Background: Diabetic foot osteomyelitis is a common infection where treatment involves multiple services, including infectious diseases, podiatry, and pathology. Despite its ubiquity in the hospital, consensus on much of its management is lacking.
Methods: Representatives from infectious diseases, podiatry, and pathology interested in quality improvement developed multidisciplinary institutional recommendations culminating in an educational intervention describing optimal diagnostic and therapeutic approaches to diabetic foot osteomyelitis (DFO). Knowledge acquisition was assessed by preintervention and postintervention surveys. Inpatients with forefoot DFO were retrospectively reviewed before and after intervention to assess frequency of recommended diagnostic and therapeutic maneuvers, including appropriate definition of surgical bone margins, definitive histopathology reports, and unnecessary intravenous antibiotics or prolonged antibiotic courses.
Results: A postintervention survey revealed significant improvements in knowledge of antibiotic treatment duration and the role of oral antibiotics in managing DFO. There were 104 consecutive patients in the preintervention cohort (April 1, 2018, to April 1, 2019) and 32 patients in the postintervention cohort (November 5, 2019, to March 1, 2020), the latter truncated by changes in hospital practice during the coronavirus disease 2019 pandemic. Noncategorizable or equivocal disease reports decreased from before intervention to after intervention (27.0% versus 3.3%, respectively; P = .006). We observed nonsignificant improvement in correct bone margin definition (74.0% versus 87.5%; P = .11), unnecessary peripherally inserted central catheter line placement (18.3% versus 9.4%; P = .23), and unnecessary prolonged antibiotics (21.9% versus 5.0%; P = .10). In addition, by working as an interdisciplinary group, many solvable misunderstandings were identified, and processes were adjusted to improve the quality of care provided to these patients.
Conclusions: This quality improvement initiative regarding management of DFO led to improved provider knowledge and collaborative competency between these three departments, improvements in definitive pathology reports, and nonsignificant improvement in several other clinical endpoints. Creating collaborative competency may be an effective local strategy to improve knowledge of diabetic foot infection and may generalize to other common multidisciplinary conditions.
Background: Burnout and medical resident well-being has become an increasingly studied topic in medical degree (MD) and doctor of osteopathic medicine (DO) fields and specialties, which has led to systemic changes in postgraduate education and training. Although an important topic to address for physicians of all experience levels and fields of practice, there is little research on this topic as it pertains specifically to the podiatric medical community.
Methods: A wellness needs assessment was developed and distributed to podiatric medical residents via electronic survey to assess overall wellness levels of residents and to highlight several subdomains of well-being in the training programs of the podiatric medical profession.
Results: A total of 121 residents completed the wellness needs assessment. Survey respondents indicated that they experienced high levels of professional burnout, with large numbers of them experiencing depression and anxiety. When analyzing the different subdomains of wellness, levels of intellectual and environmental wellness were high, and levels of financial and physical wellness were reported as low. In addition, free response answers were recorded in the survey regarding well-being initiatives that have been implemented in residency programs, and in many cases no such programs are reported to exist.
Conclusions: Podiatric medical residents experience compromised well-being similar to their MD/DO counterparts. These exploratory survey group results are concerning and warrant further investigation as well as organizational introspection. Analyzing well-being and implementing changes that can support podiatric physicians at all levels of training could decrease the deleterious effects of burnout in all its forms.
Background: Biphalangealism has been evaluated in many studies and has been shown as a common variant. Its frequency varies according to the populations. This epidemiological study aimed to determine the prevalence of biphalangealism for each toe in the Turkish population and compare it with other populations.
Methods: The local hospital radiological database was searched for all consecutive foot radiographs, obtained between 2014 and 2018. Anteroposterior (AP) and oblique radiographs obtained to evaluate trauma or foot pathologies were included. Two-phalangeal toes according to radiographical views were defined as biphalangeal and other three-phalangeal toes were defined as normal.
Results: A total of 2,881 radiographs of 2,710 adult patients met the incusion criteria. There were 1,558 (57.5%) female and 1,152 (42.5%) male patients. The cases were unilateral in 2,539 patients and bilateral in 171 patients. The overall prevalence of biphalangeal third toe was 0.29%, fourth toe was 1.29%, and fifth toe was 23.3%.
Conclusions: The presence of pedal biphalangealism is a common variant and its frequency varies according to the populations. The exact cause is still unclear. Further studies are required to assess the clinical impact of biphalangealism.
Primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL-LT) is a rare variant of the cutaneous B-cell lymphomas, with rapid growth and poor prognosis. Here, we report a case of PCDLBCL-LT on the foot in a senior woman. An 81-year-old woman presented with a rapidly growing mass on her left foot, and discoloration in both lower legs over the past 2 months was analyzed. Physical examination revealed hyperpigmented macules and papules on both lower extremities and a 3.0 × 2.0 × 0.5-cm, gray-dark nodule on the dorsal surface of the left foot. Histologic observation of the punch biopsy specimen revealed a sheet of atypical large centroblast/immunoblast-like lymphocytes; diffusely and evenly distributed in the dermis; with the immunophenotypes of CD45-positive, CD20-positive, Melan A-negative, Sox10-negative, S-100–negative, and CK20-negative; and a very high Ki-67 proliferative index (>90%). Further punch biopsy specimens of papules in the patient’s lower extremities and bone marrow did not reveal atypical lymphoid tissues. Positron emission tomography/computed tomography did not show any metastatic lesions in distant organs and lymph nodes. The lesion was diagnosed as PCDLBCL-LT stage T1N0M0. The patient was treated with four cycles of combined therapy of rituximab and cyclophosphamide, hydroxydaunorubicin, vincristine (Oncovin), and prednisolone and the tumor was further treated with local radiotherapy. The tumor size was significantly shrunken. Primary cutaneous diffuse large B-cell lymphoma, leg type is a rare entity on the foot, characterized by a confluent sheet of diffuse large centroblast- and or immunoblast-like B cells with B-cell immunophenotyping. The combined therapy of rituximab and cyclophosphamide, hydroxydaunorubicin, vincristine (Oncovin), and prednisolone is the first-line treatment regimen, with increased survival.
Pseudoaneurysms are created by a traumatic or iatrogenic perforation of an artery, resulting in accumulation of blood between the two outermost layers of a blood vessel, the tunica media and tunica adventitia. Pedal artery pseudoaneurysms are an extremely uncommon complication of foot and ankle surgery; therefore, few cases have been reported in the literature. Early diagnosis is important to ensure timely treatment of this condition. Once clinical suspicion has been established, urgent referral to the vascular surgery clinic for prompt surgical evaluation is required to prevent potentially harmful sequelae. We present the case of a 70-year-old woman who developed a pseudoaneurysm of the dorsalis pedis artery 33 days after undergoing open reduction and internal fixation of a second metatarsal fracture. Her treatment included urgent referral to the vascular surgery clinic with subsequent surgical repair of the pseudoaneurysm by means of ligation of the medial dorsal branch of the dorsalis pedis artery. At 10-month follow-up, she denied any pain, sensory deficits, or functional disability and had returned to all preinjury activities, with no recurrence of the pseudoaneurysm. Our case study demonstrates early diagnosis and successful treatment of a pseudoaneurysm of the dorsalis pedis artery that developed shorty after open reduction and internal fixation of a second metatarsal fracture.
Background: Resident-run clinics provide autonomy and skill development for resident physicians. Many residency programs have such a clinic. No study has been performed investigating the effectiveness of these clinics in podiatric medical residency training. The purpose of this study was to gauge the resident physician–perceived benefit of such a clinic.
Methods: A survey examining aspects of a resident-run clinic and resident clinical performance was distributed to all Doctor of Podiatric Medicine residency programs recognized by the Council on Podiatric Medical Education. To be included, a program must have had a contact e-mail listed in the Central Application Service for Podiatric Residencies residency contact directory; 208 residency programs met the criteria. Statistical analysis was performed using independent-samples t tests or Mann-Whitney U tests and χ2 tests. Significance was set a priori at P < .05.
Results: Of 97 residents included, 58 (59.79%) had a resident-run clinic. Of those, 89.66% of residents stated they liked having such a clinic, and 53.85% of those without a resident-run clinic stated they would like to have one. No statistically significant differences were noted between groups in how many patients each resident felt they could manage per hour or regarding their level of confidence in the following clinical scenarios: billing, coding, writing a note, placing orders, conversing with a patient, working with staff, diagnosing and treating basic pathology, and diagnosing and treating unique pathology.
Conclusions: Resident-run clinics provide autonomy and skill development for podiatric medical residents. This preliminary study found there was no difference in resident-perceived benefit of such a clinic. Further research is needed to understand the utility of a resident-run clinic in podiatric medical residency training.
Background: It remains controversial whether satisfactory outcomes can be obtained following total ankle arthroplasty (TAA) without osteotomy in patients with severe varus ankle deformities. This study aimed to examine outcomes following TAA without concomitant osteotomies in patients with severe varus ankle alignment by comparing them with those in patients with neutral alignment.
Methods: Fifty-one patients (53 ankles; mean age, 71.4 ± 5.6 years) who underwent TAA using the TNK ankle prosthesis were examined (mean follow-up, 36.8 ± 17.8 months). Patients were allocated into groups according to the preoperative talar tilt (TT) angle: the neutral group (preoperative TT angle <10°; n = 37) and the varus group (preoperative TT angle ≥10°; n = 16). Outcome measures, including the Japanese Society for Surgery of the Foot scale, Self-Administered Foot Evaluation Questionnaire, ankle range of motion, and radiographic parameters, were assessed before surgery and at the final follow-up.
