October 2011

Task Force Establishes Diabetic Charcot Foot Guidelines

By Brian McCurdy, Senior Editor

Offloading and immobilization are key in the initial treatment for diabetic Charcot foot but the current staging for the deformity may not be effective, according to new recommendations from the International Task Force on the Charcot Foot that were jointly published in Diabetes Care and the Journal of the American Podiatric Medical Association.

   The task force noted that the existing Charcot classifications are insufficient to provide adequate prognoses or treatment for the condition, according to Lee C. Rogers, DPM, a co-chairman of the task force. He and his colleagues recommended establishing a classification of “active” or “inactive” Charcot, which describes an inflamed or not inflamed foot respectively. The guidelines note that physicians often use definitions of Charcot, such as acute and chronic, although there is no accepted point to describe the transition between the two.

   Task Force Co-Chairman Robert Frykberg, DPM, emphasizes the importance of making an early diagnosis at the onset of inflammation and before deformity occurs. Dr. Frykberg urges clinicians to have a high index of suspicion. For example, when one is faced with any fracture to the neuropathic foot, Dr. Frykberg suggests treating such a fracture as if the patient had a Charcot foot even in the absence of deformity.

   Radiographs are an important initial exam and one should look for subtle fractures and subluxations in the absence of visible pathology, according to the recommendations. The task force notes that if radiographs appear normal, magnetic resonance imaging or nuclear imaging can confirm clinical suspicions.

   “Offloading and immobilization is first and foremost the most accepted conservative treatment. All else is adjunctive,” adds Dr. Frykberg, the Chief of Podiatry and Residency Director at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix. The guidelines suggest protective weightbearing after an active Charcot episode as well as lifetime surveillance for new or recurrent Charcot and other diabetic foot complications.

   The task force finds little evidence guiding the use of pharmacologic therapies to promote the healing of Charcot foot. Likewise, although bone stimulation for Charcot is promising, the task force finds limited evidence supporting this treatment.

   Although offloading is important initially, one might consider surgery as a primary treatment for acute fractures and dislocations, just as one would treat a non-neuropathic patient, notes Dr. Rogers, the Co-Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. Furthermore, the authors say surgery can be a primary treatment for severe Charcot neuroarthropathy of the ankle.

   Specifically, the task force finds that exostectomy may be beneficial in relieving bony pressures that cannot be accommodated otherwise. The authors also say lengthening of the Achilles tendon or gastrocnemius tendon may improve alignment and reduce forefoot tension. The guidelines note that arthrodesis may help patients with pain or instability.

   When treating Charcot, there are several common “myths” that physicians should be aware of, according to Dr. Frykberg. He dispels the idea that Charcot is a “vascular” disease due to insufficiency, noting that the opposite is true and Charcot is characterized by an abundance of blood flow. He also clarifies that there is usually some modest degree of pain present in the active stage of Charcot.

Online Poll Says Nearly 25 Percent Of DPMs Are Not Using EMR

By Brian McCurdy, Senior Editor

While podiatric practices are starting to embrace the technologic advances and financial incentives offered by electronic medical records (EMR), not everybody is on board with the program, according to a recent Podiatry Today online poll (see http://bit.ly/pkaRpz ). Of the 310 poll respondents, 61 percent have started using EMR and 24 percent have not. The remaining 15 percent say they will convert to EMR in the next six months.

   Bruce Werber, DPM, is not surprised at the number of those who have not adopted EMR. He cites dislike of change and fear of technology as reasons for recalcitrance, warning that reluctance to incorporate technology into practice may spell the extinction of their practices.

   Dr. Werber speculates that some of those who have not started using EMR “are concerned about ‘big brother’ watching over their shoulder … Even if you don’t adopt technology, big brother is tracking you, with or without EMR.”

   Another barrier to the adoption of EMR is the “extremely large choice” of vendors that may all look fairly similar, according to Dr. Werber. He notes that many podiatrists are being asked to choose an EMR system without being able to take it for a test drive in practice and their offices may lose productivity while implementing the system. Furthermore, he cites some DPMs’ perception that the technology “is not as easy or efficient as simply writing out a note and checking off a charge slip.”

   Electronic medical records systems can provide better documentation and cleaner electronic claims, which can lead to more cash flow, notes Dr. Werber, who is in private practice in Scottsdale, Ariz. He says EMR can also provide improved protection from malpractice and insurance audits. With EMR, he says there are no charts to pull and file, a decrease in staffing needs and everything is at the DPM’s fingertips.

   “The days of hanging a shingle and just treating patients is long gone,” says Dr. Werber, a Fellow and Past President of the American College of Foot and Ankle Surgeons. “If you are not a great business person and can’t learn and adapt to providing great medicine in a cost efficient manner, you will be out of business sooner than later.”

Can Dynamic Splinting Reduce Post-Op Stiffness In The First MPJ?

By Danielle Chicano

A new study published in the Journal of the American Podiatric Medical Association suggests that dynamic splinting can be effective in reducing the contracture of postoperative hallux limitus and improving active range of motion.

   The study involved 50 patients who were diagnosed with hallux limitus after surgery. All patients in the eight-week study received NSAIDs, orthotics and instructions for performing an exercise program at home. The study group also received dynamic splinting (via the Metatarsophalangeal Dynasplint System) for first MPJ extension and reportedly used the modality for 60 minutes, three times a day.

   After an eight-week period, the dynamic splint group showed a mean 32-degree change improvement in active range of motion in comparison with a mean 10-degree change in 25 control patients, according to the study.

   According to study researchers, the Metatarsophalangeal Dynasplint System is effective in reducing postoperative hallux limitus and should be considered in the standard of care for this condition. However, Doug Richie, DPM, FACFAS, notes there is currently insufficient data to support this conclusion.

   Dr. Richie criticizes the study on several fronts. He says the study does not discuss the measurement techniques used to assess active range of motion in the first MPJ nor do the study authors describe the protocol for home physical therapy. Dr. Riche also says the study does not provide information to support the long-term benefit or cost-effectiveness of dynamic splinting. He adds that there is “no validation of the term ‘post-op hallux limitus.’”

   William Fishco, DPM, FACFAS, sees a high prevalence of hallux limitus following bunionectomies in his private practice in Phoenix. However, he is not convinced that dynamic splinting is the ideal treatment.

   “I personally believe all of my patients with bunionectomies have hallux limitus, but in time, sometimes after a year, the problem resolves or is asymptomatic,” explains Dr. Fishco, a faculty member of the Podiatry Institute. “I have considered dynamic splinting and have prescribed it on occasion. It is not my preferred treatment though.”

   Dr. Fishco generally utilizes the aid of a physical therapist to work with such patients. Similarly, Dr. Richie deems physical therapy intervention more useful in treating postoperative joint stiffness. In addition, he notes that although postoperative joint stiffness occurs often, this does not substantiate the need for dynamic splinting.

   “In my experience, all patients eventually respond to a program of supervised physical therapy combined with home exercises carried out over a three-month period,” explains Dr. Richie, a Past President of the American Academy of Podiatric Sports Medicine.

In Brief

NuvoLase, Inc. has acquired from PinPointe USA all rights, assets and intellectual properties associated with the PinPointe FootLaser, according to the company. As part of the transaction, NuvoLase notes it also has access to all the regulatory clearances for the FootLaser, including the FDA clearances, CE Mark, TGA and Health Canada.

Add new comment