Multiple osteotomies and forms of fixation have been proposed for arthrodesis of the hallucal interphalangeal joint. In this brief article, the authors present their preferred "V"-shaped osteotomy combined with the use of internal fixation to allow for intrinsic stability and compression across the fusion site. The authors propose that this basic technique be considered in order to obtain reproducible results in patients requiring hallux interphalangeal joint arthrodesis.

Seizure monitoring unit (SMU) research typically focuses on diagnostic utility and medical management of epilepsy. However, patient safety and satisfaction are also imperative to high-quality SMU care. This study uses a standardized tool to evaluate patient experience on a SMU compared to a general neurology unit (GNU). The 27-item Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was telephone-administered post-discharge to a sample of patients from our SMU and GNU. Data from a 33-month period were reviewed, encompassing 217 SMU patient admissions and 317 GNU patient admissions. On average, SMU patients were 14.7 years younger and stayed in the hospital 4.2 days longer than GNU patients. SMU patients provided lower overall mental health ratings (p<.001), perceived nursing staff to be more responsive to the call button (p<.001), and assigned higher overall ratings to their stay (p<0.05). Lower education was associated with more favorable hospital ratings on both units (p<0.05).

A retrospective chart review was conducted of 35 patients (40 feet) who received hyperbaric oxygen (HBO) therapy after partial foot amputation between 1990 and 2000. Preoperative transcutaneous partial pressure of oxygen (tcPO2) levels, the number of hyperbaric treatments, time to final outcome, use of revascularization procedures, and postsurgical outcome were extracted from the charts. Seventy percent (n = 28) had a successful outcome, defined as complete healing and absence of ulceration at the amputation site, and lack of further surgical procedures to heal the amputation site; whereas 30%(n = 12) had a failed outcome, defined as lack of healing or the presence of an ulcer at the site of amputation or the need for further surgery to heal the amputation site. The level of amputation, use of revascularization procedures, time to final outcome, and number of hyperbaric treatments were not significantly different (P >.05) between the 2 postsurgical outcome groups. The mean preoperative tcPO2 levels were greater (P <.01) in the successful (24 +/- mm Hg) than in the failed (11 +/- mm Hg) outcome groups. All patients with a tcPO2 level > 29 mm Hg had a successful outcome. Patients with a successful postsurgical outcome had a mean of 20 HBO treatments and took 44 days to final outcome, while those with a failed postsurgical outcome had 16 HBO treatments and took 216 days to final outcome.

Heel pain is one of the most common presenting complaints to the foot and ankle specialist. There are many causes for subcalcaneal heel pain, including biomechanical, traumatic, those related to several types of arthritides and tumors, and anatomic causes. This article describes pathologic conditions of the heel, concentrating on tumors and arthritides.

Daily activities, such as walking or running, put a certain degree of stress and demand on the tendons of the lower extremities. To date, there are very few reported cases in the literature concerning pathology of the anterior tibial tendon or muscle. Of those cases reported and discussed, the majority were complete ruptures as a result of an acute forced injury, with very few reports of secondary pathological conditions or laceration injuries. This article is a review of the literature, as well as conservative versus surgical treatment and the sequelae following such injuries.

Numerous surgical procedures have been described for the treatment of the adult acquired flatfoot deformity. The surgeon should review in detail all the clinical, radiographic and imaging tests and propose the best surgical procedure for the patient. Although flexor tendon transfer has shown excellent results, the split anterior tibial tendon transfer is a second option. If used properly, the Cobb procedure results in less functional loss, since only half of the anterior tibial tendon is transferred. Furthermore, the flexor tendon is not disrupted and continues its primary function in the foot and ankle. Ultimately, the goals of the surgical procedure are to alleviate the patient's symptoms and pain, restore a normal foot alignment, and limit the loss of foot and ankle function without causing any complications.

BACKGROUND: The failure of nonsurgical treatment of patients with midfoot and hindfoot deformity secondary to diabetic Charcot arthropathy may lead to a rocker-bottom foot deformity with recurrent or persistent plantar ulceration. We report our experience with realignment and extended fusion with primary use of a medial column screw for this midfoot deformity. METHODS: From July 2001 through July 2005, we performed reconstructive surgery on fifteen adults with diabetes mellitus who had a severe neuropathic midfoot deformity consisting of a collapsed plantar arch with a rocker-bottom foot deformity. Thirteen had a nonhealing midfoot plantar ulcer. All underwent realignment and arthrodesis with a medial column screw; some required additional fixation techniques depending on the extent of the deformity. Outcome measures included ulcer and surgical wound-healing, radiographic results, complications, and the need for amputation. RESULTS: The mean duration of clinical follow-up was forty-two months. Fourteen patients were able to walk, and there were no recurrent plantar ulcers. Thirteen patients were able to wear custom-made extra-depth, wide-toed shoes with molded inserts. One patient without prior ulceration had development of a deep infection that necessitated an amputation. Four feet had a nonunion, one of which was symptomatic requiring a revision to obtain union. CONCLUSIONS: Surgical reconstruction of a collapsed neuropathic foot deformity is technically demanding, but a successful outcome can result in a plantigrade foot that is free of ulceration and abnormal pressure points and a patient who is able to walk. The procedure described has an acceptable degree of complications although it has a high rate of nonunion.

