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12/11/2013    

RESPONSES/COMMENTS (CLINICAL) - PART 1A


RE: Painful Foot Lumps



From: Bryan C Markinson, DPM. Robert P. Thiele, DPM



These are consistent with panniculitis of which erythema nodosum is one type. Do a 3 mm punch biopsy to the level of the fat. The specimen must include the fat. The TB status of the patient should also be checked. These lesions also may represent an atypical mycobacterial infection. Biopsy is best for definitive treatment.



 


Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org


 


Consider myxedema related to the thyroid disease. You can biopsy the skin of the mass and send it to a lab. E-mail a digital picture of the foot/leg mass to your lab along with a biopsy specimen and the medical history. I had a few similar cases. If you feel that the lesions are not that superficial, then perform incisional biopsy as you see fit. Let us know the results.


Robert P. Thiele, DPM, Hillsborough, NJ, drthiele@comcast.net



Other messages in this thread:


08/19/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Kent Biehler, DPM, Steven J. Kaniadakis, DPM


 


When bilateral heel pain doesn't respond to normal treatment, it is possible it can be coming from a problem in the patient's back. The example is: When you step on a dog's tail, it barks. The doctor treats the mouth, but the problem originated somewhere else.


 


Kent Biehler, DPM, Mineola, NY


 


The fact that the clinical appearance of this patient's condition is bilateral and a "sudden" onset gives the impression that this could have a proximal origin. Does this patient have a nerve root or back condition, which is otherwise not detected? Second, I would perform clinical evaluation to differentiate "heel pain", namely as a possible "plantar fasciitis" condition from what may very well present as a bilateral tarsal tunnel syndrome ("TTS"). 


 


Finally, think compensation and accommodation for either a condition that started on one side, but contributed to make the contra-lateral side symptomatic. For example, "heel pain" in the left foot was compensated by or accommodated by shifting of the patient's weight, etc. Also, some forefoot conditions cause rearfoot conditions. Rule out B/L forefoot Morton's neuromas, which is more likely to present, and cause B/L rearfoot conditions. 


 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL

06/20/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Gino Scartozzi, DPM


 


In regard to the surgical contemplation of a percutaneous screw to fix the calcaneal stress fracture, I  suggest further radiographic studies on the calcaneus. It appears that the 37 year old patient has a calcaneal unicameral bone cyst which was perhaps more likely the etiology of the stress fracture in this patient. Surgical curettage and packing with either autogenous bone or bone substitute is probably more indicated.



Gino Scartozzi, DPM, New Hyde Park, NY



06/17/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Don Peacock, DPM, MS


 


These patient often do well without bone work. Most of these patients have gastrocnemius equinus and can get significant relief in mid-foot arthritic pain by performing a gastrocnemius recession. There will be reduction in biomechanical stress in the mid-foot. Look at some of Dr. Monroe LaBorde's research on gastrocnemius recession. 


 


Don Peacock, DPM, MS, Whiteville, NC 

06/10/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Allen Jacobs, DPM, Daniel Chaskin, DPM


 


The question is why do you require the information and what do you intend to do about it? If you intend to treat with an expensive topical agent or with systemic therapy, then speciation is appropriate (e.g.: culture, genetic testing). If you merely need to answer the question as to whether it is or is not a fungus (e.g.: qualify for palliative or accommodative care, or for laser therapy), but speciation is not required, as it will not alter the specific therapy, KOH, PAS, or dermoscopy is adequate.


 


Allen Jacobs, DPM, St. Louis, MO


 


Clinically, a mycotic toenail might be thick, brittle, discolored, with subungual debris present; however, there are further ways to test for onychomycosis. To test for onychomycosis, one should consider finding a laboratory that performs Alcian blue stains. Furthermore, the feet could be checked with a dermatoscope to see if there is a wispy pigmentation present with Tinea nigra. My personal favorite dermatoscope is the Dermlite 4. With its wide field and ice cap, it is especially useful for contact dermoscopy used in toenails. 


 


Contact dermoscopy, with Purell as a medium to limit surface glare, might show spikes on the onycholytic area. Lastly, there might be a micro-Hutchinson's sign present seen on dermoscopy. One should explain the risks, benefits, and alternatives of a matrix biopsy. 


