Search Results
Background
Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis (TTCA) is used for severe hindfoot deformities, end-stage arthritis, and limb salvage. The procedure is technically demanding, with complications such as infection, hardware failure, nonunion, osteomyelitis, and possible limb loss or death. This study reports the outcomes and complications of patients undergoing TTCA with a femoral nail, which is widely available and offers an extensive range of lengths and diameters.
Methods
We performed a retrospective review of 104 patients who underwent 109 TTCAs using a femoral nail as the primary procedure (January 2006 through December 2016). Demographic data, risk factors, and outcomes were evaluated.
Results
At final follow-up, the overall clinical union rate was 89 of 109 (81.7%). Diabetes mellitus was negatively associated with limb salvage (P = .03), and peripheral neuropathy (P = .02) and Charcot's neuroarthropathy (P = .03) were negatively associated with clinical union. Only four patients (3.8%) underwent proximal amputation, at an average of 6.1 months, and 11 patients (10.6%) died, at a mean of 38.0 months. The most common complication was ulceration in 27 of 109 limbs (24.8%), followed by infection in 25 (22.9%). Twenty-three patients (22.1%) underwent revision procedures, at a mean of 9.4 months. Thirteen of these 23 patients (56.5%) had antibiotic cement rod spacers/rods for deep infection–related complications.
Conclusions
Use of a femoral nail has been shown to provide similar outcomes and limb salvage rates compared with other methods of TTCA reported for similar indications in the literature.
Objective
Porcine-derived xenograft biological dressings (PXBDs) are occasionally used to prepare chronic wound beds for definitive closure before split-thickness skin grafts (STSGs). We sought to determine whether PXBD influences rate of STSG take in lower-extremity wounds.
Methods
Lower-extremity wounds treated with STSGs were retrospectively reviewed. Patients were included in one of two groups: wound bed preparation with PXBD before STSG or no preparation. Patients were excluded if they received wound bed preparation via another method. Patient demographics, comorbidities, wound history, wound bed preparation, and 30- and 60-day outcomes were collected.
Results
There was no difference in healing outcomes between the PXBD (n = 27) and no preparation (n = 39) groups. At 30- and 60-day follow-up, percentage of STSG take was not significantly different between groups (77.9% versus 79.0%, P 30 = .818; 82.2% versus 80.9%, P 60 = .422). Mean wound sizes at these follow-up periods were not different (4.4 cm2 versus 5.1 cm2, P 30 = .902; 1.2 cm2 versus 1.1 cm2, P 60 = .689). The PXBD group had a higher mean ± SD hemoglobin A1c level (8.3 ± 3.5 versus 6.9 ± 1.6; P = .074) and age (64.9 ± 12.8 years versus 56.3 ± 11.9 years; P = .007) versus the no preparation group.
Conclusions
Application of PXBDs for wound bed preparation had no effect on wound healing compared with no wound bed preparation. The two groups varied only by mean age and hemoglobin A1c level. The PXBD may be beneficial, but these results call for randomized controlled trials to determine the true impact of PXBDs on wound healing. In addition, PXBDs may have utility outside of clinically oriented outcomes, and future work should address patient-reported outcomes and pain scores with this adjunct.
Background:
Magnetic resonance imaging (MRI) is both sensitive and specific in the diagnosis of osteomyelitis, and it is an important imaging modality in preoperative planning of resection of infected bone. In many cases, however, the extent of osseous infection is evident on plain radiographs, and little additional information is gained from the MRI. The goal of this study was to assess the accuracy of radiographs against MRIs in assessing the spread of suspected osteomyelitis from one phalanx to another or to a metatarsal.
Methods:
A medical record review was performed, and 14 patients with 16 toes confirmed to have osteomyelitis involving one or more phalanges were included in the study. An investigator blinded to the MRI findings interpreted the extent of osseous involvement based solely on the radiographic and clinical presentation. The accuracy of the radiographic interpretation was then calculated against the MRI findings.
Results:
In 14 of the 16 toes (87.5%), whether osteomyelitis had spread from one bone to another was determined based on the radiographic and clinical presentation. In one toe, the radiograph did not adequately depict osteomyelitis in adjacent infected bone. In one more toe, the radiograph depicted features of osteomyelitis in uninfected bone.
Conclusions:
In a large percentage of patients, the phalanges affected by osteomyelitis had visible findings on the radiograph, and operative planning could have been based on the radiograph alone.
Background:
Increasing amounts of diabetes-focused content is being posted to YouTube with little regulation as to the quality of the content. Diabetic education has been shown to reduce the risk of ulceration and amputation. YouTube is a frequently visited site for instructional and demonstrational videos posted by individuals, advertisers, companies, and health-care organizations. We sought to evaluate the usefulness of diabetic foot care video information on YouTube.
Methods:
YouTube was queried using the keyword phrase diabetic foot care. Original videos in English, with audio, less than 10 min long within the first 100 video results were evaluated. Two reviewers classified each video as useful or nonuseful/misleading. A 14-point usefulness criteria checklist was used to further categorize videos as most useful, somewhat useful, or nonuseful/misleading. Video sources were categorized by user type, and additional video metrics were collected.
Results:
Of 87 included videos, 56 (64.4%), were classified as useful and 31 (35.6%) as nonuseful/misleading. A significant difference in the mean length of useful videos vs nonuseful/misleading videos was observed (3.33 versus 1.73 min; P < .0001). There was no significant difference in terms of popularity metrics (likes, views, subscriptions, etc) between useful and nonuseful/misleading videos.
Conclusions:
This study demonstrates that although most diabetic foot care videos on YouTube are useful, many are still nonuseful/misleading. More concerning is the lack of difference in popularity between useful and nonuseful videos. Podiatric physicians should alert patients to possibly misleading information and offer a curated list of videos.
Background:
We sought to determine the prevalence of lower-extremity arterial calcification in a cohort of patients with diabetes and associated foot pathology receiving inpatient treatment at an urban US tertiary health-care system.
Methods:
The primary outcome measure was defined as either radiographic evidence of vessel calcification or noninvasive vascular testing that resulted in any reporting of vessel noncompressibility or an ankle-brachial index greater than 1.1. Radiographic evidence of vessel calcification was defined as radiodense calcification in the proximal first intermetatarsal space (deep plantar perforating artery), anterior ankle (anterior tibial artery), or posterior ankle (posterior tibial artery) on dorsoplantar and lateral foot projections.
Results:
Of the 367 individuals included in the study, 359 underwent radiography, with radiographic evidence of calcification in 192 (53.5%). Noninvasive vascular testing was performed on 265 participants, with any reporting of noncompressibility or an ankle-brachial index greater than 1.1 observed in 153 (57.7%). Ninety-four participants (25.6%) demonstrated evidence of arterial calcification on the radiographs and noninvasive testing, meaning that 251 participants (68.4%) demonstrated evidence of arterial calcification on at least one test, including 63.6% of participants classified as black/African American race, 65.4% as white race, and 78.3% as Hispanic/Latino ethnicity.
Conclusions:
The results of this investigation increase the body of knowledge with respect to the evaluation and treatment of diabetic foot disease and may lead to future investigations on the topic of lower-extremity arterial calcification.
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.
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)
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, F 12,108 = 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.
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.
