Tendon transfer for equinovarus deformed foot caused by cerebrovascular disease

Surgical correction was performed on 125 patients who had equinovarus deformity caused by a cerebrovascular accident and who needed an ankle foot orthosis for walking. The operative procedures involved anterior transfer of the long toe flexors (flexor hallux longus and flexor digitorum longus; long toe flexor group) or lateral transfer of the anterior tibial tendon (anterior tibial tendon group), combined with lengthening of the Achilles tendon. On evaluation more than 2 years after surgery, 83 of 110 patients of the long toe flexor group and eight of 15 patients of the anterior tibial tendon group were able to walk without a brace. Five patients of the anterior tibial tendon group who had shown strong contraction of the anterior tibial muscle during the swing phase before surgery, needed a brace because of a drop foot after surgery. Thus, lateral transfer of the anterior tibial tendon was abandoned in 1984. Recurrence of varus deformity was seen in approximately 15% of the patients in both groups. Anterior transfer of the long toe flexors, using them as dorsiflexor tendons or for tenodesis, seemed to produce better results.     

Randomized controlled trial of Asparagus racemosus (Shatavari) as a lactogogue in lactational inadequacy

Five adult patients with voluntary hand control, complicated by severe flexion contracture and spasticity secondary to brain injury, underwent subtotal carpectomy and radio-carpal or radio-metacarpal fusion. None of the patients were capable of functional prehension before surgery, and all had difficulty with hygiene due to their deformity. The deformities were beyond the scope of correction with soft tissue release. Two of the patients had previously undergone flexor-pronator origin release, musculo-tendinous lengthening of the wrist and finger flexors, or a combination of both. All five patients progressed to union without complication. Four achieved meaningful gains in functional grasp-release of the hand following the surgery.     

Evolution of chloroquine resistance in central and west Africa

Congenital deformities occur in approximately 1% of all live births. The exact incidence of congenital foot deformities is unknown. The presence of a circumferential nail of the toe is a very rare deformity. In our review of the literature, we have encountered only two previously reported cases of circumferential toenails. In these cases the patients were siblings and also had circumferential fingernails. This report describes circumferential toenails without other hand or other congenital deformities.     

Treatment of nail bed avulsions with split-thickness nail bed grafts

Experimental studies with squirrel monkeys indicated the feasibility of split-thickness grafting of segments of the nail bed. Thin grafts, when taken from the nail bed, achieved excellent take over of the avulsed areas. Thirty-one patients with avulsion of segments of the nail bed were treated with split-thickness nail bed grafts. The injured nail bed had sufficient residual nail bed to serve as a donor site in 24 patients. The remaining seven patients required split-thickness grafts from the lateral one third of the great toe. Of the 31 treated nail beds, there was a total of five deformities in which there was either nonadherence of the nail or irregularity of the nail surface. Twenty-six had nails with no deformity. No deformities occurred in the graft donor area. The split-thickness nail bed graft offers the advantage of frequent availability of tissue on the same injured digit and the absence of donor site deformity, whether on the same injured digit or a donor great toe.     

Brachymetatarsia: congenitally short third and fourth metatarsals treated by distraction lengthening--a case report and literature summary

Brachymetatarsia is an uncommon condition, and when present, it is usually asymptomatic. A case report demonstrating the use of distraction lengthening for symptomatic multiple congenital short metatarsals is presented. A 15-year-old female with congenital short third and fourth metatarsals was treated for painful transfer lesions under the second and fifth metatarsal heads and a secondary hallux valgus deformity. Surgical correction with a chevron osteotomy, soft tissue reconstruction of the second toe, and distraction lengthening of the third and fourth metatarsals was performed. Three years after treatment, the patient has an excellent clinical correction, with no evidence of recurrent transfer lesions. To our knowledge, this is the first report demonstrating the use of distraction lengthening without supplemental bone graft for multiple short metatarsals in a single extremity.     

Blue toe syndrome after initiation of low-dose oral anticoagulation

Cholesterol emboli are a known complication after arterial catheterization, arterial surgery, and after lysis with plasminogen activators. The clinical presentation of cholesterol emboli is variable ranging from a localized blue toe syndrome to a multisystem disease. The purpose of this case report is to report on a patient with blue toe syndrome and livedo reticularis occuring two months after initiation of low-dose oral anticoagulation with phenproucomon. The non-invasive studies revealed an infrarenal abdominal aneurysma lined by a thin wall thrombus as a potential source of cholesterol emboli. The patient had a benign course with resolution of toe pain after a period of four weeks, without development of an ulceration. The case report demonstrates that cholesterol emboli may also occur in patients treated with low-dose oral anticoagulation and no previous arterial catheterization.     