 


Daniel Chaskin, DPM, Ridgewood, NY

05/17/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Robert Kornfeld, DPM, Charles Morelli, DPM


 



I have great success using colloidal silver 1000ppm. It will not burn the skin at all. A few drops on the padded part of a Beiersdorf coverlet 1 inch latex free Band-Aid twice a day until resolved. Debride as needed. The Band-Aid should always be in contact with the wart unless bathing. I have used it on children as well for over 20 years. 


 


Robert Kornfeld, DPM, NY, NY


 


1. Rule out squamous cell carcinoma. It’s remarkably rare, but has to be considered. 


 


2. I use cantharadin regularly and would do so here. Gently sand it down with a small sanding disc (or debride) and place a small drop directly on the lesion (try to avoid the skin). Let dry, cover with a Band-Aid for 24 hours; being that the skin is so thin which makes the wart also be quite superficial, in two weeks when the patient returns, in all likelihood it will probably have just fallen off. If not, then AgNO3 afterwards to desiccate the remainder. 


 


Charles Morelli, DPM, Mamaroneck, NY


05/13/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Barry Wertheimer, DPM


 


I found most often an acute nail infection is simply due to the baby wearing jammies or pants with footsies. The pressure on the big toe is exceptional when, even with a good fitting pair of pants are worn, and the baby, squirming in the crib, moves about pushing the feet/foot down to the end. Often the baby is allowed to wear one that he/she has slightly outgrown and this will add even more pressure. I suggest cutting out the footsies and replacing them with either a sock or (if warm enough] nothing on the feet. Treat the present hypertrophy with a topical antibiotic. Wait a week or two and then re-evaluate. 


 


Barry Wertheimer, DPM, (Retired) Southern Pines, NC 

05/10/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Paul Betschart, DPM


 


Since it does not look actively infected, I would try taping the offending border with kinesio tape or other elastic tape. Use 1/2 inch short strip, start at the edge of the nail fold and wrap plantarly, pinching the plantar skin lightly to pull the offending nail fold away from the nail and finish on the opposite side. There is a great article by Tsunoda and Tsunoda in Annals of Family Medicine (Ann Fam Med. 2014 Nov; 12(6): 553–555) that describes this well and demonstrates the effectiveness. If this technique fails or there is an active infection, partial nail avulsion without matrixectomy is usually effective. This can be done under topical anesthetic. 


 


It sounds cruel, but it usually hurts the parent more than the child. Use lidocaine 5% cream to the toe for 30 min prior. After sterile prep, use an English anvil or small straight splitter, grab the foot firmly and split 1/3 of the nail, and pull the cut piece out while removing the instrument. You must be firm and decisive with this technique - grip it and rip it. The child will feel this and will make a fuss, but it will be short-lived. Use a large adhesive bandage as a dressing and standard wound care afterward. Infants tend to outgrow this condition, so I would not rush to a matrixectomy.


 


Paul Betschart, DPM, Danbury, CT

05/09/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Charles Morelli, DPM, Paul Busman, DPM, RN


 


In your post you mention that you "would like to do a matrixectomy to remove the offending borders....leaning toward cold steel nail procedure vs. the phenol and alcohol procedure."  I would do neither and lean more towards a Winograd to remove not only the nail, but to also excise the hypertrophic skin along the medial border. It's easy to suture through the nail plate; the child will heal quickly and this will give the best cosmetic result in the long run.


 


Charles Morelli, DPM, Mamaroneck, NY


 


How chronic is this? What have you tried so far? I'd be reluctant to do any traumatic, permanent procedure on someone this young. I never did a single one during my practice years although I did a great many straight-back procedures, sometimes with excision of granulation tissue, under simple local. They weren't crazy about it, but with some ethyl chloride and gentle handling, they all went fine and with some parental education on future nail cutting, they usually did not recur. You can always go back and do more, but you can't go back and do less. 


