Journal of Foot and Ankle Research最新文献

Background: Footwear is often recommended in the management of plantar heel pain (PHP), theoretically to reduce tissue stress during standing and walking; however, limited data exist to guide footwear design and recommendations.

Methods: Plantar pressures, impact forces and comfort during walking were recorded in 29 women with PHP (mean age 47 ± 12 years) in six randomised shoe and insert conditions. A test shoe (polyurethane outsole, 14-mm heel-toe pitch) was compared to a control shoe (rubber outsole, 4-mm heel-toe pitch), and within the test shoe, five different insoles that varied by material, density and arch contouring were also compared.

Results: The test shoe reduced heel peak pressure (15%, p < 0.01) and reduced the loading rate but not the peak magnitude of the vertical ground reaction force (average loading rate reduction: 7%, p < 0.01; maximum loading rate: 29%, p < 0.01) and was more comfortable (47%-67%, p < 0.01) compared to the control shoe. Within the test shoe, dual-density inserts with arch contouring showed lower heel peak pressure compared to a lightweight flat insert (11%-12%, p < 0.03). The insert with the firmest material and higher arch contouring showed higher midfoot peak pressure (16%-21%, p < 0.01) compared to other inserts. Forefoot peak pressure did not differ between shoe or insert conditions (p > 0.05). There were no differences in impact forces or comfort between the different inserts within the test shoe (p > 0.05).

Conclusion: Findings suggest that shoe and insert properties are both important and provide data to guide footwear design and management recommendations for PHP.

Aims/hypothesis: Charcot foot (CF), a potentially debilitating complication of neuropathy, requires offloading to avoid foot deformities. Follow-up MRI examinations are often used to determine the optimal duration of total contact cast (TCC) offloading treatment. This study investigated the use of follow-up MRI during CF treatment and its relationship to offloading duration and risk of future surgery.

Methods: People with diabetes mellitus and MRI-confirmed CF treated at Skåne University Hospital (Lund and Malmö, Sweden) between 2006 and 2022 were studied retrospectively. Individuals monitored with follow-up MRI examinations were compared with those who only underwent diagnostic MRI. A regression model was applied to evaluate factors predicting TCC and total CF treatment duration.

Results: One-hundred and twenty-two individuals (45 [37%] DM1; 47 [39%] women; median age 60 [IQR 53-68] years) with a total of 143 CF events were included. 76 (53%) of these CF events were monitored using a total of 141 follow-up MRI examinations. Individuals monitored with MRI had significantly longer TCC and total CF treatment durations (p < 0.001). Individual characteristics (with the exception of sex), rate of stage 1 CF, and risk of future surgery did not differ between the two groups and only use of follow-up MRI (p < 0.001) remained a significant predictor of both longer TCC and total CF treatment durations in a regression model.

Conclusions/interpretation: In this retrospective cohort study, use of follow-up MRI was associated with longer TCC and total treatment times despite similar characteristics and outcomes. Prospective studies are needed to further elucidate the optimal use of MRI in monitoring CF.

Introduction: The Foot Posture Index (FPI-6), widely used to quantify foot posture, is a core component of musculoskeletal curricula in undergraduate podiatry programs. Teaching the FPI-6 can be challenging but 3D foot models provide a controlled risk-free way to practice, potentially reducing anxiety and increasing confidence. This study examined the effects of 3D foot models on podiatry students' confidence and anxiety when performing the FPI-6 and compared their scores to experts.

Methods: Fifty podiatry students from three Australian universities used the FPI-6 to score nine 3D printed foot models ranging from -11 (highly supinated) to +12 (highly pronated). Students' self-confidence and anxiety were measured before and after exposure to the 3D foot models using a 10-item self-confidence questionnaire and the 27-item Competitive State Anxiety Inventory-2 (CSAI-2). Changes in self-confidence were analysed with paired t-tests, whereas median differences in CSAI-2 scores pre- and post-intervention were assessed using the Wilcoxon signed-rank test. Students' foot posture scores were compared to consensus scores from an expert panel (n = 4) with variability in agreement explored using the Bland-Altman limits of agreement (LoA) analysis.

Results: Student confidence improved across all 10 questionnaire items after the FPI-6 simulation with 3D foot models (p ≤ 0.015) with a mean increase of 8.6% across all items (range, 1.9%-11.6%) and medium to large effect sizes (Cohen's d = 0.44-0.94). On the CSAI-2, 22 of 27 items showed improvements in cognitive and somatic state anxiety or self-confidence (p ≤ 0.038), whereas five items showed no significant change. The Bland-Altman analysis revealed a small mean difference of 0.389 between student and expert consensus scores with 95% LoA ranging from -3.3 to 4.1.

