January 2013

Which Bunionectomy Technique Provides The Most Advantages?

By Brian McCurdy, Senior Editor

What type of bunionectomy do you most commonly perform? A recent Podiatry Today online poll reveals a range of preferences for the best surgery for hallux valgus (see www.podiatrytoday.com/polls/what-type-bunionectomy-do-you-most-commonly-... ).

   Out of 415 respondents, 41 percent (169 votes) perform the standard Austin bunionectomy, while 35 percent (144 votes) prefer the long-arm Austin. Seven percent favor the scarf bunionectomy, 6 percent perform the Lapidus and 11 percent voted for “other.”

   About 90 percent of the time, William Fishco, DPM, performs a traditional Austin with a 3.0 mm screw, using it for average-sized bunions. He chooses that type of bunionectomy due to its inherent stability, the fact that the osteotomy is centered into the metaphysis (which has the best potential for rapid healing), and because the technique is straightforward.

   For Bradly Bussewitz, DPM, the scarf bunionectomy is a “go-to procedure,” accounting for about 70 percent of the bunionectomies he performs. The other 30 percent of his bunionectomies are either the opening base wedge osteotomy or the Lapidus, which he will perform when indicated. He uses the Akin osteotomy as an adjunct to all three of these on a PRN basis.

   The Austin bunionectomy’s advantages include less dissection and stripping of periosteum in comparison to midshaft osteotomies and base wedge procedures, according to Dr. Fishco, a Fellow of the American College of Foot and Ankle Surgeons, who practices in Phoenix. He notes that complications of over-shortening the first metatarsal bone are less likely with the Austin than with base wedge procedures or the Lapidus. Dr. Fishco says the fact that Austin patients can bear weight immediately is the main advantage over base wedge or Lapidus procedures.

   Dr. Bussewitz cites versatility and stability as main advantages of the scarf procedure. He notes the scarf can lengthen or shorten the first ray with ease, and its corrective ability is significant. As he opines, the Lapidus can be a better choice in cases of gross medial column instability and/or first tarsometatarsal joint osteoarthritis. The opening base wedge osteotomy, explains Dr. Bussewitz, is an additional option for the short first metatarsal.

   “The primary advantage for the patient should always be pain relief and the scarf can offer that for a variety of hallux abducto valgus presentations,” says Dr. Bussewitz, a fellowship-trained foot and ankle surgeon who practices in Iowa City, Iowa.

   As Dr. Bussewitz says, the scarf offers “impressive” correction of deformity and post-op first metatarsophalangeal joint range of motion. He adds that patients usually take note of this as they return to activities. Dr. Bussewitz cites the procedure’s early weightbearing capability as a plus as patients attempt to return to work or the activities of daily living. Furthermore, he says the lack of prominent hardware in the scarf, in comparison to the Lapidus and opening base wedge procedures, improves patient tolerance.

   “Implant technology has made all of these bunionectomies great options for today’s surgeon. I want to feel confident the patient isn’t going to disrupt the corrected position during the early postoperative course and all three of these procedures allow me this confidence,” says Dr. Bussewitz.

   For further reading, see the DPM Blog “How To Solve The Dilemma Of The Jumbo Bunion” at http://tinyurl.com/3xq5bus , “Why The Lapidus Bunionectomy Is The Best Procedure For Severe Bunions” in the December 2011 issue of Podiatry Today or “Mastering The Technical Approach To The Scarf Bunionectomy” on page 22 of this month’s issue. To access the archives, visit www.podiatrytoday.com.

Could Pegloticase Be Effective For Refractory Chronic Gout?

By Danielle Chicano, Editorial Associate

Two new poster abstracts, presented at the American College of Rheumatology/Associate Rheumatology Health Professional (ACR/ARHP) Annual Meeting, support the long-term efficacy of pegloticase (Krystexxa, Savient Pharmaceuticals) for the treatment of refractory chronic gout.

   Obtaining new data from an open-label extension study, researchers concluded that treatment with Krystexxa for up to three years can benefit patients with refractory chronic gout. The study also identified no new safety signals of long-term pegloticase treatment.

