February 2014

Online Poll: Half Of DPMs Choose Austin As Their Most Common Bunionectomy Procedure

By Brian McCurdy, Senior Editor

When performing a bunionectomy, surgeons have a variety of techniques at their disposal. A Podiatry Today online poll reveals that half of the respondents use the Austin procedure as their most common bunionectomy procedure.

   Fifty percent of the 225 respondents voted for the Austin procedure as this issue went to press. Fourteen percent chose the Austin/Akin, 10 percent chose the distal metaphyseal osteotomy of the first metatarsal, 10 percent perform the Lapidus, 5 percent chose the base wedge osteotomy, 5 percent voted for the scarf and 4 percent perform the Reverdin procedure.

   Why is the Austin bunionectomy a popular choice? John Grady, DPM, cites the technique’s versatility in that one can use it to correct the proximal articular set angle (PASA), variable intermetatarsal angles, elevation/plantarflexion issues, and shorten or slightly lengthen metatarsals. He also notes surgeons can easily fixate Austin bunionectomies with screws or K-wires, and they have relatively few complications.

   “These results don’t surprise me that much,” says Christopher Hyer, DPM. “The Austin or chevron osteotomy has been very popular for decades. It is highly versatile and intrinsically stable.” He does note incidental reports of first metatarsal head avascular necrosis after the Austin, suggesting surgeons take care not to compromise the blood flow.

   Dr. Hyer, a Fellow and member of the Board of Directors of the American College of Foot and Ankle Surgeons, expresses some surprise that so many podiatrists are still performing base wedge procedures. He calls those procedures unstable, difficult to perform and says they have high complication rates.

   A scarf bunionectomy is the go-to choice for Dr. Grady, a Fellow of the American Society of Podiatric Surgeons and the Director of The Foot and Ankle Institute of Illinois.

   Dr. Hyer’s favorite bunion procedure is a Lapidus first tarsometatarsal joint fusion with a possible Akin osteotomy.

   “It is powerful, reproducible and can correct severe deformity when needed,” says Dr. Hyer, the Fellowship Director and an attending physician at the Orthopedic Foot and Ankle Center in Westerville, Ohio.

Does Running In Minimalist Shoes Increase Injury Risk?

By Brian McCurdy, Senior Editor

A recent study in the British Journal of Sports Medicine maintains that running in minimalist footwear appears to increase the chance of injury.

   Researchers focused on 99 runners with neutral or mild pronation, randomly assigning them to wear a neutral shoe (Nike Pegasus 28), a partial minimalist shoe (Nike Free 3.0 V2) or a full minimalist shoe (Vibram 5-Finger Bikila). Researchers employed baseline testing to record training and injury history as well as selected anthropometric measurements before the runners started a 12-week training program to prepare for a 10 km event, according to the study.

   The study notes there were a total of 23 injuries with four injuries in runners with neutral shoes and 12 injuries in runners with partial minimalist shoes. The authors say those who wore partial minimalist shoes reported a significantly higher rate of injury incidence throughout the 12-week period while runners in the full minimalist shoe group reported more shin and calf pain. The authors suggested caution when recommending minimalist footwear to runners who are new to barefoot running and preparing for a 10 km event.

   Bill Johncock, DPM, most commonly treats calf and Achilles injuries in runners wearing partial minimalist shoes. In addition to treating calf and Achilles injuries in those who wear full minimalist shoes, he often sees metatarsal-related problems, such as stress fractures, neuromas, capsulitis, bursitis and sesamoiditis. Dr. Johncock also frequently treats medial tibial stress syndrome but says there may be a decrease in anterior shin pain, as this study points out.

   For patients in partial minimalist shoes, Jenny Sanders, DPM, most frequently sees midfoot issues, typically associated with excessive pronation, especially posterior tibial tendonitis at the level of the navicular, and plantar fasciitis. As she notes, the Nike Free 3.0 V2, due to its outsole structure and hourglass waist, can actually cause a wide midfoot to pronate excessively simply due to the shoe design. Dr. Sanders says this may account for the higher incidence of injury.

