Toenail fungus Laser Treatment

For people with toenail fungus, there is no good time to wear sandals. Not even at the beach in July.

Toenail fungus causes nails to become thick, yellow and brittle in a way that looks pretty ugly and can be painful. Sufferers can spend years and hundreds of dollars trying to clear the infection with drugs, topical treatments and home remedies, sometimes to no avail. It tends to be a cosmetic issue for the younger set and a pain issue for older folks.

There may be hope. Podiatrists have begun using a laser treatment that combats the infection — or wastes their patients’ money because it doesn’t work, depending on whom you ask.

The treatment, in which the podiatrist aims a laser beam at the patient’s toenails to kill the organisms that cause the fungus. The nails aren’t immediately clear after the treatment, which takes up to an hour; the patient must wait for the fungus-free nails to grow out.

Last year, the Food and Drug Administration cleared the first laser, PinPointe, for “temporary increase of clear nail” in patients with onychomycosis, the medical term for a fungal infection of the nail. The FDA cleared a second one, GenesisPlus, in April. Practitioners have been using other lasers on toenail fungus since about 2009.

The most common oral treatment, Lamisil, works for about two out of three patients, according to Lamisil’s FDA-approved prescribing information, but it has been associated with rare cases of serious liver problems. Other potential side effects include diarrhea, headache, rashes and changes in taste. According to Lamisil’s manufacturer, Novartis, the relapse rate is 15 percent one year after completing treatment.

In one small study about laser treatment for toenail fungus, which appeared last year in the Journal of the American Podiatric Medical Association, “26 eligible toes (ten mild, seven moderate, and nine severe)” were treated with a laser produced by Nomir Medical Technologies, which is still seeking FDA approval. After six months, 85 percent of the toenails had improved.

Even John Strisower, the founder of PinPointe USA, says patients should expect at least a minimal reinfection within five years after laser treatment.

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Non-surgical treatment

Bunion and bunionette pain is best managed by wearing flat, roomy, soft upper or open-toe shoes. Anti-inflammatory pain killer can be used to relieve severe pain temporarily, if necessary. Physiotherapy exercises may help prevent and possibly regain some of the lost function of the big toe. Toe straightening gadgets may help mild bunions. Foot orthotics specifically prescribed for bunion condition can help reduce metatarsal calluses, metatarsal pain (metatarsalgia) and hopefully also slow down the progression of bunion deformity.

Surgical treatment

There have been reportedly more than 150 different bunion surgeries being tried in the past and there are still more than 20 of them being commonly practiced around the world at present. This larger than usual number of surgical methods for one single condition is an indication that surgeons were and are still dissatisfied with many if not most surgical methods so far.

Currently, indications and recommendations for the many different bunion surgical procedures are complex and not well defined. Doctors and patients are equally confused and frustrated.

Objectives of bunion surgery

Many may regard bunion deformity mostly a cosmetic issue but to the sufferers it is much more of a pain and compromised function problem. The primary objective of bunion surgery is always to restore normal function for the big toe and thus also resolve pain and other related problems consequently. This can only be achieved by physiological methods (Methods making logical and common sense to human body condition).

Traditional bunion surgery: bone-breaking procedures

To reposition the displaced first metatarsal bone, traditional bunion surgery has been employing the “break-n-shift” method. Currently, there are more than 20 different types of such “break-n-shift” bunion surgery being practiced around the world and they make up more than 90% of all bunion surgeries.

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Articular incongruency associated with poor results in patients with SER IV ankle fractures

CHICAGO — Surgically treated patients with supination external rotation type IV ankle fractures and articular incongruity showed worse clinical results than those without articular incongruity, according to research presented here.

“Articular incongruity was correlated with inferior short-term 1-year clinical outcomes in this group,” Milton T. Little, MD, said during his presentation. “This emphasizes the importance of articular reduction.”

Little and colleagues retrospectively reviewed the outcomes of 176 patients with supination external rotation type IV (SER IV) fractures. They considered ankles incongruent if they showed > 2 mm articular step-off, had a subchondral bone gap > 2 mm or had intra-articular loose bodies. Outcome measures included the Foot and Ankle Outcome Score (FAOS) and ankle range of motion (ROM). The average follow-up was 21 months.

