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Osteoid osteoma rarely involves the phalanges of the toes. Basically osteoid osteoma is often a diagnostic dilemma in musculoskeletal practice especially in the foot and ankle. Its presentation is confusing and this may result in delayed diagnosis. We have reported a case of osteoid osteoma of the distal phalanx of the second toe which was treated successfully with surgical excision and reviewed the literature.

We report a case of intraosseous glomus tumor that developed in the right ring finger distal phalanx of a 19-year-old man. Clinical and radiographic findings were atypical. The tumor was excised en bloc because of the extensive involvement. The left second toe was transferred to the right ring finger to reconstruct the excised finger part. Symptom relief, function, and cosmetic outcome were satisfactory during 2-year follow-up.

In congenital hand differences, microsurgical toe transfer involves the creation of one or several rays in a child that never possessed them before. Second toe transplantation was uniformly used in this series that include 65 consecutive cases. Etiologies were represented by symbrachydactyly, constriction band syndrome or central cleft hand. Second toe transfer was performed with or without the MTP joint and followed by proximal ray resection of the donor toe. In the vast majority of theses cases, transplantation was performed in adactylic or monodactylic hand, the ultimate functional goal was the creation of a "tip-to-tip" two fingers pinch. Implantation site was chosen according to the situation of the existing finger(s). The existence of a functioning recipient MCP joint was one of the key factors of the final functional outcome. There were two vascular failures in this series with complete necrosis of the transplanted toe. Two additional toes appeared mediocre with respect to the overall transfer integration. The final mobility of the fingers reconstructed was measured using the total active motion score. Average TAM was poor (42 degrees +/-24 degrees ). In 12 out of 15 patients that were evaluated with a follow-up of at least five years, the static two-point discrimination was found to be excellent (less than 6mm). Our series did not allow us to establish a firm correlation between the type of nerve suture used and the quality of sensory recovery. Growth was measured as a percentage of the intact second toe (68 to 95%). All children on a long term basis had a normal gait without any impediment during sports or leisure activities. Clinical results obtained in this series lead to think that the cerebral cortex has got some plasticity which allows the integration of the transplants.

Glomus tumors are rare benign tumors commonly occurring in the digits of the hand. Surprisingly, considering the fingertips are of a similar make-up to the toes, there have been few reports of glomus tumor in the toes. The present case highlights a glomus tumor observed in the right second toe of a 56-year-old Indian female who presented with the classical triad of spontaneous pain, cold hypersensitivity, and pressure tenderness. There was a delay in diagnosis for approximately 18 years by various general practitioners who were not aware of the rare presentation of the glomus tumor. The tumor, which measured 5 × 3 mm, was excised from the nail bed of the toe. Histopathological inspection confirmed the diagnosis of glomus tumor. We believe that reporting this rare case may make clinicians more aware of this unusual diagnosis. Level of Clinical Evidence: 4

Free second toe transfer has become a popular method for the management of thumb or finger reconstruction. However, this creates an obvious appearance defect. A new operating procedure has been used since 1999. To enlarge the perimeter of the reconstructed thumb, a composite tissue strip flap from the fibular of great toe pedicled with the fibular proper plantar digital artery, combined or not with the island dorsal index finger flap, was inlaid with the second toe at the same time before the reconstruction. A crescent double-winged dorsal metatarsus flap, connected with second toe, in combination with the partial metatarsal bone, was also used to reconstruct fingers. There were 36 patients in the study group with a follow-up time of 6 months to 3 years. The thumb and finger reconstructed in this way showed better appearance, with normal caliber and length and without obvious adverse affects. This method has ameliorated the embarrassing appearance of the reconstructed thumb with earlier methods and is a relatively ideal method for thumb or finger reconstruction.

Background: Valgus deviation of the second toe can be associated with metatarsophalangeal joint pain, footwear fitting problems, and cosmetic concerns. It also reduces the buttress effect of the second toe on the hallux and may allow progression of hallux valgus. The traditional operative approaches for digital arthrodesis or lesser metatarsal osteotomy have unpredictable results. Methods: This study reviewed the effect of a closing wedge osteotomy on the proximal phalanx in 26 women with an average age of 59 years (SD 10) who had a valgus second toe. The patients had weightbearing radiographs preoperatively and at an average 28 months postoperatively. Clinical examination assessed for floating toe, range of metatarsophalangeal joint motion, and patient satisfaction. Results: Before surgery the average second toe valgus angle measured 28 degrees and at final review this had reduced to 14 degrees ( p < 0.001). Postop-eratively, the average range of dorsiflexion of the digit was 42 degrees (SD 20). The average plantarflexion was 16 degrees (SD 10). Floating of the digit was noted in five patients and recurrrence of the deformity in four patients. Nineteen patients (73%) were completely satisfied with the outcome of their surgery, seven were satisfied with reservations, and no patient was dissatisfied. Twenty five patients (96%) considered their second toe to be better than before the operation. Conclusions: Closing wedge osteotomy of the second toe is technically simple, reasonably safe, and relatively effective for valgus deformity of the second toe. Recurrence of the second toe valgus usually was associated with recurrence of hallux valgus.

