The latest medical research on Podiatrist

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Charcot Neuroarthropathy Is Associated With Higher Rates of Phantom Limb After Lower Extremity Amputation.

Foot and Ankle International

The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to determine whether patients with Charcot neuroarthropathy and diabetes who underwent either a below-knee amputation (BKA) or above-knee amputation (AKA) had an increased rate of phantom limb pain compared with those with a diagnosis of diabetes alone.

Using international classification of disease (ICD) and common procedural terminology (CPT) codes, the TriNetX research database identified 10 239 patients who underwent BKA and 6122 who underwent AKA between 2012 and 2022. Diabetic patients with and without Charcot neuroarthropathy were compared in terms of demographics and relative risk of developing phantom limb pain after AKA or BKA.

Age, sex, ethnicity, and race did not significantly differ between groups. Charcot neuroarthropathy was associated with significantly increased risk of phantom limb pain following both BKA (risk ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1-1.3, P < .01) and AKA (RR: 1.6, 95% CI: 1.2-2.3, P < .0068).

Our results indicate that patients with a coexisting diagnosis of Charcot neuroarthropathy who require BKA or AKA may have an increased risk of developing phantom limb pain.

Level III.

Parallax and Distortion in Fluoroscopy Units.

Foot and Ankle International

Parallax is an imaging phenomenon where an object appears to be at different positions when viewed from different angles. Distortion can occur secondary to internal fluoroscopic, or external environmental, factors. Fluoroscopy is a vital tool to assist surgeons intraoperatively. However, parallax and distortion can lead to inaccuracy, potentially leading to incorrect surgical decisions. The purpose of this study was to investigate the prevalence of parallax/distortion in large fluoroscopy units at a level-1 trauma center.

Two types of C-arm models were evaluated, including (1) round image intensifiers, and (2) flat plate detectors (FPD). A square plexiglass grid with embedded wire at ½-in intervals was created, with a round metal washer secured centrally. The grid was placed 16 in from the image intensifier. A metal ball bearing (BB) was secured to the center of the x-ray tube. Fluoroscopic images were obtained until the BB and washer were "center-center." A straight blade served as a fiducial marker to ensure there was no off-axis angulation. Standard anterior-posterior and lateral views were obtained. External factors were considered, tested, and limited. Images were printed and the patterns of parallax/distortion were identified.

All 11/11 (100%) of fluoroscopy units had some degree of parallax and/or distortion. We noted 3 different patterns, including sigmoidal, converging, and diverging. The FPD units had less apparent distortion overall; however, two-thirds (66%) were off-axis in the x- and y-axes in relation to the fiducial marker.

All fluoroscopy units had varying degrees and patterns of parallax/distortion. We noted less overall distortion in FPDs. However, some of these units may produce images that are off-axis. This research has important implications for improving the accuracy of intraoperative fluoroscopy. Musculoskeletal surgeons should understand the limitations of fluoroscopy and how to combat parallax distortion to improve surgical outcomes and reduce patient morbidity.

Level V.

Disease Knowledge and Behavior Regarding Diabetic Foot Among Persons at Different Risks of Foot Ulceration According to the International Working Group Guidelines.

Am Podiatry Assoc

This article aims to analyze levels of knowledge and behavior about diabetic foot care and prevention in persons with diabetes according to International Working Group (IWGDF) risk stratification system.

A descriptive study in 83 persons with diabetes at different level of risk for foot ulceration (IWGDF risk 0-3). A previously validated questionnaire, the PIN Questionnaire, was used to analyze their levels of understanding of foot complications. Participants were responded on a 5-point Likert scale.

IWGDF-3 risk patients knew that good circulation and absence of polyneuropathy in their feet were related to healthy feet relative to the other groups (19.6 ± 2.7, p<.001 and 14.2 ± 0.7, p<.001 respectively). Additionally, they knew that a foot ulcer (DFU) on their feet will not be painful relative to other groups (6.6 ± 2.8, p<.001). High-risk patients knew which physical causes could affect the development of a DFU (18 ± 1.4, p<.001) and that foot self-care and medical control could prevent DFU appearance (23.4 ± 2.15, p<.001 and 13.9 ± 0.9, p<.001 respectively).

IWGDF-3 patients knew the natural progression of diabetes foot complications and how to prevent them. Clinicians should focus their efforts and educate diabetes at lower risk of foot ulcer.

