Showing papers in "Journal of the American Podiatric Medical Association in 2002"
TL;DR: Results from key studies suggest that neutrophil-derived matrix metalloproteinase 8 (MMP-8) is the predominant collagenase present in normal healing wounds, and that overexpression and activation of this collagenase may be involved in the pathogenesis of nonhealing chronic leg ulcers.
Abstract: The structure, classification, function, and regulation of matrix metalloproteinases in normal and abnormal wound healing is discussed. Results from key studies suggest that neutrophil-derived matrix metalloproteinase 8 (MMP-8) is the predominant collagenase present in normal healing wounds, and that overexpression and activation of this collagenase may be involved in the pathogenesis of nonhealing chronic leg ulcers. Excessive collagenolytic activity in these chronic wounds is possible because of the reduced levels of tissue inhibitor metalloproteinase 1 (TIMP-1). However, until recently, there have been no studies evaluating levels of matrix metalloproteinase or tissue inhibitors of metalloproteinase activity in chronic diabetic foot wounds. Improving basic knowledge and pharmaceutical intervention in this area ultimately may help clinicians identify and proactively intervene in an effort to prevent normal wounds from becoming chronic. This may prevent the high prevalence of morbidity associated with this significant health problem. (J Am Podiatr Med Assoc 92(1): 12-18, 2002)
328 citations
262 citations
TL;DR: Having a high index of suspicion for this deformity and subsequently addressing it through conservative or surgical means may help to reduce the risk of foot ulceration and amputation.
Abstract: The authors undertook a study to evaluate the prevalence of ankle equinus and its potential relationship to high plantar pressure in a large, urban population with diabetes mellitus. The first 1,666 consecutive people with diabetes (50.3% male; mean [+/-SD] age, 69.1 +/- 11.1 years) presenting to a large, urban, managed-care outpatient clinic were enrolled in this longitudinal, 2-year outcomes study. Patients received a standardized medical and musculoskeletal assessment at the time of enrollment, including evaluation at an onsite gait laboratory. Equinus was defined as less than 0 degrees of dorsiflexion at the ankle. The overall prevalence of equinus in this population was 10.3%. Patients with equinus had significantly higher peak plantar pressures than those without the deformity and were at nearly three times greater risk for presenting with elevated plantar pressures. There were no significant differences in age, weight, or sex between the two groups. However, patients with equinus had a significantly longer duration of diabetes than those without equinus. Having a high index of suspicion for this deformity and subsequently addressing it through conservative or surgical means may help to reduce the risk of foot ulceration and amputation.
158 citations
TL;DR: The characteristics of an ideal dressing are discussed in an effort to assist clinicians in making appropriate dressing choices from common categories, including transparent films, hydrocolloids, foams, absorptive wound fillers, hydrogels, collagens, and gauzes.
Abstract: The concept of moist wound healing has been examined and gradually accepted by wound care clinicians during the last 40 years, and has led to the development of hundreds of dressings that support a moist wound environment. This article discusses the characteristics of an ideal dressing in an effort to assist clinicians in making appropriate dressing choices from common categories, including transparent films, hydrocolloids, foams, absorptive wound fillers, hydrogels, collagens, and gauzes. Reimbursement issues are also discussed.
144 citations
TL;DR: An overview of the conservative and surgical treatment options available for predislocation syndrome are presented and a clinical staging system that is based on the clinical signs and symptoms present during examination is devised.
Abstract: Progressive subluxation/dislocation of the lesser toes resulting from idiopathic inflammation about one or more of the lesser metatarsophalangeal joints is a common cause of metatarsalgia that is frequently unrecognized or misdiagnosed. The disorder results from a failure of the plantar plate and collateral ligaments that stabilize the metatarsophalangeal joints and is typically associated with abnormal forefoot loading patterns. The authors refer to this condition as predislocation syndrome and have devised a clinical staging system that is based on the clinical signs and symptoms present during examination. A thorough review of predislocation syndrome and an overview of the conservative and surgical treatment options available for this disorder are presented.
115 citations
TL;DR: In this retrospective analysis of 772 patients with symptomatic hallux limitus, 428 patients (55%) were successfully treated with conservative care alone; of these 428 patients, 362 (84%) were treated with orthoses.
