New Global Vascular Guidelines Emphasize Timely Multidisciplinary Care For Patients With CLTI

New Global Vascular Guidelines Emphasize Timely Multidisciplinary Care For Patients With CLTI

Newly published global consensus guidelines emphasize multidisciplinary teamwork, more standard nomenclature as well as timely assessment and intervention for patients with chronic limb-threating ischemia (CLTI). 

The guidelines, published in the Journal of Vascular Surgery, were recently endorsed by the Clinical Practice Advisory Committee of the American Podiatric Medical Association (APMA). 

Of specific interest to podiatrists is a section devoted to creating a Center of Excellence for amputation prevention. Authored by David G. Armstrong, DPM, MD, PhD, and Lee C. Rogers, DPM, this section covers criteria for a Center of Excellence as a top-tier program typically found in a tertiary care hospital. At this Center of Excellence, a defined team of specialists use clinical practice pathways and guidelines for the diagnosis and treatment of CLTI, and will intervene rapidly to prevent limb loss. This center would also have access to advanced diagnostics. 

Dr. Rogers commends the Society for Vascular Surgery, the European Society for Vascular Surgery and the World Federation of Vascular Societies for joining together 54 experts in 24 countries to formulate these guidelines. 

“The Global Vascular Guidelines attempts to standardize the nomenclature in regard to vascular disease in the lower extremity. One major recommendation is the use of the term chronic limb-threatening ischemia or CLTI,” explains Dr. Rogers, a member of the Board of Directors of the American Board of Podiatric Medicine (ABPM).

He says the guidelines recognize the need for a team approach to treat those with CLTI and that podiatry is a central component of that team. Dr. Armstrong concurs.

“Time is tissue. Don’t delay teaming up,” emphasizes Dr. Armstrong, a Professor of Surgery at the Keck School of Medicine at the University of Southern California. “The sooner a patient is assessed and treated by podiatric and vascular surgery, the better the potential result.” 

“Podiatrists should specifically be aware of recommendations for all patients with CLTI to undergo a cardiovascular risk assessment, have anti-platelet therapy and a statin, and have modifiable vascular risk factors addressed,” adds Dr. Rogers, a member of the Board of Directors for the American Board of Podiatric Medicine.

He also relates that readers should make note of recommendations on the use of non-invasive vascular studies for all patients with a diabetic foot wound since clinical examination and pulse palpation alone is unreliable. 

Section 12 (addressing the formation of a Center of Excellence) describes the “Toe and Flow” model of care for the patient with CLTI, according to Drs. Armstrong and Rogers. The podiatrist may be managing the surgical aspects of infection and tissue loss, and the vascular surgeon or interventionalist may manage the perfusion. 

“This model has been shown in a number of studies to dramatically reduce amputations and change the approach from reactive and ablative to proactive and reconstructive,” says Dr. Armstrong, the Co-Director of the Southwestern Academic Limb Salvage Alliance.

Dr. Rogers cites the concept of creating a team based on the skills needed to prevent amputations, not based on professional titles or degrees, as a key factor in the success of this system.

Can The Modified Valenti Procedure Have An Impact For Athletes With Hallux Limitus/Rigidus? 

A new study in the Journal of Foot and Ankle Surgery analyzed 100 patients that underwent a modified Valenti procedure for hallux limitus/rigidus. Specifically focusing on athletes, the study found that 94 percent of the patients studied returned to their desired levels of activity. 

The study authors followed patients for an average of 49.17 monthsafter their procedures. Dancers and runners (76/100) returned to activity around eight weeks. On average, it took soccer players 16 weeks or more to return to activity.Of the patients studied, 17 had grade 2 hallux limitus/rigidus, 79 had grade 3, and four patients had grade 4 pathology. 

In the study, the authors described the modified Valenti procedure involving excision of hypertrophic synovium and bursal tissue; evaluation and addressing of the articular cartilage, a metatarsal exostectomy starting below the degenerativearticular cartilage. The study authors also noted performing a proximal phalangeal exostectomy along with remodeling of any remaining metatarsal or proximal phalangeal hyperostosis. They also addressed plantar sesamoidal adhesions and used the extensor hallucis brevis for interpositional arthroplastyduring capsular closure. 

Amol Saxena, DPM, FACFAS, the lead author on the study, says this research demonstrates that after having the modified Valenti procedure, 94 percent of the patients returned to their desired activities. He says the procedure provides a viable alternative to fusion and implants in athletes with hallux limitus/rigidus. 

“Fusions and implants have not been shown to allow for return to activity (in patients with hallux limitus/rigidus),” notes Dr. Saxena, a Fellow and Past President of the American Academy of Podiatric Sports Medicine. “Other studies say that the patients ‘return to sports’ but never say exactly what sports and after how long.”

