Healing rates and outcomes following closed transmetatarsal amputations: A systematic review and random effects meta-analysis of proportions.

Transmetatarsal amputation (TMA) is a common surgical procedure for addressing severe forefoot pathologies, such as peripheral vascular disease and diabetic foot infections. Variability in research methodologies and findings within the existing literature has hindered a comprehensive understanding of healing rates and complications following TMA. This meta-analysis and systematic review aims to consolidate available evidence, synthesising data from multiple studies to assess healing rates and complications associated with closed TMA procedures. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search of Medline, Embase, and Cochrane databases was conducted for articles published from January 1st, 1988, to June 1st, 2023. Inclusion criteria comprised studies reporting healing rates in non-traumatic transmetatarsal amputation patients with more than 10 participants, excluding open TMAs. Two independent reviewers selected relevant studies, with disagreements resolved through discussion. Data extracted from eligible studies included patient demographics, healing rates, complications, and study quality. Among 22 studies encompassing 1569 transmetatarsal amputations, the pooled healing rate was 67.3%. Major amputation rates ranged from 0% to 55.6%, with a random-effects pooled rate of 23.9%. Revision rates varied from 0% to 36.4%, resulting in a pooled rate of 14.8%. 30-day mortality ranged from 0% to 9%, with a fixed-effects pooled rate of 2.6%. Post-operative infection rates ranged from 3.0% to 30.7%, yielding a random-effects pooled rate of 16.7%. Dehiscence rates ranged from 1.7% to 60.0%, resulting in a random-effects pooled rate of 28.8%. Future studies should aim for standardised reporting and assess the physiological and treatment factors influencing healing and complications.

Update of biomarkers to diagnose diabetic foot osteomyelitis: A meta-analysis and systematic review.

The aim of this study was to evaluate the diagnostic characteristics of biomarker for diabetic foot osteomyelitis (DFO). We searched PubMed, Scopus, Embase and Medline for studies who report serological markers and DFO before December 2022. Studies must include at least one of the following diagnostic parameters for biomarkers: area under the curve, sensitivities, specificities, positive predictive value, negative predictive value. Two authors evaluated quality using the Quality Assessment of Diagnostic Accuracy Studies tool. We included 19 papers. In this systematic review, there were 2854 subjects with 2134 (74.8%) of those patients being included in the meta-analysis. The most common biomarkers were erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and procalcitonin (PCT). A meta-analysis was then performed where data were evaluated with Forrest plots and receiver operating characteristic curves. The pooled sensitivity and specificity were 0.72 and 0.75 for PCT, 0.72 and 0.76 for CRP and 0.70 and 0.77 for ESR. Pooled area under the curves for ESR, CRP and PCT were 0.83, 0.77 and 0.71, respectfully. Average diagnostic odds ratios were 16.1 (range 3.6-55.4), 14.3 (range 2.7-48.7) and 6.7 (range 3.6-10.4) for ESR, CRP and PCT, respectfully. None of the biomarkers we evaluated could be rated as 'outstanding' to diagnose osteomyelitis. Based on the areas under the curve, ESR is an 'excellent' biomarker to detect osteomyelitis, and CRP and PCT are 'acceptable' biomarkers to diagnose osteomyelitis. Diagnostic odds ratios indicate that ESR, CRP and PCT are 'good' or 'very good' tools to identify osteomyelitis.

A Preliminary Look at the Macrovascular System for Transmetatarsal Amputation Success.

