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Removal of right cerebral hemisphere for certain tumors with hemi- nifcant diferences among the diferent pathologies [51] discount 40 mg levitra extra dosage visa. L’ablation complète de l’hémisphère droit dans les cas de tumeur cérébrale localisée compliquée d’hémiplégie: la décérébration supra-thalamique bly related to aseptic meningeal reaction cheap 60mg levitra extra dosage with visa, is a common observation unilatérale chez l’homme discount 40 mg levitra extra dosage with visa. Te present status of a patient who had the right cerebral hemi- In general buy levitra extra dosage 60 mg lowest price, postoperative wound infections and haemorrhages sphere removed. Neurochirurgie 1964;10: no cases reported in the more recent larger series with sufciently 507–522. Persistent intracranial bleeding as a complication ment to a meticulous haemostasis [19,60]. Can J Neurol Sci 1983; 10: documented, including a meticulous analysis of the integrity of the 71–78. Language recovery afer lef hemispherec- Lippincott Williams & Wilkins, 2000: 741–746. Exceptional verbal intelligence surgical procedures and clinical long-term outcomes in a population of 83 chil- afer hemispherotomy in a child with Rasmussen encephalitis. Complications related to delayed hemorrhage afer hem- Tuxhorn I, Holthausen H, Boenig H (eds). Epilepsy surgery for hemispheric syndromes in come with respect to epileptic seizures. Surgical Treatment of infants: hemimegalencephaly and hemispheric cortical dysplasia. Modifcation of peri-insular hemispherotomy and surgical initial description: Promising prospects and a dilemma. Te nonmalformed hemisphere is secondari- Te reorganization of sensorimotor function in children afer hemispherectomy. Brain 2006; 129: 1822– outcome of 58 children afer hemispherectomy: the Johns Hopkins experience: 1832. Late plasticity for language in a ale, indications, results, and comparison with callosotomy. Distinct right frontal lobe activation in intractable seizures: excellent seizure control, low morbidity and no superfcial language processing following lef hemisphere injury. Tere was laboratory evidence sup- forme fruste infantile hemiplegia, Rasmussen syndrome, Lennox– porting the rationale for this procedure, notably that of Erickson Gastaut syndrome, frontal lobe epilepsy and other secondarily gen- [2], who in non-human primates demonstrated prevention of the eralized epileptics. Slightly better outcomes were found in the frst spread of the epileptic discharge to the opposite hemisphere when two groups but there was sufcient improvement in all categories to the corpus callosum had been divided. Today, most epilepsy centres perform commis- by a number of investigators [13,14,19,21,25,29,33,38,39,44,45,50, surotomy, and it retains an important role in the armamentarium of 57,58,67,69,72,74,77,79,81,85,86,89,92,95,96,97,98,99,100,101,102, interventions for intractable epilepsy. Te majority of patients have evi- Although resection of an epileptogenic region with the goal of sur- dence of bilaterally synchronous epileptiform activity and this does gical cure has always been the surgical procedure of choice, in those not necessarily represent a bad prognostic sign. Te signifcance of patients with generalized seizures in whom a discrete epileptogenic bilateral, independent foci remains undetermined. Other palliative pro- has been believed to be associated with a better surgical outcome cedures, including multiple subpial transection, vagal nerve stim- [12,115], but in the selection process their presence or absence has ulation and deep brain stimulation, have also been developed, and always been secondary to clinical and electrophysiological informa- the strategy for optimal utilization or prioritization of these various tion. Te impact of neuroimaging on the callosotomy experience non-ablative strategies remains to be determined [23,24,25]. As imaging technologies continue to evolve with From the earliest days of callosotomy it has been appreciated that increasing sensitivity and specifcity, they are directing such aspects drop attacks (variously classifed as atonic and akinetic seizures) of the seizure evaluation as intracranial recording electrode place- are among the most likely of seizure types to beneft from discon- ment, and this will obviously afect patient selection and perhaps nection; tonic and tonic–clonic generalized seizures similarly have the surgery itself. Patients in whom Given the difcult evaluation in this patient population, it is both seizure semiology, electrophysiological studies, neuroimaging