Israel Medical Association Journal

Background: Flexible flatfoot (FF) is a common foot deformity that can often consist of foot pain. Surgical treatment is designed to lengthen the lateral column.

Objectives: To resolve whether radiographic standing feet measurements of normo-plantigrade feet and FF, symptomatic or not, differ and to determine whether the lateral column is shorter.

Methods: The study comprised 72 patients (127 feet) consecutive patients, 18 years of age and older, who were divided into three groups: normal feet (56), asymptomatic FF (29), and symptomatic FF (42). All patients had a standing anterior posterior (AP) and lateral radiographs. AP images were used for the measurement of the talocalcaneal angle, talar-1st metatarsal angle, and talonavicular coverage. Lateral X-rays were used to estimate the talocalcaneal angle, talar-1st metatarsal angle, calcaneal pitch, naviculocuboid overlap, and column ratio.

Results: All three of the AP radiograph measurements differed among groups, and higher values were measured in the symptomatic FF group. Post hoc analysis found that the talonavicular coverage and the talocalcaneal angles also differed between symptomatic and asymptomatic FF patients. While some lateral measurements differed within groups, only the lateral talar-1st metatarsal angle distinguished between asymptomatic and symptomatic patients. The lateral column length was not found to be shorter among FF patients, weather symptomatic or not.

Conclusions: Only the talonavicular coverage, the AP talocalcaneal, and the lateral talar-1st metatarsal angles were found to differ between asymptomatic and symptomatic FF patients. The lateral column was not found to be shorter

Background: Lower extremities ulcers (LEU) are associated with considerable morbidity and mortality. With longer life expectancy, the prevalence of LEU in developed countries is assumed to grow, necessitating an increased demand for treatment by specialists. 

Objectives: To compare the effectiveness of a telemedicine video conferencing modality with the conventional face-to-face treatment of LEU. 

Methods: The study was conducted in conjunction with a two-million member healthcare organization in Israel (Maccabi Healthcare Services). Consecutive visits of patients to wound care specialists during a 12-month observation period reviewed in 2015 were valuated. A nurse-assisted setting was implemented during all treatment sessions. The same specialist supervised patients in both modalities. 

Results: A sample of 111 patients (n=55 in the telemedicine group; n=56 in the face-to-face group) with 593 visits was analyzed. No significant difference in healing of LEU (78.2% in telemedicine vs. 75.0% in face-to-face) was detected, P = 0.823. A reduced number of visits in telemedicine (4.36 ± 2.36) compared to the face-to-face care (6.32 ± 4.17) was shown, P = 0.003. Non-inferiority of telemedicine demonstrated within the Δ = 15% range limits and 80% statistical power was demonstrated. 

Conclusions: Compared to the usual face-to-face method, synchronous video conferencing-based telemedicine may be a feasible and efficient method for LEU management. 

 

Background: Mycetoma is a chronic and destructive infection caused by either fungus or bacteria. Mycetoma has a characteristic clinical presentation of a triad of tumor-like swelling, draining sinuses, and macroscopic grains. Mycetoma infection is extremely rare in Israel; however, in view of the recent immigration from mycetoma-hyperendemic regions of Africa to Israel, physicians in Israel may encounter this infection.

Objectives: To present two cases of mycetoma caused by Madurella mycatomatis in immigrants from endemic regions in Sudan treated at our hospital, and review the current literature. 

Conclusions: Health care professionals in Israel should suspect mycetoma in patients from endemic countries who present with tumor-like swelling especially in the lower extremity. Health care workers should be able to recognize mycetoma and provide the optimal treatment before the lesion progresses to an advanced and disabling disease. 

 

Background: Common peroneal neuropathies, usually located at the fibular head, are one of the causes of drop foot, a condition often evaluated in the electromyography laboratory.

Objectives: To study the motor conduction properties of the common peroneal nerve and its branches of distribution in patients with paralyzed drop foot, several weeks after their first stroke, assuming that its inversion position can cause neuropathy around the fibular neck.

