My Scope of Practice: Salvaging Feet, Limbs… and Hope

  Thanks to clinicians like Stanley Kalish, DPM, FACFAS, and his disciple, Brent Bernstein, DPM, FACFAS, people with foot abnormalities and wounds no longer face certain amputation. Over the past 15 years, advances in podiatry and wound care have increased opportunities for limb salvage. The shift in focus to more hopeful outcomes impacts not only morbidity and mortality, but also healthcare costs and, most importantly, the patient’s quality of life. Dr. Bernstein is championing the reconstructive surgery cause by developing and implementing protocols for Charcot patients and continuing his research to ensure provision of evidence-based care.

  Dr. Bernstein is a graduate of the Temple University School of Podiatry, Philadelphia, Pa. He completed his residency at the Delaware Valley Medical Center, Langhorne, Pa, under the tutelage of Mark Ross, DPM, FACFAS. During his residency, Dr. Bernstein performed wound care-related surgeries and found such satisfaction in the results he was seeing that his current practice with St. Luke’s Hospital and Health Network, which serves Bethlehem, Quakertown, Allentown, and the Poconos (Pennsylvania), now consists almost entirely of wound and Charcot cases. During his fellowship with Dr. Kalish (“a forefather of reconstructive surgery”), Dr. Bernstein was excited by what could be achieved through Charcot surgery. He studied Ilizarov techniques (using biology to form new bone) in Portugal, scrubbing in with experts in the field. “Wound care and podiatry mirror each other,” Dr. Bernstein says. “Where once it was said ‘People with diabetes don’t heal’, we are now seeing amazing results in wound healing with advanced dressings. The same holds true for advances in reconstructive foot surgery. Charcot patients used to be treated using simple offloading and we would watch them slowly fail because of a chronically swollen foot that eventually becomes ulcerated and infected. Worse yet, many patients with diabetes presenting to the emergency room with a big, red angry-looking foot characteristic of Charcot would be misdiagnosed as having cellulitis, abscess, or infection and an inappropriate amputation would occur. Hopefully, those days have ended. My fellowship showed me we can reconstruct the damage and subsequently the patient’s outlook.”

  To provide knowledgeable, consistent care, Dr. Bernstein developed protocols that take a proactive approach to Charcot care as opposed to “managing patients who happened to have Charcot in addition to a wound (see “Synopsis of Charcot Treatment Program”). The Charcot and Reconstructive Foot Program, based out of St. Luke’s Advanced Wound Centers, boasts a multidisciplinary team of specialist physicians and nurses in addition to six residents and one fellow. The program is the first of its kind that is designed specifically to treat the Charcot patient.

  Program protocol addresses two types of Charcot: chronic “burnt-out” Charcot (many times with associated deformities and wounds) and acute Charcot that has active fractures and destruction. The cornerstone of treatment of both types is total contact casting (TCC). In chronic Charcot, the related wound is healed before the decision is made whether the deformed foot can be safely placed in a brace or shoe or if reconstructive surgery is warranted. In cases of acute Charcot, the foot is casted until the inflammatory bone destruction resolves so that foot architecture is maintained. Also, IV osteoporosis drugs are administered to prevent any bone destruction and bone healing is stimulated with bone growth stimulators that have been used for years in the treatment of non-healing fractures. “Before such protocols were implemented, patients were in a cast for 6 to 12 months,” Dr. Bernstein says. “Now, cast time is dramatically reduced.”

  In all patients, a multidisciplinary team performs a sophisticated work-up, including computerized gait analysis, blood and urine samples to evaluate markers for bone destruction and formation, thermistor evaluation to quantify inflammation, and 3-D modeling through an advanced CT scanner available at the hospitals with which Dr. Bernstein is affiliated. The multidisciplinary team consists of vascular surgeons, infectious disease specialists, podiatric wound specialists, orthotists/pedorthists, and wound care nurses who have special interest in Charcot. “We are lucky to have a group of like-minded individuals who aggressively work to save limbs — people such as the vascular surgeons and interventional radiologists who continually raise the bar when re-perfusing these patients,” Dr. Bernstein says.

  The final goal is to accommodate all patients in a diabetic shoe and ankle brace at the end of treatment and to prevent recurrence of ulcer, infection, and deformity. “Our shoe and brace specialist, Bob Toth, CPed, is an integral part of our program,” Dr. Bernstein says.

  Approximately 25% of Dr. Bernstein’s patients require some type of surgical intervention. These interventions can be as simple as a release of the contracture of the Achilles’ tendon to as sophisticated as fusion of the foot to the leg with various internal and external fixation devices and muscle flaps to close difficult wounds.

  A database is being developed to track all interventions to determine which are most effective. “It will be a unique body of data,” Dr. Bernstein says. “Much of the ongoing research is performed in conjunction with the residency program under the direction of residency director Bob Diamond (DPM, FACFAS). Graduates of the program become valuable resources in Charcot and wound care.”

  Dr. Bernstein plans to continue to fine-tune the protocol, going through the “amalgam” of literature to help cut the chaff and streamline interventions. Meanwhile, he is already seeing change, getting referrals from the community and other wound care centers and healthcare systems. He continues to advocate for a multidisciplinary team approach that includes a podiatrist who can perform reconstructive surgery (at least on reserve) for every wound care center and practice. He urges every practitioner who treats the neuropathic foot to be well versed in the possibility of Charcot when a swollen, red foot is encountered.

  “Accurate diagnosis has made a big difference in outcomes,” he says. “Our hospital administration and nurse supervisors have been very supportive of this program. So has the local physician community. Everyone has a contribution to make in my scope of practice.”

My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.