Superficial acral fibromyxoma is a benign and slow-growing solitary soft-tissue neoplasm. Since being described in 2001, more than 100 cases of superficial acral fibromyxoma on the foot have been reported worldwide, none of which have been reported in the podiatric medical literature. Only nine cases of superficial acral fibromyxoma have been reported with presentation on the plantar heel. We report an unusual case of a 47-year-old Jamaican woman with a painful, erythematous nodule on her right heel that was diagnosed as superficial acral fibromyxoma.
Injections, punctures, and aspirations of the first metatarsophalangeal joint are common interventions. Accurate intra-articular placement of the needle is a prerequisite for the achievement of desirable results and the avoidance of complications. We evaluated the rate of successful intra-articular injections and the influence of the degree of operator experience in achieving this success.
A total of 106 cadaveric metatarsophalangeal joints were injected with a methylene blue–containing solution and subsequently dissected to distinguish intra-articular from periarticular injections. To evaluate the importance of experience, 38 injections were performed by a student, 38 by a trained resident, and 30 by an experienced surgeon. In the second part of the study, we examined the relation of pathologic findings of the metatarsophalangeal joint and the accuracy of intra-articular injection.
The overall rate of unintentional periarticular injections remained low (9.4%; 10 of 106 joints). The student achieved a successful intra-articular injection in 86.8% of joints (33 of 38), the resident in 92.1% (35 of 38), and the specialist in 93.3% (28 of 30). The number of extra-articular injections increased significantly with the presence of deformity (hallux valgus) and arthritis of the first metatarsophalangeal joint.
The presence of pathologic changes reduces the rate of successful intra-articular joint puncture. However, the overall frequency of successful intra-articular injections can be improved through experience and the use of imaging. (J Am Podiatr Med Assoc 103(3): 204–207, 2013)
Rupture of the tibialis posterior tendon associated with ankle fracture is rare and difficult to diagnose. This rupture can be easily overlooked because the clinical examination is limited owing to acute pain related to a closed ankle fracture. Complete rupture of the tibialis posterior tendon can be identified by a loss of tension during ankle fracture fixation, but partial rupture is more difficult to detect because the tibialis posterior tendon can maintain its tension. A few cases of complete rupture of the tibialis posterior tendon combined with ankle fracture have been reported. It is well-known that failure to diagnose a rupture of the tibialis posterior tendon can lead to long-term disability and a planovalgus foot. However, to our knowledge, this is the first report of partial rupture of the tibialis posterior tendon in the English literature. Herein, we describe a patient with a neglected partial rupture of the tibialis posterior tendon combined with a medial malleolar fracture.
Maggot Therapy in “Lower-Extremity Hospice” Wound Care
Fewer Amputations and More Antibiotic-Free Days
We sought to assess, in a case-control model, the potential efficacy of maggot debridement therapy in 60 nonambulatory patients (mean ± SD age, 72.2 ± 6.8 years) with neuroischemic diabetic foot wounds (University of Texas grade C or D wounds below the malleoli) and peripheral vascular disease. Twenty-seven of these patients (45%) healed during 6 months of review. There was no significant difference in the proportion of patients healing in the maggot debridement therapy versus control group (57% versus 33%). Of patients who healed, time to healing was significantly shorter in the maggot therapy than in the control group (18.5 ± 4.8 versus 22.4 ± 4.4 weeks). Approximately one in five patients (22%) underwent a high-level (above-the-foot) amputation. Patients in the control group were three times as likely to undergo amputation (33% versus 10%). Although there was no significant difference in infection prevalence in patients undergoing maggot therapy versus controls (80% versus 60%), there were significantly more antibiotic-free days during follow-up in patients who received maggot therapy (126.8 ± 30.3 versus 81.9 ± 42.1 days). Maggot debridement therapy reduces short-term morbidity in nonambulatory patients with diabetic foot wounds. (J Am Podiatr Med Assoc 95(3): 254–257, 2005)
Hereditary hemorrhagic telangiectasia (HHT), which is also known as Osler-Weber-Rendu syndrome, is a group of related disorders characterized by the development of arteriovenous malformations. These malformations occur in almost all organs but predominantly in the skin, intestines, liver, lungs, and brain. This is a case report of a patient with cutaneous manifestations of HHT in the lower extremities as diagnosed by his podiatric physician. To our knowledge, the literature does not present any case reports in which cutaneous manifestations of the lower extremities followed by a further work-up allowed a diagnosis of HHT.
