Query: Bilateral Forefoot Pain and "Fullness"
Since January, I have been treating a 71 year old, healthy male, with an active lifestyle with a one year duration of bilateral forefoot pain and ”fullness”, not aggravated by anything particular. X-rays by his PCP were negative. An MRI showed a possible ganglion in the right 1st interspace, and a left foot sprain of the 3rd metartarsal plantar plate. No neuroma was noted and there are no post-static issues. There is no rhyme or reason as to when the forefoot pain/fullness started, but it resolves fairly quickly after acute painful episodes. He has no issues with sleeping, and this is mostly a non-weight bearing issue.
A Medrol Pak and direct cortisone injection has not helped the right foot at all. He can't take gabapentin or Lyrica, due to intolerance. This does not affect sleep at all. On exam, there is no visible issue noted, but he is very sensitive to pressure with distal 2nd MPJ pain. The only thing I have not done is refer him for Neuro consult. His labs are all normal. I have made some shoe modifications that have made no difference and I don’t think orthotics would make a difference. Comments?
I have only seen one case of brachymetatarsia of the 4th metatarsal, one foot. This patient presented with brachymetatarsia of the 3rd and 4th metatarsal, bilaterally.
I find this very unusual. Has anyone else seen this?
Query: Oral Med Replacement for Famotidine
In 30+ years of practice, I have yet to find a great treatment for warts. However, I have had some success with mosaic type warts by using topical acids along with oral Tagamet 400 mg tid. When Tagamet became more and more difficult to obtain, I began using Pepsid 40 mg once daily at bedtime. Today, I found out that Pepsid (famotidine) is on recall. Are there any other oral meds out there that you all are using to battle this condition?
Rich Hofacker, DPM, Akron, OH
Query: Hardware Identification
This patient underwent surgery in 2004 and no records are available. The dorsal screw head has ulcerated through the skin with a pinpoint wound. I need to remove the screw but it appears to have an unusual head shape.
AP and Lateral X-Rays of Unidentified Cannulated Screws
It is clearly not cruciate or hexagonal and is a cannulated screw. Any ideas on what company makes this screw so I can have the matching screw driver on hand to remove it?
Query: Lower Extremity Muscle and Joint Aches from Losartan
A patient presented with bilateral lower extremity aches and pains. They were joint and muscular and affected her foot as well as a knee and hip. She is taking losartan (Cozaar) to lower her blood pressure. The literature indicates that one of the possible side-effects of this drug is lower extremity musculo-skeletal pain and weakness.
Apparently, the symptoms began a month after the patient began taking the medication. Has anyone had any patients who have experienced these symptoms with this particular medication?
Query: Cold Toes
The patient is a 33 year old, alert male with no significant medical history or trauma. His chief complaint is 10 cold toes. Upon evaluation, his toes are 18-20 degrees colder than at the MPJs. His symptoms began a few months ago and are not altered by heat or cold climates.
There are no color changes that accompany the cold sensation and decreased temperatures. His pedal pulses, including those at the toes, are within normal limits. I do not have much more to offer and would appreciate any thoughts from my esteemed colleagues and any additional testing/referrals that might be appropriate.
Query: Help With Tunneling Wound
The patient is a 63 year old white female insulin-dependent diabetic. The patient is blind (diabetic retinopathy) and requires thrice weekly dialysis for complete kidney failure. One year ago, she sustained an ulcer under her right lateral malleolus that “tunneled” to the level of the ankle joint. X-rays are consistent with osteomyelitis of the ankle structures. Culture was S. aureus susceptible to penicillin; the C&S report showed the bacterium to be “moderate” in quantity. We began to use a NPWT such that over a year we no longer express any pus or inspissated blood. The last wound C&S again shows S. aureus, but the quantity is now referred to by the lab as “rare.” Serial x-rays over the last 14 months show no appreciable difference in osteomyelitic degeneration although the talus and malleoli are very degenerated.
