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04/12/2012
QUERIES (CLINICAL)
Query: Onychomycosis in a Ten Year Old
My patient is a ten year old male with no contributory PMH. He has a history of mild injury to the left hallux 3 years ago. The nail had blood under it but never fell off and then grew out. Since then, the nail has had white thickening, migrating from the end of the nail back closer to the base. No other nails are involved. Cultures taken were positive for trichophyton spp. Topicals have been ineffective.
Since the FDA states that efficacy and safety have not been established for children, I am hesitant to start this kid on Lamasil. I am not aware of any dosage adjustment needed. Any thoughts on using pulse-dosing or another method for treating documented onychomycosis in a otherwise healthy pediatric case?
Tip Sullivan, DPM, Jackson, MS
Other messages in this thread:
09/13/2007
QUERIES (CLINICAL)
Query: INBONE Fusion System
Does anyone have any experience utilizing the INBONE Fusion System by Reiley Orthopedics (www.reileyorthopedic.com) ? It’s used for fusions such as 1st met-cuneiform, T-N and STJ . It is an interesting concept. Any surgical pearls would be appreciated.
David Sterling DPM, Santa Maria, CA
09/14/2007
QUERIES (CLINICAL)
Query: ESWT for Neuromas
I would like to know if anyone is using the Dornier Epos Ultra device for the treatment of neuromas. If so, I would appreciate the exact protocol being used.
David Zuckerman, DPM, Woodbury, NJ
09/15/2007
QUERIES (CLINICAL)
Query: KobyGard System for Neuromas
I would like to know if anyone is using the KobyGard system to treat neuroma's and/or fasciitis? What pre and post-op protocol is being used? What has been your success rate?
Paul Galluzzo, DPM, Rockford, IL
09/19/2007
QUERIES (CLINICAL)
Query: Management of a 5th Met Non-Union
I have a 50 year old white female with a history of hypophosphatasia and pernicious anemia. Her only med is methylcobalamine. She has a history of delayed healing of past fractures. She sustained a non-displaced 5th metatarsal tuberosity fracture 5 weeks ago and was placed in a non-weight-bearing, below –the-knee cast. Her circulation is normal. How long to expect for healing? Do I have to wait for complete union to allow weight-bearing? How soon should I get a bone stim?
Sandy Schustek, DPM, Charlottesville, VA
09/21/2007
QUERIES (CLINICAL)
Query: Discoloration of Nail
I have a female patient with darkening of her toenail x 2 yrs after dropping an object on the nail. She had initial darkening of the nail which was treated with Lamisil x 1 yr (no nail biopsy). The discoloration slowly improved, but remained. I saw her for the first time a few months ago. Her nail had a dark portion again. I cut out the corner of the nail and a part of the nail bed for biopsy. She has no pain and the discolored area is always confined to the area of the nail that is partially detached from the nail bed. Pathology suggested nail trauma without evidence of fungal infection and the skin biopsy was negative for malignancy.
Discoloration of Nail
The nail grew out improved without discoloration and she refrained from using nail polish. Once she started using the nail polish again, she noted the discoloration returning (photo). She is 43 years old with no significant past medical and family history and does not take any medications. On her nail biopsy, then entire thickness of the nail was deep red in color. I think this is due to a chemical in the nail polish. Any ideas on the cause?
Zeeshan Husain, DPM, Southfield, MI
09/22/2007
QUERIES (CLINICAL)
Query: Abnormal Osteoproliferative Changes in Toes
This 50 year-old Caucasian male has a chief complaint of discolored nails and a gradual enlargement of the tips of the hallux and fourth toes of both feet. There is no pain, injury, or previous surgery. Unremarkable medical history. Culture of nails revealed T. rubrum. X-rays were read by a radiologist as, "deformity of both the distal phalanx of the first and fourth digits."
Abnormal Osteoproliferative Changes in Toes The x-ray film of left foot clearly shows some form of abnormal osteoproliferative reaction involving the distal phalanges of the hallux and fourth toes in a sunburst pattern. Of special note is the erosion of the corresponding middle phalanx of the fourth toe. Is this a manifestation of an underlying systemic illness or arthride, or perhaps a bone tumor such as osteosarcoma (primary) or a malignant metastasis from an occult site? Although I intend to promptly refer this patient to a musculoskeletal tumor specialist, I am looking for some basic answers or diagnostic clues that I can use in reviewing these films with the patient.
Greg Caringi, DPM, Lansdale, PA
09/24/2007
QUERIES (CLINICAL)
Query: Sclerosing ETOH Injection for Tarsal Tunnel
I have a patient that has a chronic tarsal tunnel condition. There is pinpoint pain overlying the posterior tibial nerve and a positive Tinel's sign. He has had a previous steroid injection and a previous surgical release. He has this pinpoint pain remaining. Has anyone used a sclerosing ETOH injection in this situation? Any other treatment recommendations? I really do not want to perform surgery again.
