Discolored toenails is a common complaint presented to podiatric physicians, dermatologists, and primary-care physicians. Although various local and systemic conditions influence changes in nails, nearly 50% is due to fungal infections. We surveyed the health professions student population to gain insight into how future medical professionals may approach this condition and to explore perceptions of onychomycosis, treatments, and effects on quality of life.
The primary outcome measure was a self-reported online Google Forms survey developed by the authors and sent to podiatric, allopathic, and osteopathic medical students and nursing students in Philadelphia, Pennsylvania.
Of the 245 respondents, 92% agreed that toenail fungus is both a health and a cosmetic concern. Seventy-seven percent of respondents said “yes” when asked if they would seek treatment, and 67% would wait 1 month to 1 year to see a medical professional. When seeking treatment, 57% reported that they would see a primary-care physician initially, and 27% and 5% would seek care from a podiatric physician or dermatologist, respectively. A total of 91% would spend up to $300 annually for treatment, with only 4% willing to spend more than $500 per year. Respondents' greatest concern would be physical appearance.
Although agreement exists among the health professions students surveyed that toenail fungus presents both a cosmetic and a health concern, inconsistencies regarding time to treatment, treating professional, and effects on quality of life persist. It is not reasonable for all medical professionals to effectively recognize and treat nail disease, but it is paramount that patients are directed to medical professionals who can accurately exclude other conditions to alleviate social and financial burdens patients may face due to onychomycosis.
Hammertoe deformities are among the most common conditions treated by foot and ankle surgeons. Many different types of proximal interphalangeal joint arthrodesis fixation techniques have been used. These include implant fixation, absorbable fixation, screw fixation, two-pin fixation, and single–Kirschner wire fixation. Each of these has their own set of associated advantages and disadvantages. One of the most common techniques to address hammertoe deformity is the use of Kirschner wires. Although Kirschner wires have been reliable and produced good outcomes, there are some drawbacks associated with their use. Some disadvantages include wire failure (bending/breaking), infection, and patient anxiety associated with removal. One of the more challenging aspects with using a single Kirschner wire for fixation is stability. Pistoning and rotational instability may occur with single–Kirschner wire use. Both pistoning and lack of rotational control can lead to nonunion, fibrous union, malunion, and ultimately patient dissatisfaction. The suturedesis technique is a surgical option that may be considered when a surgeon attempts to address these disadvantages. The authors believe this technique can adequately bring stability to the frontal plane and eliminate pistoning, which may lead to better fusion rates, better postoperative alignment, and better patient satisfaction. This article outlines the authors’ surgical technique of suturedesis in correcting hammertoe deformity.
With the growing prevalence worldwide of diabetes mellitus and hyperglycemia, hospital-based health-care professionals will encounter patients with these conditions with increasing frequency. It is well known that long-term control of blood glucose reduces the rate and severity of complications in patients with diabetes, but there is also mounting evidence that even short-term glycemic control in hospitalized diabetic patients can significantly lower morbidity and mortality in many areas, from nosocomial infection to postoperative course. The results of traditional approaches to controlling blood glucose in hospitalized patients have been disappointing owing to a variety of factors, including the use of oral agents that are difficult or dangerous to use in inpatients, older insulin preparations with unphysiologic modes of action, and even provider reluctance to accept glycemic control as an essential element of the care of the diabetic hospitalized patient. This article provides guidelines for the effective management of hyperglycemia in these patients throughout the hospital stay, with specific recommendations for the perioperative, operative, and postoperative periods. (J Am Podiatr Med Assoc 94(2): 135-148, 2004)
Background: Assessing implanted biological reinforcement graft success in soft-tissue repairs is typically limited to noninvasive measurements and functional outcome measures. However, there are times when a histologic snapshot of the graft incorporation may be possible owing to a nongraft-related postoperative complication, such as hardware failure.