Thumb reconstruction by micro-vascular techniques

Sixty-three patients with thumb reconstruction by total or partial toe transfer have been reviewed. Mean age was 25 years. Males (84%) and manual workers (76%) dominated the series. The rate of failure was 3%. Second toe transfer gave a functionally acceptable thumb with 10 mm two point discrimination, 59% of strength in pinching (compared to normal side), 30 degrees of range of flexion but with a flessum deformity (average 27 degrees) and a poor cosmesis score (1.5 on a 5 point scale). Partial toe transfers were useful in amputations at metacarpophalangeal (MP) level and distal to this area. Around MP level, three techniques were available: wrap around, Twisted Two Toes and "bipolar" lengthening. More distally a "custom made" transfer allows to match exactly the defect. All of these techniques save the great toe length. When a pulp was incorporated in the transfer, two point discrimination averaged 9 mm and in the entire series the mean pinch strength was 93% normal and the mean cosmetic score was 3.5 points. Partial toe transfers are preferable in cases with any otherwise normal hand, providing good function and better cosmesis.     

Ethics in clinical research: searching for absolutes

Recently botulinum toxin has been used with increasing frequency as a safe and effective treatment for many previously refractory conditions associated with excessive muscle activity. The indications for use of botulinum toxin injection continue to expand. This report describes the case of an 83-year-old woman with a history of diabetes mellitus and lumbar spinal stenosis who developed a severe focal dystonia of the left great toe, such that the toe maintained the extended position. Functionally, the resultant deformity prevented the patient from wearing shoes. In addition, the patient had significant pain in the left great toe. Under needle electromyographic localization, 50 units of botulinum toxin were injected into the left extensor hallucis longus muscle. Two weeks after the injection the patient was symptom free and could place her left foot into a shoe. Seven months later, she remained symptom free. This case illustrates that localized injection of botulinum toxin to a specific lower limb muscle can effectively result in decreased muscle activity and functional improvement.     

The great toe as a clinical problem in rheumatoid arthritis

Two hundred consecutive in-patients with rheumatoid arthritis were examined for pain or deformity of the feet, and of the great toe in particular. Some abnormality occured in 196 feet and the deformities observed are presented. The symptoms that arise from these deformities are mainly derived from ill-fitting shoes, and the need for suitable foot-wear is emphasized. Two hitherto un-named entities are described namely Hallux tortus and chisel toe, since they give rise to their own shoe-fitting problems.     

Flexor tendon transfer for metatarsophalangeal instability of the second toe

Flexor to extensor transfer was used to treat painful second metatarsophalangeal joint instability in thirteen feet in eleven patients. All patients had their pain reproduced with vertical stress motion of 50% to 100% at the metatarsophalangeal joint. Seven feet had concomitant hallux valgus correction, two feet had no hallux valgus, and four feet underwent no correction for asymptomatic hallux valgus. Results at an average of 33.4 months followup showed that all patients had substantial pain relief, with eight patients becoming pain-free, and five patients experiencing mild pain. All but one were satisfied with their result. Stiffness appeared to be the source of the mild residual pain. All toes, including six toes with preoperative medial crossover toe deformity, were corrected into valgus alignment with adjacent toes. All toes operated on for the first time were able to touch the ground with grasp postoperatively. Flexor to extensor transfer is successful in reducing the second toe and relieving pain caused by instability of the second metatarsophalangeal joint, but may require rapid postoperative mobilization to ensure passive dorsiflexion equal to that of the adjacent toes to reduce postoperative uncomfortable stiffness.     

Management of clubfoot deformity in amyoplasia

Forty-one clubfeet in 22 patients with amyoplasia were studied retrospectively at a mean duration after surgery of 118 months (range, 45-253). The clubfeet were managed by a regimen including initial stretching casts, posteromedial release, and postoperative splinting at night. The mean age at the time of surgery was 7.3 months. Correction of deformity without recurrence was achieved in 11 (27%). Recurrent deformity was corrected by serial casting in eight feet and required secondary operative procedures in 20 feet. In the feet without recurrence of deformity, the duration of splinting at night after surgery was significantly longer than in those with recurrence (p < 0.05). At follow-up, 39 (95%) feet were plantigrade and were considered satisfactory. Our findings suggest that most clubfeet in amyoplasia can be effectively corrected by posteromedial release and that the recurrence of deformity can be reduced by splinting at night and often corrected by serial cast treatment.     

