Diabetic Foot Triage System Guides Podiatrists During COVID-19

A recent in-press special communication in the Journal of The American Podiatric Medical Association calls physicians to action worldwide in order to reduce health-care burden and facilitate the best care for at-risk patients with diabetes during the COVID-19 crisis. The manuscript proposes a Pandemic Diabetic Foot Triage System to guide providers in this pursuit, including the utilization of in-home visits, telemedicine, remote monitoring and higher acuity office encounters. 

Lee C. Rogers, DPM, a co-author of the article, shares that podiatry’s role during this pandemic includes keeping patients with complicated diabetic foot conditions safe and at home, unburdening the health-care system by shifting the site of care and helping patients with diabetes avoid coming in contact with patients who have the COVID-19 virus. 

“These patients (with diabetic foot ulcers) have a high hospitalization rate, a high ER utilization rate and longer lengths of stay,” states Dr. Rogers. “Podiatrists help to reduce all of these metrics.” 

Chet Evans, DPM, MS, FACFAS, feels that the schematic identified in this article provides a simplistic, but accurate portrayal of the scope of care needed by wound care patients. He continues to state that the triage system’s categories are comprehensively inclusive and the preferred sites of treatment are clear, but there is flexibility depending upon the clinician’s situation. 

“I, and typically the rest of medicine, prefer keeping classifications simple and understandable,” says Dr. Evans, Public Health Liaison for the Florida Podiatric Medical Association. “As circumstances conspire for us to provide care and monitoring in non-hospital settings, a common sense guide … seems to be a no-brainer.” 

In creating this triage system, Dr. Rogers relates that he and his colleagues expanded upon existing triage algorithms from the Centers for Medicare and Medicaid Services (CMS) and the American College of Surgeons. The goal is to assist practitioners in identifying which site of service is now appropriate for which situations and to stratify urgency for procedures, according to Dr. Rogers, Treasurer of the American Board of Podiatric Medicine. 

“Some states said podiatric procedures were non-essential,” says Dr. Rogers, the Managing Partner of the Amputation Prevention Experts Health Network. “We took issue with that blanket statement as it should be based on the actual procedure’s urgency, not just on who is performing the procedure.” 

Dr. Evans states that he found some hospitals classified wound care itself to be non-essential and notes these facilities did not understand the scope and range of care needed for these patients. In turn, Dr. Evans says this guideline communication clearly presents the issue, offers a solution and backs this solution up. 

“Considering the deluge of profuse information, articles, blogs, government guidelines and other issues avalanched upon our profession regarding the coronavirus and its impact on society and our health-care system, this article is an informed and useful point of light,” says Dr. Evans. 

Dr. Rogers shares that non-podiatrists and providers across the globe are also adopting this triage system as it is not exclusively for podiatrists. As this issue went to press, the International Working Group on the Diabetic Foot, Diabetic Foot International and multiple organizations across India were all implementing the system, according to Dr. Rogers. 

New Clinical Consensus Statement Addresses Adult-Acquired Flatfoot 

By Jennifer Spector, DPM, FACFAS, Associate Editor 

The American College of Foot and Ankle Surgeons (ACFAS) recently released a clinical consensus statement on the appropriate clinical management of adult-acquired flatfoot deformity. In a review of published evidence from the past 25 years, the panel generated 16 statements regarding adult-acquired flatfoot and deemed six of these statements “appropriate.” These statements referenced obesity, equinus, spring ligament damage, triplane correction and a medial incisional approach to hindfoot fusion. Additionally, they determined the remaining ten statements to be “neither appropriate nor inappropriate.” 

Michael Theodoulou, DPM, FACFAS, a co-chair of the panel, shares two statements he feels are of particular value in this consensus: that one should consider triplane correction when addressing flexible flatfoot and that the spring ligament is an essential component of flatfoot deformity. 

“In these two statements, we define pathoanatomy and the appreciation that an isolated procedure will likely not be satisfactory to correct this deformity,” emphasizes Dr. Theodoulou, Chief of the Division of Podiatric Surgery at Cambridge Health Alliance In Boston. 

Danielle Butto, DPM, FACFAS, another panelist on the consensus statement, agrees that the spring ligament statement is uniquely impactful. She adds that the spring ligament is often overlooked and that surgeons would benefit from rethinking their approach to flatfoot deformity by incorporating the role of the spring ligament in procedure selection. 

MaryEllen Brucato, DPM, FACFAS feels that this statement is useful, but comments that she still has questions as to how this statement specifically guides treatment. 

She goes on to share that for her, the most impactful statement in the consensus is that a medial incision approach does not increase risk of complication when performing hindfoot fusion. 

“This could significantly change the way some DPMs practice,” explains Dr. Brucato, who is board-certified in foot and ankle reconstructive surgery. “Many of us trained with a lateral approach to subtalar joint arthrodesis so the idea of utilizing a medial incision so close to the neurovascular bundle can be hair-raising. The article points out that there is a two cm safe distance between the middle facet and the neurovascular bundle. So when the top experts in our field agree … it should give us the confidence to try it.” 

She also relates that some other statements either validated or seemed to fit with her clinical experience. For instance, the panel deemed radiographs being adequate to evaluate adult-acquired flatfoot as “neither appropriate nor inappropriate.” In her practice, she finds it best to regularly order magnetic resonance imaging (MRIs) for these patients as well as she finds it important for surgical planning, says Dr. Brucato, who is in private practice in Clifton, N.J. 

When deeming a statement “appropriate,” Dr. Theodoulou and Dr. Butto share that the panel identified both supportive high-level literature and personal experience to achieve consensus. Statements labelled “neither appropriate nor inappropriate” represent those that the panel was unable to establish an agreement on between the literature, personal experience or both. 

“The latter suggests we still have much to learn in the management of foot and ankle pathology,” says Dr. Theodoulou, an Instructor of Surgery at Harvard Medical School. “I anticipate increasing questioning of what we appreciate as dogma and, as such, an ongoing change in practice.” 

“The consensus serves as an outline in choosing the most appropriate procedures given the presenting deformity,” says Dr. Butto, who practices for Trinity Health of New England in Hartford, Conn. 

Dr. Theodoulou says the consensus provides pragmatic, real-time considerations of current practice. He maintains the collaboration of experienced practitioners with varied backgrounds allowed for a lively debate and a Socratic method of cooperative argumentative dialogue. He shares that the findings may validate what many providers find in the care of this disorder or it may open questions not previously explored, providing a rationale for failings or successes. 

Dr. Brucato summarizes that the take-home point is that every case of adult-acquired flatfoot deformity is unique, including the etiology, physical exam and predisposing factors. 

“Therefore, (we should choose) our non-operative and operative treatments carefully on a case-by-case basis to respect this uniqueness,” explains Dr. Brucato.