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Background: Digital deformities represent a common presenting abnormality and target for surgical intervention in podiatric medicine and surgery. The objective of this investigation was to compare the radiographic width of the heads of the lesser digit proximal phalanges.
Methods: One hundred fifty consecutive feet with a diagnosis of digital deformity and performance of weightbearing radiographs were analyzed. The maximum width of the heads of the lesser digit proximal phalanges were recorded from the radiographs using computerized digital software.
Results: The mean ± standard deviation of the head of the second digit proximal phalanx was 9.74 ± 0.87 mm (range, 7.94–11.78 mm); the head of the third digit proximal phalanx, 9.00 ± 0.91 mm (range,7.27–10.94 mm); the head of the fourth digit proximal phalanx, 8.49 ± 1.01 mm (range, 5.57–10.73 mm); and the head of the fifth digit proximal phalanx, 8.67 ± 0.89 mm (range, 6.50–11.75 mm). The width of the head of the proximal phalanx decreased from the second digit to the third digit (P < .001), decreased from the third digit to the fourth digit (P < .001), and then increased from the fourth digit to the fifth digit (P = .032).
Conclusions: The results of this investigation provide evidence in support of an anatomical and structural contribution to digital deformities. The width of the heads of the lesser digit proximal phalanges decreased from the second to the third to the fourth toes, and then subsequently increased with the fifth proximal phalangeal head.
The utility of wound debridement has expanded to include the management of all chronic wounds, even in the absence of infection and gross necrosis. Biofilms, metalloproteases on the wound base, and senescent cells at the wound edge irreversibly change the physiologic features of wound healing and contribute to a pathologic, chronic inflammatory environment. The objective of this review is to provide surgeons with a basic understanding of the processes of debridement in the noninfected wound. (J Am Podiatr Med Assoc 100(5): 353–359, 2010)
It is important to have a full appreciation of lower-extremity anatomical relationships before undertaking diabetic foot surgery. We sought to evaluate the potential for communication of the flexor hallucis longus (FHL) tendon with other pedal tendons and plantar foot compartments at the master knot of Henry and to provide cadaveric images and computed tomographic (CT) scans of such communications. Computed tomography and subsequent anatomical dissection were performed on embalmed cadaveric limbs. Initially, 5 to 10 mL (1:4 dilution) of iohexol and normal saline was injected into the FHL sheath as it coursed between the two hallux sesamoids. Subsequently, CT scans were obtained in the axial plane using a multidetector CT scanner with sagittal and coronal reformatted images. The limbs were then dissected for specific evaluation of the known variable intertendinous connections between the FHL and flexor digitorum longus (FDL) and quadratus plantae (QP) muscles. One cadaver demonstrated retrograde flow of contrast into the four individual tendons of the FDL, with observation of a large intertendinous slip between the FHL and FDL on dissection. Another cadaver demonstrated contrast filling in the QP with an associated intertendinous slip between the FHL and QP on dissection. These results indicate that the master knot of Henry (the location in the plantar aspect of the midfoot where the FHL and FDL tendons decussate, with the FDL passing superficially over the FHL) has at least the potential to serve as one source of communication in diabetic foot infections from the medial plantar compartment and FHL to the central and lateral compartments via the FDL and to the rearfoot via the QP.
Background
The objective of this investigation was to determine the level of agreement between a systematic clinical Doppler examination of the foot and ankle and diagnostic peripheral angiography.
Methods
The described Doppler examination technique attempted to determine the patency, quality, and direction of the flow through the dorsalis pedis artery, posterior tibial artery, terminal branches of the peroneal artery, and vascular arch of the foot. These results were then compared with angiographic distal run-off images as interpreted by a blinded vascular surgeon.
Results
Levels of agreement with respect to artery patency/quality ranged from 64.0% to 84.0%. Sensitivity ranged from 53.8% to 84.2%, and specificity ranged from 64.7% to 91.7%. Agreement with respect to arterial flow direction ranged from 73.3% to 90.5%.
Conclusions
We interpret these results to indicate that this comprehensive physical examination technique of the arterial flow to the foot and ankle with a Doppler device might serve as a reasonable initial surrogate to diagnostic angiography in some patients with peripheral arterial disease.
Background:
One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis. This retrospective, observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital.
Methods:
A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation.
Results:
The overall rate of ambulation in a prosthesis was 29.94% (50.0% of those with unilateral below-the-knee amputation [BKA] and 20.0% of those with unilateral above-the-knee amputation [AKA]). In 24.81% of patients with unilateral BKA or AKA, a secondary surgical procedure of the amputation site was required. In those with unilateral BKA or AKA, statistically significant factors associated with ambulation included male sex (odds ratio [OR] = 2.50) and at least 6 months of outpatient follow-up (OR = 8.10), survival for at least 1 postoperative year (OR = 8.98), ambulatory preamputation (OR = 14.40), returned home after the amputation (OR = 6.12), and healing of the amputation primarily without a secondary surgical procedure (OR = 3.62). Those who had a history of dementia (OR = 0.00), a history of peripheral arterial disease (OR = 0.35), and a preamputation history of ipsilateral limb revascularization (OR = 0.14) were less likely to walk. We also observed that patients with a history of outpatient evaluation by a podiatric physician before major amputation were 2.63 times as likely to undergo BKA as opposed to AKA and were 2.90 times as likely to walk after these procedures.
