, weighed more at 11 months, and were taller at the withers and at the croup than non affected animals. Offspring of tarsocrural OC- parents did not have a lower number of lesions in this joint than foals of which at least one of the parents was affected, but no foals that were offspring of femoropatellar OC- parents themselves showed lesions. It was concluded that, in this selected group, sex had no influence on the occurrence of OC lesions. Even in this relatively homogenous group weight gain rate affected the occurrence of lesions in the femoropatellar joint, but not in the tarsocrural joint. This corresponds with the different time-frames in which the lesions develop in the various joints and with the existence of windows of 'susceptibility'.

Benchmark analysis of diabetic patients with neuropathic (Charcot) foot deformity

During a 10-year period, 237 patients (129 women, 108 men) with a diagnosis of neuropathic (Charcot) arthropathy of the foot and ankle were treated in a tertiary care university hospital medical center. During this period, 115 of the patients (48.5%) were treated nonoperatively as outpatients with local skin and nail care, accommodative shoe wear, and custom foot orthoses. A total of 120 (50.6%) underwent 143 operations. Surgery included 21 major limb amputations, 29 ankle fusions, 26 hindfoot fusions, 23 exostectomies, and 23 debridements for osteomyelitis. It is widely accepted that patients with diabetes are at risk for developing foot ulcers, which can lead to lower extremity amputation. Within the population of diabetic patients, it is widely accepted that patients with neuropathic (Charcot) arthropathy of the foot and ankle have one of the highest likelihoods of having to undergo lower extremity amputation. The current emphasis in care of the foot of a diabetic patient involves a multidisciplinary team approach combining patient education, skin and nail care, and accommodative shoe wear. As data from prophylactic programs become available, resource allocation and cost of care can be compared with this benchmark baseline. This benchmark analysis can be used by those who are responsible for allocating resources and projecting healthcare costs for this "high utilization"/high risk patient population.

Pigmented villonodular synovitis of the foot and ankle: a review of six cases

Pigmented villonodular synovitis is a rare but well recognized proliferative lesion of synovial tissue. It has been most commonly described in the knee and hip, with most series reporting <5% occurrence in the foot and ankle. Six patients with pigmented villonodular synovitis of the foot and ankle that was treated between 1978 and 1997 were reviewed. Four of the patients had not been previously diagnosed, and two patients presented with recurrent disease. All six were women. Two patients' disease presented isolated to the ankle joint. The other four involved more than one joint: subtalar joint and midfoot in two, and the metatarsal region in two. The histology of the primary and recurrent lesions did not differ. The recurrent lesions were more diffuse and locally destructive. Five were found on magnetic resonance imaging to be a low-to-medium signal intensity mass on T1- and T2-weighted images. Surgical management ranged from simple excision to synovectomy to Lisfranc amputation. Average follow-up was 13 months (range, 3 weeks to 51 months). One of the lesions recurred 4 years later.

Pharmacologic management of the arthritic foot and ankle

The arthritides discussed are presented with many drug therapies because of a not fully understood and accepted cause of the disease process. Similarly, the drug therapies offered are diverse and have mechanisms that are not always fully understood. Because of the destruction and disability the arthritides are capable of and the realization that destruction may be reversible early in the course of the disease, physicians are initiating earlier, aggressive treatment with DMARDs. Long-term outcome studies of the early institution of DMARDs, combination therapies, and newer medications need to be evaluated to produce the most efficient treatment regimens.

Bone and joint manifestations of systemic infectious diseases

Bone and joint infections can occur as the consequence of a wide variety of systemic diseases. Disseminated fungal and mycobacterial infections, hepatitis, syphilis, gonorrhea, Lyme disease, and AIDS can all have osteoarticular manifestations. A thorough knowledge of the wide range of potential pathogens is key to establishing a correct diagnosis and instituting appropriate treatment.