Background: Fat pad atrophy is the loss of subcutaneous tissue in the plantar foot, inhibiting the cushioning function. Patients experience severe pain upon 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. A 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.
Method: An IRB approved retrospective study review and analysis on 16 patients (21 feet) treated with AAM in the plantar foot was conducted. Adverse events and a patient subjective evaluation of percentage improvement were reported, sometimes supported by imaging.
Results: The average volume of AAM injected was 2.2±0.7cc (1.5-2.6cc range) with a follow-up time of 3-20 months, in patients aged 68.6±8.9 years. Overall minimal adverse events were observed and the 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.
Conclusion: 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: An abnormal hallux interphalangeal angle may be an important risk factor for the recurrence of ingrown toenails.
Methods: In this study, sixty pediatric patients who underwent surgery for an ingrown toenail were evaluated retrospectively in terms of recurrence. The patients were divided into two groups. Group 1 included 30 patients (22 male, 8 female) with hallux valgus interphalangeal deformity. Group 2 included 30 patients (20 male, 10 female) without toe deformity.
Results: The mean age was 12.8±1.42 years and 12.5±1.45 years for patients in Group 1 and in Group 2 respectively. There was no statistically significant difference between the patient and control group in terms of age and gender (p>0.05). The mean follow-up time was 40 months. We observed recurrence in six patients (20%) in Group 1 and in 2 patients (6.6%) in Group 2.
Conclusion: We concluded that the recurrence of an ingrown toenail may be associated with increased hallux interphalangeal angle in pediatric patients. Factors related to the hallux interphalangeal angle abnormality, which increases the risk of ingrown toenails, also increase the recurrence rate in these patients. Therefore, it is surmised that hallux valgus interphalangeal deformity should be evaluated before surgery, and patients and their families should be informed about the risk of increased recurrence.
Background: Historically, distal fifth metatarsal diaphyseal fractures have been treated with conservative management, with only limited research evaluating surgical treatment of these fractures. This study was performed to compare surgical versus conservative treatment of distal fifth metatarsal diaphyseal fractures in athletes and nonathletes.
Methods: A retrospective review of 53 patients with surgical or conservative treatment of isolated fifth metatarsal diaphyseal fractures was performed. Data recorded included age, sex, tobacco use, diagnosis of diabetes mellitus, time to clinical union, time to radiographic union, athletic versus nonathletic status, time to return to full activity, surgical fixation method, and complications.
Results: Patients treated surgically had a mean clinical union time of 8.2 weeks, radiographic union time of 13.5 weeks, and return to activity time of 12.9 weeks. Patients treated conservatively had a mean clinical union time of 16.3 weeks, radiographic union time of 25.2 weeks, and return to activity time of 20.7 weeks. Delayed unions and nonunions occurred in 27.0% of patients (10 of 37) treated conservatively and in none in the surgical group.
Conclusions: Surgical treatment significantly decreased time to radiographic union, clinical union, and return to activity by an average of 8 weeks compared with conservative treatment. We suggest that surgical treatment of distal fifth metatarsal fractures is a viable option that may significantly decrease the patient’s time to clinical union, radiographic union, and return to activity.
Background: Sinus tarsi syndrome is characterized by permanent pain on the anterolateral side of the ankle due to chronic inflammation characterized by fibrotic tissue remnants and synovitis accumulation after repeated traumatic injuries. Few studies have documented the outcome of injection treatments for sinus tarsi syndrome. We sought to determine the effects of corticosteroid and local anesthetic (CLA), platelet-rich plasma (PRP), and ozone injections on sinus tarsi syndrome.
Methods: Sixty patients with sinus tarsi syndrome were randomly divided into three treatment groups: CLA, PRP, and ozone injections. Outcome measures were visual analog scale, American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS), Foot Function Index, and Foot and Ankle Outcome Score before injection compared with 1, 3, and 6 months after injection.
Results: At the end of months 1, 3, and 6 after injection, significant improvements were observed in all three groups compared with baseline (P < .001 for all). At months 1 and 3, improvements in AOFAS scores were similar in the CLA and ozone groups; those in the PRP group were lower (P = .001 and P = .004, respectively). At month 1, improvements in Foot and Ankle Outcome Score were similar in the PRP and ozone groups and higher in the CLA group (P < .001). At 6-month follow-up, there were no significant differences in visual analog scale and Foot Function Index results among the groups (P > .05).
Conclusions: Ozone, CLA, or PRP injections could provide clinically significant functional improvement for at least 6 months in patients with sinus tarsi syndrome.
Background: Ankle joint dorsiflexion range of motion is essential to normal gait. Ankle equinus has been implicated in a number of foot and ankle pathologies included Achilles tendonitis, plantar fasciitis, ankle injury, forefoot pain, and foot ulceration. Reliable measurement of ankle joint dorsiflexion range of motion, both clinically and in a research setting, is important.
Methods: The primary aim of this study was to investigate the intertester reliability of an innovative device for measuring ankle joint dorsiflexion range of motion. A total of 31 (n = 31) participants volunteered to take part in this study. A paired t-test was performed to assess for systematic differences between the mean measures of each rater. Intertester reliability was evaluated using the intraclass correlation coefficient (ICC) and their 95% confidence intervals.
