Applicant perception and content exploration of the 2024 podiatric residency interview process.

Considerable resources are dedicated on an annual basis to the podiatric medicine and surgery residency interview by both students and programs. Despite this, relatively little is known about student perception of the process, nor the format and content of interview. The objective of this investigation was to study and organize experiences of fourth-year podiatric medical students following the 2024 Centralized Residency Interview Program (CRIP) process. An anonymous and voluntary survey was developed and made available to fourth year podiatric medical students. It was relatively common for there to be academic, social/personal, case work-up, and rapid-fire academic question components to the interview. It was also very common to be provided with the opportunity to ask programs questions. It was relatively uncommon for there to be ethical/moral questions, personality/psychologic assessments, logic assessments and hands-on demonstrations. The most common hands-on demonstrations were suturing, hand ties and performance of fixation principles. Relatively high yield academic topics included plain film radiography interpretation, rearfoot/ankle osseous trauma, diabetic foot infection, advanced imaging interpretation, and fixation constructs/principles. When evaluating programs, students placed high value on surgical volume, surgical variety, relative resident autonomy, program location, exposure to outpatient clinics, salary, future connections as a program alumnus, unique off-service rotations, exposure to business management/coding/billing, scope of practice, exposure to inpatient management, resident salary, and who the senior co-residents would be. The results of this investigation provide unique information for both medical students and residency programs with respect to the perception, format and content of the podiatric residency interview process. Level of Evidence: 5 (survey).

A Comparison of Adverse Short-Term Outcomes After Forefoot Amputation Based on Patient Height.

BACKGROUND: The objective of this investigation was to evaluate adverse short-term outcomes after partial forefoot amputation with a specific comparison performed based on patient height. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to select patients with a 28805 Current Procedural Terminology code (amputation, foot; transmetatarsal) who underwent the procedure with "all layers of incision (deep and superficial) fully closed." This resulted in 11 patients with a height of 60 inches or less, 202 with a height greater than 60 inches and less than 72 inches, and 55 with a height of 72 inches or greater. RESULTS: Results of the primary outcome measures found no significant differences among groups with respect to the development of a superficial surgical site infection (0% versus 6.4% versus 5.5%; P = .669), deep incisional infection (9.1% versus 3.5% versus 10.9%; P = .076), or wound disruption (0% versus 5.4% versus 5.5%; P = .730). In addition, no significant differences were observed among groups with respect to unplanned reoperations (9.1% versus 16.8% versus 12.7%; P = .630) or unplanned hospital readmissions (45.5% versus 23.3% versus 20.0%; P = .190). CONCLUSIONS: The results of this investigation demonstrate no differences in short-term adverse outcomes after partial forefoot amputation with primary closure based on patient height. Although height has previously been described as a potential risk factor in the development of lower-extremity pathogenesis, this finding was not observed in this study from a large US database.

Basic Statistics, Statistical Design, and Critical Analysis of Statistics for Surgeons.

Statistics is a set of tools used in medical decision-making no different than how a scalpel or a sagittal saw is used in the operating room. No foot and ankle surgeon is born with the inherent ability to perform, understand, and critically interpret them. Instead, it requires training and practice throughout the course of a career in medicine to develop a working proficiency. This article reviews the basic indications and interpretation of common descriptive and comparative statistical tests in the podiatric literature. Additionally, the concept of which tests are most appropriate for which investigational methodologies is introduced.

A Study Never Proves Anything: Contemporary Interpretation of the Levels of Clinical Evidence and Statistical Significance.

Critical analysis of the medical literature and an evidence-based approach to clinical practice and medical decision-making is of vital importance in contemporary podiatric practice. This article reviews the levels of clinical evidence and their application within this paradigm. This includes determining which level of evidence is most appropriate for a given methodology, as well as an appreciation of inherent limitations within each level of evidence. The article concludes with a discussion on the difference between statistical significance and clinical significance.

Special Considerations in Podiatric Science: Translational Research, Cadavers, Gait Analysis, Dermatology, and Databases.

The objective of this article is to provide a brief overview of the critical analysis and design of unique and perhaps less common methodologies in podiatric science. These include basic science translational designs, cadaveric investigations, gait analyses, dermatologic studies, and database analysis. The relative advantages, disadvantages, and inherent limitations are reviewed with an intention to improve the interpretation of results and advance future foot and ankle scientific endeavors.

Morbidity and Mortality of the Transmetatarsal Amputation: A Comparative NSQIP Analysis.

