Background: Onychomycosis is the most common nail disease seen in clinical practice. Medication safety, severity of disease, comorbidities, concomitant medications, patient age, and cost are all important considerations when treating onychomycosis. Because 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 US Food and Drug Administration–approved onychomycosis medications and off-label oral fluconazole. Total drug cost for a single great toenail was calculated using the National Average Drug Acquisition Cost. Pearson correlation coefficients were calculated to compare coverage and cost, mycologic 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 there was 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 = .040). There was no correlation between medication coverage and mycologic (r = 0.548; P = .339) and complete (r = 0.768; P = .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.
Background: The emergence of minimally invasive techniques in foot and ankle surgery has aimed to reduce iatrogenic tissue insult by utilising the smallest possible incision area to achieve maximum correction of pathological structures. The objective of this study was to assess whether adequate hallux valgus correction can be achieved via the minimally invasive chevron akin (MICA) procedure.
Methods: A retrospective analysis was conducted for a single-surgeon case series of 169 MICA procedures between June 2018 and June 2021 in Australia. Radiographic parameters were evaluated independently by two researchers using 1-2 intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) as key measures of procedural outcome.
Results: 95% of participant-operations resulted in normal 1-2 IMA and HVA being obtained post-operatively in a cohort that largely consisted of moderate hallux valgus deformities; 1-2 IMA Reduction: 6.38° ± 3.24 (95% CI 5.89 to 6.87) and HVA Reduction: 20.17° ± 7.69 (95% CI 19.01 to 21.33).
Conclusion: The results of this study help to further strengthen support for the use of minimally invasive bunion surgery as a primary treatment approach in mild to moderate hallux valgus.
Background: We evaluated the relationship between the type of accessory navicular bone (ANB) and radiographic parameters of the foot in patients with bilateral ANBs of different types.
Methods: Patients with bilateral ANBs of different types participated in this study between May 2019 and April 2020. Patient data, including age, sex, body mass index (BMI), and presence of symptoms, were obtained. We aimed to compare the radiographic parameters of both feet to evaluate the differences from one another in patients with bilateral ANBs of different types (one side type 1 and one side type 2) because the foot angles may differ in each person. Seven radiographic parameters evaluating hindfoot, midfoot, and forefoot alignment were measured: calcaneal pitch angle, talocalcaneal angle, tibiocalcaneal angle, naviculocuboid overlap, talonavicular coverage angle, and anteroposterior and lateral talo–first metatarsal angles.
Results: Twenty patients (13 women and seven men) with a mean ± SD age of 38.5 ± 12.3 years were included in the study. The patients had a mean ± SD height of 168.1 ± 7.1 cm, weight of 77.2 ± 10.5 kg, and BMI of 27.4 ± 4.3. There were no significant differences between type 1 and type 2 ANBs in any radiographic parameters and no significant correlations between radiographic parameters and age, BMI, or the presence of symptoms.
Conclusions: We found that the type of ANB had no effect on the radiographic measurements of the foot in patients with bilateral ANBs of different types. Age, BMI, and the presence of symptoms also demonstrated no correlations with the radiographic parameters.
The purpose of this article is to familiarize physicians with the risks of prescribing trimethoprim/sulfamethoxazole (TMP/SMX) for patients who have kidney or cardiac pathology, have hyperkalemia, or take other interacting medications. Although TMP/SMX is a drug that is frequently used to treat skin and soft-tissue infections of the leg and foot, particularly if methicillin-resistant Staphylococcus aureus is identified, it is not an innocuous antibiotic. Literature documenting the many adverse effects of TMP/SMX is reviewed. A case history is presented illustrating the association of TMP/SMX with the development of a life-threatening situation. Ways of avoiding these adverse events are discussed, and the use of safer antibiotics is recommended.
Background: Debridement of toenails is a common procedure that leads to the production of nail dust aerosols in the work environment. Previous studies indicate that inhaled nail dust can cause respiratory distress and eye irritation. This comprehensive review aimed to assess the available literature on the effect of nail dust exposure and to evaluate nail dust as a potential occupational hazard for podiatric physicians.
Methods: A comprehensive literature search was conducted via PubMed, Google Scholar, CINAHL, Cochrane Library, and ClinicalTrials.gov. Risks of bias of the collected studies were evaluated using various assessment tools to match the type of study design. A qualitative analysis of the included studies was performed, from which primary and secondary outcome measures were extracted: prevalence of symptoms and specific microorganisms in nail dust.
Results: Of 403 articles screened, eight met the inclusion criteria. The primary outcome measure resulted in a pooled prevalence of eye-related symptoms being the most consistent symptom reported (41%–48%). The secondary outcome measure resulted in a pooled prevalence of Trichophyton rubrum (9.52%–38%) and Aspergillus (11.11%–35.48%) as the most common microorganisms present in nail dust.
Conclusions: From the included eight articles, we found that nail dust is a potential occupational hazard, especially for those exposed more often. Aspergillus and T rubrum are most commonly associated with nail dust leading to development of respiratory illness. It is important to take preventive measures in podiatric medical clinics by using improved and efficient personal protective equipment for workers exposed to nail dust. Detailed health safety guidelines can be developed to decrease respiratory symptoms and diseases from nail dust exposure.
Background: Transmetatarsal amputations are limb salvage surgical procedures that preserve limb length and functional ankle joints. Indications for transmetatarsal amputations include forefoot trauma, infection, and ischemia. Prior research demonstrates patients who undergo transmetatarsal amputations have a lower 2-year mortality rate compared to those who undergo more proximal amputations. The aim of this study was to determine whether primary closure of a transmetatarsal amputation is a superior treatment compared to secondary healing of a transmetatarsal amputation for forefoot abnormality of infection, gangrene, or chronic ulceration.