A glomus tumor is an uncommon, predominantly benign, neoplastic lesion that primarily involves a thermoregulatory microvascular apparatus, the glomus body. Although these lesions can occur anywhere in the body, the subungual tissue of the hand represents the most common presentation site. Glomus tumors are not often encountered in the foot. Symptoms traditionally include the classic triad of pain, pressure, and cold sensitivity. This case report describes a variant location for a glomus tumor in the subcuticular tissue adjacent to the medial middle phalanx of the second toe. The nonsubungual location for this presentation should prompt the inclusion of glomus tumor in a digital soft-tissue lesion differential diagnosis. The lesion was excised surgically and was subsequently diagnosed histopathologically as a glomus tumor.
This study compares the potential benefit of fifth metatarsal head resection versus standard conservative treatment of plantar ulcerations in people with diabetes mellitus. Using a retrospective cohort model, we abstracted data from 40 patients (22 cases and 18 controls) treated for uninfected, nonischemic diabetic foot wounds beneath the fifth metatarsal head. There were no significant differences in sex, age, duration of diabetes mellitus, or degree of glucose control between cases and controls. Patients who underwent a fifth metatarsal head resection healed significantly faster (mean ± SD, 5.8 ± 2.9 versus 8.7 ± 4.3 weeks). Patients were much less likely to reulcerate during the period of evaluation in the surgical group (4.5% versus 27.8%). The results of this study suggest that fifth metatarsal head resection is a potentially effective treatment in patients at high risk of ulceration and reulceration. (J Am Podiatr Med Assoc 95(4): 353–356, 2005)
Morphological and Functional Changes in the Diabetic Peripheral Nerve
Using Diagnostic Ultrasound and Neurosensory Testing to Select Candidates for Nerve Decompression
It has been hypothesized that in individuals with diabetes mellitus the peripheral nerve is swollen owing to increased water content related to increased aldose reductase conversion of glucose to sorbitol. It has further been hypothesized that the tibial nerve in the tarsal tunnel is at risk for chronic nerve compression related to this swelling. We used diagnostic ultrasound to evaluate this hypothesis. Cross-sectional areas of the tibial nerve were measured in diabetic patients with neuropathy and compared with previously reported measurements in nondiabetic patients and diabetic patients without neuropathy. We used the Pressure-Specified Sensory Device (Sensory Management Services LLC, Baltimore, Maryland) to document the presence of neuropathy in 24 diabetic patients (48 limbs). Previous studies have found that the cross-sectional area of the tibial nerve in nondiabetic patients and in diabetic patients without neuropathy is not significantly different. We found that the mean cross-sectional area of the tibial nerve in diabetic patients with neuropathy is significantly greater than that in diabetic patients without neuropathy (24.0 versus 12.0 mm2). Our study highlights the value of newer ultrasound imaging techniques in identifying morphological change in the tibial nerve and confirms that the tibial nerve in the tarsal tunnel is swollen, consistent with chronic compression, in diabetic patients with neuropathy. (J Am Podiatr Med Assoc 95(5): 433–437, 2005)
Synovial chondromatosis is an uncommon disorder characterized by the formation of multiple cartilaginous nodules within the synovium and most commonly affects large joints, such as the knee and hip. Diagnosis in synovial chondromatosis is generally confirmed by histology after clinical and radiologic examination. Diagnosis may sometimes be difficult because synovial chondromatosis resembles a soft-tissue mass and may give no radiologic findings. We describe a case of synovial chondromatosis stemming from the subtalar joint, in which diagnosis was difficult clinically and radiologically. The patient presented with pain in the ankle and with a soft-tissue mass. This case is presented with a review of the literature on subtalar joint involvement of synovial chondromatosis (J Am Podiatr Med Assoc 98(4): 318–321, 2008)