Mucoid Cysts in the Toes

Sometimes a small cyst or ganglion will form on the toes at the joint just behind the toe nail. If punctured a thick gelatinous fluid escapes. These are technically tiny toe ganglions but in this location they are more correctly knows as a mucoid cyst. They are frequently treated by a "puncture" and the injection of a bit of cortisone. Unfortunately they often recur. A more permanent correction involves the removal of a little bone.

Solving this problem will require a "hammertoe" surgery that can be done in the office with local anesthesia or the surgery center under local anesthesia with a bit of sedation. A surgical shoe will need to be worn for a week or two followed by a tennis shoe for another week or so.

This is a fluid filled cyst that balloons out from the underlying joint (much like the inner tube of a bicycle tire can squeeze out between the cracks of an old tire). Sometimes these pesky little things will go away by puncturing the cyst with a needle (of course, after anesthetizing the toe first!) and injecting a drop or tow of cortisone. Most of the time they come back after this kind of I&D (incision and drainage) and they need to be removed surgically. Even surgery can fail if you are not aggressive and take the entire cyst, down to the bone.

Lisfranc injury ends NFL season potentially

Matt Schaub of the NFL's Houston Texans, sustained a midfoot sprain to the right foot, notably called a "Lisfranc" injury in last week's game. This is considered a "significant injury" which has the potential to end his season in 2011.







Why is that?








Most players require lateral movement and the ability to jump and stop suddenly after sprinting. These are all functions that the midfoot complex will play a significant role in accomplishing. The injury itself is a complicated one, with numerous variations that each have a significant prognosis in longterm funcion. This injury may have a pure ligamentous tear, or even a fracture component with the ligament tear. With this, some orthopedic literature has condoned the possibility that with regards to athletes, surgery may be indicated in more cases to realign the foot and promote more stability longterm. Other studies have shown that if the alignment is maintained with the bones of the midfoot, a cast or walking boot may be sufficient for a minimum of 6 weeks followed by progressive weight bearing.


Classification
There are three classifications for the fracture:

1) Homolateral: All 5 metatarsals are displaced in the same direction. Lateral displacement may also suggest cuboidal fracture
2) Isolated: 1 or 2 metatarsals are displaced from the others
3) Divergent: metatarsals are displaced in a sagittal or coronal plane. May also involve intercuneiform area and a navicular fracture.

Treatment
Treatment options include operative or non-operative treatment. If the dislocation is less than 2 mm, the fracture can be managed with casting for 6 weeks. The patient's injured limb cannot bear weight during this period. For operative treatment, screws +/- k-wire will be used for internal fixation of the fracture after closed or more likely open reduction. Again, the patient's injured limb should not bear weight for approximately 6–12 weeks. The screws/k-wires are usually removed later, sometimes before weight bearing.

At FFLC, we find this injury to be a relatively underdiagnosed entity, and have had to treat numerous late onset arthrosis, as well as acute injury patients with this mechanism of injury. If you are on the field, and you twist your foot and it remains painful, it is not a straightfoward injury and should be followed by a foot and ankle surgeon.

Even with that being said, the possibility of late onset arthrosis and deformity can ensue without proper diagnosis, and in the NFL the players are fortunate to have medical professionals there to diagnose them right at the time of injury.

Is MRI really being overutilized?

So often in this litigious society, practitioners are being scrutinized by lawyers for malpractice. This includes lacking diagnostic information to either support or negate a diagnosis. That is why wounds are cultured without looking "infected" and why radiographs are done even after soft tissue surgery. So often are practitioners forced to practice "defensive medicine" that the costs for health care are going to rise simply because of these examinations. Without these tests to "confirm" a diagnosis, surgery may not be authorized by an insurance company, or if someone is injured on the job or as part of a traffic accident, the extent of damage may be overlooked.

This is in my opinion, that these tests need to be done. MRI should be ordered to confirm or negate osteomyelitis in the presence of diabetic foot wounds. Also with severe ankle sprains to rule out underling ligamentous damage or cartilage lesions. Without the tests, even in the presence of clinically suspicious findings, there will always be a malpractice lawyer who will ask you, "why didn't you get the test, Dr?"

In the case of MRI, there are few to no real risks, as there are no radiation exposures for this exam. Also, for patients that are not able to have this test (ie. pacemaker,etc) it is usually determined by CT scan for whatever the reason for the advanced imaging. In other words, these tests are available and although not entirely necessary, they are invaluable to not only diagnose with more certainty, but also allow for surgical planning and provide further means to demonstrate pathology leading towards surgical intervention in the case of malpractice depositions.

