September 2013

Start Page: 12

How-To Insights On Orthotic Modifications For Patients With Diabetes

For a plantar ulcer on the second metatarsal head, Dr. Kirby suggests modifying the orthosis to accommodate the second metatarsal head in the forefoot extension area of the orthosis, which will place greater pressures on the first, third, fourth and fifth metatarsal heads. In addition, he says one may also modify the orthosis to have a metatarsal pad proximal to the second metatarsal head to increase the plantar pressure on the distal second metatarsal shaft and off the second metatarsal head.

Dr. Kirby says another possible modification would be adding a bar forefoot post or "dropoff" across all the metatarsal necks to increase the plantar pressures across all the distal metatarsal shafts. This should reduce the plantar pressures across all the metatarsal heads, according to Dr. Kirby.

Dr. Kirby says the sum total of ground reaction force acting on the plantar foot does not decrease with foot orthoses. However, he notes foot orthoses do have the potential to effectively redistribute ground reaction force to different areas of the plantar foot and hopefully away from the high pressure at-risk areas of the plantar skin.

“Once the biomechanics of plantar pressure reduction is understood, then the only limitation to foot orthosis therapy for patients with diabetes is the imagination and skills of the prescribing podiatrist,” says Dr. Kirby.

13

Lower extremity peripheral artery disease (PAD) can lead to amputation, difficulty walking, heart attack and stroke. Now a new report shows a significant increase in the worldwide prevalence of PAD.

   According to a recent review in The Lancet that looked at 34 studies, the number of people with PAD has increased worldwide from 164 million in 2000 to 202 million in 2010. The study added that among the 202 million people living with PAD in 2010, 69.7 percent of them live in low-income or middle-income countries in Southeast Asia and the Western Pacific region.

   Risk factors that contribute to the instance of PAD in both high and low to middle-income countries include smoking, diabetes, hypertension and hypercholesterolemia, according to the study.

   Kazu Suzuki, DPM, CWS, attributes increased medical problems including diabetes, PAD and other atherothrombotic diseases to the “graying” of America.

   “I do believe we are seeing more and more patients with extremely advanced age (90 to 100 years old),” says Dr. Suzuki, the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers in Los Angeles. “It makes perfect sense that we are seeing more PAD as it is just a natural process of aging just like osteoarthritis or skin wrinkles.”

   Dr. Suzuki notes that approximately one-third of his patients with diabetes have at least a mild case of PAD.

   “Based on many studies, we know that this number gets much worse as the age increases beyond 65 years old and if they have comorbidities such as diabetes, end-stage renal disease or if they are smokers,” says Dr. Suzuki.

   According to Dr. Suzuki, most insurance companies as well as Medicare do not reimburse screening tests for PAD. He says this precludes more frequent use of screening tools such as ankle brachial test or skin perfusion pressure tests for patients who are at high-risk for PAD “although this may change in the near future with a focus on preventative medicine.”

   Dr. Suzuki notes that his wound care center generally strongly suspects that a patient has either coronary artery disease (CAD) or PAD if they are more than 65 years old. The threshold for suspicion drops to age 50 in patients who have diabetes or smoke. If a new patient presents with limb pain, claudication or rest pain, he recommends testing for PAD with a type of non-invasive Doppler test.

   “Based on the test results, I would make a treatment recommendation to follow up with their primary care physician (for mild PAD) or immediate consultation with vascular specialists (for moderate to severe PAD),” adds Dr. Suzuki.

New Topical Antifungal Shows Promise In Phase 3 Studies

By Brian McCurdy, Senior Editor

An emerging topical agent is demonstrating promising results for onychomycosis, according to phase 3 study results presented at the recent American Podiatric Medical Association Annual Scientific Meeting.

   Investigators for two phase 3 studies enrolled about 600 patients each, who applied tavaborole once a day for 48 weeks, according to the manufacturer Anacor Pharmaceuticals. In the two studies, 6.5 percent and 9.1 percent of patients taking tavaborole achieved the primary endpoint of complete cure in comparison, respectively, to 0.5 percent and 1.5 percent of patients who used a vehicle agent, according to the company.

   Anacor submitted a new drug application to the Food and Drug Administration (FDA) in July and the company says it expects the approval and launch of tavaborole in mid-2014.

   Warren Joseph, DPM, says tavaborole is a novel class of antifungal, noting that no new topical antifungal has received FDA approval since ciclopirox (Penlac) 14 years ago. Unlike with Penlac, which required debridement every month, he notes the tavaborole studies expressly did not allow debridement but still found tavaborole to be effective. As it is a solution, tavaborole is easier to apply and it dries more quickly than the lacquer formulations, according to Dr. Joseph, a Fellow of the Infectious Diseases Society of America and a consultant to Anacor Pharmaceuticals.

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Dr. Steven Kingsays: August 26, 2013 at 6:09 pm

Aloha,

Plantar redistribution of force and shear is paramount for healing and protection.

Use of an external sole rocker or the newer technology of using a levered internal midsole shoe rocker can achieve this.

Use of compressible foams to donut hole a lesion is helpful or the newer technology of using a composite spring plate with lesion cuttouts is very helpful to not only reduce pressure but shear as well by transferring the force distally and plantar through the spring plate. Modified carbon fiber dynamic AFOs work very well for this but have only been really used for stroke support. We should start using the AFOs if we want to maximize our orthotic therapies.

Mahalo,

Dr. King

Co-Principal Investigator SBIR A11-109 "Advanced Composite Insoles for the Reduction of Stress Fractures." US Department of Defense and Army Medical Research and Materials Command,

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