News and Trends
Should You Treat Asymptomatic Pediatric Flatfoot?
By Brian McCurdy, Senior Editor
When encountering a child with asymptomatic flatfoot, it is important to decide whether you should treat the condition or see if the flatfoot will improve on its own. A recent article in the Journal of the American Podiatric Medical Association (JAPMA) examines the effects of orthoses for this condition and provides a framework for treatment.
After reviewing studies on the use of orthoses to treat pediatric flatfoot, the authors of the JAPMA article presented three recommendations for the treatment of children with flatfoot.
First, when it comes to symptomatic pediatric flatfoot, the authors emphasize the use of footwear, stretching or (usually generic) orthoses. Second, the JAPMA article also advocates monitoring and providing simple treatment for patients with a typical asymptomatic flatfoot that displays non-developmental foot morphological structures for the child’s age. Third, the authors suggest discharging those patients who have a “typical flexible flatfoot that is normally transient and developmental.” Rather than discharging such patients, Russell Volpe, DPM, suggests offering advice to and observing patients as it may require continued oversight to determine that a child has a typical flatfoot that needs no intervention.
Can Orthoses Have An Impact?
Dr. Volpe cites numerous advantages to treating flatfoot with orthoses. He says the devices correct the position of the child’s flat or pronated foot to a more neutral position. Dr. Volpe says starting orthoses at a young age, when the foot is pliable and cartilaginous, may over time improve the developing foot’s structure. Furthermore, he notes that orthoses may be advantageous in improving a child’s function in regard to gait, sports and other daily activities.
“Often, young children may not yet have pain or other symptoms, but they may be avoiding certain activities or favoring other more sedentary ones as a result of their pronated or flatfoot position/function,” explains Dr. Volpe, a Professor in the Department of Orthopedics and Pediatrics at the New York College of Podiatric Medicine.
The primary disadvantage of using orthoses at an early age is the possibility that a child with a mild deformity is being “overtreated” and has a foot position/deformity that will improve with age “physiologically” even without treatment, according to Dr. Volpe. He notes that the JAPMA article offers “sensible and evidence-based guidance” to avoid overtreating those whose flat feet may not need treatment.
Other Pertinent Considerations
Ron Raducanu, DPM, does not see any disadvantages to using orthoses if they are indicated for patients with pediatric flatfoot. The real question, he notes, is whether the devices address the patient’s comfort. Dr. Raducanu advises discontinuing insoles if they are causing patients pain, since more evaluation may be necessary for a more accurate diagnosis and treatment plan.
In regard to children with asymptomatic flatfoot, Dr. Raducanu would base the decision on the presenting deformity.
“We know that some deformities have a clear progression to further deformity and arthritic changes within the foot and ankle, so anything we can do to limit the deformity’s effect is advisable,” says Dr. Raducanu, the President of the American College of Foot and Ankle Pediatrics.
He says one example of this is a flatfoot secondary to a tarsal coalition. However, one will often see associated symptoms with these cases, according to Dr. Raducanu, who is in private practice in Virginia Beach, Va.
Dr. Volpe agrees with the JAPMA article authors about the importance of differentiating between physiological and non-physiological flatfoot. However, in his clinical experience, he says the vast majority of children with flat or pronated feet, even if they are not overtly symptomatic, do have history findings, subjective features or objective measures that warrant appropriate treatment.
Will The ICD-10 Transition Prove Costly For Physicians?
By Brian McCurdy, Senior Editor
The transition from the ICD-9 coding system to ICD-10 may not proceed without some bumps in the road. Citing increased costs for practices, the American Podiatric Medical Association (APMA) has joined over 100 medical organizations, including the American Medical Association, in opposing the Oct. 1, 2011 deadline for implementing the new system.
The APMA cites a report by Nachimson Advisers, which details increased costs for practices. The report notes that a typical small practice (three physicians and two staff members) would experience a cost increase of $83,290 while a large practice (100 providers and 64 coding staff members) would experience $2.7 million in implementation costs.
The costs of transitioning to ICD-10 would come in the form of information technology, higher documentation costs and education, according to Nachimson Advisers, which conducted the study on behalf of a broad range of professional healthcare associations.
How Will The Transition Affect DPMs?
“The costs of altering claim forms, computer systems, Superbills and our coding knowledge will be huge,” says Lloyd Smith, DPM. “In an era when our profit margins are being squeezed from every direction, we certainly do not need this change at this time.”
What are the benefits of ICD-10? The Nachimson study notes that ICD-10 has been in “widespread” use since 1988 and it lists about five times more codes than the ICD-9 system. Although the ICD-10 system will theoretically make for more accurate coding, it may prove a “major headache” for those in daily practice, according to Dr. Smith, a Past President of the APMA.
Dr. Smith agrees with the implementation delay advocated by the APMA. The association’s letter to the Center for Medicare and Medicaid Services recommends establishing an implementation timeline and process that recognizes the challenges of such a transition.
Study Assesses MRI For Osteomyelitis In The Diabetic Foot
By Lauren Grant, Editorial Assistant
A recently published study found magnetic resonance imaging (MRI) to be effective in detecting unilateral osteomyelitis in the diabetic foot.
The study, published in the Italian journal La Radiologia Medica, noted that MRI facilitated a correct diagnosis in 15 of 16 patients with one false positive result revealed by a computer tomography (CT)-guided bone biopsy. Three patients had radiographic changes due to Charcot neuropathic osteoarthropathy.
While study authors say MRI has high sensitivity when diagnosing osteomyelitis in the diabetic foot, they acknowledge that MRI has a lower specificity for Charcot neuropathic osteoarthropathy.
While MRI has become “very commonly employed” in the assessment of osteomyelitis, David G. Armstrong, DPM, PhD, says it is unnecessary in the majority of osteomyelitis cases.
“Most of the time, the diagnosis of osteomyelitis can be made with serial radiographs, the patient history and a good physical examination,” says Dr. Armstrong, a Professor of Surgery at the University of Arizona College of Medicine in Tucson, Ariz. “However, if there is a significant clinical conundrum and a bone biopsy is problematic, then MRI is the tool of choice.”
While Dr. Armstrong says bone infection is indeed a serious problem, it rarely requires “immediate, emergency action” like a necrotizing infection or other soft-tissue related malady. Especially in cases of osteomyelitis in a plantar forefoot wound, Dr. Armstrong says it is there because of a deformity that one can address surgically. In these cases, he maintains it is the clinical nature of the mechanical deformity, rather than the actual bone infection, that lies at the heart of the issue.
“Paradoxically, one could argue that osteomyelitis of the forefoot and midfoot is as much a mechanical problem as an infectious one,” points out Dr. Armstrong.
In Brief
The Podiatry Insurance Company of America (PICA) announced it has been acquired by ProAssurance, the nation’s fifth largest insurer of medical professional liability. According to PICA, ProAssurance will pay PICA’s mutual policyholders a total of $120 million to buy the stock created by the demutualization of PICA. The company says the transaction will also provide eligible renewing PICA policyholders a total of $15 million in premium credits beginning in 2010 and spread over three years.