Alan K. Mauser, DPM, Louisville, KY
09/25/2007
QUERIES (CLINICAL)
Query: Brace Recommendation for Polio Patient
I am treating a patient who has been affected by polio, in the posterior quadrant of his lower leg, at an early age. He has been treated by ankle and subtalar fusion. He isn't a surgical candidate and requires bracing. Can someone recommend a spring-loaded or regular brace which would assist in ambulation and compensate for the absent muscle group?
Frank J. DiPalma, DPM, Athens, GA, Fivetoes1946@aol.com
09/26/2007
QUERIES (CLINICAL)
Query: Treatment For Verrucae
This 64 year old female presents with cracking plantar aspect of the foot B/L. She says problem started after a pedicure after being "rubbed and scraped" with a pumice stone. The punch biopsy report from two sites says verrucae.
Verrucae
Aldara has been effective, but expensive for the whole plantar surface B/L. Her medical history is negative. Any suggestions would be very helpful.
Kevin Lam, DPM, Naples, FL
09/27/2007
QUERIES (CLINICAL)
Query: Recurrent Glomus Tumor
We have a patient who underwent excision of a painful lesion which proved to be a glomus tumor. It recurred rather quickly and she had a second surgery, after which the tumor recurred again. She has been receiving steroid injections about 1-2 times per year. These have been helpful at controlling the pain, but are there any other treatment options besides amputation as recommended in the literature? I have searched for alternatives, but mostly I see surgical resection as 'curative.'
Mike Orosz, DPM, Cedar Rapids, IA
10/01/2007
QUERIES (CLINICAL)
Query: Mixed Fungal Infections
In addition to the expected cultures positive for T. rubrum and T. mentagrophytes, we are getting a lot of mixed infections that do not cleanly fit into the rather limited indications for Lamisil. A recent culture came back with Cryptococcus albidus, Penicillium species, and Aspergillus niger, from what clinically appeared to be onychomycosis. I understand the reality of this; however, is that I am not sure which, if any, oral antifungal is appropriate for these mixed infections. Over the years, I have had much greater success and fewer safety concerns with Lamisil than Sporanox. These new culture results, however, are making me rethink the use of Sporanox. Ideas?
Greg Caringi, DPM, Lansdale, PA
10/02/2007
QUERIES (CLINICAL)
Query: Foot Pain from MRI Contrast Material?
I recently had an 82 year old male present to my office with the complaint of bilateral foot pain primarily across the metatarsal heads, duration possibly a year or so. He told me that he had seen an ad on television for a personal injury attorney soliciting potential clients with the claim of foot pain as a result of MRI with contrast material. He claims that he had an MRI with contrast on his spine about four or five years ago, and because of this commercial he is convinced that this is the source of his pain. Has anyone heard of this side effect before and if so, what are the symptoms?
Leonard Kuzmicki, DPM, Spring Valley, IL
10/03/2007
QUERIES (CLINICAL)
Query: Measuring Device For Pad Placement
Is there a measuring device to assure the appropriate placement of a metatarsal pad or metatarsal bar on an orthotic. I have found that eyeballing the foot and guessing at the correct placement has usually put the pad more proximal than it should be.
Frank DiPalma, DPM, Athens GA
10/08/2007
QUERIES (CLINICAL)
Query: Choice of Bunionectomy
I have a 63 year old patient who ten years ago had an orthopedic surgeon perform a Lapidus procedure, left with a resultant negative IM angle and a huge hallux varus. She has a 3+ bunion, right because she was afraid to repair the other foot.
Post Lapidus
She wishes surgical correction in order to relieve transfer pains laterally and to provide shoe fit. MRI shows advanced degeneration to the plantar plate and the medial side of the 1st MP Joint. My question is whether a Keller procedure is enough to establish relief and shoe cosmesis or do I need a reverse Austin incorporated or is (are) there another procedure(s) that would be better (but not more heroic).
Dennis Shavelson, DPM, New York City, NY
10/09/2007
QUERIES (CLINICAL)
Query: Mobile X-Ray Unit
Can anyone recommend a mobile x-ray model?
David Zuckerman, DPM, Woodbury, NJ
10/11/2007
QUERIES (CLINICAL)
Query: Painful Hallux IPJ Lesions in Diabetic
I have a 17y/o overweight diabetic male who has developed painful lesions on the medial IPJ of each hallux and recently developed a small ulcer. I sent him to his pedorthist to have his diabetic shoes evaluated and modified.