Background: Although there is no ideal foot type for classical dancers, second-toe length seems to be a factor in the etiology of foot disorders in ballet dancers. Methods: We investigated the relationship between second-toe length and foot disorders in 30 ballet dance students and 25 folk dance students. Second-toe length in relation to the hallux (longer or equal/shorter), hallux deformities, first metatarsophalangeal joint inflammation, number of callosities, and daily pain scores were recorded in both groups and compared. Results: There was no statistically significant difference in toe length between the two groups (P > .05). Ballet dancers with equal-length or shorter second toes had lower pain scores, less first metatarsophalangeal joint inflammation, and fewer callosities in their feet compared with dancers with longer second toes. Conclusions: Second-toe length seems to be a factor in the development of forefoot disorders in classical ballet dancers but not folk dancers. Dancers who have equal-length or shorter second toes in relation to the hallux may have fewer forefoot disorders as dance professionals. (J Am Podiatr Med Assoc 97(5): 385–388, 2007)

Purpose To compare single-site intraoperative sarcomere length values with sarcomere lengths measured from systematic sampling of the entire transferred muscle. Methods The tendon of the rabbit second toe extensor muscle was transposed to the ankle extensor retinaculum under levels of stretch over the sarcomere length range of about 2.5 μm to about 4.0 μm. Intraoperative sarcomere length was measured at a single site with a laser diffraction device. Whole-muscle sarcomere length measurement was then determined by sampling across the muscle in the proximal, middle, and distal regions. Linear regression analysis and intraclass correlation coefficients were used to validate single intraoperative sarcomere lengths relative to whole-muscle sarcomere lengths. Results Single intraoperative sarcomere lengths correlated strongly with average whole-muscle sarcomere length, although there was a systematic tendency to overestimate intraoperative sarcomere length. Intraoperative sarcomere length also matched well with all regions sampled, indicating that there was no tendency for intraoperative sarcomere length to better represent one region of the muscle compared with another. Conclusions These results show that intraoperative sarcomere lengths accurately represent the entire muscle. The relatively small sarcomere length variations validate the use of intraoperative sarcomere length measurement during tendon transfer in which the entire muscle is not available for measurement because of limited surgical exposure.

We describe a technique to improve the appearance of the donor site after hallux harvesting. The surgery has been used in 6 consecutive patients having a trimmed-toe–type transfer. Instead of the classic stump closure advised by Wei, the following steps were performed on the donor site: (1) removal en bloc of the second metatarsal and transposition of the second toe on top of the proximal phalanx of the hallux, (2) interposition of a tibial (medial) glabrous flap from the tibial aspect of the hallux onto the tibial side of the second toe to increase its size, and (3) eponichial flap to increase the nail show on the second toe. Fixation of the toe was achieved with K-wires and cerclage wire. Crossed K-wires stabilized the first to the third metatarsals for 4 to 6 weeks. Ambulation with a stiff sole was allowed a few days after surgery. The main advantage of this technique is the improved donor site appearance. As a bonus, the amount of skin that can be harvested with the trimmed toe is slightly increased. The main drawback is that the number of toes is reduced to 4.

Background The length of the first metatarsal relative to the second has been implicated in a number of different foot conditions, is commonly examined clinically, and has been analysed in the literature. Despite the interest in length differences, there is limited research that describes reliable, clinically applicable techniques of such foot measurements. Objective To develop and evaluate the retest reliability of three methods for determining relative first and second toe and metatarsal length differences. Method Both feet of 18 participants (mean age ± S.D., 29.6 ± 13.8 years) were measured using the three techniques on two occasions by one tester. Results Technique one, measuring the difference between the ends of the toes, displayed excellent test–retest reliability (ICC = 0.98) and good measurement precision (individual score 95% CI −1.66 to 1.86). Technique three, the method of measuring relative metatarsal lengths using a sliding caliper had good reliability, but greater measurement error (ICC = 0.76, 95% CI −4.91 to 4.43). Measurement of metatarsal length relative to a point outside the foot, technique two, showed only moderate reliability and poor precision (ICC = 0.67, 95% CI −5.81 to 5.67). Conclusion Two clinically relevant, inexpensive and non-invasive techniques for measuring relative first and second toe and metatarsal length have been identified. These methods have the potential to be used in future research, within the clinical setting and during screening sessions.

