Query: DVT Following Use of Rolling Knee Scooter?
I treated a patient with a rolling knee scooter for a ligament tear in conjunction with a CAM walker in an otherwise healthy moderately overweight non-smoking patient. He returned after about 2-3 weeks of use with swelling of the foot and lower leg. The initial ultrasound was negative for DVT. A week later, a repeat test was positive for a femoral DVT. I have seen only one anecdotal report of a DVT following use of a knee scooter and one article suggesting it as a possible complication. Yet, the timing seems too coincidental not to be directly causative. Have colleagues seen this complication in patients who have used knee scooters?
Query: Treatment of a Verrucae in a 3 Year Old
My patient brought in her grandson to look at a lesion on the bottom of his hallux in the skin fold area at the IP joint. It is very typical in nature characteristic of a verruca...interrupted skin lines, capillary budding, pain mostly with lateral pressure, etc. It has been present for about one month and is around 5-6 mms in diameter.
Verruca in a 3 year old
Instead of the dreaded paste application again and again, would Cantherone or a similar one-time application of a product be contra-indicated because of the patient's age? I do realize it will be uncomfortable as the blister forms, but it might be the best treatment to avoid repeated trips to the office and a real possibility of childhood fear of that type of recurring treatment. Any suggestions would be appreciated.
Query: 5th Met Head Transplant for Freiberg's Infraction
I am wondering how our colleagues are handling painful, unstable, 2nd MPJ due to Freiberg's infraction. Many years ago, a colleague of mine would transplant the 5th metatarsal head to the second MPJ. Does anyone still do this and is there any literature on this?
Norm Wortzman, DPM, Boston, MA.
Query: Ingrown Toenail on a 6 Month Old Boy
A 6 month old baby boy presented with a chronic paronychia and onychocryptosis to both big toes at the medial corners. The R big toe has a lot of granuloma and is enlarged at the tibial corner. PMH: He was a month early in birth. Otherwise, he is healthy and has no developmental issue.
Ingrown Toenail on a 6 Month Old Boy
I would like to do a matrixectomy to remove the offending borders. The procedure would be under general anesthesia. I am leaning toward the cold steel nail procedure vs. the phenol and alcohol procedure. I would love to hear the pros and cons to the treatment plan you have in mind for this particular baby boy.
Query: First MPJ Fracture Dislocation
I am looking for some insight in treatment/surgical planning for this 51 year old male who sustained a first MPJ fracture/dislocation 2 months ago. He was never treated and came to me with pain plantarly at the first metatarsal head and sesamoids with ambulation and palpation, as well as the hallux dorsally displaced 1.5 to 2cm. from the WB surface. The hallux IPJ is mildly contracted dorsally, but currently not painful with shoe pressure.
First MPJ Fracture Dislocation (oblique view)
Radiographically, the sesamoid fractures are apparent but they are not widely separated; therefore the intersesamoidal ligament is likely intact. The hallux looks only dorsally subluxed vs. dislocated. MRI confirmed that the flexor hallucis brevis is intact, but thinned at its distal insertion. Closed reduction failed, as expected. I have considered a plantar approach to excise the distal sesamoid fragments and attempt to repair the flexor with a Mitek anchor, or a combination of a complete removal of both sesamoids and fragments with a hallux IPJ arthrodesis with or without a total first MPJ Silastic implant to allow better reduction. All suggestions are welcome.
Query: Correcting an Excessively Long Toe
I have a patient with an exceptionally long 2nd toe that needs to be shortened. The toe is not contracted but juts out excessively and is painful. In the past, in correcting long toes, I have had a problem with cosmetic appearance due to excess skin once the toe is properly shortened. I have at times removed a large wedge of skin of the dorsal aspect of the toe, but sometimes this causes the toe to pull upwards.
I know this problem isn't unique, as I have a few patients that had long toes corrected by other podiatrists who now have what they call their "Shar Pei" toe because of the accordion-like wrinkles in the skin. Any ideas on how to correct an excessively long toe with a good cosmetic appearance afterwards?
Query: IM angle correction from Austin Bunionectomy
From: Greg Caringi, DPM
I understand that it is the lateral displacement of the distal capital fragment that effectively reduces the gap between the metatarsals, but it does not directly reduce the IM angle. With improved overall alignment of the soft tissues, an acceptable cosmetic and functional result is obtained without the potential drawbacks of proximal osteotomies/fusions.
My question deals with the length of the dorsal arm of the osteotomy. Although many believe that the degree of correction improves with a longer arm, I know that there have been papers published that refute this idea, stating that the long arm simply facilitates rigid internal fixation with screws. I am asking my colleagues their opinion on the long dorsal arm. Does it help with IM correction? Can anyone supply references that address this subject?
Greg Caringi, DPM, Lansdale, PA
Query: Pain 2nd MTPJ S/P Weil Osteotomy
A 61 year old female presented with pain at the dorsal lateral aspect of the left 2nd MTPJ, which has been increasingly symptomatic for the past 6 months. Direct palpation and attempts to dorsiflex the MTPJ exacerbate the condition. The patient is S/P a Weil osteotomy with arthrodesis of the left 2nd PIPJ 1-1/2 years ago.
