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02/09/2017    

QUERIES (CLINICAL)


Query: Diabetic Foot Infection  


 


A 44 year old white male presented with an with ulcer sub 5th MTP with erythema and edema, lateral foot extending to the ankle. MRIs with and without contrast show increased bone marrow signal throughout the 5th metatarsal on T1 and T2. Abscess formation lateral 5th metatarsal is also present.


 


The patient was taken to surgery for an I&D. A total 5th ray resection was performed. I had hoped to leave some of the 5th met base but decided not to, after finding a large amount of pus around the 5th metatarsal base intra-operatively (and the MRI suggested osteomyelitis of the entire 5th metatarsal). The peroneal brevis was sutured to the cuboid periosteum and the wound was packed open. Bone from the 5th met head was sent for C&S.  Remaining bone was sent to pathology. 


 


The bone C&S grew out S. aureus and Enterococcus faecalis, both sensitive to vancomycin. Pathology, however, said there was no osteomyelitis in the bone specimen. I feel given the information provided, I treated this infection appropriately; however from a malpractice standpoint, the pathology report suggests otherwise. How does one reconcile the discrepancy? There should be histologic changes if osteomyelitis is present, right?

Other messages in this thread:


10/25/2017    

QUERIES (CLINICAL)


RE: Should we Prescribe Diuretics for Pedal or Ankle Edema?


From: Elliot Udell, DPM


 


From time to time, patients present to all of our office with complaints of pedal or ankle edema. In most cases, their internists will either prescribe support hose and or oral diuretics. In discussion with colleagues, there seems to be a split in opinion over whether we as podiatrists should prescribe oral diuretics when indicated. What are some of the prevailing feelings about whether podiatrists should prescribe diuretics for patients with pedal edema or refer them to the patients' primary care physician?


 


Elliot Udell, DPM, Hickville, NY

10/19/2017    

QUERIES (CLINICAL)


Query: Acquired Digital Fibrokeratoma


 


These toes belong to a 72 year old man with no significant past medical history who presented to my office recently. He states the lesions started in childhood and have been increasing in size; local treatment including what would appear to be cauterization has been unsuccessful. 


 













Acquired Digital Fibrokeratoma



 


Biopsy results are: “features suggestive of acquired digital fibrokeratoma”, so not horrible but not much help either. I'm wondering if anyone has seen a similar lesion and can suggest an effective treatment as he is eager to explore options. My thought is to simply excise the lesions and cauterize the wound bed; however, I am concerned about coverage and recurrence. 

10/05/2017    

QUERIES (CLINICAL)


Query: Pain in Left 2nd Toe Following Ingestion of Kit Kats


 


My patient is 69 year old with intermittent pain in the left second toe following consumption of several Kit Kats. He stated that he has eaten other chocolate products and has not had any similar reaction. His medical history includes Stage 3 chronic kidney disease, DM, and depression, but he is under treatment and control. His meds include Glipizide, hydrochlorothiazide, isosorbide, Losartan, and indomethacin. His labs are WNL. 


 


The first episode occurred a few months ago with a duration lasting 1-2 days followed by complete resolution.  I just thought this was a curious finding. I had never heard of anything like this. There are no biomechanical or LE issues and his regular care is for onychocryptosis. Has anyone ever seen this idiosyncractic reaction? 


 


Editor's note: The ingredients label of this product says that it contains  PGPR (Palsgaard4150) (an emulsifier). The FDA has deemed PGPR safe for humans as long as you restrict your intake to 7.5 milligrams per kilogram of body weight.

10/03/2017    

QUERIES (CLINICAL)


Query: Verrucae Hyperplasia?


 


A 59 year old female patient presented. Her PMH is only significant for hypertension and smoking. Nothing else would explain her foot conditions. Over the past year, she has developed bilateral hallux verrucoid-like lesions that are very painful. On her initial visit, I sent a partial thickness tissue sample. It was not deep enough to confirm as verrucae, but the pathologist labelled the lesion "suspicious". 


 













Hallux Verrucae Hyperplasia?



 


As you can see from the photo, the.overall size of the lesion is approximately 3cm x 2cm. Her previous few months of treatment by her PCP and another DPM have not helped at all, and little had really been done. I don’t think that cantharidin would be a good option for this area, but I am open to other options.  

09/28/2017    

QUERIES (CLINICAL)


Query: Minimum Age for Pointe Ballet


 


What is the recommended minimum age for dancers to start pointe ballet?