Abstract: In this retrospective analysis of 772 patients with symptomatic hallux limitus, 428 patients (55%) were successfully treated with conservative care alone; of these 428 patients, 362 (84%) were treated with orthoses. Corticosteroid injections and a change in shoes allowed 24 patients (6% of conservatively treated patients) and 42 patients (10%), respectively, to have less discomfort and return to previous activity levels. Overall, 47% of the patients in this analysis were successfully treated with orthoses. Surgical procedures were performed on 296 patients (38% of all patients) who did not respond to conservative care. In this analysis, 48 of the patients (6% of all patients) who did not respond to conservative care either refused surgery or were not surgical candidates. These data are intended to provide podiatric physicians with expected outcomes for conservative care of hallux limitus. The etiology, symptoms, conservative management, and surgical treatments of hallux limitus and hallux rigidus are also reviewed.
104 citations
TL;DR: A simple technique to convert the removable cast walker into a device that is not as easily detached from the lower extremity, thereby encouraging the use of this device over a 24-hour period, is presented in this article.
Abstract: Addressing pressure reduction in the treatment of diabetic foot wounds is a critical component of therapy. The total-contact cast has proven to be the gold standard of treatment because of its ability to reduce pressure and facilitate patient adherence to the off-loading regimen. Removable cast walkers have proven to be as effective as total-contact casts in pressure reduction, but this has not translated into equivalent time to healing. A simple technique to convert the removable cast walker into a device that is not as easily detached from the lower extremity, thereby encouraging the use of this device over a 24-hour period, is presented in this article. The procedure involves wrapping the cast walker with cohesive bandage or plaster of Paris. In the authors’ opinion, this technique addresses many of the disadvantages of the total-contact cast, resulting in an adequate compromise in this aspect of care. (J Am Podiatr Med Assoc 92(7): 405-408, 2002)
99 citations
TL;DR: The reliability of biomechanical measurements of the lower extremities, as they are commonly used in podiatric practice, was quantified by means of intraclass correlation coefficients (ICCs) to evaluate interrater and intrarater reliability but also to provide an estimate for the accuracy of the measurements.
Abstract: The reliability of biomechanical measurements of the lower extremities, as they are commonly used in podiatric practice, was quantified by means of intraclass correlation coefficients (ICCs). This was done not only to evaluate interrater and intrarater reliability but also to provide an estimate for the accuracy of the measurements. The measurement protocol involved 30 asymptomatic subjects and five raters of varying experience. Each subject was measured twice by the same rater, with the retest immediately following the test. The study demonstrated that the interrater ICCs were quite low (≤0.51), except for the measurements of relaxed calcaneal stance position and forefoot varus (both 0.61 and 0.62 for left and right, respectively). However, the intrarater ICCs were relatively high (>0.8) for most raters and measurement variables. Measurement accuracy was moderate between raters. (J Am Podiatr Med Assoc 92(6): 317-326, 2002)
93 citations
TL;DR: It is demonstrated that an unsupervised range-of-motion exercise program can reduce peak plantar pressures in the diabetic foot and it may be possible to reduce the risk of such ulceration with this therapy.
Abstract: A randomized controlled study of 19 patients with diabetes mellitus (10 men, 9 women) was undertaken to determine the effects of home exercise therapy on joint mobility and plantar pressures. Of the 19 subjects, 9 subjects performed unsupervised active and passive range-of-motion exercises of the joints in their feet. Each subject was evaluated for joint stiffness and peak plantar pressures at the beginning and conclusion of the study. After only 1 month of therapy, a statistically significant average decrease of 4.2% in peak plantar pressures was noted in the subjects performing the range-of-motion exercises. In the control group, an average increase of 4.4% in peak plantar pressures was noted. Although the joint mobility data revealed no statistically significant differences between the groups, there was a trend for a decrease in joint stiffness in the treatment group. The results of this study demonstrate that an unsupervised range-of-motion exercise program can reduce peak plantar pressures in the diabetic foot. Given that high plantar pressures have been linked to diabetic neuropathic ulceration, it may be possible to reduce the risk of such ulceration with this therapy. (J Am Podiatr Med Assoc 92(9): 483-490, 2002)
84 citations
TL;DR: The pathogenesis of neuroarthropathy is reviewed, diagnosis and treatment of the stage 0 diabetic Charcot foot are presented, and a high index of suspicion and proper interpretation of clinical and diagnostic findings are essential to establish a timely and accurate diagnosis.
