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RE: Surgery to Remove Gouty Tophi

From: Thomas A. Graziano, DPM, MD


I agree with some of the posters here that at times tophaceous deposits can be managed effectively with medication.  However, in some instances surgical intervention is necessary.


Pre- and Post-op photos of Tophi Surgery


Above are pre- and post-op photos of a very interesting case I had many years ago. It was necessary to create a large flap off the hallux, debride the tophi and degenerative bone, and then repair the flap.  


Thomas A. Graziano, DPM, MD, Clifton, NJ

Other messages in this thread:



From: Lloyd Nesbitt, DPM


Consider Aldara (iImiquimod 5%). This is a cream that is applied topically on a daily basis and has to be continued for about four months -- and sometimes longer. While it doesn't kill the wart, it does boost the immune system locally so that the verruca does not survive.


Over the years, I have used laser on verrucae and in those cases when the lesions recurred, I have found the Aldara worked nicely to clear them up. So much so, that in many cases, I'll prescribe it as a first line of treatment rather than laser surgery, especially with children. It is an expensive prescription and patients have to stick with it, which most don't seem to mind, since they usually have had the verruca for such a long period of time to begin with. There is also a slightly less potent version called Zyclara (imiquimod 3.75%) which the drug reps seem to feel works equally well and is a bit less expensive.


Lloyd Nesbitt, DPM, Toronto, Canada



From: David Secord, DPM


I've used the Bleomycin treatment for verrucae for about 15 years now and think of it as my primary treatment course for adults with normal immune systems. With this treatment, I've seen an approximately 98% success rate with the added benefit that if the person has multiple verrucae, treating just the one lesion will allow resolution of all of them in the course of 5-6 weeks. 


The procedure entails using the body’s own immune system to kill the wart and follows the path of driving some of the warty material into the dermis, where the body will identify it and raise killer T-cells to the HPV (I, II, IV). As these circulate throughout the body, any place with a wart will...


Editor's note: Dr. Secord's extended-length letter can be read here. 



From: Charles Morelli, DPM


You stated that these two lesions are lateral 3rd toe and 2cm sub 1st met. These are classic locations for an IPK, which may be the reason previous treatments have failed. When treatments are not working, take a biopsy. 


Just because a patient is on blood thinners does not necessarily mean they can not have these excised. Proper technique, not going too deep and applying a topical coagulant and compressive dressing can suffice, and consider using a tourniquet along with epi in your injection (but not in the toe). Some may disagree with this, but I have performed surgery on patients on blood thinners, and they too have done well. 


Working on the assumption that these are in fact warts, when I have had resistant lesions that have not responded, I resort to injections of Candida albicans extract. Give the patient an Rx. It will cost them about $175 and they can bring it to the office (and make sure to keep it refrigerated). You can get 3-4 treatments out of a 1cc vial. The technique is easy (although can be painful and can be readily found on-line. Basically, use 0.3cc weekly with a tuberculin syringe. I have done this about six times in my career, and it has always worked. Look for clearing by six weeks after initial treatment.


Charles Morelli, DPM, Mamaroneck, NY



From: Stephen Musser, DPM,  Neil Barney, DPM


Use a local anesthetic with epinephrine (1:200,000) and pack it well with a post-op dressing.


Stephen Musser, DPM, Cleveland, OH


I have had success using 5% 5 fluorouracil daily with adhesive tape occlusion for those very stubborn verruca. It can take many weeks but is painless. Check on the patient every 2-3 weeks. In most cases, you do not even have to debride the lesions as it shrinks on its own. Pain from the lesion subsides quickly after a short time of use. I gave up excisions long ago as it is too painful and can cause scarring and severe disability while healing.


Neil Barney, DPM, Brewster, MA



From: Jesse Riley, DPM, Ben Cullen, DPM


I recommend Bleomycin injections. After having used everything else, they have given me the best results, are the least invasive, and are not very painful for the patient. You would want to shave down the superficial layers first, but then I would inject each lesion with Bleomycin reconstituted with 1% lidocaine with epinephrine.  An alternative to injecting is to do a “needle-free” version using a Madajet. It’s a great idea for kids, as it lessens the anxiety.


