Background: Verrucae are caused by infection of epidermal keratinocytes by human papilloma virus (HPV). Although there are currently more than 100 known types of HPV, certain lesions are consistently caused by infection with one or a few types. Recent studies have identified the presence of unusual HPV types in anogenital and cervical condylomata (warts) of patients infected with human immunodeficiency virus (HIV). Although cutaneous verrucae are typically caused by HPV-1, HPV-2, and HPV-4, infection with HIV may predispose an individual to infection with an unusual HPV type.
Methods: We report the detection of a rare HPV type in a clinically aggressive plantar verruca from an HIV-positive patient. The viral DNA from this specimen was analyzed to identify the predominant HPV type. To complete this analysis, HPV DNA was extracted from the formalin-fixed specimen, followed by polymerase chain reaction with consensus HPV primers and digestion with a specific group of restriction endonucleases. The fragments were separated on an agarose gel, and the restriction fragment length polymorphism pattern was compared with known patterns for identification of the specific HPV type.
Results: Identification of HPV-69, an HPV type previously reported to be rare and associated with dysplastic lesions, was confirmed by HPV DNA dot-blot hybridization with specific DNA probes for each known HPV type.
Conclusions: Plantar verrucae in HIV-positive patients may be associated with unusual HPV types and should be analyzed and treated aggressively given the potential for a more distinct clinical manifestation. Additional lesional analysis studies are needed. (J Am Podiatr Med Assoc 99(1): 8–12, 2009)
Onychomycosis is a common problem seen in clinical practice. Given the differential diagnosis of dystrophic nails, it is helpful to obtain a definitive diagnosis of dermatophyte infection before initiation of antifungal therapy. Potassium hydroxide preparation and fungal culture, which are typically used in the diagnosis of these infections, often yield false-negative results. Recent studies have suggested that nail plate biopsy with periodic acid–Schiff stain may be a very sensitive technique for the diagnosis of onychomycosis. In this article, we review the literature on the utility of histopathologic analysis in the evaluation of onychomycosis. Many of these studies indicate that biopsy with periodic acid–Schiff is the most sensitive method for diagnosing onychomycosis. We propose that histopathologic examination is indicated if the results of other methods are negative and clinical suspicion is high; therefore, it is a useful complementary technique in the diagnosis of onychomycosis. (J Am Podiatr Med Assoc 95(3): 258–263, 2005)
Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis (TTCA) is used for severe hindfoot deformities, end-stage arthritis, and limb salvage. The procedure is technically demanding, with complications such as infection, hardware failure, nonunion, osteomyelitis, and possible limb loss or death. This study reports the outcomes and complications of patients undergoing TTCA with a femoral nail, which is widely available and offers an extensive range of lengths and diameters.
We performed a retrospective review of 104 patients who underwent 109 TTCAs using a femoral nail as the primary procedure (January 2006 through December 2016). Demographic data, risk factors, and outcomes were evaluated.
At final follow-up, the overall clinical union rate was 89 of 109 (81.7%). Diabetes mellitus was negatively associated with limb salvage (P = .03), and peripheral neuropathy (P = .02) and Charcot's neuroarthropathy (P = .03) were negatively associated with clinical union. Only four patients (3.8%) underwent proximal amputation, at an average of 6.1 months, and 11 patients (10.6%) died, at a mean of 38.0 months. The most common complication was ulceration in 27 of 109 limbs (24.8%), followed by infection in 25 (22.9%). Twenty-three patients (22.1%) underwent revision procedures, at a mean of 9.4 months. Thirteen of these 23 patients (56.5%) had antibiotic cement rod spacers/rods for deep infection–related complications.
Use of a femoral nail has been shown to provide similar outcomes and limb salvage rates compared with other methods of TTCA reported for similar indications in the literature.
Background: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon.
Methods: We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation.
Results: A total of 219 surgical cases were available for review (140 males and 70 females; mean ± SD age at the time of surgery, 46.5 ± 12.6 years; age range, 16–75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after their wound complications; some had simple granuloma excision, and one necessitated a flap. Patients with risk factors such as diabetes mellitus, smoking, and rheumatoid arthritis necessitating corticosteroid therapy were more likely to have a wound complication (Fisher exact test, P = .03).
Conclusions: Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed manner. Absorbable and nonabsorbable sutures can be implicated. (J Am Podiatr Med Assoc 98(2): 95–101, 2008)
Background: We sought to determine the incidence of tinea pedis in patients with otherwise asymptomatic pedal interdigital macerations. Both diabetic and nondiabetic populations were compared. Age and body mass index were also examined for their significance.
Methods: Fungal cultures of skin scrapings from 80 patients (77 male and 3 female; mean age, 65 years) with interdigital macerations were performed; 40 patients had previously been diagnosed with type 2 diabetes and 40 did not have diabetes.
Results: Cultures revealed a 40% prevalence of tinea pedis in the total study population. The prevalence in the nondiabetic group was 37.5% and 42.5% for the diabetic group. This was not a statistically significant difference. Among patients with interdigital macerations that yielded positive fungal cultures, those in the nondiabetic group were 6.3 years older than those in the diabetic group. It was also observed that the nondiabetic patients with interdigital macerations yielding positive fungal cultures were 9.1 years older than patients with negative fungal cultures in the nondiabetic group.
Conclusion: The results of this study provide the practitioner with a guide for treating pedal interdigital macerations. Because the likelihood of a tinea pedis infection is 40%, it seems prudent to treat these macerations with an antifungal agent. In regard to age, the results suggest that as nondiabetic patients age, the likelihood of an otherwise asymptomatic interdigital maceration yielding a positive fungal culture increases, and that diabetic patients may be susceptible to interdigital fungal infections at a younger age than those without diabetes. (J Am Podiatr Med Assoc 98(5): 353–356, 2008)
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)
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.
Using a structured search of a range of databases, papers were identified that reported treatments tested on patients with the condition.
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.
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.
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.