Verrucae pedis in children with juvenile idiopathic arthritis and other paediatric rheumatic diseases: a cross-sectional study.

BACKGROUND: Verrucae pedis (verrucae / VPs) are a common viral infection of the skin seen in children. There are limited studies of the prevalence, duration and impact of verrucae pedis in children who are immunosuppressed. The studies available suggest that, in these children, the warts are more widespread and are more long-standing. The primary aim of this study was to determine the prevalence of verrucae pedis in children attending rheumatology clinics who may have some degree of immunosuppression due to their prescribed medication and compare this to the reported prevalence in the healthy population. METHOD: Children attending out-patient rheumatology appointments were recruited. The young people were aged between four and 17 years old. A visual inspection of both feet was used to identify potential verrucae. Diagnosis of a verruca pedis was confirmed on observation of the typical clinical features. The location, duration of presence, previous treatments, presence of verrucae in other family members and psychological impact was recorded. RESULTS: A total of 71 children were included. Of the group, 55 children had no verrucae present, 16 children had one or more verrucae. The prevalence of verrucae was 22.5%. Medication impacting on the immune system was prescribed in 80% of the group. There appeared to be no greater chance of having verrucae if taking immunosuppressive medication than compared to having no medication (OR = 1.1, 95%CI 0.26 to 4.48, p = 0.46). Children with verrucae tended to be between 9 and 12 years old. In total, 37.5% of the young people with verrucae had lesions reportedly present for 24 months or more. Two-thirds of the participants were not concerned about verrucae being present and most participants with a verruca were not aware of what a verruca was, but despite this the majority of participants (81%) had sought treatment for the verrucae. CONCLUSION: Children with Juvenile Idiopathic Arthritis and other rheumatic conditions have no greater prevalence of verrucae compared to the general population. The verrucae present were of a similar clinical type and did not seem to be more widespread or have atypical features, which has been reported in other immunocompromised populations. The percentage of lesions remaining beyond 24 months was found to be slightly greater than has been reported in other healthy populations. The children in this study seemed to be less emotionally concerned about their verrucae, despite this most families had sought treatment for the verrucae.

Patient perceptions of foot disability in Juvenile Idiopathic Arthritis: a comparison of the juvenile arthritis foot disability index and the Oxford ankle foot questionnaire for children.

BACKGROUND: The Juvenile Arthritis Foot Disability Index (JAFI) and the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) are two region-specific paediatric outcome tools that measure the impact on well-being in children with foot pathology. The aim of this study was to establish the level of agreement between the JAFI and the OxAFQ-C in a group of children diagnosed with Juvenile Idiopathic Arthritis (JIA). METHODS: Children with JIA accessed the questionnaire via a website. The OxAFQ-C questionnaire and the JAFI questionnaire were combined into one document consisting of 42 statements with Likert-scale responses. A further question regarding duration of disease was added. On completion, the web-linked questionnaire was returned by e-mail. RESULTS: Thirty five participants were included. Individual domain and composite score analysis was undertaken. The JAFI participation domain was compared to the OxAFQ-C school domain and showed no significant difference between the median scores of each participant (z = -1.33, p = 0.181). The JAFI activity and the OxAFQ-C physical domains were compared and showed that a significant difference between the median scores existed (z = -4.29, p < 0.001). Agreement between the two PROMs was tested using Bland Altman Levels of Agreement based upon the percentage summed composite scores. Levels of agreement between the scores were considered to be poor based on the Bland Altman plot, despite a low mean difference in scores (mean difference = -3.88, SD of difference = 9.93, p = 0.027). Pearson correlation was undertaken to measure the relationship between the summed composite score and disease duration. No relationship was found (JAFI: r = -0.08, p = 0.672; OxAFQ-C: r = 0.037, p = 0.871). CONCLUSIONS: This study has shown that despite some agreement between the individual domains, overall there is poor agreement between the OxAFQ-C and the JAFI percentage summed composite scores. The study is not able to determine if one score is superior to the other but both scores could be of value when used in this population.

Chronic recurrent multifocal osteomyelitis: the prevalence of lower-limb and foot involvement.