I use white foam that is about ½ the length of the tunnel (14 mm), loosely packed. We changed the antibiotic from Amoxicillin (MIC 0.12) to Bactrim (MIC 0.25) at the request of her nephrologist six weeks ago. Externally, there are palpable pedal pulses, mild to moderate edema, no other cardinal signs of infection. I need help closing this wound; any ideas, however innovative, would be of value.
MY CONCERN: the fluid that is now extravagated is straw-colored, odorless, and sterile; I am afraid this is synovial fluid from the open ankle joint. At first blush, I am considering deep curettage and then reapply the NPWT but without the white foam to allow drainage and negative pressure to close the wound; but I am also concerned that the negative pressure may cause an “hourglass” phenomenon, thereby closing the more superficial aspect of the tunnel, but closing off any access to the ankle joint. Also, would antibiotic cement beads be of value both in increasing the density of the now absent/degenerated osseous structures and, of course, the antibiotic within, combating the remainder of the Staph.
Query: Ultrasound-Guided Injections
It has been many years since diagnostic ultrasound has hit the podiatry market. When it first came out, reports were mixed as to the value of using it for periarticular injections of steroid in the foot and ankle. Some papers said it makes the injections more effective and others said that since the material injected spreads out, using the imaging modality is not necessary.
We have had an ultrasound imaging modality in our practice for over four years. Some patients will swear that when I use it to give an injection, they get better results. Others will tell me that it does not seem to matter. Hence, I do not use it routinely. That is my experience. What are the experiences of others? Do you use diagnostic ultrasound routinely when giving injections, some of the time or not at all? To be fair, this question should only be answered by those who own a unit.
Elliot Udell, DPM, Hicksville, NY
Query: Bilateral Foot Pain in Metadductus Foot
A 62-year-old male complained of bilateral forefoot pain and pain in the arches. He also said that he walks on the lateral side of his feet. He is obese and on his feet quite a bit during the day. He wears supportive, stiff soled, New Balance athletic shoes and has worn either over-the-counter or custom inserts for the last 15 years. He says the over-the-counter versus custom inserts do not make a difference regarding relief of pain. What helps him the most with his pain relief is 75 mg diclofenac daily that he has been taking for 10 years.
Bilateral Foot Pain in Metadductus Foot
However, he is beginning to get ringing in the ears which he attributes to the diclofenac. Radiographs of the feet show metadductus deformity bilateral as well as degenerative changes at the midfoot bilaterally. His shoes show abnormal wear on the lateral plantar heel and lateral plantar midfoot. Physical examination is unremarkable except for bunion deformity, both feet. Upon stance, his arches show mild collapse. I would like to get him off the non-steroidal anti-inflammatory drug that he has been on for 10 years. Does anyone have any suggestions on orthotics/bracing for this patient?
Query: 2 Year Old with Onychomycosis
I have a 2 year old patient with onychomycosis. The nail clipping tested positive for T. rubrum. Understandably, the mother does not want the child on oral medication. A dermatologist prescribed a topical antifungal, which did not work (The mother cannot recall the name of the topical antifungal). Any suggestions? For now, they are doing daily apple cider vinegar/water soaks and using tea tree oil. Are there any other suggestions?
Query: Embedded Ingrown Toenail in a 7 Week Old Baby
Does anybody have any recommendations for a 7 week old who was hospitalized due to an infection from an ingrown toenail at 3 weeks of age. The nail is ingrowing into the distal tuft. I can avulse it, but is there any contraindication at that age? Any help would be appreciated.
Query: Re-evaluation of Traditional Angular Parameters for Austin Bunionectomies
According to standard podiatric textbooks, the maximum angular relationship between the first and second metatarsal should be around 16 degrees but can vary due to other parameters such as metatarsal width. A wider metatarsal would allow greater translocation and maintain adequate bone to bone contact for primary bone healing. In the last year, I have been using a minimal incision neck osteotomy technique which I have found to be quite effective. The technique can be seen on Wright Medical’s website. I have been able to use this technique on intermetatarsal angles of much greater than 16 degrees without complications, and if you watch their video, you will see a bunion repair that shifts the metatarsal head over greater than 50%. I was wondering if any other podiatric surgeon has experienced the same and wondered if re-evaluation of the traditional angular parameters for this “short Austin” should be revisited.
