Recurrent eccrine poroma with malignant transformation and bony involvement of the foot: a case report and review of the literature

OBJECTIVE

Eccrine poroma is a benign appendage tumor showing either eccrine or apocrine differentiation. However malignant transformation of this tumor is very rare. The present report demonstrated a case of the eccrine poroma with malignant transformation and its rarity in terms of its high degree of recurrences and its aggressiveness with bony invasion.

CASE REPORT

A 67-year old female had a mass on plantar surface of 4th-5th intermetatarsal area of her left foot for 10 years with three recurrent episodes following excisions at local hospital with no pathological report. She was referred to our institute. A recurrent tumor was removed again with pathological findings as eccrine poroma with incomplete excision; however; the patient had a failure to follow-up. Four years later; she was back in our center again with 5th episode of recurrent tumor which was marginally excised with pathological findings revealing a malignant transformation of eccrine poroma with close resected margins. Unfortunately, the patient failed to follow-up again. Eventually, four years later she returned to our institute with 6th recurrent episode of tumor. Incisional biopsy was performed with pathological findings as appendage tumor with eccrine differentiation. Wide resection including removal of 5th metatarsal head-and-neck was performed due to aggressive behaviors of this tumor; particularly; history of malignant findings and multiple recurrences, significantly bony invasion. Final pathologicalfindings were malignant eccrine poroma with close resected margin. There were no metastases in evidence from all investigations. Local irradiation with the aim of eradication of microscopically residual tumor was initiated.

CONCLUSION

Malignant transformation is a rare occurrence of eccrine poroma. It should be initially included in differential diagnoses, especially in a patient with long standing foot lesion or history of recurrent masses. Wide excision is recommended as basis treatment, especially in a patient with high likelihood of recurrences or positive malignant transformation.

Hallux valgus correction using a Mini TighTrope device: a report of the short-term outcomes in 3 feet

OBJECTIVE

Bony works seems to be base procedure for hallux valgus correction. Due to the challenge and possible complications of these procedures, these issues generate 'Foot and Ankle Society' to consider alternative procedures. The 'Mini TightRope' (Arthrex, Inc., Naples, FL) or interrosseous suture/button device was introduced in 2007 to address the above mentioned point. Although its feasibility and utilization were attractive, some reports revealed its drawbacks and limitations. The present report is to demonstrate short-term outcomes and information that might be useful for avoidance of potential complications from application of this device.

MATERIAL AND METHOD

Three involved-feet in 2 patients with recalcitrant conditions and progressive hallux valgus, with at least a 6-month course of conservative treatment, were included. Limitation criteria for using 'Mini TightRope' were; non-athletic demand, good bone-stock, moderate severity of their hallux valgus (hallux-valgus-angle (HVA): 30-40, intermetatarsal-angle (IMA): 14-20), no hypermobility of first tarsometatarsal joint, and no signs of degenerative joint disease of first metatarsophalangeal/tarsometatarsal joint. Baseline data, American-Orthopaedic-Foot-and-Ankle-Society (AOFAS) scores, Visual-Analogue-Scale Foot-and-Ankle (VAS-FA) scores (including radiographic parameters) were collected at pre- and post-operative periods. The operations were carried out by a single surgeon. Precision in the creation of the interosseous-tunnel between 1st-2nd metatarsals was critical for this device. All patients strictly followed a similar postoperative-protocol, with austere prohibition of premature weight-bearing at forefoot-and-midfoot areas in 1-month postoperative-period.

RESULTS

Although pre-postoperative (6-month) AOFAS/VAS-FA scores and radiographic angular differences were nonsignificant as to p-value: 0.10, there were satisfactory improvements of all scores and angular values in all postoperative periods. Patient number-two reported some tightness at 1st-2nd intermetatarsal area on left-foot. This was controlled with oral-medications in 1-month postoperative-period. Besides, there were no significant complications in the present report.

CONCLUSION

'Mini TightRope' might be of merit in hallux valgus correction for well-selected patients provided that technical implementation is precise and postoperative-protocol is followed with proper discipline.

Unusual subtrochanteric femoral insufficiency fractures associated with the prolonged use of alendronate and risedronate: a report of two cases

OBJECTIVE

Previous studies reported that prolonged alendronate use was related to insufficiency fractures. Fewer reports presented this phenomenon in patients with risedronate use. The present study reported on two patients, both of whom had long-term use of alendronate and risedronate then sustained subtrochanteric femoral insufficiency fractures with minimal trauma.