BACKGROUND: Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory condition. The lesions are reported to present most frequently in the long bones. This study aimed to review the presenting features of CRMO in a cohort of children diagnosed as having CRMO and to compare the level of agreement between the clinical and published diagnostic criteria. METHODS: A case notes review was undertaken of patients with a clinical diagnosis of CRMO. Patients were younger than 16 years at the time of diagnosis. Features were identified in each patient that agreed or disagreed with the published diagnostic criteria. The location of bone lesions in the lower limb at onset and disease progression was recorded. RESULTS: A total of 37 patients were included. There was a high prevalence in white individuals. Agreement with the diagnostic criteria of Jansson et al and El-Shanti and Ferguson was poor, with levels of agreement of 40.5% and 43%, respectively, and low kappa scores (κ = 0.07 and 0.09, respectively). The lower limb was affected in 49% of patients at onset and in 72% overall. CONCLUSIONS: This study presents one of the largest published cohorts of pediatric patients with CRMO and also presents racial/ethnic group data that have not previously been reported in other studies. Despite being a condition considered to affect the metaphysis of long bones, the ankle area and foot bones were also frequently affected. The agreement between the clinical diagnosis and the published diagnostic criteria was weak.

Fungal toenail infections.

INTRODUCTION: Fungal infections are reported to cause 23% of foot diseases and 50% of nail conditions in people seen by dermatologists, but are less common in the general population, affecting 3% to 12% of people. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral treatments for fungal toenail infections in adults? What are the effects of topical treatments for fungal toenail infections in adults? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 13 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: amorolfine, butenafine, ciclopirox, fluconazole, itraconazole, terbinafine, tioconazole, and topical ketoconazole.

Assessment of gait characteristics and orthotic management in children with Developmental Coordination Disorder: preliminary findings to inform multidisciplinary care.

Developmental Coordination Disorder (DCD) is a neurodevelopmental disorder characterised by impaired motor co-ordination and awkward gait. Despite self-reported findings of pes planus and joint hypermobility in children with DCD, there is little objective evidence regarding the clinical management of the foot in children with DCD. The aims of this research were to report clinical findings of foot posture and lower limb hypermobility in children with DCD and to evaluate the impact of foot orthoses on spatio-temporal gait parameters. Children with DCD were recruited into the study. Participants were randomly assigned to an intervention group who received foot orthoses at the start of their rehabilitation programme or to a second group who received foot orthoses at the end of their intervention programme. Foot posture was assessed with the Foot Posture Index and lower limb hypermobility assessed with the Lower Limb Assessment Score. The effect of foot orthoses was evaluated through assessment of spatio-temporal gait characteristics at baseline and post-rehabilitation programme. Fourteen children were recruited (mdn age 7.5 years) with nine children assigned to the group receiving orthoses early (mdn age 8 years) and five children assigned to the post-rehabilitation orthoses group (mdn age 6.5 years). A pes planus foot posture (FPI score=8) and lower limb hypermobility (LLAS score=11) were observed. Changes in spatio-temporal gait parameters failed to reach significance (p>.012) following orthotic invention but demonstrated a trend towards a decreased cadence and increased double support duration. Despite non-significant findings this work offers preliminary support for podiatric intervention in the rehabilitation of children with DCD. Further work is required to understand the biomechanics of gait in children with DCD and appreciate the role of podiatry as a component of multidisciplinary care.

Are spatiotemporal gait characteristics reliable outcome measures in children with developmental coordination disorder?

PURPOSE: To evaluate the reliability of spatiotemporal gait parameters used in the clinical evaluation of children with developmental coordination disorder (DCD). METHODS: Participants recruited were asked to ambulate across a 4.5-meter GAITRite walkway (CIR Systems, Inc, Havertown, Pennsylvania) at a self-selected walking speed. The spatiotemporal parameters recorded for both limbs were: velocity (cm/sec), stance phase duration (%), swing phase duration (%), stride length (cm), double support duration (%), and single support duration (%). RESULTS: Intraclass correlation coefficient values attained in this study ranged from 0.24 to 0.73, with good reliability achieved for one parameter (cadence = 0.73), and moderate reliability for step length (0.55-0.58), stride length (0.57-0.61), and double support duration (0.56-0.59). CONCLUSION: The findings from this study indicate that the clinical evaluation of spatiotemporal gait parameters in children with DCD can yield reliable data for some parameters but further work on this is warranted.

Fungal toenail infections.

INTRODUCTION: Fungal infections are reported to cause 23% of foot diseases and 50% of nail conditions in people seen by dermatologists, but are less common in the general population, affecting 3% to 5% of people. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral treatments for fungal toenail infections? What are the effects of topical treatments for fungal toenail infections? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 12 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: amorolfine, butenafine, ciclopirox, fluconazole, griseofulvin, itraconazole, ketoconazole, mechanical debridement, terbinafine, and tioconazole.

Inter-rater reliability of the Foot Posture Index (FPI-6) in the assessment of the paediatric foot.

