August 2010

Online Poll: Not Enough Emphasis On Biomechanics In Podiatric Education

By Brian McCurdy, Senior Editor

The emphasis on biomechanics in podiatric education has been the subject of debate recently due to potential changes in the CPME 320 residency requirements. In a recent Podiatry Today online poll, 65 percent of poll respondents said there is not enough focus on biomechanics in podiatric education.

   Several DPMs who posted comments on the online poll (see http://www.podiatrytoday.com/does-biomechanics-have-sufficient-emphasis-...) were vocal in their opinion that podiatry schools and residency programs need to pay more attention to biomechanics. Doug Richie Jr., DPM, says every podiatry school should have a full-time faculty member who has a PhD in biomechanics and has published research in the field of lower extremity biomechanics.

    “These individuals have paved the way with our new understanding of lower limb function, which has huge implications for surgical planning as well as foot orthosis prescription,” says Dr. Richie, an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University.

   Furthermore, Dr. Richie notes that schools too frequently have teachers with “little clinical experience and no research accomplishments in the biomechanics arena.” He maintains that the faculty should include seasoned clinicians who can integrate the current body of knowledge of foot orthotic therapy into the biomechanics curriculum.

   Dr. Richie also suggests that biomechanics instructors must stay current with research published in non-podiatric journals and attend meetings in disciplines outside of podiatry. He notes that the physical therapy and athletic trainer disciplines are contributing the bulk of the new research in the field of lower extremity biomechanics. Dr. Richie says experienced faculty in this arena would be able to interpret this research and make it applicable to the podiatric curriculum.

How A Lack Of Biomechanical Knowledge Can Lead To Incorrect Surgical Choices

Jared Frankel, DPM, says one cannot be an accomplished podiatric surgeon without a strong understanding of the biomechanics of the lower extremity.

    “You cannot teach surgical care of the human foot without the goal of restoring function. An understanding of function does not come without an understanding of the biomechanics of every joint in the foot and its interrelationship to every other joint in the foot and body,” says Dr. Frankel, who is in private practice at Elmhurst Podiatry Center in Elmhurst, Ill.

   For example, Dr. Frankel says understanding the axis of motion of the first ray and how it changes in hallux valgus formation would be of central importance in selecting an appropriate procedure that restores motion.

   As Dr. Frankel suggests, without knowledge of foot function, a DPM might think it acceptable to perform a metatarsal head resection for a plantar callus, a Keller bunionectomy for hallux valgus or a fifth metatarsal head resection for a tailor’s bunion on a 15-year-old patient with a splay foot as podiatrists did in the 1970s.

   Dr. Frankel says a lack of biomechanical knowledge might also lead surgeons to perform osteotomies on all five metatarsals for the treatment of a flexible forefoot valgus with diffuse callosities of the forefoot as “minimal incision surgeons” advocated in the 1980s. A surgeon without a biomechanical background would have no idea that this was an ill-conceived surgical plan due to the destruction of the weightbearing ability of the foot and impaired biomechanics, according to Dr. Frankel.

    “I do not think our schools of podiatric medicine appreciate this nor do residency programs require this knowledge,” says Dr. Frankel. “If we are going to train the innovative surgeon, not the cookbook surgeon, this knowledge is essential in advancing surgical care.”

Suggestions For Improvement

Proposed changes in the CPME 320 residency requirements would mean residents would be exposed to fewer clinical encounters in biomechanics in favor of more rearfoot surgical procedures, according to Dr. Richie.

    “Nearly all rearfoot surgical procedures must have a biomechanical rationale and this would be a perfect opportunity to integrate biomechanics into surgical residency training,” says Dr. Richie. “A simple protocol which requires a biomechanical assessment of each and every rearfoot surgical case should be mandated if the proposed changes are approved.”

   Dr. Richie also suggests that residency programs require residents to be exposed to a gait lab sometime during the program. Residency programs should require a valid clinical rotation, which involves hands-on application of foot orthotic therapy, ankle foot orthoses, footwear modification and physical rehabilitation, according to Dr. Richie. He also advocates mandating some type of research that focuses on one of the many subject areas of lower extremity biomechanics, such as kinetics, kinematics, neuromuscular control, foot orthotic therapy or gait training.

   Dr. Frankel offers similar sentiments.

    “Biomechanics must be more than one or two courses in podiatry schools,” says Dr. Frankel, a Fellow of the American College of Foot and Ankle Surgeons.
In addition to a need for increased course curriculum in this area, Dr. Frankel says biomechanics training must also encompass and encourage investigative research.

   What should one say to a young student/resident who believes he or she can practice podiatry without understanding biomechanics? Dr. Richie would ask such students to open any issue of Foot and Ankle International. He says there is an emphasis on original biomechanical research in this journal with quality articles that have “direct relevance to foot and ankle surgery.”