CASE SUMMARY

One of the patients was treated with alendronate therapy in concern of her risk factors for osteoporosis (her previous a hysterectomy with bilateral oophorectomy) with unsubstantiated evidence of her pretreatment, bone-mineral-density measurements (BMD), for a 10-year prior episode of left prodromal thigh pain and an insufficiency fracture at 8 days post experiencing the pain. The other patient had a history of the hysterectomy and right salpingo-oophorectomy, a low-energy metatarsal fracture with resulting osteopenia verified with BMD measurements. She was treated with alendronate for 42 months before switching to risedronate for 6 months per patient's request but no history of prodromal thigh pain. Subsequently, she sustained an insufficiency fracture, while standing and turning her body. Both patients had the significant long-term uses of bisphosphonate and exhibited the typical radiographic characteristics of insufficiency fracture. From the present report, risedronate is another prospective medication that might be related to insufficiency fractures.

CONCLUSION

The present study concluded that cautious consideration is essential for long-term alendronate and risedronate use for any individual patient. The index of suspicion for the subtrochanteric femoral insufficiency fracture should be higher in the patients presenting with prodromal thigh pain. Further studies are necessary to identify the class effect of other bisphosphonate drugs, the definitive mechanisms between all generations of bisphosphonate treatments and their complications, including the individual risk factors of the insufficiency fracture.

Pretreatment and posttreatment radiography in patients with pulmonary tuberculosis with and without human immunodeficiency virus infection

PURPOSE

The purpose of this study was to determine differences in pretreatment and posttreatment radiographic findings in pulmonary tuberculosis (PTB) patients with and without human immunodeficiency virus (HIV) infection.

MATERIALS AND METHODS

All patients were reviewed in terms of pre- and posttreatment radiographic findings comparing non-HIV-related versus HIV-related PTB.

RESULTS

Among 177 PTB patients, 38 (22%) were HIV seropositive and 139 (78%) were HIV-seronegative. The most common radiographic finding in non-HIV-related TB was reticular infiltration (66.2%), whereas the miliary pattern was the most common radiographic finding in HIV-related TB (34.2%). Radiographic findings in HIV related TB significantly presented with higher prevalence of the miliary pattern (P < 0.0001) and lower prevalence of reticular infiltration (P < 0.0001), cavitation (P = 0.003), and mass-like lesions (P = 0.039) compared to non-HIV-related TB. During the posttreatment period, normal chest radiographs were significantly present in the patients who had HIV-seropositivity, the miliary pattern, and sputum negative for acid-fast bacilli during the pretreatment period (P < 0.05).

CONCLUSION

Pretreatment radiographic features of HIV-related TB had a significantly higher prevalence of the miliary pattern and lower prevalence of reticular infiltration, cavitation, and mass-like lesions. HIV-related TB and the miliary pattern seen by pretreatment radiography were significantly associated with normal chest radiographs during the posttreatment period.

Visual analogue scale foot and ankle: validity and reliability of Thai version of the new outcome score in subjective form

BACKGROUND

Nowadays, measuring score in the form of subjective questionnaires is the important tool for clinical evaluation of the foot and ankle-related problems. VisualAnalogue Scale-Foot and Ankle (VAS-FA) is the newly developed subjective questionnaire, which has sufficiency of validity and reliability from a previous study

OBJECTIVE

Translate the original English version of VAS-FA into the Thai version and evaluate the validity and reliability of Thai VAS-FA in patients with foot and ankle-related problems.

MATERIAL AND METHOD

According to the forward-backward translation protocol, original VAS-FA was translated into the Thai version. Thai VAS-FA and validated Thai Short Form-36 (SF-36) questionnaires were distributed to 42 Thai patients to complete. For validation, Thai VAS-FA scores were correlated with SF-36 scores. For reliability, the test-retest reliability and internal consistency were analyzed.

RESULTS

Thai VAS-FA score demonstrated the sufficient correlations with physical functioning (PF), role physical (RP), bodily pain (BP) domains, and total score of SF-36 (statistically significant with p < 0.001 level and r > 0.5 values). The result of reliability revealed highly intra-class correlation coefficient as 0.995 from test-retest study. The internal consistency was excellent with Cronbach alpha: 0.995.

CONCLUSION

The original VAS-FA score is a well-validated, subjective, visual-analogue-scale based outcome score. The Thai version of VAS-FA form maintained the validity and reliability of the original version. This newly translated-validated score can be distributed for the evaluation of the functions, symptoms, and limitation of activities in Thai patients with foot and ankle problems.