[Arthrodesis of the interphalangeal joint of the great toe].
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Adolescent↗
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Free combined thin wrap-around flap with a second toe proximal interphalangeal joint transfer for reconstruction of the thumb.
The combined thin wrap-around flap from the big toe and the proximal interphalangeal joint of the second toe is characterized by (1) a single vascularized joint, which is used to preserve the second toe with a free iliac bone graft, (2) a thin wrap-around flap, which allows the pulpal fatty tissue on the remaining bone of the big toe to be retained and accept a skin graft, (3) a wrap-around flap with a partial distal phalangeal bone, and (4) a microplate for firm fixation at the proximal bone union and early joint motion. The advantages of this method are (1) the cosmetic appearance is excellent with use of the thin wrap-around flap; (2) there is joint motion in the reconstructed thumb with strong pinch and vice pinch; (3) the vascularized joint with a microplate allows for early postoperative motion; (4) bone grafting from another donor site is unnecessary; (5) bone growth is possible in children with open epiphyses; and (6) the big and second toes are preserved with minimal donor-site morbidity. This method is indicated for thumb losses at a level distal to the metacarpophalangeal joint or at the level of the proximal phalanx.
Adult↗
Diagnosis of gout: clinical, laboratory, and radiologic findings.
Acute gouty arthritis typically presents with a sudden and severe exquisitely painful joint, most classically in the first metatarsophalangeal joint (toe). Demonstrating the presence of monosodium urate (MSU) crystals in the joint fluid or tophus has been the gold standard for the diagnosis of gout. However, many physicians do not perform synovial fluid analysis. In the absence of demonstrating the presence of MSU crystals in aspirated joint fluid or tophus, clinical, radiologic, and laboratory criteria are helpful. This article presents an overview of the various classification criteria, clinical presentations, and laboratory and radiologic studies needed to make the diagnosis of gout.
Acute Disease↗
Successful treatment of hyperphosphatemic tumoral calcinosis with long-term acetazolamide.
We describe a patient with tumoral calcinosis, in which acetazolamide (ACZ) was, for the first time, tested for its therapeutic efficacy. The 19-year-old Japanese man had been suffering from multiple recurrent calcific masses with tenderness around the finger, knee, and toe joints since 10 months of age. Radiographs revealed several calcific subcutaneous masses around the finger joints, and calcific myelitis around the right knee joint and in the calvarium. The patient had hyperphosphatemia with elevated maximal threshold of renal phosphate excretion in the presence of normal kidney function and normocalcemia, suggesting a reduced ability to excrete phosphorus in the urine. A delay of disappearance of orally administered phosphate from the blood stream was found. A serum parathyroid hormone (PTH) level was normal, and responses to PTH and ACZ were also normal regarding the induction of phosphaturia. Since the masses tended to recur easily despite repeated surgical resections, we started medical treatment with phosphorus deprivation by oral aluminum hydroxide. However, the drug alone had no effect on hyperphosphatemia or calcific lesions, and ACZ was added in expectation of making the patient's phosphorus balance negative by its phosphaturic effect. Fourteen years of administration of the two drugs apparently improved the patient's symptoms, the biochemical findings, and the calcific lesions on radiographs. Thus, ACZ appeared to be useful for tumoral calcinosis resistant to phosphorus deprivation by aluminum hydroxide alone.
Acetazolamide↗
Vascularized joint transfers. Indications and results.
Vascularized joint transfer can be beneficial in restoring joint function and maintaining growth. It is sometimes indicated in patients with painful post-traumatic arthritis, post-traumatic joint instability, and post-traumatic deformity. The best indication for this procedure is in children whose joint injury is associated with damage to growth plates in any of the digits; however, the complications associated with this procedure should not be overlooked. Extensor lag is common. This complication may be prevented during the surgical procedure by using a step-cut osteotomy to preserve the insertion of the extensor tendon, resecting the volar plate of the finger, harvesting the transferred joint with enough length to keep the extensor tendon tight, and placing the transferred joint in a maximally extended position to counteract the flexible trend of the toe joints. We believe this procedure holds promise for the future. Further improvement in surgical technique and clarification of its indications will likely enhance overall results.
Arthrodesis↗
Implant arthroplasty of the first metatarsalphalangeal joint.
Few topics in foot and ankle surgery incite as much debate as artificial replacement of the great toe joint. As with other implant arthroplasty procedures, such as the hip and knee, the first metatarsalphalangeal joint (MTPJ) has most assuredly had its share of failed designs. This article reviews the shortcoming of nonimplant procedures and discusses the advantage of the Arthrosurface system, a new implant that has been used in all major joints to replace degenerative areas and postpone the need for total joint replacement.
Arthroplasty, Replacement↗
A case of dorsal dislocation of the proximal interphalangeal joint of the fourth toe.