Jesse Riley, DPM, Evanston, WY


I recommend trying topical Imiquimod. I have had a couple of lesions that did not respond to months of various treatment measures and then were gone within a couple of weeks of applying this 3x/week at bedtime.


Ben Cullen, DPM, San Diego, CA



From: Sherwin Tucker, DPM, Roody Samimi DPM


Clearly a patient on anti-coagulants (blood thinners) can have an excision successfully performed. Common sense dictates that you either contact the prescriber of the anti-coagulants to see if any pre-excision changes in the medication needs to be made; or refer the patient to a provider who is more comfortable at treating a patient on anti-coagulant therapy.


Sherwin Tucker, DPM, Hartford, CT


Look up the Panacos procedure; it takes 8 months, but it works. Stitch in an inverted punch at one of the lesions).


Roodabeh Samimi, DPM Stockton, CA



From: Bryan C. Markinson, DPM


It is a little bit unsettling to ponder the original query by Name Withheld and the response by Dr. Samimi. It is true that metastatic cancer to the foot (generally considered rare) usually indicates a poorer prognosis, but so does all metastatic disease. MORE IMPORTANTLY, in metastatic disease to the foot, and specifically the nail unit, it is the first knowledge that any cancer exists in the patient anywhere in a way more than casual percentage of cases. In nail units, it approaches 50%. This puts us in a position to get the patient diagnosed and a chance at treatment for the original tumor, even though prognosis is naturally poorer. 


When a patient with a known history of cancer (as stated in original post) presents with a foot complaint or lesion, a ...


Editor's note: Dr. Markinson's extended-length letter can be read here.



From: Paul Kesselman, DPM


These cases often have tragic results (at least that' s been my experience). I have always opted to call for an orthopedic oncology opinion as they are best equipped to  order/perform  far more sophisticated testing. This is in order to determine whether or not the cancer has spread elsewhere and whether local surgical treatment is worth performing.


In all but one case that I had been involved with, the patients all had metastatic spread to vital organs and no surgical procedures were performed. Unfortunately, the 10 or so patients with these types of metastatic spread all passed away in a rather short time.  


In only one case was there no other metastatic spread other than to the foot (calcaneus). Chemotherapy took care of the recurrence to the original site (prostate) along with a BKA (as dictated by sentinel node and other biopsies performed by orthopedic oncology). That last patient lived another 20 years and recently passed away at 98. 


Paul Kesselman, DPM, Woodside, NY



RE: Treatment for Metastatic Cancer Spread to Feet

From: Roody Samimi, DPM


First of all, a biopsy is indicated. Any suspicions for metastatic cancer should be sent to  an orthopedic oncologist. Surgery by us is only indicated in benign cases.


Roodabeh Samimi, DPM Stockton, CA



From: Lawrence M. Rubin, DPM


Back in the '60s, I taught classes in roentgenology at what is now the Scholl College of Podiatric Medicine. I had read about (and believed possible) and subsequently taught my students that asymptomatic needles in the subcutaneous tissues discovered on x-ray could break apart and a fragment could penetrate a blood vessel and become a foreign object embolus -- possibly ending up in a vital organ. But to this day, I am not aware of this ever happening to anyone. Has any reader of PM News any information on this?  


Lawrence M. Rubin, DPM, Las Vegas, NV 



From: Randolph C Fish, DPM


I have had the same thing happen in my own foot. I stepped on a sewing machine needle at age 8. It broke off the square base upon entering my foot but the remainder of the needle was unable to be surgically removed. I have had the needle between the left 4th and 5th metatarsals for over 60 years. Recent x-rays show the needle to now be separated into two halves. Measuring the two portions shows that the lengths, when added together, are shorter than the original length. We must be able to dissolve things like this, or else I am growing more caustic as I age. 


