Citations

The objective documentation of foot function before and after therapeutic intervention will be greatly enhanced by the utilization of devices capable of measuring dynamic foot pressure distribution. Efforts to develop this technology date back to the late 19th century, but only with recent advances in computers has it been possible to produce quantitatively accurate high resolution foot pressure distribution with high sampling rates and easily interpreted graphic displays. Over the years, a variety of methods have been employed to study foot pressure. Many of these techniques have already improved our understanding of the foot and its function, and have had an impact on the way we practice. Effective clinical utilization of these new investigative tools depends on an understanding of their scientific basis, capabilities and limitations.

Radiographs were studied of 91 feet in 62 patients with the diagnosis of bunionette and no prior bunionette or hallux valgus operations. Various radiologic measurements were compared to a matched control group with no bunionette symptoms or previous forefoot operations. The bunionette group had a significantly increased metatarsophalangeal 5 angle, intermetatarsal 4–5 angle, and intermetatarsal 1–2 angle compared to the control group. Bunionettes were not commonly associated with lateral bowing of the fifth metatarsal or with an increased fifth metatarsal head width. Symmetry was noted between symptomatic and opposite asymptomatic feet, with the exception of an increased intermetatarsal 4–5 angle in the symptomatic feet.

Symptomatic talocalcaneal coalition can be treated surgically by either excision of the coalition or arthrodesis. The arthrodesis may be talocalcaneal, talonavicular and calcaneocuboid, or include all three joints (triple arthrodesis). Arthrodesis is indicated in talocalcaneal coalition when there is persistent pain, particularly if it is associated with deformity or degenerative changes. Arthrodesis that maintains normal contours of the foot, including its length and height, can be accomplished by the dowel technique described in this article.

Between 1978 and 1984, 20 adolescent patients underwent 35 chevron osteotomies of the first metatarsal for correction of painful hallux valgus. After an average follow-up of 64 months, 85% of the patients expressed overall satisfaction. The cosmetic effect was the most satisfactory result (90%), followed by relief of pain (85%) and lack of limitations in footwear (65%). Radiographic evaluation did not seem to correlate with the final clinical result. The chevron osteotomy is a reasonable operative procedure for correction of hallux valgus in adolescents.

When an ingrown toenail is unresponsive to simple treatment methods, surgical treatment options are available. At our institution, 100 patients with 142 affected toes were surgically treated by one of five techniques and observed for a mean of 9.7 years (range, 7.8 to 10.0 years). Plastic nail wall reduction was effective (four of four nail edges) for mild disease. After marginal nail excision with chemical matrix ablation, the recurrence rate was 20% (12 of 61 nail edges); eight required further surgical treatment. Marginal nail excision combined with surgical excision of the associated nail matrix (Heifetz procedure) was more successful: recurrence occurred in only 6% (6 of 95 nail edges), and only one toe required further surgical treatment. For severe nail deformity, nail ablation with matrix excision (Zadik procedure) was followed by recurrence in 33% (three of nine toes); all three required additional surgical treatment. After terminal amputation (Lapidus/Thompson-Terwilliger procedure), the recurrence rate was 12% (2 of 17 toes); only one nail required additional surgical treatment.

We reviewed the results of the Keller arthroplasty in combination with resection arthroplasty of the forefoot in patients with rheumatoid arthritis. Of the 29 patients (49 feet) in the series, 20 had involvement of both feet and nine had involvement of a single foot. The average age of the patients was 55.4 years, and the average follow-up period was 4.9 years. All feet had resection of the lesser metatarsal heads, resection of the base of the proximal phalanges of the lesser toe, and a Keller arthroplasty of the first metatarsophalangeal joint. The results were satisfactory in 16 feet, satisfactory with some reservations in 21 feet, satisfactory with major reservations in seven feet, and unsatisfactory in five feet. For 40 of the 49 feet (82%), the patients stated that they would repeat the procedure, knowing the results achieved. The major causes of patient reservations and lack of satisfaction were return of the hallux valgus deformity and pain (53%), forefoot instability (27%), and continuing metatarsalgia (20%). Resection arthroplasty of the lesser metatarsophalangeal joints of the forefoot in rheumatoid disease is a satisfactory procedure. When used in combination with Keller resection arthroplasty of the first metatarsophalangeal joint, however, an increased number of unsatisfactory results occur, attributable to returning pain and deformity of that joint.

Effective pain control following surgery is a concern. Oral narcotic agents may be effective yet have many side effects. Parenteral agents are impractical in outpatient procedures. Local blocks may distort tissue planes and require additional time and technical skill to administer. We have found that instillation of local anesthetic (0.5% bupivacaine [Marcaine, Sensorcaine]) into the wound prior to closure is a safe and effective means of providing significant reduction in postoperative foot pain.

In a review of the Mayo Clinic files, 17 biopsy-proven cases of metastatic tumors of the foot and ankle were found; 4 additional cases were considered to have metastatic disease on the basis of clinical and radiographic evidence but no histological confirmation was available. Lung, kidney, and colon were the most common sites of the primary tumors. The patients survived as long as 28 months after discovery of the metastasis. Treatment consisted of individualized combinations of orthotics, surgery, and radiotherapy to maintain mobility. In 9 of these 17 cases, no primary lesion was identified at the time the metastasis was diagnosed. Metastatic tumors of the foot present special problems in diagnosis and management.

Magnetic resonance imaging (MRI), a useful technique of studying soft tissues of the body, can be very effective in assessing the integrity of tendons. Usually a patient with a complete tear of the posterior tibial tendon has characteristic physical findings. In the patient presented, MRI demonstrated a complete disruption of the posterior tibial tendon, despite the absence of the commonly associated clinical findings. In view of the difficulties encountered with attempted tenography of the completely torn posterior tibial tendon, MRI provides a sensitive alternative diagnostic technique.

During a 4-year period, one of the authors (M.B.W.) performed 16 nerve reconstructions by interfascicular grafting in the lower extremities of 13 patients. Three patients were excluded from the study: one was lost to follow-up and two had less than 1-year follow-up. At an average follow-up of 30 months, the results of 13 procedures in 10 patients were evaluated. Results were good after five procedures, fair after five, and poor after three. Superior results were evident with shorter graft lengths and after nerve transection injuries.