Foot & Ankle International

Rheumatoid arthritis occurring in children under 16 years of age is defined as juvenile rheumatoid arthritis. It is more common in females and the peak incidence is between 1 and 3 years of age. It can present in different forms. Mono- and pauciarticular type is complicated by iridocyclitis in 20%. Growth disturbances are common. Any conceivable combination of foot deformities can occur. Some of the secondary deformities can be prevented with conservative care. Principals of soft tissue and bony surgery have been outlined.

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is an ossifying diathesis characterized by excessive bone formation at specific skeletal sites. The condition is best recognized for its spinal features. However, the tendency toward bone formation is often manifested in extraspinal locations, particularly the foot. The radiographical, pathological, and clinical features of the disorder are reviewed with special emphasis on the foot as a target organ. Abnormalities in the foot that suggest the diagnosis of DISH are emphasized.

Rheumatoid diseases frequently involve the forefoot producing severe hallux valgus and dislocated metatarsophalangeal (MTP) joints. One must stress the importance of continual evaluation of the foot in these patients. The relationship of midfoot and hindfoot deformities, especially pronation deformities, to the forefoot is essential. Nonoperative treatment can be highly effective and consists of skin and nail care and proper shoes which enclose and support early deformities. Operative care now spans the gamut from excising all or part of the MTP joints, to silicone implant arthroplasty of the MTP joints.

In 1972 the original ICLH ankle was first used clinically, and since then the authors have implanted 75 ICLH ankles. The overall percentage of acceptable results in this series is about 70%.

The most frequent complication seen was delayed wound healing. Talomalleolar contact with resultant pain was a significant problem early in the series. Partial collapse of the talus has occurred in five ankles. Our experience has shown that it is possible to replace the ankle and initially achieve a functioning, pain-free arthroplasty. There are many factors that may adversely influence the ultimate outcome; and thus, the procedure should be approached with caution.

Patients with inflammatory arthritic disease of the feet invariably require conservative office management. The simplest method of obtaining relief has been to use commercially available extra-depth shoes combined with cus-tommade, removable, closed-celled polyethylene foam arch supports. These supports are soft, light, and can be accurately adjusted to each patient's pathology. The technique and modifications used for relieving the commonest problems, such as anterior metatarsalgia and plantar heel pain, are discussed.

Physical therapy is often necessary in the optimum treatment of foot and ankle disorders associated with connective tissue diseases, particularly rheumatoid arthritis. Thermal modalities and transcutaneous electrical nerve stimulation use for pain control are described, as well as a therapeutic exercise, ambulatory assistive devices, below the knee bearing braces, and the prescription of appropriately supportive and corrective footwear and shoe modification are discussed in the context of increasing comfort and minimizing deformity and disability.

This report documents the treatment of 33 foot and ankle ganglia. The average patient age was 3d years (versus 25 years for patients with ganglia about the wrist joint). Twenty-one ganglia were treated operatively and nine recurred. Three patients suffered cutaneous nerve injury. The other 12 ganglia were treated by aspiration and steroid injection. There were four recurrences, one of which was cured by a second injection. Two of the four recurrences were small and asymptomatic and required no treatment. There were no complications with aspiration and injection.

In view of the high recurrence rates and inconvenience of ganglionectomy in the foot, aspiration and steroid injection is a more safe, simple, and effective treatment. We feel that surgery should generally be reserved for failures of nonoperative treatment.

In an attempt to determine failure or reoperation rates for common forefoot procedures, the records of 706 patients who had 1003 forefoot operations were studied.

The revision rate for the Keller procedure was 2.26% when no interposition implant was used. The revision rate for metatarsal osteotomies, mainly due to nonunion, was 2.7%. The revision rate for proximal phalangectomies was 3.3%, being 1.9% when the distal end of the phalanx was removed and 4.4% when the proximal end was removed. The failure rate for proximal interphalangeal joint fusion was 17.8%.

These results demonstrate that the antiquity of a procedure is not necessarily a recommendation.

The authors present a case of a parosteal osteosarcoma of the fourth metatarsal in a 19-year-old male. This location has never been previously reported. The periosteal new bone formation without bone destruction must be differentiated from foreign body reaction and stress fractures. En bloc resection of the fourth and fifth rays was done. There has been no evidence of recurrence to date, 1 year and 10 months following the surgery. There has been an excellent functional result.

The running athlete has different needs from other athletes in terms of determination of his/her specific injury. Causation determination can be done through history. Specific pointers in terms of physical examination are noted to lead one to the diagnosis. Basic general treatment modalities are noted.

The Blair fusion is the accepted method to achieve an ankle arthrodesis in the presence of avascular necrosis or absence of the body of the talus. This procedure has not however, been reliable. A pseudarthrosis rate of 28% and fibrous ankylosis of the foot secondary to prolonged immobilization compromise the end result.

A tibiotalar compression arthrodesis has been developed using an intermediate hip compression screw and a modified Stone staple. Five patients with avascular necrosis of the talus underwent a modified Blair fusion. Protected weightbearing was started at 6 weeks and healing occurred within 3 months.

Although the number of cases is small, this study indicates that the addition of compression fixation to the Blair arthrodesis will significantly decrease the pseudarthrosis rate and perhaps the healing time.