`
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`
`
`
`
`
`
`UNITED STATES PATENT AND TRADEMARK OFFICE
`
`BEFORE THE PATENT TRIAL AND APPEAL BOARD
`
`
`
`ACRUX DDS PTY LTD. & ACRUX LIMITED
`Petitioners,
`
`v.
`
`KAKEN PHARMACEUTICAL CO., LTD. and
`VALEANT PHARMACEUTICALS INTERNATIONAL, INC.
`Patent Owner and Licensee.
`
`
`
`Case: IPR2017-00190
`U.S. Patent No. 7,214,506
`
`
`
`DECLARATION OF ASHLEY WINKLER
`
`
`
`
`
`
`
`
`
`
`
`
`
`

`

`
`
`I, Ashley Winkler, declare as follows:
`
`
`1. I am an attorney at Finnegan, Henderson, Farabow, Garrett and Dunner,
`LLP.
`
`2. I have been asked to comment on Exhibits 2011 and 2018.
`
`3. I make this Declaration based on my personal knowledge and an inspection
`of these Exhibits.
`
`4. I have reviewed and am familiar with Bradley D. Castellano, Chapter 23:
`Tinea Pedis and Onychomycosis: Overview of New Systemic Therapies, in
`RECONSTRUCTIVE SURGERY OF THE FOOT AND LEG (Nancy S.
`Vickers, ed., 1997), which I understand has been produced in this
`proceeding before the Patent Trial and Appeal Board as Exhibit 2011.
`
`5. Exhibit 2011 was originally identified in an internet search as an article in
`chapter 23 of a 1997 textbook from the Podiatry Institute, Inc., available
`electronically at the following web
`address: http://www.podiatryinstitute.com/pdfs/Update_1997/1997_23.pdf.
`Exhibit 2011 is a true and correct copy of that webpage.
`
`6. The article was subsequently located in a print version of the 1997 textbook.
`A copy of that print version is enclosed as Appendix A, which provides a
`true and correct copy of that textbook chapter.
`
`7. The content of Appendix A appears to be identical to Exhibit 2011. It
`confirms that Exhibit 2011 is an accurate copy of the contents of Chapter 23
`of the textbook entitled “Reconstructive Surgery of the Foot and Leg,
`Update ’97” from the Podiatry Institute, Inc. The textbook was edited by N.
`Vickers et al., and bears a copyright date of 1997.
`
`8. I have also reviewed and am familiar with Brian McCurdy, The Top Ten
`Innovations in Podiatry, 26 PODIATRY TODAY 1 (2013), available online
`at http://www.podiatrytoday.com/top-ten-innovations- podiatry-1, which I
`understand has been produced in this proceeding before the Patent Trial and
`Appeal Board as Exhibit 2018.
`
`
`
`
`
`
`

`

`9. Exhibit 2018 is an article downloaded from the listed webpage on January
`9, 2017, as indicated by the date at the top of the exhibit. Exhibit 2018 is a
`true and correct copy of that webpage.
`
`10. A print version of the article was subsequently located. A copy of that print
`version is enclosed as Appendix B, which provides a true and correct paper
`copy identified in the Australian University Library and is dated July 2013.
`
`11. The content of Appendix B appears to be identical to Exhibit 2018. It
`confirms that Exhibit 2018 is an accurate copy of the contents of Brian
`McCurdy, The Top Ten Innovations in Podiatry, 26 PODIATRY TODAY 1
`(2013).
`
` I
`
`
`
`
`
`
`
`
`
` hereby declare that all statements made herein of my own knowledge are true and
`that statements made on information and belief are, to the best of my knowledge,
`believed to be true; and further that these statements are made with the knowledge
`that willful false statement and the like so made are punishable by fine or
`imprisonment, or both, under Section 1001 of Title 18 of the United States Code.
`
`
`
`DATE: August 1, 2017
`
`
`
`
`
`
`By: /Ashley Winkler/
`
`

`

`
`
`
`Appendix A
`Appendix A
`
`

`

`UPDATE ’97
`
`Recomsimmg’we Surgew
`Of The Few And Keg
`
`The Podiatry Institute, Inc.
`
`Page 5 of31
`
`

`

`
`
`Reconstructive Surgery
`Of The Foot And Leg
`
`UPDATE ’97
`
`
`
`EDITOR
`
`Nancy Sinnott Viekers
`Publications Editor, The Podiatry Institute, Tucker, Georgia
`Member, Council of Biology Editors
`
`SCIENTIFIC EDITORS
`
`Stephen j. Miller, D_P.M., F.A.C.F.A.S.
`Anacortes and Oak Harbor, Washington
`Editorial Adviser, Journal ofzbe American Podiatric Medical Association
`
`Kieran T. Mahan, M.S., D.P.M., F.A.C.F.A.S.
`Vice—President for Academic Affairs and Dean,
`Pennsylvania College of Podiatric Medicine, Philadelphia, Pennsylvania
`
`Gerard V. Yu, D.P.M., 1“.A.C.F.A.S.
`Director of Podiatric Residency ’l'raining,
`Mt. Sinai Medical Center, Cleveland, Ohio
`
`Craig A. Camasta, D.P.M.
`Lithia Springs, Georgia
`Fellow, Australian College of Podiatric Surgery
`
`GRAPHIC ARTISTS
`
`Diane Y. Sewell
`
`Medical Illustrator, The Podiatry Institute, Tucker, Georgia
`
`M. Elizabeth Cater
`William M. Hines
`
`Photographic Production, The Podiatry Institute, Tucker, Georgia
`
`William H. Boyd
`Computer Illustrator, The Podiatry Institute, Tucker, Georgia
`
`
`
`':1-oa4.--.~;-.-..“
`
`
`
`Page 6 of31
`
`