Randolph C Fish, DPM, Tacoma, WA



From: Steven J. Kaniadakis, DPM


Question the patient as to whether she ever had acupuncture or that sort of oriental "medicine". I have seen this on x-rays. If this was not some other sort of artifact, then consider this. Call the patient. Some patients will not recall until later, because some of those oriental providers do not inform patients that they have implanted the "pins" or wires into the patient's foot/leg. It is important to document this in the patient's record, and to inform the patient. The object(s) may be a problem with MRI or real surgery. I have seen these near the posterior tibial nerve with patients having tarsal tunnel syndrome.


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



RE: Orbactiv - A New Antibiotic Alternative

From: Ed Cohen, DPM 


I treat numerous diabetic patients with gram positive bacteria, including MRSA-infected foot ulcers. Most of the digital ulcers can be treated successfully with a MIS flexor tenotomy and oral antibiotics. Some patients present with associated bone infection and frequently need IV antibiotics. 


Until recently, this required a picc line and 6 weeks of daily IV infusions. Orbactiv is a new antibiotic featuring a once dose protocol that is as effective as 10-14 days of Vancomycin twice a day. Orbactiv is less...


Editor's note: Dr. Cohen's extended-length letter can be read here



From:  Chris Seuferling, DPM


Get two 2mm punch biopsies. You need a deeper and more diagnostic sample. Don't treat without knowing your diagnosis first. This is dangerous. I'd recommend sending the specimens to Bako labs as they are experts in this area.


Disclosure: I have no financial relationship or interest with Bako Labs.


Chris Seuferling, DPM, Portland, OR



From: Heather S. Snyder, DPM


The International Association for Dance Medicine & Science has an excellent resource paper on the guidelines for beginning pointe work. 


As medical director for a professional ballet company and the mother of a pre-professional collegiate level ballet dancer, I can assure you that age is probably one of the LEAST important factors to consider when beginning pointe training. Core and proximal muscle strength, alignment, flexibility and technical training has been determined to be significantly more critical.


Heather S. Snyder, DPM, Medical Director, Charlottesville Ballet



From: Brandon M Zuklie, DPM


I have noticed the same relationship to smoking and IPKs as Dr. Thomas Nolen has observed. My thought is that the vasoconstrictive effect of nicotine reduces capillary and arteriolar blood flow. This will alter fibroblast function of the skin. I once treated the Marlboro Man; he was loaded with IPKs.


Brandon M Zuklie, DPM, Piscataway, NJ



From: Joon Yim, MD 


I completely disagree with the comments of Dr. Chaskin. Alcian Blue is not a conventional stain used for diagnosing fungi. If anything, GMS is a more standard stain than Alcian Blue. But using PAS with another stain does not make the diagnosis any more accurate than simply repeating PAS. The shortcoming in this kind of testing is not the stain itself, but the fact that in each section we stain, we may not be cutting the diagnostic area of the sample. So, the more sections we perform, the more likely we will make the right diagnosis. On the other hand, PCR will be much more accurate, although more expensive.


Joon Yim, MD, Pathology Director, Foot and Ankle Specialists of the Mid-Atlantic, LLC, Rockville, MD



RE: Alcian Blue Stains as an Alternative to Genetic Testing 

From Daniel Chaskin, DPM, Ridgewood, NY 


PCR assays or genetic testing are more expensive than Alcian Blue Stains. Many podiatrists do not order genetic testing because of cost. Alcian Blue Stains may not be as expensive and may with PAS yield a higher positive result. Alcian Blue stains combined with PAS is likely to result in more positive onychomycotic results. Thus, if you are concerned about cost and do not want to order genetic testing, consider Alcian Blue Stains. If cost is not a factor, my personal opinion is that genetic testing is the optimum choice for detecting onychomycosis. 


Daniel Chaskin, DPM, Ridgewood, NY



RE: New Treatment of Osteoid Osteoma

From: Neil H Hecht, DPM


I just read an article where MR-HIFU (magnetic resonance–guided high–intensity focused ultrasound) is used in children to treat osteoid osteoma without incision, pain, or radiation, in contradistinction to CT-RFA (CT guided radiofrequency ablation). CT-RFA requires an invasive approach with drilling through muscle and soft tissue into bone of the patient and radiation exposure to the operator.


