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PubMed2002

Radiographic analysis of growth in pediatric microsurgical toe-to-hand transfers.

Microsurgical toe-to-hand transfers may provide improved hand function in children with absent digits. To date, documentation of the growth potential of these transferred digits has not been performed. This study reviewed the authors' series of pediatric toe-to-hand transfers, with specific attention paid to measuring growth by radiographic analysis. From 1995 to 2000, 23 toe-to-hand transfers were performed in 18 children. Age at time of transfer ranged from 2.8 to 13 years. Indications included constriction band syndrome, transverse deficiency, longitudinal deficiency, traumatic amputation, and vascular malformation. The transfers were successful in 22 of 23 procedures (96 percent success rate). Radiographic analysis of growth was performed using three criteria: (1) appearance of open epiphyseal plates, (2) comparison with preoperative radiographs, and (3) comparison with radiographs of the contralateral control toe. Epiphyseal plates remained open on postoperative radiographs in 27 of 28 phalanges (96 percent) at a mean of 12 months' follow-up (range, 1 to 36 months). The preoperative foot radiographs were compared with serial radiographs of the transferred toe over time. In 10 toe transfers with follow-up greater than 6 months (mean, 21 months), nine patients had increased bony length in the transferred digit. In four patients, radiographs of the toe transfer were compared with radiographs of the corresponding toe on the opposite foot. With a mean follow-up of 29 months, all patients had equal length measurements of the toe transfer with the contralateral toe control. These data provide objective evidence that digital growth potential is preserved in toe-to-hand transfers. Furthermore, this bone growth is comparable with that of the corresponding toe on the contralateral foot. Therefore, microsurgical toe-to-hand transfers may provide children with extra digits that maintain growth and improve hand function.

Adolescent↗
PubMed2001

[Recurrent hallux valgus treated with metatarsophalangeal arthrodesis. A series of 32 patients].

PURPOSE OF THE STUDY: We reviewed a series of 32 cases of recurrent hallux valgus treated by great toe metatarsophalangeal arthrodesis with a minimal 5-year follow-up. MATERIAL AND METHOD: Mean delay from the first surgical procedure and revision surgery was 11 years. All patients complained of forefoot pain. The average angle of the phalangeal valgus was 39 degrees. Sixteen patients had metatarsalgia. The first toe metatarsophalangeal joint was evaluated according to Regnauld's classification: two grade 1, eight grade 2a, six grade 2b, sixteen grade 3. Arthrodesis was fixed with an axial screw and associated with adductor hallux plasty. Outcome was assessed at a minimum 5-year follow-up according to Kitaoka's criteria. RESULTS: Seventy-eight percent of the patients were pain free at last follow-up. Valgus deviation of the great toe was corrected with an average angle of 19 degrees. The arthodesis healed in 90.6% of the cases. Statistical analysis showed the importance of great toe valgus pre- and postoperatively and at last assessment. Final outcome was poor in the oldest patients. The overall outcome was rated good in 84% of the cases, average in 6% and poor in 10%. DISCUSSION: Arthrodesis of the great toe is not a disabling surgery. Interphalangeal osteoarthritis may occur due to joint overuse (12 cases). Kitaoka's series compared outcome after arthrodesis with that after conservative surgery and reported better results with arthrodesis. Revision surgery for hallux valgus using great toe metatarsophalangeal arthrodesis remains an acceptable alternative.

Adult↗
PubMed2024

Congenital hallux valgus occurs in Fibrodysplasia Ossificans Progressiva and BMPR1B-associated dysplasia: an important distinction.