The researchers found 67% of ankles were congruent and 33% showed articular incongruency. The groups had similar comorbidities, injury and treatment variables. The incongruent group showed statistically significantly worse FAOS scores compared with the congruent cohort. The FAOS symptom score was 66.8 in the incongruent group and 77.3 in the congruent group. The FAOS pain score was 72.1 in the incongruent group and 84.6 in the congruent group. The FAOS activities of daily living score was 78.9 for the incongruent group vs. 87.4 in the congruent group. The FAOS sports domain score was lower at 54.9 in the incongruent group compared to 65.8 in the congruent group. The investigators found comparable range of motion between the groups.

“This does suggest a role for advanced intraoperative imaging to help avoid malreduction and improve outcomes,” Little said.

Reference:

Little M. Paper #19. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.

Ankle Fractures (Broken Ankle)

A broken ankle is also known as an ankle “fracture.” This means that one or more of the bones that make up the ankle joint are broken.

A fractured ankle can range from a simple break in one bone, which may not stop you from walking, to several fractures, which forces your ankle out of place and may require that you not put weight on it for a few months.

Simply put, the more bones that are broken, the more unstable the ankle becomes. There may be ligaments damaged as well. The ligaments of the ankle hold the ankle bones and joint in position.

Broken ankles affect people of all ages. During the past 30 to 40 years, doctors have noted an increase in the number and severity of broken ankles, due in part to an active, older population of “baby boomers.”

Anatomy

Three bones make up the ankle joint:

  • Tibia – shinbone.
  • Fibula – smaller bone of the lower leg.
  • Talus – a small bone that sits between the heel bone (calcaneus) and the tibia and fibula.

The tibia and fibula have specific parts that make up the ankle:

  • Medial malleolus – inside part of the tibia
  • Posterior malleolus – back part of the tibia
  • Lateral malleolus – end of the fibula

Doctors classify ankle fractures according to the area of bone that is broken. For example, a fracture at the end of the fibula is called a lateral malleolus fracture, or if both the tibia and fibula are broken, it is called a bimalleolar fracture.

Two joints are involved in ankle fractures:

  • Ankle joint – where the tibia, fibula, and talus meet
  • Syndesmosis joint – the joint between the tibia and fibula, which is held together by ligaments

Multiple ligaments help make the ankle joint stable.

Cause

  • Twisting or rotating your ankle.
  • Rolling your ankle.
  • Tripping or falling.
  • Impact during a car accident.

Symptoms

Because a severe ankle sprain can feel the same as a broken ankle, every ankle injury should be evaluated by a physician.

Common symptoms for a broken ankle include:

  • Immediate and severe pain.
  • Swelling.
  • Bruising.
  • Tender to touch.
  • Cannot put any weight on the injured foot.
  • Deformity (“out of place”), particularly if the ankle joint is dislocated as well.

 

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Bunion surgery: Treatments

Bunion surgery generally involves an incision in the top or side of the big toe joint and the removal or realignment of soft tissue and bone. This is done to relieve pain and restore normal alignment to the joint. If the joint is severely deformed, it may be stabilized with tiny wires, stitches, screws, or plates. There are no guarantees that a bunion surgery will fully relieve your pain.

A regional anesthetic that affects only the foot is commonly used for bunion surgery. A sedative may also be used during the procedure.
The procedure usually takes an hour or more, depending on the type of surgery.
Bunion repairs are usually done on an outpatient basis.

There are over 100 surgeries for bunions. Research does not show which type of surgery is best-surgery needs to be specific to your condition. More than one procedure may be done at the same time.

The general types of bunion surgery are:

  • Removal of part of the metatarsal head (the part of the foot that is bulging out). This procedure is called exostectomy or bunionectomy.
  • Realignment of the soft tissues (ligaments) around the big toe joint.
  • Removal of a small wedge of bone from the foot (metatarsal osteotomy) or from the toe (phalangeal osteotomy).
  • Removal of bone from the end of the first metatarsal camera bone, which joins with the base of the big toe (metatarsophalangeal joint). At the metatarsophalangeal joint, both the big toe and metatarsal bones are reshaped (resection arthroplasty).
  • Fusion (arthrodesis) of the big toe joint.
  • Fusion of the joint where the metatarsal bone joins the mid-foot (Lapidus procedure).
  • Implant insertion of all or part of an artificial joint.

What To Expect After Surgery

The usual recovery period after bunion surgery is 6 weeks to 6 months, depending on the amount of soft tissue and bone affected. Complete healing may take as long as 1 year.

