Angiokeratoma presenting as a melanoma: a case report.

Angiokeratomas are benign skin lesions that can resemble melanomas or verrucae. Although morbidity from these lesions is rare, treatment for angiokeratomas typically consists of simple surgical excision. We aim to describe a case of a painful angiokeratoma that presented with the appearance of melanoma.

Open reduction-internal fixation of a navicular body fracture with dorsal displacement of the first and second cuneiforms: a case report.

Body fractures of the tarsal navicular are relatively uncommon. To date, there is little literature discussing a navicular body fracture with dorsal subluxation of the first and second cuneiforms over the navicular. This case study presents a 30-year-old patient with this injury. He underwent open reduction internal fixation of the navicular body fracture successfully but failed adequate reduction of the navicular cuneiform joint after ligamentous reconstruction. After revisional surgery, he also failed 6 weeks of percutanous pinning with Kirschner-wire fixation. When comparing the literature of a similar injury, the Lisfranc fracture disclocation, the same principles may apply. One should consider rigid open reduction internal fixation or even primary fusion to treat disclocation of the naviculocuneiform joint following a navicular body fracture.

Ewing sarcoma in a diabetic male with history of foot ulceration.

Ewing sarcoma is a rare diagnosis, with as few as 225 new cases diagnosed in North America annually, and only 3% occurring in the foot. They generally present in the second decade of life and are very infrequently found in patients older than 40 years. The diagnosis of Ewing sarcoma can be difficult, especially in older patients with diabetes and a history of ulceration, because it can have an appearance on radiography similar to that of osteomyelitis. We present a case of Ewing sarcoma of the foot in a patient with type 2 diabetes in his sixth decade of life.

Pilomatrixoma: an infrequently encountered lesion on the lower extremity.

We discuss the clinical presentation and treatment of pilomatrixoma as it occurs in the lower extremity. Although pilomatrixoma is far more common on the head, neck, and upper extremity, it can be found on the lower extremity. Treatment is aimed primarily at excision if the lesion is symptomatic or suspicious for malignancy. The authors present a case of a 73-year-old male who presented to the diabetic foot center with this condition.

A mechanically powered negative pressure device used in conjunction with a bioengineered cell-based product for the treatment of pyoderma gangrenosum: a case report .

Pyoderma gangrenosum (PG), an uncommon inflammatory and ulcerative skin disease, typically is treated medically with a combination of immunosuppression and local wound care, but evidence to guide care is limited. PG wounds can be difficult to heal. A 76-year-old male patient presented with a history of rheumatoid arthritis and recalcitrant PG. After 9 months of treatment with local wound care, steroids, and topical tacrolimus, the wound had increased in size from 1.8 cm x 1.5 cm to 7.2 cm x 5.6 cm. At that time, he was started on a regimen of five applications of a bioengineered cell- based product (one application every 2 weeks for a total of five applications) with twice-weekly mechanically powered negative pressure device changes. The latter was started at 75 mm Hg and changed to 125 mm Hg after 4 weeks. Oral corticosteroid therapy was initially started at 40 mg of prednisone, then slowly tapered to 20 mg, but could not be completely discontinued due to a flare in the patient's rheumatoid symptoms. The wound was completely healed after 16 weeks. Research to ascertain the effectiveness of protocols of PG care, including the combination treatment described, is needed to help clinicians provide evidence-based care for these challenging wounds.

A case of a sural neuroma as a cause of lateral ankle pain.

This article reviews the diagnosis, pathology, and treatment of a lateral ankle (sural) neuroma. Though there have been vague references to neuroma of the sural nerve, no specific case report has been presented. It is felt that mechanical and biomechanical factors may contribute to the formation of this type of painful mass which warrants further discussion as an additional etiology of lateral ankle pain. In this article, we describe a case of neuroma of the sural nerve which was unresponsive to conservative treatments.

HIV neuropathy induced Charcot neuroarthropathy: a case discussion.

Charcot neuroarthropathy is a devastating joint condition that affects persons with neuropathy. With HIV/AIDS treatments prolonging the lives of these persons, it is likely that long-term sequelae of the disease will become more evident in the near future. Patients with this disease frequently develop peripheral neuropathy. A high index of suspicion must be raised in any patient with peripheral neuropathy of any cause and a red, hot, swollen, painful foot for Charcot neuroarthropathy to give these patients proper treatment to help prevent the devastating effects of Charcot neuropathy with its potential consequences including foot ulceration and amputation. We present a case of an individual with HIV peripheral neuropathy and Charcot neuroarthropathy.