Background. The adduction of the first pedal ray in humans, such that the hallux is incapable of functional opposability, is a major feature of the evolution of the hominin foot (e.g. Darwin 1872, Haeckel 1879, Latimer and Lovejoy 1990). While hallucal adduction facilitates obligate bipedalism, it inhibits but does not eliminate arboreal grasping ability. The angle of the hallux (as determined by the longitudinal axis of the first metatarsal) relative to the rest of the foot (as determined by the longitudinal axis of the second metatarsal) is a product of both hard- and soft- tissues. Given the failure of soft tissue to fossilize, direct evidence for hallucal angle evolution is scanty, and consensus has not emerged as to when and how the modern human condition of hallucal non-opposability evolved. Methodology/Principal Findings. Analysis of a large sample (n = 331) of radiographs taken from the dorsal aspect of living human feet elucidates the relationship between osteological measures and the magnitude of hallucal adduction, which is resultant of both hard- and soft-tissue anatomy (Lovejoy et al. 2009). I describe the correlation of hallucal convergence with first metatarsal posterior articular facet morphology, which allows inference of hallucal convergence in the absence of the medial cuneiform. I report parameters of modern human hallucal convergence variation and offer insight into the hominin fossil record. I infer that the hallucal convergence of the recently reported specimen from Burtele (BRT-VP-2/73) falls within the range of living human variation, inconsistent with the interpretation that this hominin retained the ability to oppose its great toe for the purpose of arboreal locomotion (Haile-Selassie et al. 2012). Of the fossil hominin first metatarsals surveyed, all fall within the range of living human variation, consistent with previous research on medial cuneiform (McHenry and Jones 2006) and first metatarsal (Berillon 1999) morphology. Conclusions/Significance. This study finds that the modern human condition of hallucal non-opposability was present in the genus Australopithecus. However, while the Burtele specimen (BRT-VP-2/73) falls within the range of living human variation, it displays a markedly divergent hallux compared to most living humans. This study suggests that, as in humans today, there was variation in hallucal divergence in Plio-Pleistocene hominins. Rather than using the terms 'opposability' and the ambiguously synonymous 'grasping,' I suggest here the term 'clamping' (as in the motion performed by a clamp) be used to describe the less powerful and less dexterous ability of modern humans to place and hold a thin, narrow object between the great toe and second toe ray in a limited, albeit functional, manner.

Background:Hallux valgus foot with laterally deviated lesser toes is a complex condition to treat. Ignoring the laterally deviated lesser toes in hallux valgus might result in unsatisfactory foot shape. Without lateral support of the lesser toes, it might increase the risk of recurrence of hallux valgus. We sought to identify associated radiographic findings in patients where lesser toes follow the great toe in hallux valgus and deviate laterally.Methods:The weight-bearing, anteroposterior foot radiographs of 24 female hallux valgus feet with laterally deviated lesser toes (group L), 34 female hallux valgus feet with normal lesser toes (group H), and 43 normal female feet (group N) were selected for the study. A 2-dimensional coordinated system was used to analyze the shapes and angles of these feet by converting each dot made on the radiographs onto X and Y coordinates. Diagrams of the feet in each group were drawn for comparison. The hallux valgus angle, lateral deviation angle of the second toe, intermetatarsal angles, toe length, metatarsal length, and metatarsus adductus were calculated according to the coordinates of the corresponding points.Results:The mapping showed the bases of the second, third, and fourth toe in group L shifted laterally away from their corresponding metatarsal head ( P < .001). The mean 2-3 intermetatarsal angles were: group L, H, N = 7.7 ± 2.6, 4.3 ± 1.9, 4.3 ± 1.3 degrees, respectively (P < .001); mean 3-4 intermetatarsal angles were, for groups L, H, N = 7.3 ± 2.3, 6.1 ± 2.1, 6.3 ± 1.4 degrees, respectively ( P < .05). Larger hallux valgus angles ( P < .001), more adducted first metatarsal ( P < .05), and divergent lateral splaying of the lesser metatarsals ( P < .001) were found in group L.Conclusion:Larger 2-3 and 3-4 intermetatarsal angles, larger hallux valgus angle, more adducted first metatarsal, and divergent lateral splaying of the lesser metatarsals were associated with lateral deviation of the lesser toes in hallux valgus.Level of Evidence:Level III, comparative study.

The authors successfully performed a series of 32 distal finger reconstructions using partial second toe-to-finger transfers solely for aesthetic indications. The resulting hand function shows an average static 2-point discrimination of 8 mm. Total active range of motion was 205 degrees. Key-pinch strength and grip strength averaged 65 and 90% of the normal contralateral side, respectively. Patient satisfaction, as reflected by the average subjective satisfaction scores for aesthetic appearance and function (SSSAF) of the reconstructed distal finger, was high at 82 and 78, respectively. The SSSAF for the donor site averaged 88 for function and 75-80 for aesthetic appearance, which is statistically significant (p

In post-traumatic losses of the thumb and fingers, reconstruction can be performed with success using various combinations of toe transfers. In this study, we have presented second toe and combined toe transfers which have been followed up for more than 20 years. Second toe transfer was used in four patients for reconstruction of the thumb. Combined second and third toe transfer was performed in two patients with a metacarpal hand for finger reconstruction. Long-term follow-up results show that patients with toe-to-hand transfers have acceptable adaptation to the reconstructed hand and good hand function. Toe transfer should be individually planned and carefully executed to obtain optimal results and minimal disability in the donor foot.

A painful neuroma in the amputation stump of a finger can be psychologically and physically disabling. Numerous surgical procedures have been attempted to prevent and treat amputation neuromas of the finger, but the results are inconsistent. Microsurgical transfer of the distal second toe to the amputated stump of the finger can provide a pathway and target for the regenerating axons and avoid recurrence of neuromas. In this article, we present the experience of successful treatment of amputation neuromas of an index finger with microsurgical distal toe transfer.

