Search Results
Glomus tumors are rare and benign vascular soft-tissue masses commonly found subungually in the foot. A glomus tumor typically manifests with a classic triad of pain, point tenderness, and cold sensitivity. This case report describes an atypical presentation of a glomus tumor in the soft tissue of the rearfoot in a 77-year-old man in the setting of urosepsis. The mass had enlarged progressively for 6 months. Originally misdiagnosed as a hemangioma based on magnetic resonance imaging and clinical appearance, an excisional biopsy was performed. The lesion was subsequently diagnosed histopathologically as a glomus tumor. This article discusses the statistics of glomus tumor and discusses the importance of the need to recognize the symptoms and clinical findings of both typical and atypical presentation of this abnormality in differentiation and differential treatment and risk management of benign and malignant soft-tissue masses.
Protein S Deficiency and Lower-Extremity Arterial Thrombosis
Complicating a Common Presentation
A 42-year-old woman presented to the emergency department with progressive painful discoloration of the digits of her right foot and symptoms previously diagnosed as neuroma. She was admitted to the hospital for dorsalis pedis arterial occlusion and ischemic foot pain. Despite attempts to restore perfusion to the right leg, ischemia of the right foot persisted and progressed to digital gangrene. The patient subsequently required right transmetatarsal amputation and eventually below-the-knee amputation. After extensive inpatient vascular and hematologic work-up of this otherwise healthy woman, test results revealed that she had protein S deficiency, hepatitis C, and human immunodeficiency virus type 1. In addition to describing this patient’s evaluation and treatment, we review protein S deficiency, including its correlation with human immunodeficiency virus type 1 infection and laboratory diagnosis. This case promotes awareness of protein S deficiency and serves as a reminder to the physician treating patients with vascular compromise and a history of human immunodeficiency virus type 1 to include protein S deficiency in the differential diagnosis. (J Am Podiatr Med Assoc 97(2): 151–155, 2007)
Digital gangrene is frequently encountered in patients who have diabetes with peripheral vascular compromise, with or without superimposed infection. Preoperative laboratory values and radiographic images are important to determine a proper course of action. Equally important is a thorough history taking to confirm or rule out systemic entities and preexisting conditions that can aggravate or predispose one to the development of digital gangrene. A patient with diabetes presented with a rare and unusual case of digital gangrene, as he clinically had strong pedal pulses. Preoperative workup revealed a suspicion of polycythemia, which was subsequently confirmed. The patient underwent several days of phlebotomy until his hemoglobin and hematocrit levels were brought down to optimized levels before a digital amputation was performed. He went on to heal uneventfully, and he is currently being closely followed by oncology/hematology colleagues with periodic phlebotomy.
Lymphangioma-like Kaposi's sarcoma (LLKS) is a rare histologic variant of KS. Kaposi's sarcoma is also known as human herpesvirus type 8. The clinical presentation of the LLKS lesion is highly unusual and similar to that of classic KS but with multinodular vascular tumors and lymphedema. We present a 63-year-old native Haitian man with multiple slowly progressive exophytic ulcerated lesions covering more than 60% of his left lower extremity with no systemic involvement. Much confusion surrounded the clinical presentation of these wounds, and we postulated several differential diagnoses. Herein we describe the evaluation, clinical appearance, and progression of LLKS. Due to the rarity of LLKS, treating physicians need to be aware of the clinical presentation and diagnostic criteria of this variant. Despite being incurable, early diagnosis of LLKS can lead to long-term treatment options and a major reduction in symptoms.
Severely comminuted fractures of the metatarsal bones with significant bone and soft-tissue loss have commonly subjected patients to proximal amputation procedures. We describe two patients who experienced high-energy traumatic injuries to their limbs that resulted in significant destruction of their first and second metatarsal bones with overlying soft-tissue trauma not amenable to local coverage. In both cases, a vascularized free fibular osteocutaneous flap was used to reconstruct the metatarsal bone defect and traumatized soft tissues so that a proximal amputation was avoided. At an average of 14 months of follow-up, both patients had recovered well and regained independent ambulation, with one patient being able to play soccer. We show that the free fibular osteoseptocutaneous flap is useful in reconstructing significant metatarsal bone defects and in avoiding amputations in this patient population. The skin component of the flap may be used to fill soft-tissue losses, and the fibula bone may be osteotomized so that more than one ray may be reconstructed. (J Am Podiatr Med Assoc 101(6): 531–536, 2011)
Background
The deep plantar (D-PL) artery originates from the dorsalis pedis artery in the proximal first intermetatarsal space, an area where many procedures are performed to address deformity, traumatic injury, and infection. The potential risk of injury to the D-PL artery is concerning. The D-PL artery provides vascular contribution to the base of the first metatarsal and forms the D-PL arterial arch with the lateral plantar artery.
Methods
In an effort to improve our understanding of the positional relationship of the D-PL artery to the first metatarsal, dissections were performed on 43 embalmed cadaver feet to measure the location of the D-PL artery with respect to the base of the first metatarsal. Digital images of the dissected specimens were acquired and saved for measurement using in-house software. Means, standard deviations, and 95% confidence intervals (CIs) were calculated for all of the measurement parameters.
Results
We found that the origin of the D-PL artery was located at a mean ± SD of 11.5 ± 3.9 mm (95% CI, 4.5–24.7 mm) distal to the first metatarsal base and 18.6% ± 6.5% (95% CI, 8.1%–43.4%) of length in reference to the proximal base. The average interrater reliability across all of the measurements was 0.945.
Conclusions
This study helps clarify the anatomical location of the D-PL artery by providing parameters to aid the surgeon when performing procedures in the proximal first intermetatarsal space. Care must be taken when performing procedures in the region to avoid unintended vascular injury to the D-PL artery.
Necrotizing fasciitis is a rare and potentially fatal infection, with mortality of up to 30%. This case report describes a patient recovering from a laryngectomy for laryngeal squamous cell cancer who developed nosocomial necrotizing fasciitis of the lower extremity due to Serratia marcescens. Only eight cases of necrotizing fasciitis exclusive to the lower extremity due to S marcescens have been previously reported. Patients with S marcescens necrotizing fasciitis of the lower extremity often have multiple comorbidities, are frequently immunosuppressed, and have a strikingly high mortality rate.
Polyarteritis nodosa is a progressive, often life-threatening, vasculitis affecting multiple organs, including the skin and peripheral nerves. We report a patient presenting with systemic features of the disease and with characteristic lesions in the feet 3 weeks after vaccination against hepatitis B virus infection.
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)
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.
