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A case is presented of replantation of 10 digits at the proximal phalangeal level. Seven digits survived. Osteotomies and flexor tenolysis were done on the right thumb, long, and ring fingers and left index and long fingers 11 months later. A toe-to-hand transfer was done to reconstruct the failed left thumb replantation. Functional and sensory recovery is satisfactory.
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Fractures of the phalanges of the feet are the most common types of injury to the forefoot. There is, however, little available literature concerning pedal digital fractures. There is a misconception that fractured toes will heal by themselves. In fact, mistreated digital fractures can lead to many painful and serious complications. A review of the classifications, mechanisms of injury, clinical presentation, complications, and various treatments of digital fractures is presented.
Subungual exostosis is an acquired, benign, often painful, and nearly always solitary bone tumor usually occurring in the dorsal medial aspect of the phalanges. An eighteen-year-old male patient presented with a progressively enlarging mass and pain that developed over two years in the distal medial aspect of the right first toe. Conventional radiographs, computed tomography, and histopathologic findings showed subungual exostosis. Complete removal of the tumor was performed including its base in the cortex of the phalanx. No recurrence was observed during a follow-up of 11 months. It was emphasized that clinical presentation of subungual exostosis may resemble other benign or malignant bone tumors.
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The term "spondyloperipheral dysplasia" (SPD) has been applied to the unusual combination of platyspondyly and brachydactyly as observed in a small number of individuals. The reported cases show wide clinical variability and the nosologic status and spectrum of this condition are still ill defined. Zabel et al. [1996: Am J Med Genet 63(1):123-128] reported an individual with short stature and SPD who was heterozygous for a frameshift mutation in the C-propeptide domain of COL2A1. To explain the additional finding of brachydactyly that is not an usual feature of the type II collagenopathies, it was postulated that the nature of the mutation induced precocious calcification and premature fusion of metacarpal and phalangeal growth plates. The C-propeptide of collagen II had previously been found to promote calcification ("chondrocalcin"). We have ascertained two further individuals with clinical and radiological findings of a type II collagenopathy in infancy who developed brachydactyly type E like changes of fingers and toes in childhood. In both individuals, heterozygosity for novel, distinct mutations in the C-propeptide coding region of COL2A1 were found. Although all three mutations (the one previously reported and the two novel ones) predict premature termination, their location close to the 3'-end of the mRNA probably protects them from nonsense-mediated decay and allows for synthesis of mutant procollagen chains. However, loss of crucial cysteine residues or other sequences essential for trimerization prevents these chains from associating and participating in procollagen helix formation, and thus leads to accumulation in the ER-consistent with EM findings. The mechanism leading to precocious fusion of phalangeal epiphyses remains to be explored. The consistency of clinical, radiographic, and molecular findings in these three unrelated individuals confirms SPD as a distinct nosologic entity. The diagnosis of SPD is suggested by the appearance of brachydactyly in a child who has clinical and radiographic features of a collagen II disorder.
In a 51-year-old woman with a history of fractures and dislocations after low intensity trauma in childhood, intensive blue sclera, short stature, and hearing loss, the diagnosis of osteogenesis imperfecta (OI) was suspected. She was referred to our clinic with hand deformities and left knee pain and stiffness. She had difficulty in walking and reported a history of immobilization for 6 months because of knee pain. She had bilateral flexion contracture of the elbows which occurred following dislocations of the elbows in childhood. She had Z deformity of the first phalanges, reducible swan-neck deformity of the third finger of the left and the second finger of the right hand, flexion contracture of the proximal interphalangeal joint of the fifth finger of the left hand, and syndactyly of the third and fourth fingers of the right hand. Flexion contractures of both knees were observed. Pes planus and short toes were the deformities of the feet. Acute phase reactants of the patient were normal. She had no history of arthritis or morning stiffness. Bone mineral density evaluated by dual-energy X-ray absorptiometry (DEXA) showed severe osteoporosis of the femur and lumbar vertebrae. She had radiographic evidence of healed fractures of the left fibula, the third metacarpal, and the fourth and fifth middle phalanges of the right hand. OI, affecting the type I collagen tissue of the sclera, skin, ligaments, and skeleton, presenting with ligament laxity resulting in subluxations and hand deformities may be misdiagnosed as hand deformities of rheumatoid arthritis.
