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A case report is presented of a 65-year-old diabetic woman with an 18-month history of a penetrating ulcer of the plantar aspect of the first metatarsal head with associated sepsis of the first metatarsophalangeal joint and adjacent underlying osteomyelitis. Salvage of the first metatarsophalangeal joint was performed through aggressive soft-tissue and osseous debridement, external fixation with antibiotic-loaded polymethyl methacrylate bone cement, and delayed interpositional autogenous iliac crest bone graft arthrodesis. Osseous incorporation of the interposed bone graft occurred 12 weeks postoperatively. No soft-tissue or osseous complications occurred during the postoperative period, and at 1-year follow-up there was no evidence of ulceration recurrence, transfer ulceration, shoe-fit problems, or gait abnormalities. A detailed review of the literature on the use of external fixation and interpositional bone graft distraction arthrodesis of the first metatarsophalangeal joint is presented. (J Am Podiatr Med Assoc 94(5): 492–498, 2004)
We present a rare case of calcaneal chondroblastoma with subsequent surgical revision after graft rejection in a 13-year-old boy. Complications were encountered after the injectable bone graft filler was placed in the calcaneus after curettage. With noted subsequent sinus tract formation, revision surgery was performed that involved dissection of the sinus tract, removal of bone void filler, and application of demineralized bone matrix sponge human allograft soaked in vancomycin-impregnated saline. Sixteen weeks after the revision surgical intervention, the patient resumed normal athletic activities without pain or restrictions. One and a half years after the initial surgery, the patient had complete resolution of the calcaneal cyst and was discharged.
Tendinopathy in the presence of gouty arthropathy is relatively common, yet the clinical suspicion for gout involvement in acute tendon pain remains low. A 49-year-old man presented with an acute, tender, erythematous mass to the right posterior heel. A computed tomographic scan was obtained, which revealed a septated fluid collection superficial to the Achilles tendon. The patient was taken to the operating room for an incision and drainage with debridement, and the abscess was found to be filled with caseous material. The diagnosis of gout was confirmed with pathology. The calcaneus was submitted to biopsy, and the results were negative for osteomyelitis. The patient was returned to the operating room for repair of the Achilles tendon with flexor hallucis longus tendon transfer. Postoperatively, the patient was nonweightbearing for 6 weeks. Oral colchicine was used perioperatively, and a steroid taper was administered. The patient was started on allopurinol and colchicine for chronic treatment. At 14 months, the patient was walking without pain or recurrence of the mass. Although the relationship between hyperuricemia and tendinopathy is not completely understood, it is apparent that tendon involvement may be a sequela in patients with gout. When a patient presents with acute tendon pain, gout should be considered in the differential diagnosis.
Verrucous Hyperplasia
A Common and Problematic Finding in the High-Risk Diabetic Foot
Although verrucous hyperplasia may be common in high-risk insensitive feet, the literature contains little discussion on this topic. Treatment of verrucous hyperplasia is aimed primarily at reducing the causative forces. In cases that result from edema, external compression has proved to be adequate. If verrucous hyperplasia on the foot results from frictional forces, then shoe modifications with proper fit, accommodative liners, or fillers in the case of amputation are necessary. In recalcitrant cases, excision of the affected tissue with local soft-tissue or graft coverage has been successful. We describe a 56-year-old man with verrucous hyperplasia. (J Am Podiatr Med Assoc 96(4): 348–350, 2006)
Giant cell tumor of the tendon sheath (GCTTS) in the foot is a rare pathology and is involved in the differential diagnosis of soft-tissue tumors of the foot and ankle. Although it can affect any age group, GCTTS mainly occurs at the 3rd and 5th decade and is more common in females. Histopathologic examination is a major definitive method for diagnosis, although physical examination and radiologic imaging are helpful in reaching a diagnosis preoperatively. Many treatment options exist but marginal excision is the most commonly used treatment. We describe the case of a 26-year-old pregnant woman with a multi-fragmented mass extending from the first web space to the plantar aspect of the metatarsophalangeal joint (MTP) of the left great toe associated with flexor hallucis longus tendon after trauma. She had pain that worsened with activity and wearing shoes. After pregnancy, a marginal excision with dorsal longitudinal incision in the first web space was performed under spinal anesthesia. The lesion was diagnosed as a localized type tenosynovial giant cell tumor. At the last follow-up appointment in the 23rd month, the patient was doing well and there was no recurrence of the lesion. GCSST should be considered in the differential diagnosis of plantar masses of foot. Although, GCTTS is frequently seen in females, it has not been previously reported in a pregnant woman with an extremely rare condition after trauma.
