August 2012

N.Y. Podiatry Scope Of Practice May Include The Ankle

By Brian McCurdy, Senior Editor

Podiatric physicians in New York State may soon be licensed to treat the ankle due to a proposed change in the scope of practice.

   The state legislature recently passed Senate Bill 7800 and Assembly Bill 9293-A, which expand the definition of podiatry to include ankle conditions and all soft tissue structures of the leg below the knee that affect the foot and ankle. The measure now awaits the governor’s signature.

   “New York is a tough state to get any legislation passed, particularly when it comes to professions. From the get-go, we felt that our entire message had merit,” says Vito Rizzo, DPM, the Immediate Past President of the New York State Podiatric Medical Association. He notes that although the bill is not as expansive as hoped, the change in scope of practice has been 10 years in the making.

   Dr. Rizzo notes that the objectives of the scope of practice changes included ensuring that New York podiatrists from residency programs are well trained and keeping them in the state. He says there has been “a real loss of young talent” due to the limited scope of practice. With retirements looming as more doctors reach their 60s, Dr. Rizzo expresses concern about the survival of the profession in New York State.

   Neal Blitz, DPM, praises several aspects of the bill as it allows surgeons the ability “to provide more comprehensive care to the lower extremity.” He cites the potential to perform ankle reconstructions as well as soft tissue procedures above the ankle such as gastrocnemius recessions when performing major foot reconstructions.

   “An expanded scope doesn’t automatically mean that the hospitals will blindly grant these privileges,” cautions Dr. Blitz, the Chief of Foot Surgery and Associate Chairman of Orthopaedics at Bronx-Lebanon Hospital Center in Bronx, N.Y. “I imagine the hospitals will be uber-selective, go slowly and institute a variety of proctoring measures.”

   In regard to future potential changes in scope of practice laws in New York, Dr. Blitz would like to see no restrictions on performing complex ankle fractures (pilon) “because this makes it difficult to be heavily involved in emergency room trauma because the podiatric surgeon couldn’t solely cover all the emergencies. As such, the hospital would still need a back-up or secondary call person.”

   A future goal of scope of practice reform is allowing podiatric surgeons access to perform soft tissue procedures up to the knee, according to Dr. Rizzo.

   “It’s very frustrating when you have people coming in who need care and you can’t do it because of some arbitrary anatomic restriction,” says Dr. Rizzo. “Hopefully, the new scope will allow DPMs the ability to render more comprehensive and complete care.”

   Editor’s note: For further reading, see “Scope Of Practice Update: Where Things Stand” in the December 2011 issue of Podiatry Today.

Podiatry Today Online Poll: DPMs Divided Over Affordable Care Act

By Danielle Chicano, Editorial Associate

Not all DPMs are on board with the Supreme Court’s latest decision to uphold the Affordable Care Act (ACA), according to a recent Podiatry Today online poll (see ). Sixty-four percent disagreed with the outcome as this issue went to press.

   Lee C. Rogers, DPM, is surprised that more doctors do not support the law, stating it is “not perfect, but it is a good building block.” He explains the individual mandate forces citizens to take responsibility for their healthcare by purchasing their own insurance on the private market.

   “The law is a compromise to achieve universal coverage between those that wanted to solely have a government-run system and others that wanted to allow the private insurers to run with little regulations,” explains Dr. Rogers, a Democratic candidate for Congress in California’s 25th District.

   In regard to how the law will affect the future of physicians, Dr. Rogers believes universal coverage will lower the cost of healthcare, reducing the number of “freeloaders” and uninsured Americans who visit the ER and make it more expensive for those who are insured. This means more patients with insurance for doctors, notes Dr. Rogers, the Co-Director for the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles.

   Brad Wenstrup, DPM, feels that real healthcare reform should focus on those who have no healthcare. Having insurance, he explains, does not ensure that one has access to healthcare, especially if there are not enough providers. Physicians should not be forced to maneuver through governmental and administrative hassles to provide their patients with care, according to Dr. Wenstrup, a Republican candidate for Congress in Ohio’s 2nd Congressional District.