  • When you are showering or bathing, the foot must be kept covered to keep the stitches dry.
  • Stitches are removed after 7 to 21 days.
  • Pins that stick out of the foot are usually removed in 3 to 4 weeks. But in some cases they are left in place for up to 6 weeks.
  • Walking casts, splints, special shoes, or wooden shoes are sometimes used. Regular shoes can sometimes be worn in about 4 to 5 weeks, but some procedures require wearing special shoes for about 8 weeks after surgery. Many activities can be resumed in about 6 to 8 weeks.
  • After some procedures, no weight can be put on the foot for 6 to 8 weeks. Then there are a few more weeks of partial weight-bearing with the foot in a special shoe or boot to keep the bones and soft tissues steady as they heal.

Why It Is Done

You may want to consider surgery when:

  • Nonsurgical treatment has not relieved your bunion pain.
  • You have difficulty walking or doing normal daily activities.

How Well It Works

After surgery, your ability to walk and do other activities is likely to improve. The big toe joint is generally less painful and, as a result, moves better. After the incision has healed and the swelling has gone down, the toe may look more normal than before.

Research does not show which type of surgery is best. A review of bunion surgeries shows that up to 33% of people who have surgery for bunions are disappointed in the result despite pain being reduced and the toe being straighter. The reasons are not clear. Some reasons for being disappointed in the surgery results could be that a person is not able to wear some types of shoes (such as high heels) after surgery, or that the joint has a little less motion compared to the other foot.

Risks of surgery include:

  • Infection in the soft tissue or bone of the foot.
  • Side effects from anesthetic medicines or other medicines used to control pain and swelling.
  • Recurrence of the bunion.
  • An outward or upward bend in the big toe.
  • Decreased feeling or sensation, numbness or tingling, or burning in the toe from damage to nerves.
  • Damage to the tendons that pull the big toe up or down.
  • A shorter big toe, if bone is removed.
  • Restricted movement or stiffness of the big toe joint (may be an expected outcome of some types of surgery).
  • Persistent pain and swelling.
  • Degenerative joint disease (arthritis) or avascular necrosis (disruption of the blood supply to the bone) after surgery.
  • Development of a callus on the bottom of the foot.

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Bunion Surgery: Overview

One day you became aware that your foot looked strange. You had a bump on the side of your foot below your big toe. Your big toe might even have looked like it was pointing in toward your second toe. Then it started to hurt.
Some might recognize that they now had a bunion, while others might need to go to a podiatrist to find out what’s going on with their feet. After the diagnosis, then what? We’ve talked before about bunion basics, but today let’s think about the decision to have bunion surgery.


That’s right, I said surgery. Bunions don’t heal on their own, so you can either manage the pain or have them fixed surgically. Of course, most people want to avoid surgery as much as they can, either because of fear of hospitals and anesthesia or because they dread a long painful recovery. But like I said, the bunion fairy isn’t going to come overnight and whisk away your bunion with her magic bunion wand, so here are some points to consider as you ponder bunion surgery.

  • How is the bunion affecting the rest of your foot? Bunions do affect the rest of your feet, especially your second and third toes which can be forced up into hammertoes. With those come painful corns and calluses. If your bunion hasn’t led to these issues, then that’s great. Your podiatrist may recommend orthotics or a change in shoes to help stop these from developing. If, however, you do have these problems already or really want to make sure you don’t get them, then you probably should seriously consider surgery.
  • How painful is your bunion? Bunions can become red, inflamed, and raw, leading to pain that’s so sever it wakes you up duirng the night. If you find that your bunion hurts so much that it’s keeping you from normal activities (for example you avoid walking whenever possible) and regular over the counter painkillers (nonsteroidal anti-inflammatories such as ibuprofen and acetaminophen) no longer work, then it’s really time for surgery. You shouldn’t let pain from a bunion change your life for the worse.
  • How about if your bunion ISN’T that painful? This is a really tricky area. Many people will say if your bunion doesn’t hurt that much or at all, then you shouldn’t have your bunion surgically repaired. However, there is the ounce of prevention school of thought: sure, my bunion isn’t a huge problem now but it’s very likely going to be so maybe I should just get it fixed now. Moreover, the simpler my bunion is now (smaller, no hammertoes), the simpler the surgery and therefore my recovery will be; conversely, leaving bunions untreated until you can’t stand them may mean that you’ll need multiple procedures. This is certainly a very logical way to approach the issue and perhaps the smarter course of action, but the decision to have surgery that’s not a dire necessity is a pretty big one. Again, the best thing to do is discuss it with a trusted podiatrist.
  • How ready are you for surgery? Many people put off bunion surgery because it’s inconvenient; all that time off their feet while their foot heals can be a real problem. Then they keep putting it off…and putting it off…and putting it off until their feet are a real mess and surgery becomes a big deal. If you think you’re going to need bunion surgery, start planning ahead. If your family usually takes vacations in the summer, get your surgery done in the winter. If you usually walk to work, make a plan with someone to drive you for a few weeks. If you know you have a major conference to attend and you don’t want to be on crutches, schedule your surgery at least two months before the date.It’s also important to realize that the better shape you’re in, the easier your recovery will be. Make sure you’re healthy and strong. Eat right and work on your upper body strength so you can manage your crutches without help. No one likes having to use crutches, but it’s more fun if you’re a crutch badass.