Pain 2nd MTPJ S/P Weil Osteotomy
X-rays reveal arthritic changes with lateral subluxation of the left 2nd toe. I am considering a left 2nd proximal phalangeal base resection. I welcome any recommendations for treatment that may ensure the best possible outcome for the patient.
Query: Pediatric Nail Deformities
An otherwise healthy and well-developed 9 month old baby girl presented with unusual nail deformities involving all 10 toes. No pain or infection was present.
Pediatric Nail Deformities
Are there any congenital or metabolic conditions that would produce this deformity? What is the prognosis? What would this be called and how would you best treat it? I advised cutting the nails straight-across and massaging the nails after bathing with an antibiotic ointment.
Query: Allergic to Orthotics
A patient returned for a follow-up visit post-orthoses dispensing and stated that he "must be allergic" to the orthoses as after a few days, his feet developed a pruritic rash. Other than the possibility of hyperhidrosis and/or a reaction to the glue utilized to adhere the Naugehyde top cover to the thermoplastic orthtoic material, I am at a loss to explain this. Can anyone provide a possible cause and perhaps even a "fix"?
Query: Severe Hyperhydrosis of Feet Affecting Bunion Surgery
I have a patient who is considering bunion surgery. On her initial exam, beads of sweat started forming and dripping from her feet within seconds of removing her shoes and continued through the entire appointment. She used to have this problem in her hands and feet. 30 years ago, all types of topicals were prescribed and used with no results. She had a surgical procedure performed which ended her hand perspiration, but not in her feet. My question is should the bunion surgery take place without addressing the hyperhidrosis? She is otherwise healthy, no meds, allergies or other relevant PMH, with no lower extremity vascular issues.
Query: Puncture Wound
A 13 year old female presented with a 3-4 week old puncture wound on her posterior heel. It is painful with no signs of infection. She was barefoot and stepped on a clean doorstop screw at a friend’s house. According to the patient, the screw only punctured superficially. Her PMH was unremarkable. The dermatological exam was unremarkable other than a local epidermal slough. There was no erythema or edema, and no signs of entry, but the area was very painful to direct pressure 2cm peripherally. X-rays were negative for any retained foreign body. I started her on Keflex, 250mg, QID and have her non-weight-bearing. Any other thoughts would be appreciated.
Query: Achilles Tendonitis with Partial Tears in a Professional Basketball Player
I’m seeking advice regarding best care for a professional basketball player who suffered an injury to his Achilles tendon. An ultrasound was done and the report said "tear of 50% of the Achilles tendon." He now is able to ambulate and play without pain; however, given the extent of injury, he asks whether he should have it surgically addressed. He also has flat feet that we intend to address with custom orthotics. His x-rays are unremarkable and the MRI report is as follows:
1. Low-grade partial-thickness interstitial tear of the Achilles tendon extending to its insertion. Mild tendinosis of the Achilles tendon.
2. Mild plantar fasciitis.
3. Mild scar remodeling of the medial and lateral ankle ligaments from chronic low-grade partial-thickness tear.
4. Tendinosis with possible low-grade partial-thickness tear of the peroneal brevis tendon.
5. Mild tendinosis of the posterior tibial tendon at its insertion. Mild tenosynovitis of the medial flexor tendons.
6. Moderate size ankle joint effusion.
Should he be evaluated for surgical intervention?
Query: Silicone Injections for Fat Pad Atrophy
Does anyone have experience with silicone injections for fat pad atrophy? If so, what has your experience been?
Frank DiPalma, DPM, Athens, GA
Query: Arthrogram of the 2nd MPJ
I am looking for instructions on performing an arthrogram of the 2nd MPJ. How much contrast should be injected into the joint? Any tips on imaging technique? I am looking for a plantar plate tear, planning to inject the joint with contrast, and have an MRI performed.
Stefan Lorincz, DPM, Minden, LA
Query: The Use of Amniotic Fluid or Stem Cell Injections for Polyneuropathy
Has anyone used amniotic fluid injections, stem cell injections, or other types of regenerative medicine in the treatment of polyneuropathy? If so, would you please describe your results.
Richard Mann, DPM, Boca Raton, FL
Query: Metanx, Vitamin B6 and Diabetic Neuropathy
I recently prescribed Metanx for a patient with diabetic neuropathy. A few weeks later, the same patient was seen by a neurologist who apparently is a “top neuropathy specialist”. The patient showed the neurologist the bottle of Metanx and was told “it’s the worst thing you can take” and was told to throw it out. The neurologist stated that recent research has shown Vitamin B6, Metanx, is not indicated for diabetic neuropathy. To say the least, I was very surprised to hear that. I have been prescribing Metanx since it has been on the market. Is anyone aware of any recent research that Metanx, Vitamin B6, is contra-indicated for diabetic neuropathy?