`

`CORPORATE SPONSORS
`
`BENEFACTORS
`
`Atlanta Leg Lengthening 8: Deformity Correction Center
`
`Dynasplint Systems, Inc.
`
`EBI Medical Systems
`
`Musculoskeletal Transplant Foundation
`
`Ortho Pharmaceutical Corporation
`
`Orthologic
`
`Ruch Orthotic Lab, Inc.
`
`Sandoz Pharmaceuticals Corporation
`
`have provided an educational grant to help defray the cost of this publication.
`The Podiatry Institute is grateful for their support.
`
`
`
`Copyright © 1997, by The Podiatry Institute, Inc.
`
`The Podiatry Institute, inc,
`1459 Montreal Road, Suite 206
`Tucker, Ga. 30084
`
`All rights reserved. No part of this publication may be reproduced,
`stored in a relriewll system, or transmitted in any form or by any means,
`electronic, mechanical, photocopying, recording or otherwise, without prior
`written pennjssion from the publisher. Printed in the United States of America.
`
`
`
`Page 7 of31
`
`

`

`PREFACE
`
`This textbook is the 16th edition of lecture presentations representing new ideas and
`experiences from the dedicated faculty of the Podiatry Institute. These faculty members are
`eager to share their interests and ideas with their colleagues, garnished With generous amounts
`of reflection on their experiences. After all, learning is sharing.
`
`This year there are 56 chapters covering a host of new topics, as well as fresh reviews of
`popular subjects. There is not a lack of tackling difficult clinical problems. Presented in the
`Forefoot Section are some focused and fresh ideas on digital surgery and lesser metatarsal
`dilemlnas, as well as forefoot techniques such as those involving sesamoid influences, two—
`component implants, and hallux valgus considerations.
`
`In the section on Medicine, there are reviews of many new advances especially in such
`areas as osteoporosis, wound care, oral treatments for diabetes, restless leg syndrome, oral
`antibiotics, and gout.
`
`Several research papers highlight the Rearfoot Section, covering subjects such as heel
`pain, arthrodesis problems, single joint fusions, tibialis posterior dysfunction, and the new
`MBA arthroereisis implant.
`
`there are
`in the section on Special Surgery and Advanced Techniques,
`Finally,
`informative papers on bone biopsies, amputations, plantar surgery, cartilage resurfacing
`techniques, ankle ligaments, running injuries and others.
`
`Our goal is to provide information you can use in your practice and put into service for
`your patients. Without your success as surgeons, our mission has no meaning.
`
`Stephen Miller, D.P.M., FA.C.F.A.S.
`Chairman, Board of Directors
`
`The Podiatry Institute
`
`
`
`
`
`
`Page 8 of3l
`
`

