What The Future Holds For Podiatric Care

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A 73-year-old patient presented with rest pain and a non-healing ulcer that had been persistent for four months. The patient was hypertensive, had hypercholesterolemia and an ankle-brachial index of 0.55 suggested peripheral arterial disease.
Here one can see the healing wound in the same patient six months after undergoing successful treatment with CLiRpath, including a laser and balloon angioplasty procedure of the totally occluded distal superficial femoral artery.
The SilverHawk Plaque Excision System is advantageous in that it can shave off the plaque without damaging the artery,” notes David G. Armstrong, DPM. He adds that this “leaves the clinician with options for future intervention if it is needed.”
This post-op radiograph demonstrates a well healed talonavicular fusion that utilizes one I.CO.S. Screw and one UNI-CLIP®. (Photo courtesy of Gerard V. Yu, DPM)
“Topaz provides us with an incredible tool to initiate tendon and fascial healing with minimal disruption of the surrounding tissue,” notes Bruce Werber, DPM.
Here is a view of a wound that resulted from a partial calcanectomy. Note the meshed Integra secured with staples. (Photo courtesy of John Steinberg, DPM)
Here is a view of the same wound two weeks after application of Integra, a non-adherent wound cover, a silver impregnated sheet and a negative pressure dressing. Note that the silicone layer has been removed from the wound surface while leaving the matrix
John Steinberg, DPM, says the Promogran Prisma™ Matrix is innovative in that it combines matrix metalloproteinases (MMPs) with low dose, slow release silver for an antimicrobial effect.
By Brian McCurdy, Associate Editor

   New technologies abound and there is certainly no shortage of new innovations. There are new medications for diabetic neuropathic pain and antibiotic-resistant infections. There are innovative matrices that may enhance the healing environment for wounds. There are leading advances in the limb salvage arena as well as impressive modalities for facilitating bone healing. With that said, let us take a closer look at several new and emerging innovations that may prove beneficial to podiatrists and their patients.

   1. Tigecycline (Tygacil, Wyeth Pharmaceuticals). Given the prevalence of resistant strains of bacteria in lower extremity infections, podiatrists may want to consider adding a new antibiotic agent to their armamentarium. Tygacil recently received FDA approval as the first in its class of glycylcyclines to treat complicated skin and skin structure infections (cSSSIs).

   The manufacturer notes that Tygacil is approved for treating adults with both methicillin-resistant and -susceptible Staph aureus. It is also indicated for those with cSSSIs caused by E. coli, Enterococcus faecalis (only vancomycin-susceptible isolates), Streptococcus agalactiae, Streptococcus anginosus group, Streptococcus pyogenes and Bacteroides fragilis, according to the company.

   Tygacil’s broad spectrum makes it unique from other drugs for resistant gram-positive drugs such as vancomycin, daptomycin or linezolid, according to Warren S. Joseph, DPM. While Tygacil is effective against resistant gram positive cocci such as MRSA, MRSE and VRE, Dr. Joseph points out that the antibiotic is also effective against a broad range of gram-negative organisms and even anaerobic organisms, including strains resistant to many other antibiotics.

    “Overall, tigecycline appears to be an exciting innovation in antibiotic therapy,” says Dr. Joseph, a Fellow of the Infectious Diseases Society of America. “It may end up being a very useful, single agent therapy for complicated lower extremity infections including severe diabetic foot infections, especially given the tremendous increases in MRSA rates over the past few years.”

   Dr. Joseph cites a phase II study by Postier, et. al., of 109 clinically evaluable, hospitalized patients with cSSSIs. The study found both the 25 mg IV q12h dose of tigecycline and the 50 mg IV q12h doses effective at 67 percent and 74 percent respectively at the test of cure visit.1 Dr. Joseph says these results are “good but not particularly spectacular.” He believes more studies need to be conducted, particularly studies that examine the drug’s efficacy in treating diabetic foot infections.

   There are a couple of drawbacks to tigecycline, according to Dr. Joseph, an Attending Podiatrist at the Coatesville Veteran Affairs Medical Center in Coatesville, Pa.

   Tigecycline is only available via IV. Accordingly, Dr. Joseph says this would limit use of the medication to hospitalized patients or those who can undergo IV therapy at home. He adds that cost may be an issue since parenteral therapy would be more expensive than oral therapy. In clinical trials, Dr. Joseph also cites a “relatively high rate” of GI problems (mostly nausea and diarrhea) with Tygacil so one should monitor this closely.

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