Podiatrist Dr. Babajide Ogunlana talks about foot care on the daily talk show program, SoulFood Health Education on SmoothFM 98.1 FM Lagos, Nigeria. Listen to how you care for your feet, and identify certain foot and ankle conditions like Athlete foot and Achilles tendon. Get simple exercises on how to strengthen your foot and ankle that you can do at home or any space.
Babajide A. Ogunlana DPM, FACFAS, PCWC -Chief of Podiatric Surgery at Memorial Hermann Southwest Hospital in Houston, Texas
Surgical wounds closed with sutures or staples1 heal by primary intention. Wounds generated from limb salvage surgery often cannot be closed simply by sutures and follow a healing path like that of a chronic wound. These surgical wounds can produce large amounts of drainage which can lead to a higher chance for maceration, breakdown to the surrounding skin, and even dehiscence. The wound dressings utilized need to not only manage the exudate but also provide protection to the surrounding skin while the wound progresses through the healing cascade.
METHOD
A case series study was conducted consisting of a 15-patient sample that underwent potential lower limb-saving surgery, such as flaps, wound closure, and digit/partial foot amputation requiring drainage control.
An advanced moisture management dressing* was utilized as the primary dressing for exudate control and protection of the peri-wound. The technology within the dressing wicks away excess exudate while maintaining a moist wound environment2.
Following sharp surgical debridement and wound bed preparation, the moisture management dressings were applied to the wound and multi-layer compression** was used when clinically necessary.
Dressing change frequency varied based on drainage levels from once a week (low) to upwards of three times per week (high). The wounds were examined for exudate amount, quality of the wound bed/peri-wound, overall patient comfort, and ease of use.
CONCLUSION
The advanced moisture management dressings were able to handle the varying drainage levels while still maintaining an optimal environment at the wound and peri-wound skin.
Patients were adherent and overall wound outcomes improved with this course of treatment.
Exudate levels managed with this moisture management dressing coupled with standard and advanced wound care treatment protocols, including serial sharp wound debridement and edema control, showed promising results in advancing wound healing in these very complex limb salvage cases.
RESULTS -CASE EXAMPLE#1
RESULTS -CASE EXAMPLE#2
FOOTNOTES
Milliken Healthcare Products, LLC, Spartanburg, SC:
†Active Fluid Management Technology
*TRITEC Silver, ULTRA Silver, ULTRA, ULTRA Border, AGILE
**CoFlex TLC two-layer compression
REFERENCES
The authors of a recent study suggest that patients with some dermatologic diseases, such as superficial fungal infections and psoriasis, may be at higher risk for the COVID-19 virus, due to a possible similarity between cutaneous and mucosal immunity.
In the study, published by Dermatologic Therapy, researchers assessed dermatological comorbidities of 93 patients with the COVID-19 virus. They found that the most common skin conditions in this patient cohort in the past three years were superficial fungal infections (25.8 percent), seborrheic dermatitis (11.8 percent), actinic keratosis (10.8 percent), psoriasis (6.5 percent) and eczema (6.5 percent).
In addition, 17 of the patients in the study also presented to the dermatology clinic in the last three months. Among this subcohort, the most common dermatological conditions included superficial fungal infections (25 percent), psoriasis (20 percent) and viral skin diseases (15 percent).
Tracey Vlahovic, DPM, FFPM, RCPS (Glasg), says the study authors have made broad assumptions and do not mention other comorbidities or contributing factors. She adds that the study is also problematic since it combines groups receiving topical and systemic/biologic therapy, and suggests that both groups are at risk. Dr. Vlahovic, who is board-certified by the American Board of Foot and Ankle Surgery, recommends monitoring the National Psoriasis Foundation and the International Psoriasis Council websites for guidance.
“The National Psoriasis Foundation recommends those who are on systemic and/or biologic therapy should remain on therapy unless they develop a COVID-19 infection. Patients who have other comorbidities should speak with their physicians regarding staying on their current treatment or changing it,” maintains Dr. Vlahovic, an Associate Professor in the Department of Podiatric Medicine at the Temple University School of Podiatric Medicine.
Joel Morse, DPM agrees that the premise that those with fungal infections or inflammatory skin disease are more likely to contract COVID-19 is suspect.
He wonders if major comorbid conditions such as diabetes could be contributing to an increased risk of developing the COVID-19 virus. Can the virus move through the skin if the stratum corneum is compromised? These are important questions to consider,
says Dr. Morse, a Past President of the American Society for Foot and Ankle Dermatology.
