Toe Deformity Research Articles

Treatment of Osteomyelitis of the Toes Without Amputation in the Wound Clinic Setting

Ulcers of the distal toe are common in patients with toe deformities and many times are complicated by osteomyelitis of the phalanx. Amputation of the toe is the standard treatment in many institutions; however, this can lead to abnormal biomechanics of the foot predisposing the patient to recurrent ulceration and further amputations, especially in patients with diabetes and those with neuropathy. It has been found that conservative, local operative procedures to remove the infected bone can avoid these complications and even avoid long-term antibiotic therapy. Many of these procedures can be performed in the wound clinic. To show its utility, a case report of this procedure and a small series of these patients treated in the wound clinic are presented.

СРАВНИТЕЛЬНАЯ ХАРАКТЕРИСТИКА ДИСТАЛЬНЫХ ОСТЕОТОМИЙ СРЕДНИХ ПЛЮСНЕВЫХ КОСТЕЙ ПРИ МОЛОТКООБРАЗНОЙ ДЕФОРМАЦИИ ПАЛЬЦЕВ СТОПЫ И ЦЕНТРАЛЬНОЙ МЕТАТАРЗАЛГИИ

Aim of the study. To compare the effectiveness of distal extension-shortening osteotomy (DESO) of the metatarsals and Weil-osteotomy in the surgical treatment of the middle hammer toe deformity and central metatarsalgia. Treatment outcomes were studied in 80 patients (75 women and 5 men) aged 31 to 79 years (median – 57 [52; 64] years) on 90 feet. The patients were divided into 2 groups: the study group – 32 people, where the DESO was used, and the comparison group – 48 people, in which a typical Weil-osteotomy was performed. Long-term results were studied within 6 to 46 months (median – 24 [10; 33] months). During the examination, a variant of hammertoe deformity was determined, radiometric parameters of the forefoot were measured, the Visual Analogue Scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society Lesser Toe Scale (AOFAS—II—V) were used. After surgery in the study group, the median VAS decreased to 1 [0; 1] points (p < 0,001), in the comparison group — up to 2 [0; 3] points (p < 0,001). Median AOFAS—II—V in the study group increased by 2,2 times and reached 93 [90; 95] points (p < 0,001), in the comparison group it increased only to 85 [73; 90] points (p < 0,001). The received data indicate a higher efficiency of DEMO for hammer toe deformity and central metatarsalgia compared to the standard Weil-osteotomy. The DEMO technique provides a pronounced reduction in pain syndrome (by 6 times), creates conditions for easy elimination of hammer toe deformity, improves the functional state of the forefoot by more than 2,2 times (according to AOFAS—II—V) and obtains positive treatment outcomes in 94,4 % of cases.

Outcome after resection arthroplasty or shortening oblique osteotomy of the lesser metatarsals combined with arthrodesis of the first metatarsophalangeal joint for severe rheumatoid forefoot deformities.

We investigated objective and patient-reported outcomes after resection arthroplasty or shortening oblique osteotomy (SOO) of the lesser metatarsals combined with arthrodesis of the first metatarsophalangeal (MTP) joint for severe rheumatoid forefoot deformities. 17 feet from 14 women (mean age, 67.8years) underwent resection arthroplasty of the lesser metatarsal heads (MTH resection group), while 13 feet from nine women and two men (mean age, 68.7years) underwent SOO of the lesser metatarsals (MTH preservation group). Arthrodesis of the first MTP joint was performed in all cases. Mean follow-up in the MTH resection and preservation groups was 25.0 and 21.3months, respectively. Preoperative and postoperative clinical evaluation included Japanese Society for Surgery of the Foot (JSSF) scale and self-administered foot evaluation questionnaire (SAFE-Q) scores. Mean total JSSF scale significantly improved from 53.4 to 76.4 in the MTH resection group (p < .001) and from 50.1 to 74.2 in the MTH preservation group (p = .002). Pain and pain-related and shoe-related SAFE-Q subscale scores significantly improved after surgery in both groups. In the MTH resection group, recurrence of painful callosities and claw toe deformity was observed in four and three feet, respectively. In the MTH preservation group, one patient experienced recurrence of painful callosities and one underwent revision surgery for IP joint dislocation. Resection arthroplasty or SOO of the lesser metatarsals combined with arthrodesis of the first MTP joint achieved significant improvement with respect to pain relief, deformity correction, and footwear comfort.

