Is Arthrodesis The Answer For First MPJ Arthritis?

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By Brian McCurdy, Associate Editor

What is the best treatment approach for seniors who have painful arthritis in the first MPJ? Arthrodesis may provide significant pain relief for these patients, according to the results of a recent 29-patient study presented at the annual meeting of the American College of Foot and Ankle Surgeons (ACFAS).
A retrospective analysis revealed that 100 percent of 19 patients who responded to a survey said they were satisfied with the results of the arthrodesis, which involves fusing arthritic bones to inhibit motion and eliminate the arthritis. These patients also noted they would undergo the procedure again if necessary.
Lawrence A. DiDomenico, DPM, one of the study’s authors, says MPJ arthrodesis can help facilitate a better quality of life for seniors with arthritis.
“When the MPJ area becomes arthritic, it is very uncomfortable as this area propels the foot when walking,” explains Dr. DiDomenico. “Therefore, walking short distances — even across a room — can be a painful experience. By eliminating this joint motion, arthrodesis surgery allows the patient to walk pain free and pursue a more active lifestyle.”
There are an array of other possible treatment modalities (such as a Keller bunionectomy or an implant) that DPMs can use to treat this condition. While Dr. DiDomenico concedes that he usually opts for a bunionectomy when these patients are over 65, he refutes the perception that arthrodesis may be a risky proposition for seniors due to possible osteoporosis.
“Patients over 65 can handle (arthrodesis) just as effectively,” notes Dr. DiDomenico. “The success rate of MPJ fusion surgery exceeds 90 percent and one of the patients in our study was 86.”
Harold D. Schoenhaus, DPM, says he uses arthrodesis as a “last resort,” but prefers procedures that maintain motion. Like Dr. DiDomenico, he also uses implants and Keller bunionectomies to treat these patients. When attempting fusion, however, Dr. Schoenhaus says there is a risk of patients experiencing mal-, non- or delayed union.
“It’s a tricky process. There’s a certain learning curve to doing fusions,” says Dr. Schoenhaus, the Chief of Foot And Ankle Surgery at the Graduate Hospital of Philadelphia.
Dr. Schoenhaus questioned the long-term results in those who have undergone the fusion technique. He wondered if patients would transfer their weight to the other foot after the surgery and experience metatarsalgia.
“There’s nothing to indicate any of that” in the study, says Dr. Schoenhaus, “but I would suspect that you may see some of that.”

The Ponseti Method: A Viable Alternative For Infant Clubfoot?
When it comes to treating infant clubfoot, experts seem to agree that using the Ponseti Method can help you achieve successful outcomes. This consensus of opinion was backed up by a recent study, in which researchers were able to achieve alignment correction in 28 out of 29 infant clubfoot patients with the Ponseti Method.
The method, which was first described in 1950, involves combining external manipulation and casting to correct soft tissue abnormalities and bring the foot into proper alignment. According to the study presented at the ACFAS annual meeting, you are able to achieve clubfoot correction in the majority of patients with five to six castings over a two-month period. After casting, researchers also employed a special shoe to help preserve the correction and usually performed an Achilles release as well.
Robert W. Mendicino, DPM, Chief of the Division of Foot and Ankle Surgery at the Western Pennsylvania Hospital in Pittsburgh, treats the majority of infant clubfoot with the Ponseti method and boasts a nearly 100 percent success rate.
Dr. Mendicino, the Immediate Past President of the ACFAS, notes that occasionally, some children do experience recurrence. In these rare instances, he casts every two weeks and may release the Achilles tendon again. If the child still has some deformity and is walking on the outside of the foot (usually seen at 2 to 3 years of age), Dr. Mendicino will perform a tibialis anterior transfer. However, he maintains that this procedure is still “a much less invasive and less complicated procedure than the traditional clubfoot release.”
Both Dr. Mendicino and Russell G. Volpe, DPM, note that the earlier you start with manipulation and casting, the more success you’ll have in using the method to treat infant clubfoot.
“If the diagnosis is made in neonates and casting can be started immediately, the likelihood of success with (the Ponseti) method is much greater,” notes Dr. Volpe, Professor and Chairman of the Department of Pediatrics at the New York College of Podiatric Medicine.
Dr. Volpe does emphasize the majority of these patients may need an Achilles tenotomy. He also says severity of the deformity is another key factor to consider. For severe deformities with greater involvement of bone and soft tissue, Dr. Volpe says there is an “increased likelihood” that surgical correction will be necessary.
“Approximately 50 percent of the infants I treat with Talipes Equino Varus (TEV) require some surgery, usually at least a release or lengthening of the heel cord,” says Dr. Volpe.
However, he says casting can be beneficial in cases of mild to moderate TEV when you use it in the first weeks of the infant’s life. Even if subsequent surgery is necessary, Dr. Volpe tells parents that early casting can reduce the complexity of the surgery.
“ … The scope of the surgery may be less if casting has corrected some components (i.e. forefoot adductus, hindfoot varus, etc.) of the deformity,” maintains Dr. Volpe.
While Dr. Volpe calls for further research on treatment outcomes, he lauds the recent study as a “valuable contribution … on this significant foot deformity.”

