Role of insole material in treatment of plantar fasciitis: A randomized clinical trial

BACKGROUND

In this randomized clinical trial, we compared the early effects of polyethylene (PE), polyurethane (PU), and Carbon Fiber insoles in the treatment of PF using a set of patient-reported outcomes.

METHODS

Patients were randomly allocated one of the three prefabricated insoles - Carbon Fiber (n = 14), PU (n = 14), or PE (n = 17) for regular use. Their response was recorded using PROMIS 3a (for pain intensity), PROMIS 4a (for pain interference), FAOS (Foot and Ankle Outcome Score), and VAS for pain at baseline, two, six, and twelve weeks.

RESULTS

The PROMIS pain intensity scores improved in both the Carbon Fiber and the PE groups starting at the 6th week (p = 0.04) and 2nd week (p = 0.002), respectively. PROMIS pain interference scores also showed positive trends in these two groups (p = 0.02, p = 0.004, respectively).

CONCLUSION

Prefabricated Carbon Fiber and PE insoles showed significant pain-reducing effects in patients with PF.

LEVELS OF EVIDENCE

Level I, Randomized controlled trial.

Responsiveness and Inter-Rater Reliability of the Pulse Volume Recording Upstroke Ratio (PVRr)

The objective of this study was to evaluate a measure of the responsiveness and reliability of the pulse volume recording upstroke ratio (PVRr). A database of 389 subjects undergoing lower extremity revascularization was analyzed. Subjects were included in the analysis if they had undergone pedal radiographs, had PVRs performed pre- and postlower extremity revascularization, and had regular pulsatile digital waveforms with a pressure recording on both PVRs. The responsiveness of the PVRr was assessed by means of the postoperative percent change in comparison to the digital pressures. A statistically significant negative correlation was observed (Pearson -0.421; p = .007) indicating that as digital pressures increased, the PVRr decreased. Further, measurement of the reliability of the PVRr was performed on a selection of 10 recordings by 2 residents and 3 board-certified surgeons. The observed intraclass correlation coefficient of measurements was 0.960. Results of this investigation provide evidence in support of the responsiveness and inter-rater reliability in the calculation of the pulse volume recording upstroke ratio.

Approximation of the Ankle-Brachial Index in the Setting of Medial Arterial Calcific Sclerosis

The presence of medial arterial calcific sclerosis is known to cause inaccuracy in the interpretation of noninvasive vascular testing. This substantially limits the utility of an important baseline diagnostic test for peripheral arterial disease. Therefore, the objective of this investigation was to derive a method to effectively factor out calcification in the interpretation of the ankle and digital brachial indices. The noninvasive vascular testing results of 160 subjects were stratified into the absence of calcification, mild calcification, moderate calcification, and severe calcification based on plain film radiographic findings of the infrageniculate vessels. Measurements were then performed of the pulse volume recording (PVR) waveforms at brachial, ankle and digital anatomic levels to include PVR wavelength and PVR upstroke length, with a calculation of the ratio of PVR upstroke length to PVR wavelength. These measurements were compared between groups and then correlated to the ankle and digital brachial indices. A significant difference was observed in the PVR upstroke ratio between the 3 anatomic levels (0.1818 vs 0.2622 vs 0.3191; p < .001), but not between the 4 calcification groups (0.2457 vs 0.2363 vs 0.2694 vs 0.2631; p = .242). A significant negative correlation was observed between the PVR upstroke ratio and the ankle brachial index (ABI) (Pearson -0.454; p = .002) with linear regression indicating the relationship is defined by the formula: Effective ankle brachial index = 1.17 - (1.33 × PVR upstroke ratio at ankle level). A significant negative correlation was also observed between the PVR upstroke ratio and the digital brachial index (Pearson -0.553; p < .001) with linear regression indicating the relationship is defined by the formula: Effective toe brachial index = 1.04 - (1.61 × PVR upstroke ratio at digital level). The results of this investigation demonstrate the feasibility of, and provide equations to approximate, the effective ankle brachial and toe brachial indices in the setting of medial arterial calcification.

A Comparison of Adverse Short-Term Outcomes Following Forefoot Amputation Performed on an Inpatient Versus Outpatient Basis

The objective of this investigation was to evaluate short-term adverse outcomes following forefoot amputation with a specific comparison between those procedures performed on an inpatient versus outpatient basis. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated to select those subjects with a 28805 current procedural terminology code (amputation, foot; transmetatarsal) that underwent the procedure with "all layers of incision (deep and superficial) fully closed." This resulted in 326 subjects who underwent the procedure on an inpatient basis and 72 subjects who underwent the procedure on an outpatient basis. Results of the primary outcome measures found no significant differences between groups with respect to the development of a superficial surgical site infection (5.8% vs 5.6%; p = .950), deep incisional infection (3.4% vs 5.6%; p = .380), or wound disruption (3.4% vs 6.9%; p = .163). Additionally, no significant differences were observed between groups with respect to unplanned reoperations (15.6% vs 12.5%; p = .500) or unplanned hospital readmissions (21.8% vs 23.6%; p = .957). The results of this investigation demonstrate no difference in short-term adverse outcomes following the performance of forefoot amputation with primary closure when the procedure is performed on an inpatient or outpatient basis. We hope that this information is utilized in future investigations specifically examining this clinical scenario as it relates to hospital admission criteria related to lower extremity tissue loss, length of hospital stay considerations, the timing of partial foot amputation following revascularization, and the economics of limb preservation.