Is There a Difference in PROMIS Outcomes Between Patients Who Received K-Wire or Intramedullary Implant PIP Joint Arthrodesis for Hammertoe Deformity?

Category:Lesser ToesIntroduction/Purpose:Hammertoe corrective procedures are common foot and ankle procedures. Traditionally Kirshner wire (K-wire) fixation has been the gold standard in terms of fixation. Due issues such as pin loosening, failure, tract infection, fibrous pseudoarthrosis, and recurrent deformity with K-wire fixation, newer intramedullary implants have become widely used in the foot and ankle community. These implants have increased cost compared to K-wire fixation. The primary purpose of this study is to evaluate PROMIS T-scores for physical function (PF), pain interference (PI), and depression domains in patients who have undergone PIP arthrodesis by either K-wire or intramedullary fixation. The secondary goal is to determine if there are any differences in these two fixation groups in regard to complication or recurrence rates.Methods:From January 2010 to November 2019, prospective Patient Reported Outcome Measure Information System (PROMIS) score data was retrospectively reviewed for patients who had undergone a hammertoe deformity correction at a multi- surgeon tertiary foot and ankle clinic. Inclusion criteria was patient's older than 18 years, failed conservative management, undergone correction of lesser toe deformity with either K wire fixation or intramedullary fixation. Exclusion criteria was inadequate PROMIS data, previous fracture in same toe, revision surgery, both K wire and intramedullary fixation in the same toe. Preoperative scores were evaluated compared to postoperative scores at multiple time points. Chart review was also performed for patient demographics, complications, and revision surgery. PROMIS physical function (PF), depression, and pain interference (PI) scores were evaluated. Patients with incomplete data sets were excluded from the study. Complications and number of reoperations were noted for each group.Results:252 patients met inclusion criteria, 111 and 138 patient in the intramedullary (IM) and K-wire groups (KW) respectively. Univarate analysis demonstrated significant improvement in PROMIS PF and PI in IM group compared to KW group. Multivariate analysis demonstrated the following: KW group demonstrates a 2.9 point decrease in PROMIS PF post-operative scores relative to the IM group (95% CI -4.75 to -0.99; p = 0.003). The IM implants had significantly higher PF scores than the K-wire group at final follow up (p<0.05). BMI, smoking, and Medicare/Medicaid insurance demonstrated worse PF scores (p<0.05). PROMIS PI did not demonstrate a difference between groups (95% CI -0.377 to 3.724; p = 0.110). The KW group did not demonstrate increase recurrance rate (OR 0.348 95% CI 0.118-1.027; p = 0.056), but did trend towards a higher complication rate compared to the IM group (OR 2.049, 95% CI 0.92 to -4.54; p = 0.078).Conclusion:There is evidence that use of intramedullary implants for operative correction of hammertoe deformity is superior to K-wire fixation in regard to post-operative patient reported measures, specifically the PROMIS domains of physical function. Intramedullary implant use does not increase complication or recurrence rates. Additionally, advanced age, increased BMI, positive smoking status, and Medicare or Medicaid payor status negatively affect patient reported outcomes, which can be used to council patients appropriately. The limitations are that cost of intramedullary implants, are more expensive when compared to conventional K-wires.

ХИРУРГИЧЕСКАЯ КОРРЕКЦИЯ ЦЕНТРАЛЬНОЙ МЕТАТАРЗАЛГИИ И МОЛОТКООБРАЗНОЙ ДЕФОРМАЦИИ СРЕДНИХ ПАЛЬЦЕВ СТОПЫ С ПРИМЕНЕНИЕМ РЕЗЕКЦИОННОЙ АРТРОПЛАСТИКИ ПЛЮСНЕФАЛАНГОВЫХ СУСТАВОВ

