The pediatric flatfoot has long occupied a place in the medical literature, with concerns about the significance of its appearance. At the end of the first decade of the 21st century, an article in this journal provoked active debate about the pediatric flatfoot as part of development, and proposed a considered titration of presenting cases in an effort to justify treatment and appreciated the range and expected change in normal foot posture with growth. A decade later, the availability of normative pediatric foot posture data, and the prospective findings to confirm lessening flat feet with age, encourage a structured and considered approach to this frequent primary care presentation. The pragmatic concept of the “boomerang” is built on the research identifying pediatric flat feet likely to be symptomatic, thus requiring intervention, and filtering from those likely to remain asymptomatic. Differential diagnoses are advisedly considered, and gait remains the hallmark outcome. In this contemporary guide, an eight-step strategy has been developed to improve the approach to community pediatric flatfoot concerns. Furthermore, the three boomerang flat feet factors delineating symptomatic from asymptomatic flat feet, and applicable cutoff levels, are availed for practical reference and use. Given the recognized state of overdiagnosis and resulting unnecessary treatment that pervades the 21st century, it is timely for clear 20/20 vision for the presentation of pediatric flatfoot.
Background: Many authors have highlighted the role of muscle strength imbalance around the ankle in the development of recurrent clubfoot following Ponseti treatment. However, this possible underlying mechanism behind recurrence has not been investigated sufficiently to date. This study aimed to explore whether there is a relationship between Achilles tendon elongation and recurrent metatarsus adductus deformity in children with unilateral clubfeet treated by the Ponseti method.
Methods: A retrospective chart review was performed on 20 children (14 boys and six girls; mean age, 7 years; age range, 5–9 years) with a recurrent metatarsus adductus deformity treated by the Ponseti method for unilateral idiopathic clubfoot. At the final follow-up, isometric muscle strength was measured using a portable, hand-held dynamometer in reciprocal muscle groups of the ankle. The length of the tendons around the ankle was measured ultrasonographically.
Results: The plantarflexion-to-dorsiflexion ratio was lower on the involved side (P = .001). No significant differences in the strength ratio of inversion to eversion were found (P = .4). No difference was observed in lengths of tibialis anterior and posterior tendons (P = .1), but the Achilles tendon was longer on the involved side (P = .001; P < .01). A significant negative correlation was discovered between involved-to-uninvolved Achilles tendon length ratios and involved-to-uninvolved plantarflexion strength ratios (r = –0.524; P = .02)
Conclusions: Achilles tendon elongation may be a contributor to the muscle imbalance in clubfeet with relapsed forefoot adduction treated by the Ponseti technique.
Fracture of an ossified Achilles tendon is a rare clinical entity. Reossification after removal of the bony fragment was reported in only one case previously. In this study, we present a 49-year-old man with a reossified Achilles tendon after the removal of a fractured and ossified Achilles tendon. Treatment of an ossified or fractured Achilles tendon should be selected on a patient-by-patient basis. Surgical treatment can be used when conservative treatment has failed. The possibility of reossification after surgical treatment, especially in patients with risk factors, should be kept in mind, and the patient should be informed about this possibility.
Background: There is a paucity of literature regarding rock climbing footwear. Rock climbers anecdotally voice numerous complaints regarding their current footwear. In an effort to improve existing rock-climbing footwear, implementation of a survey tool assessing the attitudes and practices of rock climbers was undertaken.
Methods: A Web-based survey was developed to assess the demographics, attitudes, and practices of individuals active in rock climbing, with a focus on footwear.
Results: Forty-five of the 417 respondents were male and 55% were female. The average years climbing was 7, with a majority of respondents in the 18- to 34-year-old category. The majority climbed 5 to 10 hours/week. Eighty percent identified as intermediate or advanced climbers. Climbing shoes were an average of 0.83 size smaller than the climber’s street shoes. The more elite the climber, the greater the mismatch. Overall satisfaction with current rock-climbing shoes was 88%; however, as the age of climber and number of years of participation increased, the level of satisfaction decreased. The most frequently reported problems with shoes included inconsistent sizing between brands and poor heel fit. The most commonly reported locations of pain were the toes and heel.
Conclusions: The authors concluded the following: 1) a surprisingly high satisfaction with current rock-climbing shoes was reported; 2) the difference in size between climbing shoes and street shoes was less than expected; 3) more shoe fitting problems were experienced by those with the most experience in climbing and those who spend the most time climbing; 4) the most common locations for experiencing pain were the toes and the posterior heel or Achilles tendon; 5) higher than expected satisfaction levels with climbing shoes contrasted with the very high number of specific complaints and recommendations for improvement; and 6) because of the increasing popularity of rock climbing, foot care providers should learn about the various types of climbing and the shoe gear needs that result therefrom.
