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Background: This literature review was undertaken to evaluate the reliability and validity of the orthopedic, neurologic, and vascular examination of the foot and ankle.
Methods: We searched PubMed—the US National Library of Medicine’s database of biomedical citations—and abstracts for relevant publications from 1966 to 2006. We also searched the bibliographies of the retrieved articles. We identified 35 articles to review. For discussion purposes, we used reliability interpretation guidelines proposed by others. For the κ statistic that calculates reliability for dichotomous (eg, yes or no) measures, reliability was defined as moderate (0.4–0.6), substantial (0.6–0.8), and outstanding (> 0.8). For the intraclass correlation coefficient that calculates reliability for continuous (eg, degrees of motion) measures, reliability was defined as good (> 0.75), moderate (0.5–0.75), and poor (< 0.5).
Results: Intraclass correlations, based on the various examinations performed, varied widely. The range was from 0.08 to 0.98, depending on the examination performed. Concurrent and predictive validity ranged from poor to good.
Conclusions: Although hundreds of articles exist describing various methods of lower-extremity assessment, few rigorously assess the measurement properties. This information can be used both by the discerning clinician in the art of clinical examination and by the scientist in the measurement properties of reproducibility and validity. (J Am Podiatr Med Assoc 98(3): 197–206, 2008)
Chemical matrixectomy for ingrown toenails is one of the most common surgical procedures performed on the foot. The procedure was first described in 1945 by Otto Boll, who discussed the use of phenol to correct ingrown toenails. In the years that followed, many variations of technique and method have been described. This article reviews the pertinent literature detailing chemical matrixectomies and advocates the use of an evidence basis for care. (J Am Podiatr Med Assoc 92(5): 287-295, 2002)
Background: Off-loading excessive pressure is essential to healing diabetic foot ulcers. However, many patients are not compliant in using prescribed footwear or off-loading devices. We sought to validate a method of objectively measuring off-loading compliance via activity monitors.
Methods: For 4 days, a single subject maintained a written compliance diary concerning use of a removable cast walker. He also wore a hip-mounted activity monitor during all waking hours. An additional activity monitor remained mounted on the cast walker at all times. At the conclusion of the 4 days, the time-stamped hip activity data were independently coded for walker compliance by the compliance diary and by using the time-stamped walker activity data.
Results: An intraclass reliability of 0.93 was found between diary-coded and walker monitor–coded activity.
Conclusions: These results support the use of this dual activity monitor approach for assessing off-loading compliance. An advantage of this approach versus a patient-maintained diary is that the monitors are not susceptible to incorrect patient recall or a patient’s desire to please a caregiver by reporting inflated compliance. Furthermore, these results seem to lend support to existing reports in the literature using similar methods. (J Am Podiatr Med Assoc 99(2): 100–103, 2009)
This study compares the potential benefit of fifth metatarsal head resection versus standard conservative treatment of plantar ulcerations in people with diabetes mellitus. Using a retrospective cohort model, we abstracted data from 40 patients (22 cases and 18 controls) treated for uninfected, nonischemic diabetic foot wounds beneath the fifth metatarsal head. There were no significant differences in sex, age, duration of diabetes mellitus, or degree of glucose control between cases and controls. Patients who underwent a fifth metatarsal head resection healed significantly faster (mean ± SD, 5.8 ± 2.9 versus 8.7 ± 4.3 weeks). Patients were much less likely to reulcerate during the period of evaluation in the surgical group (4.5% versus 27.8%). The results of this study suggest that fifth metatarsal head resection is a potentially effective treatment in patients at high risk of ulceration and reulceration. (J Am Podiatr Med Assoc 95(4): 353–356, 2005)
Diabetic foot ulcers combined with ischemia and infection can be difficult to treat. Few studies have quantified the level of blood supply and infection control required to treat such complex diabetic foot ulcers. We aimed to propose an index for ischemia and infection control in diabetic chronic limb-threatening ischemia (CLTI) with forefoot osteomyelitis.
We retrospectively evaluated 30 patients with diabetic CLTI combined with forefoot osteomyelitis who were treated surgically from January 2009 to December 2016. After 44 surgeries, we compared patient background (age, sex, hemodialysis), infection status (preoperative and 1- and 2-week postoperative C-reactive protein [CRP] levels), surgical bone margin (with or without osteomyelitis), vascular supply (skin perfusion pressure), ulcer size (wound grade 0–3 using the Society for Vascular Surgery Wound, Ischemia, and foot Infection classification), and time to wound healing between patients with healing ulcers and those with nonhealing ulcers.
Preoperative CRP levels and the ratio of ulcers classified as wound grade 3 were significantly lower and skin perfusion pressure was significantly higher in the healing group than in the nonhealing group (P < .05). No other significant differences were found between groups.
This study demonstrates that debridement should be performed first to control infection if the preoperative CRP level is greater than 40 mg/L. Skin perfusion pressure of 55 mm Hg is strongly associated with successful treatment. We believe that this research could improve the likelihood of salvaging limbs in patients with diabetes with CLTI.
Randomized trials must be of high methodological quality to yield credible, actionable findings. The main aim of this project was to evaluate whether there has been an improvement in the methodological quality of randomized trials published in the Journal of the American Podiatric Medical Association (JAPMA).
Randomized trials published in JAPMA during a 15-year period (January 1999 to December 2013) were evaluated. The methodological quality of randomized trials was evaluated using the PEDro scale (scores range from 0 to 10, with 0 being lowest quality). Linear regression was used to assess changes in methodological quality over time.