BACKGROUND: Fibrodysplasia Ossificans Progressiva (FOP; OMIM #135100) is an ultrarare genetic disorder characterised by congenital bilateral hallux valgus (CBHV), intermittent soft tissue swellings and progressive heterotopic ossification. We report a three-month-old girl with great toe abnormalities similar to FOP, in whom comprehensive clinical workup and genetic investigations illustrates an alternative diagnosis. CASE PRESENTATION: A three-month-old girl presented with CBHV. The antenatal period was unremarkable, she was born by spontaneous vaginal delivery with an uneventful subsequent course, except for maternal concern of her bent toes which received reassurance from several health professionals. Her mother's persisting concerns were explored via the internet and social media leading her to request referral to an expert bone centre for consideration of FOP. On examination, she was thriving, there was no dysmorphism, subcutaneous lumps, skeletal or extra-skeletal deformity except for shortened great toes with lateral deviation of the proximal and distal phalanges. FOP was a feasible diagnosis, for which CBHV is highlighted as an early sign. A cautionary potential diagnosis of FOP was counselled, including advice to defer intramuscular immunisations until genetic results available. Genetic investigation was undertaken through rapid whole genomic sequencing (WGS), with analysis of data from a skeletal dysplasia gene panel, which demonstrated no ACVR1variants. The only finding was a heterozygous variant of unknown significance in BMPR1B (c1460T>A, p.(Val487Asp)), which encodes a bone morphogenic receptor involved in brachydactyly syndromes A1, A2 and D and acromesomelic dysplasia 3 (only the latter being an autosomal recessive condition). CONCLUSION: This report highlights that CBHV serves as a vital diagnostic indicator of FOP and affected infants should be considered and investigated for FOP, including precautionary management whilst awaiting genetic studies. The second educational aspect is that CBHV may not represent a generalised skeletal disorder, or one much less significant than FOP. Receptor-ligand BMP and Activins mediated interactions are instrumental in the intricate embryology of the great toe. Recognition of non-FOP conditions caused by alterations in different genes are likely to increase with new genomic technology and large gene panels, enhancing understanding of bone signaling pathways.

Humans↗
PubMed2005

Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity.

Elevated plantar foot pressures during gait in diabetic patients with neuropathy have been suggested to result, among other factors, from the distal displacement of sub-metatarsal head (MTH) fat-pad cushions caused by to claw/hammer toe deformity. The purpose of this study was to quantitatively assess these associations. Thirteen neuropathic diabetic subjects with claw/hammer toe deformity, and 13 age- and gender-matched neuropathic diabetic controls without deformity, were examined. Dynamic barefoot plantar pressures were measured with an EMED pressure platform. Peak pressure and force-time integral for each of 11 foot regions were calculated. Degree of toe deformity and the ratio of sub-MTH to sub-phalangeal fat-pad thickness (indicating fat-pad displacement) were measured from sagittal plane magnetic resonance images of the foot. Peak pressures at the MTHs were significantly higher in the patients with toe deformity (mean 626 (SD 260)kPa) when compared with controls (mean 363 (SD 115) kPa, P<0.005). MTH peak pressure was significantly correlated with degree of toe deformity (r=-0.74) and with fat-pad displacement (r=-0.71) (P<0.001). The ratio of force-time integral in the toes and the MTHs (toe-loading index) was significantly lower in the group with deformity. These results show that claw/hammer toe deformity is associated with a distal-to-proximal transfer of load in the forefoot and elevated plantar pressures at the MTHs in neuropathic diabetic patients. Distal displacement of the plantar fat pad is suggested to be the underlying mechanism in this association. These conditions increase the risk for plantar ulceration in these patients.

Diabetic Foot↗
PubMed2003

The management of brachymetatarsia.

We treated 35 brachymetatarsal rays of 18 feet in 12 patients by one-stage lengthening with interpositional bone grafts or by gradual lengthening with callotasis combined with shortening of the adjacent metatarsals and phalanges. Definition of the two parabolas which connect the metatarsal heads and the tips of the toes, and recognition of three patterns of metatarsal length, were helpful guides in treatment. In total, 36 excisions of the phalanges and/or the metatarsals were undertaken. The mean shortening was 8 mm. The radiological results were satisfactory. The mean values were as follows: one-stage lengthening, length gain, 1.3 cm; healing index, 1.3 months/cm; percentage increase, 30%; gradual lengthening, length gain, 2.0 cm; healing index, 2.0 months/cm; percentage increase, 50%. Associated shortening of an adjacent bone can avoid the disadvantages of one-stage lengthening which may not achieve target length and can result in neurovascular complications. Reduction of the target length enables the surgeon to carry out one-stage instead of gradual lengthening. It also shortens the length of treatment in the group undergoing callotasis and improves cosmesis.

