Background
The effects of shoes and foot type on balance are unclear. We aimed to investigate the differences between static and dynamic balance among three foot types and the changes in postural balance while wearing typical athletic shoes.
Methods
Based on the Foot Posture Index, the feet of 39 participants were classified as pronated, neutral, or supinated by a physiatrist. Static and dynamic balance function were assessed by center of gravity (COG) sway velocity with eyes open and eyes closed and a modified Star Excursion Balance Test in a random order with participants either barefoot or wearing shoes.
Results
The COG sway velocity was significantly higher in the supinated foot group than in the neutral foot group (barefoot: eyes open, P = .004, eyes closed, P = .001). Normalized composite reach distance (NCRD) was significantly lower in the pronated and supinated foot groups (barefoot: P = .039, P = .008; shoes: P = .018, P = .018). In all three foot type groups, COG sway velocity was significantly decreased (P < .05) and NCRD was significantly increased (P < .05) while wearing typical athletic shoes.
Conclusions
The medial longitudinal arch of the foot affects postural balance. Typical athletic shoes improve postural balance regardless of foot type. However, the pronated and supinated foot groups still had lower dynamic postural balance compared with the neutral foot group, even when wearing athletic shoes. People with pronated and supinated feet may need additional interventions, such as foot orthoses or balance training.
Background
Diabetic foot ulcer (DFU) is well managed by infection control, euglycemic state, and debridement of the ulcer followed by appropriate dressing and off-loading of the foot. Studies show that approximately 90% of DFUs that are properly off-loaded heal in nearly 6 weeks. Platelet-rich plasma (PRP) serves as a growth factor agonist and has mitogenic and chemotactic properties that help in DFU healing. We sought to evaluate the efficacy of local application of PRP with respect to healing rate and ulcer area reduction in treating DFUs.
Methods
Sixty noninfected patients with DFUs (plantar surface area, ≤20 cm2; Meggitt-Wagner grades 1 and 2) were randomized to receive normal saline dressing (control group [CG]) or PRP dressing (study group [SG]) along with total-contact casting for 6 weeks or until complete ulcer healing, whichever was earlier. Healing rate and change in ulcer area were evaluated weekly.
Results
Mean ± SD ulcer area at baseline was 4.96 ± 2.89 cm2 (CG) and 5.22 ± 3.82 cm2 (SG) (P = .77), decreasing to 1.15 ± 1.35 cm2 (CG) and 0.96 ± 1.53 cm2 (SG) (P = .432) at 6 weeks. Mean ± SD percentage reduction in healing area at 6 weeks was 81.72% ± 17.2% (CG) and 85.98% ± 13.42% (SG) (P = .29). Mean ± SD healing rate at 6 weeks was 0.64 ± 0.36 cm2 (CG) and 0.71 ± 0.46 cm2 (SG) (P = .734).
Conclusions
The PRP dressing is no more efficacious than normal saline dressing in the management of DFU in conjunction with total-contact casting.
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.
Background
Chevron osteotomy for mild and moderate hallux valgus obtains good effects. It is suitable for a variety of cases, allowing for a significant degree of correction. This study aimed to investigate chevron osteotomy for the correction of hallux valgus in the medium-term by podiatric surgeons. It considers clinical and radiologic findings and patient perspectives and level of satisfaction.
Methods
Forty-five patients (50 feet) were assessed preoperatively, postoperatively, and at final follow-up. Mean patient age was 59.43 years (range, 32–80 years). The protocols include medical record review, clinical examination, and radiologic assessment. Anteroposterior weightbearing radiographs were analyzed preoperatively and at final follow-up. Clinical effects were analyzed with visual analog scale and American Orthopaedic Foot and Ankle Society (AOFAS) scores.
Results
Interobserver and intraobserver reliability were evaluated. Mean ± SD hallux valgus angle decreased at final follow-up (25.30° ± 7.21° versus 17.25° ± 10.32°; P = .041). There was no significant reduction in mean ± SD intermetatarsal angle at final follow-up (13.13° ± 3.03° versus 7.65° ± 3.47°; P = .078). Final AOFAS score was 82.08 ± 17.66. This study showed the relevance of magnet therapy, nail surgery, and other procedures. No patient was dissatisfied with the aesthetic scarring.
Conclusions
The radiologic results at final follow-up were not compatible with relapse of the deformity. The definitive clinical results and the degree of patient satisfaction achieved with this technique were favorable from the patients' point of view.
Background
Surgical repair of extensor hallucis longus (EHL) tendon rupture with a concomitant capsular defect has not been reported in the literature. This case presents a novel approach to EHL tendon rupture repair along with repair of a first metatarsophalangeal joint capsule defect.
Methods
A case study is presented of a 61-year-old man with a traumatic EHL tendon rupture and capsular defect treated with an EHL tendon turndown flap and tenodesis to the extensor hallucis brevis and capsularis tendons with autograft flap reconstruction of the first metatarsophalangeal joint capsule.
Discussion
A 61-year-old man presented with an acute traumatic EHL tendon rupture and first metatarsophalangeal joint capsule compromise after a chainsaw injury. He subsequently lost dorsiflexion of his hallux, and magnetic resonance imaging confirmed a 2.2-cm gap in the EHL tendon. He was treated with an EHL tendon turndown flap and tenodesis to the extensor hallucis brevis and capsularis tendons to reestablish dorsiflexion to the hallux. The injury was noted to infiltrate the first metatarsophalangeal joint capsule and was treated with an autograft of the first metatarsophalangeal joint capsule for a capsular defect. At 1-year follow-up the patient has regained dorsiflexion of the hallux and is back to activities such as snow skiing without pain.