and Te Treatment of Epilepsy. Te remaining candidate pool will be section [16], and difuse disease may render any partial section heterogeneous, including patients with infantile hemiplegia, forme futile. Te correlation between extent of disease and successful fruste infantile hemiplegia, Rasmussen syndrome, Lennox–Gastaut section, however, is insufcient to place great reliance on these syndrome, frontal lobe epilepsy and other secondarily generalized factors. Although the outcome of a seizure-free patient most have not adopted this practice. Te patient is placed in a su- is always hoped for, this is achieved in only 5–10% of cases [118]. For the anterior division, the of other epilepsy surgeries as it is usually palliative rather than neck is kept in neutral position; for the posterior division, fexion of curative. Alternatively, one may po- sition the head parallel to the foor such that the hemisphere to be retracted is dependent, thereby allowing gravity to help provide the Surgical technique exposure [65,124]. Tis has the appeal of minimizing any retracting Early clinical series ofen included division of the corpus callosum, force placed interhemispherically, although whether this retraction the underlying hippocampal commissure and additional structures, is signifcant enough to warrant the perhaps less comfortable and including the anterior commissure and, in some instances, one for- diferently oriented horizontal positioning is open to discussion. Nearly all series today restrict division to the Te incision and type of craniotomy used is a matter of the sur- corpus callosum and, in posterior or complete callosal section, to geon’s personal preference. We have used linear incisions and 5-cm the hippocampal commissure that is immediately apposed to the trephinations [10,125], but the actual type and extent of craniotomy ventral aspect of the posterior portion of the callosum. A 9-cm transverse incision with one-third mains variation, however, with regard to which part or how much of its length across the midline and placed 2 cm in front of the coro- of the structure is divided. Seizure outcome appears to have some nal suture is used for the anterior procedure. As neuropsycho- trephination at the level of the parietal eminence is employed for logical consequences of callosal section are encountered primarily the posterior procedure. Te placement of the craniotomy across with complete section [120,121], most centres today usually divide the sagittal sinus requires caution but facilitates exposure down the the anterior two-thirds to three-quarters and spare the splenium at interhemispheric fssure with minimal retraction, and this is im- initial surgery. Exceptions to this approach are division of a smaller, select or to transcallosal procedures has been advocated, but this has not portion of the callosum, division of the posterior half as an initial been a routine step for most centres, including ours. Te been possible to work on either or both sides of such a vein without presurgical evaluation and preoperative substrate may infuence the requiring its sacrifce using a microsurgical technique. Such angiographic information may be available in the consideration of the risk–beneft ratio for partial or complete in those patients who have previously undergone amytal testing section. Tis down the interhemispheric fssure under loupe magnifcation, and is especially true if drop attacks, which usually respond to anteri- retraction is aided by the earlier administration of mannitol (1 g/ or section, are not the predominant seizure pattern. Te both anterior cerebral arteries, the white corpus callosum, and the slightly exposure is that of the residual cavum septum pellucidum, and dissection darker cingulate gyri. Adhesions between the hemispheres may make initial expo- Te actual direction of subsequent section is not particular- sure difcult, especially when there is a history of previous in- ly important. With patient microsurgical technique, one performed extraventricularly as far as possible. Te rostrum at this can generally obtain good exposure; approaching the callosum point is nearly paper thin, and any remaining fbres are insignif- more posteriorly and utilizing the deeper extension of the falx cant. Te corpus callosum is dis- Division posteriorly is readily performed following the midline tinguished from the more superfcial cingulate gyrus by its glis- clef. If an attempt is being made to achieve success with a partial tening white appearance (Figure 70. Te pericallosal arteries are identifed overlying the callosum and care is taken to avoid their injury.

