May 2010

Do Age And Weight Factor Into Success With Total Ankle Replacements?

By Brian McCurdy, Senior Editor

In recent years, surgeons have looked to total ankle replacements to abate pain caused by such conditions as ankle arthritis. A recent study in the Journal of Foot and Ankle Surgery examines which patient conditions may facilitate better range of motion (ROM) and function following ankle replacement.

   Researchers retrospectively reviewed 95 patients who had received total ankle replacements, were assessed via post-op ROM fluoroscopy and had completed a subjective patient score sheet. The study compared data such as ROM, age and body mass index (BMI) with patient satisfaction to determine if any conditions could predict successful outcomes.

   Patients over the age of 60 and those with a BMI of less than 30 showed a “significant positive association” with subjective patient satisfaction scores, according to the study.

   The authors also note that post-op ROM did not correlate with patient satisfaction. The researchers conclude that patient satisfaction was not significantly associated with patients under 60, BMI over 30, additional procedures, perioperative complications, the length of time after surgery and the presenting etiology.

Addressing Patient Expectations

The study notes that although patients often expect more range of motion following ankle replacement, they most frequently appreciate pain relief. The authors suggest that this probably accounts for the rates of patient satisfaction they found in the study.

   Lawrence DiDomenico, DPM, will typically tell his total ankle replacement patients they will only get a little more motion postoperatively than they had prior to the surgery. While some patients do “extremely well” with increased ROM, Dr. DiDomenico notes this scenario is less common. Before surgery, he will educate the patients that the goal is to reduce pain and improve function. Robert Mendicino, DPM, concurs. He notes that while ankle replacements restore pain-free range of motion, they do not necessarily restore normal ROM.

Emphasizing Appropriate Patient Selection

Age and BMI “play a major role” when it comes to proper patient selection for ankle replacement procedures, according to Dr. Mendicino, the Chairman of the Department of Foot and Ankle Surgery at the Western Pennsylvania Hospital in Pittsburgh. He also considers the presence of other medical conditions, bone quality, deformity and ligamentous stability. Dr. Mendicino emphasizes that the indications are not as clear-cut as one may think and he advises considering all parameters when offering ankle replacements as a choice to patients.

   In Dr. DiDomenico’s experience, older patients do better following ankle replacement. He says such patients have fewer physical demands and their interests pertain more to walking and golfing rather than aggressive sports. Patients with higher BMI place more stress on the ankle replacement, adds Dr. DiDomenico, the Section Chief of Podiatry at St. Elizabeth’s Hospital in Youngstown, Ohio.

   To improve ankle implants in the future, Dr. DiDomenico suggests the development of longer-lasting prostheses, perhaps lasting as long as 15 years. He also suggests performing less bone resection, noting that if the ankle replacement fails, it is easier to convert it to an ankle arthrodesis.

   Dr. Mendicino notes continued advances in ankle replacement devices and emphasizes they are not a fad. While total ankle replacements may not achieve the same numbers as hip and knee replacements, Dr. Mendicino says they can have an impact for patients when they are properly indicated.

   “This is now (and in the future) a valuable option to treating debilitating ankle arthritis,” Dr. Mendicino, a Fellow and Past President of the American College of Foot and Ankle Surgeons.

Are DPMs Taking Full Advantage Of The Web?

By Lauren Grant, Editorial Assistant

As the Internet becomes more and more of a resource for patients, many DPMs have established Web sites for their practices, but not everyone is in on the game. Thirty-nine percent of 244 people who responded to a recent Podiatry Today online poll said their practice does not have a Web site.

   Bruce Werber, DPM, is not surprised by this high number.

   “I don’t think many doctors understand the changing world,” he says. “They are busy trying to maintain an income, run a practice, and take care of patients. They don’t have time to reflect on the changes in how patients find their practice and search for information.”

   Kara Hirsch also was not surprised about the large number of podiatrists without Web sites.

   “The medical field is a relatively late adopting market,” notes Hirsch, the Marketing Director for Baystone Media (, a company that provides Web site design services. “However, this percentage (in the poll) is actually lower than most medical specialties. This shows me that podiatrists are ready and eager to try new forms of advertising, especially Internet marketing.”

   Both Dr. Werber and Hirsch feel a Web site is important for the future of a practice and without a site, DPMs could be missing out on new patients. Before starting a Web site for your practice, Dr. Werber recommends searching for local podiatry Web sites to see what others are doing. If you like a particular site, he suggests going to the bottom of the page to see who designed the site. Dr. Werber, a Fellow of the American College of Foot and Ankle Surgeons, suggests checking out

   Hirsch and Dr. Werber say providing basic information on the Web site is key. This information should include office hours, contact information, location, directions to the practice, accepted insurance plans, etc.

