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.

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.

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.

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.

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.