Search Results
Angiokeratoma Presenting as Plantar Verruca
A Case Study
One of the more frequent pathologic conditions that podiatric physicians are confronted with is plantar verrucae. Plantar verrucae have been studied extensively in terms of morphological features and incidence in the population at large and in patients with human immunodeficiency virus infection. Solitary angiokeratomas can be morphologically similar to plantar verrucae, presenting as hyperkeratotic pedunculated lesions. We present a unique case study of a 40-year-old man with human immunodeficiency virus with a painful solitary angiokeratoma masquerading as plantar verrucae. The lesion demonstrated clinical signs consistent with those highlighted in the literature for verrucae, namely, showing as red and black lacunae, punctuated hyperkeratotic epidermis. We propose that solitary angiokeratomas should be an important part of a podiatric physician’s differential diagnosis in the lower extremity owing to the similarity of morphological features with plantar verrucae. (J Am Podiatr Med Assoc 100(6): 502–504, 2010)
Tourniquet failure is attributed to inadequate tourniquet pressure, inadequate exsanguination, failure to compress medullary vessels within the bone, and incompressible calcified arteries. We herein report a case of massive bleeding using a properly functioning tourniquet in a patient who had bilateral calcified femoral arteries. When incompressible calcified arteries are present, the inflated tourniquet cuff fails to adequately compress the underlying artery, yet acts as an efficient venous tourniquet, which leads to an increase in bleeding. It is therefore critical to preoperatively confirm the effectiveness of the tourniquet in arterial occlusion in patients with severe arterial calcification.
Background
Amputation has been most commonly considered the only option to achieve local tumor control for calcaneal malignancies. Advances in oncologic treatment modalities and wide resection have made limb salvage increasingly possible. We retrospectively reviewed nine patients with calcaneal malignancies treated with different surgical options.
Methods
The diagnoses included chondrosarcoma in three patients, Ewing's sarcoma in three, osteosarcoma in two, and small round cell sarcoma in one. Four patients were managed by below-the-knee amputation owing to neurovascular invasion. Five patients were managed by limb salvage procedures. Pedicled osteomyocutaneous fibular grafts were used to reconstruct the defects created after total calcanectomy in limb salvage procedures. Clinical and radiographic evaluations were performed, and functional outcomes were assessed using the Musculoskeletal Tumor Society score.
Results
The patients were followed up for a mean of 42.3 months. Wide resection margins were achieved in all of the patients with limb salvage surgery. At the final follow-up, two patients had died of disease. Lung metastasis was found in two patients who were alive with disease. Five patients had no evidence of disease. No local recurrence occurred in this series. All of the fibular flaps survived, and fibula hypertrophies were observed in three patients. Average Musculoskeletal Tumor Society scores were 74.6% and 83.2% in patients with amputation and limb salvage, respectively.
Conclusions
After wide resection of a calcaneal malignancy, biological reconstruction using pedicled osteocutaneous fibular flaps has proved to be a successful limb salvage procedure, offering a satisfactory oncologic and functional outcome alternative to amputation in selected patients.
Acquired acro-osteolysis (AOL) is defined as the resorption of bone from the tufts or shafts of the terminal phalanges. Acquired acro-osteolysis can manifest as a primary osteolysis syndrome and also appears in a number of disease states including rheumatologic disorders, neuropathic diseases, the result of prolonged exposure to polyvinyl chloride, and in rare cases, as a response to repeated mechanical stress. In this report, a 46-year-old surfer was evaluated for AOL as a complication of sports-related repetitive trauma to the right second and third toes. Radiography showed the bony tips of his right second and third toes had been eroded away. Acquired acro-osteolysis in the surfer’s toes resulted from increased blood flow initiated to repair microdamage caused by repeated trauma to the distal ends of his second and third right toes due to the habitual dragging of the affected toes across a surfboard. The always initial lytic phase of bone repair was magnified by the increased arterial input to warm the extremities after prolonged exposure to cold. At 6-years’ follow-up, the use of a protective bandage while surfing has permitted full regeneration of the affected toes. (J Am Podiatr Med Assoc 102(2): 165–168, 2012)
Validation of the Basic Foot Screening Checklist
A Population Screening Tool for Identifying Foot Ulcer Risk in People with Diabetes Mellitus
Background: We sought to evaluate the validity, reliability, and predictive value of the Basic Foot Screening Checklist.
