Citations

A late complication of fracture with dislocation involving the tarsometatarsal joints of the foot (Lisfranc fracture) is progressive degenerative arthritis and pain. A dowel-graft arthrodesis technique is described that uses percutaneous bone graft from the iliac crest supplemented by crossed-wire fixation. The cases of 15 patients who underwent surgery between 1979 and 1982 in which this technique was used were reviewed retrospectively. These patients suffered from painful posttraumatic degenerative arthritis after tarsometatarsal joint fracture-dislocation. Follow-up evaluation (mean, 37 months) of 13 of the 15 patients demonstrated satisfactory pain relief in 11 patients, whereas 2 were dissatisfied. Complications included three instances of nonunion and one postsurgical reflex sympathetic dystrophy syndrome.

A series of 76 patients with 85 neurilemomas of the lower extremity was reviewed. The tumors were located throughout the lower extremity and had varied clinical presentations, which often posed problems in diagnosis. Pain, however, was a consistent symptom, and 63 (83%) of the patients presented with local or radiating (or both) pain. Electromyography was done in seven cases, but the results were abnormal in only two. When evaluating a painful mass or an atypical pain in the lower extremity, the clinician should have a high index of suspicion for neurilemoma.

Rupture of the Achilles tendon is a relatively infrequent injury that is often missed by the initial treating physician. The diagnosis can be established on the basis of the physical examination with weakness of plantarflexion, a palpable gap in the tendon, and a positive squeeze test. Special diagnostic studies are rarely necessary. In the majority of cases, the etiologic basis for the rupture appears to be a combination of intratendon degeneration and mechanical stress. Conservative treatment of an acute rupture by immobilization with a cast provides satisfactory results. For the younger, more athletic patient, surgical repair should be considered.

Forty-one patients with 42 involved feet received local care for neuropathic foot disease. Thirty-one patients had ulcers (nine with associated fractures), and 10 did not (eight with fracture and two with severe ligamentous injury). Patients were examined at least 1 year after initiation of treatment, and follow-up averaged 3 years (range, 1 to 9). Treatment included ulcer cleansing, debridement, local bone excision, molded plaster casts, and antibiotics for patients with significant infection. Most patients used special shoes. Of the 42 involved extremities, 39 (93%) healed with treatment, 21 extremities (50%) remained healed at follow-up examination, and 16 patients (39%) continue to have difficulty with recurrent foot ulceration or osteoarthropathy. Thirty-nine patients (95%) have avoided the need for a major amputation.

The diagnosis of diabetic neuroarthropathy of the foot can be difficult. A series of 96 patients (116 extremities) who had diabetes and peripheral neuropathy with bone and joint changes was reviewed. Typically, the patients were middle-aged or older, were taking insulin, and had had diabetes for more than 10 years. Retinopathy, nephropathy, and peripheral vascular disease were often present. There were abnormalities of vibratory sensation (94%) and of the gastrosoleus reflex (88%). The finding of specific radiographic abnormalities assisted but did not reliably differentiate neuropathy from infection. Three patterns of radiographic changes were noted: (1) at the metatarsophalangeal and interphalangeal joints, usually with underlying ulceration; (2) at the tarsometatarsal joints; and (3) in the anterior pillar-medial column of the foot, with talus, talonavicular, navicular, or naviculocuneiform destruction. Ulceration and infection in patients with patterns (2) and (3) were rare. When correlated, the demographic features, mode of presentation, physical signs, specific radiographic abnormalities, and patterns of change were distinctive and allowed the diagnosis of this complication of diabetes to be readily made.

Free skin flap transfer for foot salvage and reconstruction was done in 10 patients whose follow-up exceeded 1 year. Nine of the 10 had successful results, and generally all achieved the desired reconstructive goal in one stage, with a minimum of hospitalization and disability time. In using a free skin flap transfer in weightbearing locations, the need for cutaneous innervation of the flap should be considered, but such innervation is not necessary for success.

Microscopic evaluation of the interdigital neuroma is difficult because the appearance of the normal nerve has not been described precisely. In an effort to characterize the normal interdigital nerve, 104 nerves were removed at autopsy from the intermetatarsal spaces of 14 women who were more than 48 years old. A positive relationship between perineurial width and internal diameter of the nerve fascicle in web spaces 2, 3, and 4 was defined. In addition, the number and the diameter of blood vessels had a positive correlation in all web spaces. These measurements should be of help in the objective differentiation of the common interdigital neuroma from the normal interdigital nerve.

A surface replacement prosthesis for the first metatarsophalangeal joint has been designed to be used in arthritic conditions of this joint. The components are made of stainless steel and polyethylene and fixed with methylmethacrylate. The surgical details of insertion are important in such a complex, small joint. In the series of 20 patients (21 joints), the patient and physician satisfaction rate was 81% at an average follow-up period of 43 months (range 16 to 58 months). Current use of this prosthesis is most reasonable in older patients with painful degenerative arthritis of the first metatarsophalangeal joint and minimal joint imbalance.

If one were to characterize the clinical presentation of Reiter's syndrome in the feet and ankles, it would be that of pain associated with mild to moderate swelling and tenderness without significant erythema. These changes would occur most commonly at the posterior calcaneus, metatarsophalangeal joint, and phalangeal regions. The ankles will usually show an effusion. It is very uncommon for the subtalar region, midfoot region, or even the metatarsal shaft area to be involved. Roentgenographic changes were present in a similar frequency as in physical findings. Erosions and soft tissue swelling affect the forefoot and ankle while “spurring” and erosions affect the hindfoot. It is readily apparent that no single clinical finding or radiographic change indicates Reiter's syndrome. The type and location of foot pain is what should prompt the physician to seek further elements allowing the diagnosis of Reiter's syndrome.