`

`CONTRIBUTORS
`
`Steven R. Carter, D.P.M.
`Private Practice, Roch Hill, South Carolina
`Associate, American College ofFoot and Ankle Surgeons
`Afl'ilate Member, The Podiatry Institute
`
`Bradley D. Castellano, D.P.M.
`Private Practice, Fort Myers, Florida
`Fellow, American College ofl'bot and Ankle Surgeons
`Diplomate, American Board of Podiatric Smgery
`Faculty, The Podiatry institute, 'l‘uclrer, Georgia.
`
`Matthew Cerm'glia, D.P.M.
`first Yea-rResidenl, Hillctert Health Center;
`Ohlahoma City, Oklahoma
`
`Thomas Chang, D.P.M.
`Associate Professor, Department omegety, California college of
`Pediatric Medicine, San Francisco, California
`Director, Surgical Residency Program, California College of
`Pediatric Medicine, San Francisco, California
`Fellow, American College ofFoot and Ankle Surgeons
`Diplomatic, American Board ofl’odiatric Surgery
`Faculty, The Podiatry institute, Tucker; Georgia
`
`Luke D. Cicchlnelli, D.P.M.
`Private Practice, Greenville, North Carolina
`Consultant, Cl-inica Ortocen, Madrid, Spain
`Fellow, Australian College ofPodiatric Surgery
`Diplornate, American Board ofPodiatric Orthopedics
`Faculty, The Podiatry institute, 'l‘uclrer, Georgia
`
`Stephen V. Corey, D.P.M.
`Assistant Professor; Department ofSutge-ry, Pennsylvania College
`ofPodiatric Medicine, Philadelphia, Pennsylvania
`Fellow, American College ofFoot and Anhle Surgeons
`Diplomats, American Board ofPodiatric Surgery
`Faculty, The Podiatry Institute, Tucker; Georgia
`
`Angela P. Dominique, D.P.M.
`Resident, VA Medical Center, Augusta, Georgia
`
`Michael S. Downey, D.P.M.
`Profissor and Chairman, Department thurgery, Pennsylvania
`Collge ofPodiatr‘ic Medicine, Philadelphia, Pennsylvania
`Chairman, Division ofPodiatric Surgery, Presbyterian Medical
`Center; Philadelphia, Pennsylvania
`Fellow, American College ofFoot and Ankle Surgeons
`Diplmnate, American Board ofPodiatric Surgery
`Diplomate, American Board ofPodiatric Orthopedics
`Editorial Advisory Board, journal of the American Podiatric
`Medical Association
`Faculty, The Podiatry Institute, Tucker, Georgia
`
`William D. Fishco, M.S., D.P.M.
`Second Yearli’esident, Northlalce Regional Medical Center,
`Tucher; Georgia
`
`David C. Alder, D.P.M.
`Third Yearllesident, Northlahe Regional Medical Center,
`Tucker; Georgia
`
`Alan S. Banks, D.P.M.
`Private Practice, Tucker, Georgia
`Director cfPodiatric Medical Education and Residency Training,
`Northlalte Regional Medical Center, Tucker; Georgia
`Fellow, American Collge ofFoot and Ankle Surgeons
`Diplomate, American Board ofPodiatric Surgery
`Faculty, The Podiatry Institute, Tucker; Georgia
`
`Brian N. Bennett, D.P.M.
`Resident, VA Medical Center, Augusta, Georgia
`
`Edwin L. Blitch, D.P.M.
`Private Practice, North Charleston, South Carolina
`
`Jeffrey S. Boberg, D.P.M.
`Private Practice, Southern Illinois and St. Louis, Missouri
`Fellow, American College of Foot and Ankle Surgeons
`Diplomatic, American Board of Podiatric Surgery
`Faculty, The Podiatry lnstitute, Tucker, Georgia
`
`Joules L. Bouchard, D.P.M.
`Private Practice, Roswell, Georgia
`Director ofPocliatric Medical Education and Residency Training,
`Decatur Hospital, Atlanta VAMC, Decatur, Georgia
`Fellow, American College ofFoot and Ankle Surgeons
`Diplomate, American Board qfl’odiatric Surgery
`Diplomote, American Board ofl’odiatric Orthopedics and
`Himary Pediatric Medicine
`Faculty, The Podiatry Institute, Tucker, Georgia
`
`Mark Brekke, D.P.M.
`Resident, Scripts Mercy Hospital and Medical Center,
`San Diego, California
`
`joel W. Brook, M.S., D.P.M.
`Second Year Resident, The Mt. Sinai Medical Center,
`Cleveland, Ohio
`
`Thomas A. Brosky, II
`Fourth Year Student, Ohio College rfPodiatric Medicine
`Cleveland, Ohio
`
`Michelle Butterworth, D.P.M.
`Second Year Resident, University ofPennsylvania Health System,
`Presbyterian Medical Center, Philadelphia, Pennsylvania
`
`CraigA. Casuasta, D.P.M.
`Private Practice, Lithia Springs, Georgia
`Fellow, Australian College ofPodiatric Surgery
`Faculty, The Podiatry institute, Tucker; Georgia
`
`Martin Carey
`Third Year Student, Pennsylvania College ofl’odiatric Medicine,
`Philadehrhia, Pennsylvania
`
`Page 9 of31
`
`