Annette Joyce, DPM concurs that this study has limitations including: a small sample size; lack of specificity as to the location and type of fungal infections involved; and failure to link immunosuppression specifically to these superficial fungal infections.
“Fungal infections of the nails and skin are harder to treat in some patients due to immune system phenotype,” says Dr. Joyce, the Medical Conference Chair for the DERMfoot conference.
Dr. Joyce also notes that organ-specific immune response in the evolving knowledge of antifungal immunity could play a role in future immune-based COVID-19 therapies, but there are still so many unknowns.
Dr. Morse advocates for investigation of other viruses in patients with skin disease, and whether this heightens the risk for infection.
“When someone is in the hospital with COVID-19 life- and limb-threatening issues, we are probably not looking for tinea pedis or scaling on the elbow … but maybe we should,” suggests Dr. Morse, who is board-certified by the American Board of Foot and Ankle Surgery.
Regardless of the degree of plantar plate injury, adding a plantar plate repair to a shortening second metatarsal osteotomy may improve outcomes, according to a recent study published in the Journal of Foot and Ankle Surgery.
In a prospective study, the authors evaluated 86 adult patients who had second metatarsal Weil osteotomies with and without concomitant plantar plate repair for sub-second metatarsal head pain over a 3.5-year period, and followed them for one year. Patients in the group who had a plantar plate repair with their second metatarsal osteotomy showed better foot-specific quality of life and pain scores at one year despite this group having more severe baseline injuries to the plantar plate. Researchers noted no difference in pre- or postoperative radiographic parabolas, second toe alignment or complication rates between the two groups.
Adam Fleischer, DPM, MPH, FACFAS, the lead author on the study, shares that after successful plantar plate repair from a dorsal approach, he observes patients are less “aware” of their previous foot ailment, which correlates with a higher level of confidence and higher quality of life scores.
Erin Klein, DPM, MS, AACFAS, a co-author of the study, finds in her practice that repairing the plantar plate helps with stability of the MPJ as well as pain.
Dr. Fleischer notes that in his experience, magnetic resonance imaging (MRI) and ultrasound both correlate closely with intraoperative evaluation of the extent of plantar plate injury, which he finds helpful during operative repair.
Dr. Klein agrees. She elaborates that a special MRI protocol with 0.2 to 0.3 mm slices through the metatarsal head/plantar plate region will help the surgeon understand the pathology much better.
“Correcting instability by repairing the plantar plate and then addressing the deforming osseous force (metatarsal length) provides pain relief and improved function postoperatively,” explains Dr. Klein.
Lowell Weil, Jr., DPM, MBA, FACFAS, a co-author of the study, emphasizes the clear necessity to address and correct metatarsal length.
“The plantar plate is a truly important structure that one should repair appropriately when pathology is present,” notes Dr. Weil, CEO of the Weil Foot and Ankle Institute. “Doing this combined procedure yields the highest level results in our research.”
“If patients demonstrate clinical instability of the lesser metatarsophalangeal joint and require a Weil osteotomy, (I recommend) a low threshold for anatomic repair of the plantar plate,” says Dr. Fleischer, who likens it to mechanical instability of the lateral ankle, which benefits from imbrication and advancement of the native tissues.
What organisms might one expect to see upon bone biopsy in cases of osteomyelitis? A new study in the Journal of Foot and Ankle Surgery takes a closer look at patterns that may help in prescribing effective antibiotics.
Reviewing two random cohorts of 151 patients each in 2005 and 2010, the authors examined demographics, comorbidities, microorganisms found on bone biopsy and culture, location and pre-biopsy antibiotic use. Gram-positive bacteria, specifically methicillin-sensitive Staphyloccus aureus (MSSA), was most common in both groups. However, methicillin-resistant Staphyloccus aureus (MRSA) decreased from a prevalence of 28.3 percent to 10.6 percent from 2005 to 2010. The most common gram-negative bacteria was the Pseudomonas species and patients with peripheral vascular disease exhibited a higher incidence.
Mitzi Williams, DPM, FACFAS, one of the authors on the study, was not surprised by the results as they align with her clinical experience.
Regarding the reduction in MRSA between 2005 and 2010, Dr. Williams personally feels the reason is multifactorial and could include antibiotic stewardship and striving to minimize admissions and returns to the operating room.
Windy Cole, DPM agrees that the findings correlate with her clinical practice. She adds that S. aureus is readily found in the environment as well as the normal skin flora of healthy individuals.
