Waist-What? Can a single sensor positioned at the waist detect parameters of gait at a speed and distance reflective of older adults' activity?

One of the problems facing an ageing population is functional decline associated with reduced levels of physical activity (PA). Traditionally researcher or clinician input is necessary to capture parameters of gait or PA. Enabling older adults to monitor their activity independently could raise their awareness of their activitiy levels, promote self-care and potentially mitigate the risks associated with ageing. The ankle is accepted as the optimum position for sensor placement to capture parameters of gait however, the waist is proposed as a more accessible body-location for older adults. This study aimed to compare step-count measurements obtained from a single inertial sensor positioned at the ankle and at the waist to that of a criterion measure of step-count, and to compare gait parameters obtained from the sensors positioned at the two different body-locations. Step-count from the waist-mounted inertial sensor was compared with that from the ankle-mounted sensor, and with a criterion measure of direct observation in healthy young and healthy older adults during a three-minute treadmill walk test. Parameters of gait obtained from the sensors at both body-locations were also compared. Results indicated there was a strong positive correlation between step-count measured by both the ankle and waist sensors and the criterion measure, and between ankle and waist sensor step-count, mean step time and mean stride time (r = .802-1.0). There was a moderate correlation between the step time variability measures at the waist and ankle (r = .405). This study demonstrates that a single sensor positioned at the waist is an appropriate method for the capture of important measures of gait and physical activity among older adults.

Patient Outcomes of Virtual Foot and Ankle Telephone Clinics During COVID-19 Pandemic: 1 Year Experience.

COVID-19 pandemic has instigated to find alternative methods of assessing and treating patients with foot and ankle disorders. We have implemented virtual telephone clinic consultations along with the face-to-face consultations. It has reduced overcrowding in the busy outpatient waiting area and thus limiting close patient contact. The aim of this study is to audit the patient satisfaction outcomes, assess the feasibility and to find out the potential financial implications of introducing telephone clinic consultations for foot and ankle disorders. A total of 426 patients who had telephone consultations for foot and ankle disorders for a period of 1 year were included. Patients were given individual time slots for the consultations. The patient satisfaction outcomes were assessed using a structured questionnaire. The outcomes following the telephone consultation was audited. The financial cost was calculated for the study period. Following the telephone consultation 35% of the patients were discharged and 36% were given further face to face appointments. 97.5% were very satisfied or satisfied with the methodology and outcomes of the telephone consultation. Ninety-five percent of the patients commented that they would recommend telephone consultations for foot and ankle to their friends and family. The financial savings calculated during the study period was about £25,000 ($30,000). Virtual telephone clinic consultations are safe, efficient and cost effective with good patient satisfaction outcomes. It is an alternative or can be conducted adjunct to face to face consultations with adequate planning, training, good communication skills and proper documentation.

Unstable gynaecological patient with an ankle monitor: implications of US Immigration and Customs Enforcement's Alternatives to Detention programme in the healthcare setting.

We review the case of an unstable gynaecological patient in the USA who presented with profuse vaginal bleeding after spontaneous miscarriage and was ultimately diagnosed with a uterine arteriovenous malformation managed with interventional radiology embolisation of her uterine artery. Her case was complicated by the presence of an ankle monitoring device which had been placed by US Immigration and Customs Enforcement as part of the Alternatives to Detention programme in which she was enrolled during her immigration proceedings. The device prompted important considerations regarding the potential use of cautery, MRI compatibility and device-related trauma, in addition to causing significant anxiety for the patient, who was concerned about how the team's actions could affect her immigration case. Discussion of her course and shared perspective highlights the unique clinical and medicolegal considerations presented by the expanded use of ankle monitoring devices for electronic surveillance (or 'e-carceration') of non-violent immigrants and others.

Effect of Ankle Weights as a Frailty Prevention Strategy in the Community-Dwelling Elderly: A Preliminary Report.

