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Brachymetatarsia is an uncommon condition, and when present, it is usually asymptomatic. A case report demonstrating the use of distraction lengthening for symptomatic multiple congenital short metatarsals is presented. A 15-year-old female with congenital short third and fourth metatarsals was treated for painful transfer lesions under the second and fifth metatarsal heads and a secondary hallux valgus deformity. Surgical correction with a chevron osteotomy, soft tissue reconstruction of the second toe, and distraction lengthening of the third and fourth metatarsals was performed. Three years after treatment, the patient has an excellent clinical correction, with no evidence of recurrent transfer lesions. To our knowledge, this is the first report demonstrating the use of distraction lengthening without supplemental bone graft for multiple short metatarsals in a single extremity.

A 64-year-old woman was treated for an idiopathic complete rupture of the posterior tibial tendon with transfer of the flexor digitorum longus tendon to the navicular. After an initial excellent result, she returned 41 months later after experiencing a sudden pop in the medial retromalleolar area, followed by progressive medial ankle pain. At reoperation, a complete rupture of the flexor digitorum longus tendon was noted at its insertion into the navicular. Reconstruction was performed utilizing a sliding lengthening of the flexor digitorum longus tendon and reattachment to the navicular with a suture anchor. Clinical improvement was noted at the 12-month follow-up evaluation. This case presentation is of clinical interest, as late acute failure of a flexor digitorum longus tendon transfer for posterior tibial tendon rupture has not been reported previously.

Twelve patients with rupture of the anterior tibial tendon are presented. Nine patients were aware of an acute event prior to their symptom onset and three were not aware of any acute event. Complete rupture of the tendon was noted in 10 patients and incomplete rupture was seen in two patients. Treatment was individualized based on age, etiology, preinjury function, patient health, and personal considerations. Five patients were treated without surgery. Three preferred no orthotic devices, and two believed their function was improved with an ankle-foot orthosis. Seven patients were treated operatively using a variety of individualized reconstructive techniques. All operatively treated patients demonstrated increased function and strength. Based on our findings, operative reconstruction is recommended in appropriate patients.

Two patients with combined rupture of the anterior tibial tendon and posterior tibial tendon are described. Both were elderly women with a gradually progressive valgus deformity of the ankle/hindfoot and severe pain. Arthrodesis procedures were performed in both patients; however, postoperative complications prevented significant clinical improvement. This combined tendon rupture is presented to document a new clinical entity.

We have treated seven patients with dislocation or recurrent subluxation of the posterior tibial tendon. The diagnosis of dislocation was made based on the patient's symptoms, physical examination, and magnetic resonance scanning. All patients were treated with surgical repair, which was modified according to the operative findings. The operative findings included tenosynovitis, a shallow or incompetent flexor groove, and tearing or absence of the flexor retinaculum. At an average of 28 months following surgery, all patients were markedly improved and six returned to their preinjury level of activity.

Midfoot motion was determined using an in vitro model. Ten fresh-frozen below-the-knee amputation specimens were instrumented by inserting reference pins into each of the bones of the hindfoot, midfoot and metatarsals. Dorsiflexion-plantar flexion and supination-pronation were simulated and the reference pin location in three dimensional space was determined. Comparing the location of the reference pins at each simulated position, motion was determined. Motion occurring through each articulation (dorsiflexion-plantar flexion/supination-pronation) in degrees was: talonavicular (7.0/17.7), calcaneocuboid (2.3/ 7.3), naviculo-medial cuneiform (5.0/7.3), naviculo-middle cuneiform (5.2/3.5), naviculo-lateral cuneiform (2.6/2.1), medial cuneiform-first metatarsal (3.5/1.5), middle cuneiform-second metatarsal (0.6/1.2), lateral cuneiform-third metatarsal (1.6/2.6), cuboid-fourth metatarsal (9.6/11.1), and cuboid-fifth metatarsal (10.2/9.0).

The detection of musculoskeletal sepsis, especially following joint replacement, continues to be a challenging problem. Often, even with invasive diagnostic evaluation, the diagnosis of infection remains uncertain. This is a report on the first 55 Indium-111 white blood cell (WBC) images performed in 39 patients for the evaluation of musculoskeletal sepsis. There were 40 negative and 15 positive Indium-111 WBC images. These were correlated with operative culture and tissue pathology, aspiration culture, and clinical findings. Thirty-eight images were performed for the evaluation of possible total joint sepsis (8 positive and 30 negative images); 17 for the evaluation of nonarthroplasty-related musculoskeletal sepsis (7 positive and 10 negative images). Overall, there were 13 true-positive, 39 true-negative, two false-positive, and one false-negative images. Indium-111 WBC imaging is a sensitive and specific means of evaluating musculoskeletal sepsis, especially following total joint replacement.