Necrotizing fasciitis can be a devastating infectious process when diagnosis and early aggressive therapy is delayed. The etiologic factors that may play a role in or affect this necrotizing infectious process are reviewed. An interesting case is presented of bilateral, lower extremity, necrotizing fasciitis in a patient with diabetes mellitus, peripheral vascular disease and profound sensory neuropathy.
The authors discuss a recently described bone graft material substitute derived from sea corals. They briefly review its background leading to the potential for clinical use. Radiologic evaluation is provided, with attention directed to its characteristics, compared with other bone grafts.
Potentiation of narcotic analgesics with phenothiazines have been used for preoperative and postoperative analgesia for a number of years by the podiatric community. The agents most frequently cited in studies are the combination of meperidine with either the phenothiazines chlorpromazine, trimeprazine, or promethazine. Due to the fact that the double-blind clinical studies of pain are mainly subjective, and difficult to quantify, the usefulness of phenothiazines for the sole purpose of potentiation of analgesia is questionable, especially in view of the many side effects of this group of drugs.
During an Austin bunionectomy the potential exists for the head of the metatarsal to leave the sterile field and become contaminated. The authors present a case in which this occurred, with a 20-month follow-up. Possible options for decontamination are reviewed.
Podiatric physicians see great numbers of patients with vascular insufficiency of the lower extremities. Vascular disease may be the cause of their presenting complaints or may be an incidental finding recognized on routine podiatric examination. Each of these situations may require immediate attention. Vascular consultation therefore may be necessary in providing timely and appropriate medical care to podiatric patients. This manuscript discusses various surgical modalities for the treatment of peripheral vascular disease as well as complications inherent with each.
Allergies to metals as a cause of failure of joint prostheses has historically been a controversial issue. Loosening of a prosthesis may be due to trauma, infection of the surrounding area, or a faulty implantation of the device. However, cases of loosening of the device do occur without any history of the above criteria. This leads one to consider other explanations for this phenomenon, such as sensitivity of the tissues to one of the metals in the implant. The following presentation demonstrates that metal allergies are a surgical concern when considering joint prostheses, or internal fixation.
The authors present a case of Pfeiffer syndrome, which differs from the classic description. Treatment consisted of surgical correction of the unusual digital deformity. The literature is reviewed in regard to acrocephalosyndactyly and related congenital disorders and deformities.
In the evaluation of the distal articular orientation of the first metatarsal in hallux abducto valgus, one tool that can be employed is the radiographic measurement of the proximal articular set angle (PASA). Although it has been demonstrated that the inter-evaluator reliability of the measurement of PASA is suboptimal, the measurement may still retain usefulness. If intra-evaluator reliability is acceptable and the measurement is a valid predictor of the intraoperative condition, then the measurement retains clinical usefulness. The present study was designed to determine the intra-evaluator reliability of the measurement of PASA. Five evaluators were asked to make the measurement on five radiographs. Measurements were repeated approximately every 2 weeks until a total of 12 measurements on each radiograph were complied. A Chi-square distribution test of variance was utilized to analyze the data. The results demonstrated that the intra-evaluator reliability of the measurement of PASA was acceptable in three of the five evaluators, suggesting that some physicians can achieve satisfactory consistency in the measurement. It is unclear why the intra-evaluator reliability of the measurement of PASA is suboptimal for some physicians. Further study is required to address this issue, as well as the issue of the validity of the measurement.
Structural metatarsus adductus deformity may be corrected through the use of closing abductory base wedge osteotomies of all five metatarsals. Although technically demanding, surgical precision is increased through the use of oblique wedges and a combination of screw and cerclage wire fixation. In the severe case, an opening wedge osteotomy of the inner cuneiform (Fowler procedure), with homogenous bone implantation, may be concomitantly used. Both techniques are described in this brief case presentation.
