Cognitive Bias in Postoperative Opioid-Prescribing Practice
A Novel Effect
Background: Given that excess opioid prescriptions contribute to the US opioid epidemic and there are few national opioid-prescribing guidelines for the management of acute pain, it is pertinent to determine whether prescribers can sufficiently assess their own prescribing practice. We investigated podiatric surgeons’ ability to evaluate whether 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 consisting 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 with the average (median) podiatric surgeon. We compared self-reported behavior to self-reported perception (“I prescribe less than average,” “I prescribed about average,” and “I prescribe more than average”). Analysis of variance was used for univariate analysis among 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 in April 2020. Less than half of the time, respondents accurately identified their own category. Consequently, there were no statistically significant differences among podiatric surgeons who reported that they “prescribe less,” “prescribe about average,” and “prescribe more.” Paradoxically, there was a flip in scenario 5: respondents who reported they “prescribe more” actually prescribed the least and respondents who believed 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 that of other podiatric surgeons.
Background: We aim to share our popliteal sciatic nerve block (PSB) experience, which we applied to diabetic and nondiabetic patients in the operating room of our hospital.
Methods: The patients who underwent PSB for foot and ankle surgery between October 1, 2021, and December 31, 2021, in Sakarya University Training and Research Hospital were evaluated retrospectively. All nerve blocks were administered by a single anesthesiologist. Demographic data of the patients and the duration of the operation, the type of operation, the time of application of the nerve block, whether it was single or bifurcation block, and the onset times of motor and sensory block were also recorded in the perioperative period.
Results: It was determined that PSB was applied to 49 patients over a 3-month period. The mean age of the patients was 61.33 ± 14.03 years, and 12 patients (24.5%) were women. The reason why the patients were operated on was amputation in 21 (42.9%) and wound debridement in 27 (55.1%). There were 37 patients in the diabetic group and 12 patients in the nondiabetic group. There was no significant difference between the two groups in terms of demographic data and operation characteristics, but it was observed that there was a significant difference in both sensory and motor block formation times between the two groups (P < .001).
Conclusions: In conclusion, we think that popliteal sciatic nerve block is easy to apply, the complication rate is low, and it is a suitable anesthesia method for patients who will undergo day surgery for foot ulcer.
Background: Individuals with diabetic neuropathy may experience plantar ulcers and postural instability. Although use of an insole with arch support has the potential to decrease the incidence of plantar ulcers, the choice of proper design and material density concerning postural stability is challenging. The objective of this pilot study was to conduct a preliminary evaluation of the immediate effects of custom-made ethyl vinyl acetate insoles with arch support and Shore A values of 30 or 50 on static balance in patients with diabetes and neuropathic foot/feet.
Methods: Ten women with diabetes participated in this study. Static balance was analyzed while in double-limb standing with eyes closed and eyes open and while standing on a dominant limb with eyes open wearing shoes only and wearing shoes and insoles with Shore A values of 30 and 50.
Results: With insole, the mean values of center of pressure excursions decreased significantly while standing on double limbs with eyes closed. The improvement in static balance was greater while using the insole with greater density; however, the difference was not statistically significant.
Conclusions: An insole with arch support made of ethyl vinyl acetate Shore A of 30 and 50, which could decrease plantar pressure concentration, had no negative effect on the static balance of diabetes. Therefore, further research on the long-term effects of such insoles on the static balance of diabetes is suggested.
The Diabetic Foot–Pain–Depression Cycle
A Multidisciplinary Cohort Study
Background: More than 86,000 Americans with type 2 diabetes mellitus (T2DM) undergo nontraumatic lower-extremity amputations annually. The opioid-prescribing practice of podiatric surgeons remains understudied. We hypothesized that patients with T2DM who undergo any forefoot amputation while using antidepressant medication will have reduced odds of using opioids beyond 7 days.
Methods: We completed a retrospective cohort study examining patients with T2DM who underwent forefoot amputation (toe, ray, transmetatarsal). Data were restricted to patients with a hemoglobin A1c level less than 8.0% and an ankle-brachial index greater than 0.8. The outcome was use of postoperative opioids beyond 7 days. Patients received an initial opioid prescription of 7 days or less. We developed simple logistic regression models to identify the odds of a patient using opioids beyond 7 days by patient variables: age, race, sex, amputation level, body mass index, antidepressant medication use, and marital status. Variables with P < .1 in the univariate analysis were included in the multiple logistic regression model.
Results: Fifty patients met the inclusion criteria. Antidepressant use and marital status were the only statistically significant variables. Adjusting for marital status, patients with antidepressant use had decreased odds (odds ratio, 0.018; 95% confidence interval, 0.001–0.229; P = .002) of using opioids beyond 7 days after a diabetic forefoot amputation.
Conclusions: Patients with T2DM who used antidepressants had significantly reduced odds of using opioids beyond 1 week after forefoot amputations compared with those without antidepressant use. We proposed an underlying diabetic foot–pain–depression cycle. To break the cycle, podiatric surgeons should screen this population for depression preoperatively and postoperatively and not hesitate to make a mental health referral if warranted. Nontraumatic amputations can be a traumatic experience for patients; psychiatrists and other mental health providers should be members of limb preservation teams.
Background: Fat pad atrophy is the loss of subcutaneous tissue in the plantar foot, inhibiting the cushioning function. Patients experience severe pain on ambulation from high-pressure forces. Soft-tissue augmentation, or fat pad restoration, is performed to improve the thickness and cushioning ability of the subcutaneous layer. The first of its kind, allograft adipose matrix (AAM), which has been reported to support native fat pad restoration, was evaluated to address fat pad atrophy and the cushioning ability in the plantar foot.