Dislocation of the interphalangeal joint of a toe is a rare injury, and when it does occur it usually involves the great toe. Dislocation of other toes without fracture is quite rare. We present here a case of dorsal dislocation of the proximal interphalangeal (PIP) joint which was reduced by manipulation.
Adult↗
Signaling of ankle joint position by receptors in different muscles.
Plots were made of multiunit activity versus ankle joint position for receptors in each of the 12 muscles crossing the cat ankle joint, except peroneus tertius, by recording from populations of afferent fibers in muscle nerves. The discharge was measured 15 or 30 sec after terminating the movements that altered the position of the joint. These recordings were dominated by large-spike activity that would be expected to originate mainly from primary spindle endings. Seven of the 12 muscles also cross other joints. Their responses at a given ankle joint position were so altered by changes in the position of the knee or toe joints that they could not reliably signal the position of the ankle joint. As judged from multiunit recording, receptors in each of the five muscles specific to the ankle joint were influenced by more than one axis of ankle joint displacement. Single-unit recording from dorsal root filaments was used to determine whether primary or secondary spindle receptors in soleus and tibialis anterior could selectively signal one axis of ankle joint rotation. Individual soleus receptors were tested both on the flexion-extension axis and with a combined adduction-eversion movement. For 38 of the 70 soleus receptors examined (54%), firm adduction-eversion produced a level of activity greater than that caused by 10 degrees of flexion, and for 77% the level of activity was greater than that caused by 5 degrees of flexion. For 168 of the 184 tibialis anterior receptors studied (91%), firm abduction-inversion produced a level of activity greater than that caused by 10 degrees of extension. Thus few receptors were found that responded exclusively to one axis of rotation. One way in which the position of the ankle joint could be specified in the face of multiaxial receptor activity is by examining the receptor discharge from more than one muscle. A suggestion for how the nervous system might do this is given in the discussion.
Afferent Pathways↗
[Second toe transplantation in loss of a long finger. Indications--planning--technique].
Transplantation of the second toe is a routinely employed method in reconstructive hand surgery. Most often it is used for thumb or midhand amputations. Following partial amputations of digits distal to the MP-joints, toe transplantations are less frequently employed. However, function as well as cosmesis of the hand after partial amputation of digits can considerably be improved by toe transplantation. The length of the reconstructed finger is a most important aspect of operative planning which has influence on operative technique as well as functional and aesthetic results. A smooth junction at the base of the transplanted toe should be maintained. This can be achieved by adequate soft-tissue reduction and exclusion of the metatarsophalangeal joint. Anastomoses of the subcutaneous venous and plantar as well as dorsal arterial vascular systems are recommended.
Amputation, Traumatic↗
Evaluation and management of toe fractures.
Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. Joint hyperextension and stress fractures are less common. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction.
Fracture Fixation↗
Microarterial anatomy of the lesser toe proximal interphalangeal joints.
Successful free tissue transfer requires detailed knowledge of the pertinent microvascular anatomy of the donor site. The lesser toe proximal interphalangeal joints are a source of vascularized autologous tissue. In 20 adult cadaver feet, the arterial anatomy of the second, third, and fourth toes was studied using colored latex and India ink injection. The second, third, and fourth dorsal metatarsal arteries produced small or absent dorsal digital arteries in 72.5% of distal dissections. The proper digital arteries were 0.93 to 1.37 cm in length. An additional 2.3 to 2.83 cm of length can be gained by use of the plantar metatarsal arteries if the dorsal metatarsal or dorsal digital arteries are inadequate. The diameter of the medial proper digital arteries (range, 1.2-1.26 mm) was larger than the lateral proper digital arteries (range, 0.66-0.99 mm). The proper digital arteries of the lesser toes provide the predominant arterial supply of the proximal interphalangeal joints through a system of transverse and longitudinal arches.
Adult↗
Fibrocartilages in the extensor tendons of the interphalangeal joints of human toes.
