Sensory Reconstruction of a Posterior Heel Defect Using a Proximally Based Sensate Medial Plantar Flap with Retrograde Nerve Cleavage Technique

Reconstruction of posterior heel defects is important because it requires thick and durable skin that can withstand pressure and shear from shoe and bed contact. Therefore, the sensate flap could be a better option for the defect. This paper reports on the safety of a medial plantar sensory flap for these defects as well as an objective measurement of the sensation of the medial plantar flap and the plantar surface distal to the donor site. Twelve patients had soft-tissue defects in the posterior heel and underwent reconstructive surgery using a proximally based sensate medial plantar sensory flap. Cases of plantar defects involving not posterior heel were excluded. For wider flap coverage, special neurovascular dissection was required. We evaluated levels of sensation quantitatively using Semmes–Weinstein (SW) monofilaments and a two-point discriminator at the final follow-up. All flaps survived without major complications. Postoperative follow-up was 12 to 64 months (mean 26 months). All 12 flaps healed without postoperative complications. There was no significant difference in minimal two-point discrimination and SW evaluator size between the transferred medial plantar flap area and the contralateral heel area or between the plantar area distal to the donor site and the contralateral side. Patients could walk normally and sleep without protective shoes or brace. A proximally based sensate medial plantar flap is a good option for the reconstruction of posterior heel defects. It can restore the characteristics of the posterior heel for shoe wearing and sleeping.

A Huge Plantar Intramuscular Hemangioma in the Plantar Area Treated Surgically: A Case Report and Literature Review

Intramuscular hemangioma (IH) is rare, accounting for only 0.8% of all hemangioma cases. In particular, IH of the foot has only been reported a few times. In such cases, the symptoms typically include tenderness and swelling, often in relation to physical activity, but tingling or impaired function may also be present. Here, we report a patient who presented with a significant IH in the plantar area treated surgically. A 25-year-old female visited our hospital with pain in the plantar aspect of the right foot. She had noticed a mass about 10 years prior. She had previously experienced pain only when pressing the mass, but the pain subsequently became more regular pain and was exacerbated by exercise. In fact, the pain became so intense that she could not sleep well. Upon physical examination, mild swelling and tenderness of the plantar area were noted in the second to the fourth metatarsal. Sensation and motor reflexes were normal and the results of Tinel’s test were negative. Plain radiographs of the right foot revealed phleboliths scattered throughout the first to third intermetatarsal spaces. Magnetic resonance imaging revealed a space-occupying multilobulated mass (5.6 × 2.8 × 2.5 cm) located in the flexor digitorum brevis (FDB) muscle, which penetrated the plantar fascia and spread to the subcutaneous layer. In T2-weighted images, the lesion displayed a hyperintense signal compared to the surrounding skeletal muscle. Based on radiological findings, we suspected IH. The mass surrounded by the FDB muscle was exposed and completely removed via wide excision. IH consisting of cavernous-like vascular structures was diagnosed on pathology. At 1-year follow-up, the patient was almost asymptomatic and had recovered almost full range of motion in the plantar area. Histological analysis and surgery are recommended to remove intramuscular hemangiomas in the plantar area, but if the patient is not suitable for surgery, sclerotherapy or combination treatment should also be considered.

Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy of the Lesser Toes: Clinical, Radiologic, and Pedobarographic Outcomes

Background: The minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) is a percutaneous operative technique with the aim to relieve the symptoms of metatarsalgia. To our knowledge, no previous research has analyzed both pre- and postoperative pedobarographic data including the changes in plantar pressure. Methods: Thirty patients (31 feet) were operated on with a DMMO and included in a prospective study. Clinical, radiologic, and pedobarographic outcomes were evaluated in comparison with the preoperative parameters. The American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score, the Foot Function Index (FFI), the Foot and Ankle Outcome Score (FAOS), and a visual analog scale (VAS) for pain were used in order to assess clinical parameters. Radiographs were taken to compare metatarsal lengths. The pedobarographic analysis served to determine plantar peak pressure (PPP) beneath the metatarsophalangeal (MTP) joints. Results: All scores indicated a significant mean pre- to postoperative improvement (AOFAS = 31.9 points, FAOS = 16.3%, FFI = 24.3%, VAS pain = 4.1 points, VAS general limitation = 3.3 points) ( P < .05). PPP was substantially reduced in the relevant area (M6 [plantar area beneath the second and third MTP joint] had a mean pre to post PPP = 14.15 N/cm2) and concurrently higher in the lateral and medial MTP joint areas (M5 mean pre to post = +14.37, M7 pre to post = +7.11). Our mean metatarsal shortening was 6.6 mm. However, our findings do not demonstrate a significant correlation between metatarsal length relationships and the prevalence of metatarsalgia. Conclusion: Our results demonstrate a significant improvement in clinical scores and PPP. A statistically significant relation between metatarsal length and the prevalence of metatarsalgia was not found in this prospective case series Level of Evidence: Level IV, case series.

