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Guido LaPorta, DPM, MS
Director Podiatric Medical Education
Community Medical Center
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Guido LaPorta has nothing to disclose.
So sorry to keep you so late, so I have a very short case presentation. But before I do it, I want you all to think of what you understand evidence-based medicine to be. I�ve heard that term 500 times today! And nobody has really explained it as I understand it. And I�m just wondering, since everybody�s telling you you should follow evidence-based medicine, what do you think it is? Okay? Think about that.
All right, I�m going to show you this. This is a technique that we�re currently studying in an IRB approved study utilizing a textile for our ligament as opposed to allogeneic or autogenous material. It�s done percutaneously for incisions, and basically what you�re going to try and do here is reconstitute in an anatomic fashion the calcaneal fibular ligament and the anterior talar fibular ligament.
So what we do first of all is pretty much determine where we want those ligaments to attach, both to the calcaneus and the talus. And we�re using a substance called ortoline. Now if you know anything about ortoline it has a bad rap, and it got that because of what happened to it in its use for the, in the carpal-metacarpal articulation, where it was basically used as a spacer. And if you read the articles, which I did, the reason it got that bad rap is that nobody really had a protocol. Or I shouldn�t say that � there was a protocol, nobody followed it. And therefore the results were so variable, some of them somewhat tragic, but they basically had to do with movement of the involved joint too soon after implantation. It�s a biomaterial, it�s polyurethane urea, it�s basically just a scaffold that encourages native tissue ingrowth, and it is biodegradable by five to seven years.
So we start by making our percutaneous approach and we deepen that down to the lateral wall of the calcaneus, taking care to visualize the sural nerve and protect it. We go right down � there�s no need to lift the periosteum at all � so we go right down to the bone surface. The second incision we make is posterior to the fibula. Once again, this is made in the interval between the peroneal tendons and the posterior surface of the fibula, and then we make two incisions anteriorly � one anterior and one over the proposed attachment to the neck of the talus.
We then use curved forceps and we construct a tunnel from the anterior portion from the talar neck to the front of the fibula, and posteriorly we�ll create a tunnel that goes beneath the peroneal tendon. That�s very important if you�re going to do an anatomic instruction � it�s very easy to put this structure above the peroneal tendons, and in some cases, not part of the study, we have done that, when somebody has peroneal tendons that want to or have subluxed, we�ll actually use this structure as a restraint in order to keep those tendons within the groove. We use interference screws. I do not like soft tissue ankors for this procedure, because regardless of the size of the ankor, the strength of the soft tissue ankor is the suture. So it doesn�t matter how large the ankor is � if the suture breaks you lose your attachment. So we drill holes and we use an interference screw. We happened to pick for this study the G4 system that�s made by Wright. I�m not a consultant for them, I don�t speak for them � we just happen to think it�s the easiest one to utilize for this particular procedure.
And we�ll put in the preliminary pins into the area where the ligament is going to attach to the respective bones, and you can see that very nicely here. This is all checked on c-arm. In the beginning we used to drill a hole all the way through the calcaneus, and that�s really not necessary I don�t think, but we still do drill a hole all the way through the talar neck and use that to tension the ligament as you�ll see. The most important hole and the most
difficult one to do is the one through the fibula, and I would suggest that if anybody does this procedure percutaneously, that it�s probably not a great idea to take a large drill bit and drill a hole. You should start small, and progressively enlarge it, because you want this hole directly in the center of the fibular mass, so that if you make a mistake with the initial wire, no big deal � just change its position. And then use the cannulated drill bit to start that hole and then we use solid drill bits to progressively enlarge it, depending on the size ortoline that we�re going to use. So here you see that hole being prepared.
Now, the right G force as you see, the wire that we drill through, has this wire loop on the end, and after we suture the ortoline, put this whip stitch into the ortoline, we�ll put it through this ring, and then we�ll pull this wire out through the opposite side of the foot, and this pulls the ortoline into the hole in the calcaneus. And then we will fish it up through the tunnel that we created, use a similar device from anterior to posterior, the wire loops over here, and then pull the ortoline through the fibula � here you see it being threaded and then it�s pulled through the fibula � and then we�ll fish it down through our tunnel anteriorly. So what we�ll do then is stabilize this with an interference screw in the calcaneus so that it is a really solid unit between the ortoline and the bone, and then we�re going to get ready to put it through the talar neck, and so we ream over that wire through the talar neck and then fish the remaining portion of the ortoline through the talar neck, exiting the medial side.
