Epidemiological Survey of the Impact of COVID-19 on Telemedicine in the Practice of Foot and Ankle Surgery in the United States.

In response to loosened telehealth regulations and local restrictions on elective procedures during the coronavirus disease 2019 (COVID-19) pandemic, telemedicine use has dramatically increased. The goal of this study was to analyze patterns in telemedicine use among podiatric physicians during the COVID-19 crisis on a national level. Anonymous responses to a survey of practice metrics as well as subjective impressions of telemedicine efficacy were collected from 246 respondents, representing >1% of practicing podiatrists in the United States. Linear regression was performed to identify variables associated with COVID-19 prevalence and variables associated with higher self-reported likelihood of offering telemedicine visits post-COVID-19. Physicians in areas of lower COVID-19 prevalence were found to dispense durable medical equipment more frequently in-office and conduct more post-op telemedicine visits, with fewer visits for infections and trauma. Podiatrists in these regions also rated telemedicine more effective for medical and musculoskeletal pathologies. Additionally, fewer of their practices had modified office hours, and more of them advertised telemedicine services. Physicians more likely to offer telemedicine post-COVID-19 had significantly higher new patient volume and increased acuity of cases, with patient admission to the hospital after telemedicine visits. These physicians ranked the effectiveness of telemedicine more highly for every pathology surveyed. Of note, American College of Foot and Ankle Surgeons region and years in clinical practice were not statistically associated with likelihood of offering telemedicine visits post-COVID-19. This study represents the first systematic national assessment of telemedicine use in podiatry and highlights clinically relevant changes in practice and perception of telemedicine in response to the COVID-19 pandemic.

Preliminary Clinical Evaluation Using a Novel Bioengineered Wound Product to Treat Lower Extremity Ulcers.

Diabetes mellitus affects hundreds of millions of people worldwide, each of which have up to a 25% risk of developing a diabetic foot ulcer (DFU) during their lifetime. With poor DFU healing rates using standard of care, advanced treatments are introduced to attempt to close the wound. The objective of this preliminary clinical evaluation was to evaluate lower extremity ulcers treated with a novel bioengineered wound product (BWP). The BWP, a solid absorbable and conformable sheet composed of gelatin, Manuka honey, and hydroxyapatite, was applied on 12 patients with lower extremity ulcers. The patients in this evaluation spanned across 4 sites and had complicated medical histories, including little to no progression of healing with standard of care or treatment with other biomaterials. The ulcers were treated with debridement, BWP placement, dressing, appropriate compression, and offloading as necessary. Weekly follow-up visits were recommended for evaluation, debridement, and BWP reapplication. Nine patients had the BWP applied to aid in full closure. These patients achieved 100% closure within 8 weeks, with a mean closure time of 4.1 weeks. At 4 weeks, the mean percent wound closure was 94%. Three patients had the BWP applied to aid in achieving a healthy wound bed for continued treatment (eg, splitthickness skin graft) and to cover (epithelialization over) an exposed tendon. In all 12 cases, no treatment site infections were observed. The results and observations from this preliminary clinical evaluation suggest that the BWP supports rapid wound closure, a predictor of complete healing for DFUs.

Surgical Management of Lower Extremity Pyoderma Gangrenosum With Viable Cryopreserved Umbilical Tissue: A Case Series.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare skin disease that often presents as a uniquely painful and necrotic ulceration of the lower extremity. Pyoderma gangrenosum is often misdiagnosed and can have deleterious consequences to the patient, as there is no gold standard treatment and it can be difficult to manage. Surgery for these wounds is controversial, as pathergy can develop, worsening the ulceration. Advanced wound care products such as cellular- and/or tissue-based products (CTPs) are effective in helping stagnant chronic wounds reach full closure. Amnion/chorion-based skin substitutes that have been cryopreserved and contain viable cells have been shown to promote more cell recruitment and reduce inflammation. OBJECTIVE: This case series presents evidence of using a cryopreserved umbilical cord tissue with living cells in adjunctive treatment of wounds associated with PG. MATERIALS AND METHODS: This report presents 3 different clinical scenarios of lower extremity PG treated surgically with viable cryopreserved umbilical tissue (vCUT). RESULTS: All 3 patients were successfully treated with vCUT and resulted in complete healing. CONCLUSIONS: To the best of the authors' knowledge, this is the first case series demonstrating the ability of vCUT to heal these difficult-to-treat ulcers. In addition, it may be an effective modality to adjunctive management of PG.

Treatment of Hard-to-heal Diabetic Foot Ulcers With a Hepatic-derived Wound Matrix.

INTRODUCTION: Difficult-to-heal diabetic foot ulcers (DFUs) increase the likelihood of significant pathology and increased health care costs. OBJECTIVE: This study evaluates the ability of a novel hepatic-derived wound matrix (HD-WM) to treat hard-to-heal DFUs. MATERIALS AND METHODS: In total, 53 patients were enrolled and 38 completed per protocol. Patients had ulcers that had been present for at least 90 days and were non-responsive to at least 2 applications of an advanced biologic wound care product. Patients were treated with standard of care and offloading for a 2-week run-in phase. If they satisfied criteria, they were enrolled in the trial and treated with the HD-WM, and then seen weekly for assessment and additional treatment as needed. Patients continued weekly visits until the wound healed or went 12-weeks posttreatment without healing. RESULTS: Mean starting wound size was 3.5 cm2 and mean wound duration was 41.1 weeks. Median previous treatment applications of an advanced biologic were 3.0. Complete closure of the wound occurred in 22 of the 38 patients (57.9%) within the 12-week study period, while 16 of 38 (42.1%) of the wounds had failed to completely heal. The mean time to wound closure was 8.1 weeks; these patients received a median of 1 application of the HD-WM under investigation. Closure of the wound by 50% or greater at week 4 was highly predictive of complete wound closure by 12 weeks. Except for bodily pain (36-Item Short Form Health Survey), which significantly improved in patients whose wounds healed, quality of life measures did not show changes. CONCLUSIONS: The HD-WM under evaluation did well at closing difficult-to-heal wounds with minimal applications. These results are consistent with a previous study on this HD-WM.