Conclusions
Ruptures of the EHL tendon with first metatarsophalangeal joint capsule defects have not been reported in the literature. Herein, a novel approach was used to reestablish physiologic function to the EHL tendon and provide sufficient coverage of the first metatarsophalangeal joint.
Background
There is a need for postoperative pain control that minimizes or eliminates opioid use during the first 72 hours following surgery, when pain is most severe. HTX-011 is an extended-release, dual-acting local anesthetic that demonstrated superior 72-hour analgesia over standard of care bupivacaine hydrochloride (HCl) and saline placebo in a phase 3 bunionectomy study (EPOCH-1). Having shown HTX-011 monotherapy is superior to bupivacaine HCl in reducing postoperative pain intensity and opioid use, this follow-on study evaluated the safety and efficacy of HTX-011 as the foundation of a multimodal analgesia (MMA) regimen using over-the-counter medications recommended by practice guidelines for pain management.
Methods
Following regional anesthesia administered as a lidocaine block, patients underwent unilateral bunionectomy with osteotomy and internal fixation. Prior to closure, HTX-011 (up to 60 mg bupivacaine/1.8 mg meloxicam) was applied without a needle. Patients received scheduled postoperative MMA alternating ibuprofen (600 mg) and acetaminophen (1 g) every 3 hours for 72 hours. Efficacy was assessed based on pain intensity (numeric rating scale [NRS; 0–10]) and consumption of opioid rescue medication (intravenous morphine milligram equivalents [MME]). Adverse event and vital sign monitoring, plus laboratory and wound healing assessments, were used to determine safety.
Results
Over the 72-hour assessment period following bunionectomy, mean pain scores were mild in severity (NRS <4) and 22/31 patients (71%) experienced no severe pain (NRS ≥7) with HTX-011 as the foundation of scheduled, non-opioid MMA. Patients consumed an average of 1.61 MME total, with 24/31 (77%) requiring no opioid rescue medication (opioid-free). HTX-011 was well-tolerated and demonstrated no safety concerns with the inclusion of postoperative MMA.
Conclusions
HTX-011 as the foundation of an MMA regimen including scheduled ibuprofen and acetaminophen maintained mean postoperative pain scores in the mild range and enabled opioid-free recovery for 77% of bunionectomy patients through the 28-day recovery period.
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.
Background
Many people experience gastrocnemius tightness. Few studies demonstrate the relationship between gastrocnemius tightness and forefoot pathology. This study aimed to define the association between intractable plantar keratosis of the second rocker (IPK2) (also known as well-localized IPK or discrete keratosis) and metatarsalgia.
Methods
The Silfverskiöld (ST) and lunge (LT) tests, used for measuring ankle dorsiflexion, were applied to diagnose gastrocnemius tightness. An instrument for measuring accurate performance and the force to be applied (1.7–2.0 kg of force to the ankle dorsiflexion) complemented the ST for clinical diagnosis and to obtain repeatedly reliable results (the authors apply force manually, which is difficult to quantify accurately).
Results
Of 122 patients studied, 74 were used to devise a prediction model from a logistic regression analysis that determines the probability of presenting gastrocnemius tightness in each test (LT and ST) with the following variables: metatarsalgia, IPK2, and maximum static pressure (baropodometry). The IPK2 plays the principal role in predicting this pathology, with the highest Wald values (6.611 for LT and 5.063 for ST). Metatarsalgia induces a somewhat lower change (66.7% LT and 64.3% ST). The maximum pressure of the forefoot is equally significant (P = .043 LT and P = .025 ST), taking α < .05 as the significance level.
Conclusions
The results of this validation report confirm that a model composed of metatarsalgia, IPK2, and maximum pressure in static acts as a predictive method for gastrocnemius tightness.
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%, P30 = .818; 82.2% versus 80.9%, P60 = .422). Mean wound sizes at these follow-up periods were not different (4.4 cm2 versus 5.1 cm2, P30 = .902; 1.2 cm2 versus 1.1 cm2, P60 = .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
A survey of pathology present in the subtalar joint by means of subtalar arthroscopy with anterolateral and middle portals has not been extensively explored in the literature. The focus of this study was to identify pathology in the subtalar joint with subtalar joint arthroscopy using this approach. We also compared these arthroscopic findings with those reported in the literature.
Methods
We performed a retrospective review of 49 consecutive patients who had undergone 53 subtalar arthroscopic procedures. Data were obtained from intraoperative arthroscopic findings that were documented in the operative note or with arthroscopic photography. Additional procedures, including ankle arthroscopy, lateral ankle stabilization, and peroneal tendon repair, were recorded. Descriptive statistics were calculated and reported.
Results
Subtalar arthroscopic examination revealed that all of the patients had intra-articular synovitis or adhesions present. Twenty-two procedures (42%) demonstrated subtalar joint instability, seven (13%) revealed chondromalacia, and one (2%) had an exostosis present. These observations are consistent with other reported findings in the literature.
Conclusions
This study found that the subtalar joint was most often affected by synovitis, adhesions, and instability in patients with symptomatic pathologies requiring subtalar arthroscopy. There was a relatively low incidence of chondromalacia or exostosis formation in the survey.