“It is when the bacteria enter into the deep tissues or bloodstream that potentially serious infections can occur,” explains Dr. Cole, the Director of Wound Care Research at Kent State University College of Podiatric Medicine.
MRSA infection reduction could also be attributed to better hygiene, sterilization, and cleaning techniques in the hospital setting and the community, adds Dr. Cole.
Dr. Williams also feels podiatrists approach amputations in a way that prevents future infection.
“We recognize that removal of a central ray will likely result in a transfer lesion and may subsequently become infected,” notes Dr. Williams. “Hence, we do not simply remove what is infected. We perform a functional amputation, which carries lower long-term risks.”
Dr. Cole adds that bone biopsies and deep tissue cultures are the foremost ways to isolate pathogenic bacteria and form the best treatment plan.
Currently, empiric antibiotic use should cover MSSA, says Dr. Williams, a Diplomate of the American Board of Foot and Ankle Surgery. Careful analysis for a history of MRSA, chronic ulcerations or a finding of liquefactive necrosis may lead one to redirect empiric therapy. She adds that one should choose empiric antibiotics based on the most likely organism(s) involved.
Fashionable shoes are seldom sensible. However, some trends are better for feet than others. While some might assume the current look of wearing trainers with thick, chunky soles would be good for your feet – think of all that extra cushioning – leading podiatrists say otherwise.
Part of the popularity of these shoes might have come from the fact they are much more comfortable than other fashion shoes for women, particularly high heels. However, they come with their own risks. In particular, the weight of the trainers is an issue that could lead to health problems down the line.
In the midst of the ongoing opioid crisis, this author emphasizes obtaining thorough patient and medication histories, strategies for minimizing opioid use, and maximizing the benefits of non-opioid alternatives.
Patients often present for treatment aimed at alleviating pain and improving their quality of life. As physicians in the age of the opioid crisis, we are torn between acting as responsible stewards of opioid treatment while providing enough medication to alleviate pain, which is often surgically-induced. As we try to understand and follow evolving guidelines, policies and rules on pain management, we need to broaden our understanding and, most importantly, be open to utilizing available alternatives.
While there are many resources regarding pain and opioids, there is not much evidence-based data for physicians to follow. The Centers for Medicare and Medicaid Services (CMS), state departments of public health and human services (DPHHS) programs, health insurance carriers, big box pharmacies and hospitals all have their own programs. The Centers for Disease Control and Prevention, however, provides some clinical practice guidelines, including a mobile app.1
Informing a patient of the risks of addiction and use of opioids is just as important as informing them about the risks and complications of a particular procedure. Start the conversation about post-operative pain control prior to scheduling surgery. Be realistic about surgically-induced pain and the modalities available to decrease this pain. Increase your patients’ understanding that medication will decrease but not eliminate their pain.
Have a conversation about which medications you will prescribe, the limited number of pills you will provide and/or the number of planned refills, even if it is zero. Provide supporting references to hospital, pharmacy or insurance policies regarding opioid-naïve patients and chronically opioid-exposed patients. Be prepared to treat pain in patients recovering from addiction as well, which requires additional consideration.
Are our psychosocial histories adequate? Do we know if our patients have a history of previous chronic opioid use or addiction, psychological or sexual abuse, anxiety, depression or bipolar disease or tobacco, alcohol or illicit drug abuse? Are they facing socioeconomic challenges?
These are all risk factors for long term post-operative opioid use, chronic opioid dependence and future addiction. Limiting and/or eliminating opioid use in this population may prevent future addiction.2
During the postoperative period, keep an open dialogue with patients. These phone calls or office visits should serve as a reminder regarding the healing process and the progression of post-operative pain levels. Take this opportunity to remind them about non-opioid alternative pain management techniques, such as those recommended by the American Pain Society.3
Multi-modal pain management is optimal for all pain control, not just surgical pain. Providers have many options from which to choose.
Local anesthetics. This begins with adequate pedal and regional blocks (with or without ultrasound guidance). Neuraxial anesthesia and peripheral nerve blocks are excellent for pain prevention and relief. Despite the use of general anesthesia, local infiltration with pedal and regional blocks using local anesthetics are still beneficial prior to any incision.4
Local infiltration of Exparel® (Pacira BioSciences), a newly marketed encapsulated liposomal bupivacaine preparation, can be an excellent postoperative choice. This non-opioid agent can provide 48 to 72 hours of anesthesia. It is important to note that Exparel is contraindicated for intra-articular use.5 The FDA may be reviewing additional long-acting injectable local anesthetic preparations in the next few years.