Extracorporeal shockwave therapy for interdigital neuroma: a randomized, placebo-controlled, double-blind trial.

BACKGROUND: We sought to evaluate the safety and effectiveness of extracorporeal shockwave therapy as a therapeutic treatment for destroying Morton's neuroma. METHODS: Twenty-five patients (25 feet) were included in the study. Indications for participation were more than 8 months of conservative care with a visual analog scale pain score of 4 or greater. The mean overall pain score on a modified visual analog scale was 6.9 preoperatively. RESULTS: Thirteen patients were randomized to the active group and 12 to the sham group. Two patients in the sham group were lost to follow-up. Post-treatment evaluations were performed at 1, 6, and 12 weeks by a blinded investigator (L.W.). The end point evaluation parameter was the reduction in visual analog scale score. The treatment group showed a significant difference before and after extracorporeal shockwave therapy (P < .0001). The sham group did not have a significant difference after 12 weeks (P = .1218). CONCLUSIONS: Extracorporeal shockwave therapy is a possible alternative to surgical excision for Morton's neuroma.

Extracorporeal shockwave therapy for the treatment of Achilles tendinopathies: a prospective study.

BACKGROUND: Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders. METHODS: Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score >5. The mean follow-up was 20 months (range, 4-35 months). RESULTS: Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1. CONCLUSION: High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy.

A Pilot Study to Evaluate the Effects of Perfusion-decellularized Porcine Hepatic-derived Wound Matrix on Difficult-to-heal Diabetic Foot Ulcers.

OBJECTIVE: The purpose of this prospective pilot study is to evaluate the effects of a novel perfusion-decellularized porcine hepatic-derived wound matrix (PDPHD-WM) on very difficult-to-heal diabetic foot ulcers (DFUs). MATERIALS AND METHODS: For the intent of this study, a very difficult-to-heal DFU is one with a duration > 3 months despite using at least 1 advanced healing modality. Seven patients were enrolled in the study for a length of 14 weeks, including a 2-week run-in phase of standard-of-care therapy with saline gel and offloading in a CAM walker. Average wound duration was 25.5 months (range, 5-48 months). The PDPHD-WM was applied after the run-in phase and assessed weekly by the investigator. An average of 2.1 applications of the graft were performed (range, 1-4) over the study period. RESULTS: Three patients (42.9%) reached complete wound closure, 2 had partial wound closure (28.6%), 1 (14.3%) had worsening of his wound, and 1 (14.3%) was removed from the study due to osteomyelitis. Average percent wound closure over the 12-week treatment period was 56% for all patients and 77% when only those wounds that improved were included in the data. In addition, a bimodal population distribution was noted in this small series. Patients who demonstrated an early response continued on to closure or near-closure (4 patients), while those who showed little or no early response remained unclosed at the end of the study. CONCLUSIONS: These results suggest that PDPHD-WM may be an appropriate modality to treat difficult-to-heal DFUs, and a larger randomized placebo-controlled trial should be performed to investigate these findings. To the best of the authors' knowledge, this is the first collected data on using PDPHD-WM to treat DFUs.

Imaging of diabetic foot infections.

Complications from diabetic foot infections are a leading cause of nontraumatic lower-extremity amputations. Nearly 85% of these amputations result from an infected foot ulcer. Osteomyelitis is present in approximately 20% of diabetic foot infections. It is imperative that clinicians make quick and successful diagnoses of diabetic foot osteomyelitis (DFO) because a delay in treatment may lead to worsening outcomes. Imaging studies, such as plain films, bone scans, musculoskeletal ultrasound, computerized tomography scans, magnetic resonance imaging, and positron emission tomography scans, aid in the diagnosis. However, there are several mimickers of DFO, which present problems to making a correct diagnosis.

Unilateral versus bilateral first ray surgery: a prospective study of 186 consecutive cases--patient satisfaction, cost to society, and complications.

Many studies have evaluated bilateral versus unilateral surgery in large joints, but limited research is available to compare outcomes of bilateral staged foot surgeries versus synchronous bilateral foot surgery. In total, 186 consecutive cases of first metatarsal-phalangeal (MTP) joint surgery were prospectively included in this study; 252 procedures were performed: 120 were unilateral or staged bilateral operations, and 66 were synchronous bilateral operations. Patients were evaluated at 6 and 12 weeks for specific early complications and surveyed about their return to work, activities of daily living, shoe gear requirements, satisfaction, and reasons for choosing staged or synchronous surgery. In addition, a cost analysis was performed on all surgical scenarios. Student t test showed no statistical significance between groups in all clinical settings to a 95% confidence level. Complication rates were similar and few in all situations. Patients were very satisfied when choosing bilateral synchronous surgery and would elect to repeat it the same way 97% of the time. The economic costs to the health system average 25% greater when patients undergoing first MTP joint surgery have the procedure performed one foot at a time. Combined with the time lost from work, this reveals a significant economic cost to both society and patient.