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Of course trusted 40 mg levitra extra dosage, any excess of such fragments will impair molecule is arranged in the form of a cross buy levitra extra dosage 40 mg low price. The domain the normal coagulation process—an event with serious clini- structures of the α and β chains resemble one another buy discount levitra extra dosage 40 mg line. Laminins have biological functions and fbrinolytic proteins and with C5b67 complex to block its characteristics that include facilitation of cellular adhe- insertion into lipid membranes discount levitra extra dosage 40mg fast delivery. It decreases nonselective lysis of Laminins also facilitate neurite regeneration, an activity autologous cells by insertion of soluble C5b67 complexes associated with the foot of the molecule. In plasma, 65-kDa and 75-kDa glycoproteins that facilitate adherence of cells as well as the ability of cells to spread and to differentiate are known as serum spreading factors. The structure consists of a triple helix of 95-kDa polypeptides forming a tropo- collagen molecule that is resistant to proteases. Several types of collagen have been described and most of them can be cross-linked through lysine side chain. It facilitates epithelial tissue differentiation and consists of six 210-kDa proteins that are all alike. They all consist of two proteoglycan polypeptide chains; the larger of these chains (α) is different binding site for each member of the family; the smaller chain (β) is com- figure 2. It is present on leukocytes, monocytes, macrophages, and ucts, even though they possess a high degree of homology. It is associated with the development or A human T lymphocyte encircled by a ring of sheep stabilization of synapses. S-laminin is homologous to the β-1 red blood cells is referred to as an E rosette. Laminin facilitates cell attachment and used previously as a method to enumerate T lymphocytes migration. Its function appears to be for attach- lymphocytes to exit the blood circulation and circulate into ment of cells and for the outgrowth of neurites. It T and B lymphocytes, natural killer cells, macrophages, mediates neutrophil rolling on the endothelium. Ligands are sialylated Lewis X and related node homing via binding to high endothelial venules, pre- glycans. P-selectins are involved in the binding of leuko- sentation of chemokines or growth factors to migrating cells, cytes to endothelium and platelets to monocytes in areas of and growth signal transmission. Weibel-Palade bodies are P-selectin granules found in Many cancer cells and their metastases express high levels of endothelial cells. It may be used as a diagnostic or prognostic marker surface following activation of an endothelial cell by such for selected human malignant diseases. Cytoplasmic domains of cadherins may interact interaction with monocytes and neutrophils. L-selectin is also Naive T Cell found on neutrophils where it acts to bind the cells to acti- vated endothelium early in the infammatory process. Lymphocytes from Peyer’s patches home to mucosal endothelial cells bearing ligands for the lymphocyte homing receptor. Thus, endothelial cell addressins in separate ana- tomical locations bind to lymphocyte homing receptors leading to organ-specifc lymphocyte homing. The structure of chemotactic factors and even the active region in their mol- ecules have been determined in many instances. However, advances in the clarifcation of their mechanism of action have been facilitated by the use of synthetic oligopeptides with chemotactic activities. The specifcity of such compounds Micropore filter depends both on the nature of the amino acid sequence and the position of amino acids in the peptide chain. Positively charged His and negatively charged Glu in this position are signifcantly less active, sub- stantiating the role of a neutral amino acid in the second posi- Chemotactic tion at the N-terminal. Neutrophil chemoattractants also include bac- Downregulation or mutation of the E-cadherin/catenin genes terial products such as N-formyl methionyl peptides, fbrin- can disrupt intercellular adhesion, which may lead to cellular olysis products, oxidized lipids such as leukotriene B4, and transformation and tumor progression. These chemotactic factors are derived from both infamma- These cells move into infammatory agents by chemotaxis. The of monocytes in various pathologic or physiologic condi- number of cells on the flter separating the cell chamber from tions. Neutrophil chemotaxis assays are performed using the the chemotaxis chamber refects the chemotactic infuence of microchamber technique. Chemotactic factors include substances of both endogenous Chemotactic receptors are specifc cellular receptors for and exogenous origin. In bacteria, such receptors are desig- products of tissue injury, chemical substances, various pro- nated sensors and signalers and are associated with various teins, and secretory products of cells. The cellular receptors for chemot- among them are those generated from