ACFAS Consensus Statement Addresses Ankle Arthritis

The American College of Foot and Ankle Surgeons (ACFAS) recently published a clinical consensus statement on the diagnosis and treatment of ankle arthritis in the Journal of Foot and Ankle Surgery. The panel reached consensus on 12 “appropriate” statements and eight “neither appropriate nor inappropriate” statements. 

The “appropriate” statements address concepts related to determination of causes and types of ankle arthritis; assessment of instability and alignment; appropriate use of X-rays and advanced imaging; multimodal pharmacology; bracing; intra-articular corticosteroids; realignment osteotomy; open and arthroscopic arthrodesis; total ankle arthroplasty; and amputation. The “neither appropriate nor inappropriate” statements discuss the topics of physical therapy, cast immobilization, nonsteroidal intra-articular injections, articular resurfacing, arthroscopic debridement and arthrodiastasis. 

Jeffrey E. McAlister, DPM, FACFAS, one of the authors of the consensus, shares that ACFAS approaches these annual statements with the goal of informing the public as well as practitioners on the evolution of diagnosis and treatment pathways. 

“It is also an atlas for research-based clinical judgement by practitioners who may not see ankle arthritis on a routine basis,” says Dr. McAlister, who is in private practice in Scottsdale, Ariz. 

Michael H. Theodoulou, DPM, FACFAS, a co-author of the consensus statement, says end-stage ankle arthritis is extremely challenging when symptomatic and can often affect younger individuals due to a common onset after trauma. 

“This traumatic etiology demands evaluation beyond the degeneration of the joint,” emphasizes Dr. Theodoulou, Chief of the Division of Podiatric Surgery at Cambridge Health Alliance in Massachusetts. “In this matter, the panel-established consensus on assessing instability and alignment of the joint is influential.” 

Accordingly, he shares that this is where bracing and realignment with periarticular osteotomy become important. Dr. Theodoulou explains there was positive consensus among the panelists for multimodal pain management and intra-articular corticosteroid injection, but notes there was debate regarding whether repeat injections provide relief. 

Dr. McAlister supports the clinical relevance of all of the “appropriate” statements. He adds that the commentary on obtaining plain radiographs before advanced imaging is particularly impactful and cites the importance of weightbearing radiographs. Of the statements deemed “neither appropriate nor inappropriate,” he shares that in his experience, arthroscopic debridement typically worsens the disease process. 

Dr. McAlister also shares his observation that nonsteroidal intra-articular injections, including platelet-rich plasma and amniotic allograft injection, are becoming more common in private practice,. 

“In my opinion, early arthritic changes to the ankle can be ameliorated and remain symptom-free with early application of platelet-rich plasma injection therapy and appropriate bracing,” says Dr. McAlister. 

Dr. Theodoulou comments that the panel was unable to find consensus on the topic of nonsteroidal injections and resurfacing using biologic scaffolds, due to the limited existence of studies and experience with their use. The panel expressed concern about the lack of sustainable relief from arthrodiastasis and felt that arthroscopy was not valuable for advanced disease. The panel was also not able to reach agreement on the utility of physical therapy for this pathology. 

Not unexpectedly, definitive surgical management by arthrodesis through open or arthroscopic technique and total ankle arthroplasty did achieve consensus as viable options, points out Dr. Theodoulou. 

“Early management should be conservative with bracing and judicious use of isolated glucocorticoid injection if not contraindicated. With advanced pain and dysfunction, it is appropriate to offer definitive surgical management by arthrodesis or total ankle arthroplasty considering the individual patient requirements and health status,” maintains Dr. Theodoulou. 

Study Sheds Light On Gender Gaps In Podiatry 

By Jennifer Spector, DPM, FACFAS, Associate Editor

Despite increasing numbers of women in podiatry, there is still a significant gender gap, according to a recent article in the Journal of Foot and Ankle Surgery. 

Researchers received questionnaire responses from 2,276 DPMs and gathered additional data about women in leadership roles from multiple podiatric professional societies. The study found that although women are increasingly involved in academics, research, leadership and procurement of board certification, the rate at which this occurs is slower than the rate at which women enter the profession. 

