Issue 16:
Gaenslen’s Split Heel Incision for Calcaneal Osteomyelitis: A case report
Podiatry Internet Journal
ORIGINAL ARTICLE: Patients who have a recurrent ulcer of the heel often have a below-the-knee amputation because durable soft tissue coverage cannot be obtained over the calcaneus. Often, even if the ulcer heals satisfactorily or the area appears to be revascularized as a result of a peripheral vascular procedure, the resulting surface is not durable and the ulcer recurs. We report a 40 year old lady who had a chronic osteomyelitis right calcaneum with a large non-healing ulcer and discharging sinus, treated by split heel incision of Gaenslen.
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Gait rehabilitation machines based on programmable footplates
Journal of Neuroengineering and Rehabilitation
ORIGINAL ARTICLE: Gait restoration is an integral part of rehabilitation of brain lesioned patients. Modern concepts favour a task-specific repetitive approach, i.e. who wants to regain walking has to walk, while tone-inhibiting and gait preparatory manoeuvres had dominated therapy before. Following the first mobilization out of the bed, the wheelchair- bound patient should have the possibility to practise complex gait cycles as soon as possible. Steps in this direction were treadmill training with partial body weight support and most recently gait machines enabling the repetitive training of even surface gait and even of stair climbing.
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Review: Adjunctive hyperbaric oxygen for diabetic foot ulcer
NELM
ORIGINAL ARTICLE: The Canadian Agency for Drugs and Technologies in Health (CADTH) has issued a review of adjunctive hyperbaric oxygen therapy (HBOT) for diabetic foot ulcer (DFU). Use of HBOT is thought to increase the success of healing DFU, and decrease the risk of infection and lower extremity amputation (LEA). The review examined controlled studies that compared adjunctive HBOT for DFU with standard wound care and reported the following findings:
• Adjunctive HBOT for DFU is more effective than standard care alone.
• The proportion of major LEAs can decrease from 32% among patients receiving standard care to 11% among those receiving adjunctive HBOT.
• There was a decrease in the proportion of unhealed wounds with HBOT; the reverse was true for minor LEAs.
• HBOT for DFU is cost effective compared with standard care in Canada.
Evidence-based medicine among internal medicine residents in a community hospital program using smart phones
BMC Medical Information and Decision Making
ORIGINAL ARTICLE: This article could have a real impact on the way we treat patients and access information. The use of smart phones could also be implimented in Podiatry Residency Programs. This study implemented and evaluated a point-of- care, wireless Internet access using smart phones for information retrieval during daily clinical rounds and academic activities of internal medicine residents in a community hospital. We did the project to assess the feasibility of using smart phones as an alternative to reach online medical resources because we were unable to find previous studies of this type. In addition, we wanted to learn what Web-based information resources internal medicine residents were using and whether providing bedside, real-time access to medical information would be perceived useful for patient care and academic activities.
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Knowledge of pressure ulcer prevention: A cross-sectional and comparative study among nurses
BMC Nursing
Original article: Pressure ulcers are a common, painful and costly condition. Results of a 1991 study into the knowledge among Dutch hospital nurses, on the usefulness of preventive measures for pressure ulcers, showed moderate knowledge. Results were confirmed by subsequent studies. In recent years Dutch guidelines have been updated and the attention given to pressure ulcer care has been increased. The attention was expected to improve pressure ulcer care and to increase nurses knowledge. Aims of current study were to investigate (1) how much nurses employed in Dutch hospitals know about the usefulness of 28 preventive measures considered in the most recent national pressure ulcer guideline; (2) whether differences in knowledge exist between nurses working in hospitals that audit pressure ulcers and those employed in hospitals that do not; and (3) to study whether knowledge among Dutch hospital nurses regarding the usefulness of preventive measures had changed between 1991 and 2003.