Methods: A retrospective chart review was performed on patients aged 18 years or older requiring a transmetatarsal amputation because of forefoot abnormality between September of 2011 and December of 2019. Foot and ankle surgeons performed transmetatarsal amputations. Outcome variables measured included healing time of transmetatarsal amputation site, recurrent infection, recurrent gangrene, and the need for revision surgery or higher level amputations.
Results: Of the original 112 patients, 76 met the inclusion criteria; 47 of these had primary closure of transmetatarsal amputation and 29 of these had an open transmetatarsal amputation performed. Primarily closed transmetatarsal amputations resulted in a significantly greater overall healing rate of 78.8% (37 of 47) compared to open transmetatarsal amputations, with a healing rate of 37.9% (11 of 29) (P < .01). Closed transmetatarsal amputations were statistically significantly less likely than open transmetatarsal amputations to have recurrent gangrene, require revision pedal operations, or progress to higher level amputations.
Conclusions: Our research demonstrated that primary closure of transmetatarsal amputations is a superior treatment compared with secondary healing of transmetatarsal amputations in specific cases of infection, dry gangrene, or chronically nonhealing ulcerations.
Phlegmons are unencapsulated collections of inflammation that track along soft tissues in various parts of the human body. These soft-tissue lesions are uncommon in the lower extremities and can be difficult to identify and treat. This article presents a case of a plantar foot phlegmon in a nondiabetic patient that was recalcitrant to debridement and antibiotics. The patient’s aseptic phlegmon completely resolved with surgical debridement and iodoform packing. This case report demonstrates the role of advanced imaging in the diagnosis of lower-extremity phlegmons and the importance of thorough surgical debridement and packing for successful resolution.
Background: Many surgical techniques have been reported for the treatment of ingrown toenails. Occurrences of infection after matricectomy procedures could cause clinicians to prefer using external braces to treat ingrown toenails. This study compares patients with ingrown toenails who underwent the nail fixation technique and the Winograd technique.
Methods: Patients who underwent ingrown toenail surgery were retrospectively reviewed. The patients’ demographic characteristics (age, gender, body mass index [BMI] morphology according to Heifetz classification, surgical technique, visual analog scale (VAS) values, time to return to daily activities (days), complications, and satisfaction levels were all recorded.
Results: Seventy patients were included in the study. Of the patients, 33 underwent nail fixation and 37 underwent the Winograd technique. No significant statistical differences were found in terms of patients’ age, gender, BMI, preoperative clinical features, long-term satisfaction, and ingrown toenail recurrence rates between the two groups, but time to return to daily activities and VAS values were statistically significantly lower in patients treated using nail fixation compared with the Winograd technique.
Conclusion: Nail fixation can be an effective surgical treatment option for an ingrown toenail.
Background: Digital deformities represent a common presenting pathology and target for surgical intervention in podiatric medicine and surgery. The objective of this investigation was to compare the radiographic width of the heads of the lesser digit proximal phalanges.
Methods: One hundred and fifty consecutive feet with a diagnosis of digital deformity and performance of weight-bearing radiographs were analyzed. The maximum width of the heads of the lesser digit proximal phalanges were recorded from the radiographs utilizing computerized digital software.
Results: The mean±standard deviation (range) of the head of the second digit proximal phalanx was 9.74±0.87 mm (7.94-11.78), of the head of the third digit proximal phalanx was 9.00±0.91 mm (7.27-10.94), of the head of the fourth digit proximal phalanx was 8.49±1.01 mm (5.57-10.73), and of the head of the fifth digit proximal phalanx was 8.67±0.89 mm (6.50-11.75). The width of the head of the proximal phalanx decreased from the second digit to the third digit (p<0.001), decreased from the third digit to the fourth digit (p<0.001), and then increased from the fourth digit to the fifth digit (p=0.032).
Conclusions: The results of this investigation provide evidence in support of an anatomic and structural contribution to digital deformities. The width of the heads of the lesser digit proximal phalanges decreased from the second to the third to the fourth toes, and then subsequently increased with the fifth proximal phalangeal head.
Background: The objective of this investigation was to evaluate adverse short-term outcomes following partial forefoot amputation with a specific comparison performed based on subject height.
Methods: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to select those subjects with a 28805 CPT code (amputation, foot; transmetatarsal) that underwent the procedure with “all layers of incision (deep and superficial) fully closed.” This resulted in 11 subjects with a height ≤60 inches, 202 subjects with a height >60 inches and <72 inches, and 55 subjects ≥72 inches.
Results: Results of the primary outcome measures found no significant differences between groups with respect to the development of a superficial surgical site infection (0.0% vs. 6.4% vs. 5.5%; p=0.669), deep incisional infection (9.1% vs. 3.5% vs. 10.9%; p=0.076), or wound disruption (0.0% vs. 5.4% vs. 5.5%; p=0.730). Additionally, no significant differences were observed between groups with respect to unplanned reoperations (9.1% vs. 16.8% vs. 12.7%; p=0.0630) or unplanned hospital readmissions (45.5% vs. 23.3% vs. 20.0%; p=0.190).
Conclusions: The results of this investigation demonstrate no difference in short-term adverse outcomes following the performance of partial forefoot amputation with primary closure based on subject height. Although height has previously been described as a potential risk factor in the development of lower extremity pathogenesis, this finding was not observed in this study from a large US database.