Fatigue analysis of human reinnervated muscle after microsurgical nerve repair

The reinnervated elbow flexors, biceps, and brachialis muscles were compared with the elbow flexors on the healthy opposite side in terms of muscle strength and fatigue in 10 patients who sustained sequelae of a unilateral posttraumatic brachial plexus palsy. The patients had recovered an active elbow flexion against resistance after microsurgical nerve repair. The patients were reviewed with an average postoperative followup of 12 years (range, 7.5-16 years). Despite a statistically significant difference in maximum isometric force, this study showed that after peripheral nerve repair, a partially reinnervated muscle has the same characteristics of fatigue and endurance as a normally innervated muscle, if these muscles exert the same percentage of their own maximum force.     

Requirement for multiple lymphocyte subsets in protection by a live attenuated vaccine against retroviral infection

STUDY DESIGN: A case report and literature review of thoracic hyperkyphosis deformity secondary to glucocorticoid-induced osteoporosis in Cushing's disease. OBJECTIVES: To identify the pathophysiology of glucocorticoid-induced osteoporosis and to outline the diagnosis and treatment options for a patient with severe spinal deformity secondary to unrecognized excess glucocorticoid activity. SUMMARY OF BACKGROUND DATA: Glucocorticoid-induced osteoporosis is seen in patients exposed to supraphysiologic levels of endogenous or exogenously administered glucocorticoids. In these patients, glucocorticoids act to suppress bone formation and increase bone resorption by indirect and direct effects. These patients have a high prevalence of trabecular bone loss, resulting in much higher rates of vertebral body collapse and pathologic fracture and thus causing an increased propensity toward kyphotic spinal malalignment. METHODS: The literature was reviewed and case reports studied. This case report highlights the pathophysiology of the disease process that caused the spinal deformity and the surgical intervention used to correct the kyphotic deformity after the metabolic problem was resolved. RESULTS: This patient has responded well to treatment and surgical intervention to correct a thoracic hyperkyphotic deformity without complication. CONCLUSIONS: Unrecognized endogenous production of glucocorticoids in Cushing's disease should be considered in young adult patients with progressive osteoporotic spinal deformities.     

Patterns of movement of totally intrinsic-minus fingers based on a study of one hundred and forty-one fingers

A detailed study of metacarpophalangeal flexion and interphalangeal extension movements of 141 fingers with complete intrinsic-muscle paralysis due to leprosy showed that long flexors and long extensors produce movement at the metacarpophalangeal and proximal interphalangeal joints simultaneously, and not successively as is generally believed. The amounts of flexion resulting from long flexor activity are almost equal at the two joints and metacarpophalangeal flexion is achieved without excessive flexion of the proximal interphalangeal joint, but this is masked by the claw-finger deformity. The movement resulting from activity of the long extensor is complex and there are three or more qualitatively different patterns of extension. Although the long extensor produces simultaneous extension at the metacarpophalangeal and proximal interphalangeal joints, the latter consistently lags behind the former so that full extension is not achieved at the proximal interphalangeal joint even when the metacarpophalangeal joint is maximally extended. The diverse patterns of extension are not related to duration of degree of clawing or to any particular finger.     

A simple technique for correction of complicated tibial deformity including rotational deformity

Although the simplest way to correct bone deformity is one-stage correction, the problem associated with that method is overstretching of the soft tissues, which limits the correction and leads to complications such as compartment syndrome or peripheral nerve palsy. If an adequate amount of tissue necessary for correction is formed in advance, the deformity can be corrected safely at one stage without overstretching of the tissues. A leg lengthening technique was employed to form the necessary tissues. After leg lengthening with an unilateral external fixator (Hifixator), deformities were corrected manually at one stage without anesthesia, and the corrected positions were again secured with the fixator. To correct rotational deformity, two sets of pins were inserted into the proximal bone fragment of the tibia at the time of the operation, and after lengthening the proximal pin clamp of the fixator was disconnected from one pin set and reconnected to the other set. We applied this method to four tibias of three patients without any complications. The tension of the tissues was monitored using a pressure sensor built into a Hifixator to prevent the tissues from overstretching. During and after the correction, the tension of the tissue was maintained at less than before the correction.     

Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint

Functional deficit following single distal index finger amputations has been considered insignificant, and reconstruction is usually not recommended. Herein, 19 cases of second toe transplantation for reconstruction of isolated index finger amputation distal to the proximal interphalangeal joint are presented with long-term functional results. There are 14 men and 5 women. The average age was 26 years. The toe transplantations were performed either as a primary procedure (5 patients) while the wounds were still open or as a secondary procedure (14 patients) after the wounds healed. In 11 patients, the dominant hand was involved. All toes survived completely, although re-exploration was required in three cases (16 percent). The functional evaluation included (1) sensory recovery, where the average static and moving two-point discrimination were 8 mm (range 4 to 15 mm) and 6 mm (range 2 to 15 mm); (2) motor function, where the average of index-thumb pulp-to-pulp pinch compared with the normal hand was 67.5 percent (range 36 to 96 percent); (3) average range of motion in index finger joints (extension/flexion), where metacarpophalangeal joint was 14/90, proximal interphalangeal joint was 0/94, and distal interphalangeal joint was 19/38; and (4) functional and cosmetic results, where percentage of involvement in daily activities and functional capacity of the reconstructed index were 69 percent and 70.5 in average, respectively, over a total score of 100. Average scores of aesthetic appearance and acceptability of donor-site deformity were 74 and 87.5 over a total score of 100, respectively. Toe transplantation for distal index finger amputations improved hand function when performed in selected patients with specific job requirements or high motivation.     

Impact of Routine Quality Assurance on Reliability of Bored Piles

Quality assurance (QA) tests, such as integrity tests, are routinely conducted to ensure the safety of pile foundations. QA tests provide additional information and result in changes in estimated reliability of pile foundations. This paper aims to formalize a procedure to quantitatively evaluate the impact of routine QA tests on the reliability of pile foundations. Three cases of reliability analyses based on interface coring of large-diameter bored piles are studied; namely, no toe debris detected, toe debris detected without repair, and toe debris detected and repaired. The prior information of the occurrence probability and thickness of toe debris is established based on a practice survey and accumulated QA data. The Bayesian approach is then applied to update the occurrence probability and the mean toe debris thickness based on outcomes of on-site QA tests and remedial actions taken after these QA tests. Subsequently, the reliability of the piles can be updated. The updated reliability can be significantly higher than that before the QA tests. The degree of reliability improvement depends on the pile specifics, the outcomes from the QA tests, and the remedial actions taken after the QA tests.     

The value of capnography and exhaled CO2 in neonatal intensive care units]

Congenital deficiency of the fibula is sometimes accompanied by femoral hypoplasia, genu valgum, patellar a/hypoplasia or dislocation, tibial bowing, foot deformity, and toe deficiency in the affected limb. 'Iliac horns' are bony projections extending posterolaterally from the ilium and considered to be pathognomonic of nail-patella syndrome. We report a 5-year-old Japanese girl with congenital complete deficiency of the left fibula, ipsilateral iliac horn and absence of the left kidney.     

Functional analysis of patients who have had a modified Van Nes rotationplasty

Electromyographic analysis of gait in eight patients who had had a modified Van Nes rotationplasty was performed to compare the activity of the flexors and extensors of the ankle on the side of the operation with that of the flexors and extensors of the knee on the normal, contralateral side. The resemblance in the activity of the extensors was more pronounced than that of the flexors. In three patients, the angle of flexion of the knee throughout the gait cycle was the same on the side of the rotationplasty as on the normal side. There was more symmetry in the swing phase than has been reported for patients who have had an above-the-knee amputation. The strength of the dorsiflexors of the ankle on the side of the rotationplasty was 68 percent and that of the flexors was 71 per cent when compared with that of the muscles of the normal ankle.     

Long-term followup of rheumatoid forefoot surgery

Rheumatoid forefoot deformities were treated originally at the Rheumatism Foundation Hospital by metatarsal head resection (II-V) and resection of the base of the proximal phalanx of the great toe. Recurrent great toe deformity with pain in numerous cases led to a comparative series of arthrodesis of the first metatarsophalangeal joint with resection of lesser metatarsal heads. At an average followup period of 3 years, the clinical evaluation and patient assessments were slightly in favor of arthrodesis. However, the patients' evaluation at 14 years was slightly in favor of resection. Measured in the plane of the first metatarsophalangeal joint, the recommended fusion position is 15 degrees valgus and 30 degrees dorsiflexion (females) and 25 degrees dorsiflexion (males). The position of the fusion is critical for a successful surgical outcome. Although both surgical methods give good pain relief and patient satisfaction, there is a risk of reoperation in the long term.