Journal of the American Podiatric Medical Association

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by Joseph M. Caporusso

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 431; https://doi.org/10.7547/1020431 - 1 Sep 2012

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One hundred years ago, in July 1912, 225 charter members gathered to organize a national association dedicated to the needs of practicing chiropodists [...] Full article

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Newly Approved Laser Systems for Onychomycosis

by Aditya K. Gupta and Fiona Simpson

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 428-430; https://doi.org/10.7547/1020428 - 1 Sep 2012

Cited by 29 | Viewed by 113

Abstract

Laser systems are a new treatment area for onychomycosis. As of January 2012, the US Food and Drug Administration (FDA) has approved four laser systems for the “temporary increase of clear nail in onychomycosis.” The FDA has approved these devices on the basis [...] Read more.

Laser systems are a new treatment area for onychomycosis. As of January 2012, the US Food and Drug Administration (FDA) has approved four laser systems for the “temporary increase of clear nail in onychomycosis.” The FDA has approved these devices on the basis of “substantial equivalence” to predicate devices with similar technical specifications and applications. Laser therapy appears to be a promising alternative to traditional pharmacotherapy, but these systems have been tested in only limited clinical trials; therefore, it is not possible to compare their efficacy to the oral and topical drugs currently used in the treatment of onychomycosis. (J Am Podiatr Med Assoc 102 (5): 428-430, 2012) Full article

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Incidental Findings of Massive Heel Spurs in a Veteran with a Variant of Psoriatic Arthritis

by Danae L. Lowell, Lawrence S. Osher and Angela F. Grady

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 422-427; https://doi.org/10.7547/1020422 - 1 Sep 2012

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Abstract

A middle-aged man presented for left foot diabetic ulcer care. Pedal radiographs were negative for signs of osteomyelitis. However, asymptomatic incidental osseous findings demonstrated significant plantar and posterior calcaneal spurring possibly consistent with diffuse idiopathic skeletal hyperostosis (DISH). A differential of DISH, psoriatic [...] Read more.

A middle-aged man presented for left foot diabetic ulcer care. Pedal radiographs were negative for signs of osteomyelitis. However, asymptomatic incidental osseous findings demonstrated significant plantar and posterior calcaneal spurring possibly consistent with diffuse idiopathic skeletal hyperostosis (DISH). A differential of DISH, psoriatic arthritis, Reiter’s, and ankylosing spondylitis was developed. Subsequent spinal imaging and laboratory work-up did not satisfy the diagnostic criteria for DISH. This case illustrates radiographic changes characteristic of multiple seronegative arthropathies. On initial presentation a diagnosis of DISH was most likely, but with further imaging studies a diagnosis of a variant of psoriatic arthritis may be more correct. (J Am Podiatr Med Assoc 102 (5): 422-427, 2012) Full article

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Open AccessArticle

Nephrogenic Systemic Fibrosis in the Podiatric Patient

by Lewis Freed, Josh Hill and David Gooch

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 419-421; https://doi.org/10.7547/1020419 - 1 Sep 2012

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Abstract

Nephrogenic systemic fibrosis (NSF) is a severely debilitating disease that was first described in the literature by Cowper and colleagues in 2000. It is pertinent to the field of podiatry because patients with NSF first manifest cutaneous symptoms in the lower extremity in [...] Read more.

Nephrogenic systemic fibrosis (NSF) is a severely debilitating disease that was first described in the literature by Cowper and colleagues in 2000. It is pertinent to the field of podiatry because patients with NSF first manifest cutaneous symptoms in the lower extremity in the form of fibrosing lesions. To date, these lesions have been documented only in people with moderate to severe kidney failure. There is speculation that gadolinium, used as a contrast agent for imaging, might be the inciting factor that triggers a cascade of events that results in the inappropriate fibrosis both in the dermis and in deeper tissues. Nephrogenic systemic fibrosis has been shown to cause these lesions in the lungs, pleura, diaphragm, myocardium, pericardium, and dura mater, the presence of which are typically indicative of severe progression of NSF. In cases where the lesions are manifest in the periarticular tissue, joint contractures and restricted range of motion can often result. We provide a quick synopsis of NSF, and a short case study that describes the authors’ experience with one of their patients who requested a surgical consult as a result of being wheelchair-bound due to NSF’s sequelae. (J Am Podiatr Med Assoc 102(5): 419-421, 2012) Full article

