Reginald L. Hall

Pyomyositis in a temperate climate. Presentation, diagnosis, and treatment.

The cases of eighteen patients who were treated for pyomyositis between 1970 and 1988 were evaluated. The diagnosis was often delayed because other primary diagnoses were considered, including muscle strain, synovitis, thrombophlebitis, and neoplasm, and because the symptoms were vague and prolonged (maximum duration, one year). The muscles around the hip and thigh were most commonly involved (twelve patients), and Staphylococcus aureus most commonly grew on culture (twelve patients). Computed tomography aided in the accurate diagnosis of the infection and of the extent of involvement. Incision, drainage, and antibiotic therapy eradicated the infection in all patients, and they had no residual functional limitations and minimum residual symptoms.

Stress Fracture of the Tibia after Arthrodesis of the Ankle or the Hindfoot

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture. We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.

Anatomy of the calcaneus.

The calcaneus is the largest tarsal bone in the foot and is well designed to sustain high tensile, bending, and compressive forces. However, high instantaneous loads often result in fracture. Any treatment of calcaneal fractures requires a working knowledge of the anatomy. The major neurovascular structures are located medially and are well insulated by the medial soft tissues. These structures are at risk, however, during medial approaches to the calcaneus. Laterally, there are several bony landmarks that are palpable primarily because of the relative paucity of the soft-tissue elements. Lateral approaches to the calcaneus have been associated with the areas of skin necrosis that may be related to the arterial anatomy. The calcaneus has four articular surfaces. The congruity of these articular surfaces and their relationship to one another can be assessed roentgenographically. With adequate knowledge of the bony anatomy of the calcaneus and its soft tissue envelope, a rational approach in assessment and treatment of calcaneal fractures can be developed.

Plantar fibromatosis: treatment of primary and recurrent lesions and factors associated with recurrence.

Plantar fibromatosis is a benign but often problematic foot disorder which, when surgically treated, is difficult to eradicate. The purpose of this investigation was to identify epidemiologic factors associated with disease recurrence and to determine which method of treatment most successfully eliminated recurrence. A retrospective review of surgical pathology reports and clinical histories from 1979 to 1993 was performed to identify all patients who underwent surgery for plantar fibromatosis at our institution during that time. Thirty-three feet of 30 patients were identified with a minimum 2-year follow-up. Seventeen feet underwent surgery for primary lesions, and 4 of 10 that had local excision, 1 of 3 that had wide excision, and 2 of 4 that had subtotal fasciectomy (with or without skin grafting) had recurrence. All 16 feet in patients presenting with recurrent lesions had undergone prior local excision at other institutions. When combined with patients from our institution who underwent a second procedure, 21 feet had surgery for recurrent plantar fibromatosis. Of these, three of four had further recurrence when treated with local or wide excision. In feet with recurrences treated with subtotal fasciectomy, only 4 of 17 had recurrence after the first attempt at such treatment. Average follow-up for all patients was 7.7 years, and all patients with postoperative recurrences showed evidence of disease within 14 months after surgery (mean, 6.9 months). Factors identified with an increased risk for recurrence were multiple nodules, bilateral lesions, and positive family history. In treating recurrent disease, subtotal fasciectomy was more effective than local or wide excision. This study identified factors associated with a significant likelihood of postoperative recurrence in treating plantar fibromatosis and found subtotal fasciectomy to provide the most successful treatment in eradicating disease in recurrent cases.

Acute Rupture of the Extensor Hallucis Longus Tendon

A 40-year-old man with a history of previous cheilectomy and two steroid injections for first metatarsophalangeal degenerative joint disease sustained an acute rupture of the extensor hallucis longus tendon. He was treated successfully with delayed primary repair of the tendon.

Centrocentral anastomosis with autologous nerve graft treatment of foot and ankle neuromas.

Painful neuromatas in the foot and around the ankle can be difficult to treat. Five patients of clinically and histologically proven neuromas underwent centrocentral union with autologous transplantation. Three patients had previous toe amputations involving multiple operations. One patient had failed multiple operative treatments for Mortons neuroma in his 3rd web space. One patient had a neuroma in his superficial peroneal nerve caused by a gun shot wound. All patients but one showed definitive subjective and objective improvement after centrocentral union with the interposed autologous nerve graft. The patient with “recurrent” Mortons neuroma had the least improvement. This technique can be recommended as an alternative for the prevention of painful stump neuromata.

Replacement of the lateral malleolus of the ankle joint with a reversed proximal fibular bone graft.

Infrequently, prior reports have described the use of the ipsilateral proximal fibula to replace an absent distal fibula caused by either trauma, infection, or resection for tumor. 3,4 This is a 27-year follow-up of a 12-year-old patient who lost the distal 7.5 cm of her fibula secondary to trauma. The soft tissue defect was replaced early by an abdominal flap and the bone defect was eventually replaced with 7.5 cm of proximal fibula. The lateral ankle ligaments were reconstructed with the peroneus brevis, and the ankle joint has remained stable. Although traumatic arthrosis has progressed slowly, the patient at age 39 has a relatively painless, mobile ankle joint.

A New Type of Dislocation of the First Metatarsophalangeal Joint: A Case Report

We are reporting a case of traumatic dislocation of the first metatarsophalangeal joint that does not correspond to any previously reported type. This new type of dislocation was associated with a rupture of the lateral short sesamophalangeal ligament/plantar plate, partial rupture of the intersesamoid ligament, and separation of a previously bipartite tibial sesamoid. Closed reduction was easily performed; however, the distal portion of the tibial sesamoid remained trapped within the joint. The rationale for and result of surgical treatment are presented.

Gout as a Source of Sesamoid Pain

Isolated gout of a great toe sesamoid has not been described previously. We present a case of gout of the medial sesamoid in a young athlete. Because a diagnosis is often elusive in patients with sesamoid pain, it is possible that other cases of gout of a hallucal sesamoid have gone unrecognized. Consideration of this diagnosis might lead to curative medical therapy precluding the need for surgical intervention.

Ankle arthroscopy in industrial injuries of the ankle

Industry-related injuries to the foot and ankle are not uncommon. These cases are often difficult to evaluate with respect to degree of damage and even more difficult to quantitate with regard to functional impairment. This article represents an attempt to determine the role of ankle arthroscopy in the evaluation of ankle injuries that involve compensation or liability. A retrospective review was conducted. The study group consisted of 40 patients who underwent a total of 42 arthroscopic procedures. The patients were evaluated with regard to the mechanism of injury and clinical manifestations. Pain and swelling were the most common preoperative symptoms. The majority of patients had pain localized to the lateral and anterolateral ankle. There were a high percentage of positive bone scans that correlated well with bone pathology but poorly with soft-tissue pathology. Computed tomography (CT) scans were equivalent to tomograms in the demonstration of bone pathology. Follow-up was obtained in 24 patients. At least 50% of the patients had some improvement in their symptoms. Thirty-three percent believed there was no change, and 17% said they were worse. Over 70% of the patients were able to return to work, although 20% had to change their occupation. Fifteen percent were considered disabled. In patients without a specific diagnosis, ankle arthroscopy was helpful in establishing a diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)