Accessory Bones of the Foot

The normal human foot contains twenty-eight bones. These bones help to give shape and function to the foot, and help provide the framework for shock absorption and mechanics that make movement possible. Sometimes, though, a foot contains more than twenty-eight bones. A number of accessory bones may be present in the foot as well, which may or may not be pathologic.

Accessory bones can be divided into two categories – ossicles and sesamoids. Sesamoids are small, round bones found within tendons in the foot. The two common sesamoids are within the flexor hallucis brevis, and help comprise the sesamoid apparatus. The sesamoid apparatus aids in function of the first metatarsophalangeal joint.

Some of the more common accessory sesamoids include:

• Os peroneum – located within the tendon of the peroneus longus, commonly seen near the peroneal notch of the cuboid.
• Os interphalangeus – Located within the long flexor tendons, adjacent to the interphalangeal joints of the digits.
• Capsular sesamoids – these are located within the tendons crossing the metatarsophalangeal joints, typically in the long flexors

Accessory ossicles differ from sesamoids in the way they develop. They develop from a separate center of ossification in close proximity to the normal anatomy. Some of the more common accessory ossicles include:

• Os Trigonum – develops as a separate ossicle posterior to the lateral tubercle on the posterior surface of the talus. When the ossicle is fused, it is known as a Steida’s process. These can often become pathologic as they can cause friction on the tendon of the flexor hallucis longus, which can cause irritation and pain.
• Os tibiale externum – located on the medial side of the foot in close proximity to the navicular. There are several variations of this accessory bone that exist, including those that have fused to the navicular. These are often symptomatic, and may also be referred to by some clinicians as a pre-hallux
• Os supranaviculare – also referred to as os talonavicular dorsale, it is found on the dorsal aspect of the talonavicular joint.

A number of accessory bones exist in the foot, which may or may not become symptomatic. Clinically, accessory bones can often appear as fractures on x-ray, and may even mimic them in their symptoms. Sesamoids may appear as bipartite, meaning they are split in two pieces, or tripartite, meaning they are split into three pieces. Bipartite and tripartite sesamoids can often resemble fractures on x-ray.

Accessory bones, when symptomatic, can be treated by offloading the area, debridement of callus that forms over them, or even surgical resection for some.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Oilers’ Hall Goes Down with Ankle Injury

Edmonton Oilers rookie sensation Taylor Hall was injured in a fight in Thursday’s game against the Columbus Blue Jackets, when he went up against Derek Dorsett. The injury came as the two went down to the ice, when Hall twisted his ankle.

The Oilers announced that Hall would be getting an MRI on Friday afternoon. Hall will be unable to travel with the team as they begin a five-day road trip this weekend.

Lucky for hall, there doesn’t appear to be a fracture of the ankle at this time. The MRI was most likely ordered to check for a high ankle sprain or any other type of injury to the soft tissues of the leg and ankle.

A high ankle sprain involves an injury to the tissues connecting the two bones of the leg, the tibia and the fibula. This tissue, known as the syndesmosis, helps keep the ankle joint in line and plays a critical role in stabilizing the ankle. The syndesmosis can be strained or torn in an ankle injury, and can be a particularly difficult injury to heal. They typically take longer to heal than a normal ankle sprain.

A high ankle sprain is typically treated with a cast for 6 weeks, so long as the injury is stable. When the injury is unstable, surgery may be necessary to place a screw through both the tibia and fibula, holding the syndesmosis together while it heals. These screws are typically left in for 3 months. Patients are instructed not to walk on the injured leg while the syndesmotic screw is in place. There is normally some motion between the two bones when walking, and this motion may break the screw.

Another surgery may be required after the syndesmosis is healed to remove the screw, while some doctors will let the patient begin to walk on the leg until the screw breaks. The reason for this is that there are very few reported problems with a broken screw. If there is a problem, then the screw can be removed as it would have been anyway. This way, the patient is saved an extra surgery until they need it.

If Taylor Hall is shown to have a high ankle sprain or a serious sprain or tear of the ankle joint, he will have to miss a few months of the season until he can heal.

