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.
Background: It’s well known fact that Hallux valgus (HV) alternates foot biomechanics. In different populations HV and postural stability has been studied but HV and adolescent ballet dancer has not been studied. Aim of the our study is to explore affect of HV on adolescent ballet dancers’ balance. Also we wanted to explore health related quality of life of adolescent ballet dancers with HV.
Methods: Ballets aged between 8-16 years old has been screened prospectively. The dancers divided into two groups group 1;Ballets with HV and group 2; Ballets without HV. HV diagnosis was made clinically. Two groups were compared according to balance parameters and health related quality of life (HRQOL) questionaires.
Results: Group 1 was formed with 31 participants and group 2 was formed with 24 participants. All participants in both groups were female. Mean age in group 1 was 11.6 (8-16 years old) and 12.2 (8-16 years old) in group 2. Mean first metatarsophalangeal angle was 13.4° (10°-15°) in group 2 and 19.8° (16°-25°) in HV group respectively. A statistically significant difference was found according to the nonparametric Mann Whitney U test results in the comparison of HVA (Hallux Valgus Angle) between groups. According to Spearman Rho correlation analysis, it was determined that the increase in HVA caused deterioration in the static Flamingo test. (r=0.552 p=0.019). No significant relationship was found between HRQoL questionaries and the presence of HV. (p>0,05)
Conclusions: Adolescent ballet dancers experience static balance impairment due to HV angle increase. Clinical measurement of HV and application of balance parameters made easy without need of set ups to perform evaluation with high numbers of participants in concordance with literature.
Background: It’s important to determine the plantar pressure distribution of school children by applying static and dynamic foot analyses using a pedobarography device. However, it’s difficult to obtain clear interpretations from results which can be explained by a large number of plantar pressure variables. The aim of this study is to use Principal Component Analysis (PCA) to predict main components for reducing the size of big data sets, provide a practical overview and minimize information loss on the subject of plantar pressure assessment in youths.
Methods: In total, 112 school children were included in the current study (average age 10.58 ± 1.27 years, body mass index 18.86 ± 4.33 kg / m2). During the research, a Sensor Medica Freemed pedobarography device was used to obtain plantar pressure data. Each foot was divided into six anatomical regions and evaluated. Global and regional plantar pressure distribution, load and surface areas, pressure time integrals, weight ratios and geometric foot properties were calculated.
Results: PCA yielded ten principal component (PC) that together account for 81.88% of the variation in the data set and represent new and distinct patterns. Thus, 137 variables affecting the subject were reduced to ten components.
Conclusions: Static and dynamic plantar pressure distribution, which is affected by many variables, can be reduced to ten components by PCA, making the research results more concise and understandable.
Background: One of the common causes of posterior ankle pain is posterior ankle impingement syndrome (PAIS). Many studies about PAIS have been conducted on special groups such as athletes, dancers, and football players, whereas there has been no previous study of a non-athletic population. This study aimed to evaluate the causes and treatment methods of this syndrome in the non-athletic population and compare it with the athletic population.
Methods: A retrospective review was done and 28 of 46 patients (60.9%) recovered from two-staged conservative therapy. 18 of 46 patients (39.1%) who did not benefit from conservative treatment for three months, hindfoot endoscopy was applied. Patient data, including sex, age, occupation, and sports activity level, were recorded. The Visual Analog Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and Tegner score were recorded. Patient satisfaction was assessed with a 4-point Likert scale. All complications were recorded.
Results: The mean follow-up period was 27.4 months. At the final follow-up examination, the AOFAS hindfoot score had significantly improved from 66.4 to 96.8 (p<0.001). The Tegner activity score improved significantly from 4.6 to 8.8 (p<0.001). The VAS score was 6.4 and increased to 0.9 (p<0.001). Using the 4-point Likert Scale for patient satisfaction, 13 (72.2%) stated that the surgical procedure was excellent, and 4 (27.8%) stated it as good. The mean time to return to work was 4.2 weeks. As complications, only sural nerve dysesthesia was seen in 2 patients(11.1%).
Conclusions: This study can be considered of value as the first study to have evaluated PAIS in the non-athletic population. Conservative treatment showed good results as nearly two-thirds of the patients recovered. Hindfoot endoscopy applied to cases not responding to conservative therapy is a successful treatment with low complication rates.
