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Lower Extremity Review

Snake Bites to the Lower Extremity Reported to U.S. Emergency Departments

Snake Bites to the Lower Extremity Reported to U.S. Emergency Departments

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Background: Thousands of snake bites occur in the U.S. each year. Venomous snake bites can produce serious adverse effects, and even bites from nonvenomous snakes may cause adverse effects. Snake bites are often treated at hospital emergency departments (EDs). The objective of this study was to describe snake bites to the lower extremity treated at US hospital EDs.

Methods: The data source for this study was the National Electronic Injury Surveillance System (NEISS), a database of consumer product- and activity-related injuries collected from a representative sample of approximately 100 U.S. hospital EDs. National estimates are calculated from database records according to the sample weight assigned to each case based on the inverse probability of the hospital being selected for the NEISS sample. Cases were snake bites to the lower extremity treated during 2000–2024. The distribution of snake bites to the lower extremity was determined for selected variables.

By Mathias B. Forrester, BS

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lerEXPO Highlights: Fibular Nails–Fad or New Standard?

lerEXPO Highlights: Fibular Nails–Fad or New Standard?

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This article synthesizes the key findings, surgical techniques, and clinical insights from a lerEXPO’s 2025 Gait Keepers Journal Club regarding the use of intramedullary fibular nails for distal fibula fractures. The primary focus is on a retrospective multi-center study published in the Journal of Foot & Ankle Surgery (JFAS) in 2023, which represents the largest cohort of its kind to date.

The transition from traditional Open Reduction Internal Fixation (ORIF) with plates and screws toward intramedullary fibular nailing represents a significant paradigm shift in ankle fracture management. While historically reserved for “train wreck” patients–those with compromised soft tissue, diabetes, or advanced age–current clinical evidence suggests that fibular nails are highly effective for simpler fracture patterns, such as stress-positive Weber B fractures.

By Brian Burgess, DPM with Brad Abicht, DPM, FACFAS and Jeff Dikis, DPM

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Closing the Loop on “Frequent Flyers”

Closing the Loop on “Frequent Flyers”

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I used to think that my job ended when the wound closed. Document the healing, schedule a routine follow-up, and move on to the next case. But after over 2 decades managing diabetic foot wounds at high volume, I’ve learned that the months immediately following epithelialization are (counterintuitively) when my patients need me most.

The “frequent flyers” in my practice are diabetic patients who cycle in and out: ulcer, healing, discharge, recurrence, ulcer again. Some have already lost part of a foot to amputation. Others carry multiple comorbidities–vascular disease, renal insufficiency, and poor glycemic control. These are the patients who have the deck stacked against them. Their decline follows a predictable path. Without a rigorous, closed-loop post-healing protocol, these patients almost always reulcerate. Studies show that reulceration rates hover around 40% at 1 year and up to 65% at 5 years 1. Hospitalization for cellulitis or abscess becomes routine. Amputation often feels inevitable.

By Mikel D. Daniels, DPM, MBA, President and Chief Medical Officer, WeTreatFeet Podiatry

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Zipline-Related Lower Extremity Injuries Treated at Hospital Emergency Departments

Zipline-Related Lower Extremity Injuries Treated at Hospital Emergency Departments

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A zipline is a horizontal rope, wire, or beam with a mechanical system that allows a person to slide along the rope, wire, or beam by hanging beneath it. Ziplines can range from something as simple as a piece of wire and a clothesline pulley to complex assemblies containing cables, attachments, trollies, computer control systems, hydraulics, motors, and sophisticated braking systems. Using ziplines has gained popularity as a form of outdoor recreation. As of 2020, there were over 400 commercial ziplines in the U.S. that provided more than 70 million rides annually.

By Mathias B. Forrester, BS

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Controlled Ankle Motion Walkers: Similar, but Not the Same

Controlled Ankle Motion Walkers: Similar, but Not the Same

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Controlled Ankle Motion walkers (CAMs) are prefabricated ankle-foot interventions commonly used to address a broad range of orthopedic and vascular diagnoses. Variants of these intervention types appear to have differing kinematic features despite being described by the same billing codes and regarded as belonging to the same intervention strategy.

