Apr-09

Does Diabetes Thwart The Impact Of ESWT For Plantar Fasciitis?

By Brian McCurdy, Senior Editor

   In a recent retrospective study of extracorporeal shockwave therapy (ESWT), researchers found a greater than 70 percent success rate in treating plantar fasciitis at three months and 12 months after treatment. The study authors also found that the presence of diabetes or psychological issues may have a negative impact upon ESWT results.

   The study, which was recently published in the Journal of Foot and Ankle Surgery (JFAS), offered a retrospective review of 246 feet that underwent ESWT treatment between July 2002 and July 2004. Patients who were treated with ESWT had plantar fasciitis for more than six months and had not responded to at least five conservative modalities, according to the study. The follow-up was an average of 30.2 months post-procedure.

   Researchers found that ESWT had a success rate of 70.7 percent at three months and 77.2 percent at 12 months. David Zuckerman, DPM, says the 12-month results are a “very respectable outcome.” He also notes that the current literature suggests that additional high-energy treatment after four months can relieve initial heel pain even when there is a poor initial outcome with the first ESWT treatment.

   However, in the JFAS study, researchers noted that the presence of diabetes and psychological issues negatively affects ESWT results.

   Lowell Scott Weil Jr., DPM, says his research has never stratified variables such as diabetes and psychological issues in ESWT treatment. In three different FDA approval studies on ESWT studies in which he participated, patients with diabetes were excluded from the studies. While Dr. Weil does not think that shockwave will not work on patients with diabetes and psychological issues, he notes there are multiple variables affecting those patient populations and their pain is more difficult to define as “plantar fasciitis.”

    “Heel pain can have many different etiologies and in my experience, these types of patients can be affected by neurologic issues (local nerve entrapment, radiculopathy, neuropathy) not to mention medications to treat their problems that can have neurologic side effects,” says Dr. Weil, the Fellowship Director of the Weil Foot and Ankle Institute in Des Plaines, Ill.

   Dr. Zuckerman, who has performed over 8,000 ESWT procedures for plantar fasciosis, Achilles tendinosis and patellar tendinosis, does not agree with the study’s conclusion about the impact of diabetes on ESWT results. However, Dr. Zuckerman concurs with Dr. Weil that neuropathy and poor vascularity in patients with diabetes can affect outcomes with the use of ESWT for plantar fasciitis.

Other Pertinent Insights On Patient Selection

   In regard to proper patient selection for ESWT, Dr. Zuckerman, the ESWT Medical Director of Excellence Shock Wave Therapy in Woodstown, N.J., says patients must have: plantar fasciitis pain for at least six months; a Visual Analogue Scale score of greater than 5; pain at or near the origin of the plantar fascia; and at least three failed conservative treatments.

   Dr. Weil says patients with absolute “plantar fasciitis” or “plantar fasciosis” do the best with ESWT. In his research, Dr. Weil has noted a reduced success rate for ESWT when patients have had heel pain for more than two years.

   While the JFAS study noted that plantar fascia thickness had no impact on ESWT results, Dr. Weil has found in his experience that patients with thicker than normal plantar fascia (as shown on MRI or ultrasound) do better than people who have normal thickness.

Podiatry Today Poll: ACFAS Conference Offers Most Clinical Value

By Brian McCurdy, Senior Editor

   The Annual Scientific Conference of the American College of Foot and Ankle Surgeons (ACFAS) offers the most clinical value, according to a recent online survey by Podiatry Today.

   The poll posed the question of “Which podiatry conference has the most clinical value?” Out of 267 respondents, 42 percent cited the annual ACFAS meeting as being the most clinically valuable, according to the poll on www.podiatrytoday.com.

   What makes the ACFAS annual meeting stand out? Mary Crawford, DPM, the President of the ACFAS, says the conference lecturers are “proven teachers, researchers and well known colleagues recognized by previous publications or presentations to be truthful and forthright in the information they are providing.” She adds that instructors have a background in both surgical topics and teaching. Dr. Crawford also says the ACFAS attempts to present its sessions in an unbiased way that avoids “industry or commercialism.”

   Dr. Crawford has received good feedback over the years on the conference’s debates, which “allow members to step outside the doldrums of set lectures and force them to think outside the box and hear opposing arguments.”

   Participants also enjoy the tracks concerning difficult cases that permit members to evaluate more advanced techniques to manage complications that they may encounter, according to Dr. Crawford, who practices at the Ankle and Foot Clinic of Everett, Wash.

Does Hydrosurgery Facilitate Better Skin Graft Success?

By Lauren A. Grant, Editorial Assistant

   A recent study finds the use of hydrosurgical debridement in wound bed preparation has a significant impact in promoting wound closure with skin grafts.

   The study, recently published in the Journal of Plastic, Reconstructive and Aesthetic Surgery, involved 167 wounds for 155 patients. The study authors used hydrosurgical debridement on large wounds or small wounds which had not progressed with absorbent dressings. Researchers found hydrosurgery (Versajet, Smith & Nephew) allowed for successful engraftment after immediate skin grafting in all but 5 percent of the debrided wounds.

   The authors associated the improved results to the use of hydrosurgery as it more adequately removed necrotic tissue and contaminants than the absorbent dressings.

   While hydrosurgery could be perceived as expensive in comparison to more conventional methods of wound bed preparation, Lee C. Rogers, DPM, believes it is effective, efficient and can help reduce potential complications.

    “Hydrosurgery has revolutionized the way we debride wounds,” emphasizes Dr. Rogers, the Director of the Amputation Prevention Center at Broadlawns Medical Center in Des Moines, Iowa. “It is faster than traditional methods of debridement, reducing operation room (OR) time. It rapidly removes fibrotic and necrotic tissue while allowing the surgeon to precisely avoid debriding healthy granular tissue.

    “(Hydrosurgery) is the most effective form of surgical debridement with the main advantages of speed and precision.”

   While Dr. Rogers feels one could use hydrosurgery in a clinic setting, the expense usually limits its use to the OR. In terms of proper patient selection, Dr. Rogers says patients need to be healthy enough to undergo surgical debridement in the OR. In his practice, Dr. Rogers prefers to reserve hydrosurgery for patients with extensive wounds or those with a lot of fibrosis.

   While Dr. Rogers has not seen any complications in using hydrosurgical debridement, he says there is a bleeding risk, especially when one is using the device near blood vessels.

In Brief

   Health Care Products announces the Picture of Health through Education Drawing with a grand prize of a $150 American Express Gift Card. To enter, submit a picture of the Health Care Product’s “Steps to Healthy Foot Care” poster hanging in a podiatry office. Send the photo via a pdf, e-mail or a physical picture to the following address: Picture of Health Through Education, Health Care Products, 369 Bayview Ave., Amityville, NY 11701. All entries need to be received before June 30, 2009.