Conclusions:
These results add to the body of knowledge regarding outcomes after major amputation and could be useful in the education and consent of patients faced with major amputation.
Background:
A patient “handoff,” or the “sign-out” process, is an episode during which the responsibility of a patient transitions from one health-care provider to another. These are important events that affect patient safety, particularly because a significant proportion of adverse events have been associated with a relative lack of physician communication. The objective of this investigation was to survey podiatric surgical residency programs with respect to patient care handoff and sign-out practices.
Methods:
A survey was initially developed and subsequently administered to the chief residents of 40 Council on Podiatric Medical Education–approved podiatric surgical residency programs attempting to elucidate patient care handoff protocols and procedures and on-call practices.
Results:
Although it was most common for patient care handoffs to occur in person (60.0%), programs also reported that handoffs regularly occurred by telephone (52.5%) and with no direct personal communication whatsoever other than the electronic passing of information (50.0%). In fact, 27.5% of programs reported that their most common means of patient care handoff was without direct resident communication and was instead purely electronic. We observed that few residents reported receiving formal education or assessment/feedback (17.5%) regarding their handoff proficiency, and only 5.0% of programs reported that attending physicians regularly took part in the handoff/sign-out process. Although most programs felt that their sign-out practices were safe and effective, 67.5% also believed that their process could be improved.
Conclusions:
These results provide unique information on a potentially underappreciated aspect of podiatric medical education and might point to some common deficiencies regarding the development of interprofessional communication within our profession during residency training.
Background: We evaluated adverse short-term outcomes after open lower-extremity bypass surgery in patients with diabetes mellitus with a comparison performed based on patient height.
Methods: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to select patients with Current Procedural Terminology codes 35533, 35540, 35556, 35558, 35565, 35566, 35570, and 35571 and with the diagnosis of diabetes mellitus. This resulted in 83 patients 60 inches or less in height, 1,084 between 60 and 72 inches, and 211 patients 72 inches and taller.
Results: No differences were observed among groups with respect to the development of a superficial surgical site infection (9.6% versus 6.4% versus 5.7%; P = .458), deep incisional infection (1.2% versus 1.4% versus 2.8%; P = .289), sepsis (2.4% versus 2.0% versus 2.8%; P = .751), unplanned reoperation (19.3% versus 15.6% versus 21.8%; P = .071), or unplanned hospital readmission (19.3% versus 14.8% versus 17.1%; P = .573). A significant difference was observed among groups in the development of a wound disruption (4.8% versus 1.3% versus 4.7%; P = .001). A multivariate regression analysis was performed of the wound disruption outcome with the variables of age, sex, race, ethnicity, height, weight, current smoker, and open wound/wound infection. Race (P = .025) and weight (P = .003) were found to be independently associated with wound disruption, but height was not (P = .701).
Conclusions: The results of this investigation demonstrate no significant differences in short-term adverse outcomes after lower-extremity bypass surgery based on patient height.
INTRODUCTION AND OBJECTIVES: Immobilization devices such as surgical shoes and walking boots are commonly prescribed by podiatric physicians in the treatment of a variety of lower extremity pathologies and during the post-operative recovery period, but may have the potential to affect a patient’s ability to maintain a safe level of control over the accelerator and brake pedals while operating an automobile. The objective of this investigation was to assess driving outcomes in a group of healthy participants under variable foot wear conditions.
METHODS: Following IRB approval, the braking performances of participants were evaluated with a computerized driving simulator. We assessed three driving outcomes (mean emergency brake response time, frequency of abnormally delayed braking responses, and frequency of inaccurate brake responses) under three variable footwear conditions (regular shoe gear, surgical shoe, and walking boot).
RESULTS: We found that mean brake response times were abnormally delayed in the walking boot compared to both the regular shoe (0.736 seconds vs. 0.575 seconds, p < 0.001 seconds) and surgical shoe (0.736 seconds vs. 0.611 seconds, p < 0.001). We found that abnormally delayed brake responses occurred more frequently in the surgical shoe (18.5% vs. 2.5%, p < 0.001) and the walking boot (55.5% vs. 2.5%, p < 0.001) compared to the regular shoe. And we found that inaccurate brake responses occurred more frequently in the walking boot compared to both the surgical shoe (18.0% vs. 4.0%, p < 0.001) and the regular shoe (18.0% vs. 2.0%, p < 0.001).
CONCLUSIONS: The results of these investigations provide podiatric physicians with a better understanding of how to assess the risk and how to appropriately advise their patients who have been prescribed lower extremity immobilization devices with respect to the safe operation of an automobile.
