Human amniotic membrane contains growth factors and cytokines that promote epithelial cell migration and proliferation, stimulate metabolic processes that lead to collagen synthesis, and attract fibroblasts, while also reducing pain and inflammation. Randomized studies have shown effectiveness of micronized dehydrated human amnion/chorion membrane (mdHACM) allograft injection in treatment of plantar fasciitis. We present our experience and short-term outcomes with using mdHACM injection as a treatment for Achilles tendinopathy.
Retrospective case series of patients with Achilles tendinopathy treated with mdHACM by a single physician. Participants had at least two follow-up visits within 45 days of mdHACM injection. Outcomes examined included change in reported level of pain during the 45-day observation period and treatment-associated adverse events.
Follow-up data were available for 32 mdHACM-treated patients. At treatment initiation, 97% of patients reported severe (66%) or moderate (31%) pain. At the first follow-up visit (mean ± SD of 8.1 ± 2.7 days postinjection), 27 patients (84%) reported improvement in pain levels, although 37% of patients continued to report severe (6%) or moderate (31%) pain. At the second follow-up visit (mean ± SD of 23.1 ± 6.2 days postinjection), no patients reported severe pain and one reported moderate pain. Within 45 days of mdHACM injection, complete symptom resolution was reported by 66% of treated patients (n = 21), with the remaining 34% (n = 11) reporting symptom improvement but not complete resolution. Two patients reported calf or quadricep pain or tightness after injection.
In our experience, mdHACM injection reduced or eliminated pain in all 32 patients with follow-up data.
Drop foot is a crippling condition that often requires surgical intervention to restore functional dorsiflexion. Although transfer of the posterior tibial (PT) tendon has been well described for the treatment of drop foot, there is no consensus on whether tendon transfers affecting the ankle joint sufficiently restore functional status for daily activities. In addition, most studies have focused on drop foot caused by peripheral nerve disorders. The purpose of this study was to evaluate the functional outcomes and patient satisfaction following PT tendon transfer for the correction of drop foot resulting from both peripheral and central neurologic causes.
Patients with drop foot who underwent a PT tendon transfer were followed for a minimum of 1 year and investigated retrospectively. Outcome measures included the American Orthopaedic Foot & Ankle Society ankle and hindfoot scoring system, a patient satisfaction questionnaire, postoperative ankle range of motion, and postoperative ambulatory status.
We evaluated 15 feet in 14 patients at a median follow-up of 50 months. The median postoperative American Orthopaedic Foot & Ankle Society ankle and hindfoot score was 85.0. Thirteen patients (92.9%) reported that they would undergo the procedure again. The median postoperative passive ankle dorsiflexion was 5.0°, and the median postoperative passive ankle plantarflexion was 30.0°. Thirteen patients (92.9%) were able to ambulate postoperatively. Ten (71.4%) ambulated without the use of an ankle-foot orthosis (AFO), and three (21.4%) ambulated with the use of an AFO. Overall, orthoses were able to be discontinued in 73.3% of the cases.
Our results suggest that the PT tendon transfer is an effective procedure for the treatment of drop foot that can improve the patient's functional status and ability to ambulate. The majority of patients were able to discontinue the use of their AFO postoperatively.
Crossing the barrier of an open physis by primary aneurysmal bone cyst is an exceptional phenomenon. We present a rare case of primary active aneurysmal bone cyst of the distal tibia in a 15-year-old boy in whom the lesion had crossed the open lateral distal tibia physis. The diagnosis was confirmed by radiographs, computed tomography, magnetic resonance imaging, and histopathologic findings. The lesion was successfully treated by extended curettage and allograft impaction. The patient was asymptomatic when last seen at 30 months.
Systemic lupus erythematosus is an autoimmune disorder that affects several organs and systems in the human body. Digital gangrene is known to be a rare and severe complication of systemic lupus erythematosus that could lead to amputation. We report a case of an adolescent who presented with an autoimmune disorder and multiple comorbidities and developed gangrenous toes.