Development of Multiple Epidermal Inclusion Cysts After Radiofrequency Microtenotomy for Plantar Fasciitis: A Case Report

Epidermal inclusion cysts are slowly developing intradermal lesions which form after the implantation of epidermal tissue into the dermal tissue. Epidermal cysts occur infrequently in the foot, but can occur after traumatic episodes, including surgically induced trauma. Epidermal inclusion cysts have been described as a complication of minimally invasive foot and ankle surgery; however, they have been described infrequently as a complication of radiofrequency microtenotomy. To our knowledge, only one other case study exists discussing the development of a singular epidermal cyst after undergoing radiofrequency microtenotomy. Therefore, the purpose of the present case report was to discuss a case of the development of multiple epidermal inclusion cysts of the plantar heel after radiofrequency microtenotomy for treatment of plantar fasciitis. After undergoing radiofrequency coblation in November 2017, the patient developed multiple plantar heel cysts. She went on to have them surgically removed in February 2018 and again in June 2018. By the time of presentation to our office in October 2018, multiple cysts were still present to her heel despite 2 surgical excisions. Seventeen months after surgical excision in February 2019, the patient remained cyst-free.

Evaluation of the Relationship Between Aspects of Medical Complexity and Work Relative Value Units (wRVUs) for Foot and Ankle Surgical Procedures

Work relative value units (wRVUs) have been assigned to current procedural terminology codes in an effort to help establish physician compensation. However, the ability of these to accurately and efficiently capture the time, technical, and perioperative managerial aspects required of various procedures has recently been called into question for several surgical subspecialties. Therefore, the objective of this investigation was to evaluate various measures of medical complexity against wRVUs for foot and ankle surgical procedures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify and extract data related to the perioperative medical complexity of 16 foot and ankle surgical current procedural terminology codes. We observed a "weak" positive relationship between wRVUs and operation time as defined by a correlation coefficient of 0.234 (p < .001). Other variables associated with medical complexity in the perioperative period were found to significantly vary between wRVUs categories, but these differences were neither consistently nor directly associated with assigned relative values. We conclude that wRVUs might not always represent an efficient means for determining compensation for foot and ankle surgical procedures.

Evaluating the Impact of Medial Arterial Calcification on Outcomes of Infrageniculate Endovascular Interventions for Treatment of Diabetic Foot Ulcers

BACKGROUND

Medial arterial calcification (MAC) of the tibial and pedal arteries has been associated with an increased risk of amputation among people with diabetes. Endovascular interventions on infrageniculate vessels are frequently performed with the intent of treating peripheral artery disease (PAD) and decreasing the risk of amputation in those with diabetes. This study aimed to investigate how the extent of MAC impacts outcomes of endovascular procedures in people with diabetic foot ulcers (DFU).

METHODS

We identified all patients who had undergone infrageniculate angioplasty in the setting of DFU at our institution between 2009 and 2019. Subjects were assigned a MAC score based on the severity of MAC in each vessel visualized on plain radiographs of the ankle and foot. We evaluated the relationship between MAC and the primary outcome, major adverse limb event (MALE), using stratified Cox proportional modeling.

RESULTS

Among 99 subjects with DFU who had undergone infrageniculate angioplasty, MALE occurred in 50% (95% confidence interval [CI] 38%-61%) of patients within 1 year of intervention. On univariate Cox regression analysis, each 1 point increment in MAC score (hazard ratio [HR], 1.09; 95% CI 1.01-1.18), the third tertile of MAC score (HR, 2.27; 95% CI 1.01-5.11), age (HR 0.96; 95% CI 0.93-0.99), and wound grade (HR, 5.34; 95% CI 2.17-13.14), were significantly associated with increased risk of MALE. On adjusted analysis stratified by wound grade, MAC score was found to be associated with MALE only in patients with a low wound grade.

CONCLUSION

Increased severity of MAC is associated with increased risk of MALE for subjects undergoing infrageniculate angioplasty with a low wound grade. Further research is needed to better understand the complex relationships of MAC, PAD, DFU, and interventions aimed at promoting healing of DFU.

Comparative Evaluation of Radiographic Parameters of Foot Pronation in Two Different Conditions versus Barefoot

BACKGROUND

To date, there is conflicting evidence that high-end "motion control" running shoes can correct and control rearfoot pronation. Many methods have been used to evaluate the efficacy of motion control footwear in reducing hindfoot pronation during gait, including stop-motion photography, three-dimensional camera kinematic analysis, and three-dimensional bone modeling using computed tomography. Until now, there have been no radiographic studies that examined the effect of motion control running shoes on the static posture of the foot. Murley et al devised a reliable system that correlated noninvasive clinical examinations to radiographic values that correspond to foot pronation. The aim of this prospective investigation was to determine whether motion control running shoes are able to produce a significant difference in pronation through a radiographic study, using the angular relationships as described by Murley et al, in two different shoe conditions as compared to the barefoot condition in female subjects.