Methods: We performed peroneal nerve conduction study on 76 legs of 38 patients, 12–73 days after their first stroke. All the patients had flaccid drop foot on the involved side. The stimulating electrode was placed at the postero-lateral aspect of the fibular neck. Motor nerve conduction latency and compound muscle action potential amplitude were measured along the proximal part of the deep and the superficial peroneal nerve, comparing the paralyzed to the sound leg. Paired sample t-test and paired t-test were used to compare the nerve conduction properties between the sound and the paralytic leg. The linear liaison between the two legs was determined by Pearson coefficient and the test based on it.

Results: The differences between motor conduction latencies and between CMAP[1] amplitudes, comparing the paralyzed to the sound side, recorded in both the deep peroneal nerve and the superficial peroneal nerve, were statistically significant (P < 0.05).
Conclusions: It seems that the permanent equino-varus position of the paralyzed foot might affect common peroneal nerve conduction properties at the level of the fibular neck by demyelination, axonopathy, or both. Possible reasons for these pathological changes are nerve traction or nerve compression, but temperature changes in the paralytic leg should also be considered. Ankle-foot orthoses can be prescribed for prevention or correction of deformities of the foot and ankle and reduction of the weight-bearing forces

Objectives: To describe an alternative de-loading method using a fiberglass removable walking cast.

Methods: This prospective uncontrolled study comprised 24 diabetic and non-diabetic patients with a single planter neuropathic ulcer. Exclusion criteria included the presence of osteomyelitis or cellulites, peripheral vascular disease, severe foot or leg edema, more than one ulcer on the treated foot, ulcers on the other foot, visual problems, gait instability, and personality or psychiatric problems. All patients were treated with the removable fiberglass de-loading cast. At each weekly follow-up visit the cast was removed. Data were collected using a clinical report form.

Results: The ulcer healed completely in 21 of the 24 patients treated (87.5%). The mean time for healing was 6.8 weeks (range 3–20 weeks, SD = 4.2). New ulcers developed in six patients (25% of the group).

Conclusions: The effectiveness and safety of the method is comparable to that of the total contact cast, but is less labor intensive because the cast is manufactured only once and serves for the whole length of treatment. Improving the technique is expected to lower the complication rate.

Objectives: To compare the outcomes of two groups of CICF[1] patients who underwent two different treatment protocols.

Methods: The study cohort included 72 infants treated in our hospital from August 1998 to December 2002. Group 1 comprised 40 infants (61 clubfeet) who were treated by a traditional method (a modification of the Kite and Lovell technique), and group 2 consisted of 32 infants (48 clubfeet) who were treated with the Ponseti technique. Both groups were similar in age, gender and severity of the deformity (Dimeglio scoring system)

Results: After an average follow-up of 54.9 months (range 44–68), 35 (57%) clubfeet in group 1 required surgical intervention and 27 (44%) clubfeet had a residual deformity at last follow-up. In the Ponseti group, 45 (94%) clubfeet were fully corrected at last follow-up (average 29.2 months, range 16–45) while 3 (6%) clubfeet had residual deformity and required surgery. Tendo-Achilles tenotomy was performed with no complications in 47 clubfeet (in group 2) at an average age of 2.4 months (range 2–4 months).

Conclusions: Even after a relatively short follow‑up period, our success rate with the Ponseti approach already appears to be significantly higher and to bear fewer complications than the traditional treatment, in agreement with the results published by other medical centers. We now endorse the Ponseti technique of conservative manipulative treatment for congenital idiopathic clubfoot in our department.

Background: Open reduction and internal fixation are the current trends of treatment for comminuted calcaneal fractures. Assessing treatment results is often difficult due to discrepancy between objective parameters such as range of movement, and subjective results such as pain.

Objectives: To test the reliability of footprint analysis as an adjuvant method of postoperative assessment of patients who sustained calcaneal fractures.

Methods: Dynamic and static footprint analysis was used as an adjuvant method to objectively assess operative results. This method is simple and is independent of the patient’s initiatives. This modality was used in 22 patients followed-up 9–90 months postoperatively.

Results: We found a good correlation between footprint analysis and objective and subjective parameters of results expressed by the American Orthopedic Foot and Ankle Society hind foot score. In certain cases, this method can be used to distinguish between uncorrelated parameter results, such as malingering, and workmens’ compensation claims.

Conclusion: We recommend the use of this simple, non-invasive objective test as an additional method to assess the results of ankle and foot surgery treatment.