complement and actic factors have not been isolated and characterized. This name is related to their leukocytes, the chemotactic receptor appears to activate concurrent ability of stimulating the release of mediators a serine proesterase enzyme, which sets in motion the from mast cells. Some chemotactic factors act specifcally sequence of events related to cell locomotion. Others have a appear specifc for the chemotactic factors under consider- broader spectrum of activity. Many of them have additional ation, and apparently the same receptors mediate all types activities besides acting as chemotactic factors. It has been found in chicken cal events leading to one or another type of response. Using a fbroblasts and mononuclear cells, yet no human or murine synthetic peptide N-formyl-methionyl-leucyl-phenylalanine, homolog is known. The presence of spare receptors may enhance the in wounded tissues suggests that it has a role in the wound sensitivity in the presence of small concentrations of chemo- response and/or repair. Tissue sources include epithelial Chemokinesis refers to the determination of the rate of cells and platelets. A chemotactic peptide is a peptide that attracts cell migra- A Boyden chamber (Figure 2. The two chambers in the apparatus are separated by a micropore fl- Chemotactic deactivation represents the reduced chemo- ter. The cells to be tested are placed in the upper chamber and tactic responsiveness to a chemotactic agent caused by prior a chemotactic agent such as F-met-leu-phe is placed in the incubation of leukocytes with the same agent but in the lower chamber. As cells in the upper chamber settle to the fl- absence of a concentration gradient. It can be tested by adding ter surface, they migrate through the pores if the agent below frst the chemotactic factor to the upper chamber, washing, chemoattracts them. On staining of the flter, cell migration and then testing the response to the chemotactic factor placed can be evaluated.

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A characteristic cystic hypoechoic fluid collection will be easily visualized between the gastrocnemius and semimembranosus muscles generic 40 mg levitra extra dosage with mastercard, although occasionally popliteal cysts can arise from tendons (Fig order levitra extra dosage 40 mg mastercard. Proper transverse position of the ultrasound transducer for ultrasound evaluation for Baker cyst purchase levitra extra dosage 40mg visa. Transverse ultrasound image of the posterior quadrant of the knee demonstrating a hypoechoic Baker cyst levitra extra dosage 60mg online. Transverse ultrasound image demonstrating a loculated popliteal (Baker) cyst in a 44-year-old woman. Ultrasound image transverse to the long axis of the leg demonstrating a chronic Baker cyst. Longitudinal ultrasound image demonstrating a well-defined anechoic large Baker cyst lesion. When the Baker cyst is satisfactorily identified, the skin is prepped with anesthetic solution and a 3½- in 22 gauge needle is advanced from the middle of the inferior border of the ultrasound transducer and advanced utilizing an out-of-plane approach with the trajectory being adjusted under real-time ultrasound guidance until the needle tip is resting within the Baker cyst (Fig. When the tip of the needle is thought to be in satisfactory position, the cyst can be aspirated and a small amount of local anesthetic and steroid are injected under real-time ultrasound guidance to confirm that the needle tip is within the Baker cyst (Fig. The needle is then removed, and a sterile pressure dressing and ice pack are placed at the injection site. The patient should be informed that the cyst may recur and require surgical extirpation. Transverse ultrasound image of the posterior quadrant of the knee showing placement of a needle within the Baker cyst. Coexistent semimembranosus bursitis, medial hamstring tendinitis, or internal derangement of the knee may contribute to knee pain associated with and may require additional treatment with more localized injection of local anesthetic and depot corticosteroid preparation. Aspiration and injection of symptomatic Baker cysts are safe if careful attention is paid to the clinically relevant anatomy in the areas to be injected. The incidence of ecchymosis and hematoma formation, as well as reaccumulation of fluid within the Baker cyst, can be decreased if pressure is placed on the injection site immediately after injection. White blood cell scan depicting increased uptake in the left gastrocnemius muscle consistent with infected ruptured Baker cyst. Rupture of Baker’s cyst producing pseudothrombophlebitis in a patient with Reiter’s syndrome. The boundaries of the popliteal fossa are the skin, the superficial fascia, and the popliteal fascia and the popliteal surface of the femur, the capsule of the knee joint, the oblique popliteal ligament, and the fascia of the popliteus muscle. The fossa contains the popliteal artery and vein, the common peroneal and tibial nerves, and the semimembranosus bursa (Fig. The knee joint