Is MRI really being overutilized?

So often in this litigious society, practitioners are being scrutinized by lawyers for malpractice. This includes lacking diagnostic information to either support or negate a diagnosis. That is why wounds are cultured without looking "infected" and why radiographs are done even after soft tissue surgery. So often are practitioners forced to practice "defensive medicine" that the costs for health care are going to rise simply because of these examinations. Without these tests to "confirm" a diagnosis, surgery may not be authorized by an insurance company, or if someone is injured on the job or as part of a traffic accident, the extent of damage may be overlooked.

This is in my opinion, that these tests need to be done. MRI should be ordered to confirm or negate osteomyelitis in the presence of diabetic foot wounds. Also with severe ankle sprains to rule out underling ligamentous damage or cartilage lesions. Without the tests, even in the presence of clinically suspicious findings, there will always be a malpractice lawyer who will ask you, "why didn't you get the test, Dr?"

In the case of MRI, there are few to no real risks, as there are no radiation exposures for this exam. Also, for patients that are not able to have this test (ie. pacemaker,etc) it is usually determined by CT scan for whatever the reason for the advanced imaging. In other words, these tests are available and although not entirely necessary, they are invaluable to not only diagnose with more certainty, but also allow for surgical planning and provide further means to demonstrate pathology leading towards surgical intervention in the case of malpractice depositions.

The coutnter argument is that over-utilization of MRI is expensive and wasteful, according to researchers. For example, the information needed to diagnose knee OA can be obtained using x-ray. While an x-ray can cost less than $150, the cost of an MRI is about $2,500.
Medical imaging accounts for 10 to 15% of Medicare payments to physicians. Ten years ago, medical imaging accounted for less than 5%. The cost of medical imaging is expected to continue soaring at an annual rate of at least 20%. Suffice to say, it's an expensive business.

And sometimes, MRI findings may be overly sensitive, leading to incorrect diagnosis, or over diagnosis of tendon pathology.

This nails home another concept I have discussed on here on many occasions. We treat the patients, not the MRI findings. We need to understand the personality of the injury and how that injury is presenting itself in you, how your lifestyle or quality of life is affected, and whether or not the findings that we have identified on the MRI are in fact the competent producing cause of your discomfort — and then come up with an appropriate treatment plan that will likely involve a period of nonsurgical management— which, if unsuccessful perhaps might lead to an indicated surgical procedure, if your lifestyle changes and quality-of-life dictates that this is in fact an option.

Skin lesions on the foot

Example of a MRSA infection started as a "rug burn" with this gentleman rough housing with his dog.

Many patients know about how important sunblock is to avoid cancer from the sun. However, most primary care doctors and even some dermatologists may miss looking at skin on the foot. Numerous times each year, we play a role in the diagnosis of skin disorders from biopsies of lesions on the foot and leg. Each lesion that the skin creates will tell a small story as to the inner health of each patient. And even if a lesion is not painful, or is located somewhere you are not usually able to look at, it can be something quite problematic.

We condone the biopsy of any lesion that changes colors, bleeds, or looks different than other lesions on your body. This may include open lesions, pigmented lesions, blistering lesions, and even rashes. The skin only has several ways to show a clinician that something is wrong. That means that thousands of disease processes can only be shown by skin in less than 10 ways. That is a tough thing to diagnose without a definitive biopsy. Most dermatologists require yearly skin exams for anyone with a prior squamous or basal cell carcinoma. And melanoma should be checked for at least 2x yearly. Lesions of the foot and ankle are often found by a foot and ankle surgeon prior to most other specialists or general practitioners, and it is imperitive that a biopsy be performed.

Lesions like the above can actually be a multitude of pathologies being represented by a simple rash. In this case tinea pedis was the diagnosis initially. After 2 months of topical therapy it was later diagnosed with a biopsy as a squamous cell carcinoma (skin cancer).

This is a common presentation of a plantar wart. This is also important to send to a pathologist if they are excised as this may also have several other more aggressive variations of melanomas which can mimic this otherwise harmless viral skin infection.

Any lesion that you are unsure of should get checked by a doctor, whether that is your foot and ankle surgeon, general practitioner, or dermatologist or other specialist. No lesion is too small, or insignificant to investigate.

Wound Care at FFLC

Diabetic pressure wounds are prevalent on the feet of many neuropathic patients. Usually, if the arterial circulation is adequate, and the nutrition status is evaluated for protein intake, the final step is to offload the area. This is, in my experience, the most difficult part of wound care in our population. Everyone wants to remain active, and walking is a major component of this mentality. This picture is an example of a forefoot pressure ulceration, which is directly related to an equinus deformity combined with neuropathy in an insulin dependent diabetic female who has been to a wound care center for 2 years prior to my evaluation. After my initial screening protocol, which consists of taking an xray, listening to the arterial pulse with a hand held dopplar, and recording a HA1c value to determine longterm blood glucose control, I moved on to the physical examination of biomechanics. In her case, the main issue was not an underlying bone infection, or ill fitting shoes (as she had custom shoes with offloading soft insoles already placed). A definitive diagnosis of "gastroc equinus" was diagnosed.






