Joint Preserving Limb Salvage Secondary to Septic Nonunion Following Placement of a Fibular Intramedullary Nail: A Case Report.

Several challenges exist for the foot and ankle surgeon when addressing the complications associated with ankle fracture repair. The risk of joint destruction, debilitation, and even limb loss may be amplified by the noncompliant patient. There is an abundance of literature documenting the management of fracture nonunions in the setting of infection with a variety of techniques proven successful in managing large osseous defects and eradicating infection. We present a particularly challenging case in which we modified an existing method of treatment to preserve the ankle joint of a failed reduction complicated by septic nonunion following placement of a fibular intramedullary nail.

Metastasis of Cutaneous B-Cell Lymphoma Affecting the Metatarsal Head: A Case Report.

There are few reported cases of non-Hodgkin's lymphoma metastasis to bone in the lower extremities. The authors present a case of cutaneous B-cell lymphoma thought to be in remission, with metastasis to the first metatarsal head with involvement in the synovial tissue of the first metatarsophalangeal joint. Following excision of the lesion, no further treatment was determined to be necessary. The patient was to be observed for local recurrence.

Cancelloplasty for Treatment of Osteomyelitis of the Calcaneus: A Novel Technique and Case Report.

Calcaneal osteomyelitis has the potential to cause limb- and life-threatening complications. The anatomic and biomechanical attributes of the heel make limb salvage in the setting of bone infection complex. Current treatment options include surgical resection of part or all of the calcaneus, lower extremity amputation, or prolonged intravenous antibiotic usage. Each modality has its own inherent disadvantages. We present a novel surgical technique using antibiotic-impregnated calcium phosphate as an alternative treatment option coupled with ultrasonic bone dissection as a method for enhancing delivery of antibiotics, while mitigating tissue damage and maintaining osseous integrity. The details of the surgical technique are discussed along with a single case example.

Management of Distal Fibular Fractures With Minimally Invasive Technique: A Systematic Review.

Ankle fractures are extremely common, with isolated distal fibular fractures being the most common variant. The current gold standard in treating unstable distal fibular fractures is open reduction internal fixation. However, with potential risk of wound complications, minimally invasive techniques have been introduced. This systematic review was performed to evaluate the clinical and functional outcomes of varying minimally invasive techniques including minimally invasive plate osteosynthesis, intramedullary (IM) nailing, and IM screw fixation. A comprehensive English literature search on PubMed was performed yielding 543 studies. With specific study selection criteria, a total of 13 articles were selected. After studying the reference of each of the 13 studies, an additional 7 articles were included, resulting in a total of 20 studies reviewed. A total of 8 articles reviewed used IM nailing as the fixation of choice with a total of 211 patients. Of the 211 patients, 33 experienced complications. Six articles using minimally invasive plate osteosynthesis were reviewed with a total of 264 patients. Of the 264 patients, 39 experienced complications. IM screw fixation was used in 6 articles reviewed with a total of 219 patients. There were 30 cases of complications from the 132 patients. Additionally, mean American Orthopedic Foot and Ankle Society hindfoot-ankle scores among all fixation types was 88.4 ± 3.40 whereas the mean Olerud and Molander Score among all fixation types was 76.7 ± 16.58. The results of this study indicate that minimally invasive techniques for fixation of distal fibular fractures can provide excellent functional results with low complication rates compared with traditional open reduction internal fixation.

Insights for the Growth of Stenotrophomonas maltophilia in a Diabetic Patient with Long-Term Antibiotic Use: A Case Study.

BACKGROUND: Stenotrophomonas maltophilia is an uncommon gram-negative bacterium often found in individuals with long-standing broad-spectrum antibiotic use or catheter use; individuals undergoing hemodialysis; and individuals with prolonged respiratory disease, specifically, cystic fibrosis. To our knowledge, there are few reported cases of S maltophilia being the causative pathogen of infection in a diabetic foot wound. METHODS: Following multiple surgical procedures and deep tissue cultures, S maltophilia was determined to be a secondary opportunistic colonizer of the wound, necessitating a change in antibiotic therapy. RESULTS: The cultured pathogen was sensitive to ceftazidime, levofloxacin, and trimethoprim-sulfamethoxazole. The treatment team chose to use ceftazidime, as it also provided antibiotic coverage for the initial wound and blood cultures. Change in antibiotic therapy was initiated following multiple surgical procedures and angioplasty of the lower limb. The patient was discharged with a peripheral intravenous central catheter for outpatient antibiotic therapy. CONCLUSIONS: Prolonged exposure to broad-spectrum antibiotics in individuals with multiple comorbidities including diabetes mellitus provides an advantageous environment for growth of uncommon multidrug-resistant organisms. Stenotrophomonas maltophilia may complicate the treatment of diabetic foot infections as an opportunistic pathogen. Understanding the implication of long-term broad-spectrum antibiotic treatment in the diabetic patient is important in managing postoperative complications and determining the correct course of treatment. The emergence of atypical pathogens in diabetic wounds must be managed appropriately.

Empathy in Podiatric Medical Education: Challenges and Opportunities for Comprehensive Care.