Aim of the study. To evaluate the effectiveness of resection arthroplasty of the metatarsophalangeal joints (MTP joints) in the surgical treatment of hammer toe deformity of the II­III­IV toes, accompanied by severe overload metatarsalgia. The results of surgical treatment of hammertoe deformity of 102 toes on 50 feet in 36 patients (32 women and 4 men) aged 39 to 79 years (median age 58 [54; 64] years) were studied. Long­term results were followed­up from 8 to 50 months (median – 30 [25; 38] months). Treatment outcomes were assessed by determining the placement of hammer toes in the joints, measuring the passive range of motion (PROM) in the MTP joint, calculating the forefoot X­ray parameters, using the Visual Analogue Scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society Lesser Toe Scale (AOFAS­II­V). The measurement the PROM in the 2nd, 3rd and 4th MTP joints showed a decrease in their amplitude by 20.3–22.8 % in the long­term period after surgery. The pain assessment according to the VAS scale showed a decrease in the median value from 6 [6; 7] points before surgery up to 2 [1; 4] – after the surgical procedure, and the median score on the AOFAS­II­V scale increased from 35 [30; 45] to 79 [65; 85] points. Positive outcomes were achieved in 88 % of cases. The results of the study indicate the effectiveness of resection arthroplasty of the MTP joints in the treatment of overload metatarsalgia with hammer toe deformity of the 2nd, 3rd and 4th toes. Shortening of the middle metatarsals easily correct hammer toe deformity and eliminate pain. At the same time, the disadvantage of the technique is a decrease range of motion (ROM) in the resected MTP joints, therefore, early and active development of movements in the postoperative period is necessary.

First metatarsophalangeal joint arthrodesis with titanium cage implant to address iatrogenic deformities of the first ray

First metatarsophalangeal joint arthrodesis with titanium porous lattice cage implant can be a feasible salvage procedure to restore length of the first ray, reestablish the metatarsal parabola, stabilize the first metatarsophalangeal joint and correct for positional deformity of the hallux. This case series describes the surgical technique and functional outcomes in 2 patients who underwent first metatarsophalangeal joint arthrodesis using a titanium porous lattice cage implant system secondary to significant deformities of the first metatarsal head. Patient 1 (N1) was diagnosed with avascular necrosis of the first metatarsal head and a significantly shortened first metatarsal, which subsequently developed from a previously attempted hallux valgus surgery. Patient 2 (N2) was diagnosed with a severe contracted mallet toe deformity of the hallux, which subsequently developed from a previous first metatarsophalangeal joint resection due to acute osteomyelitis of the first metatarsal head secondary to a puncture wound. Both patients achieved optimal surgical outcomes with complete radiographic and clinical osseous incorporation of the cage implant and arthrodesis site. No recurrence of any first metatarsophalangeal joint deformity was identified. Each patient eventually returned to regular shoe gear and preoperative activity levels, including full preoperative employment work status. Both patients expressed satisfaction in their surgical outcomes. Therefore, first metatarsophalangeal joint arthrodesis with titanium porous lattice cage implant can be utilized to address certain iatrogenic deformities of the first ray.

Proximal Phalanx Osteotomy in Percutaneous Correction of the Lesser Toe Deformities: A Cadaver Study

Category:Lesser ToesIntroduction/Purpose:The correction of lesser toe deformities has been traditionally performed in an open fashion. With minimal-invasive foot surgeries becoming increasingly popular, correction of lesser toe deformities via percutaneous soft-tissue procedures and osteotomies is frequently performed. The aim of this study was to evaluate the site of percutaneous proximal phalanx osteotomy of the lesser toes in relation to the metatarsophalangeal joint line when performed without fluoroscopy guidance.Methods:In this experimental cadaver study, the metatarsophalangeal joints of the lesser toes of 20 cadaver samples (=80 toes) were palpated. A plantar skin stab incision was made just distal to the joint line without fluoroscopic control. Plantar closing osteotomies of the proximal phalanx were performed with a Shannon burr. Adorsoplantar view was taken with fluoroscopy. The location of the osteotomy and the relative distance from the metatarsophalangeal joint line was evaluated.Results:The majority (78/80; 97.5 %) of the osteotomies were localized in the metaphyseal region. No osteotomy violated the metatarsophalangeal joint.Conclusion:Percutaneous osteotomy of the proximal phalanx of the lesser toes guided by palpation without using the image intensifier is a safe procedure and does not violate the metatarsophalangeal joint.

