Search Results
Surgical Management of Gout in the Foot and Ankle
A Systematic Review
Background: The surgical management of tophaceous gout has been well documented in the literature, including its effect on foot pain and disability. To date, there have been no systematic reviews assessing the quality of the literature relating to the operative management of tophaceous gout and the outcomes in the foot and ankle.
Methods: The following electronic databases were searched (1980–2014): Allied and Complementary Medicine, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Scopus, and the Cochrane Library. The articles identified were published in English and included adult participants (age ≥18 years) with diagnosed gout and surgical intervention to the foot and ankle. The Downs and Black Quality Index was modified to assess the quality of the articles being reviewed.
Results: Six articles were reviewed and were of moderate quality (mean quality score of 71%). Surgical management was conducted on men (88%) with a mean age of 52 years. There was wide variation in the types of surgical procedures performed, with 28% of studies reporting surgery to the first metatarsophalangeal joint. Most studies were retrospective. A wide range of outcome measures were reported: foot pain, function, preoperative and postoperative activity levels, monitoring of uric acid levels, and patient satisfaction after surgery.
Conclusions: The review demonstrated a limited number of good-quality studies. Several surgical procedures for the foot and ankle in people with chronic tophaceous gout were reported. Future studies should include prospective observational studies using validated and reliable patient-reported outcome measures.
Background:
The aim of this study was to observe the pressure changes in the felt padding used to off-load pressure from the first metatarsal head, the effects obtained by different designs, and the loss of effectiveness over time.
Method:
With a study population of 17 persons, two types of 5-mm semicompressed felt padding were tested: one was C-shaped, with an aperture cutout at the first metatarsophalangeal joint, and the other was U-shaped. Pressures on the sole of the foot were evaluated with a platform pressure measurement system at three time points: before fitting the felt padding, immediately afterward, and 3 days later.
Results:
In terms of decreased mean pressure on the first metatarsal, significant differences were obtained in all of the participants (P < .001). For plantar pressures on the central metatarsals, the differences between all states and time points were significant for the C-shaped padding in both feet (P < .001), but with the U-shaped padding the only significant differences were between no padding and padding and at day 3 (P = .01 and P = .02).
Conclusions:
In healthy individuals, the U-shaped design, with a padding thickness of 5 mm, achieved a more effective and longer-lasting reduction in plantar pressure than the C-shaped design.
Background
For several years, confectioned or customized interdigital silicone orthoses have been used to treat toe malformations; however, long-term clinical and biomechanical studies are missing. The aim of this study was to evaluate the biomechanical effects of these orthoses and their clinical acceptance.
Methods
In 2008, 46 patients (30 women and 16 men; average age, 56.8 years) received interdigital silicone orthoses. All of the patients were included in the biomechanical and clinical study. Compliance and acceptance were measured by the Muenster shoe and foot questionnaire, which includes 13 items on pain, activities of daily living, satisfaction, and activity. Mean follow-up was 18 months. Ten feet (eight patients) were chosen by random and underwent pedobarography. One forefoot sensor and two single sensors were attached between the skin and the orthosis. Measurements were performed in-shoe three times with and without the orthosis without removal of the sensors.
Results
Forty-four of the 46 patients (95.7%) were included. At the 18-month investigation, 19 patients no longer used their orthoses, most commonly because of pain and failure of the material. Twenty-two patients regularly used their orthoses (8 h/d on average). In-shoe peak pressure lowered significantly with orthosis use (P < .04). Patients who used the orthoses were mostly satisfied.
Conclusions
Interdigital silicone orthoses reduce in-shoe peak pressure. Patient satisfaction was good. The durability of the material has to be optimized, and manufacturing remains difficult. The effect on ulcer reduction must be evaluated in a large prospective study.
Background: Foot blisters are common and painful nuisances in competitive sports and in military service. The pathogenesis of the problem is related to excessive frictional forces experienced on or under the foot. The incidence of foot blisters in marathon runners can reach 39%. Similarly, up to 42% of cadets in Reserve Officers’ Training Corps camps might be prone to foot blisters. Although the problem usually disappears within 5 days, a single blister might be a major problem in competitive sports or in a wilderness setting. Military training and combat effectiveness might also be compromised by foot blisters. This study sought to reveal the distribution of plantar shear forces in athletic individuals and its relevance to foot blisters.
Methods: Three groups of 11 participants each were studied: blister, adult control, and pediatric control. A custom-built shear and pressure platform was used to collect plantar pressure and shear data while the participants walked over the device. Data were analyzed with repeated-measures analysis of variance.
Results: The blister group had significantly increased pressure and shear stress magnitudes compared with the other groups, although no significant group-site interaction was found. The shear-time integral values were increased approximately 50% at specific sites of the athletic feet, suggesting that contact time may play a role in blister formation.
Conclusions: The biomechanical interaction on the plantar surface of a blister-prone person is different from that of individuals who are less prone to the problem. (J Am Podiatr Med Assoc 100(2): 116–120, 2010)
The Prevalence of Interdigital Erythrasma
A Prospective Study from an Outpatient Clinic in Turkey
Background
Erythrasma is a superficial skin infection caused by Corynebacterium minutissimum. Interdigital erythrasma is the most common form and is easily confused with tinea pedis. The aim of this study was to determine the prevalence of interdigital erythrasma in patients with clinically suspected tinea pedis.