 


Paul Busman, DPM, RN, Frederick, MD

04/30/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Jeanny Rickards, DPM


 



Based on your clinical and MRI findings, and that it's reducible, try considering EHL lengthening at the dorsal 1st MTPJ (could be done percutaneous like TAL), open plantar approach repairing the FHB and potentially FHL if seen attenuated intra-op. As for the sesamoids, depending on the fracture fragment, if it's small, remove it, but if it is relatively large, try using injectable stem cells with direct visualization and/or under fluoroscope (given they are similar to the white-white three zone of the menisci of the knee). Lastly, graft augmentation can be used plantar to the sesamoid apparatus cushioning the area like internal off-loading and suturing of plantar capsule to it as part of the repair.


 


Hopefully, the EHL lengthening will also fix the IPJ contracture. If soft tissue repairs fail, you can always do bone work as a salvage procedure. The 1st MTP joint space on your lateral x-ray appears to be in relatively good shape. If violating joint space could be spared, and the soft tissue surgery worked, that would preserve the joint from arthritis a tad longer. NWB for 4 weeks and passive ROM at 3 weeks are indicated. 


 


Jeanny Rickards, DPM, Corpus Christi, TX


03/07/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Allen Jacobs, DPM


 


Dr. Graziano, with reference to distal metaphysical osteotomy, suggests that we are deforming a normal bone to correct a deformity. Do we not do the same when we perform a calcaneal osteotomy for correction of a pronation deformity? Or resect bone in performing a digital arthroplasty? Or a “cheater Akin“? There are many theoretical benefits to the Lapidus procedure. But the theoretical is not always practical. 


 


Recently, I followed a local 3 year residency-trained “foot and ankle” surgeon in the OR. The pre-op and post-op films were still up on the screen. Literally, the only difference was...


 


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

03/06/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Thomas Graziano, DPM, MD


 


With all due respect to Dr. Rettig, I would challenge him and others performing bunionectomy procedures to critically look at the long-term outcomes of their work. As I said in my post on the subject, I agree that patient satisfaction is acceptable in “most” cases after distal osteotomy. It doesn’t change the fact that we take a straight bone and make it crooked with a distal osteotomy. Yes, it’s technically much easier, and yes it’s easier on the patient post-operatively. I was simply stating that long-term, it doesn’t hold up to a 1st metatarsal cuneiform arthrodesis. 


 


It doesn’t mean I don’t perform distal osteotomies. I just don’t push them to their limit because it’s an “easier” procedure. With regard to Dr. Rettig’s comment on counseling his patients, I don’t agree in “trade-offs” and “allowing my patients to choose” which procedure to use on them. They come to you as a specialist to make that decision. Otherwise, thank you Dr. Rettig for commenting on my post.


 


Thomas Graziano, DPM, MD, Clifton, NJ

03/05/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Richard Rettig, DPM


 


Dr. Graziano said regarding a Lapidus: "From a "corrective" and more "functional" standpoint, it provides superior outcomes when compared to any distal osteotomy. The stability of the first metatarsal cuneiform joint through arthrodesis and the correction obtained cannot be surpassed by any distal osteotomy, no matter what the configuration."


 


I do not disagree with his opinion that the correction from an arthrodesis cannot be surpassed, but I challenge it nonetheless. I have a totally different philosophy than him. I do the great majority of my bunionectomies by long plantar arm head procedures. I choose this in agreement with my patients after counseling on both procedures because in my hands, the head procedure gives almost the same quality of correction as a base wedge or a Lapidus combined with a much easier post-operative course for the patient, and with lower chances of morbidity. There is a trade-off, and my patients and I make a different choice than Dr. Graziano. I believe there is more than one "best" choice. 


 


Richard Rettig, DPM, Philadelphia, PA

02/22/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Don Peacock, DPM


 


Dr. Sullivan, my experience has been good with the percutaneous metatarsal osteotomy compared to the the Weil which I did for years. Recently, Henry, et al. published a study that compared the classic fixated Weil osteotomy with a non-fixated percutaneous distal percutaneous metatarsal osteotomy (DMMO). The percutaneous DMMO procedure is an extra-articular osteotomy without internal fixation. Thomas Bauer also published findings on the non-fixated DMMO with more than 150 patients. All but a few patients had complete resolve in their symptoms and no non-union.


 


What has been documented is post-op pain and swelling up to 3 months after DMMO. The surgical recovery is longer after DMMO than...