Pre-op and Intra-op X-Rays
Above is an x-ray of a mid-aged female with a significant bunion and a pre-op intermetatarsal angle of >18 degrees as an example: pre-op and intra-op. I believe the main reason for being able to get so much stable correction is that the first and largest screw used to fixate the head passes through both the medial and lateral cortex of the first metatarsal proximal to the osteotomy and imparts significant stability when advanced into the head of the metatarsal.
Query: Itraconazole Dosage Error
I prescribed itraconazole for a patient with toenail fungus in July. She failed therapy with terbinafine a year ago. PAS was done after 12 months confirming fungal involvement, most likely saprophytes. The itraconazole was prescribed as a pulsed dose of 200mg bid. The pharmacy dispensed 100mg capsules, labeled appropriately on the bottle with the correct instructions. The patient completed 3 pulses, but mistakenly only took 100mg bid. I am unsure how to proceed following this sub-therapeutic dose. I called Janssen Pharmaceuticals and they did not have an answer. Should I just wait and see, or have her repeat now at the correct dosage?
Query: Is Synvisc Use Off-Label for Ankle Arthritis
Is using Synvisc (or its generic form) for ankle arthritis is considered off-label use or not?
Russell L. McKinley, DPM,, Elizabethtown, KY
Editor's Comment: PM News does not provide legal advice. According to the package insert, "SYNVISC (hylan g-f 20) is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics, e.g., acetaminophen." Nowhere in the package insert does it mention "ankle", so it must be inferred that using hylan g-f 20 in the ankle is an off-label use.
Query: Unusual B/L Heel Pain Case
A 58 year old Indian male presented with B/L symmetrical plantar heel pain with a sudden onset 5 months ago. The pain is severe with any type of pressure. He has a severe pes planus foot type. Current treatments include EPAT x 2 and a Medrol dose pack, which he has not responded to. The rheumatology blood test panel revealed positive ANA, homogenous, 1:80 titer. The rheumatologist consulted believed that the titer was too low, so therefore not auto-immune related.
Lateral X-Ray of Patient with Bilateral Heel Pain
The patient had similar pain 9 years ago and then failed attempted treatments including: custom orthotics, cortisone injections x 2, EPAT x 4, e-stim x 6, acupuncture, PRP, stretching, icing, and reflexology. The pain seemed to resolve at that time on its own and not as a result of any treatment. Comments?
Query: Unilateral Edema, Redness, and Pain
A 65 year male with a PMH of neuropathy, Stage 3 chronic renal failure, thyroid goiter, and ulcerative colitis presented with 2-3 months of swelling, redness, and pain to the entire left foot from the toes to the ankle. There is no allodynia or hyperesthesia. Calor, edema, and redness are worse at the 3rd met head, spreading to the 2nd and 4th met heads. His pain is concentrated in those areas.
Yet, x-rays and MRI only show severe arthritic changes to the 1st MTPJ, while the areas of pain only revealed edema to the dorsum soft tissue. There are no soft tissue lesions or bony lesions. I thought it was unusual to have worse pain, warmth, redness, and swelling away from the arthritic area if the arthritic area was the cause. I told him to compress and elevate the foot. Any other thoughts?
RE: Congenital Malalignment of Hallux Toenail
From: Chris Seuferling, DPM
Thanks to PM News and Dr. Allen Jacobs, I am now aware of this diagnosis and have seen multiple cases over the past year. This is likely an under-diagnosed pathology in our profession. The challenge now is treatment. I have not been able to find any podiatrists or surgeons in my area who surgically treat this condition with the nail rotation procedure described in the literature.
Congenital Malalignment of Hallux Toenail
I'd like to learn how to perform this procedure so I can offer this to my patients. I’m looking for someone who has performed this procedure and possibly has video on technique. Any help would be appreciated.
Chris Seuferling, DPM, Portland, OR
Query: Stucco Keratosis
Does anyone know of any cures for stucco keratosis or what they found that works best for this condition? The patient was diagnosed by a dermatologist and was prescribed a very expensive cream that did not work. The patient is healthy, is in her 40s, and gets self-conscious about how it looks. She has been using Gold Bond Rough and Bumpy Skin which seems to have helped, where the lesions are now hardly noticeable.