Abstract: Charcot's neuroarthropathy is a relatively common disease in patients with diabetic neuropathy. If unrecognized or left untreated, Charcot's neuroarthropathy can result in a severely misshapen and unstable foot and ankle. Ulceration, soft-tissue infection, and osteomyelitis frequently ensue, and partial or complete amputation of the foot is not uncommon. A high index of suspicion and proper interpretation of clinical and diagnostic findings are essential to establish a timely and accurate diagnosis and to institute appropriate treatment. The pathogenesis of neuroarthropathy is reviewed and diagnosis and treatment of the stage 0 diabetic Charcot foot are presented.
74 citations
TL;DR: The results of this study provide information on, and an understanding of, how the calcaneus, navicular, and first metatarsal function during the stance phase of normal human walking.
Abstract: The treatment of mechanically related foot disorders is often a challenge to clinicians. Sometimes this is due to the lack of information about how various segments of the foot move in relation to one another, especially during activities such as walking. The foot may be divided into three functional units: the rearfoot, the midfoot, and the first ray. Each of these units is a component of the medial longitudinal arch, which plays an important role in how the foot functions during weightbearing activities. 1
TL;DR: MIRE may be a safe, drug-free, noninvasive treatment for the consistent and predictable improvement of sensation in diabetic patients with peripheral neuropathy of the feet.
Abstract: Forty-nine consecutive subjects with established diabetic peripheral neuropathy were treated with monochromatic near-infrared photo energy (MIRE) to determine if there was an improvement of sensation. Loss of protective sensation characterized by Semmes-Weinstein monofilament values of 4.56 and above was present in 100% of subjects (range, 4.56 to 6.45), and 42 subjects (86%) had Semmes-Weinstein values of 5.07 or higher. The ability to discriminate between hot and cold sensation was absent (54%) or impaired (46%) in both groups prior to the initiation of MIRE treatment. On the basis of Semmes-Weinstein monofilament values, 48 subjects (98%) exhibited improved sensation after 6 treatments, and all subjects had improved sensation after 12 treatments. Therefore, MIRE may be a safe, drug-free, noninvasive treatment for the consistent and predictable improvement of sensation in diabetic patients with peripheral neuropathy of the feet. (J Am Podiatr Med Assoc 92(3): 125-130, 2002)
TL;DR: Appropriate wound bed preparation and debridement are necessary to improve clinical outcomes of new technologies and adversely affect the efficacy of topically-applied biological agents, including growth factors.
Abstract: A prolonged inflammatory response may adversely affect wound closure. Delayed wound closure and extended exposure to chronic wound fluid may also affect cellular activity in a wound bed and result in cellular senescence. Prolonged inflammation and cellular senescence may adversely affect the efficacy of topically-applied biological agents, including growth factors. Appropriate wound bed preparation and debridement are necessary to improve clinical outcomes of new technologies.
TL;DR: The results of this study show that the treatment goal should be to achieve an ungual labia fold of less than 3 mm, concluding that there is a correlation between the depth of the ungUAL labia Fold and the severity of the infected ingrown toenail.
Abstract: Infected ingrown toenails raise the question of how much nail should be removed and what amount of nail fold reduction should occur. Often, the ungual labia folds are found to be hypertrophic, forcing the nail to push into the flesh and start a foreign body reaction. A simplified approach to this problem is proposed on the basis of the measurement of 100 normal nail folds and 25 infected nail folds. The results of this study show that the treatment goal should be to achieve an ungual labia fold of less than 3 mm, concluding that there is a correlation between the depth of the ungual labia fold and the severity of the infected ingrown toenail.
TL;DR: The pertinent literature detailing chemical matrixectomies for ingrown toenails is reviewed and the use of an evidence basis for care is advocated.