– Gina DiGironimo
Production Editor

FDA Approves New Shockwave Therapy Device
Add another player to the shockwave therapy mix. The Epos Ultra, a device that offers shockwave and ultrasound technology to treat plantar fasciitis, recently received approval from the Food and Drug Administration (FDA).
What makes this device particularly unique? According to the Germany-based manufacturer Dornier MedTech, the Epos Ultra’s built-in ultrasound capability enables podiatrists to accurately pinpoint the pain, as opposed to other shockwave therapy devices that require patients to tell you where it hurts.
“It’s a promising and excellent new technology for treating a chronic problem,” says George Theodore, MD, one of the principal investigators for the FDA clinical trial of the Epos Ultra. Dr. Theodore, the Chief of Foot and Ankle Surgery at Massachusetts General Hospital in Boston, says the device is safe, minimally invasive and requires no casts or crutches afterward.
The company notes that 60 percent of the 150 people who participated in the FDA trial clinical study said they experienced good to excellent outcomes. Participants rated their pain on a scale where 10 was excruciating and 1 was the lowest. The company noted that most patients started at 8 and ended up at 3 after using Epos Ultra.
You can use the Epos Ultra in a single, 30-minute session in a hospital or outpatient center. The company adds that the device offers versatile, controlled power ranges (from 60 to 240 shocks per minute) and is very quiet to operate compared to other devices.

— B.M.

Research Shows Obese Kids May Have Prediabetic Condition
Disturbing news continues to emerge about the link between obesity and diabetes in children. According to a report in a recent issue of The New England Journal of Medicine, one in four obese children under the age of 10 and one in five obese adolescents under the age of 18 have impaired glucose tolerance, a condition that leads to type 2 diabetes.
The study’s researchers noted the link between obesity and reduced glucose tolerance is “likely mediated by metabolic complications — particularly insulin resistance and hyperinsulinemia.”
Kenneth Rehm, DPM, concurs, emphasizing that “ … an improper diet puts too much stress on the endocrine and metabolic processes.”
Dr. Rehm and the authors of the study also agree that changes in diet and increased physical activity can reverse the effects of impaired glucose tolerance.
“A child who is overweight might be more prone to sedentary activities and increasingly adverse lifestyle habits that may carry into adulthood,” explains Dr. Rehm, a Diplomate of the American Board of Medical Specialties in Podiatry. “A child who is active is able to build a stronger body and create more muscle development.”
Dr. Rehm believes if children overcome their weight issues through active participation, such as playing sports, their risk of developing type 2 diabetes decreases as well. Otherwise, he notes “Sedentary children become sedentary and overweight adults.”
In addition to recommending glucose tolerance testing in obese children, especially in children who may not be aware they are at risk or have diabetes (silent type 2 diabetes), Dr. Rehm is a firm supporter of a “… healthy attitude, diet and moderate exercise.”

— G.D.

In Brief
• The High Risk Diabetic Foot Center and DIALEX research group of the Southern Arizona VA Medical Center are offering free instructional videos on debridement, total contact casting, application of bioengineered skin and other techniques. For more info, see www.diabeticfootonline.com.
• Data Trace Publishing Company has teamed up with the PICA Group to provide risk management programs that policyholders can study at home and receive policy discounts for doing so.
• The California Board of Podiatric Medicine has approved the American Board of Medical Specialties In Podiatry (ABMSP) as equivalent to two previously approved boards in California. Will other states soon follow?

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