The Weil Osteotomy for Angular Correction of Axial Plane Deformities of the Lesser MTP Joints: A Radiographic Analysis

Category:Lesser Toes; Midfoot/ForefootIntroduction/Purpose:The oblique shortening (Weil) osteotomy of the distal metatarsal neck has been described as an effective means of correcting lesser toe metatarsophalangeal joint deformity. Previous studies have focused on clinical outcomes, complications, and the magnitude of plantar displacement and shortening. The aim of this study was to quantify the magnitude of axial plane correction obtainable when a medial or lateral displacing Weil osteotomy was used in conjunction with other procedures in forefoot reconstruction surgery.Methods:Consecutive patients with a minimum 12-month follow-up who were treated by the senior surgeon from January 1, 2008, to September 1, 2018, were included. Review of the medical records identified 234 toes in 190 patients that had medial or lateral displacement Weil osteotomies as a part of their treatment for metatarsalgia and lesser toe deformity. Concomitant procedures were recorded. Pre- and post-operative weightbearing radiographs were analyzed to determine the amount of transverse plane change and residual varus/valgus alignment. Radiographs were then classified as good (<10 degrees of angulation), intermediate (10-15 degrees), or bad (>15 degrees). Any worsening of the post-operative alignment compared to the pre- operative alignment was noted. Follow-up notes were reviewed for clinical observations of floating toe, resting alignment, persistent pain and swelling at 3 months, complications, and need for revision surgery.Results:The average transverse plane correction was 12.5 degrees (range 0-45 degrees). Most toes remained in some degree of radiographic varus or valgus alignment as a true neutral toe was rare. Over a third, (35%, n=81) had increased postoperative angulation; 42% of radiographs were graded as good alignment (n=99), 20% as intermediate (n=46), and 38% as bad (n=90). The most common concomitant procedures were PIP joint resection arthroplasty and distal chevron bunionectomy. Review of clinic notes revealed low incidences of floating toe (7%, n=16), clinical malalignment (8%, n=18), and need for revision surgery (3%, n=8). Persistent swelling was the most common complication, present in 44% of patients at the 3-month follow-up.Conclusion:The medial and lateral displacing Weil osteotomy can be a powerful tool to correct lesser toe MTP joint transverse plane deviation. It was typically used with PIP joint resection and hallux valgus procedures to improve the lesser toes and overall forefoot alignment. Interestingly, most toes had a neutral or good clinical alignment regardless of the radiographic alignment. Further studies to correlate radiographic and clinical outcome measures may help define its role in correcting lesser toe deformity.

Minimally Invasive Surgery for Severe Hallux Valgus with Severe Metatarsus Adductus: Case Reports

Category:Bunion; Lesser ToesIntroduction/Purpose:Metatarsus adductus (MA) is a congenital transverse plane deformity with an incidence of approximately 30% in patients with hallux valgus. Operative treatment of hallux valgus (HV) with MA can be clinically challenging, and the recurrence rate of HV has been reported as two times higher than in patients without MA. Minimally invasive surgery (MIS) for the correction of HV is growing in popularity; however, only one study has been published on MIS for HV with MA using percutaneous proximal metatarsal osteotomy. We presented our case reports using distal oblique metatarsal minimal invasive osteotomy (DOMMO) for severe MA.Methods:We corrected two feet using DOMMO for severe MA. Minimally invasive chevron Akin osteotomy (MICA) was utilized to correct severe HV. The patient had subluxations in the second and third metatarsophalangeal joints and hammer toe deformities. Therefore, those deformities were concurrently corrected using percutaneous procedures. The patient was allowed immediate full weight bearing postoperatively in a flat rigid shoe for 6 weeks. Radiographic and clinical evaluations were performed preoperatively and one year after surgery. On the anteroposterior radiograph, the hallux valgus angles (HVA), the first intermetatarsal angles (IMA), tibial sesamoid positions (TSP) and metatarsus adductusangles (MAA) were evaluated. On the lateral weight-bearing radiograph, first metatarsal inclination angles were also evaluated. We also evaluate the Japanese Society for Surgery of the Foot (JSSF) hallux and lesser toes scales and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) both before and after MIS for HV with MA.Results:In the first case, the HVA improved from 50° to 16°, the IMA from 15° to 11°, TSP from 7 to 5 using Hardy's classification, and MAA from 27° to 14.5°, pre- to postoperatively. In the second case, the HVA improved from 45° to 11°, the IMA from 10° to 6.5°, TSP from grade 7 to 3, MAA from 30 to 12, pre- to postoperatively. The first metatarsal inclination angles changed from 16.9° and 18.8° to17.7° and 22.0°, respectively. All subluxations and hammer toe deformities were resolved. Although there were delayed unions in the lesser metatarsals, unions were achieved finally. Preoperative JSSF hallux scales and lesser toes scales were 59 points and 64 points, 67 points and 80 points, respectively. Both hallux and lesser toe scales improved to 100 points one year after surgery. All SAFE-Q subscores were also improved one year after surgery.Conclusion:In conclusion, our MIS procedure, consisting of DOMMO of the second, third, and fourth metatarsals and MICA, could correct severe HV with severe MA. The patient was allowed immediate full weight bearing postoperatively in a flat rigid shoe. Although there were delayed unions in lesser metatarsals, unions were finally achieved and good results were demonstrated both radiographically and clinically.

