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Category Archives: Medical

Does Psoriasis Or Fungal Infection Make Patients More Vulnerable To COVID-19?

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.Does Psoriasis Or Fungal Infection Make Patients More Vulnerable To COVID-19?

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.

 

 

Can Adding Plantar Plate Repair To A Metatarsal Osteotomy Yield Better Results For Fo

refoot Metatarsalgia?

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.

 

Are There Identifiable Trends In The Organisms Involved In Osteomyelitis?

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 way 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

May 27, 2020
Pages: 10 – 11
By Jennifer Spector, DPM, FACFAS, Associate Editor

Does Psoriasis Or Fungal Infection Make Patients More Vulnerable To COVID-19?

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.

“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,” says Tracey C. Vlahovic, DPM, FFPM, RCPS (Glasg). (photo courtesy of Tracey C. Vlahovic, DPM)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.

Can Adding Plantar Plate Repair To A Metatarsal Osteotomy Yield Better Results For Forefoot Metatarsalgia?

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.

Are There Identifiable Trends In The Organisms Involved In Osteomyelitis?

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 way 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.

May 27, 2020
Volume 33 – Number 6 – June 2020
Pages: 10 – 11
By Jennifer Spector, DPM, FACFAS, Associate Editor
Resource Center
Podiatric Dermatology
Chucky trainer trend

Chunky trainer trend bad for feet

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.

A Guide To Non-Opioid Alternatives For Pain Management

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

 

Understanding The Importance Of Patient Communication In Pain Management

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

 

What You Should Know About A Multifaceted Approach To Non-Opioid Surgical Pain Management

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.

Non-Opioid Pain Control Options In The Non-Surgical Patient

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

 

Could Complementary Therapies And Diet Changes Have An Impact In Pain Reduction?

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

 

What About The Roles Of Cognitive Behavioral Therapy And Relaxation Techniques?

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

 

Where Do Opioids Fit In A Multimodal Approach To Pain?

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.

 

In Conclusion

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.

References
  1. Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain. Available at: https: www.cdc.gov/drugoverdose/prescribing/guideline.html . Published August 28, 2019. Accessed April 15, 2020.
  2. PainEDU. Improving pain treatment through education. Available at: www.painedu.org . Accessed April 15, 2020.
  3. American Academy of Pain Medicine. AAPM pain treatment guidelines. https://drogunlana.com/2020/05/05/aspirin-for-prevention/ . Accessed May 5, 2020.
  4. Cook D. A nation in crisis. Outpatient Surgery. 2020:10-16. Available at: http://magazine.outpatientsurgery.net/i/1198986-special-edition-opioids-january-2020-subscribe-to-outpatient-surgery-magazine/0 . Published January 2020. Accessed April 21, 2020.
  5. Pacira BioSciences. Exparel website. Available at: www.exparel.com . Accessed April 15, 2020.
  6. Nelson DL. Managing surgical pain in the opioid epidemic era. Symposium presented at: 2014 American Academy of Orthopedic Surgeons Annual Meeting. March 11-15, 2014. New Orleans, La. Available at: http://www.davidlnelson.md/PainSymposium2014AAOS.htm  Accessed April 16, 2020.
  7. Ye F, Wu Y, Zhou C. Effect of intravenous ketamine for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. Medicine (Baltimore). 2017;96(51):e9147.
  8. Hainline B. Pain management in athletes. Lecture presented at: American Academy of Pain Medicine Annual Meeting. February 28, 2020. Vancouver, BC.
  9. Sparks D. Home remedies: what are the benefits of aromatherapy? Mayo Clinic News Network website. Available at: https://newsnetwork.mayoclinic.org/discussion/home-remedies-what-are-the-benefits-of-aromatherapy/ . Published May 8, 2019. Accessed April 17, 2020.
  10. Why take an Epsom salt bath? WebMD. Available at: https://www.webmd.com/a-to-z-guides/epsom-salt-bath#1. Reviewed July 20, 2017. Accessed April 21, 2020.
  11. Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552.
  12. National Center for Complementary and Integrative Health website. Available at: https://www.nccih.nih.gov/. Accessed April 17, 2020.
  13. Daily JW, Yang M, Park S. Efficacy of turmeric extracts and curcumin for alleviating the symptoms of joint arthritis: a systematic review and meta-analysis of randomized clinical trials. J Med Food. 2016;19(8):717-729.
  14. National Center for Complementary and Integrative Health. Glucosamine and chondroitin for osteoarthritis. Available at: https://www.nccih.nih.gov/health/glucosamine-and-chondroitin-for-osteoarthritis. Accessed April 21, 2020.
  15. Brusca SB, Abramson SB, Scher JU. Microbiome and mucosal inflammation as extra-articular triggers for rheumatoid arthritis and autoimmunity. Curr Opin Rheumatol. 2014;26(1):101-107.
  16. Schubiner H. Mindfulness, CBT and ACT for chronic pain. Psychology Today. Available at: https://www.psychologytoday.com/us/blog/unlearn-your-pain/201412/mindfulness-cbt-and-act-chronic-pain . Published December 8, 2014. Accessed April 21, 2020.
  17. Hoots BE, Xu L, Kariisa M, et al. 2018 annual surveillance report of drug-related risks and outcomes. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf . Accessed April 21, 2020.
  18. Centers for Disease Control and Prevention. Calculating total daily dose of opioids for safer dosage. Available at: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf . Accessed April 21, 2020.
  19. Opioid Prescribing Engagement Network. Prescribing recommendations. Available at: https://michigan-open.org/prescribing-recommendations/ . Updated February 25, 2020. Accessed April 21, 2020.
May 05, 2020
By Gina Painter, DPM, FACFAS, FACPM, FFRCPS, Glasg.