Hall is leading his team with 22 goals this year, along with 20 assists. He is in contention for rookie of the year. Thursday’s game against the Blue Jackets gives Hall his first career “Gordie Howe Hat Trick”, in which a player scores a goal, an assist, and gets in a fight all in the same game.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Negative Pressure Wound Therapy

Negative pressure wound therapy (NPWT), also known as topical negative pressure, sub-atmospheric pressure or vacuum sealing technique, has become a topic of much interest in the area of acute and chronic wound healing. Particularly in the diabetic population, where chronic wounds run rampant, this technology has been explored as a potentially promising therapy.

NPWT is just one of several technological advances in wound care therapy that has emerged in the past several decades. This list also includes bioengineered skin equivalents, bone marrow-derived stem cell therapy, and growth factor therapy. However, the science behind Negative Pressure Wound Therapy is quite interesting.

The vacuum sealing technique involves placement of a special device, sometimes referred to as a wound-vac, on the chronic or acute wound. This device consists of a foam or gauze dressing applied directly to the wound, then sealed tight with a clear, plastic-wrap-like dressing. The dressing is then attached to an electronic device that creates a negative pressure in the newly created seal, similar to a vacuum. This negative pressure ranges anywhere from 50-175 mmHg.

The system created turns an open wound into a controlled, closed wound while removing cellular debris and excess fluid from the wound. This allows the wound to be well-controlled in terms of exudate management. Granulation tissue, the tissue that indicates the ability for the wound to heal, is stimulated to generate within the wound. There is also a decrease in the bacterial load of the wound, reducing the incidence of infection, as well as increased blood flow to the wound.

Published case-studies and small cohort studies have shown negative pressure wound therapy to be effective in the treatment of diabetic foot ulcers. However, a Cochrane review pointed to the fact these trials consisted of too few enrolled subjects to be considered significant evidence to support the use of wound-vacs. However, the growing popularity of the device may lead to more extensive research in the area, as well as better designed studies.

Another area of concern for the use of negative pressure wound therapy is the cost associated with its use. However, several studies have looked at the cost-effectiveness of NPWT, and have found that the decrease in staff required for dressing changes not only balances, but exceeds the cost-effectiveness of standard wound care therapy. Because the NPWT dressings only need to be changed after 48-72 hours, there is less maintenance required for the wound. Therefore, the staff demands are decreased in the management of chronic wounds using NPWT.

Negative pressure wound therapy remains a promising choice for the treatment of diabetic foot ulcerations. The diabetic population is particularly prone to chronic wounds, and NPWT may be a useful technology.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

New York Giants Plagued with Injuries Late in the Season

New York Giants’ wide receiver Hakeem Nicks will most likely sit out in week 17 with a broken toe. The news was released today that the injury was in fact a broken big toe on his left foot. It is not clear whether the injury occurred during the game on Sunday against Green Bay. The Giants lost that game 45 to 17.

Injuries to the great toe are extremely common in turf sports such as football. The combination of flexible shoes on a hard surface creates the perfect combination for the development of turf toe, which is a hyperextension injury to the first metatarsopahalangeal joint (MTPJ). This joint connects the great toe to the rest of the foot.

Fractures of the great toe may also be due to a single traumatic event, or to repetitive stress to the bones. In Nicks’ case, it is unclear whether the injury occurred during a game or during practice.

Nicks’ injury comes at an awful time for the New York Giants, whose playoff hopes are dwindling fast. Their injury report is crowded with players already, some of which are other foot and ankle injuries.

Center Shaun O’Hara has missed nine games this season due to Achilles, ankle, and foot injuries. O’Hara was also picked for the NFC Pro Bowl roster, a decision which many sports fans see as ill-advised. O’Hara will also be doubtful for week seventeen, as his Achillles condition has flared up in the past few days.

Running back Ahamad Bradshaw is also questionable for this week’s game with an ankle injury that limited his production in week sixteen. The official report has him listed with a sprained ankle. Lateral ankle injuries are often very difficult to rehab, as we’ve written about before. The key to non-operative treatment is adding to stability to the joint with the use of braces.