Abstract: Chemical matrixectomy for ingrown toenails is one of the most common surgical procedures performed on the foot. The procedure was first described in 1945 by Otto Boll, who discussed the use of phenol to correct ingrown toenails. In the years that followed, many variations of technique and method have been described. This article reviews the pertinent literature detailing chemical matrixectomies and advocates the use of an evidence basis for care. (J Am Podiatr Med Assoc 92(5): 287-295, 2002)
TL;DR: The use of maggot debridement therapy for intractable wounds of the lower extremity with a systematic, multidisciplinary approach is described.
Abstract: Treatment of chronic wounds of the lower extremity requires a systematic, multidisciplinary approach as well as flexibility in order to achieve acceptable, consistent short-term and long-term results. Maggots, once considered an obsolete therapeutic modality, can be a useful addition to the armamentarium of the foot and ankle specialist. This article describes the use of maggot debridement therapy for intractable wounds of the lower extremity.
TL;DR: Future descriptive and analytic works may test the hypothesis that combined therapies used at different and often overlapping periods during the wound-healing cycle may be more effective than a single modality.
Abstract: The use of bioengineered tissue and topical subatmospheric pressure therapy have both been widely accepted as adjunctive therapies for the treatment of noninfected, nonischemic diabetic foot wounds. This article describes a temporally overlapping method of care that includes a period of simultaneous application of bioengineered tissue (Apligraf, Novartis Pharmaceuticals Corp, East Hanover, New Jersey) and subatmospheric pressure therapy delivered through the VAC (Vacuum Assisted Closure) system (KCI, Inc, San Antonio, Texas). Future descriptive and analytic works may test the hypothesis that combined therapies used at different and often overlapping periods during the wound-healing cycle may be more effective than a single modality. (J Am Podiatr Med Assoc 92(7): 395-397, 2002)
TL;DR: It is found that foot measures are significantly influenced by the method used to obtain a negative foot impression, and plaster casting may be preferable to the other three methods when it is important to capture the forefoot-to-rearfoot relationship, as in fabricating a functional orthosis.
Abstract: Four methods are currently available for taking a negative impression of the foot for the purpose of fabricating an orthotic device: nonweightbearing plaster casting, partial-weightbearing foam impressions, and partial-weightbearing and nonweightbearing laser scanning. This study compares the reliability and accuracy of these methods. Each impression method was performed three times on each foot of 15 subjects. Measures of rearfoot and forefoot width, forefoot-to-rearfoot relationship, and arch height were obtained from the negative impressions. Additionally, rearfoot and forefoot width and forefoot-to-rearfoot relationship were measured clinically for each subject. This study found that 1) foot measures are significantly influenced by the method used to obtain a negative foot impression; 2) the methods differ in reliability; and 3) plaster casting may be preferable to the other three methods when it is important to capture the forefoot-to-rearfoot relationship, as in fabricating a functional orthosis.
TL;DR: It is proposed that use of external fixation with bone stimulation may be an effective alternative method of treating the Charcot foot.
Abstract: External fixation was used to reduce or arrest progressive degeneration in 28 patients with Charcot’s foot dislocations Adjunctive procedures included tendo Achilles lengthening and application of an external bone stimulator Advantages of using external fixation are that surgeries are usually performed percutaneously and that most patients are weightbearing in 10 to 14 days There was no incidence of pin tract infection or further foot collapse, with the longest follow-up period being 24 months The authors propose that use of external fixation with bone stimulation may be an effective alternative method of treating the Charcot foot (J Am Podiatr Med Assoc 92(8): 429-436, 2002)
TL;DR: In this article, the medial heel region was studied by dissecting living tissue with the use of 3.5-power loupe magnification during decompression of the medial ankle for tarsal tunnel syndrome in 85 feet.