capsule is lined with a synovial membrane that attaches to the articular cartilage and gives rise to a number of bursae, including the suprapatellar, prepatellar, infrapatellar, and semimembranosus bursae which lie between the medial head of the gastrocnemius muscle, the medial femoral epicondyle, and the semimembranosus tendon. The lateral head gastrocnemius muscle finds its origin from the lateral condyle of the femur, while the medial head of the gastrocnemius muscle finds its origin from the medial condyle of the femur (Fig. Along with the soleus muscle, the gastrocnemius muscle forms a common tendon which is known as the calcaneal tendon or Achilles tendon that inserts onto the posterior calcaneus (Figs. A fabella is an accessory sesamoid bone located within the substance lateral head of gastrocnemius muscle in the posterior knee in approximately 25% of patients. It is covered with hyaline cartilage which makes it susceptible to the development of chondromalacia or osteoarthritis. Fabellas, which is Latin for little bean, are asymptomatic in most patients, but can occasionally cause symptoms due to repeated rubbing on the posterolateral femoral condyle. Fabellas are often mistaken for a joint mouse or osteophyte or are simply identified as a serendipitous finding on imaging of the 1012 knee, especially when displaced posteriorly by swelling of the joint. A fabella may be either unilateral or bilateral and may be bipartite or tripartite, which can further confuse the diagnosis. It is subject to fracture and dislocation and has the propensity to compress the peroneal nerve. A patient suffering from a symptomatic fabella will complain of pain and tenderness over the posterolateral knee. The patient will often describe a sensation of having loose gravel in their knee and may note a grating sensation with range of motion of the knee. The pain of fabella worsens with activities that require repeated flexion and extension of the knee. A creaking or grating sensation may be appreciated by the examiner and locking or catching on range of motion of the knee may occasionally be present. Plain radiographs are indicated in all patients who present with posterior knee pain both to aid in the diagnosis and to rule out occult bony pathology (Figs. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing, magnetic resonance imaging, or ultrasound imaging of the affected area may also confirm the diagnosis and help delineate the presence of other knee bursitis, Baker’s cyst, internal derangement, calcific tendinitis, synovial disease, tendinopathy, and other abnormalities (Fig. Radionucleotide bone scanning may be useful in identifying stress fractures of the fabella that may have been missed on other imaging modalities. Observe the focal triangular ossification complete with cortex within the lateral margin of the medial meniscus (arrow). C: 3D reconstructed image (posterior view) more realistically depicts the features of this injury. A linear high-frequency ultrasound transducer is placed in a longitudinal orientation over the lateral aspect of the posterior knee at the level of the previously identified joint space and an ultrasound survey scan is obtained (Fig. The lateral femoral condyle and the lateral head of the gastrocnemius muscle are identified (Fig. The extent of the insertion of the lateral head of the gastrocnemius muscle is identified with the ovoid, smooth appearing hyperechoic fabella lying beneath it (Figs. Proper longitudinal position of the ultrasound transducer over the lateral posterior knee at the level of the joint space for ultrasound evaluation of fabella. Longitudinal ultrasound image demonstrating the lateral femoral condyle and lateral head of the gastrocnemius muscle. Longitudinal ultrasound showing a fabella (white arrow) and herniation of the lateral head of the gastrocnemius muscle (black arrow) over the fabella. Herniation of the lateral head of the gastrocnemius muscle: is it the source of the posterolateral knee pain? Longitudinal ultrasound image of the posterolateral capsule demonstrating the lateral gastrocnemius tendon with fabella (arrow). In general, a fabella will have an ovoid smooth appearance while a loose body will appear more jagged (Fig. Coexistent bursitis, tendinitis, or internal derangement of the knee may contribute to knee pain associated with and may require additional treatment with more localized injection of local anesthetic and depot corticosteroid preparation. T1-weighted sagittal magnetic resonance image showing a fabella to be more prominent in extension, causing “tenting” of the nerve (arrow). Both functions are important in stabilizing the posterior knee when walking upright and running. The lateral head of the gastrocnemius muscle finds its origin on the lateral condyle of the femur, while the medial head finds its origin on the medial condyle of the femur (Figs. The muscle descends the posterior lower extremity to join with the soleus muscle to form the Achilles tendon which inserts onto the posterior surface of the calcaneus (Figs.