Comparison of Foot Kinematics and Foot Plantar Area and Pressure Among Five Different Closed Kinematic Tasks

Background Different closed kinematic tasks may present different magnitudes of knee abduction, foot pronation, and foot plantar pressure and area. Although there are plenty of studies comparing knee abduction between different tasks, the literature lacks information regarding differences in foot pronation and foot plantar pressure and area. We compared foot angular displacement in the frontal plane and foot plantar pressure and area among five closed kinematic tasks. Methods Forefoot and rearfoot angular displacement and foot plantar pressure and area were collected in 30 participants while they performed the following tasks: stair descent, single-leg step down, single-leg squat, single-leg landing, and drop vertical jump. Repeated-measures analyses of variance were used to investigate differences between tasks with α = 0.05. Results Single-leg squat and stair descent had increased foot total plantar area compared with single-leg landing (P = .005 versus .027; effect size [ES] = 0.66), drop vertical jump (P = .001 versus P = .001; ES = 0.38), and single-leg step down (P = .01 versus P = .007; ES = 0.43). Single-leg landing and single-leg step down had greater foot total plantar area compared with drop vertical jump (P = .026 versus P = .014; ES = 0.54). There were differences also in rearfoot and midfoot plantar area and pressure and forefoot plantar pressure. Conclusions Differences in foot-striking pattern, magnitude of ground reaction force, and task speed might explain these findings. Clinicians should consider these findings to improve decisions about tasks used during rehabilitation of patients with foot conditions.

Intramuscular Ganglion Cyst of the Flexor Hallucis Brevis Secondary to Muscle Tear: A Case Report

In the current study, we present a case of an intramuscular ganglion cyst in the flexor hallucis brevis muscle (FHB) that arose secondary to a muscle tear. Through this study, we propose a possible aetiology for the development of intramuscular ganglionic cysts. A 50-year-old woman presented with acute pain and swelling over the right mid-plantar area after prolonged kneeling for scrubbing floors. Ultrasonography examination performed at 5 days after the onset of symptoms revealed a partial tear of the right FHB. Follow-up evaluations were conducted, with magnetic resonance imaging and ultrasonography, at 24 and 54 days after symptom onset. MRI revealed a ganglion cyst in the mid-portion of the FHB without connection to the adjacent joint capsule or tendon sheath. On the ultrasonography examination at 45 days after onset, at the same location where a tear was seen on the initial examination, an anechoic defect in the mid-portion of the FHB was observed, compatible with a ganglion cyst. Given the favourable natural evolution, no aspiration or surgery were performed. The patient was discharged with minimal symptoms. The results suggest that the intramuscular ganglion cyst can develop following a muscle tear.

Comparative morphofunctional and species-specific vascularization features of of the knee capsule of some mammals

The metabolic, reparative and plastic properties, as well as the functional activity of the multiorgan synovial environment of the knee joint, are organically and functionally related to their morphology and blood supply. The aim of our research was to determine the general biological and specific features of the structural organization and vascularization of the knee joint capsule in animals with different supports, locomotion and body weight. A complex of morphological research methods is used in this work: anatomical, histological, neurohistological. Used neurohistological method of impregnation in its own algorithm. The structural organization of synovial and fibrous capsule, histotopography of intraorganic vessels was studied on 43 objects of various groups of animals. The selection of animals was carried out according to the type of limb specialization to the substrate. Animals were taking into account the ecology, types of support, the nature of locomotion and the speed of movement – phalanoid animals – a domestic horse, a domestic bull and a finger animal – a domestic dog and a domestic cat. As a result of the complex comparative-morphological study the general patterns of the structural organization of the articular capsule, the general-biological and species-specific features of the angioarchitectonics and angiotopography were established. The zones of the most intense intraorganic vascularization and the topography of the vascular fields and glomeruli of the articular capsule are shown. The zones of intensive vascularization are localized: in the domestic bull – in the medial, dorsal, lateral parts, vascular glomeruli – in the lateral; in the domestic horse – in all parts of the capsule, vascular glomeruli – in the plantar area; in the domestic dog – in the medial, dorsal, plantar parts, vascular glomeruli – in the plantar area; in a domestic cat, the same type of angioarchitectonics is observed, the vascular fields and glomeruli are absent. The more intense angioarhitectonics in the capsule of the knee joint in phalanoid animals (horse, cattle) than in the finger (dog, cat) possibly due to the different nature of the support and type of locomotion, is determined. Key words: vascular fields, vascular glomeruli, angioarchitectonics, knee joint, joint capsule, domestic horse, domestic bull, domestic dog, domestic cat.

Generalized Severe Plaque Psoriasis in an HIV Positive Patient – a Challenging Treatment

Psoriasis is a systemic chronic immune-mediated disorder, rarely reported in HIV-infected patients, in which the disease is more severe and debilitating. Response to treatment is modest, and skin diseases may profoundly affect the patients’ quality of life. Anti-psoriasis therapies have immunosuppressive effects and must be carefully recommended in HIV-infected patients. Moreover, the compliance of HIV patients diagnosed with psoriasis is low, and monitoring these patients is challenging. Herein we present a rare case of severe HIV-associated psoriasis with large plaques localized on the trunk, abdomen, limbs and plantar area in a non-compliant patient, with impaired renal and hepatic functions, dyslipidemia, and anemia, for whom the therapeutic approach was disappointing.

Elhízott populációra jellemző talpnyomásminták vizsgálata

Introduction: Although the role of body weight on foot health and load has been widely documented in research, the effect of the extra load due to body weight on plantar pressure characteristics is not well known. Aim: The aim of this study was to evaluate the impact of obesity on plantar pressure patterns among the working-age population. Method: 180 participants were involved. Two groups were evaluated according to body mass index categories regarding eight regions of the plantar area, focusing on the following parameters: contact area, maximum pressure and peak pressure. Results: Compared with non-obese subjects, the peak pressure was the highest on the midfoot (p<0.001) and the forefoot (p<0.001). Regarding the maximum force, significant statistical difference was detected on the toes (p<0.001), with a value lower among the obese group. The contact area on the total foot and the midfoot was lower among the non-obese subjects (p<0.001). Conclusions: Loading is greatly increasing on the whole plantar area, especially at the midfoot and the forefoot region. Orv. Hetil., 2016, 157(48), 1919–1925.