   “Let’s realize that the ACA does not fix the problem of soaring medical costs. The ACA only further pushes the burden onto those who are already paying,” explains Dr. Wenstrup. “It is estimated that nearly 50 percent of the country will be on Medicaid when the ACA is fully enacted.”

   One point of the ruling with which both Dr. Rogers and Dr. Wenstrup disagree is in regard to the Independent Payment Advisory Board (IPAB). Dr. Rogers describes the IPAB as an “unelected group of executive branch appointees who will ‘legislate’ Medicare payment rates, which can only be overturned by a three-fifths majority of Congress.”

   “Congress did this on purpose because they’re tired of dealing with Medicare and want big cuts … so they’d like to pass blame to the IPAB,” says Dr. Rogers. “(The IPAB) can’t increase revenue, meaning it can’t raise premiums on beneficiaries. Its power is pretty limited to just cutting doctors’ reimbursements.”

   Dr. Wenstrup, who is in private practice in Cincinnati, explains that after 25 years in practice, he has found the doctor-patient relationship to be the cornerstone of healthcare. He believes that the Affordable Care Act wedges “bureaucrats” into the middle of this relationship.

   “We must empower patients and doctors to have control over their healthcare decisions and not hand that over to bureaucrats in Washington in the name of the Independent Payment Advisory Board,” explains Dr. Wenstrup.

   Dr. Wenstrup concurs with the decision that the government can no longer penalize certain states by revoking Medicaid grants. However, he explains his opposition to ruling that the ACA is a tax rather than a penalty.

   “I believe the mandate and the associated penalty are unconstitutional, and an abridgement of our personal rights,” adds Dr. Wenstrup. “When a government can tax citizens for inaction (in this case, not buying insurance), it is clearly a government that has grown too big.” Dr. Wenstrup explains this now sets the precedent for the federal government to inflict taxes on American people for anything, including inaction.

   On the topic of whether the ruling is unconstitutional, Dr. Rogers says we must keep in mind that the Supreme Court only ruled on the parts of the law under challenge, not the whole law.

   “While I agree with the constitutionality of the individual mandate, I have been a vocal critic of the ACA for mostly being a law about health insurance reform and not healthcare reform,” notes Dr. Rogers. “I also think the law doesn’t do enough to protect patients from bad insurance company practices and the IPAB provision is bad for doctors.”

Study Examines Hybrid Method Of Imaging DFIs

By Brian McCurdy, Senior Editor

A recent study in Diabetes Care cites a hybrid between two advanced imaging modalities as effective for predicting the outcome of diabetic foot infection.

   Researchers focused on 77 patients with suspected diabetic foot infection-associated osteomyelitis. The authors analyzed patients’ Composite Severity Index, a hybrid of 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/CT images. Researchers correlated index scores with the probability of a favorable outcome (no subsequent amputation/readmission after therapeutic intervention) during a median 342-day follow-up. The study notes that “image-based osteomyelitis versus no osteomyelitis assessment was less accurate” than the Composite Severity Index at predicting treatment outcomes.

   Molly Judge, DPM, is skeptical, saying 99mTc-WBC (HMPAO) SPECT/CT will reveal a focus of uptake but the target to background ratio is poor. She also notes that due to the half-life of the technetium, the agent will not persist in bone long enough to determine whether the patient has an indolent infection or a transient hyperemia as can present in those with acute neuroarthropathy.

   Furthermore, she offers a caveat for immunocompromised patients (with a low WBC count), those with a delay in perfusion (such as in chronic renal failure) or those with peripheral vascular disease. Dr. Judge says these patients will not perfuse the nuclear medicine agent well enough to localize in the given time frame necessary for 99mTc-SPECT/CT to provide diagnostic answers.

