Can partial foot prostheses effectively restore foot length?

Our understanding of how partial foot prostheses function stems from static force analyses, where assumptions about the location of the ground reaction force during terminal stance have been made. While such assumptions seemed reasonably based on an understanding of normal gait, they are often illogical based on what is observed clinically. As such, the aim of this work was to evaluate the belief that partial foot prostheses are able to restore the effective foot length. Centre of pressure (CoP) excursion data were collected as part of a complete gait analysis incorporating an Advanced Mechanical Technology Inc. force platform. The CoP excursion patterns, observed in a cohort of eight partial foot amputees and matched control subjects, highlight the inability of toe fillers and slipper sockets to restore the 'effective' foot length in transmetatarsal and Lisfranc amputees, whereas clamshell prostheses fitted to the Chopart amputees were able to restore the effective foot length. In the transmetatarsal and Lisfranc amputees, the observed CoP excursion patterns could indicate a learned gait strategy necessary to reduce the requirement of the weak triceps surae musculature as well as spare the sensitive distal stump from extreme forces. The toe fillers and slipper sockets fitted to these amputees may not be stiff enough to support the amputee's body weight or the device may not be designed appropriately to assist the weakened triceps musculature to resist the external moments caused by loading the forefoot. The clamshell prostheses restored the 'effective' foot length due to the rigid toe lever and clamshell socket, which could allow and comfortably support the generation of substantial external moments during terminal stance.     

Tibial hemimelia with ‘mirror foot’

Mirror foot anomalies are extremely rare forms of duplications of toes. They can be associated with several other anomalies such as mirror hands, fibular dimelia, tibial hypoplasia/aplasia or facial deformities. A case of a mirror foot anomaly in association with an extremely rare variant of tibial hemimelia is presented. Other similar cases in the literature and modern theories regarding the aetiology are also presented.     

The use of ‘off-the-shelf’ foot orthoses in the reduction of foot symptoms in patients with early rheumatoid arthritis

BackgroundFoot pain in patients diagnosed with early rheumatoid arthritis is common.ObjectivesTo investigate effects of off-the-shelf foot orthoses on outcomes of swollen and tender joints, and pain, in patients with early rheumatoid arthritis.MethodsThirty-five patients with painful and swollen foot joints were recruited. None had previously used foot orthoses or had contraindications to their use. Any patients with concomitant musculoskeletal disease, endocrine disorders, and neurological disease, were excluded. At baseline, participants were prescribed a customised off-the-shelf foot orthosis with chair-side modifications. Data was collected at baseline, three and six months. Foot pain (using Visual Analogue Scale) and the number of tender and swollen foot joints was measured.ResultsThere was a trend towards a reduction in the number of swollen and tender joints by 3 months with a further improvement by 6 months. Statistically (p < 0.05) and clinically significant reductions in pain levels were also noted.ConclusionPatients diagnosed with early RA may benefit from using off-the-shelf foot orthoses with the majority of their pain reduction occurring within the first 3 months of use, but with some small further symptomatic improvement up to 6 months. There was a tendency to a reduction in swollen and tender joints although more studies are required to substantiate these findings.     

Correction of ankle and hind foot deformity in Charcot neuroarthropathy using a retrograde hind foot nail—The Kings’ Experience

Background

Corrective fusion for the unstable deformed hind foot and mid foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams.

Diabetic foot disease:From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities

The burden of diabetic foot disease(DFD) is expected to increase in the future. The incidence of DFD is still rising due to the high prevalence of DFD predisposing factors. DFD is multifactorial in nature; however most of the diabetic foot amputations are preceded by foot ulceration. Diabetic peripheral neuropathy(DPN) is a major risk factor for foot ulceration. DPN leads to loss of protective sensation resulting in continuous unconscious traumas. Patient education and detection of high risk foot are essential for the prevention of foot ulceration and amputation. Proper assessment of the diabetic foot ulceration and appropriate management ensure better prognosis. Management is based on revascularization procedures, wound debridement, treatment of infection and ulcer offloading. Management and type of dressing applied are tailored according to the type of wound and the foot condition. The scope of this review paper is to describe the diabetic foot syndrome starting from the evaluation of the foot at risk for ulceration, up to the new treatment modalities.     

Diabetic foot screening: why is it neglected?

Understanding reasons for the neglect of foot screening during the annual review of people with diabetes enables the development of solutions for this omission. This study explores the reasons within the context of health care delivery systems in terms of the professional, social, political and economic aspects of this screening. Information was obtained through reviewing publications on diabetic foot and health care reform. The omission of annual foot examination for people with diabetes is attributed to the nature of diabetes-related foot problems, people with diabetes, health care professionals and the current structure of health care delivery systems. Increasing the adherence to foot screening for those with diabetes requires short- and long-term strategies. Short- and long-term strategies for reminding patients and staff about foot screening are suggested.     