A Case Report on Stoneman Syndrome

Fibrodysplasia ossificans progressive is a debilitating autosomal dominant disease characterized by postnatal progressive heterotopic which tissue that connects things together ossification and congenital deformities of the big toes. Fibrodysplasia ossificans progressiva affects about one out of every two million newborns born world wide.&#x0D; Almost ninetypercent of people with fibrodysplasia ossificans progressiva are misdiagnosed and treated wrongly, resulting in ineffective treatments. Approximately 700 cases have been identified so far around the world. Clinical examinations, radiographic evaluations, and ACVR1 gene mutation testing are all considered confirmatory approaches for early illness diagnosis.&#x0D; Case Presentation: We're reporting on the case of a 45-year-old man who was admittedt in our facility.&#x0D; He had clinical and radiological evidence of fibrodysplasia ossificans progressing, as well as multiple painful lumps on his back due to hard masses and rigidity of his shoulders, neck, and left hip.His left hip ossification was surgically removed, but he experienced an increased ossification reaction and early impairment as a result.&#x0D; Conclusion: Fibrodysplasia ossificans progressive is an uncommon and severe illness that, if misdiagnosed, can result in inappropriate surgical intervention and early paralysis with disastrous consequences.&#x0D; We need to educate clinicians and patients' families concerning the disease, as well as its symptoms for early detection and how to prevent flare-ups, in order to improve quality of life.

What is new about hallux rigidus?

Hallux rigidus (HR) represents one of the most frequent forefoot disorders, together with hallux valgus and lateral toe deformities, being the most frequent degenerative process in the foot and ankle.This publication is the result of the collaboration of colleagues of the Spanish Society of Medicine and Foot and Ankle Surgery (Sociedad Española de Medicina y Cirugía del Pie y Tobillo, SEMCPT) and the Argentinean Society of Medicine and Foot and Leg Surgery (Sociedad Argentina de Medicina y Cirugía de Pie y Pierna, SAMCPP). It is an honor for us to have this work edited in the Journal of the Foot &amp; Ankle, a journal with a marked Latin identity. We really thank Alexandre Leme Godoy-Santos, Chairman of the Editorial Board, for his help and contribution. This update topic has been coordinated by R. Viladot Pericé and A. Viladot Voegeli, together with M. Herrera and M. Núñez-Samper.Considering the interest and the extent of this topic and, according to the coordinators, we have divided the publication into two parts. The first one describes general aspects (definition, etiology, classification, treatment algorithm, etc.) and the conservative treatment of HR, whereas the second one addresses the different surgical techniques described to treat this disease.The aim of this work is to review our knowledge on HR and to perform an update on the innovations that have emerged during the last years.