Results: Significant improvements were observed in clinical and radiographic outcomes in both groups after surgery. Postoperative Japanese Society for Surgery of the Foot scale and subscale scores of pain and shoes in the Self-Administered Foot Evaluation Questionnaire were not significantly different between the groups, whereas subscale scores of function, social, and health were greater in the varus group than in the neutral group at the final follow-up. Radiographic parameters, including TT angle and tibial axis-medial malleolus (TMM) angle, improved postoperatively and were not significantly different between the neutral (mean TT angle, 0.5 ± 0.7°; mean TMM angle, 16.0 ± 4.6°) and varus (meanTT angle, 0.4 ± 0.7°; meanTMM angle, 17.0 ± 5.3°) groups at the final follow-up. To achieve neutral alignment, adjunctive procedures were required more often in the varus group.
Conclusions: Outcomes of TAA using the TNK ankle prosthesis were favorable in patients with severe varus ankle and in those with neutral ankle without concomitant osteotomy. Satisfactory outcomes could be achieved in patients with severe varus ankle alignment after TAA without concomitant osteotomy.
Background: The human foot has three arches. The medial longitudinal arch is the longest, the highest, and the most important. The development of a normal foot arch is greatly affected by genetic inheritance, differences in the environment, socioeconomic development, body weight, sex, ethnicity, and culture. The purpose of this study was to compare the arch type between shoe-wearing and barefooted individuals.
Methods: A cross-sectional study was conducted. The data obtained were checked for clarity and consistency before analysis. The analysis was done using descriptive statistics and chi-square. p-values less than 0.05 were considered to be statistically significant.
Result: From a total of 446 subjects, 217 (48.7%) were males, 131 (29.6%) were urban residents and 226 (50.6 %) were shoe wearers. From the total sample, 46.2%, 42.8%, and 11% are high, normal, and flat-arched individuals, respectively. Of the shoe wearers, 6.7% have a flat arch while 4.3% of the barefooted subjects are flat-arched. Of the total flat-arched subjects, 8.3% are males and 2.7% are females. Of the urban residents, 17.5% have a flat foot and 8.3% of rural residents were flat arched. Among the shoe wearers, 8.8% use closed-toe shoes, and 4.4% that wear sandals are flat-arched.
Conclusion: The result indicates sex, type of shoes, wearing shoes, and being barefooted affected the development of the foot arch.
Background: Plantar fasciitis (PF) is predominantly treated conservatively through some modalities such as extracorporeal shock wave therapy (ESWT) and low-level laser therapy (LLLT), yet the short effect of these modalities on pain and function is still ambiguous. This study aims to compare the short-term effectiveness of ESWT and LLLT on pain and function in patients with PF.
Methods: Participants (n=47) were randomly assigned into 2 groups as ESWT (n=27) and LLLT (n=20). ESWT (once a week) and LLLT (three times a week) were administered to the participants for 3 weeks. Foot function index (FFI) including pain, disability, and activity limitation subscales was administered at baseline and post-treatment. A reduction of one point in total scores was considered as a minimum clinically important difference. Repeated measures of ANOVA were used to analyze the changes in outcomes and compare the groups.
Results: There were significant main effects of time, and significant interaction effects between group and time on pain (P<0.001), disability (P<0.001), and activity limitation (P<0.05). The main effect of the group was not significant for all subscales (P=0.811, P=0.481, P=0.865, respectively). The LLLT group showed a significant decline in pain (P<0.001), disability (P<0.001), and activity limitation (P<0.001) while there was no change in the ESWT group over time (P=0.319, P=0.711, P=1.0 respectively). Consistently, 95% of participants in the LLLT had CID in the pain subscale whereas 48% of the ESWT group had.
Conclusions: LLLT was found to be superior to ESWT as an effective approach in the short-term management of PF.
Background: Body awareness is an expression of the extent of sensitivity and attentiveness to internal bodily signals and sensations. The foot has a critical function in providing interoceptive and exteroceptive information. The purposes of this study were to 1) compare body awareness in individuals with and without hallux valgus (HV) deformity, and 2) investigate the relationship between body awareness and HV-related parameters.
Methods: A total of 129 participants completed the assessments. The severity of the HV was evaluated using the Manchester Scale; pain severity was evaluated using the numeric pain rating scale; and the functional status was evaluated using the Manchester-Oxford Foot Questionnaire. The patients were divided into 2 groups according to the Manchester Scale scores as the presence or absence of HV. The body awareness of the individuals with HV was assessed using the Body Awareness Questionnaire.
Results: Included in this study were 69 participants with HV and 60 healthy participants. There was no difference between groups in terms of demographic properties. Two groups were found different only in pain severity (P < 0.01). The correlation analysis showed that there was a low correlation between the body awareness score and pain severity in both feet (right foot r: 0.306, P = 0.011; left foot r: 0.320, P = 0.007) in individuals with HV.
Conclusions: Participants with HV had higher pain severity and the pain severity was associated with the body awareness. The level of body awareness should be assessed and taken into consideration in the management of pain in patients with HV.