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The left thumbs and great toes of three 8 1/2 month old Rhesus monkeys (Macaca mulatta) were amputated in guillotine fashion one millimeter distal to the base of the nail and allowed to heal by the conservative open wound method. Healing occurred in seven to ten days in these small digits. Each of the thumbs and toes grew back with some blunting and shortening of the digit tips, but were functional. The new structures were cosmetically pleasing as in the human instances. The nails grew essentially to normal size and shape supported by the remaining portions of the distal phalanges. Histological studies showed no evidence of blastema formation such as is observed in the regenerating limb of the Urodele (newt) taken as the comparative representative. The possibility of improving the regrowth is discussed against the background of our knowledge of the importance of nerve during limb regeneration in lower vertebrates.
INTRODUCTION: The goal of this study was to evaluate the place of arthrodesis of the first metatarso-phalangeal joint in surgery of the fore foot. MATERIAL AND METHOD: The authors studied 225 arthrodesis of the first metatarso-phalangeal joint. 195 had a follow up of from two to fifteen years. The indications were: hallux valgus 52.5 per cent, hallux rigidus 20 p. 100, rheumatoid arthritis 12.5 per cent. The procedure used a stable axial fixation with an antero-posterior screw. The preparation of the joint surfaces allowed equalization of the length of the first two toes. RESULTS: The study found a patient subjective satisfaction rate of 89.6 per cent. There was no pain for 90 per cent of them. Activities returned to normal 80 per cent of patients. There was radiographic evidence of lack of fusion in 25 cases (13 per cent). Only two cases were painful and justified a revision. In 15 per cent of the cases slight pain at the inter phalangeal joint was noted due to excessive joint function. DISCUSSION: The best results were obtained with a dorsal flexion angle between twenty and thirty degrees. Restricted dorsal flexion concerning ankle or inter phalangeal joint is a contra-indication of the procedure. Stable fixation is essential but weight bearing on the fore-foot is not allowed for six weeks. CONCLUSION: Arthrodesis of the first metatarso-phalangeal joint restores painless satisfying function and normal use of shoes.
This paper reports the initial and long-term results of 45 Akin procedures done at the Hospital for Joint Diseases/Orthopaedic Institute from 1966 to 1985. Indications for 36 of the 45 operated feet were for an essentially asymptomatic great toe valgus deformity which caused symptoms to develop in the second toe and in 9 of 45 feet for residual hallux valgus after previous hallux valgus surgery. Excellent and good results were reported in 89% of the patients. The most common technical problem reported in 22% of the patients was plantar angulation at the osteotomy site. The only technical problem that was associated with long-term complications was bone apposition of less than 50% which may have lead to a nonunion in one case and recurrence of deformity in another. Shortening of the hallux was observed in all cases secondary to the closing wedge osteotomy. Shortening can be limited if a minimum of bone is removed from the proximal phalanx. A mathematical analysis is presented in this paper which can be used to provide guidelines to osteotomy size so that a minimum of bone necessary for correction can be removed. The Akin procedure should be performed within certain guidelines. Rarely is an Akin procedure alone indicated for the correction of a hallux valgus deformity. In most patients the proximal phalangeal osteotomy needs to be performed in combination with some other procedure to correct all components of the hallux valgus deformity. Furthermore the procedure can be used with success in those patients who present with an essentially asymptomatic great toe valgus deformity at the metatarsophalangeal joint or the interphalangeal joint which causes symptoms and/or deformity to develop in the second toe.(ABSTRACT TRUNCATED AT 250 WORDS)
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