`

`Robert M. Guecker, D.P.M.
`First Year Resident, Northlake Regional Medical Center,
`Tucker; Georgia
`
`Donald R Green, D.P.M.
`Private Practice, San Diego, Califomia
`Pediatric Residency Director, Scripts Mercy Hospital and Medical
`Center, San Diego, California
`Clinical Assistant Professor, UCSD School ofMedicine,
`Departrrrent of Orthopedics, San Diego, Califirmia
`Fellow, American College ofFoot and Ankle Surgeons
`Diplomatic American Board ofPodiatric Surgery
`Faculty, The Podiatry Institute, Tucker, Georgia
`
`M. Jay Groves, IV, D.P.M.
`Third Year Resident, Nortklake Regional Medical Center,
`Tucker, Georgia
`
`Sanford S. Hartman, M.D.
`Private Practice, Decatur, Georgia
`Clinical Associate loofessor trchdicirre (Rheumatolom), Emory
`University School ofMedicine, Atlanta, Georgia
`Wee—Chief; Medical Stafi, flaked» Medical Center, Decatur, Georgia
`
`Richard Jensen, D.P.M.
`Third Year Resident, California College ofPodiatric Medicine,
`San Francisco, Colifirrnia
`
`A. Louis Jimenez, D.P.M.
`I’rivatePractice, Snellville, Georgia
`Provident, American College ofFoot and Ankle Surgeons
`Fellow, American College of Foot and Ankle Surgeons
`Diplorrrate, American Board cnyodiotric Surgery
`Faculty, The Podiatry Brstitute, Tucker, Georgia
`
`Molly S. Judge, D.P.M.
`(.‘lriefPodiatrlc Resident, Tlrc Mt. Sinai Medical Center,
`Cleveland, Ohio
`
`William Knudsen, D.P.M.
`Second Year Resident, Hillcrest Health Center,
`Oklahoma City, Oklaltoma
`
`Gary N. Laden, D.P.M.
`Private Practice, Atlanta, Georgia
`Fellow, Arrmican College ofFoot and Ankle Surgeons
`Diplornote, American Board ofl’odiatric Surgery
`
`Stephan LaPointe, D.P.M., PILD.
`First Year Resident, Nortitlalte Regional Medical Center,
`Tucker, Georgia
`
`David R. Leech, M.D.
`Private Practice, Frsornnta Institute of
`Difrlomate, American Board ofSlecp Modicine
`Dryrlrrmate, American Board ofPsychiatry and Neurology
`
`Tucker, Georgia
`
`Ron Lieberman, D.P.M.
`Private Practice, Encinitas, Galrfiruia
`Fellow, American College quoot and Ankle Surgeons
`Diplomats, American Board ofPorliat-ric Surgery
`
`Kieran T. Median, M.S., D.P.M.
`Vice—President forAcadernic Afiairr and Dean, Pennsylvania
`College ofPediatric Medicine, Plriladelvkia, Pennsylvania
`Consultant, National Naval Medical Center, Bethesda, Maryland
`Fellow, American College ofFoot and Ankle Surgeons
`l'elkrrv, Arrrericart College afloat and Ankle Orthopedics and
`Medicine
`
`Dr’plomate, Arrrerica-rt Board ofPodiotric Surgery
`tJifrlorrrate, Amm'cart Board ofPodiatric Orthopedics and
`Primary Pediatric Medicine
`Faculty, The Podiatry Institute, Tucker; Georgia
`
`D. Scot Malay, D.P.M.
`Private Practice, State College, Pennsylvania,
`Fellow, American College officer and Ankle Surgeons
`Diplomate, American Board ofl’odiatric Surgery
`Diplomate, American Board ofl’odiatrlc Orthopedics
`Clrigfi Podiatric Surgery Section, Centre Community Hospital,
`State College, Pennsylvania
`Faculty, The Podiatry Institute, Zl‘aclrer, Georgia
`
`John T. Marcoux, D.P.M., RT.
`'l‘lrlrd Year Resident, University ofPemrsylvania Health system,
`Presoyterian Medical Center, l’lriladefi-bhia, Pennsylvania
`
`Dennis E. Martin, D.P.M.
`Private Practice, Nortlt Charleston, South Carolina
`Fellow, American College official and Ankle Surgeons
`Diplomats, American Board ofPediatric Surgery
`Faculty, Tlre Podiatry Institute, Tucker, Georgia
`
`William Martin, D.P.M.
`Associate Professor; Department glPodiatric Orthopedics, and
`Associate Woe—President and Medical Director ofHealth
`Services Division, Pennsylvania College ofPodiam'c
`Medicine, Philadelphia, Pennsylvania
`Fellow, American College ofFoot and Ankle Surgeons
`Fellow, Arrrerican College ofFoot and Ankle Orthopedics
`Diplorrrate, American Board ofPodiatric Surgery
`Diflomate, American Board ofPodiotric Orthopedics- and
`Primary Podiatric Medicine
`
`Jerry R. Maxwell, D.P.M.
`Private Practice, Edmond, Oklahoma
`Fellow, American College offioot and Ankle Surgeons
`Difrlornate, American Board (J'Podiatric Surgery
`Faculty, The Podiatry Institute, 'l‘ucker; Georgia
`
`Michael C. McGIamry, D.P.M.
`Private Practice, Gainesvitle, Florida
`Faculty, Tlre Podiatry Institute, Tucker; Georgia
`
`.M.
`Robert R. Miller, D.
`ChiefResident, University afPerrnsylvam‘a ttcaltlr System,
`Presbyterian Medical Center, Philadelphia, Pennsylvania
`
`Stephen Miller, D.P.M.
`Private Practice, Anacortes and. Oak Harkor, Washington
`Member, Northwest Podiatry Foundation
`Fellow, American College ty‘t‘hot and Ankle Surgeons
`Diplomate, American Board ofPodiatric Surgery
`Diplomate, American Board of Pediatric Ortkopedics and
`Primary Podiatric Medicine
`Editorial Adviser; Journal of the American Podiatric
`Medical Association
`Associate Editor; Briljsh Journal of l’odiaLric Medicine
`and Surgery
`Faculty, The Podiatry Institute, Tucker, Georgia
`
`
`
`Page 10 of31
`
`

