Search Results
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)
This prospective longitudinal study assessed whether baseline mean skin temperature measurements are useful in predicting the most common foot-related complications of diabetes mellitus. We evaluated the mean of baseline skin temperatures taken bilaterally from six plantar sites in 1,588 patients with diabetes. There was no difference in skin temperature based on neuropathy, foot laterality, or foot risk category or between people with and without foot deformity and elevated plantar foot pressure. Whereas people with Charcot’s arthropathy had slightly but significantly higher mean temperatures (84.8° ± 3.5° F versus 82.5° ± 4.7° F), this was not true for those who developed ulcers or infections or who underwent amputations. The presence of vascular disease was not associated with lower skin temperatures. Mexican Americans (83.0° ± 4.6° F) and blacks (83.6° ± 4.5° F) had higher mean skin temperatures at baseline than did non-Hispanic whites (81.8° ± 4.6° F). Baseline measurement of nonfocal mean skin temperatures is not an effective means of screening people for future events. Regular assessment of skin temperatures, using the contralateral site as a physiologic control, may be a better use of this technology. (J Am Podiatr Med Assoc 93(6): 443-447, 2003)
Background: We evaluated the cost of treating neuroischemic ulcers of the lower extremity in patients with peripheral artery disease by using medical and hospital claims records submitted for reimbursement to payers (private insurance, Medicare, Medicaid).
Methods: Adjudicated claims and remittance data on claims that include submitted charges, line items paid by insurers directly to providers and patient payments of copays, deductibles and co-insurance were used. Eligible patients from a commercial database containing more than 60% of US patients with health insurance were analyzed. Patient selection, performed using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, yielded a study population of 42,837 unique anonymized patients.
Results: Using the metric of “submitted charges” to overcome differences in levels of reimbursement across insurance payers and Medicare/Medicaid, we identified 34,348 patients with ulcers with an average treatment cost of $94,100 per patient ($41,800 annualized) The costliest ulcer subtype was nonpressure ulcer of the heel/midfoot among 13,184 patients with $121,400 per patient ($53,900 annualized), 29% higher than across all ulcer types. The subset of 22,281 ulcer patients who also had a surgical procedure incurred costs of $121,000 per patient ($53,800 annualized). The costliest surgical codes were complications of vascular prosthetic devices, implants, grafts among 6444 patients with $146,900 per patient ($65,300 annualized). The combination of most expensive ulcer and most expensive surgery yielded a cohort of 2355 patients with the highest average cost of $177,400 per patient ($78,800 annualized).
Conclusions: The resource burden for management of neuroischemic ulcers of the lower extremity in patients with peripheral artery disease is substantial. Mitigating this burden may help reduce significant resource utilization.
Foot pain and lower-limb neuroischemia in diabetes mellitus is common and can be debilitating and difficult to treat. We report a comparison of orthotic materials to manage foot pain in a 59-year-old man with type 1 diabetes mellitus, peripheral neuropathy, peripheral arterial disease, and a history of foot ulceration. We investigated a range of in-shoe foot orthoses for comfort and plantar pressure reduction in a cross-sectional study. The most comfortable and most effective pressure-reducing orthoses were subsequently evaluated for pain relief in a single system alternating-treatment design. After 9 weeks, foot pain was completely resolved with customized multidensity foot orthoses. The outcome of this case study suggests that customized multidensity foot orthoses may be a useful intervention to reduce foot pain and maintain function in the neuroischemic diabetic foot. (J Am Podiatr Med Assoc 98(2): 143–148, 2008)
Background: A scientific study was conducted to evaluate the effects of non–custom-molded (over-the-counter) foot orthoses.
Methods: Several parameters were examined, including foot, knee, hip, and back pain; balance; and reduction in flexible deformities, such as hammer toes and hallux valgus. Wherever possible, objective measurements were used, including measurements of shifts in center of pressure to assess balance and changes in bone position examined on radiographs. Forty-one individuals were analyzed using one of two types of prefabricated, noncustom insoles. Insoles were fit by an assistant trained to follow the fitting recommendations of the manufacturer under the direct supervision of a podiatric physician.
Results: Use of these arch supports resulted in a significant reduction in some types of foot pain associated with hallux valgus (P = .04) and pain in the arch area (P = .004), knee (P = .002), and back (P = .007) by week 4. We also measured changes in foot position documented by radiography, although some changes may be attributed to parallax associated with measurement techniques. Improvement in balance was not observed to be significant when the orthoses were worn.