BACKGROUND: Reliability is an integral component of clinical assessment and necessary for establishing baseline data, monitoring treatment outcomes and providing robust research findings. In the podiatric literature traditional measures of foot assessment have been shown to be largely unreliable. The Foot Posture Index (FPI-6) is a clinical tool used in the assessment of foot and to date, there is limited research published which evaluates the reliability of this tool in children and adolescents. METHOD: Thirty participants aged 5 - 16 years were recruited for the research. Two raters independently recorded the FPI-6 score for each participant. RESULTS: Almost perfect agreement between the two raters was identified following weighted kappa analysis (Kw = 0.86). CONCLUSION: The FPI-6 is a quick, simple and reliable clinical tool which has demonstrated excellent inter-rater reliability when used in the assessment of the paediatric foot.

Bunions.

INTRODUCTION: Bunions are prominent and often inflamed metatarsal heads and overlying bursae, usually associated with hallux valgus where the great toe moves towards the second toe. Hallux valgus is found in at least 2% of children aged 9-10 years, and almost half of adults, with greater prevalence in women. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of conservative treatments, surgery, and postoperative care for bunions? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: arthrodesis (Lapidus procedure); bone fixation (absorbable pin fixation, screw fixation plus early weight-bearing, standard fixation, suture fixation plus delayed weight-bearing, percutaneous Kirschner-wire fixation); chevron osteotomy plus adductor tenotomy; distal metatarsal osteotomy; early weight-bearing; Keller's arthroplasty; Keller-Lelievre arthroplasty; night splints; orthoses (including antipronatory orthoses in children); phalangeal (Akin) osteotomy plus distal chevron osteotomy; proximal osteotomy, and slipper casts.

WITHDRAWN: Interventions for treating hallux valgus (abductovalgus) and bunions.

BACKGROUND: Hallux valgus is classified as an abnormal deviation of the great toe (hallux) towards the midline of the foot. OBJECTIVES: To identify and evaluate the evidence from randomised trials of interventions used to correct hallux valgus. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauama Group trials register (2003/1), the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2003), MEDLINE (January 1966 to March 2003) and EMBASE (1980 to January 2003). No language restrictions were applied. Hand searching of specific foot journals was also undertaken.Date of the most recent search: 31st March 2003. SELECTION CRITERIA: Randomised or quasi-randomised trials of both conservative and surgical treatments of hallux valgus. Excluded were studies comparing areas of surgery not specific to the control of the deformity such as use of anaesthetics or tourniquet placement. DATA COLLECTION AND ANALYSIS: Methodological quality of trials which met the inclusion criteria was independently assessed by two reviewers. Data extraction was undertaken by two reviewers. The trials were grouped according to the interventions being compared, but the dissimilarity in the comparisons prevented pooling of results. MAIN RESULTS: The methodological quality of the 21 included trials was generally poor and trial sizes were small.Three trials involving 332 participants evaluated conservative treatments versus no treatment. There was no evidence of a difference in outcomes between treatment and no treatment.One good quality trial involving 140 participants compared surgery to conservative treatment. Evidence was shown of an improvement in all outcomes in patients receiving chevron osteotomy compared with those receiving orthoses. The same trial also compared surgery to no treatment in 140 participants. Evidence was shown of an improvement in all outcomes in patients receiving chevron osteotomy compared with those receiving no treatment.Two trials involving 133 people with hallux valgus compared Keller's arthroplasty with other surgical techniques. In general, there was no advantage or disadvantage using Keller's over the other techniques. When the distal osteotomy was compared to Keller's arthroplasty, the osteotomy showed evidence of improving the intermetatarsal angle and preserving joint range of motion. The arthroplasty was found to have less of an impact on walking ability compared to the arthrodesis.Six trials involving 309 participants compared chevron (and chevron-type) osteotomy with other techniques. The chevron osteotomy offered no advantages in these trials. For some outcomes, other techniques gave better results. Two of these trials (94 participants) compared a type of proximal osteotomy to a proximal chevron osteotomy and found no evidence of a difference in outcomes between techniques.Three trials involving 157 participants compared outcomes between original operations and surgeon's adaptations. There was no advantage found for any of the adaptations.Three trials involving 71 people with hallux valgus compared new methods of fixation to traditional methods. There was no evidence that the new methods of fixation were detrimental to the outcome of the patients.Four trials involving 162 participants evaluated methods of post-operative rehabilitation. The use of continuous passive motion appeared to give an improved range of motion and earlier recovery following surgery. Early weightbearing or the use of a crepe bandage were not found to be detrimental to final outcome. AUTHORS' CONCLUSIONS: Only a few studies had considered conservative treatments. The evidence from these suggested that orthoses and night splints did not appear to be any more beneficial in improving outcomes than no treatment. Surgery (chevron osteotomy) was shown to be beneficial compared to orthoses or no treatment, but when compared to other osteotomies, no technique was shown to be superior to any other. Only one trial had compared an osteotomy to an arthroplasty. There was limited evidence to suggest that the osteotomy gave the better outcomes. It was notable that the numbers of participants in some trials remaining dissatisfied at follow-up were consistently high (25 to 33%), even when the hallux valgus angle and pain had improved. A few of the more recent trials used assessment scores that combine several aspects of the patients outcomes. These scoring systems are useful to the clinician when comparing techniques but are of dubious relevance to the patient if they do not address their main concern and such scoring systems are frequently unvalidated. Only one study simply asked the patient if they were better than before the treatment. Final outcomes were most frequently measured at one year, with a few trials maintaining follow-up for 3 years. Such time-scales are minimal given that the patients will be on their feet for at least another 20-30 years after treatment. Future research should include patient-focused outcomes, standardised assessment criteria and longer surveillance periods, more usefully in the region of 5-10 years.