BACKGROUND: Many regard empathy as a critical component of comprehensive health care. Much interest has been generated in the field of medical empathy, in particular as it relates to education. Many desirable outcomes correlate with perceived empathy during the patient encounter, but paradoxically, empathy levels have been reported to decline during the years of medical education. Several new approaches have been described in the literature that intend to teach or develop empathy skills in health-care students. METHODS: PubMed, PsycINFO, and Google Scholar databases were searched for the terms empathy education, medical education, medical student, podiatric medical education, medical empathy, compassion, emotional intelligence, biopsychosocial model, and bedside manner. After implementing inclusion and exclusion criteria, articles were selected for preparation of a literature review. Analysis of the podiatric medical education on empathy was conducted by reviewing descriptions of all courses listed on each of the nine US podiatric medical schools' Web sites. The 2018 Curricular Guide for Podiatric Medical Education was analyzed. RESULTS: In this review, we examine the current state of empathy from a context of medical education in general, followed by a specific analysis in podiatric medicine. We define key terms, describe the measuring of empathy in medicine, explore outcomes of empathy in the health-care setting, review the reports of a decline in medical education, and highlight some of the current efforts to develop the skill in education. An overview of empathy in the podiatric medical curriculum is presented. CONCLUSIONS: To improve the quality of care that physicians provide, a transformation in podiatric medical education is necessary. A variety of tools are available for education reform with the target of developing empathy skills in podiatric medical students.

Utilization of bone scan and single photon emission computed tomography on amputation planning in acute microvascular injury: Two cases.

The use of single photon emission computer tomography (SPECT/CT) in acute vascular injury is not well documented. SPECT/CT combines the anatomic detail of computer tomography with the functional vascular perfusion of photon emission to determine the viability of osseous structures and surrounding soft tissue. The superimposed imaging provides the practitioner with a reliable anatomic image of viability of a specific anatomic area following insult or injury. We present two cases, bilateral lower extremity frostbite, and symmetric peripheral gangrene in which this imaging modality provided guidance for surgical intervention with adequate predictability and results.

Reduction in Size and Number of Plantar Verrucae in Human Immunodeficiency Virus-Infected Individuals After the Implementation of Highly Active Antiretroviral Therapy.

BACKGROUND: Implementation of highly active antiretroviral therapy (HAART) significantly increased the life expectancy of those living with human immunodeficiency virus (HIV). Except for prevalence, scientific reports regarding clinical manifestations of plantar verrucae in the post-HAART era are lacking. The objective of this study was to compare clinical manifestations of plantar verrucae between HIV-infected and noninfected individuals and then to compare these findings with those observed before the implementation of HAART. METHODS: Nineteen patients with plantar verrucae (ten with HIV and nine without HIV) were examined to determine the size, number, and clinical type of verrucae present. The two groups were first compared with each other and then with previously collected data from a similar analysis conducted in 1995, before the implementation of HAART. Statistical significance was determined using the Fisher exact test or the Wilcoxon rank sum test. RESULTS: No significant differences were observed in the size, number, or clinical type of verrucae between HIV-negative and HIV-positive patients. Compared with the 1995 data, there was a significant decrease in the number of verrucae lesions per individual and a nonsignificant decrease in the average size of verrucae in HIV-positive patients. CONCLUSIONS: Study results indicate that the implementation of HAART has impacted the clinical manifestations of plantar verrucae in HIV-positive individuals. Further analyses with a larger number of patients are required to confirm and substantiate these findings.

Crosstalk between delta opioid receptor and nerve growth factor signaling modulates neuroprotection and differentiation in rodent cell models.

Both opioid signaling and neurotrophic factor signaling have played an important role in neuroprotection and differentiation in the nervous system. Little is known about whether the crosstalk between these two signaling pathways will affect neuroprotection and differentiation. Previously, we found that nerve growth factor (NGF) could induce expression of the delta opioid receptor gene (Oprd1, dor), mainly through PI3K/Akt/NF-κB signaling in PC12h cells. In this study, using two NGF-responsive rodent cell model systems, PC12h cells and F11 cells, we found the delta opioid neuropeptide [D-Ala2, D-Leu5] enkephalin (DADLE)-mediated neuroprotective effect could be blocked by pharmacological reagents: the delta opioid antagonist naltrindole, PI3K inhibitor LY294002, MAPK inhibitor PD98059, and Trk inhibitor K252a, respectively. Western blot analysis revealed that DADLE activated both the PI3K/Akt and MAPK pathways in the two cell lines. siRNA Oprd1 gene knockdown experiment showed that the upregulation of NGF mRNA level was inhibited with concomitant inhibition of the survival effects of DADLE in the both cell models. siRNA Oprd1 gene knockdown also attenuated the DADLE-mediated neurite outgrowth in PC12h cells as well as phosphorylation of MAPK and Akt in PC12h and F11 cells, respectively. These data together strongly suggest that delta opioid peptide DADLE acts through the NGF-induced functional G protein-coupled Oprd1 to provide its neuroprotective and differentiating effects at least in part by regulating survival and differentiating MAPK and PI3K/Akt signaling pathways in NGF-responsive rodent neuronal cells.