May 2012

Is There An Increased Prevalence Of Equinus In Patients With Diabetes?

By Brian McCurdy, Senior Editor

A study recently published in the Journal of the American Podiatric Medical Association speculates that equinus may occur more frequently than previously reported in patients with diabetes.

   Researchers conducted a prospective pilot study of 102 outpatients, 43 of whom had diabetes. Patients underwent standard lower extremity exams and researchers used a biplane goniometer to measure their ankle joint range of motion. The study authors defined equinus as ankle dorsiflexion measured at 0 degrees or less.

   The study notes that among the overall study population, 24.5 percent of patients had equinus. Among those with diabetes, 37.2 percent had equinus while 15.3 percent of the non-diabetic patients had equinus, according to the study. Authors noted that patients with diabetes in the study had a threefold risk of equinus in comparison to those without diabetes and those with peripheral neuropathy had a 2.8 times greater risk of equinus. The authors noted that although they cannot prove causality, there was a significant association between equinus and ulceration as patients with diabetes had a fourfold risk of ulceration in comparison to those without the disease.

   When managing equinus in patients with diabetes, study author Robert Frykberg, DPM, suggests that some effective strategies would include screening, therapeutic footwear and stretching.

   Patrick DeHeer, DPM, notes that stretching has been effective for patients with equinus but patients typically do not do manual stretching correctly or for long enough. Therefore, he does not recommend it. Patients with diabetes will have a tendency to recontract and therefore require an ongoing maintenance therapy to keep them stretched, according to Dr. DeHeer, a Fellow of the American College of Foot and Ankle Surgeons, who is in private practice at Hoosier Foot and Ankle in Carmel, Ind.

   “We have cut down the amputation rates significantly with three major preventative care programs: routine diabetic foot care, diabetic foot exams periodically, and diabetic shoes and orthoses,” says Dr. DeHeer. “However, we are missing one final piece of the puzzle that is equally important and that is adequate stretching.”

   When equinus is present on examination and the patient has recalcitrant or recurrent ulcerations, Dr. Frykberg recommends considering either a gastrocnemius recession or a tendo-Achilles lengthening. However, he cautions against doing these procedures routinely if there are no associated clinical sequelae.

   Should this study make DPMs more vigilant about the effects of equinus in patients with diabetes? Dr. Frykberg says podiatric physicians should recognize the prevalence of equinus, which was higher than previously recognized, and the association of equinus with ulcerated patients. He adds that one should thoroughly assess equinus, especially in patients with neuropathy and a history of ulceration.

   “It does not mean that all patients should have routine lengthening procedures performed since this could lead to other serious consequences such as calcaneus deformities and heel ulcerations,” cautions Dr. Frykberg, who is the Chief of the Podiatry Section and Podiatric Residency Director at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix.

   “We all know equinus is a significant pathology producer of the foot and leg but often ignore treating that component of the pathology and focus only on the symptomatic area,” says Dr. DeHeer. “I am not sure why this is but my feeling is because there is not an adequate way of treatment.”

Can Ultrasound Guided Alcohol Injections Offer Relief For Morton’s Neuroma?

By Danielle Chicano

A recent study in Foot and Ankle International asserts that ultrasound guided alcohol injections may offer a safe, less invasive alternative to alleviate pain associated with Morton’s neuroma.

   According to the study, ultrasound guided alcohol ablation facilitated complete resolution of pain in 32 percent of patients with Morton’s neuroma and a partial or total treatment response in 66 percent. The authors also note that 20 percent of patients went on to have surgery due to continuing pain. Researchers included data from 87 treatment courses with a mean follow-up of 14.3 months in this retrospective case series.

   Kris DiNucci, DPM, FACFAS, notes that findings from this study are consistent with numerous studies published within the past 10 to 15 years showing clinical improvement and decreasing neuroma size with alcohol sclerosing injections.

   Although he points to evidence-based research demonstrating the benefits of alcohol sclerosing injections, Dr. DiNucci prefers to perform a neurectomy in most cases of Morton’s neuroma.

   “I rarely perform alcohol injections for neuromas unless specifically requested by the patient or if the patient is a poor surgical candidate. I find neurectomy to be a very successful surgery with very few complications if performed appropriately,” explains Dr. DiNucci, who is in private practice in Scottsdale, Ariz.

   In contrast to Dr. DiNucci’s preferred treatment methods, Gary Dockery, DPM, FACFAS, often utilizes and promotes alcohol solution injections, although he injects the solution more proximal to the neuroma than the study describes.