Other players on the Giants’ injury report include Will Blackmon (knee), Chris Canty (neck), Antrel Rolle (ankle), Dave Tollefson (knee), Justin Tuck (chest), Osi Umenyiora (knee), and Corey Webster (ribs).

Injuries like those plaguing the Giants, many of which are injuries to the lower extremity, can be extremely common in football. Especially late in the season, when fatigue and inclement weather start to play a greater factor, lower extremity injuries start popping up everywhere, effecting nearly every team. Proper training and conditioning is essential to avoiding these types of injuries, not only in the professional athlete, but in the casual athlete as well.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Microfracture Surgery for Greg Oden

Greg Oden, of the Portland Trailblazers, will be forced to miss the rest of the NBA season this year. The center, who was the #1 pick in the 2007 draft, has just recievd microfracture surgery of his left knee. Oden received a similar surgery on his right knee during his rookie year, which postponed his professional start.

Microfracture surgery is a treatment for an osteochondral lesion, which is damage to the articular cartilage within a joint. The knee is a common place for these types of injuries to occur, as well as the ankle. The surgery involves making tiny holes in the damaged cartilage, which allows for blood to access the area more easily. This brings in healing and growth factors, which can promote the generation of cartilage in the area. The new cartilage that forms is fibrocartilage, which not quite the same as the hyaline cartilage that forms the cartilage of the joint. However, this fibrocartilage does allow for a more normal range of motion postoperatively, and often can reduce the pain associated with an osteochondral lesion. In podiatry, it is common to see an osteochondral lesion of the talus following an ankle injury, which sometimes may be corrected with microsurgery.

A study out of Drexel University College of Medicine studied NBA players that received microfracture surgery of the knee between 1997and 2006. The study looked at a number of factors, and analyzed the player efficiency ratings (PER) of the NBA players both before and after the surgery. The study found that twenty-percent of the players did not return to the NBA. It also found that of the players that did return, only 17 of 24 players continued to play for more than two years, and that universally all players saw a reduction in their player efficiency rating as well as the number of minutes played.

What will be the fate of Greg Oden following his second microfracture surgery? There’s no way to know for certain, but the NBA is hopeful that he will recover and have a successful career. Certainly he will be able to have a normal life after the surgery, but will his knees be able to withstand the high impact of an NBA player? The high forces placed through the lower extremity during running and jumping, as well as the sheer forces place on the knees during cutting and pivoting moves may prove to be to much for the Portland Trailblazers’ center.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Platelet-Rich Plasma Therapy

In the world of sports injuries, healing time is of the utmost importance. The difference in a week for full recovery can mean the difference between making the playoffs and ending the season early. Because of this need for fast-tracking healing times, different innovations have become more popular in medicine. One of these innovations is the use of platelet-rich plasma.

Platelet-rich plasma (PRP) had been used previously as an adjunct to healing in spinal surgeries and in plastic surgeries with extensive soft tissue damage. The process involves drawing a small amount of blood from the patient (between 30mL and 60mL), putting the blood into a centrifuge, and spinning it down to separate the blood components. The plasma is separated from the cells, but the platelets are kept in the plasma. This platelet-rich plasma can then be injected back into the same patient, in the area that healing is needed. PRP has gained popularity, and has been used to treat tendon injuries, ligament injuries, cartilage injuries, muscle injuries, and for chronic wounds.

Part of PRP’s recent surge in popularity is due to its use in treating sports injuries. Professional athletes like Tiger Woods, Troy Polamalu, and Hines Ward have all received media attention from PRP therapy. Recently, Houston Texans wide receiver Andre Johnson has made the news for receiving platelet-rich plasma treatment. As more and more professional athletes use PRP therapy, it becomes more common for amateur athletes and weekend warriors to ask their doctors about the treatment.

