Johnson, Kenneth A.

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.

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.

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.

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.

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.

Various radiographic measurements of the normal adult foot have been reported in both early and recent literature; however, a complete description of radiographic quantitative data has yet to be reported. The purpose of this study is to describe the range of the normal foot using standard radiographic techniques that can be applied to the clinical setting. This should provide the data necessary for the accurate interpretation of foot radiographs. This study demonstrates the wide variation in bony relationships of the normal adult foot. When certain recognized criteria of radiographic measurements were evaluated, some were found to be defined as too narrow or inaccurate. Most importantly, because of this wide range, surgical procedures to produce radiographic homogeneity are not indicated. Treatment should be directed specifically toward areas of pain and not radiographic appearance.

At the Mayo Clinic between 1950 and 1975, initial fusion of the interphalangeal joint of the great toe was attempted 166 times in 139 patients utilizing a Kirschner wire for stabilization. Follow-up examination of these patients disclosed an overall pseudarthrosis rate of 44%. Because of these disappointing results, a technique involving use of a longitudinal mini-cancellous bone screw was devised which provides increased stability and compression at the arthrodesis site. With this method, used 20 times in 18 patients, the pseudoarthrosis rate was decreased to 10%.