   “In the study, the injections are placed into (or as close to) the actual neuroma by ultrasound guidance,” explains Dr. Dockery. “This will take a lot more destruction of tissue to obtain the same results and therefore results in lower responses.”

   Dr. Dockery believes that physicians can relieve 70 to 80 percent of neuroma symptoms with cortisone injections and orthotic devices, leaving 20 to 30 percent requiring additional treatments.

   Alternatively, Dr. DiNucci will look at a number of factors when deciding which patients would benefit from conservative treatment alone to reduce pain. According to Dr. DiNucci, the ideal patient is one who has had symptoms for less than six months and is able to wear appropriate shoes. In addition, he notes the ideal patient would be able to wear an over-the-counter or prescription orthotic with metatarsal support during activity.

   “In this ideal group, I believe the success with conservative treatment is in the 80 to 90 percent range,” explains Dr. DiNucci. “Patients who are unable to perform each of these measures increase the likelihood of continued persistence of the neuroma by 5 to 10 percent.”

   As more podiatrists use the modality and improve their skills in ultrasound guidance and learning the anatomy, Dr. DiNucci believes we will see more published reports of this modality for “many other conditions.”

   “Over the next 10 years, I could see podiatric foot and ankle surgeons using diagnostic ultrasound as the standard to monitor their patients’ response to treatments with many soft tissue conditions such as plantar fasciitis, neuromas and tendinopathies,” notes Dr. DiNucci.

   However, Dr. Dockery cautions that ultrasound guidance adds significant costs to the alcohol injections and offers no major improvement as far as results.

   “On the other hand, I believe that intraneural injections of cortisone with ultrasound guidance may offer some benefit,” adds Dr. Dockery, Founder and Director of Scientific Affairs of the International Foot and Ankle Foundation for Education and Research in Seattle.

Study Assesses Autologous Stem Cells In Patients With DFUs And CLI

By Brian McCurdy, Senior Editor

A recent study in the International Journal of Clinical Practice indicates promise for using autologous stem cells to promote revascularization and lower the risk of amputation in patients with diabetic foot ulcers induced by critical limb ischemia.

   The study authors used marrow mononuclear cells (BMCs) and expanded bone marrow cells enriched in CD90+ cells, also known as tissue repair cells, to induce revascularization. Twenty-two patients with critical limb ischemia and diabetic foot ulcers were randomized to receive either BMCs or tissue repair cells. One patient in the tissue repair cell group and two in the BMC group did not show wound healing during follow-up. Furthermore, one patient in each treatment group died before reaching the end of the study; one after having achieved wound healing (BMC group) and the other one without having achieved wound healing (tissue repair group), according to the study.

   The authors noted that 18 patients showed wound healing after 45 weeks and the TcPO2 had improved significantly in both groups in comparison to baseline. The study also concluded that transplantation of BMCs as well as tissue repair cells promoted improvements in microcirculation in some patients.

   Gerit Mulder, DPM, notes autologous stem cells may have potential, based on limited data, in treating problematic wounds of most etiologies. However, he cautions that the most questionable use of stem cells is in patients with CLI since their lack of blood flow will most likely still delay healing. In patients who have marginal blood flow but not complete occlusion, stem cells may show a benefit, notes Dr. Mulder, who recently received approval to perform a randomized, controlled study on the subject of stem cells.

   There is another concern with the location of extraction of stem cells as one would not want to aspirate from the lower extremity if there is arterial occlusion, notes Dr. Mulder, the Director of the Wound Treatment and Research Center and a Professor of Surgery and Orthopedics in the Division of Trauma, Department of Surgery at the University of California San Diego.

In Brief

Organogenesis announces that Apligraf® has improved coverage from multiple payors. National Government Services is changing its coverage policy for Apligraf to five applications with weekly assessments for reapplications for both diabetic foot ulcer (DFU) and venous leg ulcer (VLU) patients, according to the company. Organogenesis notes that Noridian Administrative Services, a Medicare contractor, is covering Apligraf for patients with VLU for greater than two months, including one month of documented failed conservative treatment. Organogenesis also says Apligraf is now part of the Mississippi Medicaid fee schedule for DFUs.

Valeant Pharmaceuticals announces that it has acquired Pedinol Pharmacal. Valeant Pharmaceuticals says expanding into the podiatry arena is “ ... a natural extension of our topical formulation development capabilities.” For more information, visit www.valeant.com.

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