Although scanning electron microscope technology has been used for more than 60 years in many fields of medical research, no studies have focused on obtaining high-resolution microscopic images of onychomycosis of the toenail caused by Trichophyton rubrum in a geriatric population. To provide new insight into the intricate structure and behavior of chronic toenail onychomycosis, we produced three-dimensional images of onychomycosis obtained from two geriatric patients with confirmed growth of T rubrum. The photomicrographs illustrate the pervasive integration and penetration of the fungus hyphal elements, underscoring the clinical difficulty of obtaining rapid treatment of fungal infections in the distal and lateral subungual space of the human toenail. Although the scanning electron microscope may not be a practical diagnostic tool for most physicians, it remains invaluable for the researcher to obtain insight into the spatial orientation, behavior, and appearance of onychomycosis. (J Am Podiatr Med Assoc 94(4): 356–362, 2004)
The preferred primary treatment of toe osteomyelitis in diabetic patients is controversial. We compared the outcome of primary nonoperative antibiotic treatment versus digital amputation in patients with diabetes-related chronic digital osteomyelitis.
We conducted a retrospective medical record review of patients treated for digital osteomyelitis at a single center. Patients were divided into two groups according to initial treatment: 1) nonoperative treatment with intravenous antibiotics and 2) amputation of the involved toe or ray. Duration of hospitalization, number of rehospitalizations, and rate of below- or above-the-knee major amputations were evaluated.
The nonoperative group comprised 39 patients and the operative group included 21 patients. The mean ± SD total duration of hospitalization was 24.05 ± 15.43 and 20.67 ± 15.97 days, respectively (P = .43). The mean ± SD number of rehospitalizations after infection recurrence was 2.62 ± 1.63 and 1.67 ± 1.24, respectively (P = .02). During follow-up, the involved digit was eventually amputated in 13 of the 39 nonoperatively treated patients (33.3%). The rate of major amputation (above- or below-knee amputation was four of 39 (10.3%) and three of 21 (14.3%), respectively (P = .69).
Despite a higher rate of rehospitalizations and a high failure rate, in patients with mild and limited digital foot osteomyelitis in the absence of sepsis it may be reasonable to offer a primary nonoperative treatment for digital osteomyelitis of the foot.
Treatment for Simple Plantar Verrucae
Monochloroacetic Acid and 10% Formaldehyde versus 10% Formaldehyde Alone
Verrucae are small, benign, highly vascular epithelial neoplasms that occur singly or in a multiple presentation. Plantar verrucae are usually caused by infection with human papillomavirus types 1, 2, and 4. A clinical trial was conducted to assess the safety and efficacy of monochloroacetic acid and 10% formaldehyde versus 10% formaldehyde alone in the treatment of simple plantar verrucae. Of 57 patients enrolled in the study, 26 were in the monochloroacetic acid and 10% formaldehyde group and 31 were in the 10% formaldehyde alone group. The overall cure rate for this population was 61.4%. There was no statistically significant difference in the cure rate between treatment groups. (J Am Podiatr Med Assoc 96(1): 53–58, 2006)
Retained Viable Plant Material in the Calcaneus
A Case Report of a 22-Year-Old Soldier with Atypical Heel Pain
Foreign bodies can be difficult to diagnose and should be considered in the differential diagnosis of unexplained pain, even in the absence of recalled trauma. We present the case of a 22-year-old male with a painful left heel. The patient did not recall a specific traumatic incident, and there were no clinical signs of trauma or infection. Plain films of the foot were nonrevealing, but magnetic resonance imaging revealed a sinus tract and left calcaneal defect. A biopsy of the calcaneal defect revealed viable woody material embedded and partially integrated with the surrounding bone. Postoperatively the patient's pain completely resolved. This case illustrates the importance of radiopathologic pursuit of an etiology of unexplained foot pain in an otherwise healthy person.
Onychomycosis is an extremely common condition that is increasing in prevalence. Although often innocuous, it may be complicated by discomfort and secondary bacterial infections. Recently introduced oral medications may be highly effective in the eradication of this condition; however, they may carry with them significant expense and potentially serious side effects. Prior to the initiation of antifungal oral therapy, definitive diagnosis is mandatory. This study compares the sensitivity of potassium hydroxide (KOH) preparations, surgical pathology diagnostic testing (SPDT), and culture techniques for the detection of onychomycosis in 50 cases of clinically suspected onychomycosis. Analysis showed that SPDT was significantly more sensitive when compared to KOH and culture. The results suggest that SPDT may be the true gold standard for the diagnosis of onychomycosis. (J Am Podiatr Med Assoc 91(7): 351-355, 2001)
This historical perspective highlights some of the pioneers, milestones, teams, and system changes that have had a major impact on management of the diabetic foot during the past 100 years. In 1934, American diabetologist Elliott P. Joslin noted that mortality from diabetic coma had fallen from 60% to 5% after the introduction of insulin, yet deaths from diabetic gangrene of the lower extremity had risen significantly. He believed that diabetic gangrene was preventable. His remedy was a team approach that included foot care, diet, exercise, prompt treatment of foot infections, and specialized surgical care.
