Search Results
Background: Bone and periarticular tissue discoloration can be an unexpected finding that is often disconcerting for surgeons and may alter surgical plans and overall patient management. Common causes of bone discoloration include infection, avascular necrosis, and bone inflammation. Minocycline-induced black bone disease is a rare and relatively benign abnormality encountered in foot and ankle surgery that can cause significant black, blue, and gray discoloration of bone.
Methods: Unanticipated intraoperative findings of diffuse black, blue, and gray bone discoloration during an elective forefoot operation raised concern for a metabolically malignant process and prompted the conversion of plans for a first metatarsophalangeal joint implant arthroplasty to a Keller arthroplasty. The plan for proximal interphalangeal joint arthroplasties of the lesser digits were continued as planned. Bone specimens were sent for pathologic analysis.
Results: Postoperative analysis identified chronic use of a minocycline for acne vulgaris. Pathologic analysis of the specimens ruled out malignant processes. Altogether, the data available led to the diagnosis of minocycline-induced black bone disease. Since the last follow-up, the patient has healed well without complications.
Conclusions: Our case report underscores the importance of including the chronic use of tetracyclines in medical history intake during preoperative visits to assist the surgeon in intraoperative decision-making.
Background
Podiatric physicians routinely use electric drills for the treatment of nail and skin conditions. The grinding process produces human nail and skin dust that is generally vacuumed into bags in the grinding unit. Many of the nails are thought to be mycotic, particularly because they are obtained from patients with symptoms of dermatophyte infections. Currently, there is limited information available on the detection of fungi from nail dust samples. Herein, we attempt to address this situation and outline some of the difficulties that pathology laboratories face in isolating and identifying dermatophytes from nail samples.
Methods
Fifty nail dust bags from podiatric medical clinics across all of the states and territories of Australia were collected and analyzed. Samples from the bags were inoculated onto primary isolation media. Fungal colonies that grew were then inoculated onto potato dextrose agar for identification using standard morphological (macroscopic and microscopic) features.
Results
One hundred fifty-one colonies of dermatophytes were identified from 43 of the 50 samples. In addition 471 nondermatophyte molds were isolated, along with some yeasts and bacteria.
Conclusions
The most common dermatophytes isolated were from the Trichophyton mentagrophytes/interdigitale complexes. Trichophyton rubrum, Trichophyton tonsurans, Trichophyton soudanense, and Epidermophyton floccosum were also isolated. An unidentified group of dermatophytes was also present. The three most common genera of nondermatophyte molds were Aspergillus, Penicillium, and Scopulariopsis, all of which have been implicated in onychomycosis and more general disease. The presence of viable fungal pathogens in the dust could potentially pose a health problem to podiatric physicians.
Staphylococcus is, by far, the most commonly seen organism in podiatric infections. Although common, staphylococcal infections are difficult to understand and treat. These bacteria have undergone significant changes in their pathogenicity and antibiotic susceptibility over the last few years. Methicillin-resistant strains, once relatively rare, are becoming a major therapeutic dilemma in some centers.
The podiatric physician should be alert to the possibility of underlying bony infections in cases of chronic or neglected nail infections. X-rays should be taken when drainage has been present for 4 weeks. This will rule out bony changes as well as provide assistance in following the progression, if no improvement is seen, despite treatment.
Total talar dislocation, ie, disruption of the talus from the calcaneus, navicula, and tibia, is a rare and severe injury. We present a case of closed peritalar dislocation without any accompanying fractures and, thus, discuss the conflicts encountered in this rare injury. A 25-year-old male patient presented with severe pain, swelling, and deformity in his right ankle within 30 minutes of a fall from a height. There were no wounds around the ankle. Radiographs revealed that the talus was disrupted from the calcaneus, navicula, and tibia moving in the anterolateral direction. No accompanying fractures were seen in the talus or in surrounding bones. After an unsuccessful closed reduction attempt, a further decision was open reduction. It was seen that the interposed joint capsula was preventing reduction. After reduction, stability of the ankle was checked and found to be satisfactory, so no fixation material was used. It has been 2 years since the first injury, and the patient is functioning well, with no pain. The ankle has the same range of motion as the unaffected side. No sign of an avascular necrosis or sclerosis is seen on the final radiographs. Closed total dislocation of the talus without any accompanying fractures is a rare entity. The injury is open to various important complications, such as avascular necrosis, infection in patients with open wounds, and arthritic changes. To achieve a good outcome, early reduction of the dislocation has key importance. (J Am Podiatr Med Assoc 103(1): 73–75, 2013)
The Prevalence of Interdigital Erythrasma
A Prospective Study from an Outpatient Clinic in Turkey
Background
Erythrasma is a superficial skin infection caused by Corynebacterium minutissimum. Interdigital erythrasma is the most common form and is easily confused with tinea pedis. The aim of this study was to determine the prevalence of interdigital erythrasma in patients with clinically suspected tinea pedis.