Summary Objectives To illustrate the surgical methods and clinical efficacy of microsurgical free-flaps obtained from second toe for the reconstruction of palmar soft-tissue defect of fingers. Methods We enrolled 22 patients (13 men and 9 women), who received second toe free-flap for 22 finger defects between August 2007 and July 2013. The average age was 35 years (range, 18–62 years). The average size of flap was 2.7 cm × 2.0 cm (range, 1.5 cm × 1.5 cm–3.5 cm × 2.5 cm). Results All flaps survived well without any complications. Follow-up period ranged from 8 to 30 months (mean 15 months). The Visual Analog Scale for flap appearance (VAS flap) was ranged from 8 to 10 (average, 9.5). Based on the CISS questionnaires, 6 cases had mild cold intolerance. The average value of Michigan Hand Outcome Questionnaire (MHOQ) scoring for overall hand function was 8 (range, 5–13). The sensibility outcomes in 10 patients who underwent nerve repair were satisfactory. Average value of static two point discrimination (2PD) was 6.4 mm (range, 4–10 mm) and SWM test was 3.45 (range 2.83–4.12). Conclusions Second toe free micro-flap is a very useful and reliable alternative for the reconstruction of palmer soft-tissue defect of fingers. Level of Evidence : IV.

The purpose of this study was to determine if metatarsal protrusion or the length of the first and second rays were associated with the incidence of hallux rigidus. For this retrospective study, anteroposterior radiographs from 51 patients diagnosed with hallux rigidus and 51 patients without evidence of hallux rigidus were selected for review as a control group. Radiographs were randomly assigned to one of two raters who determined the metatarsal protrusion distance, first metatarsal length, second metatarsal length, length of the proximal phalanx of the hallux, length of the proximal phalanx of the second toe, and overall hallux length. A statistical comparison of these radiographic measurements showed only first metatarsal length to significantly differ (P = .05) between the two groups (65.4 +/- 5.3 mm and 67.7 +/- 5.9 mm for the hallux rigidus and control groups, respectively). The findings of this study suggest the need to revisit the role that metatarsal protrusion distance and first metatarsal length play in the etiology of hallux rigidus. In addition the need to surgically correct a long first metatarsal should be further evaluated.

Toe-to-hand transfers to replace missing fingers have become a common reconstructive practice in our clinic. The purpose of this article is to evaluate morbidity of the donor site on the foot following the transfer. A group of 72 patients were assessed; 95 feet were examined post-transfers, i.e., 23 patients had transfers from both feet. The groups were arranged according to the numbers of patients as follows: group A (37 cases), second toe from one foot; group B (17 cases), second toes from both feet; group C (6 cases) with wrap-around flap; and group D (5 cases), the whole big toe. This was followed by group E (7 patients), who had the combination of the second and third toes harvested simultaneously, the great toe or wrap-around flap in combination with harvesting the second toe from the same or contralateral foot. Scar quality of the donor site, standing on tiptoe and tiptoeing, discomfort after prolonged walking, stair climbing, need to change the shoe size, and participation in special activities, such as sports and overall patient satisfaction, were evaluated. The least significant problems occurred in patients with the second toe harvested, they had minimum complaints with static loading and minor complaints with dynamic loading. Patients with the second toes harvested from both feet also had minimum complaints with static loading and minor complaints in dynamic loading. More problems were observed with both static and dynamic loading in the patients with the great-toe transfer. The biggest troubles were reported by the patients with the wrap-around flap or in case of multiple toe transfers. Only one patient from the sample had to seek medical help of a specialist due to some problems following the toe harvest. In the retrospective subjective evaluation of patient satisfaction and benefits of the operation, all patients declared that they would undergo the reconstruction again despite the problems encountered at the donor site.

An immunosuppressed heart transplant recipient developed Exophiala jeanselmei infection on the second toe. After unsuccessful treatment with different antifungal drugs, the infection responded to a high-dose regimen of oral terbinafine (an antifungal agent not yet approved in the United States for use against the dematiaceous fungi) and warm packs. This is, to our knowledge, the only known case of successful terbinafine treatment of E. jeanselmei infection.

Microsurgery and free tissue transfer play a vital role in the modern practice of reconstructive surgery. Prior to the advent of microsurgical free tissue transfer pedicle flaps were the workhorse of a reconstructive surgeon. We report a case of thumb reconstruction by pedicled transfer of the second toe with functional and aesthetic outcome. This case was performed in Pakistan where microsurgical facilities were not available.

