Search Results
Pseudogout of the First Metatarsophalangeal Joint Associated with Hallux Valgus
An Atypical Bilateral Case
Calcium pyrophosphate dihydrate crystal deposition disease has various clinical features, and pseudogout is one of the six clinical forms. Chondrocalcinosis is the term used to describe the radiographic appearance of the disease. A review of the literature revealed that the appearance of this type of arthropathy in the foot is infrequent. We offer a review of the disease and report an atypical bilateral case of pseudogout in a patient 56 years of age without a history who presented with symptoms of arthritis localized in the first metatarsophalangeal joint associated with hallux valgus and was treated surgically. Radiographic evaluation of the feet did not reveal signs of chondrocalcinosis. The patient had no metabolic abnormalities, except for high uric acid values. Chemical analysis of the surgical samples demonstrated the presence of calcium pyrophosphate dihydrate crystals, confirming the diagnosis. We believe that arthropathy by deposition of calcium pyrophosphate dihydrate in the foot, although rare, must be considered in the podiatric physician’s differential diagnosis when a patient presents with articular pain in the foot associated or not with deformities. (J Am Podiatr Med Assoc 100(2): 138–142, 2010)
Radiologic Morphology of the Calcaneus
A Study of Radiologic Angles in a Pediatric Population
Background:
The Fowler-Philip, calcaneal pitch, and total calcaneal angles define the radiologic morphology of the rearfoot. We studied these angles in healthy adolescents.
Methods:
We studied 141 feet. Patients with inflammatory or traumatic injuries were excluded. The mean participant age was 11.5 years. The Fowler-Philip, calcaneal pitch, and total calcaneal angles were measured on lateral weightbearing radiographs. The statistics included descriptive, sample size (α=0.05 and β=0.20), the Student t test, and analysis of variance; P < .05 was considered significant.
Results:
The samples were 141 and 35 radiographs for the Fowler-Philip and calcaneal pitch angles, respectively. Ninety percent, 25.1%, and 97.4% of the adolescents had normal Fowler-Philip, calcaneal pitch, and total calcaneal angles, respectively. In addition, 9.9%, 74.9%, and 2.6% of the values were outside the reference ranges, respectively. The Fowler-Philip angle decreased and the calcaneal pitch angle increased significantly with age (P = .0005). The total calcaneal angle did not change with age (P = .65).
Conclusions:
The mean angle values in a pediatric population did not differ from those in adults. We found a high percentage of calcaneal pitch angles outside the reference range. Age influenced the Fowler-Philip and calcaneal pitch angles but not the total calcaneal angle. (J Am Podiatr Med Assoc 103(1): 32–35, 2013)
Background:
Forefoot varus malalignment is clinically defined as a nonweightbearing inversion of the metatarsal heads relative to a vertical bisection of the calcaneus in subtalar joint neutral. Although often targeted for treatment with foot orthoses, the etiology of forefoot varus malalignment has been debated and may involve an unalterable bony torsion of the talus.
Methods:
Forty-nine feet from 25 cadavers underwent bilateral measurement of forefoot alignment using adapted clinical methods, followed by dissection and measurement of bony talar torsion. The relationship between forefoot alignment and talar torsion was determined using the Pearson correlation coefficient.
Results:
Mean ± SD forefoot alignment was −0.9° ± 9.8° (valgus) and bony talar torsion was 32.8° ± 5.3° valgus. There was no association between forefoot alignment and talar torsion (r = 0.18; 95% confidence interval, −0.11 to 0.44; P = .22).
Conclusions:
These findings may have implications for the treatment of forefoot varus since they suggest that the source of forefoot varus malalignment may be found in an alterable soft-tissue deformity rather than in an unalterable bony torsion of the talus. (J Am Podiatr Med Assoc 102(5): 390–395, 2012)
Background:
Cole osteotomy is performed in patients having a cavus deformity with the apex of the deformity in the midfoot. Correction of the deformity at this midfoot level improves foot and ankle stability by creating a plantigrade foot. We retrospectively reviewed the clinical and radiographic results of six feet (five patients) that underwent Cole midfoot osteotomy (2011–2015).
Methods:
The patients had different etiologies (spastic cerebral palsy, burn sequelae, spina bifida, and Charcot-Marie-Tooth disease). Dorsal and slightly laterally based transverse wedge osteotomy through the navicular bone medially and the cuboid bone laterally was performed. Patients were under routine clinical follow-up. We evaluated clinical and radiographic results.