Conclusion: The use of 3D foot models for FPI-6 simulation enhances podiatry students' confidence and reduces anxiety. Student's foot posture scores had good overall agreement with expert scores, though some discrepancies remained. This highlights the value of pre-scored models for targeted practice and emphasises the importance of validation and feedback to ensure confidence aligns with accuracy. The models demonstrated high utility, harnessing 3D scanning and printing technology to enhance students' proficiency in assessing foot posture.

Background: The aim of this study was to systematically review the risk of falls in people with diabetes-related foot ulcers (DFU).

Methods: A systematic search of Medline, Pubmed, Embase, Cochrane and CINAHL was undertaken to identify observational studies reporting falls and containing a group of people with a DFU and a control group with diabetes but no DFU. Risk of bias was assessed by a modified Newcastle-Ottawa Scale. Meta-analysis was performed using a random effects model.

Results: Four studies involving 3643 participants with a DFU and 42,436 participants with diabetes but no DFU were included. A meta-analysis showed high heterogeneity between studies (I² = 95%) and an increased risk of falls in people with DFU (risk ratio 2.25 and 95% CI 1.05-4.84). One study had a low risk of bias and three studies had a high risk of bias. Leave-one-out analyses showed that exclusion of the study with the largest effect on heterogeneity resulted in a risk ratio of 1.80 (95% CI 1.33-2.43 and I² = 0%).

Conclusions: Currently available evidence suggests people with a DFU have a higher risk of falls but most past studies have a high risk of bias. Further well-designed cohort studies are required.

Background: Transmetatarsal amputation (TMA) is a commonly performed procedure for gangrene in the setting of diabetes or peripheral vascular disease. The purpose of this study is to investigate the incidence of and risk factors for reoperation and perioperative complications after TMA in patients undergoing surgery for primarily infectious/diabetic wounds versus peripheral vascular disease.

Methods: Patients undergoing TMA between January 1, 2015 and December 31, 2020 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. The indication for surgery was reported using the International Classification of Disease 9/10 codes. Patients were categorized into two groups: patients undergoing surgery for primarily infectious/diabetic wounds versus peripheral vascular disease. The incidence of 30-day mortality, readmission, reoperation, nonhome discharge, and various medical and surgical complications was reported. Outcome measures were compared between the diabetic and peripheral vascular disease groups. Logistic regression was used to identify independent risk factors for each outcome measure of interest.

Results: 3392 patients were included in the final cohort. There was a 30-day mortality rate of 2.9%, reoperation rate of 13.8%, readmission rate of 16.8%, surgical complication rate of 22.2%, and medical complication rate of 15.8%. Patients undergoing surgery for a vascular indication had a higher rate of mortality, reoperation, hospital readmission, nonhome discharge, and various medical complications (p < 0.05). Patients undergoing surgery for infectious/diabetic wounds had a higher rate of deep surgical site infection and systemic sepsis (p < 0.05). A vascular surgical indication was independently associated with reoperation and overall medical complications (p < 0.05). Various factors, including age, body mass index, medical comorbidities, and the presence of preoperative sepsis were associated with poor outcomes.

Conclusion: Significant rates of mortality, reoperation, and hospital readmission were reported after TMA. The presence of peripheral vascular disease was independently associated with reoperation and medical complications. Patients undergoing TMA, particularly for peripheral vascular disease, should be counseled about perioperative risks and indicated for surgery carefully.

Introduction: Work-readiness is linked to health professional graduates' job performance, satisfaction, engagement and retention. However, there is currently no podiatry-specific graduate employer work-readiness survey tool that has been developed with employers of graduate podiatrists. The aim of this study was to conduct a modified Delphi survey to achieve consensus among employers of podiatry graduates on the key capabilities required for podiatry graduates.

Methods: A Delphi method of consensus development was used, comprising three online survey rounds. Purposive sampling was used to recruit individuals with extensive experience and knowledge in mentoring and managing graduate podiatrists in Australia or New Zealand. In Round 1, participants were asked to rate agreement/disagreement with 71 items across seven domains relating to capabilities required of podiatry graduates that were extracted from a literature search and steering committee input. Participants were also asked to contribute further ideas in relation to these items, which were incorporated as new items (n = 7) in Round 2. In Rounds 2 and 3, participants re-appraised their ratings in view of the group consensus. Consensus was defined as ≥75% agreement. In Round 3, participants were also asked to rate the importance of each item as either 'essential' or 'optional'.

Results: Twenty-five participants (mean [SD] of 14.9 [5.7] years of experience in managing podiatry graduates in clinical practice in Australia or New Zealand) completed Round 1, 24 in Round 2, and 23 in Round 3. Of the 78 items presented to our expert panel, 61 (78.2%) achieved consensus and were accepted, and 17 (21.8%) were excluded. Of the 61 items that achieved consensus, thirty-nine (63.9%) were rated as 'essential' by 75% of more respondents.

Conclusion: Consensus among employers of podiatry graduates was established on the key capabilities required for podiatry graduates. Sixty-one items were identified across seven domains, and of these, 39 items were rated as 'essential'. The findings of this study have the potential to inform the creation of a podiatry-specific graduate employer work-readiness tool to provide feedback to podiatry education program providers and new graduates in the workplace.