High–intensity focused ultrasound therapy uses focused sound wave energy to heat and destroy the targeted tumor under MRI guidance. This precise and controlled method does not require a scalpel or needle, greatly reducing the risk of complications like infections and bone fractures. 


There was a mention in the article that MR-HIFU was also used here in the U.S. to treat uterine fibroids and painful bone metastases from several types of cancer in adults, but had not previously been used in children. I thought this was interesting and wondered if our podiatric brethren have used this for adult osteoid osteoma or any other bone tumors. Also, I wondered if there was any possible use in osteomyelitis.


Neil H Hecht, DPM, Tarzana, CA



From: John Cozzarelli, DPM, RPh


I have had the opportunity to treat over 30 patients with multiple IV infusions of Krsyrtexxa at the Gout Institute of America in Belleville, NJ. I agree with Dr. Udell that the efficacy of pegloticase is tremendous. In each patient I have infused, the patient's serum uric acid levels have dropped after the first infusion to almost undetectable levels and the process of dissolving the tophi begins. 


This is due to the fact that pegloticase is the enzyme that turns uric acid into allantoin, a water soluble end product that is excreted via the kidneys. Pegloticase also mobilizes crystals out of...


Editor's note: Dr. Cozzarelli's extended-length letter can be read here.



From: James Nuzzo, DPM, Elliot Udell, DPM


Gouty tophi consuming a digit like the one depicted in the photo often actually replace the bone. The best course of action (providing the patient is a candidate) would be a distal amputation, especially if the tophi are emanating from the wound.


James Nuzzo, DPM, Fox River Grove, IL


Pegloticase is a possible option. It lowers serum urate levels more than any of the oral medications. The problem as Dr. Lenz pointed out is finding a rheumatologist who is trained and comfortable with administering this drug via infusion. The drug has a lot of potential system side-effects and the administering doctor has to be very knowledgeable and prepared to manage any of these potential problems. The rheumatologist must also be willing to examine the patient in order to make sure she has no other medical risk factors that would disqualify the patient from having this treatment.


Elliot Udell, DPM, Hicksville, NY



From: Gene Mirkin, DPM


Surgery on a non-ambulatory, 80-year old is not the best approach for your patient. The surgical risks of flare-up, infection, and the fact that your patient will still have numerous other tophi still causing pain elsewhere, are not worth it. Instead, get him to a rheumatology practice that offers IV infusions of Krystexxa (pegloticase). The tophi will resorb without the inherent risks of surgery.


Gene Mirkin, DPM, Kensington, MD



From: Robin Lenz, DPM


Consider pegloticase, which is an infusion that will dissolve gout crystals in the body. This is infused every two weeks under the order of a rheumatologist. The hardest part is finding a rheumatologist who knows about and uses this drug. 


Robin Lenz, DPM, Toms River, NJ 



From: Sherwin Tucker, DPM, Don Peacock, DPM


This case presentation screams for a biopsy. You can't treat it unless you know what it is.


Sherwin Tucker, DPM, Hartford, CT


The history of your patient would suggest this is a pressure lesion. The patient may or may not be a candidate for correcting the equinus resulting from the CVA. An easy correction would be to perform a percutaneous FHL tenotomy in the office setting. It is not likely that this has a neurological pathology with respect to the skin. The procedure is outlined in this video


Don Peacock, DPM, Whiteville, NC



From: Gary Docks, DPM


A painful problem indeed. With a history of CVA and dropfoot, in combination with wearing an AFO, has anyone checked to make sure she's wearing the correct size shoe? Perhaps she's being pushed too forward into the toebox of the shoe and whammo! That, coupled with the dropfoot, the flexor tendon to the big toe is probably over-powering the weak extensors and causing a hallux malleus when she walks. If the shoe size is correct, then consider fusing the IP joint to keep the hallux rectus.


Gary Docks, DPM, Beverly Hills, MI