The coutnter argument is that over-utilization of MRI is expensive and wasteful, according to researchers. For example, the information needed to diagnose knee OA can be obtained using x-ray. While an x-ray can cost less than $150, the cost of an MRI is about $2,500.
Medical imaging accounts for 10 to 15% of Medicare payments to physicians. Ten years ago, medical imaging accounted for less than 5%. The cost of medical imaging is expected to continue soaring at an annual rate of at least 20%. Suffice to say, it's an expensive business.

And sometimes, MRI findings may be overly sensitive, leading to incorrect diagnosis, or over diagnosis of tendon pathology.

This nails home another concept I have discussed on here on many occasions. We treat the patients, not the MRI findings. We need to understand the personality of the injury and how that injury is presenting itself in you, how your lifestyle or quality of life is affected, and whether or not the findings that we have identified on the MRI are in fact the competent producing cause of your discomfort — and then come up with an appropriate treatment plan that will likely involve a period of nonsurgical management— which, if unsuccessful perhaps might lead to an indicated surgical procedure, if your lifestyle changes and quality-of-life dictates that this is in fact an option.

Skin lesions on the foot

Example of a MRSA infection started as a "rug burn" with this gentleman rough housing with his dog.

Many patients know about how important sunblock is to avoid cancer from the sun. However, most primary care doctors and even some dermatologists may miss looking at skin on the foot. Numerous times each year, we play a role in the diagnosis of skin disorders from biopsies of lesions on the foot and leg. Each lesion that the skin creates will tell a small story as to the inner health of each patient. And even if a lesion is not painful, or is located somewhere you are not usually able to look at, it can be something quite problematic.

We condone the biopsy of any lesion that changes colors, bleeds, or looks different than other lesions on your body. This may include open lesions, pigmented lesions, blistering lesions, and even rashes. The skin only has several ways to show a clinician that something is wrong. That means that thousands of disease processes can only be shown by skin in less than 10 ways. That is a tough thing to diagnose without a definitive biopsy. Most dermatologists require yearly skin exams for anyone with a prior squamous or basal cell carcinoma. And melanoma should be checked for at least 2x yearly. Lesions of the foot and ankle are often found by a foot and ankle surgeon prior to most other specialists or general practitioners, and it is imperitive that a biopsy be performed.

Lesions like the above can actually be a multitude of pathologies being represented by a simple rash. In this case tinea pedis was the diagnosis initially. After 2 months of topical therapy it was later diagnosed with a biopsy as a squamous cell carcinoma (skin cancer).

This is a common presentation of a plantar wart. This is also important to send to a pathologist if they are excised as this may also have several other more aggressive variations of melanomas which can mimic this otherwise harmless viral skin infection.

Any lesion that you are unsure of should get checked by a doctor, whether that is your foot and ankle surgeon, general practitioner, or dermatologist or other specialist. No lesion is too small, or insignificant to investigate.

Wound Care at FFLC

Diabetic pressure wounds are prevalent on the feet of many neuropathic patients. Usually, if the arterial circulation is adequate, and the nutrition status is evaluated for protein intake, the final step is to offload the area. This is, in my experience, the most difficult part of wound care in our population. Everyone wants to remain active, and walking is a major component of this mentality. This picture is an example of a forefoot pressure ulceration, which is directly related to an equinus deformity combined with neuropathy in an insulin dependent diabetic female who has been to a wound care center for 2 years prior to my evaluation. After my initial screening protocol, which consists of taking an xray, listening to the arterial pulse with a hand held dopplar, and recording a HA1c value to determine longterm blood glucose control, I moved on to the physical examination of biomechanics. In her case, the main issue was not an underlying bone infection, or ill fitting shoes (as she had custom shoes with offloading soft insoles already placed). A definitive diagnosis of "gastroc equinus" was diagnosed.






After 2 weeks of continued debridements in the office the wound began to improve, but the central deepest portion was next to impossible to offload.










At this time, the patient was scheduled for an endoscopic gastroc recession, which is done with a 0.7 cm incision that heals in most cases after 7 days. This is a profound procedure which offloads the forefoot considerably, and in her case was the final step towards healing her wound. She also had a dermal skin graft application which also heavily increased the healing capacity of this particular wound.






There are many examples of how wound care can be performed by looking at the global picture in each patient. Sometimes the foot structure itself is the issue and requires reconstruction. Sometimes a bone infection is underlying, and excision of that portion of the bone is required, and even sometimes a leg needs more circulation requiring vascular interventions. Here at FFLC, we strive to be at the cutting edge of limb salvage, which may entail any number of procedures tailored to each individual patient. We work closely with the infectious disease and vascular surgeons to offer a team oriented approach to wound care. This allows rapid wound healing, and lowers the statistical possibility of deep seeded infections which can lead to amputations.