`

`James H. Morgan, Jr., D.P.M.
`Pint Yea-rReIriderrt, Nortlrlnke Regional Medical (renter,
`Tucker; Georgia
`
`Robb A. Mothershcd, D.P.M.
`Second Year tin-ideal, Nortlrloke Regional Medical Center;
`Tucker, Gemgia
`
`Alfred J. Phillips, D.P.M.
`Private Practice, Bedfirr‘rl, New Hampshire
`Fellow, American College oft-"oat and Ankle Surgeons
`Diplomate, American Board ofPodiatric Surgery
`Faculty, The Podiatry Institute, Tucker, Georgia
`
`Charles F. Peebles, D.P.M.
`Second Year Resident, Northlake Regional Medical Center,
`Tucker, Georgia
`
`Jane Pontious, D.P.M.
`Associate Professor, Department qumyery, Pennsylvania College
`ofPediatric Medicine, Philadelphia, Penrnylvania
`Fellow, American College affront and Ankle Surgeons
`Fellow, Arrrerican College ofFoot and Ankle Pediatrics
`Diplornate, American Board ofPediatric Surgery
`Diplornate, American Board ofPrimary Pediatric Medicine
`Affiliate Member, The Podiatry Institute, Tucker, Georgia
`
`Murray Reicher, M.D.
`Radiologist, Scripts Mercy Hospital and Medical Center,
`San Diego, Califlrr‘nia
`
`John A, Ruch, D.P.M.
`Private Practice, 'l‘rtcker, Georgia-
`Felloru, American College ofFoot and Ankle Surgeons
`Diplo mate, American Board rJPoctiatr/ic Surgery
`(IE. 0., Tire I’mliatry firstr'tate, flicker, Georgia
`Ii‘acnlrgv, Tlre Podiatry Institute, Tucker, Georgia
`
`Anna Ruelle, D.P.M.
`first Yearllesiderrt, The Mt. Sinai Medical Center,
`Cleveland, Ohio
`
`Manuel Gonzalez San Juan, Podélogo
`Clinica Ortocen, Madrid, Spain
`
`Amie Scandin, 13.5., M.S.
`Fonrtlr Year Strident, Iowa College ofPodiatric medicine,
`Des Moines, Iowa
`
`Barbara S. Schlefman, D.P.M.
`Private Practice, Tucker, Georgia
`Fellow, American College ofFaot and Ankle Surgeons
`Diplornate, Arrrerican Board ofPediatric Surgery
`Boa-rd rfDir‘ectorx, GI’MA
`Faculty, The Podiatry Institute, Tucker; Georgia
`
`John M. Schuberth, D.P.M.
`Attending 3mg; Depart-meat of Orthopedic Surgery, Kaiser
`Foundation Hospital, San Francisco, California
`Afliliate Mernlrer, Tire Podiatry Institute, Tucker; Georgia
`
`Jeffrey E. Shook, D.P.M.
`Private Practice, Huntington, West Virginia
`Member, TeaclringFaoalty, Tire Mt. Sinai Medical Center,
`Division of Podiatric Surgery, Cleveland, Ohio
`
`Thomas F. Smith, D.P.M.
`Private Practice, Augusta, Georgia
`Concultant, Residency Program, VA Medical Center,
`Augusta, Georgia
`Fellow, American College ofFoot and Ankle Surgeons
`Diplomats, American Board ofPodiatric Surgery
`Faculty, The Podiatry Institute, Tucker, Georgia
`
`Joe T. Southerland, D.P.M.
`Private Practice, Knoxville, Tennessee
`Facility, The Podiatry Institute, 'I‘ncker, Georgia
`
`Mickey D. Stapp, D.P.M.
`Private H‘actice, Augusta, Georgia
`Faculty, The Podiatry Institute, Tucker; Georgia
`
`Robert P. Taylor, D.P.M.
`'I‘frira’ Year Rericlent, Northlake Regional Medical Center,
`Tucker; Georgia
`
`Javier Aycart Testa, Podologo
`Clinton Ortocen, Madrid, Spain
`
`Sean Walpole
`Third Year Student, Pennsylvania College ofPodiatric Medicine,
`Philadelphia, Pennsylvania
`
`Ethel M. Wright, D.P.M.
`Ir‘r‘r'st Year Resident, St. Clare; Hospital, New York, New York
`
`Ian Yu, M.S., D.P.M.
`First Year Resident, Washington llosfiital Center,
`Washington, I). C.
`
`Gerard V. Yu, D.P.M.
`Private Practice Cleveland, Ohio
`Director ofl’odiatric Residency Training, The Mt. Sinai
`Medical Center, Cleveland, Olrio
`Chiral, Divirion ofPodiatry, Department of Surgery, Meridian;
`Huron Hospital East Cleveland, Ohio
`I-‘ellow, American College ofFoot and Ankle Surgeons
`Diplornate, American Board ofPodiat'ric Surgery
`Faculty, The Podiatry Institute, Tucker; Georgia
`
`Richard J. Zirm, D.P.M.
`Private Practice, Cleveland, Ohio
`Diplornate, American Board ofPocliatrlc Snrgery
`Faculty, ’l'lze Podiatry Institute, Tucker, Georgia
`
`Page 11 of31
`
`