Gabapentinoids. When employing gabapentin or pregabalin (Lyrica®, Pfizer), it is best to administer these medications at least two hours prior to surgery. These drugs shut down excitatory neurotransmitters and decrease upregulation of the central nervous system. However, these drugs do depress the respiratory system so one should exercise caution with these medications for patients who are at high risk for respiratory depression.
Non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. Whether one opts for IV or oral administration, these drugs do have a place in perioperative pain management. These medications decrease the release of pro-inflammatory prostaglandins and peripheral pain mediators.
In a presentation at a symposium on postoperative pain, David L. Nelson MD, an orthopedic hand surgeon, provided an excellent guideline for perioperative use of multimodal pain prevention and management in the orthopedic patient.6 His protocol includes the following steps:
1. Discuss the issue of pain with the patient before surgery.
2. Utilize a NSAID (naproxen sodium or celecoxib) and long-acting acetaminophen the morning of surgery.
3. Use lidocaine in the incisional area preoperatively.
4. Ensure careful tissue handling.
5. Utilize 0.5% marcaine with epinephrine in the surgical site postoperatively.
6. Have the patient use a NSAID (naproxen sodium or celecoxib) and long-acting acetaminophen after surgery.
7. Phone the patient on the first postoperative day to reinforce the pain management protocol.
8. Ask patients about their postoperative pain.
Ketamine. This is an effective drug agonist of the N-methyl-D-aspartate (NMDA) receptors and has become an adjunct intraoperatively. It continues to be more popular in the treatment of chronic opioid-dependent patients and those recovering from addiction.7 I recommend having a conversation with your local anesthesiologist about the use of this drug in your operative patients.
Alpha-2 agonists. Clonidine and dexmedetomidine hydrochloride (Precedex™, Pfizer) can be useful agents. These drugs can provide sedation, decreased anxiety, sympatholytic effects and analgesia. However, it is important to be aware that they can cause bradycardia and hypotension due to their effect on blood flow.
Podiatrists also see a significant number of non-surgical patients that need to manage pain. Although the approaches and options may differ, there are multiple diverse choices that one can employ.
NSAIDs and acetaminophen. In my experience, these are among the main treatment options that most patients and physicians use to manage pain. In a recent lecture at the annual meeting of the American Academy of Pain Medicine, Brian Hainline, MD, maintained that acetaminophen in particular is “vastly, vastly under-prescribed” for acute pain.8 Dr. Hainline noted that acetaminophen and appropriate use of an anti-inflammatory drug can actually augment each other. For athletes who have pain but want to compete the same day, if they don’t have any biomechanical limitations, acetaminophen is a viable option for pain management, according to Dr. Hainline, the Chief Medical Officer of the National Collegiate Athletic Association.8
Massage and soaking. Massage for 10 to 20 minutes can be beneficial for pain management, in my experience. An adjunctive option, massage may decrease pain and muscular tension, and one can supplement this with traditional pain-relieving topical preparations such as IcyHot®. Essential oils such as peppermint oil, lavender oil, black pepper oil, juniper oil, arnica oil and rosemary oil have also been more in vogue recently.9
Soaking the feet, lower extremities and body can have a relaxing effect, which relieves anxiety, and subsequently decreases pain levels in patients. Traditional soaking preparations have Epsom salt bases that reportedly provide magnesium through the skin, relieving muscular aches.10 Other alternatives include adding one half-cup of apple cider vinegar and one half-cup of Epsom salt to one quart of warm water. Magnesium deficiency is often found in patients with fibromyalgia, migraine and chronic muscle spasms.10
Sleep. Sleep disturbances worsen chronic pain and musculoskeletal diseases.11 Establishing a regular sleep pattern should be a top priority. For those having trouble sleeping due to pain, one may initially consider over-the-counter preparations, such as diphenhydramine-based preparations or melatonin. Physicians must never overlook sleep apnea and refer patients to sleep medicine specialists when necessary for treatment.11
Complementary modalities can have a place in providing pain control and improving health. The National Center for Complementary and Alternative Health can provide a wealth of information on this topic.12
Herbs and supplements. Turmeric is the most common herbal preparation people use to decrease inflammation.12 Researchers have suggested that eight to 12 weeks of turmeric extract 1,000 mg/day can reduce arthritic symptoms similar to the improvement patients may get with naproxen or diclofenac.13