OBJECTIVE: Transmetatarsal amputation (TMA) is a commonly used level of amputation that preserves most of the foot's function and independence. However, many TMAs fail, and patients go onto higher amputations. The primary endpoint of this study is to determine if source artery occlusions are correlated with TMA flap failure. METHODS: A total of 82 patients with TMAs were retrospectively reviewed for healing rates between 2009 and 2019 at a single center. Forty-five of the patients had an angiogram, which was analyzed for source artery and overall TMA failure. Of the initial 82 patients, a cohort of 12 had documentation of specific flap failure and an angiogram performed. This cohort of 12 patients was used for correlation of flap failure with source artery occlusion. RESULTS: Overall, the TMA healing rate was 45.28%. No correlation was noted between a specific source artery occlusion and overall TMA failure. However, a moderate positive correlation was seen with dorsalis pedis artery and peroneal artery occlusions and dorsal flap failure. No correlation was seen with the posterior tibial artery and plantar flap failure. A moderate negative correlation was seen with peroneal artery occlusion and plantar flap failure. CONCLUSIONS: The authors concluded that retrograde flow through the angiosome principle is what allowed for successful outcomes in TMAs. Physicians are urged to carefully plan, dissect, and preserve these vessels to help prevent TMA flap failure, especially in patients with vascular risk or disease.

The Financial Implications of Being a Female Fellow: Does Another Year Help Close the Gap?

In 2018, the American College of Foot and Ankle Surgeons Compensation and Benefits Survey illustrated a wage gap between male and female doctors of podiatric medicine in the United States. The purpose of the present study was to assess if an additional year of fellowship training closes that gap. To calculate the net present value, weighted mean general income data from female doctors of podiatric medicine with and without fellowship training was obtained. Demographic and clinical income data (based on 2080 hours) for 17 female graduates from 14 American College of Foot and Ankle Surgeons recognized fellowship programs was collected using an anonymous online survey. Income from general payments was collected from manual searches of Open Source Payments. Socioeconomic data from the 2018 American College of Foot and Ankle Surgeons compensation and benefits survey was used to calculate the net present value of the nonfellowship trained doctors of podiatric medicine for comparison. Overall, the net present value of female doctors of podiatric medicine with and without fellowship training was $1.91 million and $2.4 million, respectively. The comparative net present value and cumulative net income difference over 30 years for female doctors of podiatric medicine with and without fellowships was -$492,159.00 and -$820,000.00, respectively. The mean comparative income difference for fellowship trained female doctors of podiatric medicine annually was as follows: clinical (-$26,082.00) and general (+$1101.54). Based on the data, with consideration to the limitations of the study, the financial implications of fellowship on the gender wage gap is currently unclear. Additional research is warranted.

Feeling the Burnout: Perceptions of Burnout, Anxiety, Depression, and Personal Achievement in US Podiatric Medical Students.

Medical student burnout is a significant problem, which has led to the introduction of institutional intervention initiatives to combat the phenomenon. However, the incidence of burnout among podiatric medical students has not been previously assessed. The purpose of this cross-sectional study was to determine the perceptions of burnout, anxiety, depression, and personal achievement among podiatric medical students. A 50-question anonymous survey containing the Maslach Burnout Inventory-Human Services Survey and the Hospital Anxiety and Depression Scale was distributed to all students of eight US podiatric medical schools. Demographic and personal information regarding the student's free time, study time, family support, class or exam failures, loan debt, and previous work experience were recorded. Four hundred and eighty students completed the survey, and 479 responses were eligible for inclusion (response rate of 22.2%). Overall, 65.1% reported moderate or high self-perceived rates of burnout, a rate comparable to allopathic and osteopathic medical students. Respondents also reported high levels of emotional exhaustion and anxiety, but low levels of personal achievement. A predisposition for burnout was identified for third-year students between the ages of 26 to 35 years with borderline or abnormal levels of reported anxiety. The present study contributes to the growing body of literature regarding burnout with respect to the podiatric profession. Despite inherent limitations, the findings suggest institutional interventions for the promotion and development of protective factors may be warranted.

The Financial Implications of Podiatric Foot and Ankle Fellowship: Is Another Year Worth It?