The extensor tendons of the fingers and toes form part of the capsule of the interphalangeal joint and press against the proximal phalanx during flexion. Previous work on the fingers has shown that there is a "sesamoid" fibrocartilage on the deep surface of each tendon that labels immunohistochemically for a variety of glycosaminoglycans and collagens. However, we know little about the molecular composition of the tendon in the toes. This question is of special interest, because the mechanics of the interphalangeal joints differ in the upper and lower limbs-the toes balance the forefoot, distribute load during the gait cycle, and transmit the pull of larger muscles. This means that their extensor tendons are more often under higher tension than those in the fingers. Here, we report the presence of an equivalent fibrocartilage and compare its immunolabelling characteristics in all the toes. Six forefeet were removed from elderly cadavers, and the interphalangeal (IP) joints were fixed in 90% methanol. The extensor tendon and its enthesis were dissected out from the IP joint of the big toe and from the proximal interphalangeal (PIP) joint of all lesser toes, decalcified, cryosectioned, and immunolabelled with a panel of monoclonal and polyclonal antibodies for type I, II, III, and VI collagens; chondroitin 4 and 6 sulphates; and dermatan and keratan sulphate. Antibody binding was detected with the Vectastain ABC Elite avidin-biotin-peroxidase kit (Vector Laboratories, Burlingame, CA). The extensor tendon in all the toes had a metachromatic, sesamoid fibrocartilage on its deep surface that immunolabelled for all glycosaminoglycans and for type I, III, and VI collagens. Labelling for type II collagen was seen in the sesamoid fibrocartilage of all toes but was particularly characteristic of the 2nd through 5th toes. The immunolabelling patterns of the enthesis fibrocartilage were similar in all toes and to results reported previously for fingers. The normal occurrence of type II collagen in the sesamoid fibrocartilage of the 2nd through 5th toes is in contrast to our published data on the fingers. The finding can be related to the more constant loading of the tendon in the toes. The greater prominence of type II collagen in the sesamoid fibrocartilage of the 2nd through 5th toes could be related to a difference in joint position during walking between the 1st toe and the 2nd through 5th toes--the PIP joints of the latter are usually more flexed than the IP joint of the former.
Adult↗
Lapidus bunionectomy: arthrodesis of the first metatarsocunieform joint.
Fusion of the first metatarsocunieform (MC) joint allows for correction of the first metatarsal in three planes, including adduction, plantarflexion, and rotation. It also allows for decreased jamming of the great toe joint and increased medial column stability. As knowledge about other medial column procedures grows, fusion of the first MC joint will continue to grow in popularity. It is an excellent procedure for hallux limitus and also for metatarsus primus elevatus cases.
Arthrodesis↗
Dorsiflexion contracture after the Weil osteotomy: results of cadaver study and three-dimensional analysis.
For metatarsalgia caused by a dislocated lesser metatarsophalangeal (MTP) joint and isolated over-long lesser metatarsals, surgical treatment options without sacrificing the joint are limited. Recently, the Weil osteotomy has been advocated for the treatment of this deformity. In our experience, preliminary results with this technique have revealed a high rate of dorsiflexion contracture of the MTP joints at follow-up. We performed a cadaver study and a three-dimensional analysis on sawbones to investigate this phenomenon. In the cadaveric portion of this study, the second MTP joints of two fresh-frozen cadavers were dissected; the entire ray, with the metatarsal shaft, MTP joint, toe, and plantar fascia, was removed en bloc. After gross anatomic structures were photographed, a Weil osteotomy was performed at 25 degrees relative to the long axis of the metatarsal shaft. The positions of muscles, ligaments, and tendons were noted and photographed before and after the osteotomy. In the sawbones portion of this study, a Weil osteotomy was performed at four different angles (25 degrees, 30 degrees, 35 degrees, and 40 degrees) relative to the long axis of the metatarsal. To ensure reproducibility, the sawbone models were fixed proximally to a vertical milling machine with the second metatarsals inclined 15 degrees to simulate the anatomic position. After making the cut, the plantar fragment was translated along the dorsal fragment proximally for a distance of 5 mm. Before and after the osteotomy, selected x, y, and z coordinates were obtained using a Microscribe 3D digitizer. Data analysis was performed with Microsoft Excel, and ANOVA was used to determine significant differences (p < 0.05) between the various osteotomies. Analysis of the cadaver dissection revealed that after the Weil osteotomy, the tendons of the interosseous muscles move dorsally with respect to the axis of the MTP joint due to the depression of the plantar fragment of the metatarsal. The loss of their flexion effect on the joint permits the pull of the extensor to dorsiflex the toe. The size of the depression for the various osteotomies averaged: 25 degrees osteotomy, 3.03 mm (range, 1.8 to 3.8 mm); 30 degrees osteotomy, 3.2 mm (range, 1.9 to 4.0 mm); 35 degrees osteotomy, 3.5 mm (range, 1.7 to 5.7 mm); and 40 degrees osteotomy, 4.2 mm (range, 2.8 to 6.4 mm). Amounts of shortening relative to the long axis of the metatarsal for the various osteotomies averaged: 25 degrees osteotomy, 5.03 mm (range, 4.77 to 5.30 mm); 30 degrees osteotomy, 4.59 mm (range, 3.47 to 5.19 mm); 35 degrees osteotomy, 4.27 mm (range, 2.87 to 5.00 mm); and 40 degrees osteotomy, 3.65 mm (range, 3.20 to 4.31 mm). According to our analysis, depression of the plantar fragment always occurs after a Weil osteotomy. This depression changes the center of rotation of the MTP joint, and the interosseous muscles then act more as dorsiflexors than as plantarfexors.