A total of 1,143 articles were published in JAPMA between January 1999 and December 2013. Of these, 44 articles were reports of randomized trials. Although the number of randomized trials published each year increased, there was only minimal improvement in their methodological quality (mean rate of improvement = 0.01 points per year). The methodological quality of the trials studied was typically moderate, with a mean ± SD PEDro score of 5.1 ± 1.5. Although there were a few high-quality randomized trials published in the journal, most (84.1%) scored between 3 and 6.
Although there has been an increase in the number of randomized trials published in JAPMA, there is substantial opportunity for improvement in the methodological quality of trials published in the journal. Researchers seeking to publish reports of randomized trials should seek to meet current best-practice standards in the conduct and reporting of their trials.
The aim of this study was to evaluate whether high plantar foot pressures can be predicted from measurements of plantar soft-tissue thickness in the forefoot of diabetic patients with neuropathy. A total of 157 diabetic patients with neuropathy and at least one palpable foot pulse but without a history of foot ulceration were invited to participate in the study. Plantar tissue thickness was measured bilaterally at each metatarsal head, with patients standing on the same standardized platform. Plantar pressures were measured during barefoot walking using the optical pedobarograph. Receiver operating characteristic analysis was used to determine the plantar tissue thickness predictive of elevated peak plantar pressure. Tissue thickness cutoff values of 11.05, 7.85, 6.65, 6.55, and 5.05 mm for metatarsal heads 1 through 5, respectively, predict plantar pressure at each respective site greater than 700 kPa, with sensitivity between 73% and 97% and specificity between 52% and 84%. When tissue thickness was used to predict pressure greater than 1,000 kPa, similar results were observed, indicating that high pressure at different levels could be predicted from similar tissue thickness cutoff values. The results of the study indicate that high plantar pressure can be predicted from plantar tissue thickness with high sensitivity and specificity. (J Am Podiatr Med Assoc 94(1): 39-42, 2004)
The etiology of neuropathic diabetic foot wounds can be summarized by the following formula: pressure × cycles of repetitive stress = ulceration. The final pathway to ulceration consists of an inflammatory response, leading to tissue breakdown. Mitigation of this response might reduce the risk of ulceration. This proof-of-concept trial evaluates whether simple cooling of the foot can safely reduce the time to thermal equilibrium after activity. After a 15-min brisk walk, the six nondiabetic volunteers enrolled were randomly assigned to receive either air cooling or a 10-min 55°F cool water bath followed by air cooling. The process was then repeated with the intervention reversed, allowing subjects to serve as their own controls. There was a rise in mean ± SD skin temperature after 15 min of activity versus preactivity levels (87.8° ± 3.9° versus 79° ± 2.2° F; P = .0001). Water cooling immediately brought the foot to a point cooler than preactivity levels for all subjects, whereas air cooling required an average of nearly 17 min to do so. Ten minutes of cooling required a mean ± SD of 26.2 ± 5.9 min to warm to preactivity levels. No adverse effects resulted from the intervention. We conclude that cooling the foot may be a safe and effective method of reducing inflammation and may serve as a prophylactic or interventional tool to reduce skin breakdown risk. (J Am Podiatr Med Assoc 95(2): 103–107, 2005)
Background: The removal of necrotic tissue from chronic wounds is required for wound healing to occur. Hydrodebridement (jet lavage) and superoxidized aqueous solution have been independently used for debriding wounds. We sought to investigate the use of superoxidized aqueous solution with a jet lavage system.
Methods: Twenty patients with diabetic foot ulcers were randomly assigned in a 1:1 ratio to receive jet lavage debridement with either superoxidized aqueous solution or standard saline weekly.
Results: There was no significant difference between the two treatments in the reduction of bacterial load or wound size in 4 weeks. No adverse reactions were reported for either treatment.
Conclusions: The use of superoxidized aqueous solution for jet lavage debridement seemed to be as safe and effective as saline. Future investigations should concentrate on whether superoxidized aqueous solution may reduce the bacterial air contamination associated with hydrodebridement. (J Am Podiatr Med Assoc 101(2): 124–126, 2011)
Maggot Therapy in “Lower-Extremity Hospice” Wound Care
Fewer Amputations and More Antibiotic-Free Days
We sought to assess, in a case-control model, the potential efficacy of maggot debridement therapy in 60 nonambulatory patients (mean ± SD age, 72.2 ± 6.8 years) with neuroischemic diabetic foot wounds (University of Texas grade C or D wounds below the malleoli) and peripheral vascular disease. Twenty-seven of these patients (45%) healed during 6 months of review. There was no significant difference in the proportion of patients healing in the maggot debridement therapy versus control group (57% versus 33%). Of patients who healed, time to healing was significantly shorter in the maggot therapy than in the control group (18.5 ± 4.8 versus 22.4 ± 4.4 weeks). Approximately one in five patients (22%) underwent a high-level (above-the-foot) amputation. Patients in the control group were three times as likely to undergo amputation (33% versus 10%). Although there was no significant difference in infection prevalence in patients undergoing maggot therapy versus controls (80% versus 60%), there were significantly more antibiotic-free days during follow-up in patients who received maggot therapy (126.8 ± 30.3 versus 81.9 ± 42.1 days). Maggot debridement therapy reduces short-term morbidity in nonambulatory patients with diabetic foot wounds. (J Am Podiatr Med Assoc 95(3): 254–257, 2005)