Since the start of the COVID-19 pandemic, many healthy older adults have been less willing to engage in group exercise for fear of contracting this illness. Therefore, there is a need for an effective home-based exercise program to prevent frailty in the elderly. In this study, we assessed the effectiveness of ankle weights as a frailty prevention device for older adults. The study participants were aged 50-90 years and were screened for falls using the Motor Fitness Scale. Participants were divided into two age groups (≤70 and >70 years) for analysis. Older community-dwelling adults were invited to use ankle weights for 3 months. Seventy-four people responded to the invitation. Physical and cognitive status and performance (body composition, grip strength, standing on one leg with eyes open, the 30 s chair stand test (CS-30), Timed Up and Go test, walking speed, body sway, Japanese version of the Montreal Cognitive Assessment) were assessed before and after 3 months of intervention. CS-30 performance improved during the study. CS-30 reflects lower limb/trunk muscle strength and can be used to indicate the risk of falls. Wearing ankle weights can be recommended for strengthening the muscles of the lower limb and trunk in the elderly.

The Application and Patient-Reported Experience of Telephone Consultations in Elective Foot and Ankle Orthopaedic Surgery: 12-Month Follow-up.

BACKGROUND: Telemedicine offers convenient and affordable health care, overcoming the logistical challenges of face-to-face encounters. Clinicians increasingly relied on telemedicine during the global pandemic. To assess the ongoing role for telemedicine in orthopaedics, we prospectively analyzed the failure rate, safety and patient-reported experience of telephone consultations for 12 months. METHODS: 265 telephone Foot/Ankle consultations were conducted in April 2020 and were prospectively analyzed over 12 months. The primary outcome measure was the rate of failed telephone consultations. A consultation was deemed unacceptable if the patient did not answer, if the clinician could not reach a conclusion or if any outcome changed over 12 months. Secondary outcome measures included patient-reported satisfaction and time saved by avoiding a face-to-face visit. RESULTS: A clinical decision was reached in 84% of follow-up telephone consultations and 64% of new patient consultations (P = 0.001). Sixty-six percent were managed with nonoperative therapies, 16% were discharged, and 11% were added to the waiting list for surgery. The reasons for failing to achieve a clinical decision included failure to contact the patient (12.8%), inappropriate discharge with subsequent rereferral (1.9%), and insufficient clinical information (1.5%). Overall, 84.7% of patients reported that the telephone consultation was highly useful and 71.9% would recommend it to a friend or family member. Patients reported a mean time saving of 120 minutes. CONCLUSION: Based on our experience, we provide recommended criteria for the safe and practical use of telephone consultations and suggest versatile patient care pathways into which a telephone consultation can be incorporated. LEVEL OF EVIDENCE: Level IV, prospective cohort series (noncomparative).

A Custom-Made Electronic Dynamometer for Evaluation of Peak Ankle Torque after COVID-19.

The negative effects of SARS-CoV-2 infection on the musculoskeletal system include symptoms of fatigue and sarcopenia. The aim of this study is to assess the impact of COVID-19 on foot muscle strength and evaluate the reproducibility of peak ankle torque measurements in time by using a custom-made electronic dynamometer. In this observational cohort study, we compare two groups of four participants, one exposed to COVID-19 throughout measurements and one unexposed. Peak ankle torque was measured using a portable custom-made electronic dynamometer. Ankle plantar flexor and dorsiflexor muscle strength was captured for both feet at different ankle angles prior and post COVID-19. Average peak torque demonstrated no significant statistical differences between initial and final moment for both groups (p = 0.945). An increase of 4.8%, p = 0.746 was obtained in the group with COVID-19 and a decrease of 1.3%, p = 0.953 was obtained in the group without COVID-19. Multivariate analysis demonstrated no significant differences between the two groups (p = 0.797). There was a very good test-retest reproducibility between the measurements in initial and final moments (ICC = 0.78, p < 0.001). In conclusion, peak torque variability is similar in both COVID-19 and non-COVID-19 groups and the custom-made electronic dynamometer is a reproducible method for repetitive ankle peak torque measurements.

Rate of COVID-19 infection and 30 day mortality between blue and green (dedicated COVID-19 safe) pathways: Results from phase 1 and 2 of the UK foot and ankle COVID-19 national (UK-FAlCoN) audit.

