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 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.
Background: Despite national and international guidelines supporting podiatric services as a means of prevention for lower-extremity complications, especially in at-risk individuals, current coverage for these services under the US Medicaid program is not universal. The vast differences between state Medicaid programs regarding reimbursable foot care services is confusing and potentially serves as a barrier for the most vulnerable populations to receive preventative services. This article provides a brief discussion of “routine” podiatric services from a clinical perspective and provides a review of state Medicaid programs including optional services (eg, podiatric coverage).
Methods: Using data from a national survey of state Medicaid programs, we present and discuss common Medicaid coverage schemes for routine foot care provided by podiatric physicians.
Results: Analysis demonstrated that states vary dramatically in basic descriptions of preventive foot care, levels of coverage, eligibility, and methods of documenting coverage details.
Conclusions: The authors recommend bringing Medicaid in line with other federal health programs and including podiatric physicians in the definition of “physician” for coverage purposes. States should move away from describing preventative services as “routine” and choose language that more accurately reflects the true nature and purpose of the care.
Background: Chronic lower-extremity defects may lead to major amputations and have severe consequences on patient quality of life and mortality. Dermal matrices have become part of the reconstructive ladder and are often deployed in these scenarios to quickly build neodermis, especially in volumetric defects over exposed bone and tendon initially, to allow for subsequent closure by means of split-thickness skin grafting (STSG) or secondary intention. Ovine forestomach matrix (OFM) is a decellularized extracellular matrix (ECM) bioscaffold available in both sheet and particulate forms that can be used as a dermal matrix in various soft-tissue reconstruction procedures.
Methods: This retrospective case series evaluated the use of OFM products in the surgical reconstruction of 50 cases (n = 50) comprised of challenging lower-extremity defects from seven healthcare centers. Patient records were reviewed to identify comorbidities, defect cause, defect size, presence of exposed structures, Centers for Disease Control and Prevention contamination score, Wagner grade, OFM graft use, time to 100% granulation tissue, STSG use, overall time to heal, and postoperative complications. The primary study outcomes were time (days) to 100% granulation tissue formation, with secondary outcomes including overall time to wound closure (weeks), STSG take at 1 week, and complications.
Results: The results of this case series demonstrate OFM as a clinically effective treatment in the surgical management of complex lower-extremity soft-tissue defects with exposed structures in patients with multiple comorbidities. One application of OFM products was effective in regenerating well-vascularized neodermis, often in the presence of exposed structures, with a mean time to 100% granulation of 26.0 ± 22.2 days.
Conclusions: These data support the use of OFM as a safe, cost-effective, and clinically effective treatment option for coverage in complex soft-tissue wounds, including exposed vital structures, and to shorten the time to definitive wound closure in complicated patient populations.
Background: As common as plantar fasciitis is, there’s a lack of evidence regarding the true pathophysiologic process causing plantar fasciitis and plantar heel pain in general. This may partially explain the high variability and outcomes with current treatment of recalcitrant plantar fasciitis. Although Lemont reported myxoid degeneration of plantar fascia with histologic analysis of patients with fasciitis, muscle biopsy results were not reported. So far it appears we have not focused on the muscular component that may be present with plantar heel pain in general and in patients we diagnose with plantar fasciitis in particular.
Methods: In this article we performed a retrospective analysis of biopsy results from five patients with the diagnosis of recalcitrant plantar fasciitis to determine whether this diagnosis was correct or whether other component pathologies contribute to the chronicity of symptoms or to the failure of treatment.
Results: Three of the five pathology reports included specific mention of inflammation, degeneration and atrophy of the intrinsic musculature consistent with myositis. Two of these showed lymphocytic infiltration in the muscle consistent with inflammation, with no signs of inflammation in the fascia. One showed inflammation of the fascia without signs of inflammation of the muscle.
Conclusions: This small study introduces the idea that intrinsic myositis may contribute to, or be responsible for some cases of plantar heel pain and plantar fasciitis. This may be important in changing the way we deal with plantar heel pain in the future.
Background: Ingrown toenails are a common condition requiring outpatient procedures in podiatric medical clinics. To prevent recurrence, chemical matrixectomy is often recommended. Postprocedural pain management is largely based on preferences rather than on a formal guideline. This study aims to explore the postprocedural prescribing behavior among practicing podiatric physicians to foster future guideline and policy development.
Methods: We administered an open, voluntary, anonymous questionnaire via an online survey platform that included a common nail procedure scenario (chemical matrixectomy) and a prescribed demographics section. Podiatric physicians were asked what they would prescribe to manage postprocedural pain. Opioid and nonopioid options were provided. We developed two multiple logistic regression models to identify associations between prescriber characteristics and prescribing opioids after “standard” chemical matrixectomy.