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A 35-year-old man presented with a large ulcer in the plantar soft tissues of the hindfoot beneath the calcaneus buy levitra extra dosage 40mg visa. Fluid can also be seen tracking along the plantar aponeurosis (long straight arrow) (plantar fasciitis) purchase 40 mg levitra extra dosage with amex. The arching high signal intensity structures (short straight arrows) are blood vessels buy levitra extra dosage 40mg without prescription. This runner presented with pain and swelling about the posterosuperior aspect of the calcaneus buy cheap levitra extra dosage 60 mg online. Early blood pool images (A) show marked increased vascularity in the superior and inferior aspects of the right calcaneus, with persistent uptake on the delayed images (B). Characteristically on bone scintigraphy there is hyperemia on the blood pool images along the plantar fascia with more focal uptake at the inferior calcaneum on the delayed images. The tracer uptake superior to the right calcaneus is indicative of increased metabolic activity in the region of the retrocalcaneal bursa, which is consistent with bursitis. This imaging protocol enhances the diagnostic accuracy of pathology related to heel pain. With the patient in the above position, a high- frequency linear ultrasound transducer is placed in a longitudinal plane with the inferior portion of the ultrasound transducer over plantar surface of the foot with the superior end of the transducer on the anterior portion of the calcaneus, and an ultrasound survey scan is taken (Fig. The calcaneus, calcaneal spur, and linear plantar fascia are identified at its insertion on the calcaneus (Fig. When the insertion of the plantar fascia is identified, it is evaluated for evidence of calcaneal spurs, insertional tendinopathy, and plantar fasciitis (Figs. Proper longitudinal ultrasound transducer placement for ultrasound evaluation for calcaneal spurs. Longitudinal extended-field-of-view image in an adolescent with ankle pain and swelling following a “hard landing” during gymnastics. Moreover, a tear at the Achilles tendon (at) insertion can be seen (short black arrow) and is distal to the apophyseal fragment. Longitudinal ultrasound images of normal plantar fascia (arrows in A) and plantar fasciitis (B), 1203 demonstrating a thickened hypoechoic plantar fascia (arrows) inserting into the calcaneus (calc). Introduction to diagnostic musculoskeletal ultrasound: part 2: examination of the lower limb. A longitudinal gray scale image of the plantar foot shows a subcutaneous hypoechoic nodule (black arrow) within the plantar fascia (white arrows), separate from the calcaneal insertion (c). The judicious use of multiple imaging modalities will help improve the accuracy of diagnosis and help avoid clinical misadventures (Figs. The use of ultrasound-guided injection of calcaneal spurs with local anesthetic can serve as a diagnostic maneuver. A: Lateral radiograph of the ankle showing an area of sparse trabeculae in the anterior calcaneus, known as Ward triangle. A simple bone cyst (B) and an intraosseous lipoma (C) in the same location in the anterior calcaneus are thought to occur because of the blood supply of this region and are secondary to infarction. The diagnosis and treatment of heel pain: a clinical practice guideline–revision 2010. Each joint is lined with synovium and the ample synovial space allows for intra-articular placement of needles for injection and aspiration. The metatarsophalangeal joints have a dense joint capsule and strong plantar and collateral ligaments, although fracture and subluxation may still occur (Figs. The metatarsophalangeal joints of the toes are also susceptible to overuse and misuse injuries with resultant inflammation and arthritis. The interphalangeal joints of the toes are ginglymoid hinge joints which have extensive flexion and more limited extension due to the limitation of the metatarsal and collateral ligaments (Figs. A,B: The metatarsophalangeal joints of the toes are also susceptible to overuse and misuse injuries with resultant inflammation and arthritis. The interphalangeal joints of the toes are ginglymoid hinge joints which have extensive flexion