   Among the 149 study participants, 110 received pegloticase and 39 received a placebo. The mean baseline uric acid level of the patients was 10 mg/dL, according to the study. After one year of treatment with pegloticase in the open-label extension study, 59 percent of patients remaining in the study (62 out of 105) had uric acid levels below 6 mg/dL. Researchers saw a reduction in gout flare incidence over the course of the study. During the first three months of the study, 52 percent of patients had flares. In the 22nd to 24th months of the study, 17 percent of patients experienced gout flares.

   “(The study outcomes) did not identify new classes of adverse reactions and showed that the patients who sustained urate-lowering responses to treatment with (pegloticase) for the six months of the randomized trial continued to do so for up to two years or more. Sustained urate-lowering with pegloticase was accompanied by progressive improvement in patient clinical outcomes that verified the findings in the six month RCTs,” explains Michael Becker, MD, the study’s principal investigator.

   “Pegloticase should be considered in patients with clinically advanced active gout (often with many tophi and sometimes with chronic drainage or infection) and the need for rapid reversal of signs and symptoms that cannot wait years to achieve as with oral agents. I would not consider pegloticase for use unless both these criteria are met (i.e. not for cosmetic purposes alone).”

   Patients with refractory chronic gout previously had few alternatives to prevent worsening of the disease, explains Dr. Becker, a Professor Emeritus of Medicine at the University of Chicago.

   When comparing Krystexxa to other treatments for patients with refractory chronic gout, Dr. Becker notes that cost, time spent in treatment, gout attacks early in treatment and infusion reactions may be concerns to some practitioners. He adds, however, that one must keep in mind the disadvantages already present in other treatments.

   “The early gout attacks occur with allopurinol or other urate-lowering agents but perhaps not as frequently because they don’t lower urate nearly as much as pegloticase,” notes Dr. Becker. “Allopurinol is generic and cheap, but sometimes causes hypersensitivity that can be severe or fatal. Febuxostat is 10 to 20 times the cost of allopurinol and the range of adverse events is not yet entirely known after only three years of limited use.” He adds that febuxostat inhibits the same enzyme (xanthine oxidase) as allopurinol so some patients may expect ineffectiveness or intolerance of the medication.

   Dr. Becker says the outcomes of this study argue for a disease-modifying role for pegloticase in approximately 40 to 50 percent of patients treated for refractory, chronic gout.

Are Biodegradable Ankle Implants Better Than Metallic Implants?

By Brian McCurdy, Senior Editor

A recent study in the Journal of Bone and Joint Surgery notes that biodegradable implants may obviate some of the disadvantages of metallic implants for internal fixation of unstable ankle fractures, such as imaging interference and the need for revisional surgery.

   The study included 102 patients with ankle fractures who had surgery with metallic or biodegradable implants. The mean time to bone union was 15.8 weeks in the metallic group and 17.6 weeks in the biodegradable group. The outcomes of using biodegradable implants to fixate isolated lateral malleolar fractures were comparable to those of metal implants, notes the study.

   John Grady, DPM, notes that metallic ankle implants are versatile, coming in various shapes and sizes that one can manipulate. He adds that the metallic implants are also radiopaque, long-lasting, less expensive than bioabsorbable implants and have less reactivity. In contrast, Dr. Grady notes that metallic implants can sometimes loosen, requiring removal, and their radiopacity can be a factor in an inability to “see through” the implants. Furthermore, he says metal implants leave defects in bone when removed so this can weaken remaining bone.

   As for bioabsorbable implants, Dr. Grady notes they incorporate well to allow or even help bone re-integration, and the implants’ relative radiolucency can be an advantage in checking X-rays without interference. On the downside, he notes that bioabsorbable implants are more reactive, with some materials reacting within the first three months, others years later, but with reactions ranging in the 2 to 3 percent range. He says the implants’ cost is also a disadvantage.

   “You can tell from this article that (bioabsorbable implants) are not quite as effective as metallic implants, though not by much,” says Dr. Grady, a Fellow of the American Society of Podiatric Surgeons and the Director of the Podiatric Surgical Residency Program at the Westside Division of the Veterans Administration Chicago Healthcare System.

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