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The Foot Blog News this Week
The Foot Blog
Issue 11:
- Current Opinion in Orthopaedics Highlights Foot Related Articles this Month
- New Peptide Boosts Body’s Own Immunity Against MRSA, VRE and Salmonella
- Oculus Announces Initial Sites for Phase II Clinical Trial of Microcyn® Technology in Treatment of Mild Diabetic Foot Infections
- Pfizer Issues DrugWarning for Zyvoxx®
- Inimex Product Candidate Is First Immune Defense Regulator To Cure Infections Without Causing Harmful Inflammation
- Advancis Pharmaceutical Resubmits New Drug Application For Once-Daily Amoxicillin PULSYS
- MRI Drives Magnetic Beads (Not Robots) Through Arteries
- GlaxoSmithKline Announces Altargo® Receives Positive Opinion In Europe For Treatment Of Impetigo And Other Skin Infections
- FDA Extends Marketing Exclusivity For LEVAQUIN®
- Diabetic News This Week
Podiatry Today ENews
Volume 5, Issue 8
Key Insights On Treating Hallux Limitus
By Justin Franson, DPM, and Babak Baravarian, DPMHallux limitus, by definition, is a decrease in sagittal plane dorsiflexion of the hallux at the first metatarsophalangeal joint (MPJ) when the foot is in a weightbearing or simulated weightbearing position. With this in mind, let us take a closer look at the treatment approaches to this condition.Current Concepts In Treating Ischemic Foot Ulcers
Clinical Editor: Lawrence Karlock, DPMWhen it comes to patients with ischemic foot ulcers, potential complications can be dire. Accordingly, it is important to have a firm grasp on diagnostic studies as well as current and emerging treatment options that may enhance outcomes for patients.New Bone Growth Stimulator Offers Treatment For Nonunion Fractures
By Aaron Becker, Special Projects Editor When it comes to patients with ischemic foot ulcers, potential complications can be dire. Accordingly, it is important to have a firm grasp on diagnostic studies as well as current and emerging treatment options that may enhance outcomes for patients.
Podiatry Related Abstracts this Week
Entrez Pub Med, Wiley Interscience, Ingenta Connect, Blackwell Synergy and more . . .
- Early Clubfoot Recurrence After Use of the Ponseti Method in a New Zealand PopulationJBJS
- Vascular Anatomy of Plantar MusclesAnnals of Plastic Surg
- The Diabetic Foot: Perspectives From Chennai, South IndiaThe Int J of Lower Ext Wounds
- Ponseti’s vs. Kite’s method in the treatment of clubfoot-a prospective randomised study Int Ortho
- The Versatility of the Distally Based Peroneus Brevis Muscle Flap in Reconstructive Surgery of the Foot and Lower Leg Annals of Plastic Surg
- Multifocal Spectacles Increase Variability in Toe Clearance and Risk of Tripping in the ElderlyInv Opth and Vis Sc
- Endoscopic calcaneoplasty (ECP) as a surgical treatment of Haglund’s syndrome Knee Surgery, Sports Traumatology, Arthroscopy
- Clinical Outcomes of Wide Postsurgical Lesions in the Infected Diabetic Foot Managed With 2 Different Local Treatment Regimes Compared Using a Quasi- Experimental Study Design: A Preliminary CommunicationJ LOW EXTREM WOUNDS
- The Development and Application of Diabetic Foot Protocol in Chiang Mai University Hospital With an Aim to Reduce Lower Extremity Amputation in Thai Population: A Preliminary CommunicationJ LOW EXTREM WOUNDS
- Optimal Organization of Health Care in Diabetic Foot Disease: Introduction to the Eurodiale StudyJ LOW EXTREM WOUNDS
- Growth Factors in the Treatment of Diabetic Foot Ulcers: New Technologies, Any Promises?J LOW EXTREM WOUNDS
- Empirical therapy for diabetic foot infections: are there clinical clues to guide antibiotic selection?Clin Micro and Infection
- DIABETIC FOOT INFECTIONS IN OLDER PEOPLE WITH END-STAGE RENAL DISEASE: PRIMARY AMPUTATION VERSUS “FOOT- SPARING SURGERY”J Am Geriatrics
- Brown tumor with atypical localization in a normocalcemic patient Arch of Ortho Research & Trauma Surg
- A case of isolated giant plexiform neurofibroma involving all branches of the common peroneal nerve Arch of Ortho Research & Trauma Surg
- Free Fibula Donor-Site Morbidity: Clinical and Biomechanical Analysis.Annals of Plastic Surg
- Sirolimus impairs wound healing Lang Arch of Surg
- The Internet and the diabetic foot: quality of online information in French language.Diab Metab
- Forefoot adductus correction in clubfoot deformity with cuboid-cuneiform osteotomy: a retrospective analysisJAPMA
- Effect of seasonality and weather on fracture risk in individuals 65 years and older Osteoporosis Journal
© Podiatry Internet Communications (PICOMM)
ORIGINAL ARTICLE: Vancomycin has been implicated as a cause of thrombocytopenia since 1990. In a recent report of The New England Journal of Medicine, the BloodCenter of Wisconsin has identified Vancomycin-Dependent, Platelet-Derived antibodies to detect Vancomycin induced thrombocytopenia. In this case report, a 65-year old male was treated with Vancomycin for osteomyelitis. On the 10th day of treatment, he had a fever and developed a rash. Angiopathic petechiae were most pronounced on his back and arms. His platelet count dropped from 189 x 103/mm3 to 1 x 103/mm3 in 48 hours. This case report supports the use of drug- dependent antibody assays to identify and confirm the cause of thrombocytopenia in patients who show a precipitous drop in platelet levels while receiving Vancomycin. 