Methods: We histologically evaluated a 6-month biopsy sample from an Achilles tendon repair augmented with an acellular human dermal matrix (AHDM). A 57-year-old woman was treated for Haglund’s deformity of the Achilles tendon. The Achilles tendon was fixed to the calcaneus using a plate, and an AHDM was used to augment the primary repair of the tendon. At 6 months, the hardware was removed owing to prominence, and a biopsy of the AHDM was performed. The specimen was prepared and stained using hematoxylin and eosin, Verhoeff-van Gieson, Movat’s pentachrome, and toluidine blue stains.
Results: Visually, the graft appeared normal and incorporated with the native tendon. No repeated tear was observed, and results of tests for infection were negative. Histologically, the graft was infiltrated predominantly with fibroblasts and demonstrated numerous blood vessels. Positive proteoglycan staining in the AHDM and at sites of vascularity indicated probable transformation to tendon-like tissue.
Conclusions: These histologic findings suggest that the AHDM is highly biocompatible, supports revascularization and repopulation with noninflammatory host cells, and becomes incorporated by surrounding tendon tissue. (J Am Podiatr Med Assoc 99(2): 104–107, 2009)
Background: Transmetatarsal amputation (TMA) is a viable option to avoid major amputation and limb loss in patients with forefoot sepsis, infection, or tissue loss. However, TMAs are associated with a significant incidence of dehiscence, readmission, and reoperation rates ranging from 26% to 63%. To encourage tissue healing, neovascularization, and durable closure, a nonwoven, resorbable, synthetic hybrid-scale fiber matrix whose architecture is similar to native human extracellular matrix was used in an augmented closure technique. We comparatively evaluated clinical outcomes and complication rates in TMA procedures with and without augmented closure.
Methods: A retrospective analysis of ten patients who underwent TMA with augmented closure using the synthetic matrix and ten patients who underwent TMA with standard primary closure was conducted.
Results: After TMA, 80% of the patients who underwent augmented closure demonstrated complete wound healing compared with 60% of the control group. Patients undergoing augmented closure demonstrated five instances of wound dehiscence and 20% limb loss compared with eight instances of wound dehiscence and 40% limb loss in the control group. After TMA and augmented closure, patients required eight interventional procedures before complete healing compared with patients undergoing standard closure, who required 13 interventional procedures before complete healing.
Conclusions: Augmented closure of surgical wounds after TMA using a synthetic hybrid-scale fiber matrix provided a unique means of reducing time to healing (18%), wound dehiscence (29%), number of procedures performed (39%), and rate of limb loss (20%). Augmented closure, therefore, offers a means of improving quality of life and reducing risk for patients undergoing TMA, and potentially reducing total cost of care.
Background: Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration.
Methods: Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot.
Results: Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7–47.0).
Conclusions: Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.
Early military investigations of blister treatment using tissue adhesives have shown promise, finding that these agents provide pain relief, prevent infection, and allow continuation of recruit training. A trial was conducted to compare a 2-octylcyanoacrylate treatment with military standard therapy. Patients were recruited during foot evaluation at the end of a 10-km military road march. Seventy-five patients were screened, and 51 were enrolled. Twenty-six patients received 2-octylcyanoacrylate and 25 received standard treatment. A total of 80 blisters were treated (40 in each group). The mean (SD) blister size in the 2-octylcyanoacrylate group was 12.7 (6.2) mm and in the standard group was 12.0 (5.7) mm. There were no statistically significant differences in any of the baseline variables. Baseline and repeated-measures visual analog scale scores demonstrated no statistically significant differences in initial or repeat pain scores. Both groups showed a similar change across time, with a nonsignificant trend toward improvement in the standard therapy group at 10 min (28.5 versus 24.9) and in the 2-octylcyanoacrylate group at 3 days (42.9 versus 50.1). Mean Likert scores were similar, indicating no difference in patient satisfaction. Time to resumption of normal activity was similar, with one patient in each group unable to return to activity at the time of follow-up. There was a trend toward an increased proportion of patients in the 2-octylcyanoacrylate group who were able to return to normal activity within 48 hours, but this did not reach statistical significance. 2-Octylcyanoacrylate was associated with a greater degree of procedural discomfort. No infected blisters were noted in either group. (J Am Podiatr Med Assoc 96(3): 232–237, 2006)
Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment of calcaneal fractures. This study presents short-term clinical and radiologic results of patients with calcaneal fractures treated by closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis.