Ganglion cysts are relatively common entities, but intraneural ganglia within peripheral nerves are rare and poorly understood. We present a case of a 51-year-old man who presented with acute left dropfoot. Initial magnetic resonance imaging (MRI) was misinterpreted as common peroneal neuritis consistent with a traction injury corroborated by the patient’s history. However, after surgical decompression and external neurolysis were performed, the patient’s symptoms worsened. Repeated MRI revealed an intraneural ganglion cyst of the common peroneal nerve with connection to the superior tibiofibular joint by means of its anterior recurrent branch that was evident retrospectively on preoperative MRI. It is crucial to carefully inspect atypical cases to further recognize and appreciate the dynamic aspect of this disease or “roller-coaster” phenomenon. Intraneural ganglion cysts rely heavily on intraneural and extraneural pressure gradients for propagation, which can be drawn from the expanded work of the unifying articular theory. This report emphasizes the importance of understanding the pathoanatomical and hydraulic factors to appropriately identify and treat intraneural ganglion cysts. Increased recognition of this pathologic entity as a differential diagnosis for acute onset dropfoot is also highlighted.
Background: Multiple organizations have issued guidelines to address the prevention, diagnosis, and management of diabetic foot ulcers (DFUs) based on evidence review and expert opinion. We reviewed these guidelines to identify consensus (or lack thereof) on the nature of these recommendations, the strength of the recommendations, and the level of evidence.
Methods: Ovid, PubMed, Web of Science, Cochrane Library, and Embase were searched in October 2018 using the MESH term diabetic foot, the key word diabetic foot, and the filters guideline or practice guideline. To minimize recommendations based on older literature, guidelines published before 2012 were excluded. Articles without recommendations characterized by strength of recommendation and level of evidence related specifically to DFU were also excluded. A manual search for societal recommendations yielded no further documents. Recommendations were ultimately extracted from 12 articles. Strength of evidence and strength of recommendation were noted for each guideline recommendation using the Grading of Recommendations Assessment, Development, and Evaluation system or the Centre for Evidence-Based Medicine system. To address disparate grading systems, we mapped the perceived level of evidence and strength of recommendations onto the American Heart Association guideline classification schema.
Results: Recommendations found in two or more guidelines were collected into a clinical checklist characterized by strength of evidence and strength of recommendation. Areas for future research were identified among recommendations based on minimal evidence, areas of controversy, or areas of clinical care without recommendations.
Conclusions: Through this work we developed a multidisciplinary set of DFU guidelines stratified by strength of recommendation and quality of evidence, created a clinical checklist for busy practitioners, and identified areas for future focused research. This work should be of value to clinicians, guideline-issuing bodies, and researchers. We also formulated a method for the review and integration of guidelines issued by multiple professional bodies.
Despite advancements in the treatment of diabetic patients with “at-risk” limbs, minor and major amputations remain commonplace. The diabetic population is especially prone to surgical complications from lower extremity amputation because of comorbidities such as renal disease, hypertension, hyperlipidemia, microvascular and macrovascular disease, and peripheral neuropathy. Complication occurrence may result in increases in hospital stay duration, unplanned readmission rate, mortality rate, number of operations, and incidence of infection. Skin flap necrosis and wound healing delay secondary to inadequate perfusion of soft tissues continues to result in significant morbidity, mortality, and cost to individuals and the health-care system. Intraoperative indocyanine green fluorescent angiography for the assessment of tissue perfusion may be used to assess tissue perfusion in this patient population to minimize complications associated with amputations. This technology provides real-time functional assessment of the macrovascular and microvascular systems in addition to arterial and venous flow to and from the flap soft tissues. This case study explores the use of indocyanine green fluorescent angiography for the treatment of a diabetic patient with a large dorsal and plantar soft-tissue deficit and need for transmetatarsal amputation with nontraditional rotational flap coverage. The authors theorize that the use of indocyanine green may decrease postoperative complications and cost to the health-care system through fewer readmissions and fewer procedures.
Background: The deep plantar arterial arch (DPAA) is formed by an anastomosis between the deep plantar artery and the lateral plantar artery. The potential risk of injury to the DPAA is concerning when performing transmetatarsal amputations, and care must be taken to preserve the anatomy. We sought to determine the positional anatomy of the DPAA based on anatomical landmarks that could be easily identified and palpated during transmetatarsal amputation.
Methods: In an effort to improve our understanding of the positional relationship of the DPAA to the distal metatarsal parabola, dissections were performed on 45 cadaveric feet to measure the location of the DPAA with respect to the distal metatarsal epiphyses. Images of the dissected specimens were digitally acquired and saved for measurement using in-house–written software. The mean, SD, SEM, and 95% confidence interval were calculated for all of the measurement parameters and are reported on pooled data and by sex. An independent-samples t test was used to assess for sex differences. Interrater reliability of the measurements was estimated using the intraclass correlation coefficient.
Results: The origin of the DPAA was located a mean ± SD of 35.6 ± 3.9 mm (95% confidence interval, 34.5–36.8 mm) proximal to the perpendicular line connecting the first and fifth metatarsal heads. The average interrater reliability across all of the measurements was 0.921.
Conclusions: This study provides the positional relationship of the DPAA with respect to the distal metatarsal parabola. This method is easily reproducible and may assist the foot and ankle surgeon with surgical planning and approach when performing partial pedal amputation.