For prospective applicants many variables can factor into the decision to pursue fellowship level training. The purpose of the present study was to give prospective applicants an idea of the financial implications of podiatric foot and ankle fellowship. To calculate the net present value (NPV), weighted mean income data (clinical, general, research, associated research) from podiatric foot and ankle surgeon's (FAS's) with and without fellowship training was obtained. Income from general payments, research, and associated research was collected from manual searches of Open Source Payments. Demographic and clinical income data (based on 2080 hours) for graduate fellows from 4 programs was collected using an anonymous online survey. Socioeconomic data from the 2018 American College of Foot and Ankle Surgeons (ACFAS) compensation survey was used for comparison. The NPV of podiatric FAS's with/without fellowship training was $4.2 million and $3.03 million, respectively. The comparative NPV and cumulative net income difference over 30 years was $1.2 million and $2.5 million, respectively. The mean comparative income difference for fellowship trained podiatric FAS's annually was as follows: clinical (+$69,145.00), general (+$21,797.00), research (+$1,833.00), and associated research (+$414.00). The present study is the first attempt to provide prospective applicants with an idea of the financial implications of podiatric foot and ankle fellowship. Based on the positive NPV, pursuing an ACFAS recognized podiatric foot and ankle fellowship in advanced reconstruction could be considered an "acceptable financial investment", which may positively affect career earnings. Prospective applicants should be cognizant that the NPV varies between fellowship programs. Therefore, the data presented from graduate fellows of the programs included may not be generalizable to graduate fellows from other programs.

Two-dimensional metric comparison between dynamic bare and sock-clad footprints for its forensic implications - A pilot study.

Footprints may be present at crime scenes as physical evidence. This pilot study compares two-dimensional measurements of bare and sock-clad footprints to determine if significant differences or similarities exist. Dynamic footprints were collected from 30 males and 20 females between the ages of 20 and 61 years old (mean of 28.2 years) using the Identicator Inkless Shoe Print Model LE 25P system. A midgait protocol was employed for obtaining footprints. The fifth and sixth footprint of gait were collected for the right and left foot, respectively, in both sock-clad and barefoot trials. The footprint measurements between sock-clad and bare footprints were compared. The results did not indicate any significant difference (p > .05) between bare and sock-clad foot length measurements for right or left feet. Significant differences were seen for the width measurements between bare and sock-clad footprints. These findings have forensic implications, particularly in criminal cases where it is unclear if a footprint impression is from a sock-clad foot or a bare foot. This study shows that such a determination is generally not necessary when utilizing two-dimensional measurements for length comparison between a bare and sock-clad footprint. However, if width measurements are being evaluated, the distinction between bare and sock-clad footprints should be considered.

Navigating Institutional Review Boards.

Obtaining institutional review board (IRB) approval can be an overwhelming task, especially for new researchers. IRB approval can require many documents and steps. It is important to start the submission early, have patience throughout the process, and determine what can help expedite the process. Research cannot begin without IRB approval, which is necessary when working with human subjects. Ultimately, the researchers and IRB have the same goal of enabling good research with minimal subject risk. The goal of this article is to give an overview of the IRB for practitioners performing research in podiatric medicine and surgery.

Forensic measurement comparison of foot insole impressions.

In forensic podiatry, footprints have been shown to provide a valuable source of discriminatory information. Footprints may be found in various forms, such as bare footprints, sock-clad footprints, or as impressions on insoles within footwear. This study utilized quantitative measures of foot impressions on pairs of insoles from shoes worn by the same person from a population of 31 adults. The measurements were determined by using the Reel method and comprised measurements from the heel to the tips of the toes and width of the ball. The purpose of the study was to assess the margin of error for these measurements to determine whether they were sufficiently accurate for forensic use. A secondary purpose of this study was to determine whether the analyst's experience or lack thereof in forensic podiatry had an impact on the precision of measurement data. The insole foot impressions were assessed by two podiatrists with forensic podiatry experience in footprint analysis, footprint research, and in using the Reel method of footprint measurement, as well as by three students of podiatric medicine without any such experience. A statistical analysis of the data from the study was performed using SPSS v28 (IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp). The most reliable measurements were of forefoot width, heel to first toe, heel to second toe, and heel to fourth toe. The greatest variation occurred in the measurements of the heel to the third and fifth toes. The measurements of the forensic podiatrist analysts showed less variability than those of the podiatry students, suggesting that measurement precision is related to the experience of the analyst.