OBJECTIVES: The primary aim was to determine the differences in COVID-19 infection rate and 30-day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second UK national lockdowns. SETTING: This was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13th January 2020 and 30th November 2020. PARTICIPANTS: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway (no protocols to prevent COVID-19 infection). RESULTS: 10,846 patients were included, 6644 from phase 1 and 4202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6470) and 0.21% on a green pathway (9/4280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (Odd's Ratio 0.077, p < .001). There was no significant difference in COVID-19 related mortality between pathways. CONCLUSIONS: There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

Electroneurographic Evaluation of Neural Impulse Transmission in Patients after Ischemic Stroke Following Functional Electrical Stimulation of Antagonistic Muscles at Wrist and Ankle in Two-Month Follow-Up.

The available data from electroneurography (ENG) studies on the transmission of neural impulses in the motor fibers of upper and lower extremity nerves following neuromuscular functional electrical stimulation (NMFES) combined with kinesiotherapy in post-stroke patients during sixty-day observation do not provide convincing results. This study aims to compare the effectiveness of an NMFES of antagonistic muscle groups at the wrist and ankle and kinesiotherapy based mainly on proprioceptive neuromuscular facilitation (PNF). An ENG was performed once in a group of 60 healthy volunteers and three times in 120 patients after stroke (T0, up to 7 days after the incident; T1, after 21 days of treatment; and T2, after 60 days of treatment); 60 subjects received personalized NMFES and PNF treatment (NMFES+K), while the other 60 received only PNF (K). An ENG studied peripheral (M-wave recordings), C8 and L5 ventral root (F-wave recordings) neural impulse transmission in the peroneal and the ulnar nerves on the hemiparetic side. Both groups statistically differed in their amplitudes of M-wave recording parameters after peroneal nerve stimulation performed at T0 and T2 compared with the control group. After 60 days of treatment, only the patients from the NMFES+K group showed significant improvement in M-wave recordings. The application of the proposed NMFES electrostimulation algorithm combined with PNF improved the peripheral neural transmission in peroneal but not ulnar motor nerve fibers in patients after ischemic stroke. Combined kinesiotherapy and safe, personalized, controlled electrotherapy after stroke give better results than kinesiotherapy alone.

Surgically treated reactive arthritis of the ankle after COVID-19 infection: A case report.

A 37-year-old man developed right ankle pain and swelling six days after being diagnosed with coronavirus disease (COVID-19). Despite conservative treatment, his ankle symptoms persisted. Magnetic resonance imaging and computed tomography showed synovial hypertrophy and bone erosion in the ankle. Following arthroscopic synovectomy, performed 69 days after the COVID-19 diagnosis, the pain improved significantly. The clinical course was consistent with that of reactive arthritis following severe acute respiratory syndrome coronavirus 2 infection. The pathological findings resembled rheumatoid nodules. The bone erosion may have originated from the inflammatory pathway, which resembles the mechanism of rheumatoid arthritis.

Evaluation of the cardio-ankle vascular index in COVID-19 patients.

