When Suspicious Bilateral Lesions Occur On Prior Hallux Amputation Sites

Author(s): 
Jay Bornstein, DPM, FACFAS, and Larissa McDonough, DPM

These authors detail the treatment of a 56-year-old male with unusual non-healing ulcerations at previous amputation sites.

A 56 year-old male initially presented to our clinic with an unusual ulceration under the plantar aspect of his right first metatarsal head stump where a hallux amputation had been performed. In fact, both first great toes had been amputated greater than five years ago secondary to osteomyelitis from ulcerations attributed to diabetic neuropathy. Since the amputations had been performed, the patient admits that he had ulcerations over each area. The former ulcerations had subsequently healed and not returned for a few years.

   The current lesion on the right first metatarsal head stump had been present for approximately three months after the patient had driven on an extended trip without his diabetic shoe gear. Despite using current offloading modalities with his custom-molded shoes, the ulcer had not healed and he stated that it looked different (see Figure 1) than his previous ulcers.

   After debridement of the slightly fibrillated, necrotic and hyperkeratotic lesion, the ulcer measured 1.0 x 1.5cm with a granular, bleeding base. Due to the abnormal characteristics of the lesion, we obtained an initial punch biopsy during debridement and the results demonstrated pre-malignant tissue. We subsequently performed complete wide excision of the lesion in the operating room with determination of clear fresh frozen margins (see Figures 2,3 and 4). A pathological analysis revealed verrucous carcinoma with immunostaining suggesting tumor induction of human papillomavirus. After performing primary closure of the wound, we emphasized non-weightbearing by having the patient wear a fracture walking boot.

   Six months after the onset of ulceration in the left foot, we noticed a lesion on the contralateral first metatarsal head during a routine appointment after the patient had stubbed the area on a bedpost. We performed conservative care for the initial blister, which was filled with serosanguineous fluid. Upon follow-up appointments, we addressed an eschar at the site of trauma with local wound care and offloading with a wound shoe. Initial debridement of the eschar revealed fibrotic, hemorrhagic tissue. Despite conservative measures, the lesion was increasing in size, darkening in color and changing in texture (see Figure 5). With the patient’s prevalent history of pedal carcinoma, we did a total excision of the lesion and this turned out to be verrucous carcinoma as well.

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