Adolescent↗
PubMed1978

Degenerative changes in the first metatarso-phalangeal joint of ballet dancers.

In 20 female performers of classical ballet the range of dorsiflexion of the big toe was found to be significantly decreased. However, in only one case was the decrease sufficiently great to interfere with the dancer's ability to perform. In spite of the severe stress put on the first metatarso-phalangeal joint in dancers the resulting degenerative changes were found to be minor and in most instances without clinical consequences. The results indicate that professional ballet, contrary to what is believed, rarely has harmful effects on the first metatarso-phalangeal joint.

Adult↗
PubMed1995

F-syndrome (F-form of acro-pectoro-vertebral dysplasia): report on a second family.

We report on a father and daughter in the second known family affected with F-syndrome. The first family, with 8 affected members, was reported by Grosse et al. [1969: BD:OAS V (3):48-63]. F-syndrome, an autosomal-dominant trait, is mainly characterized by acral defects that may also involve the sternum and the lumbosacral spine. Synostoses between capitate and hamate, and between talus and navicular, are invariably present; other carpal and tarsal bones are sometimes incorporated into the fusion. The hand malformation is principally a malformation of the first 2 rays. In our patients, the short and malformed thumb was webbed with the index finger, which was radially deviated with duplication of the middle and distal phalanges. In the feet, polydactyly and severe metatarsal and toe anomalies were present. The father had a prominent sternum with pectus excavatum, whereas the daughter had no sternal deformity. Both of them had a mild failure of fusion of posterior arch L5 and/or S1.

Abnormalities, Multiple↗
PubMed1987

[Manifestations of diffuse idiopathic skeletal hyperostosis on the forefoot].

Diffuse idiopathic skeletal hyperostosis (DISH) also becomes noticeable at the numerous entheses of the forefoot mainly with exomarginal formation of spongious bone. The separate entheses react differently to enthesiopathic stimuli. In DISH the tuberosities of the distal phalanges react most frequently and most severely. Between the toes and the digits there are differences in DISH not only of a quantitative but also of a qualitative nature. At the toes the increased subchondral sclerosis does not occur as it does at the digits.

Adult↗
PubMed1977

Infantile convulsions: transient infantile hypocalcemia associated with skeletal deformities.

An infant with skeletal deformities and hypocalcemic convulsions is described. The convulsions, which were first noted in the 5th week of life, as well as the low serum calcium level were transient. The skeletal deformities consited of deformation of the terminal phalanges of the right third finger and right second toe, syndactyly of the third and fourth finger of both hands and left pes equinovarus. X-ray examination revealed abnormal shape and structure of some bones of the hands. The most likely diagnosis is transient congenital idiopathic hypoparathyroidism, which has not yet been described in association with congenital skeletal anomalies.

Abnormalities, Multiple↗
PubMed1976

Trigonocephaly and associated minor anomalies in mother and son.

A mother and her son are described with neonatal trigonocephaly, multiple suture synostosis; shallow orbits; unusual nose; deviation of the terminal phalanges of fingers 1, 2, and 5; and broad toes which radiologically may show duplication of the terminal phalanx. Untreated, the condition leads to a disfiguring oxycephaly with hypotelorism. This appears to be the first documented instance of autosomal dominant trigonocephaly. The importance of the minor anomalies in its recognition and its good prognosis are emphasized.

Adult↗
PubMed2006

Psoriatic onycho-pachydermo-periostitis successfully treated with low-dose methotrexate.