   Dr. Richie also offers an analogy: “How can a mechanic fix a car when he does not even know how the car works?”

Study Assesses Impact Of Surgical Preparation In Patients With Diabetes

By Brian McCurdy, Senior Editor

Removing bacteria via sound preoperative preparation is vitally important to help prevent postoperative infections, particularly in immunocompromised patients such as those with diabetes. A recent study in the Journal of Foot and Ankle Surgery investigates the potential of a “best evidence available” surgical preparation in this patient population.

   The prospective study, the recipient of a 2006 American College of Foot and Ankle Surgeons Research Grant, involved 15 patients with diabetes undergoing elective foot and ankle surgery, and 15 patients with diabetic foot ulcerations. All patients had surgical preparation consisting of a chlorhexidine gluconate 4% scrub followed by painting with a topical solution of ethyl alcohol and 1% iodine. Researchers obtained qualitative aerobic cultures from the hallux nail fold; the second, third and fourth toe web spaces (as one culture); and the distal anterior tibia.

   Prior to employing this surgical preparation, the study author cultured a total of 120 organisms. The most commonly isolated organism was methicillin-resistant Staphylococcus epidermidis (MRSE), which the study identified in 46 pre-preparation cultures (38.3 percent). The next most common organisms were methicillin-sensitive S. epidermidis (16.7 percent) and ‘‘other’’ organisms (10 percent), according
to the study.

   The study noted a “significant reduction” in both the numbers of organisms identified and positive cultures for the most commonly isolated organisms after surgical preparation. The study also noted that the surgical preparation appears to be effective for eradicating aerobic bacterial pathogens from the foot in patients with diabetes both with and without ulceration.

   Thomas S. Roukis, DPM, PhD, the author of the study, notes that the study only evaluated patients with diabetes and either an intact or ulcerated/infected skin envelope. He also notes that the study only evaluated aerobic bacteria and not anaerobic bacteria, fungus, yeast or mold. Dr. Roukis says further research is required to determine if the preparation would be as efficacious in those without diabetes and for other pathogens.

Will Surgical Preparation Have To Evolve As Pathogens Evolve?

As pathogens become more resistant to antibacterials, Dr. Roukis advocates a greater emphasis on the mechanical exfoliant action of more specialized surgical brushes and a need for longer duration of the preparation to maintain effectiveness.

    “The fact that this study demonstrated a high incidence of MRSE bacteria that persisted in some patients after the surgical preparation highlights the difficulty that exists in eradicating aerobic bacteria from the foot and ankle,” says Dr. Roukis, who is Attending Staff at the Department of Orthopaedics, Podiatry and Sports Medicine at Gundersen Lutheran Medical Center in La Crosse, Wis.

   In addition to surgical preparation, Dr. Roukis also emphasizes that surgeons follow proper hygiene practices. Routine use of a surgical preparation during outpatient or inpatient dressing changes can also decrease the development of postoperative infection and improve pedal hygiene, according to Dr. Roukis, a Fellow and member of the Board of Directors of the American College of Foot and Ankle Surgeons.

Congress Temporarily Raises Medicare Payments 2.2 Percent

By Brian McCurdy, Senior Editor

As it has in previous years, Congress recently halted a planned 21.2 percent cut in Medicare reimbursement payments. In June, both houses approved a 2.2 percent raise in payments, which is effective retroactively from June 1 and will expire Nov. 30.

   Does the payment increase keep pace with any increasing costs for podiatric practices? Yes and no, says Anthony Poggio, DPM. As he notes, the cost of living this past year has been reasonably stable so salaries and other costs have also been stable. He also points out that insurance rates, other than health insurance, have been stable.

   However, Dr. Poggio notes podiatric practices have faced repeated small decreases or even no increases in practice revenue as a result of insurance reimbursement over the past several years. Overall, he says the 2.2 percent increase does not make up for all those past losses that DPMs have had to absorb.

   This is not the first time that Congress has rejected a proposed Medicare cut. The Centers for Medicare and Medicaid Services has a formula to remain budget neutral, which calculates various medical costs, expenses and payments, and then derives a payment increase or decrease, according to Dr. Poggio. Unless the formula is changed, he says podiatric practices will see potential decreases in reimbursements every year.

    “Congress has had to step in to override the calculated formula amount every year,” says Dr. Poggio, who is board certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics. “That brings politics into the mix. Congress has tried over the entire year to fix the problem but has only succeeded in deferring the problem, this time until the end of November 2010.”

   The American Podiatric Medical Association (APMA) notes that claims dated June 2010, which had been paid at the 21.2 percent negative update, will automatically be reprocessed at the 2.2 percent increase. Practices do not need to resubmit claims, according to the APMA.

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