 


Hal Ornstein, DPM, Howell, NJ

09/21/2017    

QUERIES (CLINICAL)


RE: Plantar Cerebraform Collagenoma


 


I am curious if anyone has come across this unusual skin tumor. My patient is a 35-year-old who is very healthy. She developed the skin tumors about 10 years ago and they have been slowly growing. She relates that they seem to get worse every time she became pregnant,  or had a biopsy done. As you can see from the photo, she had a skin graft done years ago, and she relates that the tumors seemed to grow rapidly after the excision with skin graft.


 













Plantar Cerebraform Collagenoma



 


The diagnosis is plantar cerebraform collagenoma. The research I have done states that surgery is the cure. However, as you can see, these lesions are too numerous to excise. Fortunately, they are not painful to walk on. She's more concerned about the cosmetics. Any thoughts?

09/15/2017    

QUERIES (CLINICAL)


Query: Intractable Plantar Keratoma and Smoking


 


I've noticed that almost all of the patients that I treat for IPKs are cigarette smokers. Most of these patients also seem to have no causal relationship with plantarflexed metatarsals or elongation of the metatarsal within the parabola. Has anyone else noticed this relationship?


 


Thomas Nolen, DPM, Salem, IL

08/29/2017    

QUERIES (CLINICAL)


Query: Treatment for Severe and Painful Gouty Tophi


 


Due to chronic gout, this 80 year old retired dentist is non-ambulatory. The severe gouty tophi of both second digits (the symmetry has me stumped), the right much worse than the left, is becoming very painful.  


 













Severe and Painful Gouty Tophi



 


Any advice as to how to treat this condition surgically would be appreciated. This patient is followed regularly by his PCP and is taking allopurinol and colchicine for acute flares of pain; colchicine does not reduce pain of the second digits.

08/18/2017    

QUERIES (CLINICAL)


Query: Dermal Neuroma?


 


A 46 year old female has an extremely painful callus on her left hallux of several years duration. Touching it brings her to tears. Pads provide no relief. Trimming the lesion is barely tolerated and provides only minimal temporary relief.  Another podiatrist initially diagnosed it as a wart and attempted an excision. The procedure proved too painful and was abandoned midway through.  


 













Painful callus lesion pre- and post-debridement



 


Pertinent PMH: CVA and L4-L5 lumbar fusion with resulting left dropfoot. She uses an AFO brace which has been modified and does not contact the toe there. X-rays do not show any exostosis, but she has a mild hallux interphalangeus deformity. The lesion gets very thick, similar to a cutaneous horn. Debridement reveals some underlying pearly white translucent skin similar to dermal neuroma photos in Dockery/Crawford's Atlas of Foot Dermatology text. It has no petechiae to suggest a verruca. I am looking for any other treatment options.

08/09/2017    

QUERIES (CLINICAL)


Query: Early CRPS?



Six weeks ago, my patient, a 30 year old, mildly obese female had been in bed asleep lying on her side such that the medial aspect of her left foot was against the sheets, when her husband “sat down hard on it.” The patient states that the initial pain was excruciating and located about the lateral left foot from proximal to the styloid to the 5th met head. Palpation over this area is profoundly tender.  



An ultrasound showed some mild periosteal elevation lateral to the 5th met head. X-rays showed no overt fracture, and a subsequent bone scan showed no evidence of fracture. The only relief she has gotten has been from the BK walker that I dispensed that does allow her to walk short distances, though standing for a protracted period is all but untenable. I would appreciate any help or advice. Could this be an early manifestion of CRPS?


07/22/2017    

QUERIES (CLINICAL)


Query: Treatment of Plantar Scar


 


I excized a soft tissue mass from the plantar aspect of a patient's foot. She healed uneventfully; however, a plantar scar presented with a punctate keratotic lesion (similar to porokeratosis). I tried salicylic acid as well as silastic gel sheeting, both of which were ineffective at resolving the lesion. I took her back to surgery and performed a Schrudde skin flap. Unfortunately, that scarred up too and now she has another lesion that is bigger than the first one. Does anyone have any other non-surgical suggestions? 

07/06/2017    

QUERIES (CLINICAL)


Query: Calcific Tendonitis


 


A 38 year old male tennis coach and runner presented with 5+ years duration of left TAL and arch pain. He has tried multiple OTC insoles, night splints, KT taping, stretching, Advil, icing, and is essentially getting no better. This is starting to limit his activities. An exam showed moderate ankle equinus (straight knee), moderate medial plantar fascial band pain (heel pain is spared), and hallux limitus, but an x-ray is clean in terms of any spurring.  