BACKGROUND: Psoriatic onycho-pachydermo-periostitis (POPP) is a rare manifestation of psoriatic arthritis that is often misdiagnosed as a nail infection. The treatment for POPP has not yet been established. CASE REPORT: We present a case of a 67-year-old man who had no psoriatic skin lesions with POPP, characterized by psoriatic nail changes, painful swelling of the distal soft tissues on the great toes and fingers, and enthesopathies of the involved terminal phalanges. The clinical nail and arthritic changes were improved with methotrexate treatment 4 mg weekly for 6 months. CONCLUSIONS: Methotrexate can be recommended as the first-choice therapeutic agent for patients with POPP.

Aged↗
PubMed2006

[Mal de Meleda. 16 cases].

Mal de Meleda is a recessive transgression palmoplantar keratoderma. We report the epidemiological, clinical and progressiveness aspects of the disease in 16 patients of a large consanguineous tunisian family. The age ranged from 3 to 90 years. Nine were male and 7 female patients. Onset in early infancy was characterized by erythema of the palms and soles, followed by a diffuse yellowish hyperkeratosis. Thickness of the dorsal aspect of the fingers started in childhood. Extension of hyperkeratosis to the dorsal of the hand were reported only in adults and usually precede the involvement of the feet Palmoplantar hyperhidrosis with fetid odor between the toes was frequently seen as well as conical distal phalanges. In some adults keratoderma gave contracture of the fingers leading to limitation of movements Mal de Meleda must be differentiated from other recessive palmoplantar keratoderma such as Papillon-Lefévre syndrome and Mal de Naxos. the remaining inherited palmoplantar keratoderma being autosomal dominant. Mal de Meleda is a rare disease but is still relatively frequent in some tunisian regions, due to the high rate of consanguinity Mal de Meleda remains an afflicting and disabling disease.

Adolescent↗
PubMed1996

[Follow-up studies of resections of claws in cattle].

Between 1980 and 1991 205 partial resections on claws of cattle have been performed at our clinic, 111 of these cases could be included in a retrospective study. In 57.5% of these cases parts of the third phalange had to be resected (group 1), in 14.2% parts of the third phalange and the deep flexor tendon had to be removed (group 2); in 28.3% also the distal sesamoid bone and/or other structures were affected (group 3). The average duration of treatment (mean +/- s) was 6.9 +/- 4.5 weeks for group 1, 6.5 +/- 1.9 weeks and 9.3 +/- 3.9 weeks for group 2 and 3, respectively. There was a highly significant difference between the means of group 1 and 3 and a significant difference between group 2 and 3. Of 103 animals which were provided for pasturing 44.7% could meet this requirement not at all or only with limitations. This was true for 66.7% of animals of group 2 and 58.2% of animals of group 3. 84.5% of 84 animals, which could be evaluated in this respect, the normal milk production was regained after treatment. At the time the retrospective study was performed, 13 of the animals still were alive. The average survival time (mean +/- s) after surgical treatment of 74 animals, for which the date of slaughter was available, was 22.0 +/- 21.8 months. Recurring lameness from the treated or another leg was the reason for salvaging in 39.2% of the animals. A comparison with results of an earlier retrospective study of our clinic, dealing with cattle after amputation to the toe revealed that with the exception of cases with a well deliminated zone of necrosis in the third phalange for economical reasons the toe amputation should be performed rather than a partial resection. For cases, where slaughter would be the only alternative to the resection, this method can well be recommended.

Abattoirs↗
PubMed1984

[Reconstruction of grip function in cases of a fingerless or missing hand].

In two cases a grip reconstruction by double toe-to-hand transfer is demonstrated. In the first patient all fingers of the left hand were amputated at the metacarpo-phalangeal joint level. The second and the third finger were reconstructed by transplantation of the second toe from the left foot and the third toe from the right foot. The distal and middle phalanx of the transplanted third toe had to be re-amputated because of mummification two weeks after the transplantation and was covered with a groin flap. Good function of the newly formed grip could be demonstrated. The second patient was a 21-year old man with amputation of both hands. Grip reconstruction in the right lower arm was performed by transplantation of the second toe of each foot together with a metatarsal bone and a dorsalis pedis flap. One year after the operation the follow-up study demonstrated good function of the newly formed hand. The patient is able to use his two new fingers during daily life mainly to hold small objects. The sensation and the range of movement of the newly formed right hand are demonstrated and discussed.