 


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

02/20/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Martin Girling, DPM


 


Consider a plantar plate repair before resection of the base of the proximal phalanx. Wright Medical has a great system or try Smith&Nephew's HAT-TRICK.


 


Martin Girling, DPM, St. Pete Beach, FL

02/18/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A




From: Todd Lamster, DPM


 


With all due respect to my colleague who posted this query, a resection of the base of the proximal phalanx will make your patient much worse, as it will only serve to destabilize the joint further and allow the toe to dislocate, probably leading to an eventual loss of the toe. The joint is subluxed because of a plantar plate disruption; a result of overload. Look at the length of the lesser metatarsals in comparison to the 1st metatarsal. The x-rays show considerable swelling, so I would first apply a stabilizing splint around the toe with a soft cast, and have the patient take a short course of an oral steroid (if appropriate). Assuming a reduction in the swelling and inflammation of the area, an arthrodesis of the 1st MTPJ with a flexor tendon transfer of the 2nd MTPJ and toe would be your best option. (I wouldn't cut through the 2nd met again to repair the plantar plate.)


 


If you don't address the 1st MTPJ, whatever you do on the 2nd MTPJ is doomed to failure. Also, I wouldn't worry too much about arthritis of the joint, as going back into that joint and performing a flexor tendon transfer will create significant scarring and stiffness, obviating the need for an implant.


 


Todd Lamster, DPM, Scottsdale, AZ


02/15/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Jay Kaufman, DPM


 


1. Regarding the symptomatic 2nd MTPJ, I have had good success with tendon allograft interposition when few options remain. You only need a small section of tendon (about 5 cm long and 3-4 mm in diameter) and I usually use the gracilus or semitendinosus muscles. 


 


2. You would remove the screw from the metatarsal head and then use a small rotary burr to fashion contiguous joint margins in a concave manner to accept the tendon graft. The tendon is sutured on the back table until you have a good sized graft (like marble). Once you place the graft in the joint, you would cross the joint with a percutaneous driven K-wire to place the toe in correct alignment (typically, only a slight over-correction in specific planes) and also to maintain the tendon graft from migration. The pin is removed in 3 weeks. The tendon adheres to the bone and the toe will typically remains in a better position due to fibrosis, and it will allow some motion. 


 


3. The above is predicated on when the joint is opened, the amount of arthrosis is negligible, and the plantar plate cannot be repaired either primarily or through a flexor tendon transfer. 


 


Jay Kaufman, DPM, Allentown, PA

12/14/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: David Secord, DPM


 


As local anesthetics (especially Marcaine) have been shown to damage chrondrocytes, I recommend not using them intra-articularly. See effects below.


 


•Seen especially with post-op local anesthetic pumps


•Most especially with bupivacaine


•Chondrolysis continues even after wash-out of the anesthetic and with as little as 20 minutes of exposure


•All local anesthetics cause chondrolysis on a dose/time-dependent scale1


 


1. Chu CR1, IzzoNJ, Coyle CH, The in vitro effects of bupivacaine on articular chondrocytes in: J Bone Joint SurgBr.2008 Jun; 90(6):814-20


 


David Secord, DPM, Corpus Christi, TX

12/13/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Tip Sullivan, DPM


 


I have always used a 50/50 mixture of local anesthetic and Renographin under "C" arm guidance. Use a small needle and inject dorsally until the joint is full. Any leakage from the medial/lateral/plantar aspect is evidence of a capsular tear. Make sure you visualize it in multiple planes.


 


Tip Sullivan, DPM, Jackson, MS

09/28/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Elliot Udell, DPM


 


There are neurologists and podiatrists in my own geographic area who do not prescribe any of the varied vitamin compounds for diabetic neuropathy. I respect their right to their opinions.


 


The way I handle these compounds in my practice is that I give the patient a one-month supply of one of the compounds (and there are many) and tell him or her to try it for a month. If the patient feels that it helps them, they will come back every month for a new supply. If it does not help them, they won't buy it again. Some patients will want to run it past their neurologists, endocrinologists, or primary care doctors first; and in some cases, those doctors will give them a green light and in some cases they are told not to try it. I don't lose any sleep over either decision. 


