Quantifying outcomes in foot surgery: A new way forward?

Thu, 17 Apr 2008 13:36:10 -0500

CLEAR’s Human Performance Laboratory at Rosalind Franklin University of Medicine and Science

Over the past two generations, elective foot surgery has become ubiquitous. The most common surgeries on extremities have moved from amputations to osteotomies. However, the assessment of success of these procedures has, in some people’s opinion, varied little in those intervening years. We are able to ask the patient how he or she feels, but that can vary day to day. We are able to evaluate radiographs and other imaging tools, but those are of somewhat value in predicting overall function. For more than 15 years, elite centers have used plantar pressure measurement systems. However, these have largely focused on peak plantar pressure. However, this paradigm is not without its problems.

Recently, clinicians at CLEAR have been considering what they see pre and postoperatively and success has not necessarily been associated with reduction in peak pressure—but rather with relative modifications of pressure. If we used a mountain range example, a single peak coming off of a low-altitude plain, like Kilimanjaro, for instance, might be very different than a peak coming off a series of high peaks, like K2 or Mount Everest in the Himalayas. Kilimanjaro appears relatively higher to the observer on the plain than Everest would to someone standing at 20,000 feet. In that same context, a single peak of pressure—even one that is relatively mild, may be more clinically important than a very high peak in the company of other sites of high pressure. It is in that way that we believe we can mathematically help to define what some of us have seen clinically for many years.

Attached to this podcast on DiabeticFootOnline.com are a couple of figures showing how members of our Human Performance Laboratory, led by Bijan Najafi, are able to assess each foot as part of a bell-shaped curve of distribution of pressures, if you will. One can then assign a regression factor, which represents the similarity of the actual pressure distribution with the normalized distribution. These range from negative 1 to positive 1. As the value increases, so does the similarity between the actual and normalized pressure distributions. So, you can see a patient with a severe Charcot arthropathy with a rather poor regression factor normalized to a much more acceptable one at one year postoperatively. This is true even though his peak pressures are noticeably higher than the normal patients listed in the diagram.

It is this value that we believe can make a substantial difference as an additional quantitative measure of success in this population. We look forward to further discourse that can better confirm or refute these initial surgical and laboratory observations.

The Future of Residency Education

Mon, 10 Mar 2008 20:59:21 -0500

The future of professional medical and surgical residency education is
one that is on the mind of all physicians and surgeons today. The
increasing amount of information that requires dissemination and the
need for standardization is often at odds with different models and
programmatic cultures. How to standardize and how to improve? To that
end, we will discuss this with one of the leading thinkers in this
area today, John Steinberg.

Dr. Steinberg is a Podiatric Surgeon and is Assistant Professor in
the Department of Plastic and Reconstructive Surgery at Georgetown
University School of Medicine. His career has been a stellar one, from
his early work at the University of Texas through to his current work
in Georgetown, it has been punctuated by advances in Education. He is
presently Editor of PRESENTS, a podiatric foot and ankle education
program that has standardized didactics at more than 100 residency
training programs, nationwide.

Charcot: Toward a Common Language and Classification

Tue, 18 Dec 2007 10:08:54 -0600

Since its first descriptions nearly 200 years ago, the malady known as Charcot Arthropathy has proven enigmatic, elusive and often profoundly devastating. Clinician researchers worldwide have contributed much in recent years to understanding the pathophysiology of the disease. Now, a new approach seeks to assemble key clinical criteria into a simple classification system to predict outcome and direct therapy. To discuss this bold approach is Lee Rogers, a rising star in the field of amputation prevention. Lee was a former fellow at CLEAR and runs the Amputation Prevention Center at Broadlawns Medical Center in Des Moines, Iowa as well as serving as active CLEAR faculty at Rosalind Franklin University of Medicine and Science in Chicago.

Of Frogs and Men: The Promise of Peptide Antimicrobials in Wound Healing?

Wed, 5 Dec 2007 21:50:33 -0600

A generation ago, a physician scientist at the National Institutes of Health working African Clawed Frogs made a startling discovery: that strings of amino acids native to the frogs’ skin could potentially ward off bacterial invasion. That discovery has assisted in the birth of peptide-based antibiotics. That young scientist was Dr. Michael Zasloff Professor of Pediatrics and Director, Surgical Immunology at Georgetown University will discuss the potential promise of this area in wound healing and beyond.

Unsteadiness, Uncertainty, Depression and Amputation

Wed, 5 Dec 2007 08:51:21 -0600

Depression and Disease--- This has been such a substantial area of
inquiry in recent years the terms have almost been intertwined.

Work in diabetes suggests that people who are depressed are less
likely to adhere to a treatment regime and more likely to have
problems coping.

Work in the diabetic foot suggests that a) there are probably more
people who are clinically depressed than we previously thought and b)
there seems to be an association between depression, foot
complications, and mortality.

With me is one of the leading lights in the area of diabetes,
depression, and behavior. He is Mark Peyrot, Professor of Sociology at
Loyola College.

He will discuss simple questions we can ask and actions we can take—
even in a busy clinic—to make a difference in the lives of our patients.