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.
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.
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.
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.
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.
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.
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.
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.
Diabetes mellitus is a predisposing factor for onychomycosis (OM). A high frequency of nonfungal onychodystrophy (OD) is also alleged, although information on the prevalence of specific nail changes is scant. We evaluated the prevalence and types of nail changes in a cohort of diabetic patients with fungal and nonfungal OD.
During a 6-month period, inpatients with diabetes mellitus were screened for foot and toenail changes. Demographic, social, and clinical data were recorded, as was information concerning foot and toenail care. Fungal infection was confirmed by mycologic examination and by histologic analysis of nail clippings.
Of the 82 patients included, 65 (79.3%) had nail changes, and 34 of these 65 patients (52.3%) were diagnosed as having OM. The most frequently observed nail signs were subungual hyperkeratosis, onycholysis, yellow discoloration, and splinter hemorrhages, each seen in more than 25% of the patients. Tinea pedis and superficial pseudoleukonychia were observed more frequently in the OM group (P < .05). Conversely, prominent metatarsal heads and history of nail trauma were more frequent in patients with nonfungal OD (P < .05).
Physicians who care for diabetic patients should not ignore nail changes. Fungal and nonfungal OD are common and should be addressed in the global evaluation of the feet to help prevent breaks in the skin barrier and subsequent bacterial infections and ulcers.
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.
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.
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.
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.
Onychomycosis is a fungal infection of the nail primarily caused by the dermatophytes Trichophyton rubrum and Trichophyton mentagrophytes. The topical-based treatment of onychomycosis remains a challenge because of the difficulty associated with penetrating the dense, protective structure of the keratinized nail plate. Tavaborole is a novel small-molecule antifungal agent recently approved in the United States for the topical treatment of toenail onychomycosis. The low molecular weight, slight water solubility, and boron chemistry of tavaborole maximize nail penetration after topical application, allowing for effective targeting of the infection in the nail bed. The efficacy of tavaborole is associated with its novel mechanism of action, whereby it inhibits the fungal leucyl-tRNA synthetase (LeuRS) enzyme. Because LeuRS is an essential component in fungal protein synthesis, inhibition of LeuRS ultimately leads to fungal cell death. Tavaborole is the first boron-based antifungal medication approved for the treatment of mild-to-moderate onychomycosis and presents patients with a new topical option. Previously, ciclopirox and efinaconazole were the only approved topical treatments for onychomycosis. This article details the properties that are at the core of the clinical benefits associated with tavaborole.
Ingrown toenails are seen most commonly in young adults, and they can seriously affect daily life. Partial nail avulsion with chemical matrixectomy, generally by using either sodium hydroxide or phenol, is one of the most effective treatment methods. Known complications of phenol matrixectomy are unpredictable tissue damage, prolonged postoperative drainage, increased secondary infection rates, periostitis, and poor cosmetic results. To our knowledge, there have been no reports about the complications related to sodium hydroxide matrixectomy. Herein, we describe three patients who developed nail dystrophy, allodynia, and hyperalgesia after sodium hydroxide matrixectomy.
The treatment of pilon tibia fractures is challenging. Anatomical reduction of the joint surface is essential. Excessive soft-tissue dissection may interfere with the blood supply and can result in nonunion. We sought to compare the outcomes of distal tibia fractures treated with medial locking plates versus circular external fixators.
We retrospectively evaluated 41 consecutive patients with closed pilon tibia fractures treated with either minimally invasive locking plate osteosynthesis (n = 21) or external fixation (EF) (n = 20). According to the Ruedi and Allgower classification, 23 fractures were type B and 18 were type C. Soft-tissue injury was evaluated according to the Oestern and Tscherne classification. Time to fracture union, complications, and functional outcomes were assessed annually for 3 years with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score.
Mean ± SD values in the plate group were as follows: age, 42.4 ± 14 years; union time, 19.4 ± 2.89 weeks (range, 12–26 weeks); and AOFAS ankle scores, 86.4 ± 2.06, 79.5 ± 1.03, and 77.9 ± 0.80 at 1, 2, and 3 years, respectively. Four patients in the plate group needed secondary bone grafting during follow-up. In the EF group (mean ± SD age, 40.7 ± 12.3 years), all of the patients achieved union without secondary bone grafting at a mean ± SD of 22.1 ± 1.7 weeks (range, 18–24 weeks). In the EF group, mean ± SD AOFAS ankle scores were 86.6 ± 1.69, 82.1 ± 0.77, and 79.7 ± 1.06 at 1, 2, and 3 years, respectively. There were no major complications. However, there were soft-tissue infections over the medial malleolus in five patients in the plate group and grade 1-2 pin-tract infections in 13 patients and grade 3 pin-tract infections in one patient in the EF group. Post-traumatic arthritis was detected in eight plate group patients and seven EF group patients.
Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.
Below-the-knee amputation (BKA) can be a detrimental outcome of diabetic foot osteomyelitis (DFO). Ideal treatment of DFO is controversial, but studies suggest minor amputation reduces the risk of BKA. We evaluated risk factors for BKA after minor amputation for DFO.
This is a retrospective cohort of patients discharged from Denver Health Medical Center from February 1, 2012, through December 31, 2014. Patients who underwent minor amputation for diagnosis of DFO were eligible for inclusion. The outcome evaluated was BKA in the 6 months after minor amputation.
Of 153 episodes with DFO that met the study criteria, 11 (7%) had BKA. Failure to heal surgical incision at 3 months (P < .001) and transmetatarsal amputation (P = .009) were associated with BKA in the 6 months after minor amputation. Peripheral vascular disease was associated with failure to heal but not with BKA (P = .009). Severe infection, bacteremia, hemoglobin A1c, and positive histopathologic margins of bone and soft tissue were not associated with BKA. The median antibiotic duration was 42 days for positive histopathologic bone resection margin (interquartile range, 32–47 days) and 16 days for negative margin (interquartile range, 8–29 days). Longer duration of antibiotics was not associated with lower risk of BKA.
Patients who fail to heal amputation sites in 3 months or who have transmetatarsal amputation are at increased risk for BKA. Future studies should evaluate the impact of aggressive wound care or whether failure to heal is a marker of another variable.
Acute Charcot Foot Changes versus Osteomyelitis
Does Tc-99m HMPAO Labeled Leukocytes Scan Differentiate?
Osteomyelitis often complicates a diabetic neuropathic foot, leading to amputation, decreased function, and quality of life. Therefore, early detection and treatment are paramount. Furthermore, neuroarthropathic (Charcot) changes in the foot often resemble infection and must be differentiated. Currently, the Tc-99m HMPAO Labeled Leukocytes Scan is considered to be the most reliable noninvasive imaging modality of choice in determining Charcot foot changes versus osteomyelitis. The purpose of this article is to alert the clinician that although the Tc-99m HMPAO Labeled Leukocytes Scan may be the second most reliable test next to bone biopsy for determining osteomyelitis, false positives do occur. (J Am Podiatr Med Assoc 91(7): 365-368, 2001)
We report an unusual case of a variant of Lisfranc injury, plantar dislocation of the medial cuneiform with plantar fracture-dislocation of the intermediate cuneiform and dorsal fracture-dislocation of the lateral cuneiform, which has never been reported, to our knowledge. The entire pathologic abnormality was treated by open reduction and fixation with Kirschner wires, which were removed 8 weeks postoperatively because of pin-tract infection. Complex regional pain syndrome, which was a problem early in the recovery process, is now in remission, and at the 25-month follow-up examination, the patient was almost symptom free. (J Am Podiatr Med Assoc 99(4): 359–363, 2009)