Methods: An institutional review board–approved retrospective study review and analysis of 16 patients (21 feet) treated with AAM in the plantar foot was conducted. Adverse events and a subjective patient evaluation of percentage improvement were reported, sometimes supported by imaging.
Results: The mean ± SD volume of AAM injected was 2.2 ± 0.7 mL (range, 1.5–2.6 mL), with a follow-up time of 3 to 20 months, in patients with a mean ± SD age of 68.6 ± 8.9 years. Overall minimal adverse events were observed, and the mean ± SD percentage improvement, as per patient feedback, was 72.9% ± 23.0% (100% corresponds to fully satisfied). The quality of skin improved with reduced presence of callus, and patients resumed their daily activities.
Conclusions: An AAM can support endogenous fat pad restoration by supplementing fat thickness and its natural cushioning ability. The early clinical observations in this retrospective study review demonstrated that patients could resume daily activities after treatment.
Background: Integrated medical curricula commonly require the review of foundational science concepts in the context of clinical applications. A detailed analysis of the Des Moines University second-year medical curricula revealed that such reviews, conducted as hours-long basic science lectures in second-year clinical systems courses, often create undesirable redundancy and can load the curriculum with excessively detailed content. We hypothesized that short, quiz-enhanced videocasts (QEVs) would allow a more focused and efficient review of foundational sciences than traditional lectures.
Methods: Five biochemistry lectures in the second year Des Moines University Doctor of Podiatric Medicine curriculum were reviewed for relevance and redundancy, shortened to 8- to 12-min QEVs and offered to students as an alternative to the respective hours-long lecture.
Results: Download data show that students chose content delivery by QEV as frequently as delivery of lectures, with QEV use peaking in the days immediately preceding the exam. Survey comments show that students appreciate the efficiency and flexibility of content delivery by QEV, particularly for focused exam preparation.
Conclusions: We conclude that the review of foundational concepts by means of short, interactive videocasts can reduce redundant and excessively detailed content from integrated curricula. Although the faculty effort for context review, content selection, and videocast production is higher than for the design of a traditional lecture, the end product offers students a much-appreciated opportunity for efficient, focused, and individualized learning.
A 70-year-old patient with multiple medical problems presented to us with displaced closed very distal tibia and fibula fractures and a prior total knee replacement on the affected extremity. We treated the patient with an isolated fibula open reduction and internal fixation. At a 1-year follow-up, both the tibial and fibular fractures had healed, and the patient had an excellent outcome. “Fibula-only” fixation of very distal tibia-fibula fractures appears to be a viable option to manage these difficult fractures. The novelty of the case report lies in that this technique has not been described previously in the literature.
Background: Idiopathic toe-walking (ITW) is a persistent gait pattern with no known etiology characterized as premature heel rise or no heel contact. We investigated the effects of functional bandaging in children with ITW on heel contact during stance phase and on gait quality.
Methods: Nineteen children aged 4 to 16 years with ITW and ten age-matched healthy children were included in the study. Elastic adhesive bandages were applied to children with ITW to assist with dorsiflexion. Before bandaging (T0) and immediately (T1) and 1 week (T2) after initial bandaging, the initial contact, loading response, and midstance subphases of gait were analyzed using light pressure sensors and the Edinburgh Visual Gait Score (EVGS). Ten age-matched children with typical gait participated for comparison in T0. The data were analyzed with Friedman and Wilcoxon signed rank tests for within-group comparisons and Mann-Whitney U tests for between-group comparisons.
Results: In T0, for the ITW group, no heel contact was observed during stance. In T1, all of the participants achieved heel contact at initial contact and loading response and 56.8% at midstance. In T2, all of the heels continued contact at initial contact and loading response and 54.3% at midstance. The EVGS significantly improved. The Friedman test showed that there were noteworthy improvements between T0-T1 and T0-T2 in video-based observational gait analysis and EVGSs (P < .001), although no difference was found between T1-T2 in video-based observational gait analysis (P = .913) and EVGSs (P = .450).
Conclusions: In children with ITW, dorsiflexion assistive functional bandaging was an effective tool to help achieve heel contact on the ground and improve walking quality for a short period after application. Further studies with longer follow-up and larger sample sizes are required to confirm the long-term therapeutic effects of this promising functional bandaging.
Hallux Valgus Plantar Pressure Distribution Before and After Surgery
A Systematic Review
Hallux valgus is a common foot deformity that may cause pain and functional limitation, and often requires surgical correction. Clinical and radiographic parameters are typically used to assess postoperative outcomes. Plantar pressure distribution systems represent an innovative additional tool to evaluate hallux functional outcome after surgery. A systematic review of the current literature was performed to assess evaluation systems used for plantar pressure analysis and differences before and after hallux valgus surgery, and a possible relationship between different surgical techniques and clinical and radiographic results. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for this review. Initial search results yielded 40 studies. Two additional studies were found through cross-reference. Twenty-five studies were screened. A total of 10 articles were included in the review process. Two main plantar pressure analysis systems were identified. Hallux function restoration based on plantar pressure measurement did not always occur. No relevant relationships between plantar pressure distribution data and different surgical techniques were established. All patients achieved satisfactory clinical and radiographic outcomes, regardless of surgical techniques used; however, no clear relationships were observed between clinical and radiographic results and the change in foot plantar pressure patterns. The current literature on this topic showed several methodologic limitations. Therefore, it is not possible to provide sufficiently supported evidence-based data regarding plantar pressure distribution rebalance after surgery using current plantar pressure analysis systems. Further investigations are needed to fill these gaps in evidence.
