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Over the past generation, advents in topical antibiotics and oral analgesia have obscured butamen and its family of topical anesthetics. Using a modified version of the McGill University pain questionnaire, this study attempts to establish the efficacy and clinical utility of this overlooked topical anesthetic.

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Fracture of the anterior process of the calcaneus is a common injury that is often misdiagnosed. The key to management of this injury is an accurate diagnosis and proper treatment. Two case studies are presented to demonstrate how improper diagnosis can lead to surgical treatment of the condition.

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Bone healing is a process of reconstitution of tissue. With the development of rigid internal fixation, primary bone healing has exhibited certain histologic characteristics not previously seen. The authors discuss the histologic, biochemical, and physiologic processes seen in primary and secondary bone healing following fracture or osteotomy.

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Symphalangism is a rare genetic condition that may represent the earliest documentation of mendelian inheritance in man. The disorder results in interphalangeal joint fusion in the hands and feet. The authors review this rare condition and present a case study consisting of four generations with 15 affected family members. The association of multiple tarsal synostosis and the previously unreported associated occurrence of pedal hypophalangism in this pedigree is presented.

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Keloids and hypertrophic scars may complicate elective foot surgery. Differentiation between these two entities is important before treatment is contemplated. The authors review current theories on the etiology of these lesions and outline various treatment options.

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Lipomas are defined as benign tumors usually composed of mature fat cells. They are most commonly found in areas of abundant adipose tissue, which may explain why they are rarely found in the foot. Careful examination of any potential lipoma includes its anatomical location, consistency, clinical, and roentgenographic findings. The authors describe a large lipoma that was surgically excised from the dorsal aspect of the right foot.

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The effect of diabetes on the lower extremity can be devastating. Surgical intervention on the diabetic foot must be carefully planned, and long-term results must be anticipated. The authors present a case history of a patient with multiple previous amputations of the forefoot, resulting in a severe deformity and a nonfunctional foot. Transmetatarsal amputation, if performed correctly, should provide a relatively functional extremity.

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Hydroxyapatite developed from sea coral has been utilized as a bone implant. The primary application at this time is in maxillofacial surgery along with experimental use in orthopedic surgery. The acceptance of this implant in bone and by the body has been found to be excellent without signs of rejection or increase in the incidence of infection. Advantages of this material over autogenous and allogenic bone grafts will be discussed along with its potential application to podiatric surgery.

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The anatomy, mechanism of injury, and radiographic diagnosis of traumatic dislocation of the first metatarsophalangeal joint are discussed. Previously, three basic types of these dislocations have been described. The authors propose an additional classification which has not been previously reported.

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Clearly, no one surgical procedure is ideal for the treatment of degenerative joint disease. Many factors are involved in planning for the proper approach, such as age and activity of the patient, etiology, and stage of the disease. Arthroplasty, implant arthroplasty, cheilectomy, enclavement, various osteotomies, and joint fusions have been advocated as procedures for choice of degenerative joint disease of the first metatarsophalangeal joint (24-26). Similar procedures have been used to treat arthroses of the lesser metatarsophalangeal joints as well. Some of these procedures are designed to address the etiology of the degenerative process. This is the case with the enclavement and metatarsal osteotomies such as the Watermann procedure (25, 26). Most of these procedures are primarily effective in the early stages of the disease (26). Other procedures attempt to alleviate symptomatology as with the Keller arthroplasty, implant arthroplasties, cheilectomy, and joint fusions (24, 26). With the exception of the cheilectomy, these generally are reserved for late stage arthroses. Subchondral drilling has been used to treat cartilage defects in conjunction with other procedures that address the etiology and symptomatology of the disease process. It has been shown that small drill holes may be effective in producing fibrocartilage to replace full- and partial-thickness cartilage defects (14, 18). Such drilling has been useful in the treatment of osteochondral lesions of the ankle and promises to be equally effective in treatment of osteochondral lesions of the metatarsophalangeal joints. As with any procedure, applications are limited. Subchondral drilling addresses only the cartilage defect and the pain attributed to that defect. It does nothing to address the etiology of a biomechanical problem. (ABSTRACT TRUNCATED AT 250 WORDS)

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An historical review of the literature dating from the early 1800s to the present reveals numerous methods that have been reported for the repair of syndactyly. This paper presents descriptions and diagrammatic illustrations of selected surgical procedures. Surgical intervention with the use of skin flaps to repair syndactyly almost always results in deficiency of skin. Either full thickness or porcine skin grafts to cover the adjacent sides of the desyndactylized digits generally should be used to avoid the postoperative complications inherent with the isolated use of skin flaps.