ORIGINAL ARTICLE: A case report discusses the presentation and treatment of a baby boy with club foot deformity. The baby was initially treated by Ponseti’s method of weekly POP casting. The club foot did not reduce after 6 weeks of serial casting. The boy then underwent percutaneous Achilles tendon lengthening and placed in a Steinbek Splint. After 12 weeks, the equinus persisted and we decided to perform an open Achilles lengthening. An aberrant tendoachilles tendon was discovered during open tenotomy and this was released. Once the aberrant tendon was released, the club foot reduced and at 9 months, the baby could walk with good heel strike and the foot was supple with no residual deformity. 
ORIGINAL ARTICLE: A mycological study of onychomycosis was undertaken in 88 patients. The nails were judged to be infected by their clinical appearance. Direct microscopy of the nail clips in 20% KOH solution was positive in 72 (81.8%) and culture was positive in 43 (48.8%) cases. Out of the samples cultured, dermatophytes were grown in 26 cases (29.5%), non dermatophyte moulds in 12 (13.6%) and Candida spp. in 5 (5.6%) while 45 (51.1%) samples yielded no growth. Amongst dermatophytes, T. rubrum was found to be commonest etiological agent (57.6%) followed by T. mentagrophyte . Amongst the non- dermatophyte mould (NDM), Aspergillus spp. was the most prevalent species followed by Alternaria spp, Curvularia spp. and Fusarium spp. Commonest age group affected was above 31 years. Males were predominantly affected (65%), male to female ratio being 1.8:1. Fingernails were affected more frequently than toe nails with the ratio of 3:1. Distal and lateral subungual onychomycosis (DLSO) was more common (50%) than other clinical pattern followed by proximal subungual onychomycosis (PSO) (20.4%), white superficial onychomycosis (SWO) (2%), total dystrophic onychomysosis (TDO) (14%) and paronychia (10.2%). 
ORIGINAL ARTICLE: Pedometers offer researchers a convenient and inexpensive tool for objective measurement of physical activity. However, many unanswered questions remain about expected values for steps/day for different populations, sources of variation in the data, and reliability of pedometer measurements. 
Original article: Search criteria identified 24 new studies since the previous review, 8 of which fulfilled the inclusion criteria. In addition, 4 of the 12 studies included in the original 2000 review were excluded. Three were excluded as a result of insufficient indication of subject or group randomization or quasirandomization, and the fourth excluded study included subjects with the diagnosis of medial tibial stress syndrome. Overall, 16 studies were included. The authors of 13 studies focused on prevention, and 3 groups evaluated the treatment of stress fractures and reactions. The average number of subjects for prevention and treatment studies, respectively, was 1091 (range = 206 to 3025) and 34 (range = 21 to 60). All 13 prevention studies involved military personnel who performed physical training over a 9-to-14–week period. Quality assessment scores for prevention studies ranged from 4 to 10 (mean score = 7). In 9 prevention studies, the effectiveness of insoles or orthoses was evaluated, and the QAS for these studies ranged from 4 to 9 (mean = 6.2). The investigators in 4 studies assessed “shock- absorbing” insoles or orthoses in shoes or boots versus a control (shoes or boots alone), and an additional 5 groups compared insoles and orthoses against one another. One study’s authors also evaluated military training in a modified high-top shoe versus standard military boots (QAS = 8). Two groups assessed the influence of pre-exercise stretching (QAS = 8 and 9, respectively), and one investigated the effects of calcium supplementation (QAS = 10). 
ORIGINAL ARTICLE: The outcome after displaced intra-articular calcaneal fractures is influenced by the condition of the surrounding soft tissues. To avoid secondary soft tissue complications after surgical treatment, several less-invasive procedures for reduction and fixation have been introduced. The percutaneous technique according to Forgon and Zadravecz is suitable for all types of displaced intra-articular calcaneal fractures and was therefore introduced in our clinic. The aim of this study was to evaluate the long-term outcome of percutaneous treatment according to Forgon and Zadravecz in patients with displaced intra-articular calcaneal fractures. 
