Nodular Subcutaneous Phaeohyphomycosis due to Medicopsis romeroi in an Immunocompetent Patient

Fungal infections like subcutaneous phaeohyphomycosis are uncommon but are increasing lately, especially in tropical regions like India. Identification of correct aetiologic agent is essential as different species can have different organ tropism. Here, a rare case of nodular subcutaneous phaeohyphomycosis in an immunocompetent 62-year-old male patient who developed nodule over right dorsum of foot is reported. After various diagnostic tests a rare dematiaceous fungus Medicopsis romeroi was identified as a causative agent in the nodular material by Internal Transcribed Spacer (ITS) sequencing. Surgical excision and antifungal therapy of itraconazole proved beneficial with no recurrence during a six months of follow-up. Medicopsis romeroi has been debated for its role in human infections however, it should be considered as one of the aetiologic agents of subcutaneous phaeohyphomycosis.

Outcome of treatment with modified Ponseti technique in atypical congenital talipes equinovarus

Background: The atypical congenital talipes equinovarus (CTEV) patients tend to have a different clinical foot presentation with small great toe, deep transverse crease of sole, tender swollen dorsum of foot and rigid equinus.Methods: This study was conducted in GMC Jammu to evaluate efficacy of modified Ponseti technique in atypical CTEV patients. It was a prospective study and the patient data was collected during OPD visits of patients from August, 2018 to June, 2020. Twenty-one patients were diagnosed as atypical CTEV and were managed with modification of conventional Ponseti technique and percutaneous release of achilles tendon was done in all patients. Three patients were lost to follow-up. Hence, the final number of study participants was 18 (n=18).Results: With modified Ponseti technique, functional correction was achieved in all the patients in our study. The average number of casts required was 8 (range; 5-10). At final follow-up visit, all feet are functionally corrected. Only one case of relapse was seen.Conclusions: Early diagnosis and treatment with modified Ponseti technique is an effective and easy method of treatment in atypical CTEV.

“Pauci-Hemosiderotic” Fibrolipomatous Tumor: A Mimicker of Various Lipomatous Lesions

Hemosiderotic fibrolipomatous tumor is a rare soft tissue tumor that preferentially affects the dorsum of foot, shows recurrent t(1;10) translocation targeting TGFBR3 and OGA ( MGEA5) genes, and has a high recurrence potential. Hemosiderin deposits, mature adipocytes, and interspersed spindle cells are the 3 cardinal morphologic features of this tumor. We describe a “pauci-hemosiderotic” example involving the left wrist of a 45-year-old female, posing a diagnostic pitfall. The tumor comprised mature adipose tissue traversed by variably thick fibrous septa containing short fascicles of spindle cells. Prominent small- to medium-sized blood vessels were present, often with perivascular fibrosis or aggregates of foamy histiocytes, sometimes associated with red cell extravasation. Hemosiderin was not conspicuous, but fine deposits could be found focally on careful search and with the aid of Perls stain. The diagnosis was further confirmed by diffuse expression of CD34 and presence of OGA translocation by fluorescence in situ hybridization. Pathologists should be aware that hemosiderin deposition can be scanty and focal in hemosiderotic fibrolipomatous, but the rich vasculature with a “damaged” appearance is a useful diagnostic clue.

VARIATIONS IN DORSALIS PEDIS ARTERY

Introduction: Dorsalis pedis artery is the chief artery of the dorsum of foot and is the artery of choice for grafting in vascular surgery of ischemic lower limbs in diabetic patients. Material & Methods: Dorsalis pedis artery was dissected and traced during routine cadaveric dissection in 41 foots. Observation & Results: We observed origin of dorsalis pedis artery from peroneal artery in 2.44% cases. Five branches from dorsalis pedis artery were observed in 2.44% and 6 branches in 2.44% cases. Conclusion: Study of variation in origin and branching pattern of dorsalis pedis artery is helpful in delimiting the graft

REVERSE FLOW SURAL FLAP;

Background:Soft tissues injuries at foot especially at heel expose the tendons, bones and especially joints, which leads to risk of infections and necrosis. These often result from trauma (spoke wheel), tumors, systemic diseases and their wounds such as venous ulcers and diabetic foot wounds. Surgical planning of these defects remains a challenge due to shortage of local scar free tissue and reliable blood supply. The current study is conducted to observe the purposeful benefits of reverse sural artery flap to cover wounds at dorsum of foot, ankle & heel.Study Design:Descriptive, experimental study.Setting: Department of Plastic & Reconstructive Surgery, Dr. Ruth KM Pfau Civil Hospital Karachi.Period:January 2015 to January 2018.Material & Methods:All patients who presented with wounds at heel, dorsum of foot, and exposed calcaneus or Achilles tendon were included. A peroneal based perforator identified by hand held Doppler, a superficial vein, and the sural nerve were included in the pedicle. Patients were followed during the first 6 postoperative months. Postoperative outcomes like flap congestion, tip necrosis and flap failure were noted. Results:Total of 36reverse low sural flaps were done for the soft tissue coverage of the 24 heel defects, 8 ankle defects and4 dorsum of the foot defects. Twenty eight patients were male and eight were females and age ranged from 6 to 36 years (mean 21). Partial flap failure was seen in 3 cases and complete flap failure in 2 cases. There were no serious donor site complications and all patients were satisfied with the functional and aesthetic outcome postoperatively.Conclusion:Reverse sural artery flap is very suitable in providing soft tissue coverage of the wounds of heel and dorsum of foot. Harvesting sural flap is dependable and safe as it does not ends in any major postoperative donor site morbidity.

Continuation of perforating branch of fibular artery as dorsalis pedis artery

For the effective management of vascular surgeries such as arterial cannulation, bypass surgery, percutaneous trans arterial catheterization etc. needs a sound knowledge of the vessels of the lower extremity, their branching pattern, course followed by them and their diameter. The knowledge of arterial variation is a must before a surgeon deals with the concerned area. We are reporting a case in which the perforating branch of fibular artery passes through the gap in the interosseous membrane and continues as the dorsalis pedis artery. Normally anterior tibial artery, a branch of popliteal artery is the main artery of the extensor compartment of the lower limb which continues on the dorsum of foot as dorsalis pedis artery but in this case, it became hypoplastic and disappeared below, proximal to the ankle joint.