OBJECTIVE: This study aimed to investigate the relationship and prognostic significance of cardio-ankle vascular index, which is a measure of arterial stiffness that can lead to endothelial dysfunction and poor cardiovascular issues in COVID-19 patients, with COVID-19. METHODS: The study included 115 patients, of which 65 patients in the case group with Real time reversetranscription-polymerasechainreaction test positive and diagnosed for COVID-19 and 50 volunteers in the control group. Patients with COVID-19 were classified as moderate/severe or mild COVID-19 in the subgroup analysis based on the severity of the disease. We investigated the relationship between cardio-ankle vascular index and COVID-19 by using the VaSera VS-1000 device to automatically measure each patient's cardio-ankle vascular index and ankle-brachial pressure index. RESULTS: The mean age of participants included in the study was 65.7±10.7 years. Patients and volunteers were statistically similar in terms of age, gender, comorbidities, Charlson comorbidity index scores, and body mass index values (p>0.05). The right-cardio-ankle vascular index value was 9.6±2.4 in the case group and 8.5±1.1 in the control group (p=0.004). The left-cardio-ankle vascular index value was 9.4±2.7 in the case group and 8.5±1.2 in the control group (p=0.01). The right-cardio-ankle vascular index value was 10.8±3.4 in the moderate/severe disease group and 8.8±0.9 in the mild disease group (p=0.008). The left-cardio-ankle vascular index value was 10.7±3.6 in the moderate/severe disease group and 8.5±1.5 in the mild disease group (p<0.001). The right-cardio-ankle vascular index and left-cardio-ankle vascular index values were found to be significantly higher in COVID-19 patients in our study. When receiver operating characteristic analysis was performed to distinguish moderate/severe COVID-19 patients from mild patients, right-cardio-ankle vascular index was area under the curve 0.757 (0.630-0.884), and left-cardio-ankle vascular index was area under the curve 0.782 (0.661-0.902). CONCLUSION: The right-cardio-ankle vascular index and left-cardio-ankle vascular index values increased in COVID-19 patients in our study, and this was thought to be prognostically significant.

Virtual clinics in foot and ankle surgery: patient and clinician perceptions.

BACKGROUND: The worldwide COVID-19 pandemic has led to the popularisation of 'virtual' clinics. In orthopaedics, little is known about the use of virtual clinics within foot and ankle surgery, specifically. METHODS: A cross-sectional observation study of patients and clinicians in response to virtual clinics in foot and ankle surgery. Patients seen in a virtual clinic were contacted by telephone from two weeks after their consultation and asked to complete a 12-point questionnaire. Demographic information was also collected. Clinicians in foot and ankle completed a 10-point questionnaire. RESULTS: One hundred patient responses were collected. Patient satisfaction with virtual clinics was positive, with 65% of respondents reporting they were very happy (Likert scale rating 5). More than 90% of patients felt they received enough information, felt involved, felt the virtual clinic was helpful and knew who to contact if there was a problem. However, 79% would still prefer a face-to-face consultation, and 22% would have preferred a video consultation. Clinician responses were more cautious, with 60% stating they were neither happy nor unhappy (Likert scale rating 3). Virtual clinics may be faster for the clinician. CONCLUSIONS: Virtual clinics may be more convenient for patients, with high satisfaction levels reported, but represent significant clinical challenges for foot and ankle surgeons. Elements of virtual clinics may persist post pandemic, particularly in routine follow-up. Virtual clinics are not appropriate for new patient referrals.

Elective foot and ankle surgery following the peak of the COVID-19 pandemic is safe: A report of 30-day morbidity and mortality.

INTRODUCTION: The safety of resuming elective surgical services remains unclear following several surges of the COVID-19 pandemic worldwide. Multiple studies have reported high rates of post-operative mortality and pulmonary complications. 30-day outcomes on an initial cohort of patients undergoing elective foot and ankle surgery at 3 central London hospitals are presented. MATERIALS AND METHODS: This study is a retrospective review of the first 63 patients undergoing surgery following the first UK surge via a modified treatment pathway, based on published national guidelines, designed to minimise the risks to patients and staff associated with COVID-19. RESULTS: 90% of patients were ASA 1 or 2, with an average age of 46. All tested negative for COVID-19 pre-operatively and all but one underwent a general anaesthetic. 10 patients required one night hospital stays and 1 was admitted for four nights. 52 were day case procedures. 2 complications were identified, not relating to COVID-19 infection. No 30-day mortalities or pulmonary complications were recorded. CONCLUSIONS: With a community prevalence of COVID-19 of between 1 in 1500 and 1 in 1700, elective foot and ankle surgery was safe following the first surge of the pandemic in the UK. This data can guide elective service planning in countries with pandemic curves behind the UK's or in the event of further surges in national cases.

Experience of Using Telehealth for Foot and Ankle Examination During The SARS-COV-2 Crisis.