The relationship between onychocryptosis and foot type was investigated in a series of 512 patients. Of these patients, 124 had signs or a history of onychocryptosis. Among the nine foot types identified by digital and metatarsal formulas, the Greek index minus and squared index minus types showed the strongest association with onychocryptosis, which was present in more than one-third of such feet. When anteroposterior radiographs of each type of foot were taken after binding the first and second toes together to simulate a tight shoe, the enlargement of bony structures of the second toe at the distal interphalangeal level in the Greek and squared index minus feet moved toward the distal enlargement of the distal phalanx of the first toe where the ingrowing occurs. Ten cases of stage I and four cases of stage II onychocryptosis were treated by placing a toe spacer between the first and second toes; all healed in about 3 weeks, suggesting that counterpressure of the second toe in tight shoes is a factor in the development of onychocryptosis. (J Am Podiatr Med Assoc 93(1): 33-36, 2003)

Between 1980 and 2000, 26 pollicizations of the index finger and 32 transplantations of the second toe were performed for reconstruction of the thumb after traumatic loss. Twenty-three patients with index finger pollicization and 26 patients with second toe transplantation could be reviewed after an average follow-up of 6.4 years. Vascular complications occurred in two toe transplantations and one index finger pollicization. One transplanted toe was lost after vascular complications. Mobility of the interphalangeal joints was reduced after both procedures. Pinch grip was achieved in 20 of 23 patients after pollicization and 20 of 26 patients after second toe transplantation. Sensitivity was better after pollicization. The most common complaints were cold intolerance after both procedures. Fourty of 49 patients would have the operation again, nine patients would refuse thumb reconstruction.

The treatment options for the loss of an entire human hand and part of the forearm are currently limited to the transplantation of toe(s) to the amputation stump or a Krukenberg's bifurcation hand, and using a cosmetic or functional prosthesis. The functional prosthetic hand, such as the prevailing myoelectrically controlled prosthetic hand, has an action accuracy that is affected by many factors. The acceptance rate of the three planes freedom myoelectronic hand by the patients was 46-90% because of poor function caused by the weakness of signal and strong external interference. In this report, the left second toe was transplanted to the patient's forearm amputation stump. Mandates from the brain are relayed by the action of this reconstructed digit, to control a special designed multidimension freedom electronic prosthetic hand. After rehabilitation and adaptation training, the correct recognition rate of the electronic prosthetic hand controlled by this reconstructed digit is a remarkable 100%.

Summary A cornu cutaneum (cutaneous horn) is a clinical descriptive term referring to a skin tumor having the appearance of an animal horn. Histopathologically, the lesion may be associated with several different tumors. Along with some benign entities such as warts or seborrheic keratoses, a cutaneous horn may be also associated with actinic keratoses, Bowen disease and squamous cell carcinoma. When an underlying malignancy is present, the entire tumor must be removed with careful control of margins. We report a case of a 68-year-old man with a cornu cutaneum-like HPV 45 positive sub-ungual squamous cell carcinoma on the left second toe.

Background:Plantar pressure abnormalities after open reduction with internal fixation (ORIF) of intra-articular calcaneal fractures have been observed previously, but high-grade fractures were not selectively investigated and follow-up times were shorter than 2 years. The purpose of this study was to characterize plantar pressure anomalies in patients with exclusively high-grade calcaneal fractures after ORIF with a minimum 2 years of follow-up, and to test the association between plantar pressure distribution and the clinical outcome.Methods:The orthopaedic registry was reviewed to identify patients with isolated high-grade calcaneal fractures (Sanders types III-IV) who were operated on and had a minimum 2 years of follow-up. Sixteen patients were evaluated. Mean age was 47 years and follow-up was between 2 and 6 years. The Pedar-Mobile system was used to measure 3 loading and 3 temporal variables and compare these between the operated and the uninjured limbs.Results:Mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 76 ± 7 at latest follow-up. Bohler’s angle was 5 ± 8 degrees before surgery and 25 ± 7 degrees at latest follow-up. Stance was shorter in operated limbs ( P = .001). Timing of the peak of pressure was delayed in operated limbs under the hallux and the second toe ( P ≤ .03). Peak pressure, force time integral, and pressure time integral were increased under the lateral midfoot ( P ≤ .03) and decreased under the second metatarsal ( P ≤ .03). Force time integral was decreased under the first metatarsal ( P = .02) and under the hallux and the lateral toes ( P ≤ .05). Increased loading under the lateral midfoot and decreased loading under the lateral toes were correlated with poorer clinical outcome ( r = −.53, P < .05, and r = .63, P < .01, respectively).Conclusions:Side-to-side plantar pressure mismatch persisted at more than 2 years after ORIF of high-grade calcaneal fractures performed via lateral approach, despite improvement of Bohler’s angle. This was characterized by shortened stance phase, delayed timing of peak of pressure under the hallux and second toe, lateral load shift at the midfoot, and decreased toe pressures in operated limbs. Since loading abnormalities were correlated with the clinical outcome, modifications in treatment strategy that can improve foot loading may be desirable in these cases.Level of Evidence:Level III, case control.

We report the results of a percutaneous technique to correct a proximal plantar flexion deformity of the second toe that combines several procedures: tenotomy of the Flexor Digitorum Brevis, plantar capsulotomy for release of the proximal interphalangeal joint and proximal phalangeal osteotomy. The goal of these procedures is to improve anatomical correction and preserve articular range of motion. From 2009 to 2011, 54 patients, mean age 64.4 years old (43–81) underwent surgery for a proximal deformity of the second toe. Associated tenotomy of the extensor digitorum longus and brevis was performed in the presence of an extension deformity of the metatarsophalangeal joint (24 cases). After a mean follow-up of 30.7 ± 8.9 months, the rate of satisfaction and morphological correction was high (89.5% in both cases), as well as the number of flexible toes (88%). Active plantar flexion was preserved in 86% of the cases. This seems to be an effective technique to correct proximal plantar flexion deformity of the second toe, while preserving active plantar flexion.