Glucosamine chondroitin, according to the National Center for Complementary and Integrative Health, is a safe and well tolerated supplement.14 Glucosamine chondroitin can provide relief from osteoarthritic symptoms when patients take it in recommended doses. However, physicians must remember that glucosamine chondroitin may interfere with warfarin and high doses of the medication may harm the kidneys, and interfere with glucose metabolism in those with diabetes.14
Anti-inflammatory diets. Getting any patient to change his or her diet can be extremely difficult. That said, diet modification can be a great addition to pain treatment and when it is successful, patients have expressed remarkable improvement in my clinical experience. Increased body mass index (BMI) is associated with increased pain, anxiety, fatigue and decreased activity, and quality of life in patients with fibromyalgia.15
Patients with pain should avoid inflammatory foods such as refined grains (rice, white potatoes, pasta, and bread), deep fried foods, pre-packaged/fast foods, corn oil, dairy products, soda, trans fats, margarines and grain-fed meats. Conversely, one should consume anti-inflammatory foods such as raw nuts, sweet potatoes, root vegetables, green tea, wild caught fish, bone broths, eggs, dark chocolate, garlic olive oil, coconut oil, avocado, green leafy vegetables and berries regularly. These changes may improve BMI and be beneficial to the patient’s general health.15
Cognitive behavioral therapy and relaxation techniques. Cognitive behavioral therapy addresses some of the underlying issues, such as anxiety, fear, distress and avoidance, that make the perception of physical pain worse.16 Counseling provides the opportunity for support groups along with the introduction to self-management techniques for coping and relaxation.16
Periodic deep breathing and meditation can be helpful. Movement with meditation such as yoga and tai chi can be extremely beneficial in increasing relaxation with range of motion, stretching and toning exercises.16
While there a variety of non-opioid options for pain management, opioids still may play a role in treatment algorithms. However, it is essential to ensure proper opioid stewardship.
In the area of perioperative pain control, I follow the motto “give patients only what they need.”
Why should we limit the number of opioids we prescribe?
The Centers for Disease Control and Prevention (CDC) reports that 20 percent of patients who are still taking opioids at 10 days postoperatively will continue to take opioids a year later. That figure rises to 40 percent for those on opioids at 30 days post-op.17 The CDC also notes that 32 percent of opioid addicts report their first exposure from someone else’s medical supply.4
Despite these alarming numbers, in a recent survey in Outpatient Surgery magazine, 44 percent of physicians noted they do not decrease the number of opioids they prescribe due to the convenience of fewer postoperative phone calls from patients.4
There are relatively recent CDC guidelines on chronic pain management.1 Overall, they serve as excellent reminder of the risks of combining medications as well as reinforcing that we should provide the lowest amount of opioid medication for the shortest time possible. However, what is the magic number or should there be one?
Many resources recommend three days of opioid medication with reassessment at that time.1,18
Published limits for an initial prescription in an opioid-naïve patient range from five to seven days of opioids and a maximum of 50 morphine milligram equivalents (MMEs) or less per day.18 No longer should physicians provide prescriptions for 35, 40, 50 or 60 pills.
Some limits on opioid prescriptions are written into state laws. In the state of Michigan, the Michigan Opioid Prescribing Engagement Network (OPEN) has been in place since 2016 with the support of the Michigan Department of Public Health and Human Services, Blue Cross/Blue Shield and the Institute for Healthcare Policy and Innovation at the University of Michigan. This network has released evidence-based opioid prescription guidelines for 25 different surgeries.19 However, we should remember that we may need to be flexible based on a patient’s individual needs.
We won’t address the emerging role of cannabinoids in pain control in this article. We can’t list all of the alternative treatments or modalities available. However, it is important for the provider to realize that we don’t understand exactly how much pain experienced by an individual is due to structural/physical changes versus the body’s response to psychosocial stressors.
As prescribers, it is our responsibility to understand a variety of ways to help our patients control pain adequately and safely. In an age when opioid addiction continues to grow, familiarity and comfort with alternative options to supplement or replace opioids may help improve outcomes and avoid risk.
Dr. Painter is the Immediate Past President for the American Board of Podiatric Medicine, and is in practice in Great Falls, Montana. She is an Adjunct Professor at the Pacific Northwest College of Osteopathic Medicine and an Adjunct Professor of Podiatry at the Idaho College of Osteopathic Medicine.