Syndesmosis Injuries in Lateral Malleolar Fractures Accompanied by a Posterior Malleolar Fracture: A Nonfixed Posterior Fracture Fragment May Not Affect Postoperative Tibiofibular Joint Malreduction Rates.

Am Podiatry Assoc

The fact that lateral malleolar fracture is accompanied by posterior malleolar fracture may adversely affect syndesmosis malreduction rates. We aimed to compare syndesmosis malreduction rates determined on postoperative radiographs between isolated lateral malleolar fractures and lateral malleolar fractures accompanied by posterior malleolar fractures.

We retrospectively examined 128 operative patients: 73 with isolated lateral malleolar fractures (group L) and 55 with lateral + posterior malleolar fractures (group LP). In group LP, no patients received posterior fragment fixation. In both groups, indirect syndesmosis fixation was performed with a single screw after open reduction and internal fixation of the lateral malleolus. Patient age, sex, fracture side, fracture type (Lauge-Hansen and Danis-Weber classifications), Kellgren-Lawrence osteoarthritis classification, syndesmotic incongruency on postoperative radiographs, syndesmotic malreduction of postoperative fibula fracture, fracture union time, complication rates, accompanying injuries, and preoperative and postoperative radiographic syndesmotic measurements (tibiofibular overlap, tibiofibular clear space, medial clear space) were recorded, and the groups were compared.

Mean ± SD age was 44.32 ± 15.66 years in group L and 48.93 ± 14.03 years in group LP (P = .087). There were no significant differences in preoperative and postoperative tibiofibular distance, tibiofibular overlap, and medial clear space values between groups (P > .05). The prevalence of grade 2 fractures according to the Kellgren-Lawrence classification was significantly higher in group LP (P = .047). Postoperative syndesmosis malreduction was detected in 12 patients in group L and in nine in group LP (P = .991).

In lateral malleolar fractures accompanied by small-fragment posterolateral or avulsion-type posterior malleolar fractures, closed syndesmotic screw fixation does not cause syndesmosis malreduction.

Combined Open and Percutaneous Plating for the Treatment of Pilon Fracture.

Am Podiatry Assoc

With the advent of percutaneous plating techniques and anatomical locking plates, open plating combined with percutaneous plating may be a feasible option to reduce pilon fracture soft-tissue complications. The purpose of this study was to evaluate the outcomes of a combined open and percutaneous plating approach for the treatment of pilon fracture.

Forty-two consecutive patients treated with a combined open and percutaneous plating approach between March of 2010 and February of 2020 for pilon fracture were reviewed retrospectively. The study population consisted of four female patients and 38 male patients with an average age of 47.5 years (range, 15-71 years). The mean follow-up duration was 25.7 months (range, 12-48 months). The combination of a small anterolateral approach and a small anteromedial approach (or a small direct medial approach) was used in all cases. A small posterolateral approach or a small posteromedial approach was added as necessary.

The average ranges of ankle sagittal motion and hindfoot coronal motion at 1 year postoperatively were 43.3° (range, 30°-60°) and 47.7° (range, 40°-55°), respectively. The mean 1-year postoperative visual analogue scale score and American Orthopaedic Foot and Ankle Society score were 0.90 (range, 0-4.0) and 94.5 (range, 78-100), respectively. All patients except one achieved bony union. The mean time to union (except in the one case of nonunion) was 4.5 months (range, 3-8 months). Minor wound breakdown occurred in five cases using combined approaches, but these eventually healed with local wound care. There were no major soft-tissue complications and no instances of deep infection.

A combined open and percutaneous plating approach is a feasible option for the treatment of pilon fracture. This combined plating technique involving a combination of a small anterolateral approach and a small anteromedial approach (or a small direct medial approach) yielded satisfactory outcomes without major soft-tissue complications.

Is Tenderness of Medial Malleolus Circumference a Sign of Syndesmosis Injuries?

Am Podiatry Assoc

Syndesmosis injuries occur in approximately 10% of all ankle fractures. The integrity of the deltoid ligament is important in the decision of surgical treatment of lateral malleolus fractures.

Patients who were operated on for Weber B ankle fracture were evaluated retrospectively, and the relationship between tenderness around the medial malleolus and syndesmosis injury was investigated. Patients with visual analog scale, Foot and Ankle Ability Measure daily living, and sports activity scores in their files were included. This study enrolled 38 patients. The patients were divided into two groups. Group 1 consisted of patients with a medial space greater than 4 mm on preoperative radiographs and a positive intraoperative Cotton test, in which a syndesmosis screw was used. Group 2 consisted of patients with a medial space less than 4 mm on preoperative radiographs and negative intraoperative Cotton test, for whom no syndesmosis screw was used.