Feasibility, safety, and primary efficacy of DermaStream: a novel continuously streaming device for chronic wounds.

Chronic wounds are associated with significant morbidity, mortality, and economic burden. Once a wound has settled into a senescent phase, outside factors must be used to convert that wound back to a more acute phase. Traditional methods, such as surgical debridement or biologic debridement, can cause removal of healthy tissue as well as pain to the patient. Enzymatic debridement has been under much scrutiny lately as popular drugs have been pulled by the Food and Drug Administration. The purpose of this study was to test feasibility, safety, and primary efficacy of 5 control subjects and 10 treatment subjects to the DermaStream system. It is a device that uses a continuously streaming infusion to create a stable, granular wound bed in a relatively short amount of time. The device provides for continuously streaming of therapeutic solutions to the wound while removing exudates by vacuum-assisted drainage throughout the treatment cycle.

Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients.

PURPOSE: To evaluate the effectiveness of home temperature monitoring to reduce the incidence of foot ulcers in high-risk patients with diabetes. METHODS: In this physician-blinded, 18-month randomized controlled trial, 225 subjects with diabetes at high risk for ulceration were assigned to standard therapy (Standard Therapy Group) or dermal thermometry (Dermal Thermometry Group) groups. Both groups received therapeutic footwear, diabetic foot education, regular foot care, and performed a structured foot inspection daily. Dermal Thermometry Group subjects used an infrared skin thermometer to measure temperatures on 6 foot sites twice daily. Temperature differences >4 degrees F between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized. RESULTS: A total of 8.4% (n=19) subjects ulcerated over the study period. Subjects were one third as likely to ulcerate in the Dermal Thermometry Group compared with the Standard Therapy Group (12.2% vs 4.7%, odds ratio 3.0, 95% confidence interval, 1.0 to 8.5, P=.038). Proportional hazards regression analysis suggested that thermometry intervention was associated with a significantly longer time to ulceration (P=.04), adjusted for elevated foot ulcer classification (International Working Group Risk Factor 3), age, and minority status. Patients that ulcerated had a temperature difference that was 4.8 times greater at the site of ulceration in the week before ulceration than did a random 7 consecutive-day sample of 50 other subjects that did not ulcerate (3.50+/-1.0 vs 0.74+/-0.05, P=.001). CONCLUSIONS: High temperature gradients between feet may predict the onset of neuropathic ulceration and self-monitoring may reduce the risk of ulceration.

Variability in activity may precede diabetic foot ulceration.

OBJECTIVE: To evaluate the role of activity in the development of neuropathic foot ulceration in individuals with diabetes. RESEARCH DESIGN AND METHODS: We evaluated the first 100 consecutive individuals with diabetes (95.0% male, aged 68.5 +/- 10.0 years with concomitant neuropathy, deformity, and/or a history of lower-extremity ulceration/partial foot amputation) enrolled in an ongoing prospective longitudinal activity study. Subjects used a high-capacity continuous computerized activity monitor. Data were collected continuously over a minimum of 25 weeks (or until ulceration) with daily activity units expressed as means +/- SD. RESULTS: Eight subjects ulcerated during the evaluation period of 37.1 +/- 12.3 weeks. The average daily activity was significantly lower in individuals who ulcerated compared with individuals who did not ulcerate (809.0 +/- 612.2 vs. 1,394.5 +/- 868.5, P = 0.03). Furthermore, there was a large difference in variability between groups. The coefficient of variation was significantly greater in the ulceration group compared with the no ulceration group (96.4 +/- 50.3 vs. 44.7 +/- 15.4%, P = 0.0001). In the 2 weeks preceding the ulcerative event, the coefficient of variation increased even further (115.4 +/- 43.0%, P = 0.02), but there was no significant difference in average daily activity during that period (P = 0.5). CONCLUSIONS: The results of this study suggest that individuals with diabetes who develop ulceration may actually have a lower overall activity than their counterparts with no ulceration, but the quality of that activity may be more variable. Perhaps modulating the "peaks and valleys" of activity in this population through some form of feedback might prove to reduce risk for ulceration in this very-high-risk population.

Computerized activity monitoring preoperatively and postoperatively.

One of the central goals of reconstructive foot and ankle surgery is restoration of or improvement in the quality of physical activity. Until recently, objective assessment of how well this goal has been attained has been elusive at best. Recent advances in activity monitoring have advanced sufficiently to help many clinicians and researchers objectively measure and potentially modulate activity. In this brief article, we describe our current experience with computerized activity monitoring. Use of modalities such as these may ultimately be able to monitor and dose levels of activity just as we do with a drug.