Introduction: Infantile digital fibromatosis, also known as Reye tumor, is a rare, as ymptomatic, benign nodular proliferation of fibrous tissue, which occurs almost ex clusively in the dorsolateral region of the fingers and toes. This article reports a case of infantile digital fibromatosis. Case report: This case was diagnosed by clinical, im aging, and histopathological examination. The patient presented at the Orthopedic Department of our hospital, with a 4-year history of a painless, erythematous nodular lesion on the second toe of the left foot. On physical examination, a deformity of the second toe caused by a nodular, erythematous, painless lesion of approximately 1.5 cm diameter was noted; the lesion did not result in functional changes. Ultrasound examination revealed a solid, hypoechoic nodule involving the extensor tendon in the middle phalanx of the second toe. The initial diagnosis was fibroma or synovioma.

Twelve patients underwent reconstruction of injured finger joints using our technique of a vascularized transfer of the second toe proximal interphalangeal joint. The age of the patients at operation ranged from 7 to 47 years and the postoperative follow-up was 9 to 48 months. All the joint transfers survived and united with resolution of the preoperative joint pain, deformity and instability. The average range of motion of the reconstructed joints was 59° in the proximal interphalangeal and 54° in the metacarpophalangeal joints. No patient complained of pain or functional deficits in the donor foot.

The study aimed to find out the problems connected with feet during work in cold loose housing barns in wintertime. Thirteen dairy farms and 20 workers were studied. Skin temperatures and subjective responses were collected, and at the end of a work period the subjects filled in a questionnaire about the workday. The foot skin temperatures were measured on dorsal foot and second toe. Most of the workers used rubber boots. The ambient temperature outdoors varied from +5 to −11°C. Indoor temperatures could be the same as outdoors (cold barns and fodder storage) but also close to +30°C (milk room). The lowest mean foot and toe skin temperatures were 24.1±2.6°C and 16.0±1.4°C. The lowest measured values were 20.1°C and 12.8°C, respectively. The toe temperatures were on average 7.3°C colder than foot temperatures (mean 28.8°C). The low foot skin temperature was well related to cold sensation. Low toe temperatures fitted well with wetness sensation. On average the thermal sensation of feet over the work period was neutral. The lowest ratings were cold (−2). The combination of various environmental factors in farms complicates finding of perfect footwear for work. Recommendations on the choice of footwear and their care are given. Relevance to industry Dairy farms function as small enterprises. The owners’ family usually does the work. The workdays are often long. In spite of modern machinery and industrial methods, several work moments are heavy and the work conditions are considered to be harsh.

Pigmented villonodular synovitis is a rare proliferative disorder of the synovium of unknown aetiology. We present a case of pigmented villonodular synovitis in an unusual location, the interphalangeal joint of a toe, diagnosed by ultrasound with colour Doppler. The role of various imaging modalities in the diagnosis of pigmented villonodular synovitis is discussed.

To devise a new classification of vascular variations in second toe transfer we analyzed the anatomic details of the first dorsal metatarsal artery in 304 cases of second toe transplantation and the venous structure in 200 cases. According to location, the arterial vascularity was classified as superficial (18% of cases), intramuscular (54%), inframuscular (23%), and absent (5%). According to diameter, it was classified into large (16%), medium (64%), and small (20%). Based on branching pattern, the artery was classified into ramifying type (88%), main trunk (4%), and fine branch type (8%). The venous drainage of the second toe was categorized as greater saphenous vein main trunk type, greater saphenous vein fine branch type, dorsal digital vein main trunk type, and dorsal digital vein fine branch type. Variations of the first dorsal metatarsal artery are common. Classification should be done according to its location, diameter, and branching pattern at the toe web. Regardless of location, big vessels entering the second toe are the most important attribute for successful outcome. (J Hand Surg 2000;25A: 277–281. Copyright © 2000 by the American Society for Surgery of the Hand.)

Summary Between April 1994 and May 1998, 15 amputated index fingers were treated based on three classifications: group 1 consisted of patients with index finger defects immediately proximal to, yet including, the distal interphalangeal joint, group 2 were those patients with defects from the proximal part of the distal interphalangeal joint to the distal part of the proximal interphalangeal joint and group 3 comprised patients with more proximal defects than group 2. With a total of six men and nine women, seven cases were included in group 1, five in group 2 and three in group 3. For the patients in groups 1 and 2, only a partial length of the second toe was transferred to the index finger, whereas in group 3 the total length of the toe needed to be transferred. The results can be summarised as follows: 1.The two-point discrimination of the reconstructed index tip was 2.2 mm for group 1, 2 mm for group 2 and 2.3 mm for group 3. 2.In group 1, the average range of motion in the transferred toe was 43.8° in the distal interphalangeal joint. In groups 2 and 3, the average range of motion in the transferred toe was 30° and 30.7° in the distal interphalangeal joint, and 50° and 39.3° in the proximal interphalangeal joint, respectively. 3.When compared with the contralateral index finger, the pinching power was measured at 83% in group 1, 70% in group 2 and 60% in group 3. 4.Excellent results were obtained in group 1, good results in group 2 and fair results in group 3. Accordingly, the more proximal the defect in the index finger, the less satisfactory the result obtained.