Adult↗
PubMed1982

Surgical importance of the radio-automatic study of the arterial vascularization of the forefoot.

The authors have studied anatomically and angiographically 50 cadaveric foot specimens, emphasizing; the vascular flow predominance between dorsalis pedis and plantar arteries; the anastomosis between the three arterial supplies in the foot; the dividing pattern and the distribution of each artery; the blood flow distribution pattern at the level of the first and second toes and especially the anastomosis between the dorsal and plantar vessels and the branches for the metatarsic-phalangeal joint. The study presents new data about the indications of preoperative angiography of the forefoot, about the surgical technique of toe transfer, articular transposition and multiple transposition (2 toes, skin and bone...).

Angiography↗
PubMed1983

Pseudoclubbing in a patient with sarcoidosis of the phalangeal bones.

We treated a patient who had sarcoidosis with pseudoclubbing. The involvement was asymmetric and involved some fingertips more than others. It did not involve the toes. The pseudoclubbing totally disappeared with effective prednisone therapy. Roentgenograms of the hands showed bone cysts of the distal and middle phalanges, and a gallium citrate Ga 67 scan showed uptake in two of the phalanges. We believe the pseudoclubbing in this patient is a manifestation of phalangeal bone involvement by sarcoidosis with associated dactylitis. A literature review indicates that true clubbing can exist in patients with sarcoidosis, but this case indicates that it must be distinguished from dactylitis.

Adult↗
PubMed2004

Clinical, cytogenetic, and molecular findings of prenatally diagnosed mosaic trisomy 4.

OBJECTIVES: To present the clinical, cytogenetic, and molecular findings of prenatally diagnosed mosaic trisomy 4. CASE: An amniocentesis was performed at 21 weeks' gestation because of maternal anxiety. Cytogenetic analysis revealed mosaicism for trisomy 4, 47,XX,+4[4]/46,XX[16]. Level II ultrasound demonstrated tetralogy of Fallot. Repeated amniocentesis at 23 weeks' gestation revealed 47,XX,+4[4]/46,XX[19]. The pregnancy was terminated. Phenotypic findings included tetralogy of Fallot, hypertelorism, micrognathia, abnormal ears, duplicated phalanges of the left thumb, clinodactyly, and overlapping of the toes. The karyotype of the cord blood was 46,XX. Cytogenetic analyses of the multiple tissue samplings showed a karyotype of 47,XX,+4 in 40/40 cells of the amniotic membrane (amnion), and 47,XX,+4/46,XX with various levels of trisomy 4 in the cells of the liver, lungs, placenta, skin, and umbilical cord. The levels of trisomy 4 were 11/40 in the liver, 8/40 in the lungs, 31/40 in the placenta, 9/40 in the skin, and 8/40 in the umbilical cord. METHOD: The parental origin and meiotic origin of trisomy 4 were determined by examining the amniotic membrane using quantitative fluorescent polymerase chain reaction assays with polymorphic markers specific for chromosome 4. The result was consistent with a paternal meiosis I nondisjunction error. The cord blood showed a biparental inheritance. An extra paternal heterozygous allele with partial dosage increase was noted in other fetal and extraembryonic tissues studied. CONCLUSION: A diagnosis of trisomy 4 mosaicism in amniocytes indicates an increased risk for fetal abnormalities. Associated abnormal findings include congenital heart defects and anomalies of the digits and thumb. A confirmatory placental sampling may be helpful, whereas a fetal blood sampling is of a very limited value. A postnatal amnion sampling may provide additional clues to the fetal involvement of trisomy 4.

Abortion, Induced↗