ORIGINAL ARTICLE: Dr. Mary Elizabeth Crawford discusses the management of frequently encountered surgical complications. An in-depth discussion is presented that covers basic pre- surgical considerations of surgery to various post- operative infectious complications. Bleeding complications, seroma formation, hematoma formation, wound dehiscence, tissue necrosis, post- operative edema , scar formation, how to manage post-operative infections and life-threatening complications are all discussed in this informative article. 
ORIGINAL ARTICLE: Erythema nodosum, a painful disorder of the subcutaneous fat, is the most common type of panniculitis. Generally, it is idiopathic, although the most common identifiable cause is streptococcal pharyngitis. Erythema nodosum may be the first sign of a systemic disease such as tuberculosis, bacterial or deep fungal infection, sarcoidosis, inflammatory bowel disease, or cancer. Certain drugs, including oral contraceptives and some antibiotics, also may be etiologic. The hallmark of erythema nodosum is tender, erythematous, subcutaneous nodules that typically are located symmetrically on the anterior surface of the lower extremities. Erythema nodosum does not ulcerate and usually resolves without atrophy or scarring. Most direct and indirect evidence supports the involvement of a type IV delayed hypersensitivity response to numerous antigens. A deep incisional or excisional biopsy specimen should be obtained for adequate visualization. Erythema nodosum represents an inflammatory process involving the septa between subcutaneous fat lobules, with an absence of vasculitis and the presence of radial granulomas. Diagnostic evaluation after comprehensive history and physical examination includes complete blood count with differential; erythrocyte sedimentation rate, C- reactive protein level, or both; testing for streptococcal infection (i.e., throat culture, rapid antigen test, antistreptolysin-O titer, and polymerase chain reaction assay); and biopsy. Patients should be stratified by risk for tuberculosis. Further evaluation (e.g., purified protein derivative test, chest radiography, stool cultures) varies based on the individual. Erythema nodosum tends to be self-limited. Any underlying disorders should be treated and supportive care provided. Pain can be managed with nonsteroidal anti- inflammatory drugs. 
Original Article: Dr. Edwin Harris discusses fractures and dislocations most commonly seen in the pediatric patient. Growth plate injuries, open fractures, closed fractures, manual closed reductions, reduction by traction and open reduction of fractures are discussed. Treatment discussion is highlighted of various fractures including intra- articular, comminuted fractures, open fractures, traumatic penetrating injuries, dislocation injuries and mal-alignement fractures. 
Original article: It is not clear whether bone turnover markers can be used to make inference regarding changes in bone mineral density (BMD) in untreated healthy elderly men. The present study was designed to address three specific questions: (i) is there a relationship between bone turnover markers and femoral neck BMD within an individual; (ii) is there a relationship between baseline measurements of bone turnover markers and subsequent change in BMD; and (iii) is there a relationship between changes in bone turnover markers and changes in femoral neck BMD? 
ORIGINAL ARTICLE: Staphylococcus simulans, a coagulase-negative pathogen, is not commonly seen in the foot. The pathogen has been isolated in chronic osteomyelitis and infected internal fixation. This case describes a 65 year old, diabetic male with recalcitrant osteomyelitis following partial metatarsal head resection. Staphylococcus simulans was the primary pathogen isolated. This may be the first reported case of Staphylococcus simulans osteomyelitis of the foot. 
ORIGINAL ARTICLE: We report on a 77-year old women with a history of peripheral vascular disease who presented with an acute-onset tender blue toe and deteriorating renal function. A clinical diagnosis of blue-toe syndrome was made but the patient deteriorated rapidy and died. This case demonstrates the rapidly devastating nature and fatality of blue toe syndrome. There is no effective treatment for this condition.
ORIGINAL ARTICLE: Braces and splints can be useful for acute injuries, chronic conditions, and the prevention of injury. There is good evidence to support the use of some braces and splints; others are used because of subjective reports from patients, relatively low cost, and few adverse effects, despite limited data on their effectiveness. The unloader (valgus) knee brace is recommended for pain reduction in patients with osteoarthritis of the medial compartment of the knee. Use of the patellar brace for patellofemoral pain syndrome is neither recommended nor discouraged because good evidence for its effectiveness is lacking. A knee immobilizer may be used for a limited number of acute traumatic knee injuries. Functional ankle braces are recommended rather than immobilization for the treatment of acute ankle sprains, and semirigid ankle braces decrease the risk of future ankle sprains in patients with a history of ankle sprain. A neutral wrist splint worn full-time improves symptoms of carpal tunnel syndrome. Close follow-up after bracing or splinting is essential to ensure proper fit and use.