Ghosting phenomenon in static and dynamic footprints in India and the United States.

Ghosting is the phenomenon that exists when a footprint has a lighter area around the tip of one or more toes or a shadow-like area at the back of the heel. To date, ghosting has been considered primarily a finding of dynamic (walking) footprints, rather than static (standing) footprints. The prevalence of ghosting in static footprints is unknown, and research on its presence in static and dynamic footprints from the same participant is sparse, as are studies on its occurrence in different geographic populations. This study is among the first to evaluate the occurrence of ghosting in the static and dynamic footprints from a particular individual with participants in two geographic populations. A combination of both inkless and ink footprint collection systems were used to obtain a total of 206 bare footprints from 103 adult participants from the United States and India. The data comprised 103 static and 103 dynamic footprints. Ghosting occurred significantly in static footprints, though less frequently than in dynamic footprints. Ghosting in static footprints was seen most often at the first toe, followed by the third and second respectively. This aspect appeared least at the heel. In dynamic footprints, it occurred most at the first toe, followed by the second and fourth toes, and then the third toe and the heel. The prevalence of ghosting in footprints from the United States and India differed in their locations, notably at the first and second toes in the static footprints and at the heel in the dynamic footprints.

Understanding the zebras of wound care: an overview of atypical wounds.

Atypical wounds account for approximately 5% to 20% of chronic ulcerations. Typically, clinical suspicion of an uncommon etiology is warranted for wounds that do not show signs of healing with conventional care, that are associated with pain out of proportion to the clinical presentation, or that are atypical in appearance. This review provides a general overview of various atypical wound etiologies, clinical presentations and appearance, and current treatment protocols. The clinical presentation, pathophysiologic etiology, and current literature on each etiology are presented. The etiologies discussed are pyoderma gangrenosum, calciphylaxis, lichen planus, necrobiosis lipoidica, infectious ulcers, hidradenitis suppurativa, artefactual ulcers, hydroxyurea-induced ulcers, vasculopathies, and neoplastic ulcers. Patients with atypical wounds experience a poorer prognosis and slower healing rate compared with patients with typical wound etiologies (eg, vascular and diabetic wounds). Biopsy is often vital in wound care to identify and differentiate wound etiologies. It is important to note that multiple characteristics or histologic features can overlap in a biopsy with atypical wounds. Therefore, a biopsy will still require an understanding of the presentation of these different wounds and should only be used when appropriate. The proper diagnosis for an atypical wound can greatly hasten wound closure, decrease the cost for the patient and the health care system, and improve the patient's quality of life. Because of the limited availability of patient populations with atypical wound etiologies, literature concerning specific pathologies is limited. More research on each pathology is needed, as is a universally accepted treatment protocol for atypical wounds.

Saphenous Nerve Denervation for Chronic Pain After Compartment Syndrome of the Foot.

Denervation has been a recommended treatment option for a range of pathologies, including relief from chronic pain; however, literature discussing complete denervation of the distal saphenous nerve for foot pain has not been found. A case report of surgical decompression for compartment syndrome resulting in chronic, debilitating foot pain that was successfully alleviated by complete saphenous nerve denervation is presented. The predominant area of the patient's pain was on the medial aspect of the foot, where a thickened scar from a decompression fasciotomy was noted. The patient's initial pain score was reported as 10 of 10, with no relief from numerous conservative treatments attempted over an 11-year period. After a diagnostic injection of a local anesthetic to the distal saphenous nerve provided the patient with immediate, temporary relief, complete denervation of the distal saphenous nerve was performed. The patient reported significant pain reduction shortly after the procedure. This case suggests that physicians should be cognizant of the saphenous nerve and its branches, as well as its variable pathways during surgery. In addition, practitioners should be aware of its influence as a progenitor of pain in the foot that may require denervation.

