Journal of the American Podiatric Medical Association最新文献

This case report highlights the unusual presence of Hafnia alvei, a gram-negative bacillus, as the causative agent in a severe diabetic foot ulcer. While diabetic foot ulcers are typically associated with gram-positive cocci, this case underscores the importance of considering atypical pathogens. The patient, a long-term diabetic, presented with a nonresponsive wound that had progressed to a severe grade 4 ulcer, despite antibiotic treatment. A multidisciplinary medical team, including infectious disease specialists, surgeons, and endocrinologists, advocated for surgical intervention, involving debridement, VAC therapy, and hyperbaric oxygen treatment. Surprisingly, post-treatment cultures revealed the presence of Hafnia alvei and Proteus spp. Despite rigorous antibiotic therapy and debridement, wound complications persisted, leading to a unanimous decision for amputation. The patient underwent Chopart amputation, followed by a 21-day course of antibiotics due to the absence of microbial growth in post-amputation cultures. At the 6-month follow-up, the wound had completely healed, and effective glycemic control had been achieved. Key takeaways from this case include the need to consider unusual pathogens in diabetic foot ulcers, the importance of a multidisciplinary approach, cautious consideration of amputation in severe cases, and the significance of tailored antibiotic therapy. This case report serves as a reminder of the complexities involved in managing diabetic foot ulcers and the potential involvement of nontypical pathogens.

Background: Pedal fissures present challenges for affected individuals, from cosmetic concerns to potential infection risks. Urea 40% was previously a common treatment for pedal fissures, particularly in its prescription form, but its use has declined and it is now widely available over the counter and is no longer covered by many insurance plans. Alternatives to prescription urea 40% often contain additional ingredients, such as salicylic acid. Although a common exfoliant in dermatologic treatments, salicylic acid can cause burning and exacerbate irritation, particularly when used on pedal fissures, thus hindering healing. This study aimed to assess the efficacy of urea 40% compared with a novel skin barrier repair cream designed to address pedal fissures without the irritation while still providing healing results. The novel skin barrier repair cream uses natural ingredients without fragrances or dyes and incorporates hyaluronic acid, which helps the skin retain moisture and stay hydrated without breaking down the surrounding tissue.

Methods: This double-blind study enrolled 48 participants who were assessed every 2 weeks over 28 days of treatment. Participants were divided into two groups, each receiving either urea 40% or the novel skin barrier repair cream for daily use. Follow-up visits included detailed records of xerosis and fissure progression, with parameters analyzed for comparative efficacy.

Results: Significant improvement in function was observed in the group treated with the novel skin barrier repair cream. The results showed minimal statistical difference in healing between the novel skin barrier repair cream and urea 40% across all measured parameters.

Conclusions: The novel skin barrier repair cream provides a comparably effective treatment for pedal fissures without additional side effects. This finding highlights the potential of the novel skin barrier repair cream as a viable alternative to the currently available over-the-counter formulations, addressing both effectiveness and affordability in managing pedal fissures.

Background: Minority disparities have been documented in the diabetic community since the late 1990s. Historically, the literature acknowledges that higher rates of diabetes-related complications occur in this subgroup. Despite this, disparities among patients with Charcot's neuroarthropathy have yet to be explored. We compared incidence and management among patients with Charcot's neuroarthropathy with emphasis on racial and geographic differences.

Methods: We retrospectively reviewed patients from two hospitals, an inner-city tertiary center and a suburban facility, between 2013 and 2022. Patients were managed by the same attending physician as either referrals or initial consultations for a diagnosis of Charcot's neuroarthropathy of the foot and ankle. Patient selection was performed via International Classification of Diseases, 10th Revision codes associated with Charcot's joint of the foot.

Results: Of 120 patients identified, 87.5% were nonminority white individuals. The minority community had an increased frequency of medical comorbidities. Minorities were two times more likely to undergo a staged reconstruction. Compared with suburban patients, inner-city patients, on average, had higher hemoglobin A1c levels and more ulceration and osteomyelitis. Similarly, this cohort was more apt to undergo reconstructive surgery and had a reduced mortality rate.

Conclusions: Although there may be a correlation with medical comorbidities in minority communities, there does not seem to be a difference in the management of Charcot's neuroarthropathy. Location has the potential to play a role in diagnosis, management, and potential outcomes, likely due to access to health care and community education. More prospective studies are warranted to better understand the influence of racial and geographic differences on management of the Charcot foot.