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Pilomatrixoma. An Infrequently Encountered Lesion on the Lower Extremity

by Billy R. Martin, Katherine Neiderer and James F. Dancho

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 417-418; https://doi.org/10.7547/1020417 - 1 Sep 2012

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Abstract

We discuss the clinical presentation and treatment of pilomatrixoma as it occurs in the lower extremity. Although pilomatrixoma is far more common on the head, neck, and upper extremity, it can be found on the lower extremity. Treatment is aimed primarily at excision [...] Read more.

We discuss the clinical presentation and treatment of pilomatrixoma as it occurs in the lower extremity. Although pilomatrixoma is far more common on the head, neck, and upper extremity, it can be found on the lower extremity. Treatment is aimed primarily at excision if the lesion is symptomatic or suspicious for malignancy. The authors present a case of a 73-year-old male who presented to the diabetic foot center with this condition. (J Am Podiatr Med Assoc 102(5): 417–418, 2012) Full article

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Assessment of Partial First-Ray Resections and Their Tendency to Progress to Transmetatarsal Amputations. A Retrospective Study

by John Kadukammakal, Sydney Yau and William Urbas

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 412-416; https://doi.org/10.7547/1020412 - 1 Sep 2012

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Abstract

Background: Diabetic foot infections tend to lead to amputation. Partial first-ray resections are used to help salvage the foot and maintain bipedal ambulation. Losing the first metatarsophalangeal joint has biomechanical consequences that lead to further foot deformities and result in more proximal [...] Read more.

Background: Diabetic foot infections tend to lead to amputation. Partial first-ray resections are used to help salvage the foot and maintain bipedal ambulation. Losing the first metatarsophalangeal joint has biomechanical consequences that lead to further foot deformities and result in more proximal amputations of the ipsilateral limb, such as a transmetatarsal amputation. Methods: We reviewed 48 patients (32 male and 16 female; mean age ¼ 62.44) who underwent 50 partial first-ray resections between April 1, 2003, and July 31, 2009. These partial first-ray resections were done at various levels of the first metatarsal. We hypothesize that partial first-ray resections that require further bone resection will lead to poor biomechanics that can result in further amputation. Results: We found that out of 50 partial first-ray resections, 24 cases required further surgical intervention, 12 of which were a transmetatarsal amputation (TMA) (mean time between partial first-ray resection and TMA ¼ 282.08 days). Forty-eight percent of patients did not require further surgical intervention and were considered a success. Conclusions: Partial first-ray resections are not highly successful. Our study found a higher success rate compared to a previous study done by Cohen et al in 1991. Partial first-ray amputations can be a good initial procedure to salvage the foot and prolong a patient’s bipedal ambulatory status, thereby lowering the patient’s morbidity and mortality. (J Am Podiatr Med Assoc 102(5): 412-416, 2012) Full article

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Weightbearing and Nonweightbearing Ankle Dorsiflexion Range of Motion. Are We Measuring the Same Thing?

by Alon Rabin and Zvi Kozol

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 406-411; https://doi.org/10.7547/1020406 - 1 Sep 2012

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Abstract

Background: Ankle dorsiflexion range of motion has been measured in weightbearing and nonweightbearing conditions. The different measurement conditions may contribute to inconsistent conclusions regarding the role of ankle dorsiflexion in several pathologic conditions. The purpose of this study was to examine the [...] Read more.