Beau M. Hawkins, Jun Li, Luke R. Wilkins, Teresa L. Carman, Amy B. Reed, David G. Armstrong, Philip Goodney, Christopher J. White, Aaron Fischman, Marc L. Schermerhorn, Dmitriy N. Feldman, Sahil A. Parikh, and Mehdi H. Shishehbor
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) is a small- to medium-vessel vasculitis associated with asthma and eosinophilia. If left untreated, it can lead to systemic complications with a high mortality rate. The authors present a case of eosinophilic granulomatosis with polyangiitis that initially presented with adult-onset asthma, asymmetric neuropathy to the right lower extremity, and erythematous maculopapular cutaneous lesions to bilateral lower extremities. Through an extensive work-up, the diagnosis of eosinophilic granulomatosis with polyangiitis was made. Steroid therapy was initiated, causing his eosinophil count to return to normal and his presenting symptoms to improve, although his neuropathy and weakness remained. It is our hope that presenting this unusual condition manifesting in the lower extremity can provide guidance to clinicians who might encounter this condition and help them to recognize and treat it before severe chronic complications can manifest.
Background: Given that excess opioid prescriptions contribute to the United States opioid epidemic and there are few national opioid prescribing guidelines for the management of acute pain, it is pertinent to determine if prescribers can sufficiently assess their own prescribing practice. The purpose of this study was to investigate podiatric surgeons’ ability to evaluate if their own opioid prescribing practice is less than, near, or above that of an “average” prescriber.
Methods: We administered a scenario-based, voluntary, anonymous, online questionnaire via Qualtrics which consisted of five surgery-based scenarios commonly performed by podiatric surgeons. Respondents were asked the quantity of opioids they would prescribe at the time of surgery. Respondents were also asked to rate their prescribing practice compared to the average (median) podiatric surgeons. We compared self-reported behavior to self-reported perception (“I prescribe less than average,” “I prescribed about average,” and “I prescribe more than average”). ANOVA was used for univariate analysis between the three groups. We used linear regression to adjust for confounders. Data restriction was used to account for restrictive state laws.
Results: One hundred fifteen podiatric surgeons completed the survey from in April 2020. Less than half of the time, respondents accurately identified their own category. Consequently, there were no statistically significant differences between podiatric surgeons who reported that they “prescribe less,” “prescribe about average,” and “prescribe more.” Paradoxically, there was a flip in scenario #5, whereas respondents who reported they “prescribe more” actually prescribed the least and respondents who believed that they “prescribe less” actually prescribed the most.
Conclusions: Cognitive bias, in the form of a novel effect, occurs in postoperative opioid prescribing practice; in the absence of procedure-specific guidelines or an objective standard, podiatric surgeons, more often than not, were unaware of how their own opioid prescribing practice measured up to other podiatric surgeons.
Background: The purpose of this retrospective audit was to compare patient based clinical outcomes to amputation healing outcomes twelve months after a minor foot amputation in people with diabetes.
Methods: Hospital admission and community outpatient data were extracted for all minor foot amputations in people with diabetes in 2017 in the Central Coast Local Health District.
Results: A total 85 minor foot amputations involving 74 people were identified. At the twelve-month follow-up 74% (n=56) of the minor foot amputations healed, 63% (n=41) of the participants achieved a good clinical outcome (healed, no more proximal amputations, or death within the 12 month follow up period), and the mortality rate was 18%. Poor clinical outcomes were associated with those aged greater than 60 (RR 5.75, 95% CI: 0.85 to 38.7, p=0.013), those undergoing a further surgical debridement procedure during their hospital stay (RR 2.42, 95% CI: 1.3 to 4.4, p=0.005) and those who did not attend CCLHD Podiatry clinics post-amputation (RR 2.3, 95% CI: 1.2 to 4.1, p=0.010).
Conclusions: To improve patient based clinical outcomes post-minor foot amputation, targeted follow-up in a high-risk foot clinic, and tailored discharge treatment plans for people aged over 60 or those undergoing a debridement procedure may be considered.
Background: To evaluate the clinical characteristics of ingrown toenail cases in one of the biggest reference centers.
Methods: This retrospective cohort study was conducted on patients admitted to Ufuk University Hospital with ingrown toenail between January 1. 2014 and December 31. 2019. Firstly, clinical charactersitcs and demographic features of all cases were evaluated afterwards the study population was divided into two groups: 1) Group1(Patients who were ≤ 20 years old), 2) Group 2 (Patients who were >20 years old) and these groups were compared in terms of their clinical findings.
Results: Duration of diseases, BMI, rate of medications for chronic diseases and rate of joint diseases were significantly higher in group 2. On the other hand, rates of hyperhidrosis and sudden weight gain were significantly higher in group 1(p<0.05). Severity of ingrown toenail was significantly different between the groups (p=0.006). Stage 1 was the most common stage in both groups and rate of stage 3 was higher in group 1. Onycoshisis and was more common in group 1 while nail thickening was more common in group 2 (p<0.05). Medications were also significantly different between the groups as nail wire and Aluminum chloride were the most common treatment modalities in group 2 and 1, respectively (p<0.05). Periungual edema, presence of pus, hypertrophie and granulation were more common in group 1 (p<0.05). Thin nail plate was more common in group 1 while normal and thick nail nail plate were more common in group2 (p<0.05).
Conclusion: Clinical characteristics of ingrown toe nail vary between younger and older populations. Thus, individualized approach should be preferred in the management of ingrown toe nail for different age groups.