Methods: Five hundred patients with type 2 diabetes mellitus and impaired glucose tolerance were screened by a generalist foot screener and a specialist podiatric physician to determine the sensitivity and specificity of the Basic Foot Screening Checklist. One hundred twelve of the 500 participants had their feet screened by two foot screeners to determine reliability.
Results: The sensitivity of the screening tool was 0.54 (95% confidence interval, 0.50–0.58), and the specificity was 0.77 (95% confidence interval, 0.73–0.81), with a positive predictive value of 0.82 (95% confidence interval, 0.79–0.85). Overall, the reliability of the tool was poor (κ = 0.35; 95% confidence interval, 0.17–0.53).
Conclusions: The validity and reliability of the Basic Foot Screening Checklist was poor despite the finding that generalist foot screeners performed individual tests with good sensitivity and specificity. This inconsistency was likely attributable to the inability of screeners to adequately interpret the test findings and form accurate risk classification outcomes. (J Am Podiatr Med Assoc 99(4): 339–347, 2009)
Background: Lower-extremity amputation for a diabetic foot is mainly performed under general or central neuraxial anesthesia. Ultrasound-guided peripheral nerve block (PNB) can be a good alternative, especially for patients who require continuous anticoagulation treatment and patients with additional comorbidities. We evaluated bleeding due to PNB application in patients with diabetic foot receiving antiplatelet or anticoagulant therapy. Perioperative morbidity and mortality and the need for intensive care hospitalization were analyzed.
Methods: This study included 105 patients with diabetic foot or debridement who underwent distal foot amputation or debridement between February and October 2020. Popliteal nerve block (17 mL of 5% bupivacaine and 3 mL of saline) and saphenous nerve block (5 mL of 2% lidocaine) were applied to the patients. Postoperative pain scores (at 4, 8, 12, and 24 hours) and complications due to PNB were evaluated. Intensive care admission and 1-month mortality were recorded.
Results: The most common diseases accompanying diabetes were hypertension and peripheral artery disease. No complications due to PNB were observed. Mean ± SD postoperative first analgesic need was determined to be 14.1 ± 4.1 hours. Except for one patient, this group was followed up without the need for postoperative intensive care. In 16 patients, bleeding occurred as leakage from the surgical area, and it was stopped with repeated pressure dressing. Mean ± SD patient satisfaction score was 8.36 ± 1.59. Perioperative mortality was not observed.
Conclusions: Ultrasound-guided PNB can be an effective and safe anesthetic technique for diabetic patients undergoing distal foot amputation, especially those receiving antiplatelet or anticoagulant therapy and considered high risk.
Diabetic Foot Infections
Time to Change the Prognostic Concept
Patients with diabetic neuropathy are subject to ulcerations that may be complicated by infection and gangrene, with subsequent risk of amputation. It is the job of the foot specialist to identify and manage these problems early to avoid the unfortunate complication of amputation regardless of the presenting condition of the patient’s limb. We shed light on the hypothesis that suggests that infection and gangrene in a diabetic patient aggravate the degree of ischemia (microvascular, macrovascular, or both) already present enough to endanger the viability of the surrounding tissues unless urgent drainage with decompression and debridement of the necrotic sloughs is performed, with consequent reduction of tissue pressure and improvement in circulation to the area. We present cases with severe infections leading to gangrene and ischemia, which were improved following surgical management with consequent improvement in tissue viability. In these cases, we demonstrate that immediate treatment of the wound despite the delayed presentation of the patients resulted in limb salvage with much less soft-tissue loss than expected before treatment. (J Am Podiatr Med Assoc 99(5): 454–458, 2009)