Doug Richie, DPM, FACFAS, conversely relates that he only uses two surgical procedures for hallux rigidus in athletes: cheilectomy and arthrodesis. Dr. Richie comments that the study does appropriately point out that initially a joint-preserving procedure that will allow for future revision is preferred, citing that similarity between a cheilectomy and the Valenti procedure. He also agrees that surgeons should avoid first metatarsal osteotomies in patients with hallux limitus/rigidus. 

However, Lisa Schoene, DPM, ATC, FACFAS, has had positive results with a shortening/decompressing plantarflexory osteotomy, even in patients with later-stage hallux limitus/rigidus. 

When considering barriers to return to activity after surgery for hallux limitus, Dr. Richie feels the primary barrier is pain. 

“It is not usually related to range of motion, which was not evaluated in this study. If you can eliminate pain, the athlete returns to activity,” he elaborates. Dr. Richie also cites swelling, which is related to pain, as an additional barrier.

Dr. Saxena feels the most challenging aspect of return to activity is the patient him- or herself. 

“He or she needs to be patient and realize that it takes a full year to recover, even if they start running at two months,” he relates. 

Dr. Saxena also cites arthrofibrosis, transient sesamoiditis or flexor tendonitis as as potential complicating factors in less than 10 percent of cases. “If needed, after six-months post-surgery a cortico-steroid injection or soundwave can be utilized to decrease symptoms."

Dr. Schoene cites bone healing time as a challenge for the athlete to return to activity. She notes that the bone healing time in her procedure of choice would take longer than a cheilectomy or implant, but could be shorter than that for a fusion. 

“I generally employ rigorous physical therapy and massage therapy very quickly after surgery, and am adamant about compression for reduction of swelling,” notes Dr. Schoene, who has been treating athletes in Chicago for over 29 years. 

Dr. Schoene says she may employ the modified Valenti procedure in the future, especially for patients that prefer a shortened postoperative course or for those that cannot have an osteotomy.

Dr. Richie cautions that if there is over-exuberant resection of bone and cartilage on the dorsal surface of the first metatarsal head, there could be a resultant instability of the MPJ, leading to a hallux extensus deformity. He also notes that the results of the study for grades 3 and 4 hallux limitus are remarkable. However, he comments that only one endpoint measure (return to activity) was reported in this study. Dr. Richie feels that it is only one measure of the overall success of a surgical treatment. 

Dr. Saxena urges readers of this study to strongly reconsider the use of the arthrodesis as a first-line option for hallux limitus, especially in grade 2 and 3 cases. Citing a systematic review by Roukis also in the Journal of Foot & Ankle Surgery (2010;49(6):553-60.) on first metatarsal osteotomies for hallux rigidus, he notes that periarticular osteotomies should be performed with caution due to their high complication rates and be compared to the Valenti.Dr. Saxena also feels patients with grade 4 pathology, regardless if they are active or athletic, may benefit from avoiding fusion. 

Study Assesses Impact Of End-Stage Ankle Arthritis Procedures On Quality Of Life

How does surgery for end-stage ankle arthritis affect health and quality of life? A new study in Foot and Ankle International attempts to address this question. 

In the prospective study, 89 patients, 61 having ankle arthrodesis and 28 having total ankle replacement completed multiple pain or quality of life questionnaires both pre- and post-operatively. Employing multivariate regression models, the study authors measured the changes, adjusting for demographic, clinical and health service utilization.

The majority of patients completing the study (64 percent) reported a clinically significant improvement in pain. Mild depression was common among participants and 22 percent of those studied noted clinically significant improvement with these symptoms. Gains in health were more pronounced among participants reporting the worst preoperative health status, according to the study. However, not all of the participants noted clinically significant gains in health-related quality of life, and the authors suggest further study to delve into this issue.

Patrick Burns, DPM, states that both procedures in this study can positively impact quality of life. In his experience, Dr. Burns says patients undergoing these procedures can have reduced pain, improved activity level and improved participation although most activities still remain non- or low-impact. The improvement in depression scores may be in part due to less frequent office visits, less pain and less interventions overall, adds Dr. Burns, the Director of the University of Pittsburgh Medical Center Podiatric Medicine and Surgery Residency Program and Lower Extremity Reconstruction/Trauma Fellowship. 

When examining total ankle replacement versus ankle arthrodesis, Dr. Burns relates that appropriate patient selection is vital to optimal outcomes. 

“I think proper preoperative examination and understanding of deformities and implant designs available helps make accurate decisions about the proper intervention, which in turn aids in outcomes,” notes Dr. Burns.