The era of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) is rapidly evolving. To comply to the guidelines for social distancing and reducing travel to prevent the spread of disease, many centers made rapid adjustments to conduct follow-up appointments through telehealth mediums. We explore our center's adaptation to the pandemic, reflecting on how we formulated telehealth clinics for our patients. We share our experience, discuss the challenges encountered, the feedback received, as well as consider the future role of telehealth in everyday orthopaedic practice.Levels of Evidence: Level V.

The UK foot and ankle COVID-19 national (FAlCoN) audit - Regional variations in COVID-19 infection and national foot and ankle surgical activity.

AIMS: This paper details the impact of COVID-19 on foot and ankle activity in the UK. It describes regional variations and COVID-19 infection rate in patients undergoing foot and ankle surgery before, during and after the first national lock-down. PATIENTS & METHODS: This was a multicentre, retrospective, UK-based, national audit on foot and ankle patients who underwent surgery between 13th January and 31st July 2020. Data was examined pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Regional, demographic and COVID-19 related data were captured. RESULTS: 6644 patients were included. In total 0.53% of operated patients contracted COVID-19 (n = 35). The rate of COVID-19 infection was highest during lockdown (2.11%, n = 16) and lowest after lockdown (0.16%, n = 3). Overall mean activity during lockdown was 24.44% of pre-lockdown activity with decreases in trauma, diabetic and elective foot and ankle surgery; the change in elective surgery was most marked with only 1.73% activity during lock down and 10.72% activity post lockdown as compared to pre-lockdown. There was marked regional variation in numbers of cases performed, but the proportion of decrease in cases during and after lockdown was comparable between all regions. There was also a significant difference between rates of COVID-19 and timing of peak, cumulative COVID-19 infections between regions with the highest rate noted in South East England (3.21%). The overall national peak infection rate was 1.37%, occurring during the final week of lockdown. General anaesthetic remained the most common method of anaesthesia for foot and ankle surgery, although a significant increase in regional anaesthesia was witnessed in the lock-down and post-lockdown periods. CONCLUSIONS: National surgical activity reduced significantly for all cases across the country during lockdown with only a slow subsequent increase in elective activity. The COVID-19 infection rate and peaks differed significantly across the country.

AnkFall-Falls, Falling Risks and Daily-Life Activities Dataset with an Ankle-Placed Accelerometer and Training Using Recurrent Neural Networks.

Falls are one of the leading causes of permanent injury and/or disability among the elderly. When these people live alone, it is convenient that a caregiver or family member visits them periodically. However, these visits do not prevent falls when the elderly person is alone. Furthermore, in exceptional circumstances, such as a pandemic, we must avoid unnecessary mobility. This is why remote monitoring systems are currently on the rise, and several commercial solutions can be found. However, current solutions use devices attached to the waist or wrist, causing discomfort in the people who wear them. The users also tend to forget to wear the devices carried in these positions. Therefore, in order to prevent these problems, the main objective of this work is designing and recollecting a new dataset about falls, falling risks and activities of daily living using an ankle-placed device obtaining a good balance between the different activity types. This dataset will be a useful tool for researchers who want to integrate the fall detector in the footwear. Thus, in this work we design the fall-detection device, study the suitable activities to be collected, collect the dataset from 21 users performing the studied activities and evaluate the quality of the collected dataset. As an additional and secondary study, we implement a simple Deep Learning classifier based on this data to prove the system's feasibility.

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.

The Virtual Foot and Ankle Physical Examination.

The COVID-19 pandemic has necessitated a rapid and drastic shift for clinicians and patients away from traditional in-person visits and toward internet-based virtual visits. The adoption of telehealth services is likely to persist in some capacity even as in-person visits resume, given the convenience and efficiency of telehealth consultations for patients and perhaps surgeons. A primary challenge of virtual visits, particularly in the field of orthopedic surgery, is the physical examination. However, for the foot and ankle, routine physical examination maneuvers can be completed virtually with little modification given proper patient instruction. We present a comprehensive virtual foot and ankle examination for telehealth visits, including instructions that can be provided to patients verbatim and a corresponding checklist for provider documentation.Level of Evidence: Level V, expert opinion.