`

`CONTENTS
`
`Page
`
`Chapter
`
`Chapter
`
`Section I: Forefoot and Hall“X
`
`Valgus Surgery
`1 / Surgical Decision Making in
`Hammei’toe Deformity
`Jamey 5. 13015ch
`
`13 / Spinal Ratliculopathy and Its
`importance in Pediatric Medicine
`Wiflr'crm D. Fisbco
`
`14 / The Current Role of MRI in the
`
`Management of infection
`Micbefk.’ BMImIIJO-PTb and Stephen 'Ir'. Corey
`
`15 / Oral Antibiotics in Pediatric
`Medicine
`Robb A. Mammalian?
`
`16 / Osteoporosis
`Sanford 5. Hartman
`
`17 / New Oral Agents for the
`Treatment of Diabetes
`fairies H. Morgan, Jr.
`
`18 / Gout Update
`A. HJtrt'sJinze-nez and .S'Iayibmzj. [chru'nm
`
`19 / Benign Osseous Tumor of
`Soft Tissue
`Lake 1:). (.‘Fccbincr‘it, Manuel Gonzales Szmjtmn,
`andjcwier AJm‘m‘t Term
`
`20 / Benign Bone Tumors of the
`Foot and Ankle
`Robe)? R, Hitler and Stephen V. Carey
`
`21 / Reslless Legs Syndrome
`Robe]? M'. Goeckcr mth 1'3er X. £656.!)
`
`22 / Systemic Lupus Erythematosus
`Sanford .S‘. Hammm
`
`23 / Tinea Pedis and Onyehomycosis:
`Overview of New Systemic
`’l"|1erapies
`Bradley: D. C'asfeiiarm
`
`85
`
`87
`
`94
`
`100
`
`105
`
`114
`
`120
`
`125
`
`130
`
`134
`
`Section III: Rearfoot and Ankle Surgery
`
`24 / Avascular Necrosis of the Talus
`foe! Break and Michael“ S. Downer
`
`25 / Tarsal Coalition
`lime! M. might Ron Liehm‘mzm, Mania Emil-rite,
`Murmur Ratchet; and Darwin? Green
`
`26 / The Subtalar Joint Sprain
`Germri V. 1’1:
`
`27 / Cuboid Syndrome
`Richard]. Zr'rm
`
`28 / Retrospective Analysis of
`Subtalar Aithroclesis Utilizing
`Ins-rm Cartilage Resection
`ferry Masai/eff, Wiflt'am Knudsen,
`Matthew Cemigir'a, and Amie SCGHHFH
`
`143
`
`151
`
`164
`
`.171
`
`176
`
`2 / A Surgical Technique for Repair
`of the “Pie—Dislocation Syndrome”
`fr)th A. Ruck
`
`3 / Flexor Digitorum Longus Transfer
`for Second Metatarsophalangeal
`Joint Dislocation/Subluxation
`Job}? M. Scimbewh and Rfciaawfjenseu
`
`4 / Lesser Metatarsal Surgery for the
`Treatment of Chronic Intractable
`Plantar Kei‘atosis
`fang Pamions and Wither» Mai-rm
`
`'5 / Technique for Tailor’s
`Bunionectomy
`joim A. Red)
`
`6 / Current Indications for the
`Closing Base Wedge Osteotomy
`of the First Metatarsal
`am 5. scrubs
`
`7 / Weight Bearing Analysis of the
`Keller Arthroplasry
`Stephen V. Corey HHdJUbH T. Margaux
`
`8 / The Akin Osteotoniy with
`Horizontal Interosseous Wire
`Loop Fixation
`Btu-bani S. Sch-Winnie
`
`9 / Hallux Valgus Surgery and the
`Sesamoid Apparatus
`Germ-d 1/. Ya, Mor‘eh’Sjmr'gta and Robert P. Itiyfur
`
`10 / Hallux Varus: Congenital vs.
`Acquired
`Am.ng Phil’in
`
`11 / Reflections on the RCFlCXlOnTM
`First Metatarstmhaiangeal Joint
`Implant
`Stephen-l. JWHJ'GJ'
`
`Section 11: Medicine
`
`12 / Wound Care Concepts, principles,
`and Products
`Robert P. Tajer
`
`11
`
`15
`
`22
`
`27
`
`33
`
`37
`
`42
`
`50
`
`59
`
`Page 12 of31
`
`