The objective of this investigation was to compare the morbidity and mortality of transmetatarsal amputation to other frequently performed surgical procedures utilizing a large US database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated for the purposes of this investigation. We initially extracted data related to the Current Procedural Terminology (CPT) code 28805 (amputation, foot; transmetatarsal) and the variable labels "estimated probability of morbidity" and "estimated probability of mortality." We subsequently performed a CPT code search for those procedures occurring at a frequency greater than 10,000 in the database, and additionally extracted data for estimated probability of morbidity and estimated probability of mortality for these procedures. This resulted in identification of 17 additional procedures. CPT code 28805 was associated with the highest estimated probability of morbidity of the cohort (0.1360 ± 0.0669), and this demonstrated statistical significance higher than all other CPT codes (p < .001). CPT code 28805 was associated with the second-highest estimated probability of mortality of the cohort (0.0327 ± 0.0596). This demonstrated statistical significance less than that of CPT code 27245 (0.0327 ± 0.0596 vs 0.0547 ± 0.0661; p < .0001), but statistical significance higher than all other CPT codes (p<0.001). The results of this investigation indicate that transmetatarsal amputation carries a substantial risk for morbidity and mortality in comparison to other commonly performed surgical procedures.

Minor and Major Amputation Rates Following Midfoot Charcot Reconstructive Surgery.

Charcot neuroarthropathy (CNA) is a progressive disease that affects the bones and joints of the foot. To prevent collapse and loss of stability within the pedal architecture, CNA should be diagnosed and managed early. The objective of this retrospective study was to review patients who underwent midfoot CNA reconstructive surgery and evaluate subsequent rates of minor and major amputations. Secondary objectives include identifying patients that underwent midfoot CAN with and without a subtalar joint (STJ) arthrodesis. Out of the 72 patients, 4 (5.6%) underwent minor (digital, ray) amputation, 2 (2.8%) underwent proximal amputations (either below or above the knee), and none underwent midfoot amputation (transmetatarsal, Lisfranc, Chopart). A Fisher's exact test was employed to compare the outcomes of minor and major amputation rates in our CNA cohort with those who underwent midfoot CNA reconstruction with STJ arthrodesis and found no statistical significance (p = .15). Overall, a total progression to amputation was 8.4% following midfoot CNA reconstruction, with 2.8% of patients undergoing major amputation (below knee or above knee). Despite no statistical significance, we recommend surgeons to consider including an STJ arthrodesis in addition to midfoot CNA reconstruction to establish a stable and plantigrade foot.

Correlation Analysis Between Clinical Hypermobility Measurement and Radiographic Parameters of the Hallux Valgus Deformity.

The finding of "hypermobility" has conventionally been considered as a dichotomous categorical variable in both clinical practice and in the literature. In other words, it is defined as being either "present" or "absent" in patients with hallux valgus. Yet it might be far more likely that this represents a continuous variable described by a bell-shaped distribution. Therefore the objective of this investigation was to consider hypermobility as a continuous variable, and to compare the sagittal plane first ray motion to radiographic parameters commonly used in the evaluation of the hallux valgus deformity by means of correlation analyses. The radiographs and measurements of 86 feet were included and measurement of sagittal plane first ray motion was performed with the validated Klaue device. No statistically significant correlation was observed between the total first ray motion with the first intermetatarsal angle (Pearson correlation coefficient 0.106; p = .333), hallux valgus angle (Pearson correlation coefficient -0.106; p = .330), nor sesamoid position (Pearson correlation coefficient 0.155; p = .157). The results of this investigation uniquely consider measurement of hypermobility as a continuous variable, and find no correlation between first ray sagittal plane motion and radiographic parameters associated with the hallux valgus deformity. These results might indicate that although the concept of hypermobility has traditionally been coupled with presentation of the hallux valgus deformity, this might simply represent the result of a historical confirmation bias.

Progression to Hindfoot Charcot Neuroarthropathy After Midfoot Charcot Correction in Patients With and Without Subtalar Joint Arthrodesis.

Charcot neuroarthropathy (CNA) is a disabling and progressive disease that affects the bones and joints of the foot. Successful Charcot reconstruction focuses on restoring anatomic alignment, obtaining multiple joint arthrodesis, selecting stable fixation, preserving foot length, and creating a foot suitable for community ambulation in supportive shoegear. Intramedullary fixation arthrodesis of the medial and lateral columns has been previously reported to produce improvement in midfoot Charcot reconstruction. More recently, a growing trend of stabilization of the subtalar joint (STJ) has been incorporated alongside the medial and lateral column fusion. Our objectives were to retrospectively review patients who underwent midfoot Charcot reconstructive surgery, whether with or without accompanying STJ arthrodesis, and establish which patients progressed to ankle CNA. Of the 72 patients who underwent midfoot Charcot reconstruction, 28 (38.9%) underwent STJ arthrodesis, and 22 converted to ankle CNA (30.6%). Fourteen (63.6%) of 22 ankle CNA cases had not undergone STJ arthrodesis; 8 patients (36.4%) had it. A Fisher exact test was performed to identify the relationship between those without STJ arthrodesis and those progressing to ankle CNA; it revealed statistical significance (p = .001). Performing an STJ arthrodesis with midfoot Charcot reconstructive surgery may be beneficial to aiding in hindfoot stability, establishing a plantigrade foot, and providing further insight into the management of midfoot Charcot.