Conclusions: Using both subjective and objective measures, we found that these over-the-counter foot orthoses were effective in bringing about changes in foot shape and concomitant relief of certain specific painful conditions. This study indicates that there is a scientific basis for attempting to relieve pain with orthoses. (J Am Podiatr Med Assoc 99(3): 206–215, 2009)
Diabetic foot infections are a common and often serious problem, accounting for more hospital bed days than any other complication of diabetes. Despite advances in antibiotic drug therapy and surgical management, these infections continue to be a major risk factor for amputations of the lower extremity. Although a variety of wound size and depth classification systems have been adapted for use in codifying diabetic foot ulcerations, none are specific to infection. In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific to these infections. The following year, the Infectious Diseases Society of America published their diabetic foot infection guidelines. Herein, we review some of the critical points from the Executive Summary of the Infectious Diseases Society of America document and provide a commentary following each issue to update the reader on any pertinent changes that have occurred since publication of the original document in 2004.
The importance of a multidisciplinary limb salvage team, apropos of this special issue jointly published by the American Podiatric Medical Association and the Society for Vascular Surgery, cannot be overstated. (J Am Podiatr Med Assoc 100(5): 395–400, 2010)
Background: In this study, we aimed to describe a case series of revision first metatarsophalangeal joint fusion with a three-dimensional (3-D)–printed implant for osseous deficits of the first metatarsophalangeal joint. Bone defects of the first ray are a common problem in foot and ankle surgery. Etiologies include nonunion, avascular necrosis, osteomyelitis, failed first metatarsophalangeal joint implant arthroplasty, and failed hemijoint resection arthroplasty. Treatment options include acute shortening, block allograft, block autograft, distraction osteogenesis, vascularized free fibula, Masquelet technique, and partial first-ray amputation. Three-dimensional printing provides an opportunity to improve outcomes, with less donor site morbidity and less extensive recovery time than an external fixation device. It has been used in other facets of foot and ankle surgery with encouraging results.
Methods: Three patients (four feet) underwent revision first metatarsophalangeal joint fusion with a 3-D–printed implant. Reasons for revision included avascular necrosis after distal metatarsal osteotomy in one patient and bone deficit after failed first metatarsophalangeal joint implant in two patients.
Results: All patients had a minimum follow up of 12 months. Two patients had painful hardware and had to undergo revision due to implant design. At most recent follow up all patients were pain free with improved pain scores.
Conclusions: In revisional first metatarsophalangeal joint surgery with osseous deficits, the goal is to restore length and alignment, which improves function of the medial column. Custom 3-D–printed implants for first metatarsophalangeal joint revision can provide an opportunity for improved outcomes and healing.
Ovine Forestomach Matrix in the Surgical Management of Complex Lower-Extremity Soft-Tissue Defects
A Retrospective Multicenter Case Series
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.
Foot Biomechanics in Patients with Diabetes Mellitus
Doubts Regarding the Relationship Between Neuropathy, Foot Motion, and Deformities
Background:
We sought to identify the biomechanical characteristics of the feet of patients with diabetes mellitus and the interrelationship with diabetic neuropathy by determining the range of joint mobility and the presence and locations of calluses and foot deformities.
Methods:
This observational comparative study involved 281 patients with diabetes mellitus who underwent neurologic and vascular examinations. Joint mobility studies were performed, and deformities and hyperkeratosis locations were assessed.
Results:
No substantial differences were found between patients with and without neuropathy in joint mobility range. Neuropathy was seen as a risk factor only in the passive range of motion of the first metatarsophalangeal joint (mean ± SD: 57.2° ± 19.5° versus 50.3° ± 22.5°, P = .008). Mean ± SD ankle joint mobility values were similar in both groups (83.0° ± 5.2° versus 82.8° ± 9.3°, P = .826). Patients without neuropathy had a higher rate of foot deformities such as hallux abductus valgus and hammer toes. There was also a higher presence of calluses in patients without neuropathy (82.8% versus 72.6%; P = .039).
Conclusions:
Diabetic neuropathy was not related to limited joint mobility and the presence of calluses. Patients with neuropathy did not show a higher risk of any of the deformities examined. These findings suggest that the etiology of biomechanical alterations in diabetic people is complex and may involve several anatomically and pathologically predisposing factors. (J Am Podiatr Med Assoc 101(3): 208–214, 2011)