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Diabetic Foot Care: Inspect your feet daily

Diabetes can be dangerous to your feet – even a small cut can produce serious consequences. Diabetes may cause nerve damage that takes away the feeling in your feet. Diabetes may also reduce blood flow to the feet, making it harder to heal an injury or resist infection. Because of these problems, you may not notice a foreign object in your shoe. As a result you could develop a blister or a sore. This could lead to an infection or a non-healing wound that could put you at risk for an amputation.

To avoid serious foot problems that could result in losing a toe, foot, or leg, follow these guidelines.

Inspect your feet daily: Check for cuts, blisters, redness, swelling, or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything.

Wash your feet in lukewarm (not hot!) water: Keep your feet clean by washing them daily. Use only lukewarm water – the temperature you would use on a newborn baby.

Be gentle when bathing your feet: Wash them using a soft washcloth or sponge. Dry by blotting or patting, and carefully dry between the toes.

Moisturize your feet – but not between your toes: Use a moisturizer daily to keep dry skin from itching or cracking. But DON’T moisturize between the toes – that could encourage a fungal infection.

Cut nails carefully. Cut them straight across and file the edges: Don’t cut nails too short, as this could lead to ingrown toe nails. If you have concerns about your nails, consult your doctor.

Never treat corns or calluses yourself: No “bathroom surgery” or medicated pads. Visit your doctor for appropriate treatment.

Wear clean, dry socks. Change them daily.

Avoid the wrong type of socks: Avoid tight elastic bands (they reduce circulation). Don’t wear thick or bulky socks (they can fit poorly and irritate the skin).

Wear socks to bed: If your feet get cold at night, wear socks. NEVER use a heating pad or hot water bottle.

Shake out your shoes and feel the inside before wearing: Remember, your feet may not be able to feel a pebble or other foreign object, so always inspect your shoes before putting them on.

Keep your feet warm and dry: Don’t let your feet get wet in snow or rain. Wear warm socks and shoes in winter.

Never walk barefoot: Not even at home! Always wear shoes or slippers. You could step on something and get a scratch or cut.

Take care of your diabetes: Keep your blood sugar levels under control.

Don’t smoke: Smoking restricts blood flow in your feet.

Get periodic foot exams: Seeing your foot and ankle surgeon on a regular basis can help prevent the foot complications of diabetes.

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Tailor’s Bunion (Bunionette)

Tailor’s bunion, also called a bunionette, is a prominence of the fifth metatarsal bone at the base of the little toe. The metatarsals are the five long bones of the foot. The prominence that characterizes a tailor’s bunion occurs at the metatarsal “head,” located at the far end of the bone where it meets the toe. Tailor’s bunions are not as common as bunions, which occur on the inside of the foot, but they are similar in symptoms and causes.

Why is it called a tailor’s bunion? The deformity received its name centuries ago, when tailors sat cross-legged all day with the outside edge of their feet rubbing on the ground. This constant rubbing led to a painful bump at the base of the little toe.

Causes
Often a tailor’s bunion is caused by an inherited faulty mechanical structure of the foot. In these cases, changes occur in the foot’s bony framework, resulting in the development of an enlargement. The fifth metatarsal bone starts to protrude outward, while the little toe moves inward. This shift creates a bump on the outside of the foot that becomes irritated whenever a shoe presses against it.

Sometimes a tailor’s bunion is actually a bony spur (an outgrowth of bone) on the side of the fifth metatarsal head.

Regardless of the cause, the symptoms of a tailor’s bunion are usually aggravated by wearing shoes that are too narrow in the toe, producing constant rubbing and pressure.

Symptoms
The symptoms of tailor’s bunions include redness, swelling, and pain at the site of the enlargement. These symptoms occur when wearing shoes that rub against the enlargement, irritating the soft tissues underneath the skin and producing inflammation.