Results: Of the 860 podiatrists who completed the survey, 8.7% opted to prescribe an opioid. Hydrocodone was most commonly chosen. A median of 18 opioid pills were prescribed. No prescriber characteristics were associated with prescribing opioids after chemical matrixectomy scenario. There is a large discrepancy and knowledge gap in the literature on the optimal postprocedural pain management for outpatient procedures, including procedures in specialties such as dentistry and dermatology. The median number of opioids prescribed by podiatrists is higher than that by dentists for management of third molar extraction. In contrast, opioid-prescribing behavior among the 8.7% of respondents is similar to dermatologic management of postprocedural pain in Mohs surgery.
Conclusions: Podiatric physicians cannot assume that their prescribing of opioids does not affect the opioid abuse problem in the United States. The presented study serves to be an initiation for procedure-specific opioid prescription benchmarking to foster future guideline and policy development. After nail procedures, opioids should not be routinely prescribed.
Background: Chronic wounds, especially in patients with diabetes, often represent clinical challenges. Recently, the use of a topically applied blood clot has garnered significant interest. This stromal matrix contains viable cells that are autologous, biocompatible, biological, and consistent with a metabolically active scaffold. It has been shown to be safe, effective, and cost-efficient. However, the mechanism of action of this modality remains elusive. We sought to identify a potential mechanism of action of an autologous blood clot.
Methods: Review of clinical and scientific literature hypothesizes on how autologous blood clots may stimulate healing and facilitate the movement of critical substrates while lowering bioburden and fostering angiogenesis.
Results: Blood serves as a carrier for many components: red blood cells, white blood cells, platelets, proteins, clotting factors, minerals, electrolytes, and dissolved gasses. In response to tissue injury, the hemostatic mechanism uses a host of vascular and extravascular responses initiating primary, secondary, and tertiary hemostasis. The scaffold created by the autologous blood clot tissue provides a medium in which the body can transform the wound from a nonhealing chronic condition into a healing acute condition. The autologous blood clot tissue also creates a protective setting for the body to use its own mechanisms to promote wound healing in an organized manner. This transient scaffold recruits surrounding fibroblasts and promotes cell ingrowth to foster granulation tissue remodeling. Cells in this matrix sense not only soluble factors but also their physical environments. This well-orchestrated mechanism includes signals from soluble molecules, from the substrate/matrix to which the cell is adherent, from the mechanical or physical forces acting on it, and from contact with other cells. Topically applied autologous blood clot tissue can lower bacterial bioburden while stimulating angiogenesis and fostering the movement of keratinocytes and fibroblasts.
Conclusions: Topically applied autologous blood clot tissue is a formidable cellular and tissue-based therapy that has been shown to be safe and effective. Although the central component of this therapy is blood, the autologous clot tissue creates a scaffold that performs as a biological delivery system that functions to control the release of growth factors and cytokines over several days.
Necrotizing fasciitis is a devastating inflammatory infection requiring emergent medical treatment and surgical intervention. Even with timely management, the mortality rate of necrotizing fasciitis approaches 25%. The causative bacteria invade fascial planes and express toxins that advance rapidly. Here, we document a rare case of necrotizing fasciitis from Serratia marcescens infection. Serratia marcescens is capable of inducing a necrotizing inflammatory cascade mediated by extracellular cytotoxin and lipase. In this case report, a 90-year-old man presented to our emergency department from a long-term care facility with a relatively benign-appearing ulcer with surrounding cellulitis on the right ankle. Blood cultures and wound cultures confirmed the organism to be S marcescens. A multidisciplinary team was consulted for management. The patient received antibiotic therapy and medical support, but because of his comorbid conditions and social situation, the designated medical decision maker opted for comfort care rather than aggressive surgical debridement. The patient progressed through the clinical stages of necrotizing fasciitis. Within 36 hours, the patient died as result of sepsis-induced organ failure.
Tillaux fractures in adults are rare and, if unrecognized, can lead to ankle fracture healing complications, early progression of arthritis, and limited ankle movement caused by pain and degenerative changes. The Tillaux fracture was first described by Paul Tillaux as an external rotation injury of the ankle, involving an avulsion fracture of the distal anterolateral tibia. This fracture can be easily overlooked on plain radiographs in the adult. A high index of suspicion for this type of fracture pattern along with the use of computed tomographic scanning can help confirm the suspected diagnosis, rule out other tibial injuries, and provide more information on the best course of action. Historically, Tillaux fractures have been more common in adolescents because of the open tibial epiphyseal plate. Once the epiphyseal plate fully closes, skeletal maturity is achieved, thus making it extremely unusual for the anterior tibiofibular ligament to cause an avulsion fragment of the distal anterolateral tibia. Because of how uncommon this type of fracture is in adults, it has rarely been reported in our literature. We reviewed the literature and present a case report of this rare fracture injury.