Addressing Impingement Issues After Total Ankle Replacement

Addressing Impingement Issues After Total Ankle Replacement

As total ankle replacements (TARs) become more prevalent, it is essential for surgeons to be able to properly assess and address complications. Impingement of the bone or soft tissues can be a significant cause of pain after TAR. With this in mind, the authors provide salient diagnostic insights and offer perspective on conservative and surgical treatments for impingement, including open and arthroscopic repair. 

Total ankle replacement (TAR) is becoming an increasingly viable treatment method for ankle arthritis. Researchers have shown that TAR is a non-inferior option to ankle arthrodesis and recent data even demonstrates a trend toward better quality of life in patients who had TAR in comparison to those who had a tibiotalar arthrodesis.1-3 Due to continued improvements in technique and implant design, there has been an increase of published data on long-term survivorship of total ankle arthroplasty.4 Despite these improvements, there are still common postoperative complications surgeons may need to address.4-6

A common but often aggravating complication is gutter pain secondary to soft tissue or bony impingement. Multiple total ankle designs reportedly cause symptomatic gutter impingement in patients post-operatively.7-11 In a 2013 study involving four different ankle replacement systems and a total of 489 procedures, Schubert and colleagues reported a seven percent incidence of symptomatic gutter impingement.12 The exact etiology behind painful malleolar gutters following TAR remains unclear but the causes seem to be complex and multifactorial in nature. Potential inciting factors include technical error, ectopic bone formation, implant design, oversized components, inadequate ligamentous balancing, undercorrection of varus/valgus deformity or component loosening.9,12-15 

Pertinent Pearls In The Diagnosis Of Ankle Impingement After TAR 

The diagnosis of true ankle impingement following total ankle replacement hinges on history and physical exam in combination with radiographic evidence. The pain is localized upon palpation of the medial and lateral gutters. Additionally, eliciting pain with range of motion of the ankle joint in the sagittal and coronal planes may help localize the area of impingement. Symptoms of focal gutter pain usually present three to six months following implantation as the patient increases activity.14 