By Michael S. Ginzburg PsyD, CO; Rachel White CPO

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Failed Forefoot MIS Surgery: What Can You Do to Prevent This from Happening

Failed Forefoot MIS Surgery: What Can You Do to Prevent This from Happening

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Minimally Invasive Surgery (MIS) in foot and ankle continues to evolve, offering new avenues for patient care. This discussion delves into the nuances of MIS, particularly concerning bunion correction and common challenges. For those venturing into or deepening their expertise in MIS, understanding the learning curve is paramount. While historically mastering bunion correction required 60–70 cases in 2017, to 40 cases in 2022, advancements like third-generation bunion correction with 2 screws, stable fixation, and jigs have significantly reduced this learning. It is important to note that these learning curves are not directly correlated to complication.

By Raquel Sugino, DPM, MS, FACFAS

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lerEXPO Conversation: Congestive Lower Extremity Failure (CLEF)

lerEXPO Conversation: Congestive Lower Extremity Failure (CLEF)

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Healthcare professionals are continually striving to improve patient outcomes through enhanced understanding and precise diagnosis. Yet, a significant pathological continuum, chronic venous insufficiency (CVI) and chronic venous disease (CVD), remains grossly underrecognized and misunderstood by many across the healthcare spectrum. This gap in knowledge often leads to delayed or incorrect diagnoses, suboptimal patient care, and unnecessary suffering for millions worldwide.

By John Chuback, MD

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Expert Guidance: Beating the Heat–Back to School Takes Preparation

Expert Guidance: Beating the Heat–Back to School Takes Preparation

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Approximately 9,000 high school athletes are treated for heat-related illnesses every year in the United States. Back-to-school means back-to-sports for many students around the country. With the return of sports, health and safety guidelines must be in place. The National Athletic Trainers’ Association recommends 6 strategies for Exertional Heat Stroke (EHS) preparedness including: 1) hydration access; 2) emergency response plan enacted for school athletics; 3) policy with instructions for initiating emergency medical reservices response; 4) trained athletic training staff for recognition and treatment of EHS; 5) immersion tub filled with ice water before start of practice; 6) monitor wet-bulb globe temperature.

By Ciara L. Taylor, EdD, LAT, ATC

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First MPJ Arthrodesis – Techniques, Non-Union Management & Key Considerations

First MPJ Arthrodesis – Techniques, Non-Union Management & Key Considerations

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First metatarsophalangeal joint (MPJ) arthrodesis has been studied extensively since its inception in 1852. The procedure primarily aims to relieve pain, restore length, and stabilize the medial column of the foot. This in turn helps re-establish the foot’s weight-bearing pattern, contributing to a balanced foot tripod. Despite its long history and effectiveness, MPJ arthrodesis is not without complications, the most notable of which is non-union.

By Patrick DeHeer, DPM FACFAS, FFPM RCPS (Glasg)

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3D Printing Enables Dose-Response Approach to Foot Orthotic Therapy

3D Printing Enables Dose-Response Approach to Foot Orthotic Therapy

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No matter which biomechanical principles we utilize to prescribe and produce custom foot orthoses for our patients, we all must admit that prescribing footwear interventions is not like prescribing medication – no one knows the right dose. How stiff should the shell be? How high should the arch be? How much rearfoot or forefoot posting is optimal for that specific patient? An experienced practitioner can make reasonable inferences and often produce a beneficial…

By Paul Langer, DPM

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How Biomechanics Helped Me Run My 1st Half Marathon at Age 60

How Biomechanics Helped Me Run My 1st Half Marathon at Age 60

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With a focus on muscle activation, range of motion, and neuromotor training, this 60-year-old went from not being a runner to a half marathon in just a few months. I have never been a runner. The furthest I had ever run was the 7.5-mile Bay to Breakers race across San Francisco, 40 years ago while in college. A few years ago, I started running 1 mile per week to maintain my health for my family, my fitness, and for myself.

By Christopher K. Wong, PT, PhD

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Firefighter Footwear

Firefighter Footwear

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Firefighter footwear is subject to a host of regulations, primarily set by the National Fire Protection Association (NFPA) – but selected by the local authority for fire jurisdiction. This footwear is designed to provide adequate protection against multiple hazards encountered during firefighting as well as…

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Firefighter Lower Extremity Injuries in the United States

Firefighter Lower Extremity Injuries in the United States

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Background: In 2020, there were over 1 million career and volunteer firefighters in the United States (US). Thousands of injuries involving firefighters occur annually. The body part involved in the highest proportion of injuries is the lower extremity. The objective of this study was to characterize firefighter lower extremity injuries in the US.

By Mathias B. Forrester, BS

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