Background: Chronic lower limb pain is common in children and adolescents and is frequently managed by podiatrists. Due to the complexities of understanding the cause of chronic pain, clinicians may experience uncertainty around the diagnosis, which in turn may impact their communication and management approaches. Limited research explores how podiatrists manage chronic lower limb pain in children, especially in the presence of diagnostic uncertainty. This study aimed to explore the management strategies including language that podiatrists report using to address the pain experience of children with chronic lower limb pain and to investigate if and how the reported management strategies used by podiatrists to address the pain experience of children with chronic lower limb pain vary based upon the level of diagnostic uncertainty.

Methods: Eight focus groups were conducted with a total of 48 podiatrists. Participants were presented with three vignettes, each describing a child with chronic lower limb pain. They were then asked to discuss their certainty in the child's diagnosis presented and their approaches to explain and manage the child's pain. Audio data were recorded, transcribed and analysed using thematic analysis. Three key themes were generated: Language strategies, non-verbal communication strategies and treatment strategies.

Results: Podiatrists were overall certain in the diagnosis presented in vignettes 1 (calcaneal apophysitis) and 2 (juvenile idiopathic arthritis); however, they expressed significant uncertainty in vignette 3, which was written to elicit uncertainty presenting a case with generalised lower limb pain. Many groups fixated on the Beighton score of 5/9 and interpreted this to mean hypermobility, which is inconsistent with the current clinical guidance. Podiatrists used similar language strategies across all 3 vignettes and supported their language strategies with non-verbal communication strategies. Podiatrists also discussed activity modification, passive and self-care strategies and building a team as the treatment strategies they would use.

Conclusions: This study highlights the variety of clinical management strategies used by approaches and highlights how their approach may change depending on their certainty in the diagnosis.

Introduction: The lateral longitudinal arch (LLA) is an essential structure of the foot. However, LLA evaluation methods remain underexplored compared to those of the medial longitudinal arch (MLA). This study sought to develop a method for measuring the cuboid height, the keystone of the LLA, using ultrasonography and to verify its correlation with radiography, as well as intrarater and interrater reliability.

Methods: This cross-sectional study included 21 university students (14 males and seven females). The cuboid height was measured using radiography and ultrasonography. The validity of ultrasonographic measurements was assessed through correlation with radiographic measurements and Bland-Altman analysis. Intrarater and interrater reliabilities were evaluated using intraclass correlation coefficients (ICCs).

Results: A strong correlation was observed between cuboid heights measured using radiography and ultrasonography (r = 0.98, p < 0.01). The Bland-Altman analysis revealed a fixed bias of -0.71 mm (95% confidence interval [95% CI]: -0.96 to -0.46 mm). Intrarater and interrater reliability for ultrasonographic measurements were almost perfect, with ICCs of 0.98 and 0.99, respectively.

Conclusions: Cuboid height measurements using ultrasonography demonstrated high validity and reliability. This method offers a noninvasive and cost-effective alternative to radiography, with potential clinical applications in the evaluation of LLA and related conditions such as cuboid syndrome and lateral foot injuries.

Objective: This study aimed to identify how computer aided design and manufacture (CAD/CAM) technologies are currently being used for insole production by UK orthotic services in the National Health Service (NHS), including any variation in the specific processes and identify barriers to implementation.

Design: A cross-sectional study was undertaken using freedom of information requests sent to all 214 NHS Trusts and Health Boards (HBs) across the UK. The request comprised 22 questions relating to CAD/CAM for insole production by UK NHS orthotic services during the 2021/22 financial year.

Outcome measures: Analysis was undertaken and presented in terms of response rate to individual questions. Where free text responses were provided, thematic analysis was conducted.

Results: Responses were received from 186 (86.9%) Trusts/HBs, those who did not have an orthotic service were excluded, and 131 responses were included in the final analysis. 70.5% (91/129) of Trusts/HBs used CAD/CAM to manufacture bespoke insoles. The most common workflow associated with CAD/CAM insole production was foot-shape capture with a foam box impression cast (86.8% (79/91)); casts transported to another site (90.8% (79/87)); foam boxes scanned into a CAD/CAM system (81.6% (71/87)); insoles designed by a technician (73.6% (67/91)) and insole produced with reduction milling (59.1% (SD 37.92)). The greatest barriers to the use of CAD/CAM were those of equipment costs and staff experience and training.

Conclusions: UK orthotic services have widely adopted CAD/CAM insole production, but fully-digital workflow is uncommon. Hybrid-digital workflow involves physical casts and their transportation, generating waste and impacting sustainability. Further research is required to understand how hybrid-digital and fully-digital workflow affect patient treatment outcomes, costs and sustainability. Barriers to CAD/CAM including costs and staff training which should be considered alongside the growing body of research around CAD/CAM technologies.