Methods
This study was performed between January 1, 2011, and January 31, 2012. It included 182 patients who presented with concerns about interdigital lesions. All of the patients were examined with a Wood's lamp, and smears were stained with Gram's method. Direct examination with 20% potassium hydroxide was performed.
Results
Of 182 patients with interdigital lesions, 73 (40.1%) were diagnosed as having erythrasma. The mean ± SD age of the patients with erythrasma was 45.52 ± 10.83 years (range, 22–70 years). Most of the patients with erythrasma were women (56.2%). The most often clinical finding was desquamation. Using only Wood's lamp examination or Gram's staining resulted in 31 (42.5%) or 14 (19.2%) positive patients, respectively. Using Wood's lamp examination and Gram's staining concurrently resulted in 28 positive patients (38.4%).
Conclusions
Interdigital erythrasma is a common condition and can be difficult to differentiate from tinea pedis. Simple and rapid diagnosis can be made with Wood's lamp examination, but Gram's staining is also a useful method, especially in patients with negative Wood's lamp examination findings.
Confirmation of Dermatophytes in Nail Specimens Using In-Office Dermatophyte Test Medium Cultures
Insights from a Multispecialty Survey
Using data from a multicenter nationwide multispecialty survey, the authors investigated the efficacy of in-office dermatophyte test medium (DTM) and central laboratory cultures used to confirm onychomycosis across samples collected by podiatric, dermatologic, and primary-care physicians. The samples collected by podiatric physicians were both positive or both negative in 43% and 27% of patients, respectively. Samples harvested by dermatologists were both positive in 37% of patients and both negative in 32%, while the samples collected by primary-care physicians were both positive in 28% of patients and both negative in 38%. The accuracy of DTM and central laboratory tests is dependent on the proper collection of nail samples, and the accuracy of mycologic test results varied significantly across nail specimens harvested by podiatric, dermatologic, and primary-care physicians. DTM culture was found to be an effective and convenient method of confirming dermatophyte infections in patients with signs of onychomycosis. The data presented here indicate that the special expertise of podiatric physicians in treating foot-related illnesses translates into more accurate mycologic testing. (J Am Podiatr Med Assoc 93(3): 195-202, 2003)
Background: Historically recalcitrant to treatment, infection of the nail unit is a pervasive clinical condition affecting approximately 10% to 20% of the US population; patients present with both cosmetic symptomatology and pain, with subsequent dystrophic morphology. To date, the presumptive infectious etiologies include classically reported fungal dermatophytes, nondermatophyte molds, and yeasts. Until now, the prevalence and potential contribution of bacteria to the clinical course of dystrophic nails had been relatively overlooked, if not dismissed. Previously, diagnosis had largely been made by means of clinical presentation, although microscopic examinations (potassium hydroxide) of nail scrapings to identify fungal agents and, more recently, panel-specific polymerase chain reaction assays have been used to elucidate causative infectious agents. Each of these tools suffers from test-specific limitations.
Methods: Molecular-age medicine now includes DNA-based tools to universally assess any microbe or pathogen with a known DNA sequence. This affords clinicians with rapid DNA sequencing technologies at their disposal. These sequencing-based diagnostic tools confer the accuracy of DNA-level certainty, and concurrently obviate cultivation or microbial phenotypical biases.
Results: Using DNA sequencing-based diagnostics, the results in this article document the first identification and quantification of significant bacterial, rather than mycotic, pathogens to the clinical manifestation of dystrophic nails.
Conclusions: In direct opposition to the prevailing and presumptive mycotic-based causes, the results in this article invoke questions about the very basis for our current standards of care, including effective treatment regimens.
Background: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus.
Methods: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes.
Results: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were “minor” was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001).
Conclusions: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss. (J Am Podiatr Med Assoc 100(4): 235–241, 2010)
Background
This study describes the technique for decompression of the intermetatarsal nerve in Morton's neuroma by ultrasound-guided surgical resection of the transverse intermetatarsal ligament. This technique is based on the premise that Morton's neuroma is primarily a nerve entrapment disease. As with other ultrasound-guided procedures, we believe that this technique is less traumatic, allowing earlier return to normal activity, with less patient discomfort than with traditional surgical techniques.
Methods
We performed a pilot study on 20 cadavers to ensure that the technique was safe and effective. No neurovascular damage was observed in any of the specimens. In the second phase, ultrasound-guided release of the transverse intermetatarsal ligament was performed on 56 patients through one small (1- to 2-mm) portal using local anesthesia and outpatient surgery.
Results
Of the 56 participants, 54 showed significant improvement and two did not improve, requiring further surgery (neurectomy). The postoperative wound was very small (1–2 mm). There were no cases of anesthesia of the interdigital space, and there were no infections.
Conclusions
The ultrasound-guided decompression of intermetatarsal nerve technique for Morton's neuroma by releasing the transverse intermetatarsal ligament is a safe, simple method with minimal morbidity, rapid recovery, and potential advantages over other surgical techniques. Surgical complications are minimal, but it is essential to establish a good indication because other biomechanical alterations to the foot can influence the functional outcome.