Background: Ankle dorsiflexion range of motion has been measured in weightbearing and nonweightbearing conditions. The different measurement conditions may contribute to inconsistent conclusions regarding the role of ankle dorsiflexion in several pathologic conditions. The purpose of this study was to examine the relationship between ankle dorsiflexion range of motion as measured in weightbearing and nonweightbearing conditions. Methods: We compared ankle dorsiflexion range of motion as measured in a weightbearing versus a nonweightbearing position in 43 healthy volunteers. Measurements were taken separately by two examiners. Results: Weightbearing and nonweightbearing ankle dorsiflexion measurements produced significantly different results (P , .0001). The two measurements correlated moderately (r ¼ 0.6 and r ¼ 0.64 for examiners 1 and 2, respectively; P , .001). Conclusions: Weightbearing and nonweightbearing ankle dorsiflexion measurements produce significantly different results and only a moderate correlation, suggesting that these two measurements should not be used interchangeably as measures of ankle dorsiflexion range of motion. (J Am Podiatr Med Assoc 102(5): 406-411, 2012) Full article

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Partial or Total Calcanectomy as an Alternative to Belowthe- Knee Amputation for Limb Salvage. A Systematic Review

by Valerie L. Schade

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 396-405; https://doi.org/10.7547/1020396 - 1 Sep 2012

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Abstract

Background: Below-the-knee amputations are regarded as definitive treatment for calcaneal osteomyelitis. They may be less than desirable in patients with a viable midfoot and forefoot. Partial and total calcanectomies have been reported as an alternative for limb salvage. However, the durability of [...] Read more.

Background: Below-the-knee amputations are regarded as definitive treatment for calcaneal osteomyelitis. They may be less than desirable in patients with a viable midfoot and forefoot. Partial and total calcanectomies have been reported as an alternative for limb salvage. However, the durability of the residual limb is questionable. Methods: A systematic review was undertaken to identify material relating to the potential for limb salvage with partial or total calcanectomy in ambulatory patients with calcaneal osteomyelitis. Studies eligible for inclusion consecutively enrolled ambulatory patients older than 18 years who underwent partial or total calcanectomy without adjunctive free tissue transfer for the treatment of calcaneal osteomyelitis and had a mean follow-up of 12 months or longer. Results: Sixteen studies involving 100 patients (76 partial and 28 total calcanectomies) met all of the inclusion criteria. Weighted mean follow-up was 33 months. Minor complications with subsequent healing occurred in less than 24% of patients. Most major complications were related to residual soft-tissue infection and osteomyelitis. Approximately 10% of patients required a major lower-extremity amputation. Major complications and major lower-extremity amputations occurred more frequently after total calcanectomy and in patients with a diagnosis of diabetes. Eighty-five percent of patients maintained or improved their ambulatory status postoperatively. Only 3% of patients decreased their ambulatory status postoperatively, becoming unlimited household ambulators. Conclusions: This systematic review provides evidence that partial or total calcanectomy is a viable option for limb salvage in ambulatory patients with calcaneal osteomyelitis. (J Am Podiatr Med Assoc 102(5): 396-405, 2012) Full article

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Open AccessArticle

Anatomical Origin of Forefoot Varus Malalignment

by Rebecca S. Lufler, T. M. Hoagland, Jingbo Niu and K. Douglas Gross

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 390-395; https://doi.org/10.7547/1020390 - 1 Sep 2012

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Abstract

Background: Forefoot varus malalignment is clinically defined as a nonweightbearing inversion of the metatarsal heads relative to a vertical bisection of the calcaneus in subtalar joint neutral. Although often targeted for treatment with foot orthoses, the etiology of forefoot varus malalignment has [...] Read more.

Background: Forefoot varus malalignment is clinically defined as a nonweightbearing inversion of the metatarsal heads relative to a vertical bisection of the calcaneus in subtalar joint neutral. Although often targeted for treatment with foot orthoses, the etiology of forefoot varus malalignment has been debated and may involve an unalterable bony torsion of the talus. Methods: Forty-nine feet from 25 cadavers underwent bilateral measurement of forefoot alignment using adapted clinical methods, followed by dissection and measurement of bony talar torsion. The relationship between forefoot alignment and talar torsion was determined using the Pearson correlation coefficient. Results: Mean 6 SD forefoot alignment was 0.98 6 9.88 (valgus) and bony talar torsion was 32.88 6 5.38 valgus. There was no association between forefoot alignment and talar torsion (r ¼ 0.18; 95% confidence interval, 0.11 to 0.44; P ¼ .22). Conclusions: These findings may have implications for the treatment of forefoot varus since they suggest that the source of forefoot varus malalignment may be found in an alterable soft-tissue deformity rather than in an unalterable bony torsion of the talus. (J Am Podiatr Med Assoc 102(5): 390-395, 2012) Full article

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First Metatarsophalangeal Joint Motion in Homo sapiens. Theoretical Association of Two-Axis Kinematics and Specific Morphometrics

by Michael N. Durrant, Tucker McElroy and Lara Durrant

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 374-389; https://doi.org/10.7547/1020374 - 1 Sep 2012

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Abstract

Background: The metatarsal head and proximal phalanx exhibit considerable asymmetry in their shape and geometry, but there is little documentation in the literature regarding the prevalence of structural characteristics that occur in a given population. Although there is a considerable volume of [...] Read more.