 













Calcific Tendonitis



 


There is TAL pain at the lower edge of the calcification. Haglund's deformity has also been noted. I strapped his foot with a moderate low-Dye and also added 1/4" felt to his heel.  He had no relief at all after 48 hours. I am looking for possible custom orthotic recommendations before recommending surgical intervention. Suggestions?

06/22/2017    

QUERIES (CLINICAL)


Query: Tibial Sesamoiditis in Dancer


 


I have a question concerning a 16 year old female who likes dancing, and wants to pursue it as a career. She has a forefoot valgus of 5 degrees left foot with a prominent head of the 1st metatarsal. ROM of the ankle, STJ, and 1st MTP were normal. The pain is located on the tibial sesamoid. X-rays were normal. The right foot was normal.


 


She likes to dance both with shoes and barefooted. She is not interested in ballet. The patient has had this discomfort for three months, and reports it has gradually increased in intensity. The question I have is what would be the best form of shoe and/or orthotic treatment? Are there other treatments I need to look into?  

06/19/2017    

QUERIES (CLINICAL)


RE: Metallic Foreign Body Within a Toenail Plate


 


While mechanically debriding a hypertrophic hallux nail plate, I noticed I was not making progress reducing the nail and also heard an odd noise from the grinding disc. Close inspection of the nail plate revealed a localized dark discoloration that appeared possible for metal. Clinically, there was no sign of infection, erythema, exudate, or any other soft tissue manifestation. AP and hallux lateral elevated radiographs confirmed an apparent metallic foreign body within the nail plate proper. There was no nail bed penetration and likewise no osseous breach at the dorsum of the distal phalanx. No other foreign body fragments were evident.


 













Metallic Foreign Body Within a Toenail Plate



 


There was no contributory history to explain the foreign body presence. The patient denied history of failed or problem self-care. The patient has dystrophic onychomycosis in multiple nails. There is no history of neuropathy, vascular disorder, or diabetes. There is no major ambulatory defect. Does anyone have any explanation for the etiology of this?

06/16/2017    

QUERIES (CLINICAL)


Query: Syndactyly in an 11 Month Old


 


An 11 month old presented with bilateral syndactyly of the first and second toes. There are no other digits involved, and the patient does not have a family history of syndactyly. The patient does not yet independently ambulate and does not “want to walk” according to his mother. The pediatric orthopedist  gave the child a clean bill of health except for the syndactylized toes (no osseous abnormality) and some strabismus which may be causing some visual difficulties.


 













Syndactyly in an 11 Month Old



 


His mother believes that because his nail on the second toe seems to irritate the first, he does not want to walk. Basically, I taught the mother how to conservatively manage his nail until he is older and is able to ambulate. The syndactyly is mostly a cosmetic problem at this point. If the nail continues to be an unmanageable problem and requires surgery which will require anesthesia, then I plan to repair the nail and do a desyndactylization at the same time. Comments welcome.

06/05/2017    

QUERIES (CLINICAL)


Query: Bulbous Lesion on Distal Hallux


 


This is a 26 year old male with a growth tip of right great toe present for "a few years". It is getting larger. There is no history of pain or trauma. PMH: unremarkable. There is a bulbous firm lesion tip of hallux extending under the distal nail plate. X-rays reveal no osseus pathology.


 













Bulbous Lesion on Distal Hallux



 


A biopsy is scheduled before determining future treatment. If the lesion is benign, what is the best way to remove this lesion in order to close the likely large soft tissue defect?

06/02/2017    

QUERIES (CLINICAL) - PART 2



From: John D Lanthier, DPM


 



Dr. Graziano: Can you please describe the flap that you used in this interesting case of tophaceous gout?


 


John D Lanthier, DPM, Sudbury, ON

06/02/2017    

QUERIES (CLINICAL) - PART 1


Query: Curled Nails in 8 Year Old Boy


 


This is a healthy 8 year old boy. Developmentally, he was a little delayed with walking - 14 months. He seems to be a fairly habitual toe-walker. His parents try to encourage correct walking, purchase shoes with stiffer soles, yet it still persists. There is certainly a considerable amount of forefoot ambulation with virtually no heel-toe. Periodically, there is slight in-toe left. He does not trip or fall. He has a deviated-curled varus 2nd toe at the DIPJ bilaterally.  