New method of surgical correction of lesser toes deformity

Background. Patients’ dissatisfaction with the results of surgical correction of lesser toes deformities, the shortcomings of methods aimed at eliminating the lateral deviation of the toe in the metatarsophalangeal joint necessitated the development of a new surgical method.The aim. To evaluate short-term results of the new surgical method for the treatment of patients with lesser toes deformity, accompanied with deviation of the toe.Materials and methods. A method of surgical treatment of deviated deformity of the small toes is proposed. The method includes precise marking of the metatarsal osteotomy line according to the previously calculated parameters of optimal shortening and displacement of the metatarsal bone, performing oblique diaphyseal osteotomy of the metatarsal bone, displacing its distal part along the osteotomy plane. According to the proposed method, nine patients were operated on who had a syndrome of nonrigid hammer-like deformity of the second toe with lateral deviation of the toe in the metatarsophalangeal joint. In all patients, the deformity of the second toe was associated with hallux valgus.Results. As a result of the application of the proposed method, it was possible to achieve deformity correction, eliminate the lateral deviation of the second toe in the metatarsophalangeal joint, restore congruence in the joint, achieve consolidation of bone fragments without loss of correction, and improve the appearance and function of the foot. Three months after the operation, a statistically significant improvement was determined, according to the AOFAS LMIS scale, having reached 94.5 ± 4.64 points, which made it possible to speak about the achievement of a good functional result of treatment. Patients noted the opportunity to wear standard footwear, to carry out their labor activity, to engage in physical culture, were satisfied with the result.Conclusion. The use of the proposed new surgical method for deflected deformity of the lesser toes makes it possible to correct the deformity, eliminate lateral deviation of the toe, relieve pain syndrome, achieve a good cosmetic and functional result, restoring the patients’ ability to wear standard shoes.

Hallux Valgus Deformities: Preferred Surgical Repair Techniques and All-Cause Revision Rates.

Hallux valgus is a commonly treated condition by foot and ankle surgeons with more than 200 different described correction techniques. Recurrence rates range from 5% to 50%, with increasing support of the theory that arthrodesis procedures may have a lower recurrence rate than osteotomies. Arthrodesis procedures to the first metatarsophalangeal (MTP) joint or tarsometatarsal (TMT) joint for correction of hallux valgus deformity are becoming more commonly utilized. The purpose of this study is to investigate the surgical incidence and revision rates of hallux valgus deformities corrected by arthrodesis compared to osteotomy in the state of South Carolina. The South Carolina Revenue and Fiscal Affairs Office was queried from 2000 to 2017 to identify all surgically treated hallux valgus deformities. Data extraction included patient demographics, ICD-9 diagnoses, CPT procedure codes, and dates of surgery. A logistic regression model was used for statistical inference. A total of 22 199 feet had surgical treatment for hallux valgus during this time period, with 20 422 (92.0%), 592 (2.7%), and 1185(5.3%) receiving an osteotomy, arthrodesis, or other procedure at initial treatment, respectively. There was an all-cause revision rate of 5.6% in the osteotomy group and 6.4% in the arthrodesis group. Demographic factors such as female sex, white race, and surgery pre-2010 were associated with higher revision rates. Multiple comorbidities were correlated with higher revision rates such as tobacco use, hypothyroidism, osteoarthritis, recurrent dislocations, hallux rigidus, lesser toe deformities, metatarsus varus, and talipes cavus. Despite the recent increase in arthrodesis procedures for the treatment of hallux valgus deformity, our results suggest that osteotomy procedures are more commonly performed and there is no difference in all-cause revision surgery. However, there are multiple patient demographics and comorbidities that are associated with higher rates of revision surgery and should be considered and discussed during the preoperative planning period. Level IV.

Osteopoikilosis with bony deformities of the right toes in a female child: Case report.

IntroductionOsteopoikilosis (OPK) is an extremely rare benign condition with sclerosing bony dysplasia and multiple benign enostoses. OPK is usually asymptomatic and is typically an incidental finding on imaging studies for unrelated conditions.Case presentationWe presented a case of OPK in a 7-year-old female with hallux valgus, shortening and deformity of second and third metatarsals in the right foot. These abnormalities were observed on clinical findings with X-ray imaging, and osteopoikilosjs was confirmed by histopathology. The deformities were treated with surgical intervention, and the patient's condition was followed for 3 months until the patient walked and removed the gypsum.DiscussionOP is a rare, benign disease that rarely causes bony deformities. It is diagnosed clinically and radiographically, so that the deformities are treated only surgically. Follow-up is necessary to assess the movement of the limb.ConclusionThe distinctive thing that can be added to the medical literature is that it is possible for osteopoikilosis to cause bone deformities at an early age.