In 17 of 38 patients, syndesmosis screws were used because of intraopeative positive Cotton test. In 21 patients, the Cotton test was negative and the syndesmosis screw was not used. Comparing the groups statistically revealed no statistically significant difference in all scores. Tenderness around the medial malleolus was detected in two patients in group 2 and nine patients in group 1. A statistically significant difference was detected in terms of medial clear space values and tenderness around the medial malleolus between both groups.

The absence of tenderness around the medial malleolus in Weber B ankle fractures indicates no syndesmosis injury, whereas the presence of tenderness around the medial malleolus does not mean that there is a syndesmosis injury.

Pathergy After Endovenous Ablation for Lower-Extremity Venous Disease: A Case Report of an Unexpected Complication.

Am Podiatry Assoc

A 64-year-old woman presents with wounds to her left ankle. Although her soft-tissue cultures and arterial Doppler and duplex studies were unremark...

Is Subclassification by Number of Fracture Fragments Necessary for Sanders Type IV Calcaneal Fractures?

Am Podiatry Assoc

The Sanders classification is a widely used method for classifying calcaneal fractures. Type IV fractures (>4 fragments) are known to vary in the number of fracture fragments. However, all relevant cases are classified as type IV irrespective of the number of fragments. We investigated the need for evaluation of postoperative prognoses based on radiologic factors and subtypes of Sanders classification type IV fractures.

Fifty-six Sanders type IV calcaneal fractures were enrolled between 2010 and 2018. Patients were divided into two groups according to the number of fragments: four fragments (group 1) and more than four fragments (group 2). Radiologic evaluation was performed using a postoperative recovery percentage calculated from postoperative reduction of the Böhler angle, Gissane angle, and vertical height. Radiologic evaluation was divided into two groups according to postoperative recovery: good and bad recovery groups. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analog scale (VAS) score were used for clinical outcome evaluation.

There was no significant difference in AOFAS ankle-hindfoot score (P = .909) or VAS score (P = .963) between groups 1 and 2. However, there was a significant (P = .001) difference in AOFAS ankle-hindfoot score or VAS score between good and bad recovery groups.

Clinical results of Sanders type IV fractures were not related to the number of bone fragments but to the degree of injury to the Böhler angle, Gissane angle, and vertical height. Therefore, subtype classification of type IV calcaneal fractures is superfluous, and it is important to try to restore these parameters during surgery.

Relationship Between Diabetes-Related Large-Fiber Neuropathy and Dorsiflexion Range of Motion at the Ankle and First Metatarsophalangeal Joints.

Am Podiatry Assoc

Diabetes-related peripheral neuropathy (DPN) and limited joint mobility of the foot and ankle are implicated in the development of increased plantar pressures and diabetes-related foot ulcers. The extent of this relationship has not been conclusively established. We aimed to determine the relationship between ankle joint and first metatarsophalangeal joint dorsiflexion range of motion and DPN using a cross-sectional observational study design.

Primary outcomes were DPN status, ankle joint range of motion (extended and flexed knee lunge tests), and nonweightbearing first metatarsophalangeal joint range of motion. Correlations were performed using Pearson r, and hierarchical regression analyses were undertaken to determine the independent contribution of DPN to the variance in dorsiflexion range of motion of ankle and first metatarsophalangeal joints using standardized β regression coefficients, controlling for age, sex, body mass index, diabetes duration, and hemoglobin A1c level.

One hundred one community-dwelling participants (mean ± SD age, 65.0 ± 11.2 years; 55 men; 97% type 2 diabetes; mean ± SD diabetes duration, 8.7 ± 7.8 years; 23% with DPN) were recruited. Diabetes-related peripheral neuropathy demonstrated significant correlations with reduced range of motion at the ankle joint (knee extended: r = -0.53; P < .001 and knee flexed: r = -0.50; P < .001) and the first metatarsophalangeal joint (r = -0.37; P < .001). Also, DPN made significant, unique contributions to the regression models for range of motion at the ankle joint (knee extended: r2 change = 0.121; β = -0.48; P < .001 and knee flexed: r2 change = 0.109; β = -0.45; P < .001) and first metatarsophalangeal joint (r2 change = 0.037; β = -0.26; P = .048).