And then you, placing the foot in the position that we want it, we will adjust the tension of that ligament, pulling that ortoline through that hole in the talus, and then put our interference screw in so that we have a good tight fit. Now, what are we doing here? Well, you know, you can do a percutaneous approach, and you don�t have to use a textile like this, but you�ve got to get a tissue from somewhere. So you can either use a free tendon graft from the foot � a gentleman on our staff, John Sheland in Scranton, likes to harvest xxxx [7:50] and then that�s fine, that works really nice, but I keep going back to the point that Peacock and Van Winkle made that any time you use a free tendon graft in the foot, it�ll swell to three times its size while it�s incorporating, and I�m not sure that�s a good idea or that I want that to happen over here. Or you can use allogeneic tissue, and that�s fine too, but you know, expensive, and it has to vascularize. So we use this because we can pull it right off the shelf. We can get whatever thickness we need. It�s got a good track record for repair of ligaments and tendons and we think it�s going to work real well here. The beauty about this is it�s percutaneous � there�s very little to heal. There�s minor discomfort � it takes about 20 minutes to do. And the patient�s weight-bearing in a cam walker or some other form of protection at the end of the first week. So we�re pretty happy with how this has progressed so far, and look forward to publishing these results.
We like it much better � regardless of what you use � we like it much better than doing the traditional lateral ankle stabilization procedures � most of which, by the way, you�ll understand, have shown the use of the peroneus brevis in order to stabilize the ankle. But interestingly, Harold Schoenhaus was the first one to point out that that�s really not a real bright idea. Since the brevis is really the only stabilizing structure you have on the lateral side of the ankle to prevent instability, why would you go and mess with it and do your lateral ankle stabilization with that? It�s probably much better to do it with a portion of the longus than it is to brevis. I think it�s much better not to interfere with them at all, and use either allogeneic or a textile. But I thought that this is an interesting procedure, and regardless of what you use, or how you attach it, it�s something that you may want to consider.
Now I have questions, okay? And my question is, how many products do you use in your office, clinic or hospital that have Level 1 evidence? I would suggest to you that if you only do things you have Level 1 evidence for, you�re going to be able to golf a hell of a lot. You�ll be working about two hours a week! And that�s the nature of our specialty, and I�ll explain that as we go along. I heard today that neuropathic ulcer mortality rate was greater than that of colorectal cancer. Does that mean the patient dies from the neuropathic ulcer? I don�t think so. So that�s a statistic that�s nice and it certainly outlines the severity of the patient who has a neuropathic ulcer, but the mortality rate for neuropathic ulcer is not greater than that of colorectal cancer. Most of these patients are cardiovascular train wrecks. They�re on dialysis. They die from that, not neuropathic ulcer.
We did a study on the mortality rate at community medical center. 98% of the patients who died at our hospital last year were horizontal. So if you can keep your patients vertical, maybe they won�t die. Do we need a study on parachutes? Think about this now, right? I scoured the literature on this. Do we need a study on parachutes? I haven�t found one scientific article on the function of parachutes. So let�s do a study. Let�s have two cohorts. We�ll take six people up in a plane, not give them parachutes. We�ll take another six up and give them parachutes, have them all jump out. And let�s see what happens. I mean, some things are so blatantly obvious that doing a study is a total waste of time. So what do you think evidence-based medicine is? Anybody give me a�? Are they all Level 1 studies? Is that the only thing that you can use? Evidence-based medicine is simply using the best available evidence that�s attained by scientific method to help you make a clinical decision. And it can be anything from a meta-analysis or a triple blinded randomized control trial, down to expert opinion. That�s medical evidence also, that�s evidence-based medicine � expert opinion. Of course there are certain strengths to different ones, but we�re not even going, you know, if you look at what we do, doing a Level 1 study on some of our surgical approaches actually may be unethical. There�s a difference between talking about evidence-based medicine with medicines, and surgical procedures. When�s the last Level 1 evidence article you read on the Austin procedure? There ain�t any! The base wedge osteotomy? There aren�t any! Lapidus? There aren�t any! Hammertoes? There aren�t any? So does that mean we have no evidence that that is a useful approach to certain deformities? When you test medicines and you have two arms, and you see a medicine doesn�t work or isn�t working as advertised, that patient can switch over into the arm. Well, suppose you do a surgical procedure, and it doesn�t work. All right, what are you going to say? Well, why don�t you switch over to the other arm? I�ll operate on you again. That�s unethical. So a lot of what we do surgically will never have Level 1 evidence, and I just hope you realize that when you hear from the podium that we don�t have Level 1 evidence for a lot of what we do, for good reason. In most cases it would be unethical to do it that way.
Okay, thank you.