A common complication associated with diabetes is the development of a rigid structural lesser toe contracture, which, when combined with peripheral sensory neuropathy, can lead to ulceration, infection, and amputation. Surgical correction of lesser toe contractures in persons with diabetes has been advocated to decrease the potential for ulceration and amputation. Lesser toe proximal interphalangeal joint arthrodesis employing myriad joint preparation and fixation methods is commonly performed to correct a rigid structural toe contracture. The author performed a retrospective, observational, cohort study involving 10 patients (30 toes) with diabetes, dense peripheral neuropathy, and rigid structural toe contracture treated with a 1-piece shape-memory Nitinol intramedullary internal fixation device for arthrodesis of the proximal interphalangeal joint. Successful fusion was achieved in 28 of 30 toes (93%), with a stable nonunion achieved in the remainder. Complications that arose occurred early in the author's experience with this implant and consisted of secondary contracture of the distal interphalangeal joint (23%), displaced fixation (13%), and malunion (7%). No patient developed ulceration, and no additional surgery has been required to date. When properly performed, the use of this implant for arthrodesis of the proximal interphalangeal joint in neuropathic patients with diabetes appears safe and reliable.

Degenerative joint disease is not uncommon in patients with lower extremity amputations. These patients are candidates for joint arthroplasty procedures; however, certain modifications may be necessary during the procedure to overcome the challenges presented by the amputation. The authors describe a total hip arthroplasty in a 51-year-old patient 45 years after an ipsilateral through-knee amputation. The patient was informed that the data concerning his case would be submitted for publication, and he consented.

Pedal amputations are necessary procedures performed by a foot and ankle surgeon that may lead to gross positional deformities of the foot. To achieve a plantigrade foot, proper balancing of the foot is required often through the use of tendon transfers and lengthening. This article describes the basic tendon transfers needed to achieve a successful outcome when performing various pedal amputations. A case is presented in which Achilles tendon lengthening was used to heal a forefoot ulcer. A full understanding of tendon function and transfer techniques is paramount for surgeons performing pedal amputations. By rebalancing the foot, patients are able to ambulate with custom shoes or bracing, and more proximal amputations, which can be physically and psychologically devastating, are prevented.

Ball-and-socket deformity of the ankle joint is a rare entity that is usually associated with inequality of leg length, fibular hypoplasia, coalition of the tarsal bones, and ray deficiency. This deformity was encountered in a nine-year-old girl with a short right limb, cavovarus foot, partial fusion of the 4th and 5th metatarsals, and talocalcaneonavicular coalition. No surgical intervention was necessary; the patient was recommended to wear a high-heeled shoe of 2.5 cm thickness to compensate for the difference in the leg length.

This paper presents an overview of therapy for the wrist after soft tissue reconstruction, arthroscopic debridement, arthroscopic ganglionectomy, total wrist arthrodesis, and vascularized bone grafts. Postoperative problems common to each of these procedures include stiffness, edema, scarring, decreased strength, and decreased use of the involved extremity. An understanding of the surgical procedure and its specific purpose is necessary for the hand therapist to formulate a plan of treatment and appropriate goals for rehabilitation. Treatment techniques and modalities for these procedures are reviewed, as well as the importance of patient education and activity modification.

With proper patient selection and perioperative planning, selective rearfoot arthrodesis in the patient with rheumatoid arthritis is effective in relieving pain and restoring ambulatory status. The overwhelming majority of current literature supports the early fusion of involved rearfoot joints in an effort to arrest the compensatory progression, which yields a rigidly deformed lower extremity. In keeping the patient with rheumatoid arthritis ambulatory, we can positively affect his or her quality of life and prevent the degradation into a sedentary disposition, and therefore heighten the long-term prognosis.

The surgical management of osteoarthritis has progressed greatly in the past 30 years and often is indicated when noninvasive measures can no longer provide sufficient pain relief and maintenance of function. Physicians can choose from a variety of surgical procedures, depending on patient age, the joint involved, functional expectations, patient activity demands, and degree of cartilaginous loss. Surgical procedures for arthritic joints can be classified in two broad categories: those that are cartilage-sparing, such as osteotomy, and those that are cartilage-sacrificing, such as arthroplasty. This article discusses those procedures most commonly used for the major weightbearing joints of the lower extremities (hip, knee, ankle) as well as the large joints of the upper extremity (shoulder, elbow).

Surgical technique and results of surgical correction for substantial flexion contracture of the knee in 15 children with spina bifida or other spinal conditions with lower extremities paresis is presented. Extensive posterior capsulotomy, occasionally supplemented with posterior cruciate sectioning is necessary to correct considerable flexion contracture of the knee. The technique is also effective in congenital flexion contracture with no articular surfaces deformity. Serial redressing and casting are imperative in postoperative management.

Camptodactyly is caused by an imbalance between the flexor and extensor forces at the proximal interphalangeal joint of the fingers. Although the etiology is not completely clear, the lumbrical muscle anomalies seem to play an important part in the pathogenesis of camptodactyly. The insertion of this intrinsic muscle often differs greatly from that described in anatomical textbooks. In our series, we transposed the lumbrical muscle and the superficial flexor tendon to the extensor tendon creating a better balance between extensor and flexor forces. Additionally, we performed skin-lengthening procedures and, if necessary, an arthrolysis of the proximal interphalangeal joint. In this study, we present a new classification of preoperative guidelines to ameliorate the operative treatment of camptodactyly.