Abstract: Previous anatomic studies of the medial heel region were done on embalmed human cadavers. Here, the innervation of the medial heel region was studied by dissecting living tissue with the use of 3.5-power loupe magnification during decompression of the medial ankle for tarsal tunnel syndrome in 85 feet. The medial heel was found to be innervated by just one medial calcaneal nerve in 37% of the feet, by two medial calcaneal nerves in 41%, by three medial calcaneal nerves in 19%, and by four medial calcaneal nerves in 3%. An origin for a medial calcaneal nerve from the medial plantar nerve was found in 46% of the feet. This nerve most often innervates the skin of the posteromedial arch, where it is at risk for injury during calcaneal spur removal or plantar fasciotomy. Knowledge of the variations in location of the medial calcaneal nerves may prevent neuroma formation during surgery and provide insight into the variability of heel symptoms associated with tarsal tunnel syndrome.
TL;DR: Of the study population, 17% and 21% reported that their quality of life was affected by pain and discomfort, respectively, much lower than those obtained in other studies; it may therefore be inferred that foot complaints are being neglected by the ethnic Chinese population in Hong Kong.
Abstract: A prospective epidemiologic survey on the prevalence of foot disease in Hong Kong found foot disease in 64% of patients screened. All of the patients were ethnically Chinese. Of the conditions specified in the questionnaire, fungal foot infection, tinea pedis, and toenail onychomycosis were the most frequently encountered conditions, followed by metatarsal corns, eczema, psoriasis, and pes planus. Vascular disease, osteoarticular pathology, diabetes mellitus, obesity, atopy, and participation in sports were the main factors coexisting with the foot conditions. Of the study population, 17% and 21% reported that their quality of life was affected by pain and discomfort, respectively. These percentages are much lower than those obtained in other studies; it may therefore be inferred that foot complaints are being neglected by the ethnic Chinese population in Hong Kong.
TL;DR: A plantar fascia index was established consisting of the ratio of the mean thickness of symptomatic medial, central, and lateral plantar Fascia bands to that of asymptomatic bands, which is 1.98 (5.35/2.70 mm).
Abstract: The authors measured the thickness of the medial, central, and lateral bands of the plantar fascia using ultrasonographic techniques in 109 symptomatic patients with 211 painful heels. Plantar fasciitis was diagnosed by the presence of plantar heel pain and tenderness of the plantar fascia on palpation and was correlated with plantar fascia thickness. All of the symptomatic feet had medial band tenderness, with an average thickness of 5.9 mm, 68% had central band tenderness, with an average thickness of 5.3 mm, and 26% had lateral band tenderness, with an average thickness of 4.4 mm. The average thickness of all symptomatic bands was 5.35 mm, which was significantly greater than that for all asymptomatic bands, which was 2.70 mm. There were also significant differences in the thickness of the three plantar fascia bands in symptomatic patients. A plantar fascia index was established consisting of the ratio of the mean thickness of symptomatic medial, central, and lateral plantar fascia bands to that of asymptomatic bands; for this study, the index value is 1.98 (5.35/2.70 mm).
TL;DR: The authors studied the histologic effects of phenol on the nail matrix and determined the optimal concentration of Phenol and time the phenol solution needs to be in contact with the nail bed.
Abstract: Chemical matrixectomy using phenol is one of the most common surgical procedures for the permanent removal of toenails. The concentration of phenol solution and duration of its application have varied widely and have not been subjected to scientific study. The authors studied the histologic effects of phenol on the nail matrix and determined the optimal concentration of phenol and time the phenol solution needs to be in contact with the nail bed. (J Am Podiatr Med Assoc 92(10): 575-579, 2002)
TL;DR: The amputation rate was significantly decreased during the test period, and the amputations that were required were at a significantly more distal level, suggesting that unified care is an effective approach for the patient with diabetic foot problems.
Abstract: The lower-extremity amputation rate in people with diabetes mellitus is high, and the wound failure rate at the time of amputation is as high as 28%. Even with successful healing of the primary amputation site, amputation of part of the contralateral limb occurs in 50% of patients within 2 to 5 years. The purpose of this study was to provide valid outcome data before (control period) and 18 months after (test period) implementation of a multidisciplinary team approach using verified methods to improve the institutional care of wounds. Retrospective medical chart review was performed for 118 control patients and 116 test patients. The amputation rate was significantly decreased during the test period, and the amputations that were required were at a significantly more distal level. No above-the-knee amputations were required in 45 patients during the test period, compared with 14 of 76 patients during the control period. These outcome data suggest that unified care is an effective approach for the patient with diabetic foot problems.