Each wound has a cause, and without a thorough examination, followed by extensive diagnostics and microbiologic cultures, many wounds will remain nonhealed. At FFLC, we offer comprehensive limb salvage efforts which transcend most private offices. We really do have the mindset of a wound care center. Weekly comprehensive debridements, Xrays on site, MRI and ABI testing nearby, and for the more complex wounds a reconstruction repitoire which may consist of internal and external fixation. We take limb salvage very seriously, and we all know that once a limb is lost, the statistics are not in a patient's favor for a 5 year lifespan afterwards in diabetic patients.

Navicular Fractures in Athletes

Numerous patients experience this sort of injury living an active lifestyle in Naples Florida.

Recently, Ben Roethlesberger of the Pittsburg Steelers also suffered a similar injury (although not confirmed by the Steelers), and he may need some time off his foot to sufficiently heal his injury. We see a number of patients who will have the vague symptoms of pain after activity in the medial aspect of the rearfoot area, which will not show anything on regular xrays. After 3 months, most doctors will refer to us for further workup. We usually will obtain more advanced study such as CT or MRI, and depending on what it shows, treatment ensues. This is one of the latest articles regarding this topic, which in short, demonstrates how a minimally displaced fracture may still require screw fixation in select cases to adequately relieve symptoms and ensure return to sporting activity in a reasonable timeline.

Published in: Journal of Foot & Ankle Surgery, March/April, 2000
Amol Saxena, DPM


22 Navicular Stress Fractures sustained during athletic activity were retrospectively reviewed for return to activity time and the appearance of fracture pattern on Computerized Tomography. Average follow-up was 36.5 months. There were 10 females and nine males, with the average patient age being 27.2 years. Three patients sustained bilateral injuries at separate times.

Nine patients underwent open reduction, internal fixation (some with bone grafting); this group’s average return to activity (RTA) was 3.1 +1.2 months (range = 1.5-5 mos). Thirteen patients treated conservatively had an average return to activity of 4.3 +2.8months (range = 2 –13 months). The difference between the two groups’ RTA was significant (P=.02). Eleven patients utilized Pulsed Electromagnetic Fields and had an average RTA of 4.2 +3.4 months with three patients also having surgery. (The latter three patients had the fastest RTA at 3.0 months.) Two conservatively treated fractures that eventually took five and eight months to RTA, respectively, re-fractured during the treatment process.

Retrospective review showed CT fracture patterns in the frontal plane classified as: Dorsal cortical break (Type I), fracture propagation into the navicular body (Type II), and fracture propagation into another cortex (Type III). This is proposed as a classification system and is to include modifiers "A" (Avascular Necrosis of a portion of the navicular),"C" (Cystic changes of the fracture), and "S" (sclerosis of the margins of the fracture), the latter of which was most common in our series, particularly in continually symptomatic patients. Type I fractures were more likely to receive conservative treatment (P = .02) and Type III fractures took significantly longer to heal than Types I and II, (P values .001 and .01, respectively.) Type I and II injuries had an average RTA of 3.0 and 3.6 months, respectively. Type III injuries had an average RTA of 6.8 months. Based on our findings we recommend surgery for patients with these modifiers, particularly with Type II and III injuries.

Conservative treatment may be prolonged, and requires at least 6 weeks of non-weight bearing in a below knee cast/boot to be successful.

Achilles Injuries in the NFL

Jon Beason out for year with torn Achilles

Even the most conditioned athlete, with the support of numerous athletic trainers and coaches, can succumb to the devastating injury of Achilles ruptures. The worst part about this fact, is that the injury can eliminate most patients from returning to prior-injury function without adequate treatment.




The Achilles is the strongest tendon in the body, however the forces that are exerted by this structure exceed loads equal to tow trucks pulling on a stationary car for portions of a second during exercises. Many patients are seen in our office with various injuries to this area, and some with spontaneous ruptures. I had previous discussed how this can occur, and for the sake of sports injuries I will limit this discussion to when load exceeds the Young's modulus for the tendinous structures.


This bascially means that the tendon has more force than the inherent scaffolding is able to withstand. This leads to weakening of the collagen matrix and eventually can lead to ruptures. In partial and complete ruptures associated with exercise and impact sports, surgery is recommended to reduce the rate of re-rupture. But as you may have read, our Carolina Pro Bowl linebacker will be sidelined with this for the season, because it may take up to 12 months for full remodeling of the tendon to occur even with surgical repair.

We use a nonabsorbable suture method which contains a metallic wire filament called a "tightrope". This is never absorbed by the body, and is interwoven throughout the tendon to reapproximate it's tension prior to the rupture. The body then needs to augment this surgical repair by bridging the collagen matrix across the damaged portion of the tendon until full strength is achieved. I always tell patients that it will take 3 months to walk again, and a year to run again. This is by no means a minor injury.

Hopefully the Panthers have a good backup for their otherwise healthy linebacker this season !