 













Curled Nails in 8 Year Old Boy



 


The main concern is the ends of his toes and nails. He is doing Karate, with pain to the distal toes and nails. Cutting his nails has always been a chore for mom. Sometimes, bleeding occurs. The nail beds appear to be rounded with a slight dorsal bump with the nail curling over. The DIPJ is in rectus, with no 'fixed' or rigid contracture. Any advice would be appreciated.

05/29/2017    

QUERIES (CLINICAL)


Query: Surgery to Remove Gouty Tophi


 


I currently have a patient whom I treated for the second gouty attack in his right big toe joint. The first attack was 18 months prior. Grossly, it looks like he has huge bunion bumps bilaterally, but they're all tophi. Now that the pain from his recent gouty attack is resolved and his uric acid is down to normal levels, I plan to surgically remove the gouty tophi from his big toe joints (with the right foot initially and the left foot once the right is healed).  


 














X-Rays of Gouty Tophi




 


I have surgically removed tophi from around toe joints periodically in the past, but this patient has larger deposits around the joint than I have ever removed before, and it appears to extend all the way around the joint and into the first interspace. I would like to hear from my esteemed colleagues regarding any pearls they might have regarding removal of such a large number of tophi from around the big toe joint.

04/20/2017    

QUERIES (CLINICAL)


Query: Protocol for Testing When Prescribing Oral Antifungals 


 


I have been doing KOH, cultures, and liver function tests when prescribing oral antifungals for many years. Most of the time, these tests have not revealed much useful information.  As we all know, KOH and cultures are fraught with errors (please do not tell me to use other tests. I work at a community health center and my patients can’t get other tests covered by their insurance). The hepatic function tests rarely indicate serious liver problems. My question is this: has there been any change in standards of care in the testing required to treat onychomycosis prior to initiation of treatment by oral medications?


 


Edmond F. Mertzenich, DPM. Rockford, IL

03/23/2017    

QUERIES (CLINICAL)


Query: AmnioFix for Chronic Plantar Fasciitis 


 


I recently read several articles regarding AmnioFix injections for treatment of chronic plantar fasciitis. I was wondering how many of my colleagues are using this method. What is your experience and/or results? What is the protocol for this type of treatment? Is special training necessary? What are the risks, complications, and cost?


 


Paul A. Galluzzo, DPM, Rockford, IL

03/09/2017    

QUERIES (CLINICAL)


Query: Transdermal Verapamil for Plantar Fibromatosis


 


Is anyone using topical verapamil for plantar fibromatosis? If so, where can it be obtained, and how are the results?


 


Donald Carlson, DPM, Hermiston, OR

03/07/2017    

QUERIES (CLINICAL)


Query: Bilateral Heel Pain


 


My patient is a mailman with rearfoot varus. His pain has been in both heels, especially laterally, until I made orthotics for him. I have detected some diminution of bilateral peroneal muscle strength. His shoe wear of the lateral heel is so severe that a new pair of boots becomes unwearable after a few weeks. At his request, I ordered some OTC heel stabilizers, but these have helped only a little.  


 













Orthotics of patient with heel pain.



 


This picture of the worn orthotics really tell the tale: The left lateral heel cup corresponds to his painful left heel. These devices are the fourth iteration of orthotic care for him. Before I remake orthotics with a really high heel cup, I would like the erudite comments on possible treatment options from my esteemed colleagues. 

03/01/2017    

QUERIES (CLINICAL)


Query: BOTOX For Pain Management


 


A patient recently asked me if I use BOTOX for neuropathy pain. I also see a patient who periodically receives BOTOX from a pain clinic for muscle spasms in his legs. In reviewing the literature, I came across several studies in which BOTOX has significantly reduced pain for patients with diabetic neuropathy, trauma, post-surgery, and CRPS for up to 4 months or more.  


 


I would like to hear from colleagues who have used BOTOX. What is your experience in treating neuropathy and in pain management? Is there any special training necessary? Where do we purchase it and what is the cost?


 


Tom Silver, DPM, Minneapolis, MN

02/20/2017    

QUERIES (CLINICAL)


Query: Nitroglycerin Patches for Overuse injuries


 


Recently, a patient of mine went to his orthopedist for an Achilles tear and plantar fasciitis. His orthopedist gave him nitroglycerin patches to induce neovascularization. He is improving. Is anyone utilizing Nitro patches for tendon overuse injuries, and if so, what has your experience been? 


 


Howard Dinowitz, DPM, Brooklyn, NY 
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