Additionally, less women complete fellowships, speak at national meetings, lead residency programs or obtain sponsored grants, according to the study. The study authors also noted that female DPMs were more likely to be less satisfied with their work, put in more clinical hours, be single, have fewer children and experience more work stress than their male counterparts. Male respondents reported a six percent and five percent incidence, respectively, of gender discrimination and sexual harassment whereas women reported experiencing these scenarios at a rate of 73 percent and 42 percent during their careers. 

Brittany Brower, DPM, AACFAS, the lead author of the study, says that despite the feminization of medicine, there are still large barriers to female advancement in podiatry. One potential issue is mentorship, she explains, as research shows that individuals with mentors publish more, feel more confident and experience more career satisfaction overall. 

Karen Langone, DPM, DABPM, FAAPSM agrees there is still significant bias and barriers that impede the success of women in the profession. She says the statistics in this study mirror her experience with over 30 years in the profession. 

“Education and awareness are paramount, and this (study) contributes to these efforts,” says Dr. Langone, President of the American Association for Women Podiatrists. “We can instantly address bias in our own corner of the world by treating each other with dignity and respect. Workplaces also need to be more flexible and address the multifaceted lives of those in the medical profession.” 

Change needs to happen at the top and trickle down from prominent organizations, says Dr. Brower, who is in private practice in Holly Springs and Raleigh, N.C. She cites sensitivity training for residency directors and heightened consideration of female candidates for leadership roles, grants and awards as steps to accomplish this change. 

“This is clearly a systemic problem that needs a systemic solution,” maintains Dr. Brower. “Based on our findings, it is clear that more research is necessary and our team may consider a 10-year follow up study to see if raised awareness resulted in implementation of change.” 

How Common Are True Cutaneous Manifestations Of COVID-19? 

By Jennifer Spector, DPM, FACFAS, Associate Editor 

A recent systematic review and meta-analysis in the International Journal of Dermatology revealed a 5.69 percent estimated prevalence of cutaneous manifestations in patients with COVID-19. This review also revealed other related presentations including urticaria, chilblain-like lesions, livedo reticularis and gangrene of the fingers or toes. 

Drawing upon 43 articles for qualitative analysis and 10 articles for meta-analysis published between December 1, 2019 to May 1, 2020, the meta-analysis authors concluded that although it is too early to definitively determine the prevalence of these cutaneous manifestations during the pandemic, they hope this publication inspires careful and robust reporting to contribute to knowledge of this evolving issue. 

Bryan C. Markinson, DPM, FASPD states the predominance of articles on purely podiatric skin manifestations of COVID-19 are simple case reports with chilblain-like changes. 

“My initial impression was that the relationship to COVID-19 was only suggestive. I was definitely more concerned about other causes of such presentations, like systemic inflammatory diseases in which vasculitis is a finding. It is clear now that new information about the affinity of the virus for the vascular endothelium and resulting response makes COVID-19 clearly in the differential,” notes Dr. Markinson, an Associate Professor in the Department of Orthopedic Surgery and an Instructor in the Department of Dermatologic Surgery at Mount Sinai Medical Center in New York. 

Dr. Markinson relates that podiatrists must stay engaged and view the emerging literature with a critical eye. 

“Some of the studies in the earliest phases of the pandemic may have understated the dermatologic manifestations due to concern for the much more urgent respiratory issues,” explains Dr. Markinson. “However, as this meta-analysis indicates, we should not spend a lot of time waiting for undiagnosed COVID-19 patients who may present with these manifestations.” 

It is important that providers make appropriate rheumatology referrals for broad workup since these pedal cutaneous manifestations seem to largely reflect a vascular response most resembling vasculitis, according to Dr. Markinson. 

He adds that one might consider hospital admission if the presentation involves frank signs of critical ischemia, infection or local gangrene. 

“My initial impression remains that most of these (cutaneous) presentations currently and in the future will not represent COVID-19 infection but rather the more familiar diagnoses attendant to the presentation of cutaneous vasculitis,” says Dr. Markinson. ”With available vaccines in the future, hopefully these issues will disappear.”