With the rapid development and use of new cancer therapies, cutaneous reactions related to systemic toxicities are becoming common. This case report establishes the importance of the podiatric physician’s role in the care of oncologic patients with plantar erythrodysesthesia taking a tyrosine kinase inhibitor.
Background: We evaluated the clinical characteristics of ingrown toenails in one of the biggest reference centers in Turkey.
Methods: This retrospective cohort study was conducted on patients admitted to Ufuk University Hospital with ingrown toenail between January 1, 2014, and December 31, 2019. Clinical characterstics and demographic features of all of the participants were evaluated, and then the study population was divided into two groups: group 1 (patients ≤20 years old) and group 2 (patients >20 years old). These groups were compared in terms of clinical findings.
Results: Disease duration, body mass index, rate of medications for chronic diseases, and rate of joint diseases were significantly higher in group 2. Rates of hyperhidrosis and sudden weight gain were significantly higher in group 1 (P < .05). Severity of ingrown toenail was significantly different between groups (P = .006). Stage 1 was the most common stage in both groups, and rate of stage 3 was higher in group 1. Onycoshisis and was more common in group 1, and nail thickening was more common in group 2 (P < .05). Nail wire and aluminum chloride were the most common treatment modalities in groups 2 and 1, respectively (P < .05). Periungual edema, presence of pus, hypertrophy, and granulation were more common in group 1 (P < .05). Thin nail plate was more common in group 1, and normal and thick nail nail plates were more common in group 2 (P < .05).
Conclusions: Clinical characteristics of ingrown toenail vary between younger and older populations. Thus, an individualized approach is preferred in the management of ingrown toenail for different age groups.
Background: Tibia pilon fractures are associated with high complication rates, decreased quality of life, and low patient satisfaction. Although many factors such as reduction quality and soft-tissue coverage have been identified, researchers continue to investigate the factors that affect healing in tibia pilon fractures. Our objective was to investigate the effect of initial fracture crack width and displacement degree on clinical functional results in tibia pilon fractures.
Methods: In this retrospective cohort study, 40 patients with Arbeitsgemeinschaft für Osteosynthesefragen and Orthopaedic Trauma Association type 43B and 43C tibia pilon fractures and operated on through the extensile anteromedial approach were analyzed. The demographic data of the patients, injury mechanisms, fracture type, reduction quality, clinical results, and postoperative complications were recorded. To evaluate the objective quantity of initial fracture crack width and displacement, a new parameter was defined: “fracture area.” All measurements were conducted using a feature from the picture archiving and communication system on anteroposterior and lateral radiographs taken separately in standard fashion.
Results: With an average follow-up period of 29.2 months (range, 24–40 months), 34 patients (85%) had excellent or good results, whereas only two patients (5%) had poor clinical results. Age, injury mechanism, and reduction quality have a significant relationship with Maryland Foot Score (P < .001, P < .037, and P < .001, respectively). Preoperative fracture area, measured on both the anteroposterior and the lateral views, are significantly related to both Ovadia-Beals Score and Maryland Foot Score (P < .001 for each).
Conclusions: Preoperative fracture area measurement has a major effect on healing of tibia pilon fractures. Increased initial fracture area is correlated with poor clinical functional results. High-energy injuries, older age, and poor reduction quality are also related to worse clinical outcomes.
Background: Plantar first metatarsal ulcerations pose a difficult challenge to clinicians. Etiologies vary and include first metatarsal declination, cavus foot deformity, equinus contracture, and hallux limitus/rigidus. Our pragmatic, sequential approach to the multiple contributing etiologies of increased plantar pressure sub–first metatarsal can be addressed through minimal skin incisions.
Methods: A retrospective review was performed for patients with surgically treated preulcerations or ulcerations sub–first metatarsal head. All of the patients underwent a dorsiflexory wedge osteotomy, and the need for each additional procedure was independently assessed. Equinus contracture was treated with Achilles tendon lengthening, cavovarus deformity was mitigated with Steindler stripping, and plantarflexed first ray was treated with dorsiflexory wedge osteotomy.
Results: Eight patients underwent our pragmatic, sequential approach for increased plantar pressure sub–first metatarsal, four with preoperative ulcerations and four with preoperative hyperkeratotic preulcerative lesions. The preoperative ulcerations were present for an average of 25.43 weeks (range, 6.00–72.86 weeks), with an average size of 0.19 cm3 (median, 0.04 cm3). Procedure breakdown was as follows: eight first metatarsal osteotomies, four Achilles tendon lengthenings, and six Steindler strippings. Postoperatively, all eight patients returned to full ambulation, and the four ulcerations healed at an average of 24 days (range, 15–38 days). New ulceration occurred in one patient, and postoperative infection occurred in one patient. There were no ulceration recurrences, dehiscence of surgical sites, or minor or major amputations.
Conclusions: The outcomes in patients surgically treated for increased plantar first metatarsal head pressure were evaluated. This case series demonstrates that our pragmatic, sequential approach yields positive results. In diabetic or high-risk patients, it is our treatment algorithm of choice for increased plantar first metatarsal pressure.
Tuberosity fractures of the fifth metatarsal are common. The majority of these fractures are treated nonoperatively with good outcome. Surgery is indicated for nonunions, delayed unions, comminuted fractures, and displaced fractures. The surgical modalities include screw fixation, suture anchor fixation, Kirschner wires, tension band wiring, and locking plates. We report a case of a symptomatic nonunion of a displaced fracture of the tuberosity of the fifth metatarsal in a young patient treated with a tension band suture fixation that to our knowledge has not been described before.
Background: Generally, posterior malleolar fragments are fixed either with percutaneous anteroposterior screws or through a posterolateral approach using screws and/or a buttress plate. Both surgical methods have some shortcomings, and the use of anteroposterior screws to fix osteoporotic posterior malleolar fractures carries a risk of failure.
