Search Results
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)
Diagnosis and Prevalence of Onychomycosis in Diabetic Neuropathic Patients
An Observational Study
Background: An observational study was conducted to assess the prevalence of onychomycosis in clinically suspected diabetic neuropathic patients and to assess the reliability of the diagnosis.
Methods: One hundred successive type 1 and 2 diabetic patients with diabetic neuropathy were followed. Diabetic neuropathy was defined by a vibration perception threshold greater than 25 V and onychomycosis by clinical diagnosis. Samples of the most affected nail were taken. Potassium hydroxide testing and culture were performed. Photographs of the nails were used by two dermatologists for diagnosis.
Results: The mean ± SE age was 62.3 ± 11.4 years for the 20 onychomycotic patients and 60.3 ± 10.4 years for the entire cohort; 14 onychomycotic patients (70%) were male versus 56 in the full cohort (56%) (P < .05). The prevalence of onychomycosis was 20% (culture and potassium hydroxide test positive) and 24% (culture positive). Twenty or 30 patients were positive by the potassium hydroxide test, depending on the investigator. The most frequent pathogen found was Trichophyton rubrum (11 of 20 patients; 55%). The positive predictive values of the dermatologist’s diagnoses were 57.8% and 35.6%, and the negative predictive values were 85.0% and 90.5%. The two expert’s results were significantly different (P < .05).
Conclusions: The diagnosis of onychomycosis is difficult to make. The diagnostic methods commonly used are not satisfactory. If onychomycosis is dangerous for the diabetic foot, a better diagnostic method is needed. (J Am Podiatr Med Assoc 99(2): 135–139, 2009)
As of 2016, Medicaid accounted for nearly 20% of state general fund budgets. Optional Medicaid services such as podiatry are often subject to cost-cutting measures in periods of economic downturn, as was the case in the wake of the 2007 financial crisis. Although the cuts were intended as a cost-saving measure, research indicates that they had the opposite effect. The restriction and limitation of these services during the Great Recession resulted in both poorer health outcomes for beneficiaries, and poorer financial outcomes for state Medicaid programs. With states citing record levels of unemployment as of April of 2020 and projecting significant declines in annual revenue in 2021, the economic conditions resulting from the coronavirus disease of 2019 pandemic are likely to rival those of the Great Recession. Given the historical precedent for restricting or eliminating optional Medicaid services as a cost-saving measure, it is likely that podiatric services will once again come under scrutiny. Previous efforts by state-level podiatric societies have proven successful in lobbying for the reinstatement of coverage under Medicaid by conveying evidence of the negative outcomes associated with elimination to stakeholders. The specialty must once again engage policymakers by drawing on evidence gleaned and lessons learned from past cuts of optional Medicaid services to avert counterproductive coverage restrictions intended to mitigate the financial impact of the coronavirus disease of 2019 pandemic.
Background: Along with significant case transmission, hospitalizations, and mortality experienced during the global severe acute respiratory syndrome coronavirus 2 pandemic, there existed a disruption in the delivery of health care across multiple specialties. We studied the effect of the pandemic on inpatients with diabetic foot problems in a Level I trauma center in central Ohio.
Methods: A retrospective chart review of patients necessitating a consultation by the foot and ankle surgery service were reviewed from the first 8 months of 2020. A total of 270 patients met the inclusion criteria and were divided into prepandemic (n = 120) and pandemic groups (n = 150). Data regarding demographics, medical history, severity of current infection, and medical or surgical management were collected and analyzed.
Results: The odds of undergoing any level of amputation was 10.8 times higher during the pandemic versus before the pandemic. The risk of major amputations (below-the-knee or higher) likewise increased, with an odds ratio of 12.5 among all patients in the foot and ankle service during the pandemic. Of the patients undergoing any amputation, the odds for undergoing a major amputation was 3.1 times higher than before the pandemic. In addition, the severity of infections increased during the pandemic, and a larger proportion of the cases were classified as emergent in the pandemic group compared to the prepandemic group.
Conclusions: The effect of the pandemic on the health-care system has had a deleterious effect on people with diabetes mellitus (DM)–related foot problems, resulting in more severe infections and more emergencies, and necessitating more amputations. When an amputation was performed, the likelihood that it was a major amputation also increased.
Background: Bibliometric studies in the field of orthopedics have increased because of the large volume of the available literature that prevents understanding the general status of the related field. This study aimed to identify and analyze the 100 most-cited articles related to flatfoot to reveal their characteristics and research trends.
Methods: Available literature on the Web of Science database until the end of 2020 were analyzed, and the 100 most-cited articles were determined. The characteristics of articles including publication year, authors, institutions, country, journal, number of pages, number of references, study design, level of evidence, main topic, age group, the specialty of the first author, and availability of funding were extracted and statistically analyzed for any association with the number of citations or citation density.
Results: The average citation number was 63.1 ± 43.8 (range, 30–278). The average citation density was 3.4 ± 1.8 (range, 0.8–12.6). The United States was the leading country with 65 articles, followed by Taiwan and the United Kingdom with five articles from each. Twenty-six papers had Level III evidence and 36 papers had Level IV evidence. Only three studies had Level I evidence and three had Level II evidence. The majority of articles (43 papers) were published in Foot & Ankle International. Citation density was positively correlated with publication year (P < .001) and the number of references (P = .004).