TL;DR: The authors review the literature, clinical findings, proposed etiology, classification, ancillary tests, histopathology, differential diagnosis, treatment options, and prognosis of synovial osteochondromatosis.
Abstract: Synovial osteochondromatosis is a benign disease of unknown etiology that involves the articular and periarticular structures. The disorder primarily affects men, and trauma is the most common predisposing factor. The authors review the literature, clinical findings, proposed etiology, classification, ancillary tests, histopathology, differential diagnosis, treatment options, and prognosis. A case report of this rare entity is also presented.
TL;DR: A traumatic extensor hallucis longus tendon rupture sustained 2 days after hallux valgus and hammer toe correction demonstrates a serious complication of a commonly performed procedure and a salvage technique useful for dealing with large tendon defects.
Abstract: The authors present a case of a traumatic extensor hallucis longus tendon rupture sustained 2 days after hallux valgus and hammer toe correction. The ruptured tendon, separated by a 6-cm defect, was repaired using a fascia lata allograft. This case demonstrates a serious complication of a commonly performed procedure and a salvage technique useful for dealing with large tendon defects.
TL;DR: The author presents a method of rigid internal fixation using 2.4-mm-diameter pins fashioned out of freeze-dried allogeneic cortical bone to conclude that use of cortical bone pins can yield successful results in most cases.
Abstract: In hammer toe correction by means of digital fusion, fixation so that the bone can unite while maintaining appropriate realignment can be a challenge. Metal fixation pins can be associated with many problems and potential complications. The author presents a method of rigid internal fixation using 2.4-mm-diameter pins fashioned out of freeze-dried allogeneic cortical bone. These devices avoid most of the risks of metal pins. Proximal interphalangeal joint arthrodesis using cortical bone pins was performed on 26 toes in 18 patients with very few complications. The author concludes that use of cortical bone pins can yield successful results in most cases. The outcomes of the fusions can be further enhanced by using flexor digitorum longus tendon transfer.
TL;DR: It is concluded that the Green-Watermann procedure is an effective treatment approach for hallux limitus and rigidus, resulting in a significant reduction in pain, an increase in function, and a high degree of patient satisfaction.
Abstract: The authors undertook a retrospective analysis of the long-term efficacy of the Green-Watermann procedure for the treatment of painful hallux limitus or rigidus. Questionnaires were sent to 80 consecutive patients who had such procedures performed between 1990 and 1999. Medical records and radiographs were reviewed for the 32 patients who completed the questionnaires, representing 40 Green-Watermann procedures. Twenty-four patients were able to return for clinical evaluation. The average length of follow-up was 4 years (range, 1 to 10 years). The questionnaires addressed pain before and after surgery, function after surgery, complications, and overall impression and satisfaction. Nearly all of the patients (30 of 32; 94%) reported that surgery had significantly relieved their hallux joint pain, and a slightly smaller proportion (28 of 32; 88%) felt that their chief complaints were at least 70% improved. Clinical evaluation revealed adequate range of motion at the first metatarsophalangeal joint. It is con...
TL;DR: The sensitivity and specificity of this clinical test to predict abnormal excessive midtarsal joint function during gait were found to be low, suggesting that clinicians should consider functional hallux limitus when there is late midstance pronation of the midtARSal joint duringgait.
Abstract: Functional hallux limitus is an underrecognized entity that generally does not produce symptoms but can result in a variety of compensatory mechanisms that can produce symptoms. Clinically, hallux limitus can be determined by assessing the range of motion available at the first metatarsophalangeal joint while the first ray is prevented from plantarflexing. The aim of this study was to determine the sensitivity and specificity of this clinical test to predict abnormal excessive midtarsal joint function during gait. A total of 86 feet were examined for functional hallux limitus and abnormal pronation of the midtarsal joint during late midstance. The test had a sensitivity of 0.72 and a specificity of 0.66, suggesting that clinicians should consider functional hallux limitus when there is late midstance pronation of the midtarsal joint during gait.