   Hirsch also recommends including testimonials from patients as well as pictures of yourself and the staff. Hirsch says these things increase the level of comfort for those who are seeking podiatric care. Having educational material on the site can also be helpful in this regard, according to Dr. Werber.

Can Locking Plates And Compression Screws Improve Outcomes With First MPJ Fusion?

By Brian McCurdy, Senior Editor

A recent poster presentation at the American College of Foot and Ankle Surgeons Annual Scientific Meeting notes positive results for first metatarsophalangeal (MPJ) fusion when one combines compression screws with locking plates.

   In a retrospective review of 45 patients, the study authors found that 43 patients attained fusion after a first MPJ fusion with a locked plate and compression screw. As the study notes, the mean time to union was 51.12 days, the mean time to partial weightbearing was 7.03 days and the mean time to full weightbearing was 62.04 days.

   Abstract co-author Christopher Hyer, DPM, notes that while a lag or compression screw can achieve the compression necessary for fusion, the screw by itself has difficulty resisting the sheer and bending forces of the first MPJ. Dorsal plating can resist such forces although the plate by itself does not provide good compression, notes Dr. Hyer, a Fellow of the American College of Foot and Ankle Surgeons.

   However, Dr. Hyer says applying the compression screw first and following with the dorsal plate “achieves the best of both devices,” making for a stable, solid construct. This stability is enhanced even further with the addition of locking plates, according to Dr. Hyer.

   As he notes, the construct permits immediate protected weightbearing in a fracture shoe or walker boot.

   He says one may perform this procedure in any patient undergoing a first MPJ fusion, except patients with infection in whom internal fixation may be contraindicated.

   “One might think that dorsal plating at the first MPJ would be prone to soft tissue irritation and hardware prominence but that is rarely the case,” adds Dr. Hyer, who is in private practice in Columbus, Ohio.

   For further reading, see “Can Locking Plates Improve First MPJ Fusion?” in the May 2009 issue of Podiatry Today.

Does Nerve Decompression Reduce The Risk Of DFU Recurrence?

By Brian McCurdy, Senior Editor

A recent study in the Journal of the American Podiatric Medical Association (JAPMA) suggests that patients with diabetic neuropathy who undergo surgical nerve decompression have a reduced risk of diabetic foot ulcer (DFU) recurrence.

   The study authors retrospectively reviewed 75 feet in 65 patients who had diabetes and a previous neuropathic ulcer. Patients had undergone surgical decompression of the peroneal and posterior tibial nerve branches at the fibro-osseous tunnels. In a mean follow-up of 2.49 years, researchers measured the incidence of ipsilateral diabetic foot ulcers.

   Researchers noted the recurrence of four ulcers and another four ulcers developed at new sites. The study notes the combined linear annual risk of ipsilateral recurrence and new ulcer formation is 4.28 percent, which the study authors say is the lowest rate noted in the literature.

   Stephen Barrett, DPM, says the ulcer recurrence rate of 4.28 percent with surgical nerve decompression is “very significant.” In comparison, Dr. Barrett cites a 23.4 percent DFU recurrence rate, which Lavery and colleagues reported (in a 2007 Diabetes Care study) in patients who received standard diabetic foot care.

   Dr. Barrett says his own experience concurs with the JAPMA study’s statement that “the accepted dogma that metabolically induced, length-dependent axonopathy alone is causal may well be incomplete, and unsuspected nerve entrapment might be present and contributory in a surprisingly high percentage of patients with diabetic foot ulcer.”

   “It cannot be emphasized enough that what is being done surgically is simply decompression of a compressed nerve. This also happens to have a metabolic component, which certainly increases the chance of that entrapment to begin with. We are not operating on diabetic peripheral neuropathy,” emphasizes Dr. Barrett, an Adjunct Associate Professor in the Arizona Podiatric Medical Program at the Midwestern University College of Health Sciences.

   As Dr. Barrett points out, hand specialists and neurologists would not find it difficult to perform decompression for carpal tunnel syndrome in patients with diabetic neuropathy so he questions why decompression is so controversial in the lower extremity.

Do The Advantages Of Decompression Outweigh The Risks?

If the patient with sensory loss/and or pain from diabetic peripheral neuropathy has adequate vascularity, Dr. Barrett says the advantages of the surgery “far outweigh” the disadvantages. He notes that more than 85 percent of his patients have returned for decompression of their contralateral leg/foot. If decompression can restore sensation, he says the patient’s chance of repeated ulceration is “greatly diminished.”

   Dr. Barrett says possible disadvantages include wound dehiscence and infection, but he notes these are very minimal if one emphasizes good intra- and postoperative management.

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