METHODS

This prospective study screened 28 female subjects ranging in age from 22 to 27 years on the basis of arch height index. The 24 subjects with a standing arch height index less than 0.370 were invited to participate in the study. Unilateral weightbearing dorsoplantar and lateral foot radiographs were taken in barefoot, neutral shoe, and motion control shoe conditions. Calcaneal inclination angle, calcaneal-first metatarsal (CFMA) angle, talonavicular coverage angle (TNCA), and talus-second metatarsal angle were measured in each condition by two independent observers using the Opal-Ortho PACS software package and then averaged. Angles were compared to barefoot baseline values using paired t tests.

RESULTS

The motion control running shoe produced average decreases of 2.64% in CFMA, 12.62% in TNCA, 5.3% in talus-second metatarsal angle and an average increase of 1.3% in calcaneal inclination angle. Statistically significant ( P > .05) improvements in CFMA were noted in both the motion control ( P < .000) and neutral shoe conditions ( P < .000) when compared to barefoot, whereas TNCA improved only in the motion control shoe condition as compared to barefoot ( P = .003).

CONCLUSIONS

This investigation found evidence that the particular models of motion control running shoes studied could correct foot pronation in the transverse and sagittal planes in stance. Motion control running shoes improved CFMA and TNCA from the barefoot condition and were more effective in correcting pronation compared with neutral running shoes in this radiographic study simulating static foot posture in stance.

A clinical trial simulation study of a new pediatric phase I trial methodology: The rolling six design

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Background: Phase I cancer trials have traditionally used the 3+3 study design in which cohorts of three patients at a time are enrolled. The study is suspended to accrual with every 3rd patient, and again suspended to replace inevaluable patients. As the pediatric phase I starting dose is based on adult phase I safety data, we hypothesized that pediatric study timelines could be shortened without increasing risk using a novel rolling six design, in which up to 6 patients are concurrently enrolled per dose level. Methods: A trial simulation approach comparing the standard 3+3 design to the rolling six design was performed. Discrete time events (accrual/enrollment, evaluation and/or time to dose limiting toxicity (DLT) or inevaluability) with outcome probabilities (DLT/inevaluability) assigned to each subject based on historical data from phase I pediatric oncology trials. The probability of DLT was a function of dose level and varied distributions were used to assign discrete time elements. Metrics for study efficiency (time to complete study, total number of patients required) were determined for each design. Simulated trials and decision rule logic were coded using PC/Windows SAS v9.1. Results: The rolling six design outperformed the 3+3 design for the most relevant metrics. Average (±SD) time to study completion was 373±90 days vs. 431±98 days and the total number of patients required was 20±5 vs. 17±4 for the rolling six vs. 3+3 designs, respectively. There was no difference in the number of DLTs per study (3±1) between designs. Conclusions: The rolling six design is predicted to shorten pediatric phase 1 study timelines and will be tested prospectively in upcoming COG phase I trials.

No significant financial relationships to disclose.

Increased proteasome degradation of cyclin-dependent kinase inhibitor p27 is associated with a decreased overall survival in mantle cell lymphoma

Mantle cell lymphoma (MCL) is an aggressive neoplasm characterized by the deregulated expression of cyclin D1 by t(11;14). The molecular mechanisms responsible for MCL's clinical behavior remain unclear. The authors have investigated the expression of p53, E2F-1, and the CDK inhibitors p27 and p21 in 110 MCLs, relating their expression to proliferative activity (Ki-67). For comparison, they have similarly analyzed low-grade (12 MALT, 16 CLL/SLL) and high-grade (19 DLCL) lymphomas. p53 was detected more frequently in large-cell MCL (l-MCL; 5 of 7) than in classical MCL (s-MCL; 13 of 103) and DLCL (8 of 19). In MCL and DLCL, the percentage of E2F-1+ nuclei was high, correlating with high Ki-67 expression. Most MCLs (91 of 112) and DLCLs (12 of 19) showed a loss of p27; MALT and CLL/SLL, however, were p27 positive. Reverse transcription-polymerase chain reaction and in vitro protein degradation assays demonstrated that MCLs have normal p27 mRNA expression but increased p27 protein degradation activity via the proteasome pathway. Correlation of MCL p53 and p27 expression with clinical data showed an association between reduced overall survival rates and the overexpression of p53 (P =.001), the loss of p27 (P =. 002), or both. Loss of p27 identified patients with a worse clinical outcome among p53 negative cases (P =.002). These findings demonstrated that MCL has a distinct cell cycle protein expression similar to that of high-grade lymphoma. The loss of p27 and the overexpression of p53 in MCL are prognostic markers that identify patients at high risk. The demonstration that low levels of p27 in MCL result from enhanced proteasome-mediated degradation should encourage additional clinical trials. (Blood. 2000;95:619-626) (Blood. 2000;95:619-626)