Nail pathologies have a broad range of origin and may sometimes be complicated in presentation or clinical course, specifically when the pathology remains recalcitrant after treatment. In this case report we discuss a pathologic disorder that was initially misdiagnosed as a pyogenic granuloma surrounding an ingrown nail but was later found to be a benign neoplastic bone growth, Dupuytren exostosis, also known as a subungual exostosis. Operative treatment was deemed appropriate for the patient, and the exostosis was resected, leaving a soft-tissue void at the distal toe. The remaining void was filled with a perinatal graft, the use of which has been deemed effective anecdotally in both chronic and acute lower-extremity wounds but has not been widely discussed in the lower-extremity literature. This graft was placed to aid in wound healing over a potentially difficult wound bed. As amniotic, chorionic, and umbilical grafts become more prevalent in lower-extremity surgery, its antitumor effects should be further explored and published. This is the first case report, to our knowledge, of the successful use of a perinatal graft in the setting of a bone tumor, and it demonstrates that certain benign neoplasms can be treated with resection and placement of a perinatal graft while helping to prevent chronic wounds at surgical sites.
Primary Invasive Squamous Cell Carcinoma of the Foot
A Case Report
Malignant transformation of wounds is a rare complication that if missed can lead to loss of life or limb. This case report presents a rare invasive variant of squamous cell carcinoma presenting in the setting of a chronic wound complicated by osteomyelitis. This aggressive form of squamous cell carcinoma has a high growth rate and a high propensity for metastasis and recurrence. Early intervention greatly decreases the risk of metastasis and recurrence. We present the systematic evaluation and surgical management of an aggressive primary tumor occurring in the forefoot.
Fibro-osseous Pseudotumor of the Distal Phalanx
An Unusual Finding
Fibro-osseous pseudotumor of the digit is an unusual benign tumor that appears on the extremities. A 45-year-old, human immunodeficiency virus–positive man presented with a painful lesion on the tip of the fourth toe of his right foot. The tumor was completely excised without any connection to the underlying bone being observed, although the phalanx had to be extirpated. Histopathology confirmed the diagnosis of fibro-osseous pseudotumor. At the follow-up visit, 12 months later, no abnormalities were found.
Chronic decubitus ulceration of the heels is a common condition encountered by podiatric physicians, especially in diabetic patients. Very often these ulcerations can progress to osteomyelitis of the calcaneus. Many times, this in turn leads to a below-the-knee amputation. A partial calcanectomy is a viable alternative to below-the-knee amputation. A more functional limb both mechanically and cosmetically is achieved, and the morbidity and mortality associated with the calcanectomy is less than with a below-the-knee amputation. A brief overview of the history and outcomes associated with this procedure is outlined and a case utilizing a partial calcanectomy is presented. (J Am Podiatr Med Assoc 91(7): 369-372, 2001)
Spontaneous Achilles tendon rupture associated with long-term oral steroid use is not uncommon, particularly in older patients who use these drugs daily to treat systemic diseases. Rupture often results in a large defect, which complicates surgical repair. The authors review Achilles tendon rupture associated with systemic and local steroid use and present a case of rupture due to chronic oral steroid use in a patient with Addison’s disease. (J Am Podiatr Med Assoc 92(6): 355-358, 2002)