Background: The American Orthopaedic Foot and Ankle Society (AOFAS) scale is used to evaluate foot and ankle complaints, both in the general population and in athletes. The objective of this study was to review different versions of the AOFAS scale for hindfoot and ankle problems and to evaluate the methodological quality of studies published in this respect.

Methods: The study design was a systematic review, and a search was conducted in five databases: PubMed, Scopus, CINAHL, PEDro: Physiotherapy Evidence Database, and PROSPERO from inception to January 2023. The following inclusion criteria were applied: validation studies of the AOFAS scale, in different languages, with no time limit, in a population aged 18 years and older. Two of us (J.G.-M. and S.S.-M.) independently assessed the quality of the studies located and extracted the relevant data. The COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) checklist was used to assess methodological quality.

Results: Six instruments were analyzed in this review. In many cases, significant methodological flaws were detected, mostly regarding internal consistency and criterion validity.

Conclusions: The Dutch (ankle fractures) version of the AOFAS scale presents the best quality and is considered valid and reliable. Further studies, with greater methodological rigor, are required of the cultural adaptations of this measurement instrument.

Background: From traumatic injury to diabetic foot infections, minor amputations of the foot and ankle rely on viable and adequate soft-tissue coverage. When employing a plantar foot flap, coverage often determines amputation level. This study examined the relative plantar foot flap length needed to cover various levels of minor foot amputations.

Methods: Demographic data and plantar flap length of ten cadaver specimens were recorded. The minimum plantar flap length needed to cover transmetatarsal, Lisfranc, and Chopart amputations was measured following each amputation. Absolute and percentage of total flap length were determined. The Pearson correlation coefficient among demographic and anthropometric data was calculated. The threshold for statistical significance was set at P ≤ .05. Among the 14 dissected cadavers, eight were male and six were female.

Results: The height and weight were 177.21 ± 10.42 cm and 171.79 ± 58.18 pounds, respectively. The minimum percent lengths of the total plantar flap needed to cover transmetatarsal, Lisfranc, and Chopart amputations were 85.35 ± 3.75%, 75.31 ± 3.43%, and 63.55 ± 5.08%, respectively. There existed a statistically significant relationship between cadaver height and plantar flap needed to close Lisfranc (P = .04) and Chopart (P = .04) amputations.

Conclusions: In the clinical and surgical setting, these results provide an estimation of the level of amputation based on available plantar flap length. Future studies may examine the application of these estimates both surgically and preoperatively when discussing predicted amputation level with patients.

Background: Ankle fractures represent the most common type of intra-articular fracture. The standard treatment for unstable ankle fractures is open reduction and internal fixation through a lateral approach. Recently, intramedullary nail fixation has become popular for distal fibula fractures to limit soft-tissue damage.

Methods: A prospective cohort study was conducted of 61 consecutive ankle fracture patients treated with a fibular nail.

Results: The median follow-up time was 15.9 months (interquartile range, 13.6-23.2 months). Open reduction of the fibula fracture with an incision measuring between 3 and 5 cm was performed on 54 patients (88.5%). The overall complication rate was 24.6%. The complication rate of fibular fixation or lateral approach was 16.4%. The most common complications were minor infection (8.2%) and hardware removal (8.2%). Two deep infections (3.3%) occurred. Malreduction occurred at a rate of 1.6% (n = 1). Relevant comorbidities included diabetes (14.8%), renal disease (3.3%), and current or former smoking (24.5%). There were no statistically significant associations between patient demographics (age, body mass index, sex, smoking status, diabetes) and complications.

Conclusions: Given the complication rate, our data suggest that the benefit of fibular nailing is limited when open reduction is used. Further study comparing fibular nail fixation with percutaneous versus open reduction is warranted.

Background: In patients with rheumatoid arthritis (RA), the pathologic progression of lower-limb biomechanics is established. Although specific aspects of RA gait patterns have been studied and described, we are aware of no studies of gait pattern compensations across the entire disease course. This study aimed to describe a model that could predict the evolution of lower-limb pathomechanics in patients with RA.