Hallux valgus (HV) is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected. The relationship between the dome height of the first metatarsal head and the HV deformity has not been studied previously. This study aimed to investigate a possible relation of the dome height of the first metatarsal head with articular alignment and the hallux valgus angle (HVA), which is frequently used to evaluate HV.
A total of 129 feet of 68 patients were included in the study. Anteroposterior digital radiographic images of the foot taken in a weightbearing, standing position were used to assess the HVA, dome height, and shape of the first metatarsal head and the alignment of the MTP joint. The dome height of the first metatarsal head is the vertical distance from the base to the highest point of the articular surface doming. The alignment was categorized into three groups: aligned, deviated, and subluxated. Patients were assigned into three groups based on the HVA: Normal, Mild HV and Moderate HV.
A statistically significant, positive correlation was found between the HVA and the dome height of the first metatarsal head (r = 0.293, P = 0.001 and P < 0.05). The dome height was significantly lower in the patients with a normal HVA than those with a high HVA (P1 = 0.042, P2 = 0.039 and P < 0.05, respectively). The dome height of the first metatarsal head was found significantly higher in feet with subluxation, compared to feet aligned and deviated (P1 = 0.001; P2 = 0.0089 and P < 0.05, respectively).
Our study results suggest that HV deformity may be related to an increased dome height and the measurement of the dome height of the first metatarsal head might be used to evaluate an anatomic tendency toward HV development.
Plantar pressure plate instruments are commonly used in clinical practice and biomechanical analysis and are useful to establish a relationship between gait disorders and foot pressure. The aim of this study was to verify the reliability and repeatability of the Footwork pressure plate system for static and dynamic conditions.
Forty healthy adults, without apparent gait pathology, were recruited. For the static condition, participants were asked to stand static on the Footwork pressure plate for 5 sec in natural position (arms on either side of the body, feet shoulder-width apart in a comfortable angle, and looking ahead). For the dynamic condition, subjects were told to step five times with each foot on the plate following the three-step protocol. Both conditions were performed in two testing sessions spaced by 1 week.
Intrasession and intersession reliability for both conditions showed substantial to almost perfect intraclass correlation coefficient (ICC) values, and low coefficient of variation, low standard error measure, and low percentage error. Intrasession ICCs were 0.724 to 0.993 for static condition evaluation and 0.639 to 0.986 for dynamic condition evaluation. Intersession reliability ICCs ranged from 0.850 to 0.987 for the static condition and from 0.781 to 0.996 for the dynamic condition. Coefficient of variation values were below 8% in both cases and percentage error calculated from standard error measure were less than 10%.
The present work demonstrates that the Footwork plantar pressure plate system is a reliable instrument for collecting plantar pressures in static and dynamic conditions. Reliability data were higher for the static trials, probably because of the individual physiologic fluctuations, which are larger during dynamic gait. Reliability for intersession and average intrasession trials were higher than single-test reliability. The results from the present work can be used as a starting point for future research and to establish a basis for sample sizes for investigations that would use the Footwork platform.
Subungual exostosis (SE) is a benign, relatively uncommon bony growth underneath the nails of the distal phalanx of toes or fingers, with a majority on the toes. Clinically, it has two subvariants—protruded and nonprotruded growths from nail plates—which are treated differently. In this article, we report a case of protruded SE in a teenager with illustrative surgical excision. A 15-year-old boy presented with a painful growth on his right great toe of 6 months' duration. Physical examination revealed a 1-cm-diameter, solid, erythematous, rough, irregular growth penetrating through the skin along the dorsolateral nail bed of the right hallux with deformity of the lateral nail plate. Radiographs showed an elevated mass over the distal phalanx of the right lateral hallux. The mass was surgically excised and histopathologic examination confirmed the diagnosis of SE. The patient had no relapse or recurrence at follow-ups of 6 and 18 months. Subungual exostosis is a relatively uncommon bony growth in the toes. Radiography is favored for the diagnosis. Complete surgical excision is the optimal treatment, with rare recurrence. It needs to be differentiated from other bony lesions, including bizarre parosteal osteochondromatous proliferation, myositis ossificans, fibro-osseous pseudotumor, osteochondroma, and enchondroma.