Diagnosis
Tailor’s bunion is easily diagnosed because the protrusion is visually apparent. X-rays may be ordered to help the foot and ankle surgeon determine the cause and extent of the deformity.

Non-Surgical Treatment
Treatment for tailor’s bunion typically begins with non-surgical therapies. Your foot and ankle surgeon may select one or more of the following:

  • Shoe modifications. Choose shoes that have a wide toe box, and avoid those with pointed toes or high heels.
  • Padding. Bunionette pads placed over the area may help reduce pain.
  • Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help relieve the pain and inflammation.
  • Icing. An ice pack may be applied to reduce pain and inflammation. Wrap the pack in a thin towel rather than placing ice directly on your skin.
  • Injection therapy. Injections of corticosteroid may be used to treat the inflamed tissue around the joint.
  • Orthotic devices. In some cases, custom orthotic devices may be provided by the foot and ankle surgeon.

Metatarsal Fracture

The metatarsal bones are the long bones in your foot that connect your ankle to your toes. They also help you balance when you stand and walk.

A sudden blow or severe twist of your foot, or overuse, can cause a break or acute (sudden) fracture in one of the bones.

There are five metatarsal bones in your foot. The 5thmetatarsal is the outer bone that connects to your little toe. It is the most commonly fractured metatarsal bone.

A break in the part of your 5thmetatarsal bone closest to the foot is called a Jones fracture. This area of the bone has low blood flow. This makes healing difficult.

An avulsion fracture occurs when a tendon pulls a piece of bone away from the rest of the bone. An avulsion fracture on the 5thmetatarsal bone is called a “dancer’s fracture.”

What to Expect
If your bones are still aligned (meaning that the broken ends meet), you will probably wear a cast or splint for 6 – 8 weeks.

  • You may be told not to put weight on your foot. You will need crutches or other support to help you get around.
  • You may also be fitted for a special shoe or boot that may allow you to bear weight.

If the bones are not aligned, you will need surgery. A bone doctor (orthopedic surgeon) will do your surgery. After surgery you will wear a cast for 6 – 8 weeks.

Relieving Your Symptoms
You can decrease swelling by

  • Resting and not putting weight on your foot.
  • Elevating your foot.

Make an ice pack by putting ice in a zip lock plastic bag and wrapping a cloth around it.

  • Do no put the bag of ice directly on your skin. It could damage your skin.
  • Ice your foot for about 20 minutes every hour while awake for the first 48 hrs, then 2 – 3 times a day.

For pain, you can use ibuprofen (Advil, Motrin, and others) or naproxen (Aleve, Naprosyn, and others).

  • Do not use these medications for the first 24 hours after your injury. They may increase the risk of bleeding.
  • Talk with your health care provider before using these medicines if you have heart disease, high blood pressure, kidney disease, liver disease, or have had stomach ulcers or internal bleeding in the past.
  • Do not take more than the amount recommended on the bottle or more than your health care provider tells you to take.

Stiff Big Toe

The most common site of arthritis in the foot is at the base of the big toe. This joint is called the metatarsophalangeal, or MTP joint. It’s important because it has to bend every time you take a step. If the joint starts to stiffen, walking can become painful and difficult.

In the MTP joint, as in any joint, the ends of the bones are covered by a smooth articular cartilage. If wear-and-tear or injury damage the articular cartilage, the raw bone ends can rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The result is a stiff big toe, or hallux rigidus.

Hallux rigidus usually develops in adults between the ages of 30 and 60 years. No one knows why it appears in some people and not others. It may result from an injury to the toe that damages the articular cartilage or from differences in foot anatomy that increase stress on the joint.

Symptoms:

  • Pain in the joint when you are active, especially as you push-off on the toes when you walk.
  • Swelling around the joint.
  • A bump, like a bunion or callus, that develops on the top of the foot.
  • Stiffness in the great toe and an inability to bend it up or down.

 

Diagnosis
If you find it difficult to bend your toe up and down or find that you are walking on the outside of your foot because of pain in the toe, see your doctor right away. Hallux rigidus is easier to treat when the condition is caught early. If you wait until you see a bony bump on the top of your foot, the bone spurs will have already developed and the condition will be more difficult to treat.

Your physician will examine your foot and look for evidence of bone spurs. He or she may move the toe around to see how much motion is possible without pain. X-rays will show the location and size of any bone spurs, as well as the degree of degeneration in the joint space and cartilage.