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A review of medical literature reveals that there is inconsistency in the reported incidence of Charcot joint disease or neuroarthropathy in the diabetic foot. There is also controversy as to which articulations are most commonly afflicted. Radiographs of 21 patients with bilateral diabetic neuroarthropathy were reviewed to determine the distribution of joint disease in the foot and ankle. Many patients had multiple sites of joint involvement. The results of this study show that the incidence of metatarsophalangeal joint involvement has been greatly underestimated.

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Previously reported avulsion fractures of the calcaneus have been confined to the attachment of the tendo achillis, bifurcate ligament, extensor digitorum brevis muscle, or the plantar fascia. A case report of a previously undescribed avulsion fracture of the calcaneus due to the abductor hallucis muscle is presented. The mechanism of injury, forced dorsiflexion of the forefoot, is described. A diagnostic and treatment regimen is provided. With appropriate identification of the injury, this unusual calcaneal fracture can be adequately managed.

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The development of pin tract reactions and their sequelae is based on a complex series of events. Analysis of pin tract infections directly related to static external wire fixation at Kern Hospital for Special Surgery from 1981 through 1988 showed an incidence of 0.46%; however, the overall incidence is probably higher. A discussion of the pathogenesis and guidelines for prevention, diagnosis, and treatment are presented. The authors suggest that pin tract infections occur because of postoperative skin contamination, rather than intraoperative implantation.

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The authors review the properties and podiatric applications of biodegradable internal fixation devices. These devices include sutures, rods, and screws. Fixation of fractures and osteotomies with absorbable materials has been shown to be as effective as fixation with more traditional means, and it also provides several advantages.

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Since indomethacin was first marketed, some 40 years ago, the class of nonsteroidal anti-inflammatory drugs has grown larger than any other drug class in history. At present, there are at least 25 such drugs being used in the US and abroad, both clinically and in research. Despite their widespread use, their implications to health care are just beginning to be understood. The authors review updated theories on the mechanism of action, side effects, and drug interactions of nonsteroidal anti-inflammatory drug therapy. Proposed guidelines for monitoring their use are given. A more thorough understanding of the risks-to-benefits ratio is provided in an effort to achieve maximum patient satisfaction and safety.

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Malignant melanoma, the leading cause of death from disease of the skin, often is found on the lower extremity. A thorough understanding of the disease entity is essential, because misdiagnosis or delayed diagnosis can be fatal. In Part I of this two-part clinical and surgical review of malignant melanoma, the authors discussed etiology, risk factors, signs, symptoms, clinical features, and growth patterns. Part II places special emphasis on diagnosing malignant melanoma and differentiating it from other lesions of the lower extremity. Clinical staging of the tumor and the corresponding surgical criteria are presented from a podiatric medical standpoint.

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Malignant melanoma, the leading cause of death from diseases of the skin, often is found on the lower extremity. When encountered by the podiatric physician, a thorough understanding of the disease entity is essential, as misdiagnosis or delayed diagnosis can have fatal consequences. The authors present the first of a two-part comprehensive clinical and surgical review of malignant melanoma. Part I reviews etiology, risk factors, signs, symptoms, clinical features, and growth patterns. In Part II, a pictorial lower extremity differential diagnosis will be provided, along with diagnostic and surgical criteria for the podiatric surgeon.

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The Swanson Silastic HP 100 Flexible Hinge Toe Implant (Dow Corning Wright, Arlington Tennessee) displays superior tensile, elongation and tear propagation strength in comparison to other silicone implant materials. It is, however, subject to many factors which may shorten its life-span. One reason for such failure has been attributed to the irregular contour of bone ends created after metatarsophalangeal joint arthroplasty, resulting in abrasion shards and shearing fractures of the implant stems and hinge. Titanium grommets were developed to alleviate this factor. This case report demonstrates a complication subsequent to total first metatarsophalangeal joint implant arthroplasty and the effectiveness of the Swanson Flexible Hinge Toe Joint Grommet. (Dow Corning Wright, Arlington, Tennessee).

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