The patient walks with a significantly abducted gait with his weight transfer from the lateral heel to the medial forefoot and hallux due to abduction of his hips. Although there is mild hallux interphalangeus, I don't foresee any procedure in the foot that would reduce the weight and pressure sufficiently to this area. Does anyone have recommendations on shoe/orthotic modifications that would transfer weight off the hallux and not cause any problems in his knees, hips or back?
Michael J. Ryan , DPM, Charlotte, NC
10/12/2007
QUERIES (CLINICAL)
Query: Transdermal Verapamil 15% Gel for Plantar Fibromatosis
I would like to hear the experiences of anyone who has used Verapamil 15% Gel transdermal patches for the treatment of plantar fibromatosis.
Kenneth E. Jacoby, DPM, Elgin, IL
10/15/2007
QUERIES (CLINICAL)
Query: Pulsating Bilateral Great Toe Pain
An otherwise healthy 25 year old female with unremarkable medical history reports pulsating pain of both great toes after some time while using an elliptical machine. The problem has worsened over past two years. The pulsating pain is equal bilateral and increases with her heart beat. There is no pain on palpation or ROM. She has a mild cavus-type foot. Her nails and pedal pulses are unremarkable, but her toes are somewhat cool. I would appreciate input.
Gary Hoberman, DPM, Chicago, IL
10/19/2007
QUERIES (CLINICAL)
Query: Charcot Dilemma
Over the past ten years or so I've been involved with a number of Charcot reconstructions. The majority of these patients, after long post operative periods filled with morbidity and complications, eventually ended up with major amputations, or expired with their bandages still on. In over twenty five years of practice, the patients whose condition was amenable to a palliative "lump and bump" fared somewhat better, also not without complications and recurrent ulcerations [also, brace or AFO-related wounds], but in general a better quality of life.
I'm beginning to wonder if I wouldn't be doing a greater service to these patients in need of a major reconstruction if I listened to some of my orthopedic and vascular colleagues and more strongly suggested a primary BKA with the goal of getting them into a good functional prosthetic and letting them have their life back again - a life without wound care and bandages and with real showers. The flip side is the very high potential for a contra-lateral major amputation and/or death in a relatively short period. What do PM News subscribers think?
Arden Smith, DPM, Great Neck NY
10/20/2007
QUERIES (CLINICAL)
Query: Surgically-Induced Keloid Scar
Could anyone recommend a treatment to shrink/resolve a surgically-induced keloid scar?
Frank Stoddard, DPM, Massillon, OH
10/25/2007
QUERIES (CLINICAL)
Query: Medication Use for Diabetic Peripheral Neuropathy
I have been asked to participate in a survey regarding medication use for painful DPN. I currently utilize Neurontin and Lyrica, as well as various narcotic and non-narcotic analgesics and NSAIDS to help these patients. I am curious about the general podiatric community use of other anticonvulsants (Tegretol, Topamax, Mysoline, etc) and anti-depressant medication use including SSNRI drugs (Cymbalta) and older tricyclic antidepressants (Elavil, Pamelor, Tofranil, etc). Any input would be appreciated.
Neil H Hecht, DPM, Sherman Oaks, CA
10/26/2007
QUERIES (CLINICAL)
Query: OTC Dispensing for Chemical Nail Post-Op
I am wondering what other podiatrists are using for “post-op kits” dispensed in-office over the counter available to patients after phenol or sodium hydroxide nail procedures. What and how much do you put in these kits Amerigel, Band-Aids, Poly-Mem, gauze, Betadine, etc.? How much do you charge patients?
Michael B. DeBrule, DPM, Marshall, MN
10/27/2007
QUERIES (CLINICAL)
Query: Source for UAM Burrs
Our office has used the UAM brand round burrs and reciprocating saw blades that were notched special for the Stryker TPS System. Our supply has now run out. The telephone number on the UAM Catalog is not in service. Does anyone know of a source for these items?
Cosmina Dragomir, DPM
10/29/2007
QUERIES (CLINICAL)
Query: Supplier for Stainless Steel/Carbon Fiber Insert
I am trying to locate a supplier for a full-length stainless steel or carbon fiber insert for a patient with bilateral TMAs, to maintain the shape of his shoes (i.e., the toes of the shoes turn upward distal to the amputation site even with toe filler). Any help would be appreciated.
Kurt Gustafson, DPM, Lehighton, PA
10/30/2007
QUERIES (CLINICAL)
Query: Surgical Power System
Our local community hospital has budgeted replacement of our vintage Hall Micro-100 power set. I need a very practical, no-frills recommendation for replacing this system. Our OR supervisor showed me a Synthes system with an electric hand piece with about 20 replaceable heads. It’s too complicated and unnecessary for our needs. I am looking for recommendations on a good, reliable, workhorse system.
Greg Caringi, DPM, Lansdale, PA