Non-Hodgkin's lymphoma of the foot is a relatively uncommon pedal neoplasm. The authors discuss the etiology, incidence, histology, morphology, metastatic rate, and treatment of this entity. Non-Hodgkin's lymphomas rarely present as destructive lesions of bone; when they do, they usually involve the axial skeleton or proximal long bones. Additionally, the authors present a clinical case reporting findings of Non-Hodgkin's lymphoma after surgical correction of a hammertoe deformity and subungual exostosis. The pathologic microscopic evaluation of the resected bone assisted in diagnosis of this condition.
Leiomyosarcoma of the skin and subcutaneous tissue is a rare soft tissue neoplasm comprised of spindle-shaped smooth muscle cells. The statistical incidence of superficial leiomyosarcomas varies from 2.3% to 5.3% of malignant soft tissue tumors and from 4.0% to 6.5% of soft tissue sarcomas. Its occurrence in the foot is even more unusual. In a literature review extending from 1936-present, the authors have been able to locate only 12 known cases of leiomyosarcoma involving the foot and ankle. A presentation of the incidence, demographics of distribution, clinical characteristics, histopathologic features, prognosis, and treatment of leiomyosarcoma will be presented along with a unique case history involving a recalcitrant heel ulcer complicated by leiomyosarcoma.
The authors explain the sequential development of a bunion beginning with hallux abducto valgus, then hypertrophy of the dorsomedial tubercle, followed by proximal articular set angle adaptation. This manuscript emphasizes the importance of transverse plane motion and the pull of the tibial sesamoid metatarsal ligament, and adductor hallucis tendon in the formation of a bunion.
Periungual fibromas may be acquired lesions or they may be associated with tuberous sclerosis or von Recklinghausen's Disease. Such tumors are comparatively rare benign dermatological entities. Periungual fibromas associated with the posterior nail fold have a potential for inducing deforming nail deformity. Pain resulting from the growth is due to concentration of pressures which may be placed on the nail matrix and contiguous soft tissue structures. This is further complicated by compression developed within the toe box of the shoe. The preferred treatment in symptomatic cases is that of complete surgical excision of the entire lesion. The present study presents such a case, together with histopathological features of this type of growth, with special emphasis on the subcellular features of the neoplasm.
Joint distraction, whether manual or mechanical, is a common practice in orthopedic surgery for knee and shoulder arthroscopy and can be extrapolated to include ankle joint arthroscopy. Manual joint distraction involves manipulation of the ankle joint by gravity or manual traction applied by an assistant. Mechanical distraction can be achieved by joint infiltration with solution or a joint distractor. Although the use of a joint distractor in arthroscopy of the ankle is not a new technique, podiatric literature has rarely reported on its use to allow for easier access and implementation of arthroscopic instruments. The ankle joint distractor allows the surgeon to take advantage of pathologic ligamentous laxity, thus increasing the joint space from an average 3.4 to 7.8 mm.
This is a retrospective study of two different types of fixation for the offset-V modification of the Chevron (Austin) bunionectomy for correction of hallux abducto valgus deformity. Both screw fixation and Kirschner wire fixation were evaluated radiographically for hallux abductus angle, intermetatarsal angle, proximal articular set angle, tibial sesamoid position, and first metatarsal length. In addition, charts were reviewed for complications selective to each type of fixation. Radiographically, there was no apparent difference in preoperative and postoperative measurements between the two types of fixation. However, chart review led the authors to conclude certain advantages to screw fixation, in terms of clinical results and patient satisfaction.
The authors used magnetic resonance imaging (MRI) to evaluate the formation rate of avascular necrosis following performance of 20 modified Austin bunionectomies. Five modified McBride bunionectomies without first metatarsal osteotomy were also performed as an MRI control. Results showed an avascular necrosis formation rate of 50%. The majority of the avascular necrosis areas were found dorsally within the cancellous bone substance of the first metatarsal head. These lesions, in all cases, did not cause any patient disability or result in any decline in the degree of patient satisfaction. The MRI positive avascular necrosis evaluations do suggest potential problem areas with the surgical technique that may be eliminated through further modification of the classic Austin bunionectomy procedure.