 


Elliot Udell, DPM, Hicksville, NY

08/21/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Lawrence Rubin, DPM


 


The characteristic radiographic appearance of chronic gouty arthritis in the foot is the presence of clearcut, “punched-out” erosions with dense, sclerotic margins in a juxta-articular distribution, often with overhanging edges. What's going on in the proximal interphalangeal joint of the second toe and the distal-medial tuft of the distal phalanx in the great toe is highly suspicious.


 


Arthrocentesis with even just a couple of drops of synovial fluid enables microscopic examination which can make the diagnosis. If crystals are seen, their shape and appearance under polarized light are diagnostic. Way back when I taught in the classrooms and clinics of the Illinois College of Podiatric Medicine, when we saw this kind of arthropathy on an x-ray, we used to say, "When in doubt, think of gout."  


 


Lawrence Rubin, DPM, Las Vegas, NV

07/31/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Steven Finer, DPM


 


I have used EMLA on some patients with diabetic neuropathy. Mainly, I used it on patients' toes, with some improvement. I have never used it as a pre-injection nor procedure anesthetic. 


 


Steven Finer, DPM, Philadelphia, PA.

07/12/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: George Flanagan, FCPodS


 


I am very interested to hear the replies following this query. In the UK, despite common usage of Xiaflex by hand surgeons, we have still only just had NICE (National Institute for Health and Care Excellence) approval for its use in hands. Effective use for Ledderhose disease would be off-license. I have used it once, with minimal benefit. In the hand, it largely improves contracture. As the contracture rarely develops in the foot, I wonder if collagen breakdown alone is sufficient to reduce the mass.


 


Luck’s (1959) work on pathogensis of Dupuytren’s would suggest it will only be beneficial for ‘mature’ lesions. I am only aware of Ziyad Hammoudeh’s brief 2014 article in Plastic & Reconstructive Surgery which highlights its use in one patient, without success. I look forward to hearing readers' experiences.


 


George Flanagan, FCPodS, Podiatric Surgeon & Medical Advisor to the British Dupuytren’s Society, UK

06/23/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Andrew Cassidy, DPM


 


I have found that not all physical therapy is the same. For a small spur like this, I suggest PT do aggressive soft tissue mobilization (it’s supposed to hurt but not be worse the next day) combined with phonophoresis (ultrasound with 10% hydrocortisone in the ultrasonic gel that can be compounded), as well as stretching protocols and eccentric loading exercises, maybe combined with a CAM walker.


 


If this fails, I would surely consider trying a growth factor, or stem cell injection in lieu of surgery. I have had many patients that failed conservative measures get complete resolution of pain with the use of biologics, which I would use in the form of PRP intra-operatively as well. The spur has been around longer than the pain. Be sure to treat the patient, not the x-ray.   


 


Andrew Cassidy, DPM, Austin, TX

06/22/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Paul Clint Jones, DPM, Thomas Graziano DPM, MD


 


The quick way to triangulate the intra-tendinous ossicle is to use a 25 gauge needle to probe the tendon intra-operatively to locate the mass, then dissect the mass free. If there is too much of the tendon missing following the ossicle removal, then doing a split tendon autograft works nicely. This is a technique developed by John Mozena, DPM. I made an animation that shows the technique nicely.  


 


Paul Clint Jones, DPM, Portland, OR


 


I recommend you refer this patient out to someone who regularly performs this procedure. No magical mystery cures for this condition. The Achilles tendon needs to be detached, ostectomy performed with Achilles tenodesis. The newer fixation techniques for Achilles tenodesis are excellent and provide exceptional stability and repair.  


 


Thomas Graziano DPM, MD, Clifton, NJ

04/18/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: John J. Brummer, DPM, Allen Jacobs, DPM


 


I think that Lamisil 250 mg Qd x 3 months with LFT monitoring is a good treatment option along with topical Jublia with or without a total nail avulsion  Discuss all possible side-effects with the child's parents . 


 


John J. Brummer, DPM, NY, NY


 


Part of wisdom is knowing what you do not know. Refer this child to a pediatric dermatologist. By virtue of the inquiry, it is likely you are not experienced in this area. You have completed your job by making an appropriate referral to someone with more experience with this pathology. 



 


Allen Jacobs, DPM, St. Louis, MO
Kerasal


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