The Role of Equinus in Flatfoot Deformity.

Equinus plays an important role in flatfoot deformity. Proper evaluation and surgical management are critical to comprehensively treat and successfully resolved patients' symptoms. We have discussed the cause, evaluation, and some of the common surgical options. Each procedure has its inherent benefits and risks. It is imperative that the foot and ankle surgeon identify and include these procedures as part of the complete reconstructive surgery.

Factors Associated With Successful Closed Reduction of Dislocated Ankle Fractures at a US Level-1 Trauma Center.

Dislocated ankle fractures represent a common presenting pathology at US emergency departments, and several different procedural and anesthetic techniques are employed for attempted closed reduction of these injuries. The objective of this investigation was to evaluate the frequency of and factors associated with success in the closed reduction of dislocated ankle fractures. A diagnostic code search produced 1050 ankle fractures presenting to an urban US level-1 emergency department. These medical records were interrogated and first categorized into whether or not a closed reduction was attempted. Those identified closed reduction attempts were further categorized into whether the attempt was successful. A comparative analysis was subsequently performed of variables associated with procedure success. Of the 1050, 97 (9.2%) required closed reduction and of these, 76 (78.4%) were successfully closed reduced on the first attempt. No differences were observed in initial procedure success with respect to subject age (p = .701), subject gender (p = .623), fracture laterality (p = 1.00), open versus closed injuries (p = .282), fracture mechanism (p = 1.00), utilized anesthetic technique (p value range 0.291-0.616), or the specialty performing the reduction (p-value range 0.402-1.00). A descriptive subanalysis was performed on those fractures with an unsuccessful first closed reduction attempt. It is our hope that this investigation adds to the body of knowledge with respect to a commonly performed procedure by foot and ankle surgeons.

Multiplanar, Multivariate Analyses of Hallux Valgus Radiographic Parameters.

Hallux valgus is a complex condition understood to involve pathomechanics in all 3 of the cardinal planes. Despite this, the bulk of its historical evaluation has been in the transverse plane, and one might argue that the traditional and more commonly performed univariate and bivariate analyses within the literature do not comprehensively describe the potential interrelationships between the planes during perioperative assessment. Therefore this investigation aimed to evaluate relationships between common radiographic parameters measured in the three cardinal planes by means of a multivariate regression analysis. Serial analyses utilizing the first intermetatarsal angle, hallux valgus angle, tibial sesamoid position, proximal articular set angle, Engel's angle, first metatarsal inclination angle, and the sesamoid rotation angle were performed with varying dependent and independent variables. The tibial sesamoid position (p < .001) and proximal articular set angle (p = .014) were found to be independently associated with the first intermetatarsal angle, while the hallux valgus angle (p = .712), Engel's angle (p = .646), first metatarsal inclination angle (p = .097), and sesamoid rotation angle (p = .099) were not. The tibial sesamoid position (p = .003), proximal articular set angle (p < .001), Engel's angle (p = .006), and sesamoid rotation angle (p = .003) were found to be independently associated with the hallux valgus angle, while the first intermetatarsal angle (p = .712) and first metatarsal inclination angle (p = .400) were not. The first intermetatarsal angle (p < .001), hallux valgus angle (p = .003), and proximal articular set angle (p = .015) were found to be independently associated with the tibial sesamoid position, while Engel's angle (p = .400), the first metatarsal inclination angle (p = .088), and the sesamoid rotation angle (p = .649) were not. These findings appear to question a direct relationship between the first intermetatarsal angle and hallux valgus angle, as well as potentially infer a relationship between the frontal plane with the hallux valgus angle.

Comparative Radiographic Analysis of the Width of the Lesser Digit Proximal Phalangeal Heads.