One then correlates the clinical findings with radiographic evidence, most commonly in the form of heterotopic ossification or abutment of the talar implant against the malleoli. Although osteophytes and ectopic bone ossification may be common following TAR, studies show that heterotopic ossification may not be associated with functional outcomes.16,17 Therefore, it is important to assess the clinical relevance of ossifications in relation to gutter pain. Heterotopic ossification may or may not coincide with synovial impingement following total ankle replacement.18

When there is uncertainty, utilizing other diagnostic tools may be beneficial. Employing computed tomography (CT) can allow surgeons to further assess the positioning of the prosthetic component and osseous impingements. Computed tomography is preferable to magnetic resonance imaging (MRI) because artifacts secondary to the metallic components may impede detailed assessment.19 

Diagnostic injection with local anesthetic is another useful tool in localizing the area of pain. Due to varus or valgus deformity in the ankle joint, patients often have limited use of the posterior tibial or peroneal tendons prior to ankle replacement. After correction of the deformity, patients may commonly experience inflammation and pain in those tendons because of increased activity. A diagnostic injection within the ankle joint or tendon sheaths can help delineate whether the pain is extra-articular in nature or secondary to impingement.

Conservative Treatment For Impingement After TAR: What You Need To Know 

Before considering another surgery to address gutter impingement pain following total ankle replacement, one should exhaust conservative treatments. In the early post-operative period, the patient may aggravate gutter pain from increasing activity in concurrence with post-operative inflammation. Patients may benefit from a few weeks of offloading with immobilization, rest or bracing.

Intra-articular corticosteroid injections offer another conservative treatment that can help decrease inflammation in the capsular tissues of the ankle joint. With this reduced inflammation, the reduced pressure from the thickened capsular tissue may help relieve the impingement within the medial or lateral gutters. It is important to clean the outside of the ankle prior to injection with betadine or chlorhexidine gluconate swabs so as to avoid infection to the prostheses. Also, one should avoid contacting the needle with the metallic implant as this can accelerate wear.

While it is possible that these conservative treatments may provide symptom relief, there are no current studies, to our knowledge, that assess the efficacy of these treatments for impingement symptoms following total ankle replacement.

Assessing Surgical Options For Post-TAR Ankle Impingement 

Prophylactic gutter resection is not part of the surgical technique with most available TAR systems. However, in our opinion and experience, certain prostheses such as the Scandinavian Total Ankle Replacement (STAR, Stryker) allow for gutter decompression through talar margin resection. Schuberth and colleagues found that patients who had prophylactic gutter debridement had a significantly lower incidence of secondary gutter resection than those who did not.12 

Gaudot and colleagues have also identified mobile-bearing implant systems as a potential cause of malleolar gutter pain because of the excessive subluxation of the polyethylene insert.19 Thus, adopting a fixed-bearing implant design may avoid gutter impingement. Yet the evidence is unclear on whether there is a significant difference between the two types of prostheses.

If a surgeon encounters painful malleolar gutters following TAR, it is paramount to identify the underlying cause for proper treatment. Technical error leading to malpositioning of the prosthesis is a common cause of gutter impingement pain (see top image to the left). In cases in which pain is due to malpositioned prostheses, surgeons may need to perform periprosthetic osteotomies (supramalleolar or inframalleolar) or revisional arthroplasty (see bottom image to left) to correct the deformity. The goal is to realign the joint in order to take pressure off of the symptomatic gutter. In instances of mild malposition of the prothesis, upsizing of the polyethylene insert is an option to alleviate symptoms through increased separation of the tibial and talar components.14 However, one must carefully consider the potential loss in range of motion.

Osseous overgrowth causing impingement may also attribute to aseptic loosening of the talar component.20 In such instances, a CT scan can provide a detailed assessment of the bone stock beneath the talar component. Bone cyst curettage and bone grafting may be beneficial in conjunction with resection of the osseous overgrowth. Cyst recurrence is common and complete filling of each individual cyst is often difficult.21 Therefore, revisional arthroplasty or even ankle arthrodesis may be the only solutions.

