November 2013

Study Finds Low Risk Of DFU Recurrence After Nerve Decompression

By Brian McCurdy, Senior Editor

While there has been controversy over the years about the use of nerve decompression for diabetic sensorimotor polyneuropathy, a recent study in the Journal of the American Podiatric Medical Association concludes that the risk of recurrent ulcers following the procedure is low.

   Researchers looked at follow-up data on 75 legs in 65 patients with diabetes who had neuropathic foot ulcers and underwent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels. The study notes that nine of 75 operated legs had developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, the study says 16 had ulcerated, of which three were amputated.

   The authors conclude that the study’s long-term decrease of the risk of diabetic foot ulcer recurrence after operative nerve decompression compares “very favorably” with the historical literature and the contralateral legs of the study cohort, which had no decompression.

   “I have been performing (decompression) since 2000 and the ulcer recurrence rate is extremely low,” says Stephen Barrett, DPM, FACFAS.

   Study co-author Andrew Rader, DPM, notes that decompression is most effective in patients with a positive Tinel’s sign at known sites of possible nerve entrapment and those with adequate vascularity (venous and arterial) and diabetes control. People without a positive Tinel’s sign at entrapment sites are poor candidates for this type of surgery, according to Dr. Rader, a Fellow of the Association of Extremity Nerve Surgeons who practices at Indiana Foot and Ankle.

   Dr. Barrett concurs, saying patients who have a positive Tinel’s sign have an approximately 85 percent chance for some improvement in sensation and reduction of pain. In contrast, he notes patients who have significant nerve damage and who cannot feel the Semmes Weinstein 5.07 monofilament will usually get the least benefit from decompression.

   “This is why I am so distraught that the use of the Semmes Weinstein 5.07 monofilament has become the ‘holy grail’ in the universe of providers treating diabetic ulcers because by the time the patient cannot feel this monofilament, his or her nerve damage is so bad that the patient’s chance of regeneration is very low,” says Dr. Barrett, an Adjunct Professor at the Arizona Podiatric Medical Program at the Midwestern University College of Health Sciences.

   Complications with decompression are rare but Dr. Rader says incisional dehiscence seems to be the greatest concern. “It was rare in our study cohort but can be frustrating when it happens,” he notes.

   Dr. Barrett adds that complications are very low if the surgeon is experienced in peripheral nerve surgery and the patient has a proper assessment. Excessive edema is a relative contraindication and he notes that absolute contraindications to the surgery would be any significant peripheral arterial disease or vascular problem that could compromise wound healing. He cites the efficacy of peripheral nerve decompression in patients with diabetes.

   “These patients, provided that selection criteria is proper, should have this surgery as it will reduce the chance of re-ulceration and subsequent amputation,” says Dr. Barrett, a Fellow and the incoming President of the Association of Extremity Nerve Surgeons. “This surgery is life changing and ultimately saves significant healthcare dollars.”

Can Proximal Opening Wedge Osteotomies Have An Impact For Severe Hallux Valgus?

By Danielle Chicano, Editorial Associate

A recent study in the Journal of Foot and Ankle Surgery concludes that the proximal opening wedge osteotomy is an effective surgery to correct high-level hallux valgus deformities.

   The study authors looked at 41 patients with moderate and severe hallux valgus who underwent proximal opening wedge osteotomies between 2005 and 2009. In the study, surgeons also utilized biplanar Chevron and/or Akin osteotomy procedures adjunctively according to the magnitude of distal angles. Additionally, the researchers used either the Darco BOW (Wright Medical Technologies) or the LPS plate (Arthrex) to obtain fixation. Researchers noted that following the procedure, patients’ American Orthopaedic Foot and Ankle Society (AOFAS) scores improved from a mean of 50 to 82 and the sesamoid position improved in 79 percent of the feet.

   Patrick DeHeer, DPM, FACFAS, utilizes proximal opening wedge osteotomies in less than 2 to 3 percent of his cases. His first choice is to treat the “apex of the deformity” or the first metatarsocuneiform joint in severe hallux valgus cases. He notes that arthrodesis of the first metatarsocuneiform joint is his procedure of choice in these cases with a few exceptions.

   Dr. DeHeer will often opt for a first metatarsophalangeal joint (MPJ) arthrodesis alone if there are adaptive changes of the MPJ. This plantarflexes the first ray and stabilizes the medial column while correcting the MPJ deformity, he adds.

   “If the patient is a pediatric patient with open growth plates and a severe hallux valgus deformity, then this is where I choose the proximal opening wedge (osteotomy),” explains Dr. DeHeer, a Diplomate of the American Board of Podiatric Surgery.

   When Dr. DeHeer performs proximal opening wedge osteotomies, he always uses opening wedge locking plates in combination with either an allograft or autograft. To minimize the risk of complication, Dr. DeHeer ensures the patient has three to four weeks of non-weightbearing followed by two to four weeks of partial weightbearing and finally four weeks of assisted weightbearing.

   Regardless of the procedure, Dr. DeHeer maintains that there are key considerations one must keep in mind when treating and assessing patients with severe hallux valgus. “You must correct all levels of deformity to fully correct the severe hallux valgus. This may mean a gastroc recession, a first metatarsocuneiform joint arthrodesis, MPJ procedures and an Akin osteotomy,” he explains. “When each level of deformity is corrected, results are more consistent and predictable.”

How Effective Are Autologous Conditioned Plasma And ESWT For Plantar Fasciitis?

By Brian McCurdy, Senior Editor

Autologous conditioned plasma and extracorporeal shockwave therapy (ESWT) are two of many treatment options for plantar fasciitis and a recent randomized trial in Physical Medicine and Rehabilitation says both can be effective in relieving heel pain.

   The study focused on 54 patients with unilateral plantar fasciitis for more than four months. Nineteen received autologous conditioned plasma and conventional treatment, 19 had ESWT and conventional treatment, and 16 had conventional treatment alone. Conventional treatment included stretching exercises and orthotics if indicated.

   The Visual Analogue Scale (VAS), the AOFAS ankle-hindfoot scale, and plantar fascia thickness improved in all groups at one, three and six months, according to the study. However, the authors noted that the autologous conditioned plasma and ESWT groups experienced significant improvements in pain on VAS scores in comparison to the group that only got conventional treatment.

   Lowell Weil Jr., DPM, MBA, FACFAS, cites several advantages of ESWT for plantar fasciitis, including no complications or risks, a large body of randomized controlled trials in the therapy’s favor, no pain after treatment and a quick return to activity. On the downside, he notes shockwave can be expensive and is typically not covered by insurance.

   As for autologous conditioned plasma, Dr. Weil says although it is less expensive than shockwave, there are minimal studies showing the treatment’s benefits and many studies indicating that autologous conditioned plasma has no benefits. Autologous conditioned plasma is also slightly invasive and can cause post-procedural discomfort, according to Dr. Weil, the President and Fellowship Director of the Weil Foot and Ankle Institute in Illinois.

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