A 23-year-old man sustained traumatic loss of both hands. His left defective forearm underwent lengthening with a 3-cm segment of the ipsilateral radius; this was immediately followed by an ipsilateral second toe microvascular transfer to the stump of the radius to provide pinch. Two years after the procedure the reconstructed hand had recovery of both motion and sensibility.

Mutilating hand injuries can significantly alter a patient's life. Return to work and daily activities remain the ultimate goal. A case report and long-term follow-up of a patient who caught his hand in a generator fan at work is presented. He sustained an injury that left him with a wrist and metacarpal stump. When prostheses failed, an extra-anatomic second toe transfer was used to produce a functional distal extremity. This transfer allowed the patient to return to his job and was surprisingly durable, resulting in a useful helper hand for 15 years.

Extraskeletal chondroma is a rare, benign cartilaginous tumor seen most frequently in the soft tissues of the hands and feet. The authors present a case of extraskeletal chondroma in a 52-year-old male patient who had a small mass on the left foot involving the flexor surface of the second toe. Radiographs showed the presence of a soft-tissue mass with scattered calcified foci. Surgical excision revealed a benign, lobulated cartilaginous tumor with prominent areas of calcification. Histologically; the lesion consisted of cartilage cells with centralized zones of cellular pleomorphism and giant-cell proliferation at the tumor margin consistent with extraskeletal chondroma.

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.

Utilizing the tissue obtained from the plantar surface (metatarsophalangeal-distal interphalangeal region) of the second toe is an ideal procedure for reconstruction of partial finger tissue defects. The major advantage of this method is that it provides satisfactory aesthetic and functional improvement at the recipient site: furthermore, good results from the aesthetic point of view and minimum morbidity at the donor site are obtained. Our procedure utilizes the free neurovascular skin flap (second toe plantar flap) and full-thickness skin graft. As for the free flap, artery and nerve are obtained from the plantar neurovascular bundle and vein from the dorsal or plantar vein. All cases reconstructed with this procedure revealed satisfactory sensory restoration and aesthetic appearance. The donor sites also revealed no contracture and visible scar. In this paper, we discuss the application of this procedure for finger tissue reconstruction.

A new microvascular flap from the plantar aspect of the second toe is described. The flat is usually cutaneous, but it may also include nerve and tendon. It is ideal for finger reconstruction and its use and versatility is illustrated in five cases.

Repairing complex soft-tissue defects of the hand and fingers remains a daunting task. Maintenance of functional mobility and sensibility are paramount in determining donor-site tissue. Critical sensibility is important for defects of the fingers and can be replaced only with tissue from the palmar surface of the hand itself or by free-tissue transfer from the toes. In this regard, glabrous skin and pulp from the great toe demonstrates the most critical level of sensibility, followed by tissue from the second toe. Complex soft-tissue defects of the palm, dorsum of the hand, or first web space can be replaced effectively by flaps that provide protective sensibility. The standard flaps employed are the lateral arm or radial forearm. The ultimate consideration in dealing with these difficult problems must be determined by the judgment and technical sophistication of the surgeon.

Toe-to-hand transfer is a well established procedure and is one of the best ways of reconstructing the missing fingers or parts of fingers. In congenital deformities of fingers and hands such as absence of digits, second toe transfer may create the grip function and is superior to all other procedures. We present three cases of four second toe transfer to reconstruct long finger defects after congenital malformations of the long fingers. The aim of this paper is to discuss some aspects of the procedure and to evaluate achieved results. All our four patients were operated on when they were over 10 years of age.

Data on footprints and gait of 54 Hadzabe, 6-70 years of age expand understanding of pedal morphology of unshod people and assist the development of ideas about the evolution of hominid bipedality and upright posture. Contrary to published data on gaits and pedal morphology of unshod populations, Hadzabe (also known as Hadza) from northern Tanzania exhibit values of stride length, relative stride length, and walking speeds that exceed those of rural and small-town populations. In all observable plantar features, including foot indices, an interdigital space between the hallux and second toe, fanning of the foot anteriorly, and foot angles (in-toeing and out-toeing), Hadzabe feet are comparable with those of never-shod Machiguengas in Peru ´ . On average, Hadzabe hallucal gaps and ball widths are narrower than those of Machiguengas and other unshod short people. Hadzabe feet are also charac- terized by valgus halluces versus the varus halluces of never-shod Machiguen- gas and certain West Africans. Although characterized by a valgus toe, Had- zabe hallucal angles, which do not exceed 208, are lower than those of Northern Hemispheric urbanites and shod rural populations of the Southern and North- ern Hemispheres. Hadzabe also exhibit less medial and lateral rotation of the hip joint than Machiguengas do. The heel and the longitudinal arch impressions of the Hadzabe footprints closely resemble those of the Laetoli bipeds in the manner of weight distribution during locomotion. The striking similarity of footprint impressions, especially the heel and the longitudinal arch, between Hadzabe and Laetoli hominid footprints clearly imply that the pedal features of the Laetoli printmakers are remarkably humanoid. Am. J. Hum. Biol. 9:303-321, 1997. q 1997 Wiley-Liss, Inc.