Background: The metatarsal head and proximal phalanx exhibit considerable asymmetry in their shape and geometry, but there is little documentation in the literature regarding the prevalence of structural characteristics that occur in a given population. Although there is a considerable volume of in vivo and in vitro experiments demonstrating first metatarsal inversion around its longitudinal axis with dorsiflexion, little is known regarding the applicability of specific morphometrics to these motions. Methods: Nine distinctive osseous characteristics in the metatarsal head and phalanx were selected based on their location, geometry, and perceived functional relationship to previous studies describing metatarsal motion as inversion with dorsiflexion. The prevalences of the chosen characteristics were determined in a cohort of 21 randomly selected skeletal specimens, 19 of which were provided by the anatomical preparation office at the University of California, San Diego, and two of which were in the possession of one of us (M.D.). Results: The frequency of occurrence of each selected morphological characteristic in this sample and the relevant summary statistics confirm a strong association between the selected features and a conceptual two-axis kinematic model of the metatarsophalangeal joint. Conclusions: The selected morphometrics are consistent with inversion of the metatarsal around its longitudinal axis as it dorsiflexes. (J Am Podiatr Med Assoc 102(5): 374-389, 2012) Full article

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Performance of the Probe-to-Bone Test in a Population Suspected of Having Osteomyelitis of the Foot in Diabetes

by Mesut Mutluoglu, Gunalp Uzun, Onur Sildiroglu, Vedat Turhan, Hakan Mutlu and Senol Yildiz

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 369-373; https://doi.org/10.7547/1020369 - 1 Sep 2012

Cited by 21 | Viewed by 76

Abstract

Background: We investigated the validity of probe-to-bone testing in the diagnosis of osteomyelitis in a selected subgroup of patients clinically suspected of having diabetic foot osteomyelitis. Methods: Between January 1, 2007, and December 31, 2008, inpatients and outpatients with a diabetic [...] Read more.

Background: We investigated the validity of probe-to-bone testing in the diagnosis of osteomyelitis in a selected subgroup of patients clinically suspected of having diabetic foot osteomyelitis. Methods: Between January 1, 2007, and December 31, 2008, inpatients and outpatients with a diabetic foot ulcer were prospectively evaluated, and those having a clinical diagnosis of foot infection and at least one of the osteomyelitis clinical suspicion criteria were consecutively included in this study. Results: Sixty-five patients met the inclusion criteria and were prospectively enrolled in the study. Forty-nine patients (75.4%) were hospitalized, and the remaining 16 (24.6%) were followed as outpatients. Osteomyelitis was diagnosed in 39 patients (60.0%). Probe-to-bone test results were positive in 30 patients (46.1%). The positive predictive value for the probe-to-bone test was fairly high (87%), but the negative predictive value was only 62%. The sensitivity and specificity of the test were 66% and 84%, respectively. White blood cell counts and mean C-reactive protein levels did not statistically significantly differ between groups. However, erythrocyte sedimentation rates greater than 70 mm/h reached statistical significance between groups. Wound area and depth were not found to be statistically significantly different between groups. Conclusions: Positive probe-to-bone test results and erythrocyte sedimentation rates greater than 70 mm/h provide some support for the diagnosis of diabetic foot osteomyelitis, but it is not strong; magnetic resonance imaging or bone biopsy will probably be required in cases of doubt. (J Am Podiatr Med Assoc 102(5): 369-373, 2012) Full article

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Meta-analysis of Flexor Tendon Transfer for the Correction of Lesser Toe Deformities

by Marta E. Losa Iglesias, Ricardo Becerro de Bengoa Vallejo, Kevin T. Jules and Michael J. Trepal

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 359-368; https://doi.org/10.7547/1020359 - 1 Sep 2012

Cited by 20 | Viewed by 44

Abstract

Transfer of the flexor digitorum longus tendon is one of the surgical techniques described to treat lesser toe deformities. A global analysis of the benefits of this procedure has not been presented in the literature to date. The aim of this meta-analysis was [...] Read more.

