October 2012

Are Obese Patients More Prone To Ankle Fractures?

By Brian McCurdy, Senior Editor

As the American population trends toward becoming more overweight and obese, such patients may have a greater risk for musculoskeletal problems such as ankle fractures. A recent study in the Journal of Foot and Ankle Surgery concludes that obese patients have a higher risk of sustaining a more proximal distal fibula fracture.

   Researchers performed a retrospective review of radiographs of 280 patients with ankle fractures using the Weber classification. Authors found a body mass index of 30 kg/m2 or greater in 45 percent of patients with Weber A fractures, in 50 percent of patients with Weber B fractures and in 60 percent of patients with Weber C fractures. The results did not demonstrate that diabetes mellitus, osteoporosis/osteopenia and current tobacco use had any significant association with the severity of the ankle fracture.

   Neither Christopher Hyer, DPM, nor Patrick DeHeer, DPM, have seen obesity as an independent or significant risk factor for ankle fractures.

   However, Dr. Hyer does note that as more of the population is becoming obese, physicians are more likely to see people with ankle fractures who are obese. He adds that with more weight, there is more force involved during the injury, which may make fracture more likely. Dr. Hyer says the strength of the bone is among the other factors that relates to the risk of fracture.

   Will ankle fractures become more common with the rise in obesity? “I think obese patients are less active than non-obese patients and oftentimes these types of injuries are activity-related such as basketball injuries, so for activity-related injuries, I do not see a correlation,” says Dr. DeHeer, a Fellow of the American College of Foot and Ankle Surgeons, who practices at Hoosier Foot and Ankle in Carmel, Ind. He notes that obese patients are more prone to injuries due to slips and falls, such as ice-related injuries.

   For obese patients with ankle fractures, the biggest challenge is medical management, according to Dr. Hyer, the Director of the Advanced Reconstructive Foot and Ankle Fellowship at the Orthopedic Foot and Ankle Center in Westerville, Ohio. As he notes, obese patients have difficulty adhering with non-weightbearing during the healing phase and are also at greater risk for postoperative deep vein thrombosis and other medical complications.

   Dr. DeHeer notes that surgical correction can be more difficult in obese patients due to the presence of more adipose tissue to dissect through. He says the obese patient’s bone is often more osteoporotic, and such patients tend to have edema in their lower extremities to begin with, which makes wound complications more likely.

Antimicrobial Therapy And Early Surgical Debridement: A Good Combination For Limb Salvage?

By Danielle Chicano, Editorial Associate

Given the high rate of major amputation in patients with diabetic foot osteomyelitis, a new study concludes that limited amputation plus antimicrobial therapy is an effective method for achieving clinical cure and limb salvage in patients with diabetic foot osteomyelitis.

   The two-year retrospective cohort study, which was recently published in the Journal of the American Podiatric Medical Association, tracked 50 patients with diabetic foot osteomyelitis. Researchers administered broad-spectrum empirical antimicrobial therapy tailored to microbiologic culture data for most patients. After a median follow-up of 26 months, study authors noted that 32 patients were cured. Out of the 18 patients who failed initial therapy, 15 underwent limb-sparing surgery. Only three patients required a below-the-knee amputation.

   Valerie L. Schade, DPM, AACFAS, notes that approximately 10 percent of patients with diabetic foot osteomyelitis that she sees in practice require major amputations. The results of the study are fairly consistent with what she sees in her clinic.

   “Antimicrobial therapy is an adjunctive treatment to surgical debridement,” explains Dr. Schade. “Overall, patients who present with peripheral vascular disease do not fare as well as patients who have adequate vascular supply and present with a diabetic foot ulceration and osteomyelitis.”

   Dr. Schade notes the most effective strategies in limb salvage and/or limited amputation include:

• surgical removal of all infected and necrotic soft tissue and bone;
• wound bed preparation and/or final closure;
• a properly balanced limited amputation; and
• an emphasis on appropriate shoe gear and bracing.

   “Final closure should consist of a procedure that maintains a functional limb that can be protected in appropriate shoe gear and/or bracing, reducing the potential for future complications,” explains Dr. Schade. “The final procedure often consists of some sort of amputation.”

   If the podiatric surgeon takes care to ensure the foot is properly balanced via osseous or tendon balancing procedures, he or she can minimize the risk of future complications, adds Dr. Schade, the Chief of the Limb Preservation Service and Director of the Complex Lower Extremity Surgery and Research Fellowship at Madigan Healthcare System in Tacoma, Wash.

Could A New Cell Therapy Offer Potential For Venous Ulcers?

By Brian McCurdy, Senior Editor

A recent study in The Lancet concludes that a new cell therapy may have promise in treating venous leg ulcers.

   The therapy in question, HP802-247, is a spray that contains growth-arrested allogeneic neonatal keratinocytes and fibroblasts. The phase 2 study focused on 205 patients, who were randomly assigned to receive 5.0×106 cells per mL every seven days or every 14 days; 0.5×106 cells per mL every seven days or every 14 days; or to the vehicle alone every seven days. As the study notes, there was a significantly greater mean reduction in wound area associated with active treatment as the dose of 0.5 ×106 cells/mL every 14 days demonstrated the biggest improvement in comparison with the vehicle. Furthermore, authors say adverse events were similar across all groups with only new skin ulcers and cellulitis occurring in more than 5 percent of patients.

   As lead study author Robert Kirsner, MD, PhD, notes, HP802-247 is a first in class cell-based therapy that offers promise for better treatment of chronic venous ulcers.

   “Existing tissue therapies Apligraf (Organogenesis) and Dermagraft (Advanced Biohealing) were engineered to look like skin. Since they don’t function as skin replacement but rather as a stimulus to healing, it raised the question of whether the cells, growth factors and cytokines could be delivered in another fashion,” notes Dr. Kirsner, a Professor, Vice Chairman and Stiefel Laboratories Chair in the Department of Dermatology and Cutaneous Surgery and the Chief of Dermatology at University of Miami Hospital at the University of Miami Miller School of Medicine.

   The less intense regimen — fewer cells administered less frequently — proved most effective, notes Dr. Kirsner. As he points out, the Lancet study demonstrates the best results thus far for the treatment of refractory venous ulcers.

   Dr. Kirsner notes the study reinforces physicians’ understanding that “more is not always better when it comes to stimulating cytokines and keratinocytes involved in the wound healing response.” He emphasizes that two phase 3 studies must be completed prior to FDA approval of the product.

In Brief

The American Board of Podiatric Orthopedics and Primary Podiatric Medicine has changed its name to the American Board of Podiatric Medicine. The board notes the name change fulfills the will of its voting members and appropriately aligns the certification process of the board with the new residency training model (Podiatric Medicine and Surgery Residency) as defined in the Council on Podiatric Medical Education Document 320 (CPME 320).

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