Search Results
Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a “hot foot line” for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.
Neuropathic foot ulcers are a common complication in patients with diabetes. These ulcers are often slow to heal and can lead to infection, further tissue destruction, osteomyelitis, and amputation. These patients pose a challenge to clinicians who must determine the best treatment options while balancing the risks, benefits, and costs. Conservative therapies often present disappointing results, and a number of newer “biologic bandages” have been developed to better assist the healing process. We describe results from diabetic patients with neuropathic foot ulcers treated with a new amniotic membrane–based allograft.
External fixation was used to reduce or arrest progressive degeneration in 28 patients with Charcot’s foot dislocations. Adjunctive procedures included tendo Achilles lengthening and application of an external bone stimulator. Advantages of using external fixation are that surgeries are usually performed percutaneously and that most patients are weightbearing in 10 to 14 days. There was no incidence of pin tract infection or further foot collapse, with the longest follow-up period being 24 months. The authors propose that use of external fixation with bone stimulation may be an effective alternative method of treating the Charcot foot. (J Am Podiatr Med Assoc 92(8): 429-436, 2002)
Over a time frame of less than 1 year, a 23-year-old competitive horseback rider experienced a midsubstance tear of both the tibialis anterior and extensor hallucis longus tendons without inciting injury. It was after the second spontaneous tear that the patient's recent diagnosis of Lyme disease became the likely culprit. Often, patients with chronic Lyme disease present with an elaborate clinical picture that can mimic many more common diagnoses such as septic arthritis, transient synovitis, ligamentous sprain, and various other traumatic injuries. With the pathognomonic erythema migrans rash reported to be present less than 50% of the time in late-stage infections, the diagnosis of Lyme disease can often be difficult, with a high rate of underdiagnosis. It is important that Lyme disease be included in the differential diagnosis of spontaneous tendon pathology, especially for physicians practicing in highly endemic areas. The treatment is relatively simple and successful—especially for an acute infection—and it is important to initiate treatment promptly to prevent disability.
Pitted Keratolysis
A Clinical Review
Background
Pitted keratolysis is a bacterial infection that affects the plantar epidermis. Despite the condition being reported in many countries affecting both shod and unshod populations, there is little guidance for clinicians providing evidence or best practice guidelines on the management of this often stubborn infection.
Methods
Using a structured search of a range of databases, papers were identified that reported treatments tested on patients with the condition.
Results
Most of the literature uncovered was generally of a low level, such as case-based reporting or small case series. Studies were focused mainly on the use of topical antibiotic agents, such as clindamycin, erythromycin, fusidic acid, and mupirocin, often in combination with other measures, such as hygiene advice and the use of antiperspirants. From the limited evidence available, the use of topical antibiotic agents shows some efficacy in the treatment of pitted keratolysis. However, there is currently no suggestion that oral antibiotic drug therapy alone is effective in managing the condition.
Conclusions
Currently, there is no consensus on the most effective approach to managing pitted keratolysis, but a combination of antimicrobial agents and adjunctive measures, such as antiperspirants, seems to demonstrate the most effective approach from the current literature available.
To Cipro or Not to Cipro
Bilateral Achilles Ruptures with the Use of Quinolones
Ciprofloxacin and other fluoroquinolones are commonly used broad-spectrum antimicrobial agents for treating bacterial infections. This class of antibiotic drugs has uncommon adverse effects that include tendonitis, tendon ruptures, and other tendon abnormalities. We describe a patient with spontaneous bilateral complete Achilles tendon rupture after ciprofloxacin treatment. Surgical repair was performed successfully, and the patient completed physical rehabilitation without incident. Care should be exercised when selecting pharmaceutical agents to maintain a positive benefit-to-risk balance.
A 17-year-old boy presented with a totally dislocated talus and open bimalleolar ankle fracture dislocation. After thorough debridement and irrigation, the talus and bimalleolar fracture were reduced and fixed. At 21 months after surgery, he could walk using regular shoes without any aid but with moderate pain in the sinus tarsi during activities. No evidence of osteonecrosis or infection was seen in the last radiograph, except for a small degree of narrowing in the talonavicular joint. Reimplantation and fixation of pantalar dislocation seems to have an acceptable outcome.