Reliability of a two-dimensional sock-clad footprint linear measurement method.

A two-dimensional linear measurement approach for footprints, herein referred to as the "Reel Method," has been shown to be valid and reliable when used on bare footprints, however, few measurement approaches have been examined on sock-clad footprints. The present investigation examines the validity and reliability of the Reel Method as a two-dimensional linear measurement approach for use on sock-clad footprints. A walking, mid-gait footprint was collected from 30 volunteer participants using the Identicator Inkless Shoe Print Model LE 25P system. The width of the ball of the foot, calcaneal width, and distance from the most posterior aspect of the heel to the most distal aspect of the first toe were each measured and compared between and within three raters. The statistical analysis demonstrated high reliability of the Reel Method among these three raters. The data were found to be normally distributed, and measurements were consistent between and within raters. 95% Intraclass Correlation coefficients, 95% Bland-Altman Limits of Agreement and 95% Standard Error of Measurement determined high statistical agreement between and within raters, demonstrating that the Reel Method is reliable and thus valid for the linear measurement of sock-clad footprints.

The contact area of static and dynamic footprints: Forensic implications.

When found at crime scenes, footprints may be evidentially valuable and can assist with the identity of a perpetrator based on their features and/or measurements. Footprints can be either static (made while standing) or dynamic (made while walking). While extensive research has been performed on the linear measurements obtained from static and dynamic footprints, research on the comparisons between the contact area of static and dynamic footprints in the forensic context are limited. The present study compares the contact area of static and dynamic bare footprints to determine if statistically significant differences exist between the two. Static and dynamic footprints were obtained from a sample of randomly-selected 461 Jatt Sikh adults (230 males and 231 females) of Indian origin between the ages of 19 and 32 years. The footprint contact area was calculated from each footprint (excluding the toes) using a PedoGRID® sheet. No statistically significant differences were observed between the contact area of static and dynamic footprints for each foot among males and females. However, statistically significant differences between both the sexes were found in the footprint contact areas of both footprint types. The right dynamic footprint contact area was found to be the most predictive measurement for classifying and estimating sex from a footprint's contact area. The study has implications in the analysis of footprints recovered from crime scenes.

Vascular Assessment of the Foot Surgery Patient.

Foot surgery is common. Orthopaedic nurses charged with evaluating and treating patients who have undergone foot surgery are required to evaluate the vascular status of the patient's foot (or feet). As a result, these nurses are often the first to identify vascular issues. This article provides orthopaedic nurses with the background to understand how the patient's history, the procedure(s) performed, and a thorough assessment of the foot's circulation will allow them to promptly identify circulatory problems and potentially save a patient from having a serious complication.

Chasing ghosts: An investigation of the ghosting phenomenon in footprints.

Ghosting is a phenomenon that has been identified in dynamic (walking) footprints. There is sparse research on the occurrence of ghosting; however, due to the forensic value of footprints and their use in other scientific fields, the phenomenon of ghosting warrants further study. Ghosting can be used to determine if a footprint is static (standing) or dynamic, which can help forensic investigators create a sequence of events at a crime scene. Furthermore, this can help in footprint comparisons from this determination, as "like versus like" comparisons of dynamic or static footprints can be made. The purpose of this research was to determine the prevalence and locations of the ghosting phenomena in dynamic footprints. 136 dynamic footprints from 68 volunteers were collected using an inkless collection system. Each footprint was visually inspected for ghosting as well as examined using software. Ghosting was present on at least one location in all footprints. The highest prevalence occurred at the tip of the great toe, followed by the second digit and the heel. To a lesser extent, ghosting appeared at the tips of the other three digits. Ghosting often occurred at two or more areas in a given footprint.

Two-dimensional metric comparisons between dynamic bare footprints and insole foot impressions-forensic implications.