BACKGROUND Free vascularized joint transfer for reconstructing the posttraumatic proximal interphalangeal joint has enjoyed limited popularity because of the low range of motion typically achieved after transfer. One of the commonest complaints is the significant extensor lag. Part 2 of this two-part study is focused on the clinical outcomes following a more anatomical approach to extensor tendon reconstruction. METHODS Nine patients (eight male and one female), with a mean age of 31.7 years, underwent free vascularized joint transfer for posttraumatic proximal interphalangeal joint injuries using the second toe proximal interphalangeal joint. In Part 1, two arrangements of the central slip mechanism were found: type I with an attenuated and type II with a distinct central slip. An algorithm was constructed using this information: in a type I toe with sufficient recipient lateral bands, a centralization procedure was carried out; and when the lateral bands were insufficient, a modified Stack procedure was carried out. In type II toe joints, a tight repair of the corresponding extensor tendons was performed. RESULTS Four patients underwent centralization procedures, two underwent a modified Stack procedure, and three underwent tight extensor repair. At 23.4 months, the average extensor lag was 18.3 degrees. A total range of motion of 53.9 degrees (mean flexion, 72.2 degrees) was achieved that approximated 81.1 percent of the pretransfer passive range of motion at the toe proximal interphalangeal joint. CONCLUSION This preliminary result demonstrates that much improved range of motion can be achieved by reducing the extensor lag using an anatomical reconstruction that takes into account the recipient finger and toe joint anatomy. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Posttraumatic loss of the thumb is devastating. Toe-to-hand transfer is considered the criterion standard of reconstruction but is associated with donor-site issues. The twisted-toe technique uses parts from the great toe and the second toe, which allows for almost anatomical restoration of the donor foot. The authors present their experience and technical modifications of this method.Between January of 2003 and November of 2011, 18 patients suffering from loss of thumb because of a variety of indications were treated with the authors' modification of the twisted-toe technique. The neothumb was constructed with a partial onychocutaneous flap from the great toe and an osseotendinous flap from the second toe.Of 18 transplanted twisted-toe flaps, 17 survived completely (5.6 percent flap loss rate). Similarity of the reconstructed thumb compared with the healthy side was very acceptable in all cases. All patients in whom the procedure was successful were able to use the neothumb in daily life without constraints. Reconstruction of the donor site yielded very acceptable outcomes with a distinct reduction in morbidity and disfigurement compared with conventional toe harvest.The modified twisted-toe technique is the authors' preferred choice of thumb reconstruction. It allows the reconstructive surgeon to construct a very natural-appearing neothumb with good stability and grip force. In addition, it eliminates many of the donor-site problems associated with pure great toe harvest, by recreating a "neo-great toe" at the donor foot. Although the procedure is more complicated and time-consuming compared with single toe harvest, the authors firmly believe that this extra effort takes thumb reconstruction to a next level.Therapeutic, IV.

Background: Surgical treatment of multiplanar (varus and dorsal angulation) second toe deformities due to degenerative instability can lead to recurrence, stiffness, and pain. The goal of this study was to evaluate the short-term outcomes associated with a new technique using an extensor digitorum brevis (EDB) tendon reconstruction to correct such deviation of the second metatarsophalangeal (MTP) joint. Methods: Ten patients (10 female, 0 male) with 11 operated second toes having undergone correction with a reconstruction using the EDB tendon were assessed at an average of 18.5 months (range, 12-34) after surgery. The technique was indicated when MTP and medial partial plantar plate release alone were not sufficient to correct multiplanar deformity. Radiographic parameters (AP and lateral metatarsal-proximal phalanx angles), physical exam (MTP joint range of motion), and subjective outcomes (the Foot and Ankle Outcome Score [FAOS]) were assessed. A toe-specific survey captured more detailed subjective information, including patient satisfaction. Results: Preoperatively, the average MTP joint angle was 4.5 degrees in the varus direction, which changed to 14.2 degrees in the valgus direction postoperatively. On exam, the average MTP joint range of motion was 60.9 ± 11.6 degrees dorsiflexion and 11.1 ± 2.5 degrees plantarflexion. Postoperative FAOS scores demonstrated an average of 89.9 ± 9.8 for the symptoms domain. In all, 9 of 11 patients were either highly satisfied or moderately satisfied (none dissatisfied). Conclusion: With the stated limitations, the EDB tendon reconstruction technique described in conjunction with collateral ligament and partial plantar plate release provided powerful correction. Minimal release of the medial plantar plate and not overtightening the reconstruction are recommended to avoid shifting the toe in the opposite direction. Level of Evidence: Level IV, retrospective study.