These findings suggest that DPN contributes to reduced ankle and first metatarsophalangeal joint range of motion. Due to the established link between reduced ankle and first metatarsophalangeal joint range of motion and risk of diabetes-related foot ulcer, we recommend that clinicians assess dorsiflexion range of motion at these joints as part of routine foot assessment in people with diabetes, especially those with DPN. Globally, approximately 436 million adults aged 20 to 79 years are living with diabetes.1 Diabetes is the leading cause of lower-limb amputation and is associated with a lifetime incidence of diabetes-related foot ulcer (DFU) of up to 34%.2 Diabetes-related peripheral neuropathy (DPN) affects approximately 30% to 50% of people with diabetes3 and is one of the most significant risk factors for the development of DFU and amputation.4 Diabetes-related peripheral neuropathy occurs as a result of neural ischemia and perineural edema causing neural demyelination, affecting nerve conductivity.5 In the presence of DPN, intrinsic foot muscle wasting can lead to the development of foot deformities such as digital clawing, which, when coupled with structural and functional changes to the skin, make it less resistant to shear forces and further increase plantar pressure and risk of DFU.6,7.

Clinicopathologic Characterization of Kaposi Sarcoma on the Foot and Ankle: Analysis of 11 Patients Seen in Our Clinics.

Am Podiatry Assoc

Kaposi sarcoma (KS) has multiple clinical variants, and most frequently presents on the lower extremities. Anti-human immunodeficiency virus (HIV) therapy has significantly reduced the incidence of KS. However, KS is still prevalent in both HIV-infected and HIV-uninfected patients. This case series analysis aims to reveal the clinical presentations, differential diagnosis, and treatment options of KS on the foot and ankle.

Eleven cases of KS involving the foot and ankle were retrieved from our patient database, and their clinicopathologic features were analyzed.

All patients were men, aged 29 to 85 years. Two types of KS were found: classic and acquired immunodeficiency syndrome-associated epidemic. The average ages of classic and epidemic KS were 65.7 and 41.8 years, respectively. Clinically, three patients manifested multiple erythematous or deep violaceous, or blue-violaceous macules on either the dorsal or plantar surfaces of both feet. Eight patients showed exophytic, pyogenic granuloma-like nodules on the plantar surface, heels, and toes. Histologically, all KSs had uniform intervening fascicles of elongated spindle cells with slit-like vascular spaces filled with red blood cells and immunoreactivity with human herpesvirus-8. The patients were treated according to HIV infection status. Human immunodeficiency virus-infected patients were treated with anti-HIV therapy after primary surgical excision or biopsy. Human immunodeficiency virus-negative patients were treated with either surgical excision, Mohs surgery, or a combination of surgical excision and local radiotherapy according to individual patient clinical presentation.

Kaposi sarcoma is still prevalent in both HIV-infected and HIV-uninfected patients with a variety of clinical presentations. Biopsy, with histologic evaluation, in combination with immunohistochemistry is essential for the differential diagnosis. The patient should be treated according their clinical manifestation, staging, comorbidity, and immune function.

Treatment of Recalcitrant Isolated Congenital Fibular Pseudarthrosis: Fibular Segment Transfer and Tibiofibular Synostosis with Unilateral External Fixator.

Am Podiatry Assoc

Isolated congenital pseudarthrosis of the fibula is a rare entity with a limited number of cases reported in the literature. Treatment is challengi...

A Biomechanical Investigation of Children with Type 1 Diabetes Mellitus: Are Children's Feet a Precursor to Adulthood Foot Complications?

Am Podiatry Assoc

There is limited evidence on the biomechanical effects of type 1 diabetes mellitus (T1DM) on children's feet. This study aimed to determine whether children living with T1DM aged 10 to 16 years have altered foot structure and gait parameters compared with same-aged children without medical conditions.

A nonexperimental, case-control study was conducted. Thirty-four healthy children and children living with T1DM were recruited. Participants underwent a clinical biomechanical examination followed by instrumented gait analysis using the Oxford Foot Model to investigate foot segment motion.

Children with T1DM demonstrated more dermatologic lesions and structural foot abnormalities, including claw toes (33.3%), hammertoes (22.2%), and hallux abducto valgus (11.1%), than their healthy counterparts. Gait analysis results indicate a significant difference between the two groups at the hindfoot-to-tibia angle at heel strike and toe-off, suggesting limited ankle joint motion.

Children with T1DM demonstrated a higher frequency of structural foot pathologies than did healthy children possibly associated with limited ankle sagittal plane movement. Screening is warranted to identify and manage these conditions early to reduce their risk of more significant foot problems associated with DM in adulthood.