Nov-09
Study Examines Effect Of Smoking On Elective Foot Surgery
By Brian McCurdy, Senior Editor
Although studies have previously shown a link between smoking cigarettes and delayed bone healing, research has until now been scarce on the effects of smoking on elective foot surgery. A recent study in the Journal of Foot and Ankle Surgery finds that bone healing can take as much as 42 percent longer in patients who smoke.
Researchers analyzed 46 patients who had undergone Austin bunionectomies and separated the patients into three groups according to nicotine use. Seventeen patients were smokers, 12 were secondhand smokers and 17 did not smoke as measured by the standardized modified Fagerstrom test and a urine test. The study determined bone healing with the use of post-op radiographs.
The healing time after the Austin bunionectomy was 69 days in non-smokers, 78 days in secondhand smokers and 120 days in smokers, according to the study. Researchers found that in smokers, the osteotomy took 1.73 times longer to achieve radiographic bone consolidation in comparison to non-smokers.
Lawrence Fallat, DPM, a co-author of the study, says many of his patients smoke. When he discusses elective surgery, Dr. Fallat will educate smokers on the consequences of lighting up and why it delays healing. When undergoing Austin bunionectomies or any osteotomy of the foot or ankle, smokers should expect to take several weeks longer to heal, according to Dr. Fallat.
“Many will tell me they are going to ‘cut down’ on smoking and that is good, but if they inhale one time, the vasoconstrictive effects of nicotine can last 12 hours. Less blood flow to the osteotomy results in longer healing,” notes Dr. Fallat, a Fellow of the American College of Foot and Ankle Surgeons.
If smokers still choose to have elective surgery after being educated on the possible risks with delayed healing, Dr. Fallat will use extra fixation to achieve better stability and will keep patients non-weightbearing. Using those measures, he can usually overcome the disadvantages of smoking. Dr. Fallat also uses heparin postoperatively on all smokers.
However, he will not perform ankle fusions, malleolar osteotomies or triple arthrodeses on smokers given the high risk of nonunion in this patient population.
William Fishco, DPM, has encountered delayed union, nonunion and wound healing problems with patients who smoke. He also says wound dehiscence is a “real problem” and says the larger joint fusion cases are more prone to delayed healing. If patients smoke and need a fusion, Dr. Fishco will not refuse them.
“I personally believe that although everyone knows that tobacco kills, it is an addiction that is hard to overcome. These are real people having real problems (with their foot/feet) that oftentimes need surgery to get better,” says Dr. Fishco, a Fellow of the American College of Foot and Ankle Surgeons.
As Dr. Fishco notes, depression can sometimes go hand in hand with chronic pain, contributing to the need to smoke. He will have a candid conversation with potential surgery patients who will not quit smoking before surgery. Dr. Fishco conveys the real risk of the bone(s) not healing and notes that subsequent surgery may be required if that should happen. He uses a bone growth stimulator immediately after the surgery instead of waiting six to eight weeks when there are not enough radiographic signs of bone healing.
Online Poll Questions Lasers For Onychomycosis
By Lauren Grant, Editorial Assistant
While lasers may provide emerging treatment options for onychomycosis, will DPMs be receptive to the technology? A majority of those who responded to a recent poll on the Podiatry Today Web site feel lasers would not be effective.
With a total of 228 responses, 63 percent (144 votes) of DPMs responding to the poll feel that laser care is not a viable option for treating onychomycosis while 37 percent (84 votes) believe it is a viable option.
“(The poll results) do not surprise me given the fact that the decision on whether or not lasers will be effective should be based on good clinical data and that has not been widely disseminated yet,” notes Warren Joseph, DPM. He does not believe anyone can really answer the question knowledgably without the necessary research.
John Mozena, DPM, is surprised by the results of the study. “It is most likely because of a lack of knowledge of the product. People in this profession are under-informed about new technologies,” notes Dr. Mozena, who is in private practice in Portland, Ore.
Dr. Joseph mentioned that podiatrists should be wary at this point surrounding claims of Food and Drug Administration (FDA) “approval.” As this issue went to press, no lasers have a specific FDA indication for onychomycosis.
“People should be suspicious about any laser when studies of the laser for onychomycosis have not been submitted to the FDA for approval,” explains Dr. Joseph.
As a consultant with Nomir Medical Technologies, Dr. Joseph has worked closely with the company on a new laser it has developed. He says the study findings the company has submitted to the FDA are “promising” and come from a controlled clinical trial.
He also notes lasers may be a better option for people unwilling to use the oral or topical treatments. “Up until this point, we haven’t had a big boon for new topical treatments of onychomycosis,” claims Dr. Joseph, a Fellow of the Infectious Diseases Society of America.
“Lasers are the future of the profession though it can be restrictive due to the high cost of the equipment,” notes Dr. Mozena, a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Mozena has personally undergone onychomycosis treatment with the PinPointe laser device and notes that his nails improved but more treatments may be required. He adds that one laser session may not be enough to treat onychomycosis.
However, Dr. Mozena concurs with Dr. Joseph that more studies need to be conducted prior to a specific FDA approval to treat onychomycosis.
Can Total Plantar Fasciotomies Lead To Biomechanical Complications?
By Brian McCurdy, Senior Editor
While total plantar fasciotomies may help patients achieve pain relief, a recent literature review published in the Journal of the American Podiatric Medical Association (JAPMA) notes potential post-op biomechanical problems.
The authors searched several databases for studies between 1976 and 2008 concerning plantar fasciotomies and the medial longitudinal arch. Cadaver studies have identified potential post-op problems such as weakness in the medial longitudinal arch and lateral midfoot pain, according to the literature review. While in vivo studies found that patients received satisfactory results from plantar fasciotomies, there was a decrease in medial longitudinal arch height, according to the review authors. Postoperatively, the center of pressure of the weightbearing foot also had excessive deviation medially, note the authors.
“This review just confirms what we have taught for many years — doing a partial plantar fasciotomy is a very efficacious procedure for recalcitrant cases of plantar fasciopathy,” says Stephen Barrett, DPM.
Dr. Barrett notes that the literature review confirms the early observations that occurred upon the 1992 introduction of the endoscopic plantar fasciotomy. He says the JAPMA authors limited the article by not including studies of endoscopic and open techniques. Dr. Barrett says data from those studies correlates with the later cadaver studies. As he explains, surgeons learned total fasciotomies were unnecessary as they significantly increased the risk of complications as evidenced in a multi-surgeon study of more than 600 patients.
“Endoscopic plantar fasciotomy is still one of the most successful surgical techniques for the treatment of recalcitrant plantar fasciopathy. When it is utilized properly, the minimal potential for complication far outweighs the course of ‘failed continued conservative care’ in patients with severe heel pain,” says Dr. Barrett, a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Barrett also cautions that the review’s biomechanical findings from cadaveric work cannot fully be extrapolated into in vivo situations, noting that the plantar fascia heals in vivo and does not in cadavers. He notes one can prevent almost all biomechanical sequela by controlling the patient during the initial postoperative phase.
As Dr. Barrett notes, one can always make an academic argument for or against any surgical procedure. He says the keys are: how much the patient is really suffering; accurate preoperative assessment via staging and grading; intraoperative technical performance (medial one-third release); and proper postoperative management.
He notes that those in severe pain from plantar fasciopathy, who have tried a myriad of orthotic devices, do not benefit from “over-concern about a potential drop in medial arch height when they cannot walk normally to begin with due to their severe plantar fasciopathy.”