ORIGINAL ARTICLE: Venous malformations are one of the commonest anomalies of the vascular tree and their management has always remained a major challenge. Surgery and other treatment modalities are not always satisfactory and have a higher morbidity, recurrence and complication rate. The author retrospectively analyzed 40 patients of venous malformations who underwent sclerotherapy with sodium tetradecyl sulfate solely or as an adjunct to surgery. The purpose of the study was to evaluate the efficacy and safety of sodium tetradecyl sulfate sclerotherapy in the treatment of venous malformations. 
PODIATRY IN PRACTICE: VA System Has Excellent Care For Vets, Advantages For DPMs. Jeffrey Robbins, DPM, notes, the Veterans Health Administration (VA) is the benchmark in the care of many chronic diseases, including diabetes and amputation prevention. Point-Counterpoint: Should You Cover MRSA? Given the increasing incidence of methicillin- resistant Staphylococcus aureus, Guy R. Pupp, DPM, and Mark A. Kachan, DPM say one should consider empiric coverage against MRSA in high-risk patients with infected ulcerations in the lower extremity. Not necessarily. Warren S. Joseph, DPM, says the current evidence does not support routine coverage of MRSA in the bulk of uncomplicated skin and skin structure infections of the lower extremity. A Guide To Surgical Offloading In The Neuropathic Foot. It can be a challenge to offload the neuropathic foot while avoiding further ulceration. Accordingly, these authors discuss common pedal ulcerations in the neuropathic foot and offer key insights on treating these ulcerations via surgical offloading procedures. 
Writing articles in podiatry can bring back bad memories for many of us. You remember that paper we had to write before graduating from residency. Or the paper that was due for externship. For most of us, it was a laborious task. If you were lucky enough to have something worthwhile to write about, it usually meant hours spent in the library on research and reading historical articles. Most of us, however, had very little to write about and this made for an even more daunting task. 
ORIGINAL ARTICLE: Plantar heel ulcers are common in the diabetic patient. Very often, the ulcers can become chronic and resistant to closure through conservative means. A case is presented describing the presentation, clinical work up and surgical management to promote closure of the plantar heel ulcer. The Midas Rex pneumatic burr is used to perform a plantar calcaneal saucerization and promote rapid closure of a chronic ulcer. 
ORIGINAL ARTICLE: Achilles tendinopathy is understood to be a failed healing response. Operative management is utilised following the failure of non- operative methods. A case of Achilles tendon rupture is presented, sustained whilst isometrically loading the Achilles tendon during an eccentric loading exercise programme. Conclusions: Bilateral surgical exploration and debridement had previously been performed after conservative management of bilateral Achilles tendinopathy had been unsuccessful.
ORIGINAL ARTICLE: An examination of the feet is an essential component of an evaluation of a newborn. A thorough examination can be performed quickly. Despite its small size, the newborn foot is a complex structure. Most deformities can be diagnosed easily with physical examination alone, using few diagnostic studies. A thorough examination includes assessment of vascular, dermatologic, and neurologic status of the lower extremities, and observation, palpation, and evaluation of joint range of motion in both feet. Common newborn foot abnormalities include metatarsus adductus, clubfoot deformity, calcaneovalgus (flexible flatfoot), congenital vertical talus (rigid flatfoot), and multiple digital deformities–polydactyly, syndactyly, overlapping toes, and amniotic bands. Most treatments include conservative measures, such as observation, stretching, and splinting, which can be performed easily in the family medicine setting. Cases that require surgical correction should be referred to a subspecialist with expertise in correcting lower extremity deformities in children. When surgery is indicated, procedures generally are postponed for six to nine months so that the child will better tolerate anesthesia. (Am Fam Physician 2004;69:865-72.) 
Original Article: Chiropractors use a variety of supine and prone leg checking procedures. Some, including the Allis test, purport to distinguish anatomic from functional leg length inequality. Although the reliability and to a lesser extent the validity of some leg checking procedures has been assessed, little is known on the Allis test. The present study mathematically models the test under a variety of hypothetical clinical conditions. In our search for historical and clinical information on the Allis test, nomenclatural and procedural issues became apparent. 