Methods: A literature review was conducted of electronic databases (MEDLINE, PEDro, Trip Database, DOAJ, BioMed Central, PLoS Clinical Trials, ScienceDirect, CRD York University, AHRQ, NICE, and Cochrane Library) to October 3, 2023.

Results: A theory was developed that all people with RA induce or augment gait evolution syndromes following the same biomechanical course. Specifically, we postulate rheumatoid equinus syndrome, rheumatoid abnormal pronation syndrome, and rheumatoid shuffle syndrome, which have never been described before.

Conclusions: A new model of the evolution of gait compensation in RA is proposed. An important challenge of RA is that it increases the risk of ulcerative lesions, falls, pain, fractures, and health-care costs. The proposed model can be used to reduce morbidity in this patient group by helping explain and reduce the pain, deformity, and ankylosis of foot RA.

Background: Falls in the geriatric population lead to increased risk of injury and health-care costs. Orthotics are commonly prescribed because of this risk or after injury. This study aimed to evaluate center of pressure (COP) sway and velocity, functional testing, and participant preferences in different braces.

Methods: In this laboratory-based crossover study, four conditions were evaluated: the participant's own shoe, own shoe plus TayCo brace, own shoe plus Moore balance brace, and walking boot. A total of 18 ambulatory adults over the age of 65 completed three bilateral stance balance trials in which COP excursion and velocity were measured on a Bertec instrumented force plate followed by a Timed Up and Go test for each condition. Participants rated each condition for overall perceived stability and comfort on a visual analog scale, ranking them from 1 to 4.

Results: There was significantly less anteroposterior COP excursion (P = .001; effect size [ES] = 1.03) in the TayCo brace versus the walking boot, and there was significantly less mediolateral COP excursion (P = .02; ES = 0.60) in the TayCo brace versus the Moore brace. There was significantly less overall COP velocity (P = .02; ES = 0.94) in the TayCo brace versus the Moore brace or walking boot. There were no significant differences (P > .05) between the rest of the conditions. Timed Up and Go times were found to be significantly higher (P < .05) for the walking boot compared with the other bracing conditions. There were no significant differences (P > .05) between the other orthotic conditions. The walking boot was perceived to be significantly (P < .05) less stable than the other conditions. Participants' shoes were perceived to be significantly (P = .03; ES = 1.44) more comfortable than the TayCo brace, but the TayCo brace was perceived to be significantly more comfortable (P < .01) than the Moore balance brace (ES = 0.74) and walking boot (ES = 2.37).

Conclusions: The TayCo brace demonstrated decreased COP excursion compared with other conditions and performed similarly to the participants' own shoes. Further study should investigate the effects of this brace for clinical implementation.

Background: Infrapopliteal arterial calcifications (IPACs) are commonly seen on radiographs. No studies have examined the association between IPACs on radiographs and coronary artery calcium scores among the general population.

Methods: This retrospective cohort study examined patients who had both a heart scan for calcium scoring and foot, ankle, heel, or tibia/fibula plain film radiographs within a year of each other. Two radiologists and three foot and ankle specialists reviewed radiographs independently followed by a consensus review. Agatston scores and demographics were recorded via chart review. Univariate and regression analyses were performed to compare rates of abnormal and severe cardiac scans among patients with and without IPACs.

Results: Blind concordance was achieved among five reviewers for 211 of 283 radiographs (74.5%); each reviewer scored higher than 89% compared with the consensus results. Thirty-four of 283 patients were found to have IPACs and were more likely to have a nonzero heart scan score compared with those without IPACs (91% [31 of 34] versus 55% [136 of 249]; odds ratio, 8.6; 95% confidence interval, 2.6-28.8; P < .0001). Sixty-two percent (21 of 34) of patients with IPACs had category 3 or 4 heart scores, whereas only 21% (52 of 249) of those without IPACs had category 3 or 4 heart scores (P < .0001). IPACs remained significantly associated with category 3 or 4 heart scores (odds ratio, 4.4; 95% confidence interval, 2.0-9.7; P = .0003) even after controlling for age and diabetes with logistic regression modeling. Only four of 34 patients (11.7%) had IPACs reported on their original radiology report.

Conclusions: IPACs were accurately identified on radiographs by several reviewers but are often not mentioned on radiology reports. When present, IPACs are strongly associated with nonzero heart scores and severe heart scores. This finding could influence preventive cardiac care in asymptomatic patients.