Methods
This study was performed between January 1, 2011, and January 31, 2012. It included 182 patients who presented with concerns about interdigital lesions. All of the patients were examined with a Wood's lamp, and smears were stained with Gram's method. Direct examination with 20% potassium hydroxide was performed.
Results
Of 182 patients with interdigital lesions, 73 (40.1%) were diagnosed as having erythrasma. The mean ± SD age of the patients with erythrasma was 45.52 ± 10.83 years (range, 22–70 years). Most of the patients with erythrasma were women (56.2%). The most often clinical finding was desquamation. Using only Wood's lamp examination or Gram's staining resulted in 31 (42.5%) or 14 (19.2%) positive patients, respectively. Using Wood's lamp examination and Gram's staining concurrently resulted in 28 positive patients (38.4%).
Conclusions
Interdigital erythrasma is a common condition and can be difficult to differentiate from tinea pedis. Simple and rapid diagnosis can be made with Wood's lamp examination, but Gram's staining is also a useful method, especially in patients with negative Wood's lamp examination findings.
Background
Diabetic foot infection (DFI) is a serious, difficult-to-treat infection, especially when caused by methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin has been the standard treatment for MRSA infection, but lower response rates in MRSA skin infections have been reported. This analysis assessed the outcome and safety of daptomycin therapy in patients with a DFI caused by MRSA.
Methods
Using the Cubicin Outcomes Registry and Experience and the European Cubicin Outcomes Registry and Experience (2006–2009), 79 patients with MRSA DFI were identified and included in this analysis.
Results
In the 74 evaluable patients, daptomycin was administered at a median dose of 4.8 mg/kg primarily every 24 hours (85.1%) and for a median of 15.0 days. Overall, 77.0% of the patients (57 of 74) received initial therapy with activity against MRSA; however, of patients receiving daptomycin as second-line therapy (n = 31), only 45.2% were treated with an antibiotic agent active against MRSA. The overall clinical success and treatment failure rates were 89.2% and 10.8%, respectively. Success with daptomycin therapy was higher in patients who had surgery and in those whose initial therapy was daptomycin. Eleven patients had 14 adverse events, two of which were possibly related to daptomycin use and led to discontinuation.
Conclusions
In a large real-world cohort of patients with MRSA DFI, daptomycin therapy was shown to be generally well tolerated and effective. The use of an anti-MRSA antibiotic agent should be considered when implementing first-line antibiotic drug therapy for DFI in countries where MRSA is common to avoid inappropriate empirical treatment and potential negative effects on outcomes.
Chemical Matrixectomy for Ingrown Toenails
Is There an Evidence Basis to Guide Therapy?
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
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.
Maggot debridement therapy is rapidly increasing in popularity at major diabetic foot and wound care centers worldwide. However, we are unaware of specific guidelines on the short-term storage of larvae. We sought to evaluate differences in maggot motility over time in larvae refrigerated versus those stored at room temperature. We also introduce a simple surrogate method for evaluating maggot vitality that may be useful for in vivo studies if validated in future works. We randomly selected ten larvae from the same shipment at ten different times in 9 days. Larvae were placed on a translucent acetate grid, and their total excursion in 30 sec was measured. This was converted into a Maggot Motility Index. In the refrigerated group, the index remained at or above 40 mm/min for approximately 60 hours from baseline, when there was a significant decrease. This same phenomenon occurred during the first 12 hours in the nonrefrigerated group. There were significant differences in motility between refrigerated and nonrefrigerated larvae immediately after baseline until day 8. Larvae are more practical for repeated clinical use if kept refrigerated between applications. (J Am Podiatr Med Assoc 94(4): 353–355, 2004)
Background
The clinical diagnosis of osteomyelitis is difficult because of neuropathy, vascular disease, and immunodeficiency; also, with no established consensus on the diagnosis of foot osteomyelitis, the reported efficacy of magnetic resonance imaging (MRI) in detecting osteomyelitis and distinguishing it from reactive bone marrow edema is unclear. Herein, we describe a retrospective study on the efficacy of MRI for decision-making accuracy in diagnosing osteomyelitis in diabetic foot ulcers.
Methods
Twelve diabetic patients with infected foot ulcers underwent preoperative MRI between January 1, 2008, and December 31, 2011. The findings were compared with the histopathologic features of 67 parts of 45 resected bones, the cut ends of which were also histopathologically evaluated.
Results
Osteomyelitis was disclosed by MRI and histopathologically confirmed in 30 parts. In contrast, bone marrow edema diagnosed by MRI in 29 parts was confirmed in 23; the other six parts displayed osteomyelitis. Among 17 resected bones, 13 cut ends displayed bone marrow edema and four were normal. All of the wounds healed uneventfully.
Conclusions
In the diagnosis of diabetic foot ulcers, osteomyelitis is often reliably distinguished from reactive bone marrow edema, except in special cases.