I have not heard of any oral medication for this, but would like to know if there is such a thing. The lesions do not hurt or itch.
Query: Restless Legs Syndrome (RLS)
I had a simple case scheduled in the OR this week and ran into a complication I had not seen previously. I suspect we have all had restless patients on the table, but I had a patient so agitated that we had to convert to LMA anesthesia before any prep or draping due to the almost violent movement of both of her arms and legs. Other than some IV sedation, there was no noxious stimuli to explain her reaction.
Once in PACU, the patient explained that she has suffered from this problem for years. She says she cannot sleep at night because of it despite her regular use of ropinirole. Since her primary seems to have ignored the severity of this problem, I want to help my patient by referring her for a specialist consult. I'm not sure where to send her - neurology, pain management? I admit to having very limited knowledge of RLS. Any input is appreciated.
Query: EpiFix Micronized Amniotic Membrane
I am interested in hearing from physicians who are using EpiFix Micronized amniotic membrane allograft for plantar fasciitis as to what type of results they are seeing. Apparently, there are no procedure codes for this allograft; however, the company suggests Q4145. They charge the physician $1,000 for 40 mg. product size. Are any insurance companies paying for this procedure and if so, what is the reimbursement rate? Any other options for non-viable cellular membrane allografts?
Paul A. Galluzzo, DPM, Rockford, IL
Query: Can These Toes be Saved?
This 66 year old male had the following co-morbidities: Coumadin necrosis as per bone biopsy, diabetes, heart condition, and is post-stroke. Surgical history: left and right hallux partial amputations, a partial amputation of his right 2nd toe, and his left 2nd toe was amputated due to osteomyelitis with MSRA. His treatment included IV antibiotics, hospitalizations, hyperbaric oxygen therapy, off-loading, and vascular surgery.
Can These Toes be Saved?
When the left 3rd toe had surgery and primary closure, the toe did not heal and kept getting worse. He finally had an endovascular specialist perform a surgical procedure to attempt to improve blood flow. The specialist’s opinion was that there was a "window of opportunity for a transmetatarsal amputation." Any opinions on if any of the toes can be saved?
Query: Calcaneal Avulsion Fracture
This is a 37 year old patient who was walking rapidly yesterday. He said he turned to change directions and felt a horrible pain in his heel. He has a significant medical history of a motorcycle accident approximately a year ago with multiple fractures of the contralateral limb, but there was no trauma to the limb involved today.
Calcaneal avulsion fracture
It's rare to see avulsion fractures of the plantar fascia attachment. Achilles attachment avulsions are more common in about 1% of calcaneal fractures. The question is surgical repair or no surgical repair? It is almost asking for a percutaneous screw.
Query: Lateral Column Fusions vs. Arthroplasties of the Metatarsal Cuboid Joints
I have an active slightly overweight active middle aged female patient with a non-contributory medical history who has developed painful osteoarthritic changes across the Lisfrancs joint involving 2nd met/cuni, 3ed met/cuni, 4th met/cub and 5th met/cub. Conservative treatment has failed to give her significant relief of pain. She gives no history of acute trauma recently or in the past. On clinical evaluation, the majority of pain is produced with range of motion/stress of the 2nd and 5th metatarsals at the base. Her forefoot to rearfoot is slightly varus. She has a cavus foot type.
AP and oblique views
These are well aligned joints, just arthritic and painful. I am concerned about fusion of the 4th and 5th metbase/cuboid in this foot because of the independent motion required by the lateral column. I was thinking about cleaning up the 4th and 5th met/cuboid joint and placing a joint spacer there to maintain some motion. I would appreciate comments on lateral column fusions vs. arthroplasties of the metatarsal cuboid joints.
Query: Best Way to Test for Onychomycosis
Should nail cultures be performed on all possible fungal nails, and if so, what type of culture? Is it best to use a lab or perform the test in-office?
Martin Marks, DPM, Compton, CA