Twenty-one feet of 18 patients (four women and 14 men) with calcaneal fractures were retrospectively analyzed. Böhler and Gissane angles were measured from the preoperative, postoperative, and latest follow-up lateral radiographs of the feet. American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the 6-month and latest follow-up clinical assessments.
The mean preoperative Böhler angle of 17.1° was corrected to a mean of 20.4° postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3°. The mean preoperative and postoperative Gissane angles were 116° and 117.8°, respectively. The mean value of this angle measured at the time of latest follow-up was 117.4°. The mean 6-month postoperative AOFAS score was 59.8 points. The mean AOFAS score at the time of latest follow-up (79.1 points) was significantly higher than the mean score 6 months postoperatively (P < .001). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent.
With a low learning curve and satisfactory clinical outcomes, this technique can be used in acute, edematous cases with soft-tissue injuries to avoid calcaneal enlargement, infection, and soft-tissue problems.
We describe a retrospective study that uses the Broström-type surgical procedure with modifications that augment deficient and torn ligaments with acellular human dermal grafts. At the onset of this study, the most prevalent dermal graft available to us was GraftJacket (Wright Medical Technology, Arlington, Tennessee). Greater than 50% of the study participants were grafted with this product, but more recently other equally effective human dermal grafts have been used with no apparent difference.
Thirty-five lateral ankle stabilization procedures were performed in the past 6 years on 33 patients. Eight patients were considered athletes (mean age, 23 years). The balance of the study group consisted of sedentary patients (mean age, 41 years). The mean patient body mass index (calculated as the weight in kilograms divided by the square of the height in meters) was 31.
All of the patients were satisfied with their results, with no recurrent instability. Two patients in this group went on to have contralateral ankle stabilization in a similar manner owing to their satisfaction. Complications included two soft-tissue infections.
Lateral ankle stabilization using acellular human dermal graft augmentation is a useful tool in the surgical treatment of ankle instability. This procedure offers distinct advantages over traditional methods of ankle repair and can be performed with relatively limited surgical exposure. Ease of operation, consistent results, and limited patient morbidity should allow surgeons to use this procedure independently or adjunctively to improve surgical outcomes.
Pigmented villonodular synovitis (PVNS) is a rare disorder around the ankle joint. The optimal treatment for diffuse-type PVNS is still controversial because of the high incidence of recurrence. We present the clinical features of our patients and review the current diagnostic and treatment modalities.
Five patients with PVNS located around the ankle were surgically treated. In three patients, diffuse PVNS arose from the ankle joint, and in the other two it arose from the calcaneocuboid and intercuneiform joints. The average follow-up time after surgery was 2.9 years (range, 2–4.6 years).
The average time between onset of pain and diagnosis of PVNS was 6.4 years (range, 4–10 years). Arthrotomic tumor resection was performed in all of the patients. In the three patients with ankle joint PVNS, both medial and lateral approaches were used. One patient experienced mild infection at the surgical site, but this healed conservatively. No tumor recurrences had occurred after minimum follow-up of 2 years, although mild pain persisted in the three patients with ankle PVNS.
Diagnosis of diffuse PVNS is frequently delayed due to vague symptoms and variable growth patterns. Orthopedic clinicians should be aware of the existence of this lesion, and it should be suspected in patients with persistent ankle swelling. To prevent tumor recurrence, accurate evaluation of tumor location and careful operative planning are mandatory. A combined surgical approach involving medial and lateral incision is necessary to expose the entire joint cavity.