Footwear may be found at crime scenes as physical evidence. Such footwear often has impression features of the wearer's foot on the insole of the shoe. Scientific research and literature have established that footprints are distinct. This study compares two-dimensional measurements on bare footprints to foot impressions on insoles to determine if significant differences or similarities exist. Dynamic footprints were collected from 51 donors using theIdenticator® Inkless Shoe Print Model LE 25P system. Seven foot length and width measurements were taken based on the Reel linear measurement method. Footprint measurements between bare footprints and foot impressions on the insoles were compared. Only two differences (p > 0.05) were observed between the various bare footprint and insole foot impression measurements on the right and left side for most of the measurements, CALC (p < 0.001) and A1 (p = 0.04). Bare footprint and insole A5 measurements on the left side were also significantly different (p = 0.015). The results of the study have implications in the forensic analysis of foot impression evidence on insoles in footwear in assisting with identifying the wearer of said footwear. Situations may arise in the forensic context when comparing the foot impression on the insole of footwear to a suspect's bare footprint or a footprint from post-mortem remains. This study contributes to the scant literature available on the topic and to understanding the similarities and differences observed in the various linear measurements that may be utilized in the comparison process of footprint impressions on shoe insoles to bare footprints.

Comparative analysis of static and dynamic bare footprint dimensions in a north Indian population.

Footprints recovered from the scene of a crime may be made while the perpetrator is standing, termed static, or walking, termed dynamic. Numerous studies on the medical and forensic aspects of static and dynamic footprints have been done and determining whether a footprint found at a crime scene is static or dynamic may have important forensic implications. Yet, little research has focused on the similarities or differences between static and dynamic footprints in the forensic context. The present study compared static and dynamic footprint two-dimensional variables to determine if statistically significant differences existed between them and if one can be estimated from the other. Footprints were taken from a sample of randomly selected 461 Jatt Sikh adults; major north Indian population. A total of 230 males and 231 females aged between 19 and 32 years were included in the study. Static and dynamic footprints were obtained from the participants using standard methodology. Seven linear footprint measurements and three footprint indices were calculated from each footprint. The dynamic footprint variables showed higher magnitudes than the static variables, and the differences were statistically significant for the length and width measurements. Furthermore, all measurements on the static and dynamic parameters exhibited statistically significant sexual dimorphism and bilateral differences. An attempt was made to estimate the static footprint dimensions from the dynamic footprint dimensions using the regression models to check the extent of differences between the two to help the investigators in estimating dimensions of one from another.

Two-dimensional linear analysis of dynamic bare footprints: A comparison of measurement techniques.

In forensic intelligence-gathering, footprints have been shown to be valued evidence found at crime scenes. Forensic podiatrists and footprint examiners use a variety of techniques for measuring footprints for comparison of the crime scene evidence with the exemplar footprints. This study examines three different techniques of obtaining two-dimensional linear measurement data of dynamic bare footprints. Dynamic bare footprints were gathered from 50 students from a podiatric medical school using the Identicator® Inkless Shoe Print Model LE 25P system. After obtaining 100 bilateral footprints from the participants, the quantitative measurement data were collected by using three different measurement techniques: (i) a manual technique using a ruler (direct technique); (ii) an Adobe® Photoshop® technique; and (iii) a GIMP (GNU Image Manipulation Program) technique. The seven Reel linear measurement methodology was used for producing measurements using these three techniques. This study showed that all the mean bare footprint measurements on the right and left feet obtained using the direct technique were larger than those obtained using GIMP and Adobe® Photoshop® images. Differences were also observed in measurements produced using GIMP software and Photoshop images. However, the differences observed in the three techniques used for bare footprint measurements were not found to be statistically significant. The study concludes that there are no significant differences between the three measurement techniques when applied to two-dimensional bare footprints using the Reel method. It further concluded that any of these measurement techniques can be used when employing the Reel methodology for footprint analysis without significant difference.