Background
Many operative techniques have been studied for correction of ingrown toenails, yet the role of nail fold resection without matricectomy is poorly defined. Current literature on this topic is sparse, and previous systematic reviews are absent.
Methods
A MEDLINE/Cumulative Index to Nursing and Allied Health Literature/Scopus search was performed and a systematic review was undertaken for articles discussing surgical treatment of ingrown toenail by nail fold resection without matricectomy. Outcome measures were systematically reported, and variations in operative technique were identified.
Results
Of the 14 articles that fit the inclusion criteria, 2 were level V evidence, 11 were level IV, and 1 was level III. Minimum follow-up time and the criteria for a satisfactory outcome were not consistently defined. Recurrence rates varied from 0% to 20%. The postsurgical infection rate was 0% for all nine studies reporting infection. Ten different operative techniques were identified. Three studies used partial or total nail avulsion as an adjunctive operative procedure. Triangular-, crescent-, elliptical-, semi-elliptical–, and radical-shaped skin excision strategies were identified. Primary and secondary intentions were used for closure.
Conclusions
Operative algorithms for the treatment of ingrown toenail are still unclear regarding nail fold resection without matricectomy and are supported by almost entirely level IV evidence. Future prospective comparative studies and randomized trials are necessary to support and strengthen current practice.
Background
Dermatomycoses are a group of pathologic abnormalities frequently seen in clinical practice, and their prevalence has increased in recent decades. Diagnostic confirmation of mycotic infection in nails is essential because there are several pathologic conditions with similar clinical manifestations. The classical method for confirming the presence of fungus in nail is microbiological culture and the identification of morphological structures by microscopy.
Methods
We devised a nested polymerase chain reaction (PCR) that amplifies specific DNA sequences of dermatophyte fungus that is notably faster than the 3 to 4 weeks that the traditional procedure takes. We compared this new technique and the conventional plate culture method in 225 nail samples. The results were subjected to statistical analysis.
Results
We found concordance in 78.2% of the samples analyzed by the two methods and increased sensitivity when simultaneously using the two methods to analyze clinical samples. Now we can confirm the presence of dermatophyte fungus in most of the positive samples in just 24 hours, and we have to wait for the result of culture only in negative PCR cases.
Conclusions
Although this PCR cannot, at present, substitute for the traditional culture method in the detection of dermatophyte infection of the nails, it can be used as a complementary technique because its main advantage lies in the significant reduction of time used for diagnosis, in addition to higher sensitivity.
Background
Diagnosis of onychomycosis using the periodic acid–Schiff (PAS) test for sensitive identification of hyphae and fungal culture for identification of species has become the mainstay for many clinical practices. With the advent of polymerase chain reaction (PCR) testing, physicians can identify a fungal toenail infection quickly with the added benefit of species identification. We compared PAS testing with multiplex PCR testing from a clinical perspective.
Methods
A total of 209 patients with clinically diagnosed onychomycosis were recruited. A high-resolution picture was taken of the affected hallux nail, and the nail was graded using the Onychomycosis Severity Index. A proximal sample of the affected toenail and subungual debris were obtained and split into two equal samples. One sample was sent for multiplex PCR testing and the other for PAS testing. The results were analyzed and compared.
Results
Six patients were excluded due to insufficient sample size for PCR testing. Of the remaining 203 patients, 109 (53.7%) tested positive with PAS, 77 (37.9%) tested positive with PCR. Forty-one patients tested positive with PAS but negative with PCR, and nine tested positive with PCR but negative with PAS.
Conclusions
Physicians should continue the practice of using PAS biopsy staining for confirmation of a fungal toenail infection before using oral antifungal therapy. Because multiplex PCR allows species identification, some physicians may elect to perform both tests.