The theory behind how PRP therapy works is somewhat simple. Platelets in the blood normally release chemical signals to promote healing at a specific site. These signals attract more platelets to the area, which increases the amount of signal being release, and thus the healing process continues. By removing blood from a person and concentrating the amount of platelets in a particular area, the healing time is theoretically increased.

In podiatry, common uses for PRP therapy include plantar fasciitis and Achilles tendon tears/ruptures. Both of these areas are prone to chronic injuries that can be very difficult to heal, and can often take a very long time for the symptoms to go away. Therefore, platelet-rich plasma therapy becomes an interesting option for these patients. These areas of injury can also have a relatively low blood supply, which may be why they are prone to injury in the first place. Injecting platelet-rich plasma into these areas can promote healing in an area that may be difficult for platelets to reach on their own.

While platelet-rich plasma seems to be a great therapy to boost the healing of certain types of injuries, there are certain limitations to its use. The studies that have been performed show inconsistencies in the method of use, as well as small sample sizes and a lack of control subjects. Additionally, there are many studies that show inconclusive results as to the efficacy of PRP. This takes away from the studies that show PRP to be an effective method of treatment, as the results may not be able to be repeated.

While there may be some controversy over its efficacy, PRP is still becoming a popular method of treatment for chronic injuries, particularly among professional athletes. This is due to a vast amount of resources for this patient group, as well as the desire to fast-track recovery time. As more studies are performed on the topic, watch for more solid results to be shown.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Metatarsalgia (Forefoot Pain)

The term metatarsalgia translates to “pain in the metatarsals”. It is most commonly used to describe pain in the metatarsal heads, at or near the ball of the foot. Though it is sometimes used as a discrete diagnosis, the term metatarsalgia is a very general term that does not offer a reason for the pain. There are a number of different conditions that can cause metatarsalgia, and many others that may mimic the findings.

True metatarsalgia results from increased pressure in the metatarsal heads. This is most commonly the result of biomechanical deformities such as hallux valgus or an elevated first ray. Conditions like this may also be associated with bunion formation. Most frequently it is associated with a flatfoot, or a foot that is prone to pronation syndrome. However, increased pressures through the metatarsal heads may also be seen in a high-arched foot, or pes cavus.

Another common cause of metatarsalgia is a thinning of the fat pads at the bottom of the foot. Fat pads are normally found underneath the heel and at the ball of the foot. These well-organized structures help to cushion the forces applied to the foot while walking. In older people, the fat pads can thin as a normal part of aging, a component of some disease processes, or with the use of some drugs such as oral steroids. When the fat pad at the ball of the foot thins, the cushioning underneath the metatarsal heads is lost, and metatarsalgia may ensue.

Pain in the metatarsal heads is also commonly seen with hammertoes, as the contracted digits force the metatarsal heads into the ground with excessive force. Over time, this can create a painful situation.

Other conditions of the foot may appear as metatarsalgia, but may actually be a different pathological process. Neuromas, particularly those found between the metatarsals such as Morton’s neuroma, can appear at first as metatarsalgia. Stress fractures of the foot may also lead to pain in the ball of the foot or at the metatarsal heads.

Rheumatoid arthritis may appear initially as metatarsalgia, and should be ruled out as a part of the clinical exam. This may include x-rays as a diagnostic study, which can also look for avascular necrosis of the metatarsal heads as a cause of the pain. Tendinitis, bursitis, and capsulitis (a swelling of the joint capsule) can also appear as metatarsalgia. It is up to the clinician evaluating the patient to differentiate between these pathologies.

The best treatment, therefore, for metatarsalgia, is to address the underlying cause of the condition. If it is a biomechanical etiology, such as from over-pronation, conservative therapy may address correcting the deformity. The use of custom orthotics or another type of shoe insert is commonly employed as a first-line treatment. Simply resting and icing the area while taking anti-inflammatory medications may alleviate the pain, but can also delay the proper and necessary treatment. Custom orthotics, specialized shoe inserts, a change in shoes, and possibly shoe modifications will all help the person with a loss of the protective fat pads found on the bottom of the foot as well.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com