Methods: Nine elderly patients (average age, 67 years) with posterior malleolar fractures were treated with transfibular Kirschner wire tension band fixation. According to the Lauge-Hansen classification, all fractures were of the supination-external rotation type. The operative duration, intraoperative blood loss, and wound healing outcome were recorded. During the follow-up period, clinical outcomes were measured using the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, and the occurrence of complications was observed.
Results: The patients were followed up for 12 to 18 months (mean, 15 months). The operative duration ranged from approximately 30 to 95 minutes, with an average of 70 minutes. Anatomical reduction was achieved in nine cases, and there were no complications, such as skin necrosis, wound infection, or skin sensory disturbance. There was one case of delayed wound healing caused by fat liquefaction, which was cured by a dressing change. The functional scores were excellent in four cases, good in four cases, fair in one case, and poor in zero cases. The rate of excellent and good results was 88.89% (eight of nine), with an average of 78.78 points.
Conclusion: Kirschner wire tension band fixation through a transfibular approach for the treatment of posterior malleolar fractures does not require a change in patient posture. It facilitates the reduction and internal fixation of the posterior malleolar fragment; furthermore, it is easier to remove internal fixation after fracture healing, which provides a new surgical method for elderly patients with posterior malleolus fracture. Thus, this has potential as a new surgical method for elderly patients with posterior malleolar fractures.
Sea urchin spine injuries have been reported in the hand and foot, but there are no published cases in the Achilles tendon. We report an unusual case of Achilles tendinopathy secondary to sea urchin spine injury. The patient had Achilles tendon pain that increased over time and was worsened with weightbearing activity. His left ankle plantarflexion was limited by pain. He had received medical care 3 months earlier to remove sea urchin spines after stepping on a long-spined sea urchin. Bedside ultrasound and imaging studies revealed that there were foreign bodies related to sea urchin spines on the surface of the tendon. The patient was given education about proper footwear and activity modification. His symptoms resolved over time, and he avoided surgical intervention.
Herpetic whitlow is a viral infection of the fingers or toes caused by the herpes simplex virus. Herpes simplex virus is a common pathogen that causes infections in any cutaneous or mucocutaneous surface, most commonly gingivostomatitis or genital herpes. However, infection of the digits is also infrequently reported. Herpetic whitlow occurs when the virus infects the distal phalanx of the fingers or toes by means of direct inoculation, causing pain, swelling, erythema, and vesicle formation. The proper diagnosis is important because the condition can mimic various other podiatric abnormalities such as paronychia, bacterial cellulitis, or even embolic disease. Improper diagnosis often leads to unnecessary work-up, antibiotic therapy, or even surgical intervention. This case will help illuminate the clinical presentation of herpetic whitlow in an atypical location, and the patient’s subsequent treatment. We present an atypical case of right hallux herpetic whitlow with delayed diagnosis and associated cellulitis. The patient was admitted after seeing multiple providers for a progressive right hallux infection that presented as a mixture of vesicular lesions and apparent cellulitis. His history was positive for biting his fingernails and toenails, and the lesions were noted to be honeycomb-like, with minimal drainage. The lesions were then deroofed and viral cultures were obtained, which were positive for herpes simplex virus type 1, thus confirming a diagnosis of herpetic whitlow. Although he remained afebrile with negative wound cultures during admission, a secondary bacterial infection could not be excluded because of his nail avulsion and surrounding cellulitis. He was discharged on oral antibiotics, antivirals, and wound care recommendations. Herpetic whitlow should be included in the differential diagnosis of pedal digital lesions that appear as vesicular or cellulitic in the pediatric population.
Abstract
Background: Onychomycosis is the most common nail disease seen in clinical practice. Medication safety, severity of disease, co-morbidities, concomitant medications, patient age, and cost are all important considerations when treating onychomycosis. Since cost may affect treatment decisions, we sought to analyze Medicaid formulary coverage of onychomycosis antifungals.
Methods: Public state Medicaid formularies were searched for coverage of FDA approved onychomycosis medications and off-label oral fluconazole. Total drug cost for a single great toenail was calculated using National Average Drug Acquisition Cost. Pearson correlation coefficients were calculated to compare coverage and cost, mycological cure rate, and complete cure rate.
Results: Oral terbinafine and off-label fluconazole were widely covered for onychomycosis treatment. There was poor coverage of oral itraconazole and topical ciclopirox, and no coverage of topical efinaconazole and tavaborole without step-edits or prior authorization. There was a significant negative correlation between medication coverage and cost (r = −0.758, p= 0.040). There was no correlation between medication coverage and mycologic (r = 0.548, p = 0.339) and complete (r = 0.768, p = 0.130) cure rates.
Conclusions: There is poor Medicaid coverage of antifungals for the treatment of onychomycosis, with step-edits and prior authorization based on cost rather than treatment safety and efficacy. We recommend involving podiatrists and dermatologists in developing criteria for insurance approval of onychomycosis treatments.
Abstract
This case describes delayed treatment of a medial talonavicular dislocation with a shear fracture of the talar head, comminuted posterior talar process fracture, and an intra-articular cuboid fracture with subtle medial displacement of the calcanealcuboid joint and the associated treatment. The injury was sustained in a 35-year-old male following a high-energy motor vehicle accident. Three weeks following the injury, delayed treatment was achieved following an attempted closed reduction under general anesthesia followed by open reduction and percutaneous kirschner wire fixation. After a 12-month follow-up the patient was able to return to work and regular activities pain free without complications. Several associated injuries have been described with isolated talonavicular dislocations. This case reviews the technique and care surrounding this injury pattern and its delayed treatment.