Иерсиниозный реактивный артрит: трудности диагностики и лечения (собственный опыт)

Реактивный артрит (РеА) остается важной проблемой в практике ревматолога и является одним из самых распространенных видов острого артрита у лиц молодого возраста. Актуальность РеА связана с его высокой частотой, трудностями диагностики, достаточно частой хронизацией при недостаточно эффективном лечении. В статье обсуждаются современные данные литературы об иерсиниозном артрите, особенностях патогенеза, диагностики и лечения. Возникновение РеА чаще всего ассоциировано с желудочно-кишечной или урогенитальной инфекцией, которая предшествует развитию суставного синдрома. Среди РеА, связанных с кишечной инфекцией, иерсиниозный артрит встречается достаточно часто. Кишечный иерсиниоз отличается тяжестью, значительной длительностью течения с тенденцией к хронизации, вовлечением в патологический процесс различных органов и систем. При этом особенности возбудителей иерсиниоза в сочетании с условиями заражения обусловливают разнообразие клинических проявлений. Болезнь имеет высокую ассоциацию с антигеном HLA-B27. Общими клиническими симптомами РеА являются асимметричный артрит, чаще суставов нижних конечностей, сосископодобная дефигурация пальца стопы, тендинит, энтезит (наиболее характерен энтезит пяточного сухожилия), асимметричный сакроилеит. Частота и выраженность внесуставных проявлений могут быть различными: поражение глаз, кожи, слизистых оболочек, урогенитального или желудочно-кишечного тракта. Препаратами первой линии в лечении РеА являются нестероидные противовоспалительные средства. Пациенты с активным очагом инфекции также требуют длительного лечения с применением антибактериальной терапии, а при хронизации артрита к терапии добавляют сульфасалазин. В статье изложен клинический случай иерсиниозного реактивного артрита с акцентом на мультидисциплинарном подходе в ведении больного.

Assessment of the severity of curly toe

BackgroundCurly/underlapping toe involves flexion, adduction, and varus deformity of the interphalangeal joints. There are no previous reports showing the relationship between physical examination and X-ray findings among patients with curly toe deformity. MethodsWe investigated the clinical findings of 116 consecutive patients associated with 239 underlapping toes. We compared the age and affected toes between patients whose deformities were pointed out at a pediatric medical examination (group 1) and those referred for medical treatment (group 2). The degree of curly toe deformity was graded by a physical examination and X-ray. ResultsThe average age at presentation was 2.7 years. The affected toes were significantly different between groups 1 and 2 (p < .001). The morbidity of each toe differed significantly in group 2 (p < .005) but not in group 1. The correlation between the appearance grading and classification by X-ray was very strong using Spearman's rank correlation coefficient. The severity of curly toe was divided into mild in 104 toes, moderate in 105 toes, and severe in 17 toes. The methods of conservative treatment were observation only in 15 cases, manipulations in 30 cases, taping in 67 cases, and a brace in 9 cases. Surgery was performed in 8% of cases. ConclusionCurly toe deformity of the third or fourth toes tend to be referred for medical treatment because of the abnormality. Our grading system using a physical examination and classification by X-ray was useful for assessing the severity of curly toe.

Are foot deformity and plantar sensitivity impairment associated with physical function of community-dwelling older adults?

BackgroundFoot deformities are highly prevalent in older adults and negatively impact their mobility and quality of life. However, the association between foot problems and physical function is still unclear. ObjectiveTo investigate whether structural foot deformities and plantar tactile sensitivity are associated with lower extremity physical function impairment in community-dwelling older adults. MethodsWe included 200 men and women aged 60 years and older from a community-based program. The foot assessment included toe deformities and calluses inspection and evaluation of plantar tactile sensitivity using monofilaments. The Short Physical Performance Battery (SPPB) was used to assess lower extremity physical function. We conducted a multivariate logistic regression analysis to investigate the association between foot problems and lower extremity physical function. ResultsHallux valgus was the most prevalent deformity among older adults. Those participants with reduced plantar tactile sensitivity (OR= 2.77; 95% CI: 1.38, 5.55) and a hallux valgus (OR= 2.23; 95% CI: 1.10, 4.52) were more likely to present poor lower extremity physical function. ConclusionHallux valgus and impaired plantar sensitivity were associated with reduced lower extremity physical function in older adults. Further studies are necessary to identify this causality and to what extent management of these foot problems can improve general mobility and quality of life of older adults.

