Search Results
Background:
Gout is a purine metabolism disease. Tophaceous gout may cause joint destruction and other systemic problems and sometimes may be complicated by infection. Infection and sinus with discharge associated with tophaceous gout are serious complications, and treatment is difficult. We present a patient with tophaceous gout complicated by infection and discharging sinus treated by bilateral amputation at the level of the first metatarsus.
Methods:
A 43-year-old man previously diagnosed as having gout, and noncompliant with treatment, presented with tophaceous gout associated with discharging sinus and infection on his left first metatarsophalangeal joint. Because of the discharging sinus associated with the tophaceous deposits, the soft-tissue and bony defects, and the noncompliance of the patient, amputation of the first ray was undertaken, and a local plantar fasciocutaneous flap was used to close the defect. After 8 months, the patient was admitted to the emergency department with similar symptoms in his right foot, and the same surgical procedure was performed.
Results:
One year after the second surgery, the patient had no symptoms, there was no local inflammatory reaction over the surgical areas, and laboratory test results were normal.
Conclusions:
Gout disease with small tophi often can be managed conservatively. However, in patients with extensive lesions, risk of superinfection justifies surgical treatment. Results of complicated cases are not without morbidity; therefore, early surgical treatment may prevent extremity loss and further complications. In severe cases, especially with compliance issues, amputation provides acceptable results.
We present a case of a pediatric patient with a history of spina bifida who presented to the emergency department of a large Army medical treatment facility with a partially amputated right fifth digit she sustained while sleeping with the family canine. There are several reports in the popular press that suggest that an animal, particularly a dog, can detect human infection, and it is hypothesized that the toe chewing was triggered by a wound infection. This case provides an opportunity to provide further education in caring for foot wounds in patients with spina bifida.
Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a “hot foot line” for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.
Reconstruction of large bone defects of the metatarsals, whether resulting from trauma, infection, or a neoplastic process, can be especially challenging when attempting to maintain an anatomical parabola and basic biomechanical stability of the forefoot. We present the case of a 42-year-old man with no significant medical history who presented to the emergency department following a severe lawnmower injury to the left forefoot resulting in a large degloving type injury along the medial aspect of the left first ray extending to the level of the medial malleolus. The patient underwent emergent debridement with application of antibiotic bone cement, external fixation, and a negative-pressure dressing. He was subsequently treated with split-thickness skin graft and iliac crest tricortical autograft using a locking plate construct for reconstruction of the distal first ray. Although the patient failed to advance to radiographic osseous union, clinically there was no motion at the attempted fusion site and no pain with ambulation, suggestive of a pseudoarthrosis. The patient has since progressed to full nonpainful weightbearing in regular shoes and has returned to normal activities of daily living. The patient returned to his preinjury level of work and has had complete resolution of all wounds including his split-thickness skin graft donor site. This case shows the potential efficacy of the Masquelet technique for spanning significant traumatic bone defects of the metatarsals involving complete loss of the metatarsophalangeal joint.
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)
The decision to amputate or reconstruct after high-energy foot injuries is controversial. A 25-year-old male patient was admitted to our clinic with a complex injury to his left foot sustained during a mine explosion, and the second to fifth digits and metatarsals of the left foot had been traumatically amputated before admission to our facility. The complex left foot defect was reconstructed with an osteocutaneous fibula flap during a single session. An osteotomy was performed on the bone segment of the flap, and both lateral longitudinal and transverse arches were repaired. Both aesthetic and functional outcomes were very satisfactory, including independent ambulation, light jogging, and full performance of activities of daily living without limitation. Many factors, including comorbidities, should be considered during the decision-making process of amputating or reconstructing complex foot injuries.
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)
Fibrosarcoma is an uncommon, malignant soft-tissue tumor that is rarely found as a primary neoplasm in the foot. A case report is presented that demonstrates a large, locally invasive fibrosarcoma of the plantar aspect of the foot with initial symptoms consistent with plantar fasciitis. Below-the-knee amputation was performed as curative treatment. (J Am Podiatr Med Assoc 92(9): 507-511, 2002)
Group B and F Beta Streptococcus Necrotizing Infection–Surgical Challenges with a Deep Central Plantar Space Abscess
A Diabetic Limb Salvage Case Report
We present the case of a 66-year-old, type II diabetic male with a deep wound to the plantar-lateral aspect of his right hallux. On examination, the central plantar compartment of his right foot was moderately erythematous and tender on palpation. After obtaining a deep wound culture, treatment was complicated by a progression of a group B and F beta streptococcus, necrotizing infection. The patient underwent a right hallux amputation, followed by a plantar medial incision for drainage of an abscess to the medial and central plantar compartments of the foot. Due to the extent and limb threat of the infection, the patient ultimately underwent a transmetatarsal amputation. Advanced healing modalities were also employed to decrease wound healing times, which allowed the patient to achieve early weightbearing and return to activities of daily living. This study depicts how the astute podiatric surgeon needs to make a decision in a timely manner to surgically debride all nonviable and necrotic tissue in order to minimize further amputation and preserve foot function.
Verrucous carcinoma of the foot is a rare malignancy, and proper diagnosis can be delayed. Furthermore, misdiagnosis often results in delayed appropriate treatment. Herein, we present an unusual case of verrucous carcinoma of the fifth toe with bone invasion in a 63-year-old woman that was mistaken for a plantar wart for 3 years. The condition was treated by ray amputation. We emphasize the need for appropriate biopsy to achieve an accurate diagnosis.