Complex post traumatic foot deformities – Outcomes after corrective surgery

IntroductionComplex posttraumatic foot deformity results in painful foot, altered gait and affects cosmesis. We did a retrospective study on 16 patients to analyse the etiology, types of foot deformity and their outcomes after corrective surgery.MethodsThis retrospective study was done on a consecutive series of patients who underwent corrective surgery for complex post-traumatic foot and ankle deformities. There were 16 patients with 18 foot deformities. The duration of deformity, soft tissues, radiographic changes and measurements, type and anatomic localisation of the deformity determined the surgery needed to correct the deformity.ResultsAmong the 18 foot injuries, 16 were open injuries. Among the type of foot deformity, isolated equinus deformity was seen in 12 feet followed by equinovarus and equinocavovarus in three feet each. Seven patients needed modified footwear. None of the patients required walking aid for ambulation at the end of one year follow up.ConclusionTo conclude, soft tissue injuries were the most common cause of posttraumatic foot deformities compared to bony injuries. Equinus deformity was the commonest deformity. Fifteen patients returned to their preinjury work status.     

The Queensland high risk foot form (QHRFF) – is it a reliable and valid clinical research tool for foot disease?

Background

Foot disease complications, such as foot ulcers and infection, contribute to considerable morbidity and mortality. These complications are typically precipitated by “high-risk factors”, such as peripheral neuropathy and peripheral arterial disease. High-risk factors are more prevalent in specific “at risk” populations such as diabetes, kidney disease and cardiovascular disease. To the best of the authors’ knowledge a tool capturing multiple high-risk factors and foot disease complications in multiple at risk populations has yet to be tested. This study aimed to develop and test the validity and reliability of a Queensland High Risk Foot Form (QHRFF) tool.

Methods

The study was conducted in two phases. Phase one developed a QHRFF using an existing diabetes foot disease tool, literature searches, stakeholder groups and expert panel. Phase two tested the QHRFF for validity and reliability. Four clinicians, representing different levels of expertise, were recruited to test validity and reliability. Three cohorts of patients were recruited; one tested criterion measure reliability (n?=?32), another tested criterion validity and inter-rater reliability (n?=?43), and another tested intra-rater reliability (n?=?19). Validity was determined using sensitivity, specificity and positive predictive values (PPV). Reliability was determined using Kappa, weighted Kappa and intra-class correlation (ICC) statistics.

Results

A QHRFF tool containing 46 items across seven domains was developed. Criterion measure reliability of at least moderate categories of agreement (Kappa?>?0.4; ICC?>?0.75) was seen in 91% (29 of 32) tested items. Criterion validity of at least moderate categories (PPV?>?0.7) was seen in 83% (60 of 72) tested items. Inter- and intra-rater reliability of at least moderate categories (Kappa?>?0.4; ICC?>?0.75) was seen in 88% (84 of 96) and 87% (20 of 23) tested items respectively.

Conclusions

The QHRFF had acceptable validity and reliability across the majority of items; particularly items identifying relevant co-morbidities, high-risk factors and foot disease complications. Recommendations have been made to improve or remove identified weaker items for future QHRFF versions. Overall, the QHRFF possesses suitable practicality, validity and reliability to assess and capture relevant foot disease items across multiple at risk populations.     

The aponeurosis of the “slacksole” of the foot

Summary A case is presented with folded sole of the foot caused by absence of the aponeurosis and hypertrophy of the muscles of the little toe. Operative treatment gave a good result.     

Large foot schwannoma with bone invasion – A case report

A rare case of a large foot schwannoma with an intraosseous component is presented. Due to suspicion of malignancy, an amputation had previously been proposed. When the patient presented to us, the prolonged clinical course as well as some elements of the imaging exams suggested benignancy and we decided for complete tumor excision. Intraoperative findings supported the benign character of the neoplasm and pathology would later confirm the diagnosis of a benign schwannoma. The outcome, at 18 months of follow-up was a fully functional limb. Recurrence must still be considered but malignant transformation is very rare in a solitary schwannoma and can be discounted.Solitary benign schwannomas have a negligible malignization potential independently of their size or osseous component. When benignancy is considered, primary total tumor excision, as part of a staged procedure, is a safe approach. It allows for a thorough pathologic examination and eventually for a definitive treatment.     

Débridement and primary closure of nonhealing foot wounds

Fifty-eight chronic nonhealing foot wounds (51 patients) were treated with irrigation, aggressive débridement, and primary tension-free closure. Factors such as wound location, wound size, presence of infection, and healing outcome were recorded. In addition, medical comorbidities and preoperative laboratory test results were reviewed. Thirty-seven (64%) of the 58 wounds healed after primary closure. Of the other 21 wounds, 16 healed after repeat irrigation, debridement, and closure or local wound care; 2 patients were lost to follow-up after initial failed wound healing, 1 patient died after initial failed wound healing, and 2 cases were salvaged with amputation. Failed primary closures were thought not to increase wound size; all but 3 of these closures decreased wound size significantly. Differences between the wounds that healed primarily and the wounds that failed healing were not statistically significant. Diabetes was present in 46% of the patients whose wounds healed primarily versus 71% of the patients whose wounds failed healing (P = .06). Irrigation, débridement, and primary closure of nonhealing foot wounds can be a useful treatment option for most such patients. Complete healing or reduced wound size occurs in 95% of cases.