`

`Chapter
`
`Page
`
`Chapter
`
`43 / Tibialis Posterior Dysfunction:
`A Critical Look at Surgical
`Approaches
`Kieran 1'". Main?” and Sean Walpole
`
`Page
`
`265
`
`29 / Isolated Subtalar Joint Arthrodesis:
`Refinements in Fixation Technique
`Gemini V. In, foai W. Limos, Amm Riiciie,
`and iibomas A. Brushy, ii
`
`30 / Cole Osteotomy: A Follow—Up
`Evaluation
`H-iicbciei 5. Downey
`
`180
`
`192
`
`31 / lncisional Approaches and Soft Tissue
`Dissection for Ankle Arthrodesis
`197
`David C, Alder midjoiiii 11. Rad:
`
`32 / Rearfoot and Ankle Degeneration
`Following Malpositionecl
`Arthrodesis
`Craig A. Cmimsm
`
`33 / Intramcdullaw Nail in Foot and
`Ankle Arthrodesis
`jog T, .S‘ouihericmci
`
`34 / Lesions of the Heel
`Mfcbcrei C. McGicimiy
`
`55 / Atypical Heel Pain
`M. Jay Grows, iV
`
`56 / Haglund’s Deformity and Posterior
`Heel Pain: A Retrospective Analysis
`of ’l‘reatmcnt
`D. Scoi Mainy
`
`57 / Endoscopic Plantar Fasciotomy:
`Current Controversies
`Micbciei' .5'. Decency
`
`58 / Retrospective Analysis of Minimal
`Incision, Endoscopic and Open
`Procedures for Heel Spur
`Syndrome/Plantar Fasciitis
`Mani? X. Bi‘ekl'ac and Houdini R. Green
`
`39 / Tibialis Posterior Dysfunction:
`A Clinical and Radiographic
`Classification
`Dennis Mama and Edwin L. Biii‘cb
`
`4O / Tibialis Posterior Dysfunction:
`Conservative Treatment
`
`Considerations
`Mickey i). 5‘1qu
`
`41 / Talo-Navicular Arthrodesis for
`
`Adult Flatfoot Deformity
`Sieve” R. (Javier micijoim A. Rucb
`
`42 / The MBA Arthroereisis Implant:
`Early Prospective Results
`ferry Mzrri'meii,
`li'ffiiimn Knudsen,
`crmi Maritime Ccmrjgiici
`
`205
`
`209
`
`213
`
`220
`
`223
`
`227
`
`231
`
`236
`
`245
`
`248
`
`256
`
`Page 13 of31
`
`Section IV: Special Surgery and Advanced
`
`Techniques
`
`44 / Appropriate Environment and
`Surgical Considerations for
`Bone Biopsy
`A. Loriisflmenez mm’ Cbm'ies I". Peebies
`
`45 / Basic Principles and Techniques
`of Forefoot Amputations
`fairies I, Boucimrci
`
`46 / Current Concepts of Articular
`Cartilage Resurfacing Techniques
`’i'i'mmnsf Chang and Fan hr
`
`273
`
`276
`
`284
`
`47 / The Effect of Damage to the Lateral
`Collateral Ligaments on the Three
`Dimensional Flexibility Characteristics
`of the Ankle Complex
`287
`Stephan ]. {xiPoinfe
`
`48 / Hydroxyapatite as 3 Bone
`Substitute
`Kiemn ‘1‘. Main“: rind Marin: Canny
`
`49 / Hallux Interphalangeal Joint
`Ulceration: A Surgical Correction
`Desi-iris E. Mm‘iiii am? Edwin L. Biiici;
`
`50 / Soft Tissue Anchors: An Update
`Thomas}, Chang
`
`51 / The Plantar Skin and Soft Tissues:
`
`Surgical Anatomy Review
`iimnms J". Smith am! Brian N. Barman
`
`52 / Fibular Sesamoidectomy: Plantar
`Approach Surgical Technique
`Thomas F. Smin and Angela P. Dominique
`
`53 / Excision of the Plantar Mass
`Aim: S. Banks
`
`54 / Plantar Fibromatosis: Diagnosis
`and Management
`Kiemr: T. Mame
`
`55 / The “Jones Fracture” Revisited:
`A New Surgical Approach for
`Consideration
`Gmmti V. Ya arzdfeffiey i3. Shook
`
`56 / Case Studies of Talonavicular
`Arthroclesis
`joim A. Each
`
`57 / Running Injuries of the Lower
`Extremity
`Cbm'iesE Peebies and (any N. laden
`
`295
`
`297
`
`301
`
`506
`
`314
`
`319
`
`325
`
`330
`
`539
`
`544
`
`

`

`
`
`CHAPTER 23
`
`TINEA PEDIS AND ONYCHOMYCOSIS:
`Overview of New Systemic Therapies
`
`Bradley D. Candler/m, DEM.
`
`Tinea pedis and onychomycosis are the most
`frequently occurring superficial fungal
`infections.
`Recently, new oral antimycotic agents have brought
`significant enthusiasm for the treatment of these
`often recalcitrant conditions. Onychomycosis was
`often unsuccessfully treated with topical agents
`prior to the introduction of these systemic agents.
`While tinea pedis is often treated successfully with
`topical agents, the author can say that in eight years
`of practice in podiatry, he has never successfully
`cleared a single case of onychomycosis with any of
`the topical antifungal agents promoted as treatment
`for
`this
`toenail
`infection.
`In the recent past,
`griseofulvin was
`the only oral agent with a
`satisfactory safety profile to allow its long term use
`for
`the treatment of onychomycosis. However,
`even this form of t'l'leiapy proved to be of little
`value in the treatment of toenail onychomyeosis. A
`brief overview of superficial Fungal infections of the
`feet will be presented. Special attention is given to
`new forms of therapy for these conditions.
`
`EPIDEMIOLOGY
`
`infections has gradually
`The prevalence of fungal
`increased in the United States. Many factors are
`considered
`to
`contribute
`to
`this
`increased
`
`incidence. An aging population, combined with
`frequent use of systemic antibiotics are considered
`to be major reasons for the prevalence of these '
`conditions. It has been estimated that 15% to 20%
`
`of those over 40 years old have onychomycosis.
`The vast majority of
`superficial
`fungal
`infections are caused by dermatophytes. Recent_
`emphasis has been placed on the occurrence of
`nonderrnatophytes as etiological agents in these
`diseases. However, Kemna found after reviewing
`561 specimens,
`that 94.7% of the cases of tinea
`pedis and 81.9% of onychomycosis cases in the
`United States were caused by dermatophytesfi
`Iiv'cbopbyton rubmm was the most commonly
`isolated organism in tinea pedis and onychornye
`cosis,
`representing 78.9% and 76.2% incidence
`
`respectively. Another study, performed in Canada,
`reported similar
`results with
`det‘matophytes
`causing 90.7% of tinea pedis cases and 97.1% of
`onychomycosis.2
`sometimes
`are
`Non—dermatophyte molds
`recovered from nail, hair, and skin cultures.
`However, most agree that
`these organisms are
`contaminants. In fact, one investigator suggests that
`in order to consider a non—dermatophyte mold to
`he considered clinically significant,
`it must grow
`from 5 of 20 inocula.’ However, more recent
`studies have suggested that nondermatophytic
`molds and yeasts are having an increasing role in
`the pathogenesis of onychomycosis." Kemna'
`proposed a classification system for onychomycosis
`similar
`to
`that
`used
`for
`tinea
`pedis.
`“Onychomycosis complex” was described as a
`condition resulting when dermatophytic fungi
`create a condition favorable to the overgrowth of
`saprophytic molds. He also states that though the
`saprophyte may not have been the original
`pathogen,
`it still may represent “valid growth.” In
`any event, it is probably reasonable to assume that
`as new therapies emerge so too will infections due
`to resistant organisms.
`
`DERMATOPHYTOSES
`
`Fungal infections of the superficial skin, hair, and
`nails are caused by keratinophilic fungi called
`dermatophytes. They are a small fraction of the total
`number of know fungi and are generally not
`considered normai skin flora. These organisms are
`found in soil and in infected animals and humans.
`
`The infection of a host occurs when an organism is
`deposited on the skin and secretes keratolytic
`enzymes
`that enable the fungi
`to invade the
`epidermal layers of skin. Since the organism is being
`sustained by keratin, it is rate that it invades deeper
`tissues that do not contain this food source. Host
`
`response to the invading fungi may vary depending
`on the organism involved, location of the infection,
`and the individual host’s immune status.
`
`
`
`Page 14 of31
`
`
`
`