Cadaver↗
[Pure sensory stroke due to a pontine lesion: a study of clinical symptomatology and somatosensory evoked potential findings].
We studied clinical symptomatology and somatosensory evoked potentials(SEP) of 7 pure sensory stroke patients due to pontine lesions. Clinical symptoms were examined by modality(pinprick, touch, vibration and joint position sense), intensity and distribution of the sensory disturbance. SEP were recorded by the median nerve stimulation in the upper extremities, and the posterior tibial nerve stimulation in the lower extremities. Patients 1-4 were characterized by decreased contra-lesional fingers or fingers, toes joint position sense, normal pinprick and vibration sense. We think that these patients' lesions were localized in the lemniscus medialis. Patients 5-7 were characterized by decreased contra-lesional upper extremity or upper and lower extremity vibration sense, decreased pinprick sense and normal joint position sense. We think that these patients' lesions involved spinothalamic tract. There was no abnormal finding of SEP with upper extremity stimulation, but disappearance or very low amplitude of P38 with lower extremity stimulation in 4 of the 7 patients. We conclude that 1) the vibration sense may be conducted also through the spinothalamic tract, 2) SEP findings are abnormal only with lower extremity stimulation in pontine pure sensory infarction.
Evoked Potentials, Somatosensory↗
Comparison of the validity and reliability of self-reported articular indices.
Our objective was to compare the validity and reliability of three formats for self-administered articular indices assessing pain (PAI) or swelling (SAI). Fifty-five patients with rheumatoid arthritis were asked to mark the degree of pain on a list of 16 joints (PAI list), to mark 'painful joints' on a mannequin presenting 42 joints (PAI diagram), and to mark 'swollen or tender joints' on a mannequin presenting 38 joints (SAI diagram). The test--retest reliability (intraclass correlation coefficient) ranged from 0.63 (SAI diagram) to 0.67 (PAI diagram) and 0.85 (PAI list). The correlation with clinical parameters was strongest for the PAI list and the SAI diagram. The association of the SAI diagram with clinical parameters increased with omission of the less reliable toe joints and/or weighting for joint size according to Lansbury. As expected, the short and weighted SAI diagram correlated more strongly with the physician-derived swollen joint count (r = 0.49), C-reactive protein (r = 0.49) and erythrocyte sedimentation rate (r = 0.41) than did the PAI list whereas the PAI list correlated more strongly with physician-derived tender joint count (r = 0.43), global pain measured on a numerical rating scale (r = 0.57) and the Health Assessment Questionnaire (r = 0.49) than did the SAI diagram. We concluded that patients' rating of tender and swollen joints on a mannequin diagram and calculation of a 26-joint and weighted articular index produces an excellent estimate of total joint inflammation, which may be useful in clinical, health services and epidemiological research. An articular index calculated from ratings of pain degree of 16 joints or joint groups may provide complementary information.
Arthritis, Rheumatoid↗
Medical history and physical findings in football players of different ages and skill levels.
The physical and physiologic demands of football on its participants become more pronounced as the level of competition increases. The aim of this study was to compare the medical history and physical findings in players from different levels of play as well as to analyze the relationship between pathologic findings in the joints of the lower extremities and the medical history. Five hundred eighty-eight football players from eight age and skill levels were investigated. The medical histories of the players were obtained by questionnaire. A physical examination conducted by specially trained physicians incorporated anthropometric and body fat measurements and examination of the spine and the hip, knee, foot, and great toe joints. On average, the players reported 6.6 (SD, 8.8) previous injuries. At the time of the examination, 136 players (24%) still felt the effects of a previous injury. Almost one-quarter of the players (134, 23%) had a pathologic finding in either the right or left knee, and even more players (162, 28%) had a pathologic anterior drawer sign either in the right or left ankle. A correlation was found between the location of the pathologic findings and the preferred leg for playing football. We recommend that further research should address the prevalence of pathologic findings and complaints in football players as well as the secondary structural changes that may occur as the result of playing football.
Adolescent↗
[Ankylosing spondylitis with and without peripheral joint involvement. The significance of HLA-DR4 in the diagnosis, disease risk and pathogenesis].
50 patients with ankylosing spondylitis without any peripheral arthritis are compared with 50 cases of ankylosing spondylitis complicated by arthritis of different kind. Radiological and clinical features were evaluated and assessed. HLA-DR4 typing was carried out. This antigen was found in 16% of 200 normal individuals, in 18% of all patients with ankylosing spondylitis confined to the spinal column, and in 54% of patients with only peripheral arthritis (wrist, finger, ankle, toe joints). The conclusion that HLA-DR4 represents nonspecific evidence for peripheral arthritis in patients with ankylosing spondylitis is discussed.
Adult↗