Background: Along with significant case transmission, hospitalizations, and mortality experienced during the global severe acute respiratory syndrome coronavirus 2 pandemic, there existed a disruption in the delivery of health care across multiple specialties. We studied the effect of the pandemic on inpatients with diabetic foot problems in a Level I trauma center in central Ohio.
Methods: A retrospective chart review of patients necessitating a consultation by the foot and ankle surgery service were reviewed from the first 8 months of 2020. A total of 270 patients met the inclusion criteria and were divided into prepandemic (n = 120) and pandemic groups (n = 150). Data regarding demographics, medical history, severity of current infection, and medical or surgical management were collected and analyzed.
Results: The odds of undergoing any level of amputation was 10.8 times higher during the pandemic versus before the pandemic. The risk of major amputations (below-the-knee or higher) likewise increased, with an odds ratio of 12.5 among all patients in the foot and ankle service during the pandemic. Of the patients undergoing any amputation, the odds for undergoing a major amputation was 3.1 times higher than before the pandemic. In addition, the severity of infections increased during the pandemic, and a larger proportion of the cases were classified as emergent in the pandemic group compared to the prepandemic group.
Conclusions: The effect of the pandemic on the health-care system has had a deleterious effect on people with diabetes mellitus (DM)–related foot problems, resulting in more severe infections and more emergencies, and necessitating more amputations. When an amputation was performed, the likelihood that it was a major amputation also increased.
The aim of this systematic review was to examine the effects of foot orthoses on gait kinematics and low back pain (LBP) in individuals with leg length inequality (LLI). This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and has been undertaken in the PubMed-NCBI, EBSCO Host, Cochrane Library, and ScienceDirect databases. Inclusion criteria were the analysis of kinematic parameters during walking or LBP before and after foot orthosis use in patients with LLI. Ultimately, five studies were retained. We extracted the following information: study identity, patients, type of foot orthosis, duration of orthopedic treatment, protocols, methods, and data to assess gait kinematics and LBP. The results showed that insoles seem to reduce pelvic drop and active compensations of the spine when LLI is moderate/severe. However, insoles do not always seem to be efficient in improving gait kinematics in patients with low LLI. All of the studies noted a significant reduction of LBP with use of insoles. Consequently, although these studies revealed no consensus on whether and how insoles affect gait kinematics, the orthoses seemed helpful in relieving LBP.
As of 2016, Medicaid accounted for nearly 20% of state general fund budgets. Optional Medicaid services such as podiatry are often subject to cost-cutting measures in periods of economic downturn, as was the case in the wake of the 2007 financial crisis. Although the cuts were intended as a cost-saving measure, research indicates that they had the opposite effect. The restriction and limitation of these services during the Great Recession resulted in both poorer health outcomes for beneficiaries, and poorer financial outcomes for state Medicaid programs. With states citing record levels of unemployment as of April of 2020 and projecting significant declines in annual revenue in 2021, the economic conditions resulting from the coronavirus disease of 2019 pandemic are likely to rival those of the Great Recession. Given the historical precedent for restricting or eliminating optional Medicaid services as a cost-saving measure, it is likely that podiatric services will once again come under scrutiny. Previous efforts by state-level podiatric societies have proven successful in lobbying for the reinstatement of coverage under Medicaid by conveying evidence of the negative outcomes associated with elimination to stakeholders. The specialty must once again engage policymakers by drawing on evidence gleaned and lessons learned from past cuts of optional Medicaid services to avert counterproductive coverage restrictions intended to mitigate the financial impact of the coronavirus disease of 2019 pandemic.
The coronavirus disease of 2019 pandemic has disrupted health care, with its far-reaching effects seeping into chronic disease evaluation and treatment. Our tertiary wound care center was specially designed to deliver the highest quality care to wounded patients. Before the pandemic, we were able to ensure rapid treatment by means of validated protocols delivered by a colocalized multidisciplinary team within the hospital setting. The pandemic has disrupted our model’s framework, and we have worked to adapt our workflow without sacrificing quality of care. Using the modified Donabedian model of quality assessment, we present an analysis of prepandemic and intrapandemic characteristics of our center. In this way, we hope other providers can use this framework for identifying evolving problems within their practice so that quality care can continue to be delivered to all patients.
Background: Tarsal tunnel syndrome (TTS) can be divided into proximal TTS and distal TTS (DTTS). Research on methods to differentiate these two syndromes is sparse. A simple test and treatment is described as an adjunct to assist with diagnosing and providing treatment for DTTS.
Methods: The suggested test and treatment is an injection of lidocaine mixed with dexamethasone administered into the abductor hallucis muscle at the site of entrapment of the distal branches of the tibial nerve. This treatment was studied with a retrospective medical record review in 44 patients with clinical suspicion of DTTS.