`

`
`
`CHAPTER 23 135
`
`TINEA PEDIS
`
`Chronic Hyperkeratotic Tinea Pedis
`
`Tinea pedis is very common in the shoe wearing
`population. Over—thc—countcr
`topical
`therapy is
`often successful in the treatment of this condition.
`
`However, in many instances the patient treats the
`condition incompletely, or not at all. Therefore,
`chronic infections and acute exacerbations are a
`
`frequent reason the patient seeks medical attention.
`There are three general
`types of
`tinea pedis:
`intertriginous, chronic hyperkeratotic, and acute
`inflammatory. Generally, the inter‘tr‘iginous type of
`infection is subdivided into simplex and complex,
`depending on the degree of superinfection and
`maceration of the intertriginous spaces of the toes.
`
`Intertriginous Tinea Pedis
`
`The typical intertriginous infection of tinea pedis
`can be subdivided into two types. Der‘matophytosis
`simplex is the condition that produces dry, scaly
`lesions of the intertriginous areas, often spreading
`to the dol‘sum of the foot (Fig.
`l). KOH will be
`positive for dermatophyte.
`fl‘tcbopbyirm, or less
`frequently, Epider‘mopbyton are the organisms most
`likely encountered.
`If
`the conditions exist
`for
`progression of the disease process,
`the organism
`causes skin damage and build up of macerated
`dcsquamated skin. This “media” of detritus can
`allow the overgrowth of other organisms to occur,
`specifically, cocci, diptheroids, and gram negative
`organisms that are not inhibited by the penicillin—
`like substances secreted by the dermatophytes.
`This
`condition of “superinfection”
`is
`called
`dermatophytosis complex. Usually severe over-
`growth with gram negative organisms such as
`Pseudo-.Inonm, Corynebacter‘ium minmissimnm, or
`M. sedentar‘a’m cause a pungent malodor that aids
`in the diagnosis of this condition (Fig. 2).
`Treatment of the simplex condition is often
`successful with
`various
`over—thc—counter
`or
`
`the
`as
`prescription antifungal agents. However,
`simplex condition gives way to the complex form of
`dermatophytosis, treatment may need to be altered to
`reduce bacterial growth and remove macerated
`tissue. The author has found that
`improved foot
`hygiene combined with Castellani’s paint
`(carbol—
`fushin dye and phenol) is very helpful in drying the
`Webspaoes, and as a keratolytic to reduce desqua—
`mated cells that have become infected. Eventually,
`treatment of the dermatophyte on a long—terrn basis is
`generally required to prevent recurrent infections.
`
`This form of tinea pedis is generally caused by
`the
`organism fi‘icbopbyion mrbrum or
`T.
`menmgmpbytes. In general, this form of tinea pedis
`is restricted to the soles of the feet. In some cases,
`the palm of the hand can become involved. This two
`feet one hand presentation is sometimes helpful in
`distinguishing tinea from psoriatic lesions that are
`usually bilateral symmetrical. The thickness of the
`soles of the feet act as a barrier to the fungus, while
`allowing a dry scaly infection to occur without
`causing the host to mount an immune response.
`Moccasin foot distribution is used to describe the
`
`typical presentation of this infection.
`The treatment of this condition can at times be
`
`therapy may be
`difficult. Prolonged topical
`curative, however, many practitioners have found
`
`intertriginous tinea pedis. Dermatophyte was
`Figure 1. Dry. scaly,
`cultured. One month course of topical terbinaline successfully cleared
`this infection.
`
`
`
`
`Figure 2. This patient suffered a painful intertriginous infection of the
`left foot. The infection cleared with oral cipr‘ofloxacin. Howe