Giant cell tumors are benign tumors that are locally aggressive and rare in the foot. Giant cell tumors involving bone in the foot have an incidence of 1.2% to 2.8%, whereas giant cell tumors of the tendon sheath constitute 3% to 5% of all giant cell tumors in the foot and ankle. We present a case of giant cell tumor of the soft tissue disguised as a giant cell tumor of bone in a healthy 29-year-old male patient. Through radiographic and magnetic resonance imaging evaluation, it was determined that this patient had a bone tumor invading the distal and proximal phalanges of his left great toe with the involvement of soft tissue. With the use of the evidence-based medicine and patient expectation, the decision was made to amputate the digit. To much surprise, when the histopathologic results were reviewed, it was determined that the excised lesion was consistent with giant cell tumor of soft tissue that did not involve the bone.
BACKGROUND:Diabetic foot ulceration is a severe complication of diabetes characterized by chronic inflammation and impaired wound healing. This study aims to evaluate the effect of a medical device gel based on Adelmidrol + Trans traumatic acid in the healing process of diabetic foot ulcers. METHODS: Thirty-seven diabetic patients with foot ulcers of mild/moderate grade were treated with the gel applied daily for 4 weeks on the affected area. The following parameters were evaluated at baseline and weekly: a) wound area, measured drawing a map of the ulcer then calculated with Photoshop6 tools, b) clinical appearance of the ulcer, assessed recording the presence/absence of dry/wet necrosis, infection, fibrin, neoepithelium, exudate, redness, granulation tissue. RESULTS: Topical treatment led to progressive healing of diabetic foot ulcers with a significant reduction of the wound area and an improvement in the clinical appearance of the ulcers. No adverse events treatment-related were observed. CONCLUSIONS: The results of this open-label study show the potential benefits of Adelmidrol + Trans traumatic acid topical administration to promote re-epithelialization of diabetic foot ulcers. Further studies need to confirm the observed results.
BACKGROUND: Normative studies on the Arch Height Index (AHI), Arch Rigidity Index (ARI), and arch stiffness have primarily focused on healthy populations, with little consideration of pathology. The purpose of this study was to create a normative sample of the aforementioned measurements in a pathological sample and to identify relationships between arch structure measurements and pathology. METHODS: AHI was obtained bilaterally at 10% and 90% weightbearing conditions using the Arch Height Index Measurement System (AHIMS). ARI and arch stiffness were calculated using AHI measurements. Dependent t-tests compared right and left, dominant and non-dominant, and injured and non-injured limbs. Measurements of the dominant foot were compared between sexes using independent t-tests. Relationships between arch stiffness and age, sex, and AHI were examined using the coefficient of determination (R2). One-way ANOVAs were used to determine differences between arch structure measurements and number of pathologies or BMI. RESULTS: A total of 110 participants reported either one (n=55), two (n=38), or three or more (n=17) pathologies. Plantar fasciitis (n=31) and hallux valgus (n=28) were the most commonly reported primary concerns. AHI, ARI, and arch stiffness did not differ between limbs for any comparisons, nor between sexes. Between subgroups of BMI and number of pathologies, no differences exist in AHI or ARI; however, BMI was found to have an impact on AHI (10%WB) and arch stiffness (p<.05). Arch stiffness showed a weak relationship to AHI, where a higher AHI was associated with a stiffer arch (R2=0.06). CONCLUSIONS: Normative AHI, ARI and arch stiffness values were established in a pathological sample with a large incidence of plantar fasciitis and hallux valgus. Findings suggest relationships between arch stiffness and both BMI and arch height; however, few trends were noted in AHI and ARI. Determining relationships between arch structure and pathology is helpful for both clinicians and researchers.