If one addresses malalignment or aseptic loosening of the prosthesis appropriately, one can perform malleolar gutter debridement through an arthroscopic or open approach.22-24 A 2.9 mm, 70-degree scope is ideal for malleolar gutter debridement. Use of an ankle distractor is the surgeon’s preference.22-24 Utilizing a combination of the shaver and grasper, the surgeon should continue to debride the gutters until there is distinct visualization of clear space between the talar bone/component and the malleoli. Once the debridement is complete, one should be able to fit the shaver within the gutters without difficulty. The advantage of arthroscopic debridement is a quicker return to activity as opposed to the open approach. However, there is significant risk of damaging the ankle components with the arthroscopic instruments due to a confined space to use the instrumentation. It is important to avoid contact to the metallic components with the shaver or burr. One must also be aware of the reflection off of the metallic component when entering the ankle joint with the shaver or burr (see top image to the right). If the surgeon is not cognizant of the orientation of the instrumentation, he or she may unintentionally damage the ankle components, and leave inflammatory debris within the ankle joint.

Debridement through an open approach allows for easier visualization and consequently a more thorough debridement of the malleolar gutters. An open approach may also decrease operating time. In instances of posterior gutter impingement secondary to ectopic ossification, an open arthrotomy is the preferred treatment option. This allows for direct visualization of the neurovascular structures that are in close proximity and difficult to avoid through an arthroscopic approach. For the open approach, one makes the incision directly over the painful gutter, taking care to protect neurovascular and tendinous structures. The surgeon can employ osteotomes and electric burrs to resect osteophytes and ectopic ossifications.

Postoperatively, patients that undergo debridement through an open ankle arthrotomy should be non-weightbearing in a posterior splint for approximately two weeks with subsequent physical therapy and progression back to regular shoes. Conversely, the patients that have arthroscopic debridement may immediately perform protected weightbearing and begin physical therapy after the first post-operative visit at one week.

Concluding Thoughts 

Total ankle prostheses continue to show improvement in long-term survivorship with each evolution of implant design. Accordingly, as prostheses show increasing longevity, complications will perpetually arise following total ankle replacement. Impingement issues after total ankle replacement are a common but complex complication that require careful consideration for management. Detailed preoperative and postoperative assessments of the patient are necessary in order to properly treat symptomatic gutter impingement. Surgeons should understand the underlying causes contributing to painful impingement so they can properly address them in conjunction with gutter debridement.

Dr. Chu is a Foot and Ankle Fellow with Coordinated Health-Lehigh Valley in Bethlehem, Pa. 

Dr. Brigido is the Director of the Coordinated Health-Lehigh Valley Fellowship in Bethlehem, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. Dr. Brigido is board-certified in foot surgery and rearfoot/ankle surgery. 

References

1. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 2007;89(9):1899-1905.

2. Saltzman CL, Mann RA, Ahrens JE, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009;30(7):579-596.

3. Dalat F, Trouillet F, Fessy MH, Bourdin M, Besse JL. Comparison of quality of life following total ankle arthroplasty and ankle arthrodesis: retrospective study of 54 cases. Orthop Traumatol Surg Res. 2014;100(7):761-766.

4. Clough T, Bodo K, Majeed H, Davenport J, Karski M. Survivorship and long-term outcome of a consecutive series of 200 Scandinavian Total Ankle Replacement (STAR) implants. Bone Joint J. 2019;101-B(1):47-54.

5. Rippstein PF, Huber M, Naal FD. Management of specific complications related to total ankle arthroplasty. Foot Ankle Clin N Am. 2012;17:707-717.