Conclusions: The available data provide general characteristics of the 100 most influential papers about flatfoot. The vast majority of papers had a low level of evidence, indicating the need for higher quality research.
Foot Kinetic and Kinematic Profile in Type 2 Diabetes Mellitus with Peripheral Neuropathy
A Hospital-Based Study from South India
Background:
A kinetic change in the foot such as altered plantar pressure is the most common etiological risk factor for foot ulcers in people with diabetes mellitus. Kinematic alterations in joint angle and spatiotemporal parameters of gait have also been frequently observed in participants with diabetic peripheral neuropathy (DPN). Diabetic peripheral neuropathy leads to various microvascular and macrovascular complications of the foot in type 2 diabetes mellitus. There is a gap in the literature for biomechanical evaluation and assessment of type 2 diabetes mellitus with DPN in the Indian population. We sought to assess and determine the biomechanical changes, including kinetics and kinematics, of the foot in DPN.
Methods:
This cross-sectional study was conducted at a diabetic foot clinic in India. Using the purposive sampling method, 120 participants with type 2 diabetes mellitus and DPN were recruited. Participants with active ulceration or amputation were excluded.
Results:
The mean ± SD age, height, weight, body mass index, and diabetes duration were 57 ± 14 years, 164 ± 11 cm, 61 ± 18 kg, 24 ± 3 kg/m2, and 12 ± 7 years, respectively. There were significant changes in the overall biomechanical profile and clinical manifestations of DPN. The regression analysis showed statistical significance for dynamic maximum plantar pressure at the forefoot with age, weight, height, diabetes duration, body mass index, knee and ankle joint angle at toe-off, pinprick sensation, and ankle reflex (R = 0.71, R2 = 0.55, F12,108 = 521.9 kPa; P = .002).
Conclusions:
People with type 2 diabetes mellitus and DPN have significant changes in their foot kinetic and kinematic parameters. Therefore, they could be at higher risk for foot ulceration, with underlying neuropathy and biomechanically associated problems.
Therapeutic Options for Diabetic Foot Infections
A Review with an Emphasis on Tissue Penetration Characteristics
Foot complications are common in diabetic patients; foot ulcers are among the more serious consequences. These ulcers frequently become infected, and if not treated promptly and appropriately, diabetic foot infections can lead to septic gangrene and amputation. Foot infections may be classified as mild, moderate, or severe; this largely determines the approach to therapy. Staphylococcus aureus is the most common pathogen in these infections, and the increasing incidence of methicillin-resistant S aureus during the past two decades has further complicated antibiotic treatment. Chronic infections are often polymicrobial. Physiologic changes, and local and systemic inflammation, can affect the plasma and tissue pharmacokinetics of antimicrobial agents in diabetic patients, leading to impaired target-site penetration. Knowledge of the serum and tissue concentrations of antibiotics in diabetic patients is, therefore, important for choosing the optimal drug and dose. This article reviews the commonly used therapeutic options for treatment, including many newer antibiotics developed to target multidrug-resistant gram-positive bacteria, and includes available data relating specifically to the tissue penetration of these agents. (J Am Podiatr Med Assoc 100(1): 52–63, 2010)
Background
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).
Methods
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.
Results
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.
Conclusions
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.
Background
The Amputation Prevention Initiative is a project conducted jointly by the Massachusetts Public Health Association and the Massachusetts Podiatric Medical Society that seeks to study methods to reduce nontraumatic lower-extremity amputations from diabetes.
Methods
To determine the rate of diabetes-related lower-extremity amputations in Massachusetts and identify the groups most at risk, hospital billing and discharge data were analyzed. To examine the components of the diabetic foot examination routinely performed by general practitioners, surveys were conducted in conjunction with physician meetings in Massachusetts (n = 149) and in six other states (n = 490).
Results
The average age-adjusted number of diabetes-related lower-extremity amputations in 2004 was 30.8 per 100,000 and 5.3 per 1,000 diabetic patients in MA, with high-risk groups being identified as men and black individuals. Among the general practitioners surveyed in Massachusetts, only 2.01% reported routinely conducting all four key components of the diabetic foot examination, with 28.86% reporting not performing any components.
Conclusions
These findings suggest that many general practitioners may be failing to perform the major components of the diabetic foot examination believed to prevent foot ulcers and lower-extremity amputations.
Acral lentiginous melanoma is commonly misdiagnosed, and when detected late it portends a poor prognosis. Acral lentiginous melanoma can be mistaken for verruca, pyogenic granuloma, poroma, an ulcer, or other benign skin conditions. Patients with acral skin growths often present initially to a podiatric physician or their primary care physician. It is at this point when the growth is triaged as benign or potentially malignant. Dermoscopy aids in this decision making. Historically, dermoscopy training has been geared toward dermatologists, but there is increasing recognition of the need for dermoscopy training in primary care and podiatric medicine. Dermoscopy is particularly helpful in pink (amelanotic) growths, which can lack the traditional clinical findings of melanoma. A literature review of acral melanoma and dermoscopy was performed in PubMed. We also describe a case of amelanotic acral melanoma in a 58-year-old with a rapidly enlarging painful mass on her heel. The lesion was initially thought to be a pyogenic granuloma and was treated with debridement (curettage). She was ultimately seen in the dermatology clinic, and the findings under dermoscopy were worrisome for amelanotic melanoma. Biopsy confirmed the diagnosis. The cancer metastasized, and the patient died less than 2 years later.