After 2 weeks of continued debridements in the office the wound began to improve, but the central deepest portion was next to impossible to offload.










At this time, the patient was scheduled for an endoscopic gastroc recession, which is done with a 0.7 cm incision that heals in most cases after 7 days. This is a profound procedure which offloads the forefoot considerably, and in her case was the final step towards healing her wound. She also had a dermal skin graft application which also heavily increased the healing capacity of this particular wound.






There are many examples of how wound care can be performed by looking at the global picture in each patient. Sometimes the foot structure itself is the issue and requires reconstruction. Sometimes a bone infection is underlying, and excision of that portion of the bone is required, and even sometimes a leg needs more circulation requiring vascular interventions. Here at FFLC, we strive to be at the cutting edge of limb salvage, which may entail any number of procedures tailored to each individual patient. We work closely with the infectious disease and vascular surgeons to offer a team oriented approach to wound care. This allows rapid wound healing, and lowers the statistical possibility of deep seeded infections which can lead to amputations.

Each wound has a cause, and without a thorough examination, followed by extensive diagnostics and microbiologic cultures, many wounds will remain nonhealed. At FFLC, we offer comprehensive limb salvage efforts which transcend most private offices. We really do have the mindset of a wound care center. Weekly comprehensive debridements, Xrays on site, MRI and ABI testing nearby, and for the more complex wounds a reconstruction repitoire which may consist of internal and external fixation. We take limb salvage very seriously, and we all know that once a limb is lost, the statistics are not in a patient's favor for a 5 year lifespan afterwards in diabetic patients.

Navicular Fractures in Athletes

Numerous patients experience this sort of injury living an active lifestyle in Naples Florida.

Recently, Ben Roethlesberger of the Pittsburg Steelers also suffered a similar injury (although not confirmed by the Steelers), and he may need some time off his foot to sufficiently heal his injury. We see a number of patients who will have the vague symptoms of pain after activity in the medial aspect of the rearfoot area, which will not show anything on regular xrays. After 3 months, most doctors will refer to us for further workup. We usually will obtain more advanced study such as CT or MRI, and depending on what it shows, treatment ensues. This is one of the latest articles regarding this topic, which in short, demonstrates how a minimally displaced fracture may still require screw fixation in select cases to adequately relieve symptoms and ensure return to sporting activity in a reasonable timeline.

Published in: Journal of Foot & Ankle Surgery, March/April, 2000
Amol Saxena, DPM


22 Navicular Stress Fractures sustained during athletic activity were retrospectively reviewed for return to activity time and the appearance of fracture pattern on Computerized Tomography. Average follow-up was 36.5 months. There were 10 females and nine males, with the average patient age being 27.2 years. Three patients sustained bilateral injuries at separate times.

Nine patients underwent open reduction, internal fixation (some with bone grafting); this group’s average return to activity (RTA) was 3.1 +1.2 months (range = 1.5-5 mos). Thirteen patients treated conservatively had an average return to activity of 4.3 +2.8months (range = 2 –13 months). The difference between the two groups’ RTA was significant (P=.02). Eleven patients utilized Pulsed Electromagnetic Fields and had an average RTA of 4.2 +3.4 months with three patients also having surgery. (The latter three patients had the fastest RTA at 3.0 months.) Two conservatively treated fractures that eventually took five and eight months to RTA, respectively, re-fractured during the treatment process.

Retrospective review showed CT fracture patterns in the frontal plane classified as: Dorsal cortical break (Type I), fracture propagation into the navicular body (Type II), and fracture propagation into another cortex (Type III). This is proposed as a classification system and is to include modifiers "A" (Avascular Necrosis of a portion of the navicular),"C" (Cystic changes of the fracture), and "S" (sclerosis of the margins of the fracture), the latter of which was most common in our series, particularly in continually symptomatic patients. Type I fractures were more likely to receive conservative treatment (P = .02) and Type III fractures took significantly longer to heal than Types I and II, (P values .001 and .01, respectively.) Type I and II injuries had an average RTA of 3.0 and 3.6 months, respectively. Type III injuries had an average RTA of 6.8 months. Based on our findings we recommend surgery for patients with these modifiers, particularly with Type II and III injuries.

Conservative treatment may be prolonged, and requires at least 6 weeks of non-weight bearing in a below knee cast/boot to be successful.

Achilles Injuries in the NFL

Jon Beason out for year with torn Achilles

Even the most conditioned athlete, with the support of numerous athletic trainers and coaches, can succumb to the devastating injury of Achilles ruptures. The worst part about this fact, is that the injury can eliminate most patients from returning to prior-injury function without adequate treatment.




The Achilles is the strongest tendon in the body, however the forces that are exerted by this structure exceed loads equal to tow trucks pulling on a stationary car for portions of a second during exercises. Many patients are seen in our office with various injuries to this area, and some with spontaneous ruptures. I had previous discussed how this can occur, and for the sake of sports injuries I will limit this discussion to when load exceeds the Young's modulus for the tendinous structures.