The history of the team approach to management of the diabetic foot chronicles the rise of a new health profession—podiatric medicine and surgery—and emergence of the specialty of vascular surgery. The partnership among the diabetologist, vascular surgeon, and podiatric surgeon is a natural one. The complementary skills and knowledge of each can improve limb salvage and functional outcomes. Comprehensive multidisciplinary foot-care programs have been shown to increase quality of care and reduce amputation rates by 36% to 86%. Development of distal revascularization techniques to restore pulsatile blood flow to the foot has also been a major advancement.
Patients with diabetic foot complications are among the most complex and vulnerable of all patient populations. Specialized diabetic foot clinics of the 21st century should be multidisciplinary and equipped to coordinate diagnosis, off-loading, and preventive care; to perform revascularization procedures; to aggressively treat infections; and to manage medical comorbidities. (J Am Podiatr Med Assoc 100(5): 317–334, 2010)
Onychomycosis is a fungal infection of the nail that can be caused by dermatophytes, yeasts, or nondermatophyte molds. To diagnose onychomycosis, a clinician must use the patient's history, physical findings, and diagnostic testing, which can include calcofluor white/potassium hydroxide (KOH) mount, fungal culture (FC), and periodic acid–Schiff (PAS) stain. Some insurance companies require authorization for antifungal medication and request laboratory results to confirm infection. We sought to compare the reliability of KOH, PAS, and FC diagnostic results for confirmation of fungal disease, to determine the sensitivity and specificity of each test, and to investigate the cost of each test. In addition, we statistically observed the relationship between the test results and demographic variables.
Toenail clippings were obtained from 108 patients clinically diagnosed as having onychomycosis. Diagnostic tests were then performed on each sample; the results were obtained from medical records.
For PAS, KOH, and FC, 60.2%, 43.5%, and 39.8% of results, respectively, were positive. Agreement for each pair of tests was slightly higher for FC and KOH. Sensitivities for KOH and PAS were 0.64 and 0.79, respectively. Specificity was 0.79 for KOH and 0.54 for PAS. Both PAS and KOH had a higher percentage of positive test results for men than for women.
Of the three tests evaluated, PAS gives the most consistent positive results and has the highest sensitivity. Therefore, PAS should be considered as the best test to verify clinically significant onychomycosis.
Onychomycosis, by definition, is a mycotic infection of the keratinized tissue of the nail plate. Although it is commonly considered to be caused by one of the dermatotropic fungi, a variety of other organisms have been implicated as etiologic agents in the disease, including some bacteria and yeasts. When it is caused by a fungus, any or all of three types of organisms can be involved: dermatophytes, yeasts, and nondermatophyte organisms. The purpose of this study was to identify the microorganisms found in fungal cultures of clinically suspected onychomycosis in the patient population of the Foot Clinics of New York in New York City, the largest foot clinic in the world. Of the 1,800 medical charts reviewed, 214 had culture results, of which 120 were positive. Trichophyton rubrum was the most prevalent pathogen, found in 67% of positive cultures. The most remarkable risk factor was age, with 80% of affected individuals older than 35 years. False-negatives may account for the high percentage (44%) of negative cultures in this study. (J Am Podiatr Med Assoc 92(6): 327-330, 2002)
Surgical Treatment of Pressure Ulcers of the Heel in Skilled Nursing Facilities
A 12-Year Retrospective Study of 57 Patients
Background: Chronic nonhealing pressure ulcers of the heel in nursing homes are frequent occurrences among bedridden patients with lower-extremity contractures of varying degrees of severity. Conservative local wound care for these patients can be time consuming, ineffective, costly, and may only delay an eventual major leg amputation. This study evaluates the efficacy of limb salvage surgical procedures, partial calcanectomy, total calcanectomy, and excision of the entire calcaneus and talus, for heel ulcers.
Methods: We performed a retrospective review of 57 nursing home residents who had chronic infected nonhealing pressure ulcers of the heel that we had treated over 12 years. Forty-three patients underwent partial calcanectomy, nine underwent total calcanectomy, and five underwent excision of the entire calcaneus and talus. Average postoperative follow-up was 15 months. Also included in this study are representative surgical cases.
Results: Forty-three patients completed follow-up. Complete healing occurred in 25 patients (58%). Failure to resolve the heel ulcer owing to persistent infection, or recurrence was seen in 18 patients (42%) who eventually had a below-the-knee or above-the-knee amputation. All of the patients with heel pressure ulcers were found to have lower-extremity contractures.
Conclusions: In the nonambulatory contracted patient with a heel ulcer, partial or total calcanectomy or excision of the entire calcaneus and talus offer a viable alternative not only for resolution of infection but also for prevention of limb loss. An aggressive plan must also be instituted to address the lower-extremity contractures in order to prevent recurrence. (J Am Podiatr Med Assoc 101(2): 167–175, 2011)
The incidence of human immunodeficiency virus (HIV) infection in the US has increased over the past decade. This increase has effected concern regarding the risks of HIV infection within the podiatric medical practice. Implementation of an effective infection control program for blood-borne pathogens within the podiatric medical practice can minimize such risks.