November Journal Club

[ldsrmdude]

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As long as there is continued interest in discussing some literature, I think we should try to discuss an article a month on here. Since it's the beginning of a new month, I'll open the call for article ideas. Pre-pods, students, residents, attendings, please post an article or two you think we should discuss. We'll decide in a few days which article to discuss. Keep the articles relatively recent.

 

[ldsrmdude]

Well, since no one has thrown out any suggestions, I'll toss a couple out there:

Low long-term risk of foot ulcer recurrence after nerve decompression in a diabetes neuropathy cohort.
Nickerson DS, Rader AJ.
J Am Podiatr Med Assoc. 2013 Sep-Oct;103(5):380-6.
PMID:24072366

Pinning across the Metatarsophalangeal Joint for Hammertoe Correction: Where Are We Aiming and What Is the Damage to the Metatarsal Articular Surface?
Galli MM, Brigido SA, Protzman NM.
J Foot Ankle Surg. 2013 Jul 18. doi😛ii: S1067-2516(13)00263-9. 10.1053/j.jfas.2013.06.014. [Epub ahead of print]
PMID:23871175

Factors associated with nonunion, delayed union, and malunion in foot and ankle surgery in diabetic patients.
Shibuya N, Humphers JM, Fluhman BL, Jupiter DC.
J Foot Ankle Surg. 2013 Mar-Apr;52(2):207-11. doi: 10.1053/j.jfas.2012.11.012. Epub 2013 Jan 11.
PMID:23313498

What other articles would anyone like to propose?

 

[ldsrmdude]

Any other articles? We'll choose in a few days.

 

[ldsrmdude]

Alright, we'll do this one:
Low long-term risk of foot ulcer recurrence after nerve decompression in a diabetes neuropathy cohort.
Nickerson DS, Rader AJ.
J Am Podiatr Med Assoc. 2013 Sep-Oct;103(5):380-6.
PMID:24072366

Is there anybody who wants to be in charge of getting a little introduction to the article together (maybe over the weekend) and then we'll get the discussion going?

 

[JR2011]

Interesting article. Looks like therapeutic/prophylactic nerve decompressions may decrease effects of sensory neuropathy on ulcer formation. Raises lots of other questions though. Ulceration in diabetics multifaceted, largely dependent on how diligent patients are on checking feet regularly and wearing correct shoe gear as well as how controlled their diabetes is. The article never mentioned BMI, HgA1c, concomitant use of neuropathy medications, or any objective parameters of neuropathy at time of surgery. Examples of objective neuropathy testing may include nerve fiber density testing or even Dellon's own neurosensory testing with the pressure specified sensory devices: http://dellon.com/publications/ipns.brochure.9.05-2010.update.2pp.pdf
All these factors clearly contribute to development of ulcer and infection. I also didn't see the number of patients that subjectively got neuropathic pain relief post operatively, which was an indication for the procedure. It would be interesting to see if pressure specified testing using Dellon's device improved post operatively from pre operatively. (may already be studies out there) None the less, its an interesting study and I appreciate the work done by the two authors.

 

[ldsrmdude]

Interesting article. Looks like therapeutic/prophylactic nerve decompressions may decrease effects of sensory neuropathy on ulcer formation. Raises lots of other questions though. Ulceration in diabetics multifaceted, largely dependent on how diligent patients are on checking feet regularly and wearing correct shoe gear as well as how controlled their diabetes is. The article never mentioned BMI, HgA1c, concomitant use of neuropathy medications, or any objective parameters of neuropathy at time of surgery. Examples of objective neuropathy testing may include nerve fiber density testing or even Dellon's own neurosensory testing with the pressure specified sensory devices: http://dellon.com/publications/ipns.brochure.9.05-2010.update.2pp.pdf
All these factors clearly contribute to development of ulcer and infection. I also didn't see the number of patients that subjectively got neuropathic pain relief post operatively, which was an indication for the procedure. It would be interesting to see if pressure specified testing using Dellon's device improved post operatively from pre operatively. (may already be studies out there) None the less, its an interesting study and I appreciate the work done by the two authors.

I'm definitely skeptical when it comes to prophylactic nerve decompressions reporting to restore sensation or decrease ulcerations, at least in large numbers. Like you mentioned, there are data that are not presented that would be interesting to have to be able to more fully evaluate the authors results. However, I think overall it was a pretty well-done study. It definitely makes me think about why the ulcer rate was lower in the decompressed leg compared to contralateral legs. I've discussed this topic with some attendings from other specialties because I think the topic is interesting, and they've all been very skeptical as well (rightly so, IMO). At this point, I would definitely not say that the science is settled on the topic and that it probably isn't standard of care to perform a nerve release in all of the instances the authors are performing them in. That brings up another topic that is related. How do you alter your practice habits to fit into the community you are in? Standard of care is typically defined on a community level, so if you're practicing in a community where this is not standard of care, I would imagine you are opening yourself up for not only potential medicolegal troubles, but grief from your referring physicians. This is actually being discussed over in the general surgery forums (here) that has started me thinking about this. Any thoughts on either the article or changing practice to fit the community discussions?

 

[ldsrmdude]

Maybe it's just the areas we have been in or the doctors we have met, but while I agree that many other specialties don't understand all of the nuances of our training, most have a pretty good general idea of what we can do. Certainly I would say it would be the minority who don't understand we do surgery. There are probably more that don't understand the full scope of the surgeries we are trained to do, but I think most understand we do surgery.
If anything, I would say that podiatrists would come under increased scrutiny if there is confusion about training. I think that the scenario you are describing relatively infrequently, but if the standard of care in the community is to surgically correct a painful bunion after a course of conservative care has failed (which I would assume to be the case), then I can't imagine the PCPs will keep sending their patients to the Dr who just prescribes orthotics. I guess that my point with this article is that if you are in a community where prophylactic nerve releases aren't standard of care (I'd imagine it's not standard of care in most places), the literature probably isn't there yet to justify it in a wide-scale way. Just my admittedly not expert opinion, but I think the discussion is interesting.