Results: A paired t-test demonstrated that the mean ankle joint dorsiflexion range of motion did not significantly differ between raters. The ankle joint ROM mean for rater 1 was 4.65 SD (3.71) and rater 2 was 4.67 SD (3.91). Intertester reliability for the use of the Dorsi-Meter was excellent and demonstrated a very narrow range of error. The ICC (95%CI) was 0.991 (0.980 to 0.995) the SEM (in degrees) was 0.07, the MDC95, in degrees was 0.19 and 95% LOA, degrees was –1.49 to 1.46.
Conclusions: We found the intertester reliability of the Dorsi-Meter to demonstrate higher levels of intertester reliability compared to previous studies investigating other devices. We reported the MDC values to provide an estimate of the smallest amount of change in the ankle joint dorsiflexion range of motion that must be achieved to reflect a true change, outside the error of the test. The Dorsi-Meter has been established as an appropriate reliable device to measure ankle joint dorsiflexion for clinicians and researchers with very small minimal detectable change and limits of agreement.
Eccrine poroma is a benign adnexal neoplasm often mistaken for pyogenic granuloma, skin tag, squamous cell carcinoma, and other soft-tissue tumors. We describe a 69-year-old woman with a soft-tissue mass on the lateral aspect of her right hallux that was initially clinically diagnosed as a pyogenic granuloma. Histologic examination proved that this mass was instead an eccrine poroma, the rare benign sweat gland tumor. This case exemplifies the importance of a broad differential diagnosis, especially regarding soft-tissue masses of the lower extremity.
Background: The purpose of this study was to evaluate the effectiveness of tap water iontophoresis as a treatment for plantar hyperhidrosis.
Methods: Thirty participants living with idiopathic plantar hyperhidrosis and consented to undergo treatment using iontophoresis were recruited. The Hyperhidrosis Disease Severity Score was used to evaluate the severity of the condition before and after treatment.
Results: Tap water iontophoresis was found to be effective in the treatment of plantar hyperhidrosis in the study group (P = .005).
Conclusions: Treatment with iontophoresis led to the reduction of disease severity and improvement of quality of life, and it is a safe, easy-to-use method with minimal side effects. This technique should be considered before the use of systemic or aggressive surgical interventions, which could have potentially more severe side effects.
People at risk for diabetic foot ulcer (DFU) often misunderstand why foot ulcers develop and what self-care strategies may help prevent them. The etiology of DFU is complex and difficult to communicate to patients, which may hinder effective self-care. Thus, we propose a simplified model of DFU etiology and prevention to aid communication with patients. The Fragile Feet & Trivial Trauma model focuses on two broad sets of risk factors: predisposing and precipitating. Predisposing risk factors (eg, neuropathy, angiopathy, and foot deformity) are usually lifelong and result in “fragile feet.” Precipitating risk factors are usually different forms of everyday trauma (eg, mechanical, thermal, and chemical) and can be summarized as “trivial trauma.” We suggest that the clinician consider discussing this model with their patient in three steps: 1) explain how a patient’s specific predisposing risk factors result in fragile feet for the rest of life, 2) explain how specific risk factors in a patient’s environment can be the trivial trauma that triggers development of a DFU, and 3) discuss and agree on with the patient measures to reduce the fragility of the feet (eg, vascular surgery) and prevent trivial trauma (eg, wear therapeutic footwear). By this, the model supports the communication of two essential messages: that patients may have a lifelong risk of ulceration but that there are health-care interventions and self-care practices that can reduce these risks. The Fragile Feet & Trivial Trauma model is a promising tool for aiding communication of foot ulcer etiology to patients. Future studies should investigate whether using the model results in improved patient understanding and self-care and, in turn, contributes to lower ulceration rates.
Background: We sought to evaluate clinicians’ compliance with national guidelines for tetanus vaccination prophylaxis in patients with high-risk feet.
Methods: We retrospectively evaluated 114 consecutive patients between June 1, 2011, and March 31, 2019, who presented to the emergency department with a foot infection resulting from a puncture injury. Eighty-three patients had diabetes mellitus and 31 patients did not have diabetes mellitus. Electronic medical records were used to collect a broad range of study data on patient demographics, medical history, tetanus immunization history and tetanus status on presentation to the emergency department, peripheral arterial disease, sensory neuropathy, laboratory values, and clinical/surgical outcomes.
Results: Of the 114 patients who presented to the emergency department with a puncture wound, 53 (46.5%) did not have up-to-date tetanus immunization. Of those patients, 79.2% received a tetanus-containing vaccine booster, 3.8% received intramuscular tetanus immunoglobulin, 3.8% received both a tetanus-containing vaccine booster and tetanus immunoglobulins, and 20.8% received no form of tetanus prophylaxis. Comparing data between patients with and without diabetes mellitus, there were no statistically significant differences in tetanus prophylaxis.
Conclusions: Guidelines for tetanus prophylaxis among high-risk podiatric medical patients in this study center are not followed in all patients. Patients with diabetes mellitus are at high risk for exposure to tetanus; therefore, we recommend that physicians take a detailed tetanus immunization history and vaccinate patients if the tetanus history is unclear.