and more limited extension due to the limitation of the plantar and collateral ligaments. The primary function of the metatarsophalangeal and interphalangeal joints of the toes is to aid in the gripping function of the foot. The articular cartilage of the metatarsophalangeal and interphalangeal joints of the toes are susceptible to damage, which left untreated, will result in arthritis with its associated pain and functional disability. Osteoarthritis is seen in the metatarsophalangeal and interphalangeal joints of the toes which results in pain and functional disability, with rheumatoid arthritis, posttraumatic arthritis, and crystal arthropathy also causing arthritis of the metatarsophalangeal and interphalangeal joints of the toes. Gout selectively afflicts the metatarsophalangeal joint of the first toe and is called podagra (Figs. Less common causes of arthritis-induced pain of the metatarsophalangeal and interphalangeal joints of the toes include other collagen vascular diseases, infection, psoriatic arthritis, villonodular synovitis, and Lyme disease (Figs. Acute infectious arthritis of the metatarsophalangeal joints of the toes is best treated with early diagnosis, with culture and sensitivity of the synovial fluid, and prompt initiation of antibiotic therapy. The collagen vascular diseases generally manifest as a polyarthropathy rather than a monoarthropathy limited to the metatarsophalangeal and interphalangeal joints of the toes, although pain of the metatarsophalangeal and interphalangeal joints of the toes, secondary to the collagen vascular diseases, responds exceedingly well to ultrasound-guided intra-articular injection. Gout frequently afflicts the first metatarsophalangeal joint and is called podagra. Plain radiograph demonstrating tophaceous gout of the first interphalangeal and tarsometatarsal joint. Plain radiograph demonstrating psoriatic arthritis of the metatarsophalangeal and first interphalangeal joint. Posteroanterior radiograph of the toes shows septic arthritis of the metatarsophalangeal joint. At the third joint there is loss of the normal articular cortical bone of both the metatarsal head and base of the proximal phalanx (arrowhead). Activity, including walking and weight bearing makes the pain worse, with rest and heat providing some relief. Sleep disturbance is common with awakening when patients roll over onto the affected foot. Some patients complain of a grating, catching, or popping sensation with a range of motion of the joints, and crepitus may be appreciated on physical examination. Functional disability often accompanies the pain associated with the many pathologic conditions that affect the metatarsophalangeal joints of the toes. Patients will often notice increasing difficulty in performing their activities of daily living and tasks that require standing, walking, or weight bearing. If the pathologic process responsible for pain of metatarsophalangeal and interphalangeal joints of the toes is not adequately treated, the patient’s functional disability may worsen and muscle wasting and ultimately frozen metatarsophalangeal and interphalangeal joints of the toes may occur. Plain radiographs are indicated in all patients who present with pain of the metatarsophalangeal and interphalangeal joints of the toes (Fig. Based on the patient’s clinical presentation, additional testing may be indicated including complete blood cell count, sedimentation rate, and antinuclear antibody testing. A: Anteroposterior radiograph showing an expanded lucent lesion in the fourth metatarsal shaft, sharply defined but no sclerotic rim. A: Aggressive lesion in the distal metaphysis of the second metatarsal exhibiting cortical destruction laterally and sclerotic soft tissue extension projecting medially. Longitudinal ultrasound image along the plantar aspect of the foot at the level of the first metatarsal head demonstrates an encapsulated, mildly heterogeneous collection superficial to flexor hallucis longus tendon consistent with an adventitial bursa. With the patient in the above position, the dorsal surface of the metatarsophalangeal joint of the affected toe is identified by palpation.

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