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Does Early Weightbearing After Lapidus Increase Non-Union Risk?

Non-union can be a consequence of Lapidus arthrodesis but a recent study says allowing patients to bear weight early may not increase the risk of non-union.  

The study, published in the Journal of Foot and Ankle Surgery, focused on 367 consecutive patients who had a unilateral modified Lapidus arthrodesis. Researchers categorized patients into early weightbearing (21 days or fewer) and delayed weightbearing (more than 21 days) groups. The study noted a total of 24 non-unions with 13 in the early weightbearing group and 11 in the delayed weightbearing group.

Study co-author Bradly Bussewitz, DPM, notes surgeons can perform the Lapidus for any bunion deformity in which the intermetatarsal space is widened. However, he suggests the Lapidus is ideally suited for those with large intermetatarsal angles, patients with excessive instability at the first tarsometatarsal joint and those with osteoarthritis at the tarsometatarsal joint.

Study co-author Christopher Hyer, DPM, FACFAS, has found the modified Lapidus to be very reproducible with a predictable outcome. In his hands, the procedure works best for patients with moderate to severe bunion deformity and those needing revision surgery. He cites contraindications for the Lapidus procedure such as open growth plates, active infection and an inability to remain non-weightbearing.

Dr. Bussewitz, a fellowship-trained foot and ankle surgeon who is in private practice in Iowa City, Iowa, says the post-op weightbearing protocol for the Lapidus bunionectomy is similar to that of other bunion procedures due to newer locking plate technology and application. He cites multiple studies that confirm locking plates as the most stable fixation construct for the Lapidus bunionectomy.

Traditionally, Dr. Bussewitz notes the first tarsometatarsal joint has been notorious for relatively high rates of non-unions. However, he says recent and upcoming studies point to improved joint preparation techniques and improved fixation techniques. Dr. Bussewitz says these developments “will likely lead to fusion rates for the first tarsometatarsal joint that are comparable to other, more predictable healing fusion sites.”

Deciding whether to allow postoperative weightbearing depends on the surgeon’s preference, according to Dr. Hyer, the Fellowship Director of the Advanced Foot and Ankle Surgical Fellowship in Westerville, Ohio. He says most surgeons allow patients with distal osteotomies to bear weight immediately or use a short period (one week) of non-weightbearing. Dr. Hyer notes patients with proximal osteotomies and traditional Lapidus bunionectomies might be non-weightbearing for six to eight weeks.

“Those having a modified Lapidus, and particularly those fixated with locked plating, may be allowed to bear weight as early as one week depending on surgeon and patient factors,” says Dr. Hyer, a member of the Board of Directors for the American College of Foot and Ankle Surgeons.

Dr. Hyer cites numerous studies demonstrating an equivalent if not better healing rate with early weightbearing in comparison to the reported healing rates of the traditional Lapidus technique. He emphasizes that surgeons must observe thorough and precise surgical techniques, and select a fixation construct that will withstand the stresses of early weightbearing.

For further reading, see “Addressing Common Complications Of The Lapidus Bunionectomy” on page 50 of this month’s issue.

CMS To Penalize Providers For Not Meeting Meaningful Use In 2014

By Brian McCurdy, Managing Editor

Penalties assessed by the Centers for Medicare and Medicaid Services (CMS) will affect eligible providers who did not show meaningful use of their electronic health records (EHR) in 2014, according to CMS.

Medscape Medical News estimates the CMS penalties will target about 209,000 eligible professionals, who will lose up to 2 percent in Medicare reimbursement in 2016. Those 2014 penalties are not affected by recent legislation making it easier for providers to obtain hardship exemptions from meaningful use stage 2, according to Medscape Medical News.

Jeffrey D. Lehrman, DPM, FASPS, cites multiple reasons practices fail to meet meaningful use, including failing to understand the actual requirements for meaningful use incentives. As he notes, CMS has modified the stages of meaningful use and the reporting periods multiple times (often after the year has already started). This has caused confusion for many clinicians, according to Dr. Lehrman.

Inferior EHR can also cause failure to meet meaningful use standards, according to Dr. Lehrman, a Fellow of the American Academy of Podiatric Practice Management (AAPPM). He notes the importance of having the EHR keep track of all the meaningful use criteria and have it easily accessible by running a report.

“Some practices understand the requirements and have the software in place to meet them, but just don’t have the necessary help or staff training to accomplish all that is needed,” maintains Dr. Lehrman.

Dr. Lehrman notes CMS has already taken multiple steps to make it easier for practices to meet meaningful use standards. Among these are changing stage 2 to modified stage 2, which he says carries objectives that are easier to achieve. Dr. Lehrman also points out that CMS shortened the reporting period from a full year to 90 days for 2015.  

Dr. Lehrman snotes that Andy Slavitt, the Acting Administrator for CMS, recently said the meaningful use program will soon come to an end and be “replaced by something better.” As Dr. Lehrman says, Slavitt claims CMS has a goal to “move away from rewarding providers for use of technology and toward achieving good patient outcomes.”  

“Those that have been critical of meaningful use feel it has been more of a ‘jumping through hoops’ phenomenon just to meet the criteria rather than a program that actually improved patient care,” says Dr. Lehrman. “His comments seem to acknowledge this concern.” 

FDA Approves New Matrix For Diabetic Foot Ulcers

By Brian McCurdy, Managing Editor

The Food and Drug Administration (FDA) recently approved the Omnigraft Dermal Regeneration Matrix (Integra LifeSciences) for the treatment of chronic diabetic foot ulcers (DFUs).

The matrix, composed of silicone, cow collagen and shark cartilage, can help regenerate new skin and tissue for wound healing, according to the FDA. The FDA adds that the indication is for wounds that have been present longer than six weeks and that do not involve exposure of the joint capsule, tendon or bone. Physicians should use the matrix in conjunction with standard diabetic ulcer care, according to the FDA.

Lawrence Lavery, DPM, notes physicians have used Omnigraft for burns for decades, citing the product’s “long, successful track record,” particularly for facilitating less scarring in burn patients. Unlike similar products on the market, Omnigraft is a composite material, according to Dr. Lavery.

The FDA cites a study that found that 51 percent of 154 patients treated with Omnigraft had healed ulcers after 16 weeks in comparison to 32 percent of 153 patients who received standard diabetic foot ulcer care alone. Dr. Lavery, a Professor of Plastic Surgery, Orthopedic Surgery, and Physical Medicine and Rehabilitation at the University of Texas Southwestern, was involved in one of the sites for the pivotal trial of Omnigraft for DFUs. He cites experience using the product in the operating room on diabetic foot wounds with large soft tissue deficits to fill the void, cover vital structures like tendon and bone, and prepare the site for skin grafts.

Dr. Lavery notes that Omnigraft is durable so one can apply it on large wounds and use negative pressure wound therapy (NPWT). He says this is a key benefit as “not many products can stand up to” NPWT with repeated NPWT dressing changes. For DFUs, Integra notes that in the study, patients received a median one application each of Omnigraft.

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