BACKGROUND: Digital deformities represent a common presenting abnormality and target for surgical intervention in podiatric medicine and surgery. The objective of this investigation was to compare the radiographic width of the heads of the lesser digit proximal phalanges. METHODS: One hundred fifty consecutive feet with a diagnosis of digital deformity and performance of weightbearing radiographs were analyzed. The maximum width of the heads of the lesser digit proximal phalanges were recorded from the radiographs using computerized digital software. RESULTS: The mean ± standard deviation of the head of the second digit proximal phalanx was 9.74 ± 0.87 mm (range, 7.94-11.78 mm); the head of the third digit proximal phalanx, 9.00 ± 0.91 mm (range,7.27-10.94 mm); the head of the fourth digit proximal phalanx, 8.49 ± 1.01 mm (range, 5.57-10.73 mm); and the head of the fifth digit proximal phalanx, 8.67 ± 0.89 mm (range, 6.50-11.75 mm). The width of the head of the proximal phalanx decreased from the second digit to the third digit (P < .001), decreased from the third digit to the fourth digit (P < .001), and then increased from the fourth digit to the fifth digit (P = .032). CONCLUSIONS: The results of this investigation provide evidence in support of an anatomical and structural contribution to digital deformities. The width of the heads of the lesser digit proximal phalanges decreased from the second to the third to the fourth toes, and then subsequently increased with the fifth proximal phalangeal head.

A Critical Biomechanical Evaluation of Foot and Ankle Soft Tissue Repair.

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated.

An Evaluation of Basic Demographic Characteristics in Foot and Ankle Surgery From the American College of Surgeons National Surgical Quality Improvement Program.

It has become increasingly prevalent in the foot and ankle surgical literature to evaluate outcomes and trends obtained from large databases. The objective of this investigation was to provide a broad descriptive analysis and compare basic demographic characteristics relating to foot and ankle surgery within the American College of Surgeons National Surgical Quality Improvement Program database. The 16 Current Procedural Terminology® (CPT) codes available within this database pertaining to foot and ankle surgery were studied. Several CPT codes were observed to be more frequently associated with male gender: 27650 (Achilles tendon repair), 27698 (Lateral ankle reconstruction), 27702 (Total ankle arthroplasty), 27766 (ORIF medial malleolus fracture), 27792 (ORIF lateral malleolus fracture), and 28805 (Metatarsal amputation). Several other CPT codes were observed to be more frequently associated with female gender: 27658 (Primary peroneal tendon repair), 27814 (ORIF bimalleolar fracture), 27822 (ORIF trimalleolar ankle fracture without posterior lip fracture), and 27823 (ORIF trimalleolar ankle fracture with posterior lip fracture). The elective case designation was observed to be more frequently associated with male gender (65.4 vs 58.7%; p < .001). These data have potential use in the development and interpretation of quality improvement/performance improvement protocols at individual health care delivery centers, as well as the interpretation of other published investigations utilizing this database.

An Evaluation of Patient Characteristics Associated With Medical Disposition in the Surgical Treatment of Ankle Fractures.

The objective of this investigation was to evaluate patient characteristics associated with medical disposition in treatment of ankle fractures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated with data extracted related to the 6 current procedural terminology (CPT) codes available pertaining to ankle fractures: 27766, 27769, 27792, 27814, 27822, and 27823. The primary outcome analysis involved a comparison of patient characteristics and short-term adverse outcomes between those fractures repaired on an inpatient basis versus outpatient basis. A secondary analysis was then performed on patient characteristics and adverse short-term outcomes between those fractures treated on an inpatient basis who were discharged home versus elsewhere. Age (p < .001), race (p < .001), ethnicity (p < .001), body mass index (BMI) (p < .001), estimated probability of mortality (p < .001), estimated probability of morbidity (p < .001), CPT code of fracture designation (p < .001), functional status (p < .001), elective surgery designation (p < .001), American Society of Anesthesiologists class (p < .001), diabetes (p < .001), smoking status (p < .001), dyspnea (p < .001), COPD (p < .001), congestive heart failure (p < .001), hypertension (p < .001), dialysis (p < .001), cancer (p < .001), steroid use (p < .001), blood transfusion history (p < .001), and sepsis/systemic inflammatory response syndrome history (p < .001) were all independently associated with the ankle fracture repair being performed on an inpatient basis on regression analysis. Age (p < .001), race (p = .025), ethnicity (p < .001), BMI (p = .001), CPT code of fracture designation (p < .001), preoperative functional status (p < .001), and American Society of Anesthesiologists class (p < .001) were all independently associated with inpatient ankle fracture repairs being discharged to home following the procedure on regression analysis. The results of this investigation demonstrate that differences in patient demographic characteristics might contribute to medical decision-making as it relates to patient management and discharge disposition in the treatment of ankle fractures.