A Novel Radiographic Measurement Method for the Evaluation of Metatarsophalangeal Joint Dislocation of the Lesser Toe in Patients with Rheumatoid Arthritis.

Dorsal dislocation of metatarsophalangeal (MTP) joints of the lesser toe frequently occurs in patients with rheumatoid arthritis (RA), and may cause painful and uncomfortable plantar callosities and ulceration. The current study examined the reliability and clinical relevance of a novel radiographic parameter (the MTP overlap distance [MOD]) in evaluating the severity of MTP joint dislocation. The subjects of the current study were 147 RA patients (276 feet; 1104 toes). MOD, defined as the overlap distance of the metatarsal head and the proximal end of the phalanx, was measured on plain radiographs. The relationship between the MOD and clinical complaints (forefoot pain and/or callosity formation) was analyzed to create a severity grading system. As a result, toes with callosities had a significantly larger MOD. ROC analysis revealed that the MOD had a high AUC for predicting an asymptomatic foot (−0.70) and callosities (0.89). MOD grades were defined as follows: grade 1, 0 ≤ MOD < 5 mm; grade 2, 5 ≤ MOD < 10 mm; and grade 3, MOD ≥ 10 mm. The intra- and inter-observer reliability of the MOD grade had high reproducibility. Furthermore, the MOD and MOD grade improved significantly after joint-preserving surgeries for lesser toe deformities. Our results suggest that MOD and MOD grade might be useful tools for the evaluation of deformities of the lesser toe and the effect of surgical intervention for MTP joints in patients with RA.

Correction of Severe Crossover Toe Deformity By Plantar Plate Tenodesis, Arthroscopic Release of Lumbrical and Plication of Lateral Capsuloligamentous Complex

Plantar plate deficiency is the major cause of instability of the metatarsophalangeal joint, and plantar plate tenodesis can provide dynamic stabilization of the plantar plate. In case of crossover toe deformity, incorporation of arthroscopic release of the medial capsuloligamentous complex and the lumbrical tendon can eliminate the medial deforming force. However, in case of severe deformity, the lateral capsuloligamentous complex is attenuated. The purpose of this Technical Note is to incorporate the technique of arthroscopic plication of the lateral capsuloligamentous complex into the technique of plantar plate tenodesis and arthroscopic release of the medial capsuloligamentous complex and the lumbrical tendon.

Associations between changes in loading pattern, deformity, and internal stresses at the foot with hammer toe during walking; a finite element approach

Over the past decade, Finite Element (FE) modelling has been used as a method to understand the internal stresses within the diabetic foot. Foot deformities such as hammer toe have been associated with increased risk of foot ulcers in diabetic patients. Hence the aim of this study is to investigate the influence of hammer toe deformity on internal stresses during walking. A 3D finite element model of the human foot was constructed based on capturing Magnetic Resonance Imaging (MRI) of a diabetic neuropathic volunteer exhibiting hammer toe. 3D gait measurements and a multi-body musculoskeletal model for the same participant were used to define muscle forces. FE simulations were run at five different instances during the stance phase of gait. Peak plantar pressure and pressure distribution results calculated from the model showed a good agreement with the experimental measurement having less than 11% errors. Maximum von Mises internal stresses in the forefoot hard tissue were observed at the 3rd and 5th metatarsals and 4th proximal phalanx. Moreover, presence of hammer toe deformity was found to shift the location of maximum internal stresses on the soft tissue to the forefoot by changing the location of centre of pressure with internal stress 1.64 times greater than plantar pressure. Hammer toe deformity also showed to reduce the involvement of the first phalanx in internal/external load-bearing during walking. The findings of this study support the association between changes in loading pattern, deformity, and internal stresses in the soft tissue that lead to foot ulceration.