Fungal toenail infections.

INTRODUCTION: Fungal infections are reported to cause 23% of foot diseases and 50% of nail conditions in people seen by dermatologists, but are less common in the general population, affecting 3-5% of people. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral treatments for fungal toenail infections? What are the effects of topical treatments for fungal toenail infections? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 11 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: amorolfine, butenafine, ciclopirox, fluconazole, griseofulvin, itraconazole, ketoconazole, mechanical debridement, terbinafine, and tioconazole.

Foot pressure measurement differences between boys and girls with reference to hallux valgus deformity and hypermobility.

BACKGROUND: Previous studies that compared foot pressures in boys and girls found that girls had greater peak pressures under the hallux than did boys. Only one of these studies considered plantar pressure measurements in children. The purpose of the study was to investigate the effect of gender on foot pressure measurements in children. METHODS: This is a comparative study using the F-Scan pressure platform (F-Mat; Texscan Boston, MA) on a sample of children attending a podiatric clinic. Pressure measurements and temporal parameters were measured in 61 children between the ages of 5 and 16 years. Associations between joint hypermobility and hallux valgus angle also were investigated. RESULTS: Girls were found to have significantly greater peak pressure under the hallux, faster timing of heel contact to first metatarsal head loading, and a more medially placed center of pressure trajectory. No associations were found between these significant variables and hypermobility scores or hallux valgus angle. CONCLUSION: The results indicate that there are differences in pressure measurements between boys and girls, but the reasons for these remain unclear. Differences in pressure measurements in the feet of boys and girls may be useful in establishing the cause of foot pathologies for which a prevalence has been shown in boys or girls, such as hallux valgus deformity, which is known to be more frequent in females of all ages.

Size and shape differences between male and female foot bones: is the female foot predisposed to hallux abducto valgus deformity?

This study introduces a new technique to measure bone size and shape. A three-dimensional laser scan was taken of the talus, navicular, medial cuneiform, and first metatarsal from 107 skeletons of known age and sex. The bones were analyzed for differences in bone morphology between the sexes and the ability of each bone to contribute to the adducted position of the first metatarsal. Linear measurements showed that male bones were larger than female bones. Measurements of articular surfaces suggested that female bones had the potential for more movement to occur in the direction of adduction, possibly resulting in the female first metatarsal being more adducted than that in the male skeleton. Such differences may underlie the predisposition of the female foot to develop hallux valgus deformity.

A radiographic study of the relationship between metatarsus adductus and hallux valgus.

The relationship between metatarsus adductus and hallux valgus was evaluated on 100 dorsoplantar weight-bearing radiographs. The metatarsus adductus angle varied positively with the degree of hallux valgus. By using measures of correlation, a significant linear association was found for women (r =.53, P <.001) and men (r =.48, P <.001). The relationship was strongest in women when all cases of abnormal metatarsus adductus (>24 degrees ) were associated with abnormal degrees of hallux valgus (>15 degrees ). This relationship was different in men in that abnormal metatarsus adductus angles were not always associated with abnormal hallux valgus angles. With male and female data combined, the prevalence of metatarsus adductus was 55% in subjects with hallux valgus deformity compared with 19% in subjects without hallux valgus. A Chi(2) test showed this to be a significant difference in the distribution of the data (P =.002). The data of this study suggests that there may be a clinical association between metatarsus adductus and hallux valgus. The need to further evaluate the role of metatarsus adductus angle in hallux valgus surgery is emphasized.