   Runners in minimalist shoes also commonly experience forefoot issues such as midshaft metatarsal stress fractures (primarily of the second metatarsal), neuromas, metatarsalgia, Achilles tendonitis and anterior tibial tendonitis, according to Dr. Sanders, an Adjunct Clinical Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif.

   When switching to minimal shoes, Dr. Sanders advises runners to start slowly, first running on a treadmill or doing trail (soft) surface running. She says runners should run every other day in minimal shoes, building up slowly to the desired time and distance. When runners are at 50 percent of the desired time/distance, she says they should start running outdoors on hard surfaces (concrete), first flat surfaces and then hills.

   Likewise, for patients without an injury history, Dr. Johncock suggests caution when switching to minimal shoes and using the shoes as a training device. To that end, he suggests doing warm-ups either barefoot or in minimalist shoes, or doing five minutes of running at a time, increasing the running time very slowly.

   “Gradual transitions are best and the longer you have run in standard running shoes and the older you are (think 35 plus since the elasticity of the Achilles goes down after that time), the slower you need to make the transition,” says Dr. Johncock, a Fellow of the American Academy of Podiatric Sports Medicine who practices in Hickory, NC. “If you have calf/Achilles and/or metatarsal pain, back off. The risk may not be worth the benefit.”

Study Compares Gait In Ankle Arthroplasty And Arthrodesis Patients

By Brian McCurdy, Senior Editor

A recent study in the Journal of Bone and Joint Surgery concludes that gait patterns of patients after total ankle arthroplasty are closer to normal than the post-op gait of arthrodesis patients.

   Researchers performed gait analysis on patients with isolated ankle arthritis more than one year after they had either a total ankle arthroplasty or an ankle arthrodesis. The study included 17 arthroplasty patients, 17 arthrodesis patients and 10 control patients.

   The study found that patients who had arthroplasty, in comparison with those who had arthrodesis, had greater postoperative total sagittal plane motion (18.1 degrees versus 13.7 degrees), dorsiflexion (11.9 degrees versus 6.8 degrees), and range of tibial tilt (23.1 degrees versus 19.1 degrees). However, plantarflexion motion was not equivalent to normal in either group and ankle moments and power in both treatment groups remained significantly lower in comparison with the control group, according to the study.

   Nicholas Bevilacqua, DPM, has found that patients who had total ankle replacement and fusion significantly improve their gait after surgery. He notes that arthroplasty patients appear to achieve closer to a normal gait, exhibiting increased stride length and higher cadence in comparison to the fusion group.

   “Although neither group achieves a ‘normal’ gait, both groups achieve a significantly improved gait,” says Dr. Bevilacqua, who is in private practice at North Jersey Orthopaedic Specialists in Teaneck, N.J.

In Brief

Organogenesis recently announced its purchase of the Dermagraft® assets from Shire. Dermagraft, a human fibroblast-derived dermal substitute, is approved for the treatment of non-healing diabetic foot ulcers in the U.S. and Canada, notes Organogenesis. The company notes that since it already markets Apligraf, it now has “two products containing living cells that are FDA-approved for wound healing.” In addition, the company says the purchase was necessary to keep both technologies on the market due to recent coverage decisions by the Centers for Medicare and Medicaid Services, which it says limit access to FDA-proven technology.


In regard to the December 2013 Diabetes Watch column, “Exploring the Potential of Advanced Wound Care Products for Diabetic Wounds,” BioDlogics should have been noted as the source tissue bank for AmnioMatrix instead of Applied Biologics. AmnioMatrix is also not FDA-approved as a void filler. AmnioMatrix, which is intended for the treatment of wounds, is registered with the FDA as a human cell, tissue and cellular or tissue-based product (HCT/P) under 21 C.F.R. Part 1271 and Section 361 of the Public Health Service Act.

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