Results:
Mean clinical follow-up was 15.7 months (range, 6–36 months). The mean preoperative and postoperative talo–first metatarsal angles on lateral radiographs were 29.9° and 8.7°, respectively (P < .05) and on anteroposterior radiographs were 30.3° and 8.6° (P < .05). The mean preoperative talocalcaneal angle on anteroposterior radiographs increased from 19.2° to 29.8° postoperatively (P < .05). The mean postoperative calcaneal pitch angle change was 10.8° on the lateral radiograph (P < .05). At final follow-up, all five patients were independently active, had plantigrade feet, and were able to wear conventional shoes. The mean American Orthopaedic Foot and Ankle Society questionnaire score was 38.8 preoperatively and 79.5 postoperatively (P < .05). Only one patient did not have full bony union. Achilles tightness was seen in one patient.
Conclusions:
Cole midfoot osteotomy is a laboring procedure to correct adult pes cavus deformity with the apex in midfoot, although having some complication risks.
Background
We aimed to evaluate radiologic and clinical outcomes of ankle fractures involving posterior fragments that were fixed with a posterior plate by the posterolateral approach.
Methods
Sixty-five patients who were followed for at least 12 months and were older than 18 years were included. The posterior malleolus fractures were classified according to the Haraguchi classification system with computed tomography (CT). The posterior malleolus fragments were fixed with a plate through a posterolateral approach. Intra-articular step-off, reduction of the posterior malleolar fragment, and fibular position in the incisura were evaluated by early postoperative CT. American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analog scale pain score were used for clinical assessment.
Results
The posterior malleolus fractures were classified as Haraguchi type 1 in 45 patients (69.2%), Haraguchi type 2 in 12 patients (18.5%), and Haraguchi type 3 in eight patients (12.3%). No patients showed signs of instability or loss of reduction on direct radiographs during follow-up. Postoperative CT showed no loss of reduction in the posterior malleolus and tibiofibular alignment. On evaluation, there was no intra-articular step-off (<1) in any of the patients. The mean AOFAS score was calculated to be 91.6. The mean visual analog scale score was 1.2.
Conclusions
We conclude that direct posterior fixation with the posterolateral approach can be a good option for ankle fractures involving posterior malleolar fragments.
Contralateral Peak Plantar Pressures with a Postoperative Boot
A Preliminary Study
Background: Frequent use of walking boots in podiatric medicine often elicits patient complaints and sequelae from the imposed limb-length discrepancy. This study was designed primarily to determine whether peak plantar pressures are decreased in the contralateral foot when a moderately worn athletic shoe is worn opposite a high-calf walking boot and, if so, secondarily to determine whether a specialized surgical shoe worn on the contralateral foot can also effectively reduce this pressure. The pressure reductions were then compared to determine whether significantly greater plantar pressure reduction was provided by either the athletic shoe or the surgical shoe.
Methods: Participants without a foot abnormality walked on a treadmill in four footwear combinations: barefoot bilaterally, high-calf rocker-bottom sole (HCRB) walking boot/ barefoot, HCRB walking boot/athletic shoe, and HCRB walking boot/modified walking boot shoe. Measurements were taken with the participants wearing socks. Peak plantar calcaneal pressures were collected.
Results: Peak plantar pressures under the calcaneus opposite the HCRB walking boot were significantly reduced from barefoot pressures when either an athletic shoe or the modified walking boot shoe was worn. However, no significant difference was seen when comparing the reduction by the athletic shoe with that by the modified walking boot.
Conclusions: Wearing an athletic shoe on the foot opposite an HCRB walking boot reduces calcaneal pressures; however, wearing a modified device with structural properties of an HCRB walking boot sole is no better than an athletic shoe at reducing peak calcaneal pressures. (J Am Podiatr Med Assoc 101(2): 127–132, 2011)
True Pathologic Abnormality versus Artifact
Foot Position and Magic Angle Artifact in the Peroneal Tendons with 3T Imaging
Magnetic resonance imaging is a commonly ordered examination by many foot and ankle surgeons for ankle pain and suspected peroneal tendon pathologic abnormalities. Magic angle artifact is one of the complexities associated with this imaging modality. Magic angle refers to the increased signal on magnetic resonance images associated with the highly organized collagen fibers in tendons and ligaments when they are orientated at a 55° angle to the main magnetic field. We present several examples from a clinical practice setting using 3T imaging illustrating a substantial reduction in magic angle artifact of the peroneal tendon in the prone plantarflexed position compared with the standard neutral (right angle) position.