Edward Orman, DPM, Perry Hall, MD
Query: Pyogenic Granuloma
This is a 53 year old diabetic female who is paralyzed from the waist down. She had a previous ulceration to the site. It healed with local wound care. Now, this lesion is present at the same site. Two separate punch biopsies were performed and the pathology report came back as a pyogenic granuloma.
The lesion measures 3 x 2.5cm. The skin is intact. Silver nitrate and phenol were applied to the site with minimal reduction of size. I would prefer not to surgically excise it due to her slower healing rate. Any suggestions?
Query: Unusual Unilateral Dermatitis
This 54 year old gentleman has a greater than 20 year history of dermatitis on one foot only. There has been no benefit from topical antibiotics, antifungal, or steroids. Biopsy results show spongiotic dermatitis, with no fungal elements on special stains.
Unusual Unilateral Dermatitis
The patient is otherwise very healthy and takes no medications. The dermatitis is very pruritic and the fissures become painful. Any thoughts or suggestions would be greatly appreciated.
Query: Embolic Phenomena
I had a 64 male non-diabetic patient being treating for endocarditis. He is on week 5 of IV ampicillin/rocephin. He developed an acute onset of pain and swelling in the left forefoot. The pain and swelling is going away but this is the appearance after 4 days. He still has a painful purpura type of skin in the first interspace.
I think this may be embolic, but did consider isolated vasculitis from the antibiotics. Any suggestions appreciated.
This 26 year old male presents with pain in his 4th toes bilaterally. The 4th digits are contracted and causing pain in shoes. He also complains of “big” 5th digits bilaterally. There is syndactyly of toes 4 and 5 bilaterally and of toes 2 and 3 right foot. He has no pain in toes 2 and 3 right foot and has no desire to address the syndactyly of the 2nd webspace right foot. He is interested in surgical remodeling of the syndactyly of digits 4 and 5 on both feet. X-rays reveal an extra middle and distal phalanx of the 5th digit bilaterally and an enlarged 5th metatarsal bilaterally. The decision has been made to release the syndactyly on digits 4 and 5 bilaterally, remove the extra middle and distal phalanx of the 5th digit, and perform hammertoe correction on the 4th digits.
Syndactyly of toes 4 and 5 bilaterally
After excision of the extra middle and distal phalanx, how would you address the remaining distal phalanx? The thought now is to just leave it with the medial deviation. It will be okay in shoes and it is not bothering him. A wedge osteotomy of the proximal phalanx to provide a straighter toe may be warranted, but it is a relatively small bone and he has been living with this condition his entire life. The 5th digit is not painful. The hammertoe and de-syndactyly remodel are pretty straight-forward, but what about the excision of the extra middle and distal phalanx?
Query: Leukonychia Following Nd-YAG Laser Treatments
My patient is a healthy, middle-aged Hispanic female whom I have been treating for onychomycosis with an FDA-approved Nd-YAG laser. The onychomycosis had been resolving nicely on all toenails with the nail plate returning to normal thickness, color, texture, etc. When she later came in for a re-check, the nail plates on the hallux toenails only appeared white in color.
Leukonychia Following Nd-YAG Laser Treatments
I have used the same FDA-approved protocol for many years, but I have never seen this. I am sending in samples from the toenails for pathological analysis, but I’m curious if any of my colleagues have had a similar experience and, if so, what their experience(s) have been?
Query: Gout in a Diabetic?
A 65 year old male with a history of type II diabetes presented last week with a red left 2nd digit. He reported no pain or wound and he had no recollection of any injuries. I thought it could be a bug bite and put him on doxycycline. The redness resolved in a day, but then the toe got swollen with a purplish hue to it.
AP and MO views of swollen 2nd digit in a 65 year old diabetic
His circulation is normal. I took x-rays (above). I'm wondering if is gout? The bone deformity looks old, but corticol disruption at the base in the medial oblique view could be gouty change? Thoughts?
Query: Asymptomatic Bilateral Puntate Heel Lesions
A healthy 65 year old female presented the other day wondering what was on her heels. The lesions don’t hurt and are only noticeable when walking barefoot on hard tile floors. They developed over a three-year time frame. To her knowledge, no one else in her family has anything similar. Her hands are clear. She is presently taking Lipitor.
Asymptomatic Bilateral Puntate Heel Lesions
I started her on 30% urea cream to soften the lesions and hopefully prevent problems. Any ideas as to the cause? What treatment besides debridement should be tried if these lesions were to become symptomatic? Is there anything I should have looked for that I didn’t?
Query: EMLA Cream
Does anyone use EMLA® (lidocaine 2.5% and prilocaine 2.5%) cream to numb the skin before minor procedures or injections? I treat the daughter of an elderly patient who would like a prescription to apply to the toes prior to having her nails cut. Any idea if this medication would be effective for that? Could it be used on a patient with painful diabetic neuropathy?
Richard A. Simmons, DPM, Rockledge, FL