Can A New Brace Provide A Treatment Alternative For Ingrown Toenails?

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By Brian McCurdy, Associate Editor

While the matrixectomy is a common procedure of choice for ingrown toenails, researchers from Germany believe an orthonyxia procedure, delivered via a new brace, may be more effective in treating these toenails. In a study, which was recently published in the Journal of the American Podiatric Medical Association (JAPMA), the researchers found that patients who wore the brace experienced reduced pain and a quicker return to work than those who underwent surgery. However, a couple of DPMs are skeptical. The recent study in JAPMA examined 41 patients with ingrown toenails. Twenty received the Emmert surgical procedure, which is a standard procedure in Germany. Twenty-one patients received orthonyxia via the VHO-Osthold Brace. Orthonyxia consists of implanting a small metal brace or plate onto the dorsum of the nail, according to the researchers. Although both groups had pain at similar levels before treatment, study results showed pain resulting from treatment was “significantly lower” in patients who received a brace than in those who underwent the Emmert procedure. The study authors also pointed out that those wearing the brace could wear shoes without pain earlier than those who underwent the surgery. Patients who received the brace did not take time off from work while 10 of the patients who underwent the surgical procedure needed an average of 14.7 days off from work postoperatively. Although basic treatment costs were higher for the brace group versus the Emmert surgery group, researchers note that the time off from work raised the total economic cost to $1,975.20 for the surgical group compared to $334.30 in the brace group. Alexander Reyzelman, DPM, has used a similar orthonyxia brace before and thinks patients should receive that option for ingrown toenail treatment. However, Dr. Reyzelman does not find bracing appropriate for patients with a paronychia. He says these patients should undergo surgery instead. John Mozena, DPM, recalls a glued-on plastic brace for ingrown toenails that was introduced about 10 years ago and that it did not gain acceptance among podiatrists. Dr. Mozena finds the orthonyxia procedure described in the JAPMA study similar to the plastic brace of a decade ago. “The procedure orthonyxia looks like a lot of work and seems painful to me,” says Dr. Mozena, a Fellow of the American College of Foot and Ankle Surgeons. How Does Orthonyxia Compare To Matrixectomies? Study authors compared the Emmert procedure to the Winograd procedure, which Dr. Mozena says involves stitches. He notes the surgery also has a longer recuperation time than phenol or laser matrixectomies, which he says let patients return to work the next day. Dr. Reyzelman also notes the most common care for ingrown toenails is no longer surgery but chemical matrixectomy. He notes differences in pain and time off from work would be “much less significant” if one compares orthonyxia with chemical matrixectomy. “The chemical matrixectomy procedure is much less painful than the surgical matrixectomy and patients rarely take time off work,” notes Dr. Reyzelman, the Chairman of the Department of Medicine at the California College of Podiatric Medicine at Samuel Merritt College. While patients may favor any non-surgical procedure such as orthonyxia, Dr. Mozena says the bracing procedure is mildly invasive and the study’s conclusions about pain and time off from work are “misleading. “I feel we still should continue our current conservative and surgical approaches to treatment of infected ingrown nails that deals with the hypertrophic ungual labia and deformed nail itself,” comments Dr. Mozena. Congress Delays Action On Physician Payments, Diabetes Program Cuts By Brian McCurdy, Associate Editor When Congress adjourned for its winter break, it delayed action on several expected pieces of legislation. As a result, legislators did not avert a 4.4 percent decrease in the Medicare physician fee schedule, part of a bill expected to be passed in late December. In addition, when Congress reconvenes in early February, a diabetes surveillance program may face decreased funding. As part of Congress’ appropriations bill, legislators were expected to cut funding to the Division of Diabetes Translation, according to the American Diabetes Association (ADA). The diabetes programs, run by the Centers for Disease Control and Prevention (CDC), translate medical research into practices and programs that communities can use. The ADA notes that proposed budget cuts would mean the Division of Diabetes Translation could conduct disease surveillance programs in 22 rather than the current 28 states. John S. Steinberg, DPM, supports such programs as run by the Division of Diabetes Translation. Although he does not know if the effects of such programs are measurable, he believes the surveillance programs should be available in more states and not fewer as proposed. To treat a disease such as diabetes, researchers first must fully understand the genetic predisposition and other causes, says Dr. Steinberg, an Assistant Professor in the Department of Surgery at the Georgetown University School of Medicine in Washington, D.C. Since the House of Representatives did not pass the Deficit Reduction Act before the December break, Medicare physician payments decreased by 4.4 percent, effective Jan. 1. The bill, expected to gain House approval in early February after this issue went to press, would freeze the conversion factor at 2005 levels, according to the American Podiatric Medical Association (APMA). If the bill does pass, the APMA says Medicare contractors are expected to automatically reprocess 2006 Medicare claims without the 4.4 physician payment decrease. The bill under congressional consideration does not include a redefinition of podiatrists as physicians under Medicaid, as advocated by the APMA. The APMA notes that the original bills proposing the Medicaid redefinition, House Resolution 699 and Senate Bill 440, are still viable and the association will seek other avenues for passage this year. Researchers Study Emerging Modalities For Diabetic Foot Ulcers By Brian McCurdy, Associate Editor Can a new growth factor provide effective treatment for diabetic foot ulcers? Researchers have completed phase I trials on a new topical recombinant human vascular endothelial growth factor (rhVEGF), which they say has potential as an ulcer treatment. As part of the randomized, double-blind study, submitted as an abstract for the Symposium on Advanced Wound Care, researchers examined 55 patients with diabetic neuropathic ulcers, 29 of whom received the rhVEGF telbermin and 26 of whom received a placebo. Of the telbermin group, 41.4 percent experienced complete healing in six weeks, compared to 26.9 percent in the placebo group. “We believe that the biology of VEGF may provide a more potent pathway to accelerate wound healing in diabetics,” says abstract author Tim Breen, PhD. He says becaplermin (Regranex, Johnson & Johnson) is currently the only biologic agent approved to treat diabetic foot ulcers. Dr. Breen, a Medical Director of Genentech, says researchers are in the early stages of a clinical program to evaluate telbermin, and they will further assess the growth factor’s advantages and disadvantages as they garner more data. Phase II trials will include 240 patients with diabetic foot ulcers and will measure telbermin’s incidence of complete healing at 12 weeks, as well as provide safety and efficacy data, according to Dr. Breen. Another symposium abstract concerns the use of talactoferrin alfa gel, a new immunomodulatory protein, to heal diabetic neuropathic ulcers. As part of a phase I study, 30 patients with diabetic neuropathic ulcers received either 2.5% or 8.5% concentrations of talactoferrin while 16 patients with ulcers received a placebo. In regard to the number of patients who reached the primary end point of 75 percent healing, researchers note that those treated with the gel were two times more likely than those in the placebo group to achieve the primary treatment endpoint. The Symposium on Advanced Wound Care will be held from April 30 to May 3 in San Antonio, Texas. For more info, please visit www.sawc.net.

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