Results: The lidocaine injection test and treatment (LITT) was positive in 84% of patients. Of patients available for follow-up evaluation (35), 11% of those with a positive LITT test (four) had complete lasting symptom relief. One-quarter of patients with initial complete symptom relief at LITT administration (four of 16) maintained this level of symptom relief at follow-up. Thirty-seven percent of patients evaluated at follow-up (13 of 35) who had a positive response to the LITT experienced partial or complete symptom relief. No association was found between level of symptom relief maintenance and the immediate level of symptom relief (Fisher exact test = 0.751; P = .797). The results showed no difference in the distribution of immediate symptom relief by sex (Fisher exact test = 1.048; P = .653).
Conclusions: The LITT is a simple, safe, invasive method to help diagnose and treat DTTS, and it provides an additional method to assist with differentiating DTTS from proximal TTS. The study also provides additional evidence that DTTS has a myofascial etiology. The proposed mechanism of action of the LITT suggests a new paradigm in diagnosing muscle-related nerve entrapments that may lead to nonsurgical treatments or less invasive surgical interventions for DTTS.
Background: Lipomas, derived from adipose tissue, most frequently occur in the cephalic regions and proximal extremities, but rarely in the toes. We aimed to highlight the clinical features, diagnosis, and treatment of lipomas of the toes.
Methods: We analyzed 8 patients with lipomas of the toes who were diagnosed and treated during a 5-year period.
Results: Lipomas of the toes were equally distributed by sex. Patients ranged in age from 28 to 67 years (mean age, 51.75 years). Six patients (75%) had a single lesion, and all of the patients developed lipomas on the hallux. Most patients (75%) presented with a painless, subcutaneous, slow-growing mass. The duration from symptom onset to surgical excision ranged from 1 month to 20 years (mean, 52.75 months). Lipoma size varied from 0.4 to 3.9 cm in diameter (mean, 1.6 cm). Magnetic resonance imaging showed a well-encapsulated mass with hyperintense signal on T1-weighted images and hypointense signal on T2-weighted images. All of the patients were treated with surgical excision, and no recurrences were found at mean follow-up of 38.5 months. Six patients were diagnosed as having typical lipomas, one a fibrolipoma, and one a spindle cell lipoma, which needs to be differentiated from other benign and malignant lesions.
Conclusions: Lipomas of the toes are rare, slow-growing, painless, subcutaneous tumors. Men and women are equally affected, usually in their 50s. Magnetic resonance imaging is the favored modality for presurgical diagnosis and planning. Complete surgical excision is the optimal treatment, with rare recurrence.
Background: Arch pain in athletes is a common complaint with many causes. One uncommon cause of arch pain related to exercise that is often overlooked is chronic exertional compartment syndrome. This diagnosis should be considered in athletes who presents with exercise-induced foot pain. Recognition of this problem is paramount because it can significantly affect an athlete’s ability to pursue further sports activities.
Methods: Three case studies are presented that underscore the importance of a comprehensive clinical evaluation. Unique historical information and findings on focused physical examination after exercise strongly suggest the diagnosis.
Results: Intracompartment pressure measurements before and after exercise are confirmatory. Because nonsurgical care is typically palliative, surgery involving fasciotomy to decompress involved compartments can be curative and is described in this article.
Conclusions: These three cases with long-term follow-up were randomly chosen and are representative of the authors’ combined experience with chronic exertional compartment syndrome of the foot.
Background: Diabetic foot infections (DFIs) can lead to limb loss and mortality. To improve patient care at a safety-net teaching hospital, we created a multidisciplinary limb salvage service (LSS).
Methods: We recruited a cohort prospectively and compared it to a historical control group. Adults admitted to the newly established LSS for DFI during a 6-month period from 2016 to 2017 were included prospectively. Patients admitted to the LSS had routine endocrine and infectious diseases consultations according to a standardized protocol. A retrospective analysis of patients admitted to the acute care surgical service for DFI before creation of the LSS during an 8-month period from 2014 to 2015 was performed.
Results: A total of 250 patients were divided into two groups: the pre-LSS (n = 92) and the LSS (n = 158) groups. There were no significant differences in baseline characteristics. Although all patients were ultimately diagnosed with diabetes, more patients in the LSS group had hypertension (71% versus 56%; P = .01) and a prior diagnosis of diabetes mellitus (92% versus 63%; P < .001) compared to the pre-LSS group. Significantly, with the LSS, fewer patients underwent a below-the-knee amputation (3.6% versus 13%; P = .001). There was no difference in the length of hospital stay or 30-day readmission rate between the groups. Further broken down into Hispanic versus non-Hispanic, we noted that Hispanics had significantly lower rates of below-the-knee amputations (3.6% versus 13.0%; P = .02) in the LSS cohort.
Conclusions: The initiation of a multidisciplinary LSS decreased the below-the-knee amputation rate in patients with DFIs. Length of stay was not increased, nor was the 30-day readmission rate affected. These results suggest that a robust multidisciplinary LSS dedicated to the management of DFIs is both feasible and effective, even in safety-net hospitals.