Plantar heel pain is often managed through podiatric and physical therapy interventions. Numerous differential diagnoses may be implicated in patients presenting with plantar heel pain; however, symptoms are often attributed to plantar fasciitis. Abductor hallucis, flexor digitorum brevis, and quadratus plantae share proximal anatomic attachment sites and mechanical function with the plantar fascia. Although these plantar intrinsic muscles each perform isolated digital actions based on fiber orientation and attachment sites, they function collectively to resist depression of the lateral and medial longitudinal arches of the foot. Overuse injury is the primary contributing factor in tendinopathy. The close anatomic proximity and mechanical function of these muscles relative to the plantar fascia suggests potential for proximal plantar intrinsic tendinopathy as a result of repetitive loading during gait and other weightbearing activities. To date, this diagnosis has not been proposed in the scientific literature. Future studies should seek to confirm or refute the existence of proximal plantar intrinsic tendinopathic changes in patients with acute and chronic plantar heel pain through diagnostic imaging studies, analysis of lactate concentration in pathologic versus nonpathologic tendons, and response to specific podiatric and physical therapy interventions germane to tendinopathy of these muscles.
Plantar heel pain syndrome, which has a multifactorial and widely disputed etiology, affects more than 2 million people annually. A survey was conducted of members of the American Academy of Podiatric Sports Medicine about their strategies for managing plantar heel pain syndrome, especially the role of injectable corticosteroids. The respondents tended to be experienced (10–24 years in practice) podiatric physicians with a concentration in sports medicine. They reported that for early-stage plantar heel pain syndrome they generally recommend avoidance of wearing flat shoes and walking barefoot (92%), use of over-the-counter arch supports and heel cushions (90%), regular stretching of the calf muscles (88%), strapping of the foot (75%), cryotherapy applied directly to the affected part of the foot (67%), and nonsteroidal anti-inflammatory drug therapy (60%). When these measures fail to relieve heel pain, most of the responding podiatric physicians recommend using custom orthotic devices (60%) and corticosteroid injections (60%) as intermediate therapy. Surgical plantar fasciotomy (88%), cast immobilization (77%), and extracorporeal shockwave therapy (69%) are generally recommended as late-stage therapy for resistant cases. A staged approach seems to yield the best results in treatment of this common condition. (J Am Podiatr Med Assoc 97(1): 68–74, 2007)
Subtalar Arthroereisis for Pediatric Flexible Pes Planovalgus
Fifteen Years Experience with the Cone-shaped Implant
Flexible pes planovalgus is a common condition with flattening of the medial longitudinal arch accompanied by hindfoot valgus. Severe cases of pes planovalgus may need surgery, and a technique that has gained popularity over the past decades is subtalar arthroereisis. An endoorthotic implant of various shapes is inserted in the sinus tarsus, which limits the excessive eversion of the subtalar joint present in flexible pes planovalgus. None of these implants, however, allow for easy control of the extent of talocalcaneal and talonavicular correction. The primary aim of this study was to describe our technique with the custom-built cone-shaped implant. Our secondary aim was to evaluate patient satisfaction, clinical and radiologic results, and complications with a minimal follow-up of 5 years. Between January 1992 and June 2002, 40 patients (80 feet) underwent subtalar arthroereisis for flexible pes planovalgus. After temporary sinus tarsi tenderness (12 feet), implant dislocation (two feet) was the most common complication. Questionnaires from 27 patients (54 feet) were analyzed and 44 feet were also clinically and radiographically evaluated. Thirteen patients were lost to follow-up. Mean (± SD) follow-up was 12.6 years (range, 5.9–16.1). Eighty-one percent of the patients were satisfied with the result. Clinically, normal alignment was present in 14 feet, and mild deformities remained in 26 feet. Radiographically, the average foot angle measurements were normal. We conclude that subtalar arthroereisis is a simple, minimally invasive operative option with satisfactory subjective and clinical results after mid- to long-term follow-up. (J Am Podiatr Med Assoc 99(5): 447–453, 2009)
