Search Results
Background:
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.
Methods:
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.
Results:
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).
Conclusions:
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.
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.
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
A prospective epidemiologic survey on the prevalence of foot disease in Hong Kong found foot disease in 64% of patients screened. All of the patients were ethnically Chinese. Of the conditions specified in the questionnaire, fungal foot infection, tinea pedis, and toenail onychomycosis were the most frequently encountered conditions, followed by metatarsal corns, eczema, psoriasis, and pes planus. Vascular disease, osteoarticular pathology, diabetes mellitus, obesity, atopy, and participation in sports were the main factors coexisting with the foot conditions. Of the study population, 17% and 21% reported that their quality of life was affected by pain and discomfort, respectively. These percentages are much lower than those obtained in other studies; it may therefore be inferred that foot complaints are being neglected by the ethnic Chinese population in Hong Kong. (J Am Podiatr Med Assoc 92(8): 450-456, 2002)
The surgical records of three podiatric physicians were reviewed to identify all chevron-type osteotomies performed during 2000–2001 for the correction of bunion deformity, and complications were reviewed for each. In the 95 cases identified, 15 complications occurred in 12 patients. Of these 15 complications, 4 were soft-tissue infections (4 patients), 4 were cases of painful hardware (3 patients), 4 were cases of second metatarsal head pain (2 patients), 2 were cases of cystic changes initially interpreted as osteomyelitis but later determined to be degenerative changes (2 patients), and 1 was a case of stiff toe (1 patient). There were no cases of avascular necrosis, hallux varus, or recurrence. (J Am Podiatr Med Assoc 93(6): 499-502, 2003)
Background: Ingrowing toenail is a common condition treated by general surgeons. Our aim was to analyze the effectiveness of wedge resection with phenolization in the surgical treatment of ingrowing toenails.
Methods: We retrospectively audited 100 patients who underwent wedge resection with phenolization for the treatment of ingrowing toenail between January 2000 and June 2004 by a single surgeon. We reviewed all charts and attempted to contact all patients for a telephone interview to assess patient satisfaction. Outcome measures were: 1) recurrence rate, 2) duration of analgesic use, 3) postoperative complications including wound infection, 4) time to return to normal activities, and 5) satisfaction with the procedure.
Results: A total of 168 wedge resection with phenolization procedures were performed on 100 patients. There was only one recurrence (0.6%). Two patients (2%) had wound infection and were treated with oral antibiotics. The average time for a single wedge resection with phenolization procedure was 7.3 minutes. The mean time to return to normal activities was 2.1 weeks. The patient response rate for the telephone interview was 60%. Most respondents (93.3%) were satisfied with the overall outcome.
Conclusions: Wedge resection with phenolization is a very effective mode of therapy in the surgical treatment of ingrowing toenail, with a very low recurrence rate and minimal postoperative morbidity. Wedge resection with phenolization should be considered as a good alternative technique in the treatment of ingrowing toenail. (J Am Podiatr Med Assoc 98(2): 118–122, 2008)
Background: A high rate of false-negative dermatophyte detection is observed when the most common laboratory methods are used. These methods include microscopic observation of potassium hydroxide–digested nail clippings and culture methods using agar-based media supplemented with cycloheximide, chloramphenicol, and gentamicin to isolate dermatophytes. Microscopic detection methods that use calcofluor white staining or periodic acid–Schiff staining may also be substituted for and have previously been reported to be more sensitive than potassium hydroxide–digested nail clippings.
Methods: Trichophyton rubrum infections were detected directly from nails in a double-round polymerase chain reaction assay that uses actin gene–based primers. This method was compared with detection of fungal hyphae by using calcofluor white fluorescence microscopy of nail samples collected from 83 patients with onychomycosis who were undergoing antifungal drug therapy.
Results: Twenty-six of 83 samples (31.3%) were found to be positive by calcofluor white fluorescence microscopy, and 21 of 83 samples (25.3%) yielded positive results for T rubrum when actin gene–based primers in a double-round polymerase chain reaction assay were used. When calcofluor white fluorescence microscopy and polymerase chain reaction assay were used, the combined detection was 46.9% compared with 31.3% when calcofluor microscopy and culture of nail samples on Sabouraud’s dextrose agar supplemented with cycloheximide, chloramphenicol, and gentamicin were used.
Conclusions: These results suggest that the use of a direct DNA protocol is an alternative method for detecting Trichophyton infections. When this protocol is used, the presence of T rubrum DNA is directly detected. However, the viability of the dermatophyte is not addressed, and further methods need to be developed for the detection of viable T rubrum directly from nail samples. (J Am Podiatr Med Assoc 98(3): 224–228, 2008)
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)
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)