Transfer of the flexor digitorum longus tendon is one of the surgical techniques described to treat lesser toe deformities. A global analysis of the benefits of this procedure has not been presented in the literature to date. The aim of this meta-analysis was to evaluate the clinical benefit of transfer of the flexor digitorum longus tendon regarding patient satisfaction. A reviewer formally trained in meta-analysis abstraction techniques searched several databases to identify relevant published studies. Initially, 203 citations were identified and evaluated for relevance. Abstract screening produced 112 articles to be read in their entirety, of which 17 articles studying 515 procedures with a mean ± SD follow-up of 54.21 ± 20.64 months met all of the inclusion criteria necessary for analysis. Overall crude patient satisfaction after flexor digitorum longus tendon transfer was 86.7% (95% confidence interval, 81.7%–90.5%). A low grade of heterogeneity across studies (Q = 24.458, I² =34.583, P = .080) and no influence of the individual studies on overall estimation were found. When adjusting for higher-quality prospective studies, overall patient satisfaction increased to 91.8%, although it did not reach statistical significance. Additional a priori sources of heterogeneity (age, sex, studies with <3 years of follow-up, percentage of patients lost to follow-up, and year of publication) were evaluated by subgroup analysis and meta-regression, but no statistical significance was found. This adjustment also significantly decreased heterogeneity across studies (crude Q = 24.458, high-quality studies Q = 1.504). Regarding patient satisfaction, this comprehensive analysis provides supportive evidence of the clinical benefit of flexor digitorum longus tendon transfer. (J Am Podiatr Med Assoc 102(5): 359–368, 2012) Full article

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Equine Pericardium as a Biological Covering for the Treatment of Diabetic Foot Wounds. A Prospective Study

by Jeffery H. Alexander, David A. Yeager, Dean S. Stern, Carlo A. Messina, Brian J. Griffeth, Elizabeth Pacocha and Mark Barakat

J. Am. Podiatr. Med. Assoc. 2012, 102(5), 352-358; https://doi.org/10.7547/1020352 - 1 Sep 2012

Cited by 5 | Viewed by 50

Abstract

Diabetic foot wounds remain a significant health-care issue. Healing these wounds in a timely manner is of paramount importance because the duration of ulceration correlates with increased rates of infection and amputation, costing billions of dollars yearly. Collagen-based matrices have been used as [...] Read more.

Diabetic foot wounds remain a significant health-care issue. Healing these wounds in a timely manner is of paramount importance because the duration of ulceration correlates with increased rates of infection and amputation, costing billions of dollars yearly. Collagen-based matrices have been used as wound covers and have been shown to improve and expedite healing. We present our experience with equine pericardium biomatrix for the treatment of neuropathic foot wounds. Thirty-four patients with 37 diabetic foot wounds were evaluated at two institutions prospectively. All of the wounds were debrided, and equine pericardium biomatrix was applied. Secondary dressings were changed every 48 to 72 hours until healed or for 12 weeks after application. Healing rate at 12 weeks, time to wound closure, and complications were evaluated. Twenty-two men and 12 women (mean age, 56.9 years) were treated and evaluated. Mean and median wound sizes at initial treatment were 715.8 and 440 mm², respectively. The overall wound healing rate by 12 weeks was 75.7% (n =28). Mean and median times to wound closure were 7.2 and 7.0 weeks, respectively. No device or procedure-related complications were reported. The use of equine pericardium as a temporary biological scaffold is safe and effective for the treatment of chronic neuropathic foot wounds. (J Am Podiatr Med Assoc 102(5): 352–358, 2012) Full article

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J. Am. Podiatr. Med. Assoc., Volume 102, Issue 5 (09 2012) – 13 articles , Pages 352-431

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