6. Jonck JH, Myerson MS. Revision total ankle replacement. Foot Ankle Clin N Am. 2012;17(4):687-706.

7. Koivu H, Kohonen I, Mattila K, Loyttyniemi E, Tiusanen H. Long-term results of Scandinavian Total Ankle Replacement. Foot Ankle Int. 2017;38(7):723-731.

8. Cerrato R, Myerson MS. Total ankle replacement: the Agility LP prosthesis. Foot Ankle Clin. 2008;13(3):485-494.

9. Rippstein PF, Huber M, Coetzee JC, Naal FD. Total ankle replacement with use of a new three-component implant. J Bone Joint Surg Am. 2011;93(15):1426-1435.

10. Harston A, Lazarides AL, Adams SB Jr, DeOrio JK, Easley ME, Nunley JA 2nd. Midterm outcomes of a fixed-bearing total ankle arthroplasty with deformity analysis. Foot Ankle Int. 2017;38(12):1295-1300.

11. Nunley JA, Adams SB, Easley ME, DeOrio JK. Prospective randomized trial comparing mobile-bearing and fixed-bearing total ankle replacement. Foot Ankle Int. 2019;40(11):1239- 1248.

12. Schuberth JM, Babu NS, Richey JM, Christensen JC. Gutter impingement after total ankle arthroplasty. Foot Ankle Int. 2013;34(3):329- 337.

13. Gross CE, Adams SB, Easley M, Nunley JA 2nd, DeOrio JK. Surgical treatment of bony and soft-tissue impingement in total ankle arthroplasty. Foot Ankle Spec. 2017;10(1):37-42.

14. Schuberth JM, Wood DA, Christensen JC. Gutter impingement in total ankle arthroplasty. Foot Ankle Spec. 2016;9(2):145-158.

15. Krause FG, Windolf M, Bora B, Penner MJ, Wing KJ, Younger ASE. Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement. J Bone Joint Surg Am. 2011;93(9):830-839.

16. Choi WJ, Lee JW. Heterotopic ossification after total ankle arthroplasty. J Bone Joint Surg Br. 2011;93(11):1508-1512.

17. Bemenderfer TB, Davis WH, Anderson RB, et al. Heterotopic ossification in total ankle arthroplasty: case series and systematic review. J Foot Ankle Surg. 2020. [Epub ahead of print] Available at: https://www.jfas.org/article/ S1067-2516(19)30452-1/fulltext . Published January 16, 2020. Accessed April 14, 2020.

18. Besse J, Bevernage BD, Leemrijse T. Revision of total ankle replacements. Tech Foot Ankle Surg. 2011;10(4):176-188.

19. Gaudot F, Colombier J-A, Bonnin M, Judet T. A controlled, comparative study of a fixed-bearing versus mobile-bearing ankle arthroplasty. Foot Ankle Int. 2014;35(2):131-140.

20. Younger A, Penner M, Wing K. Mobile-bearing total ankle arthroplasty. Foot Ankle Clin. 2008;13(3):496-508.

21. Besse J-L, Lienhart C, Fessy M-H. Outcomes following cyst curettage and bone grafting for the management of periprosthetic cystic evolution after AES total ankle replacement. Clin Podiatr Med Surg. 2013;30(2):157-170.

22. Richardson AB, DeOrio JK, Parekh SG. Arthroscopic debridement: effective treatment for impingement after total ankle arthroplasty. Curr Rev Musculoskelet Med. 2012;5(2)171-175.

23. Shirzad K, Viens NA, DeOrio JK. Arthroscopic treatment of impingement after total ankle arthroplasty: technique tip. Foot Ankle Int. 2011;32(7):727-729.

24. Kim BS, Choi WJ, Kim J, Lee JW. Residual pain due to soft-tissue impingement after uncomplicated total ankle replacement. Bone Joint J. 2013;95-B(3):378-383.

May 04, 2020
Pages: 26 – 29
By Anson K. Chu, DPM, AACFAS and Stephen A. Brigido, DPM, FACFAS
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