Aug-11

CPMA Seeks Parity For DPMs In Historic Task Force

By Brian McCurdy, Senior Editor

California podiatric physicians could eventually have the same license as their fellow physicians and surgeons from other disciplines. The California Podiatric Medical Association (CPMA) recently formed a task force with the California Medical Association and the California Orthopaedic Association to develop a plan for California’s podiatric medical schools to eventually attain accreditation as full-fledged allopathic medical schools.

   The primary advantage of the initiative is that it would grant DPMs parity with MDs and DOs in all statutes governing the practice of medicine and reimbursement, notes CPMA Executive Director Jon Hultman, DPM. Podiatrists would no longer be classified as non-physicians or ancillary practitioners, nor would they be categorized as providing an optional service, says Dr. Hultman.

   In addition, Dr. Hultman notes the podiatric scope of practice would be “determined by training and education rather than by arbitrary geographic boundaries or the need to change a law.

   “With the change, I think we would have the best of both worlds, a DPM degree and physician status,” says Dr. Hultman. “If you look closely at today’s practitioners, they are practicing a specialty of medicine no differently than any other medical specialty, and their training and education is quite similar to that of other physicians.”

   As Don Green, DPM, notes, one advantage of the measure is that podiatrists would be included in every bill passed in California regarding physicians. As these bills currently only include MDs and DOs, Dr. Green says DPMs have to take extra measures to ensure their inclusion in any legislation even if podiatry were the intended focus of the law.

   If California does recognize physicians and surgeons of the foot and ankle, Dr. Green sees minimal downsides. However, he does note some caveats.

   “If we are looking to be little MDs with the goal of ‘treating’ systemic disease, there would be a huge downside,” opines Dr. Green, a Clinical Professor at the California School of Podiatric Medicine at Samuel Merritt University. “The podiatry profession would go away. Already there are those that think the palliative side of podiatric medicine is beneath them. If this becomes more universal in the profession, a new ‘chiropathy’ group will probably emerge.”

   In regard to changes in the educational programs of California podiatry schools, Dr. Hultman does not believe an overhaul will be necessary.

   He notes that in 1993, the Medical Board and the Board of Podiatric Medicine convened a joint study of the podiatric curriculum and postgraduate training. Dr. Hultman points out that the resulting Nelson/Medio report concluded that podiatric medical students entering residency programs were the equivalent of fourth-year medical students.

   Furthermore, he says the study found after the first year of residency, podiatrists were performing at the same level as medical residents.

   In the past 18 years, Dr. Hultman says many of the curriculum recommendations of the Nelson/Medio report have been implemented and virtually every residency program in California has evolved from a two- to a three-year program. He also notes the implementation of many of the American Podiatric Medical Association’s Vision 2015 curriculum recommendations.

   “Our opinion is that the final changes necessary to achieve physician and surgeon status should ideally be done collaboratively with medicine so no political battles would later arise to derail the process after these changes have been made,” says Dr. Hultman.

Can Minor Amputation Prevent Major Amputations In Patients With Diabetes?

By Brian McCurdy

Performing a minor amputation in patients with diabetes can make a subsequent major amputation unnecessary, according to a new study in the Journal of Wound Care.

   The study authors focused on 309 patients with diabetes who had undergone 410 minor amputations between 1982 and 2006. The median age of patients in the study was 73. The authors concluded that nearly two-thirds of the minor amputations they performed helped prevent major amputation but conceded long healing times. The study notes that the median healing time was 26 weeks for amputations below the ankle.

   Valerie Schade, DPM, agrees that minor amputations can obviate major amputations as long as one considers the proper procedure for the patient. As she notes, physicians often focus on single digital or ray amputation without considering the biomechanics of the foot that caused the ulceration or what the biomechanics of the foot will be after amputation. Dr. Schade says this can result in the “whittling” factor of patients undergoing multiple minor amputations.

   “A single procedure such as a transmetatarsal amputation (TMA) that results in a properly balanced foot can minimize the risk for future complications. In these cases, a TMA procedure may be better than a single digit or ray amputation,” says Dr. Schade, the Chief of the Limb Preservation Service and the Director of the Complex Lower Extremity Surgery and Research Fellowship at Madigan Healthcare System in Tacoma, Wash.

   When it comes to an elderly or more sedentary patient, Dr. Schade says performing a single digital or ray amputation without considering the biomechanics of the foot can limit the postoperative recovery time. In more active patients, she notes the final procedure may require soft tissue or osseous corrective procedures to properly balance the foot for protection in shoe gear.

   Dr. Schade says a minor amputation is unsuccessful if the patient experiences delayed healing or a chronic wound, which can be a result of factors like residual chronic osteomyelitis or vascular insufficiency. She advises continually reassessing the patient for possible infection with serial radiographs or advanced imaging such as magnetic resonance imaging or bone scans. Dr. Schade says one should repeat non-invasive vascular studies every six months if healing remains delayed as the status of healing can change and necessitate vascular intervention.

   In addition, Dr. Schade urges DPMs to consider the autonomy of the patient. At times, patients may be distressed with their quality of life, particularly if they have endured months or years of treatment, according to Dr. Schade, an Associate of the American College of Foot and Ankle Surgeons.

   “Although studies have shown a higher risk for amputation with the contralateral limb and increased mortality rates following major amputation, the patient may gain a ‘quality of life’ with primary major amputation,” notes Dr. Schade.

Study Compares Ankle Arthroplasty To Arthrodesis For Post-Op Quality Of Life

By Brian McCurdy, Senior Editor

Arthroplasty has increasingly become an effective treatment option for patients with ankle arthritis. A new study in the Journal of Foot and Ankle Surgery compares quality of life following arthroplasty with the quality of life following arthrodesis.

   Researchers compared 16 ankle arthrodesis patients with 14 arthroplasty patients, using the American Orthopaedic Foot and Ankle Society (AOFAS) scale and the SF-36 form. Two years after surgery, researchers noted that although the quality of life improved significantly in both groups of patients, arthroplasty patients saw more of an improvement in comparison to arthrodesis patients.

   Over the last 25 years, John Grady, DPM, has performed over 250 ankle replacements, over 350 arthrodeses and thousands of ankle procedures. His patients have responded “very well” to ankle replacements and arthrodeses. As for comparing the two procedures, Dr. Grady says arthroplasty “clearly wins” over ankle arthrodesis when it comes to patient satisfaction and improved quality of life. He also has seen fewer complaints about the contralateral limb from patients who have undergone arthroplasty.

   “In fact, if I had arthritis in my ankle, I would only consider arthroplasty,” says Dr. Grady, who is a Fellow of the American Society of Podiatric Surgeons and has a private practice in Oak Lawn, Ill.

   However, Dr. Grady does point out that studies that compare arthrodesis with arthroplasty often use the AOFAS scoring system. He says this gives an advantage to arthroplasty as the AOFAS scoring system considers range of motion, which penalizes arthrodesis.

   Dr. Grady cites a higher learning curve with ankle arthroplasty. He also notes that many studies compare numbers from inexperienced ankle replacement surgeons to experienced arthrodesis surgeons, which “tremendously favors” arthrodesis.