   “There is nothing about this form of CT that changes the inherent question: ‘Can we differentiate between what is an infection in an ulcer versus an infection in bone?,’” says Dr. Judge, a Fellow of the American College of Foot and Ankle Surgeons, and Adjunct Faculty at the Kent State University College of Podiatric Medicine. “CT has always been available but it is a structural imaging modality and does not speak to the physiologic issue of concern, namely ‘Are we looking at infection in bone or are we seeing a transient hyperemia throughout bone and joint?’”

   To image diabetic foot infection, Dr. Judge frequently uses indium labeled WBC scans combined with 99mTc-MDP. She calls this combination imaging the mainstay to discriminate between infection in bone versus post-surgical changes or active neuroarthropathy.

Study Looks At Risk Factors For Non-Contact Ankle Sprains In Soccer Players

By Danielle Chicano, Editorial Associate

A recent study in the American Journal of Sports Medicine finds that ankle asymmetries along with higher body mass index and body weight raise the propensity of non-contact ankle sprains in professional soccer players.

   The authors of the study evaluated 100 professional soccer players in the preseason and recorded potential risk factors of non-contact ankle sprains. Following the 10-month playing season, researchers noted that 17 players sustained at least one non-contact ankle sprain. According to the study results, those with eccentric isokinetic ankle flexion strength asymmetries, increased body mass index and increased body weight each had a significantly higher risk of a non-contact ankle sprain. There was also a trend for younger players and players with ankle laxity asymmetries to be at greater risk for ankle sprain, but researchers noted this trend had limited statistical significance.

   In her San Francisco practice, Jenny Sanders, DPM, typically sees more contact ankle sprains from soccer than non-contact ankle sprains, which usually result from a slippery playing field. She primarily sees youth and adult club soccer players, and notes an increase in body mass is a clear correlation when dealing with ankle sprains.

   “I also see more injuries, both contact and non-contact, in players having high degrees of tibial varum, more frequently unilateral than bilateral. This would indirectly but definitely correlate to functional strength asymmetries of the ankle flexors,” explains Dr. Sanders, an Adjunct Clinical Professor in the Department of Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University.

   The study notes that ankle laxity and age are potential factors worth revisiting in regard to ankle sprains. Dr. Sanders agrees that ankle laxity from prior history of sprains correlates to additional injury. However, she is hesitant to claim age as a correlation. This is less clear-cut as she notes older club players (over age 25) typically spend less time warming up and practicing than younger college or professional soccer players.

   In regard to treatment and prevention of ankle sprains, Dr. Sanders finds custom orthoses are beneficial in patients having calcaneal eversion and excessive pronation with or without tibial varum.

   “Eccentric muscle strengthening and proprioceptive exercises seem to be beneficial in the rehab phase of acute injury and for this, we will refer patients to a qualified sports medicine physical therapist,” adds Dr. Sanders. “In cases of moderate or severe ankle sprains, we dispense an Aircast Air-Stirrup ankle brace to be worn during all athletic activities for at least six months after the ankle injury.”


Re: Hybrid method of imaging DFI
As the lead author on the paper entitled, Indexing Severity of Diabetic Foot
Infection With 99mTc-White Blood Cell Single Photon Emission Computed
Tomography/Computed Tomography, published in Diabetes Care 35:1826-1831, 2012, I would like to emphasize the following:

1) Contrary to the statements above, the target to background ratio of Tc WBC is exceptionally high. This has been documented by other investigators quoted in our paper.

2) We performed 2-hour delay imaging specifically to differentiate WBC accumulation in focal infection as opposed to transient reactive hyperemia. This was quite effective and we frequently visualized intense focal uptake in gauze packing within the infected ulcer as well as the ulcer itself.

3) The spatial resolution of this hybrid technique exceeds that of convential MRI for defining cortical surfaces and (by several times) that of convential nuclear medicine infection imaging.

4) Most importantly, although we were clearly able to localize infection to bone or soft tissue, we found that inclusion of other factors, such as grading the intensity of WBC activity, significantly enhanced prediction of successful therapy, thus the superiority of the Composite Severity Index (CSI) over the conventional paradigm.

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