This bascially means that the tendon has more force than the inherent scaffolding is able to withstand. This leads to weakening of the collagen matrix and eventually can lead to ruptures. In partial and complete ruptures associated with exercise and impact sports, surgery is recommended to reduce the rate of re-rupture. But as you may have read, our Carolina Pro Bowl linebacker will be sidelined with this for the season, because it may take up to 12 months for full remodeling of the tendon to occur even with surgical repair.

We use a nonabsorbable suture method which contains a metallic wire filament called a "tightrope". This is never absorbed by the body, and is interwoven throughout the tendon to reapproximate it's tension prior to the rupture. The body then needs to augment this surgical repair by bridging the collagen matrix across the damaged portion of the tendon until full strength is achieved. I always tell patients that it will take 3 months to walk again, and a year to run again. This is by no means a minor injury.

Hopefully the Panthers have a good backup for their otherwise healthy linebacker this season !

How can diabetes deform my foot ?

Collapse of my foot and diabetes:



Charcot neuroarthropathy is a common cause of morbidity in persons with diabetes mellitus and sensory neuropathy. Although Charcot neuroarthropathy is a clinical diagnosis, recent advances in diagnostic imaging have eased the clinical challenge of deciphering infection from Charcot changes. Bone infections should be ruled out entirely before this can be said to be the diagnosis. Advances in surgical treatment have demonstrated new options for limb salvage.




There are several proposed mechanisms, but mainly it is most acceptable to believe that uncontrolled or difficult to control diabetic blood sugar levels lead to nerve damage which allows numbness to replace sensation. This allows bones to break naturally over time which go unnoticed by the individual, and the bones become inflamed and eventually break down and collapse with extensive fractures and swelling. This is a simplified description of the deforming process of Charcot foot.




Then and now.

In the recent past, the best treatments have been said to include below the knee amputations, and cumbersome braces which need to be consistently maintenenced and refurbished.

"Surgery on a diabetic is dangerous".




This was a common theme which precluded the possibility of reconstructive procedures to minimize deformity and were largely not based on evidence based medicine. Today it is known that in the vast majority of patients who develope these deformities, circulation is not compromised on a macrovascular level, but instead may be such in a microvascular setting. That means essentially that the small vessels may have glycosylated end products which impede wound healing. This usually is not on it's own a contraindication to reconstruction either, as the most common driving force for wound healing complications in this patient population may be more directly related to the abnormal bone prominences formed by the collapsing foot.

Today's current outlook on this disease process:




At FFLC, we treat all stages of this disease. Initially, we will order several important tests and imaging studies to assess the structural deformity and assess the body as a whole to come to the conclusion which is best for each patient. Newer external treatments such as multiplanar external fixation with either Achilles tenotomy or gastroc recessions, and immobilization have been a mainstay in the acute stages of the disease over the last 10 years. For chronic stable deformities, medial beaming techniques are utilized to realign the foot and ankle to a more straight position to offload centrally located ulcers.

A team approach is also essential for treatment of this complexity. Diabetes is a difficult clinical beast to slay, and whenever this systemic concern is not maintenced well, recurrence of Charcot (along with many other deletarious concerns) is likely. Usually reconstruction of the foot and ankle is performed on the presumption that multidisciplinary functions are well coordinated, such as endocrinology referral, infectious disease, vascular surgery, home health care nursing, physical therapy, and primary care are all significant parts of the entire process.

It literally takes an entire team of healthcare professionals to save a limb.

"TAKE YOUR VITAMINS" :

How vitamin D levels can impact even healthy active patients !

Low Vitamin D Linked to NFL Injuries.

Low levels of vitamin D can increase a professional athlete’s odds of injury, according to study findings by Summit Medical Group, a study of 89 players from the NFL’s New York Giants during their 2010 pre-season evaluations, 80 percent of the players were found to have insufficient levels of vitamin D. Findings also revealed that African American players and players who suffered muscle injuries had significantly lower levels. For the study they analyzed data on the number of players who had lost time due to muscle injuries. Vitamin D levels were then classified based on player race and time lost due to muscle injury.

It was presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Annual Meeting in San Diego on Sunday July 10, 2011.

Symptoms and Health Risks of Vitamin D Deficiency

Symptoms of bone pain and muscle weakness can mean you have a vitamin D deficiency. However, for many people, the symptoms are subtle. Yet even without symptoms, too little vitamin D can pose health risks. Low blood levels of the vitamin have been associated with the following:

1, Increased risk of death from cardiovascular disease
2. Cognitive impairment in older adults
3. Severe asthma in children
4. Some forms of cancer


Vitamin D is manufactured in the human body when bare skin is exposed to sunlight. Your body needs vitamin D to absorb calcium, a mineral essential to bone structure, muscle function and cardiovascular health. According to the Linus Pauling Institute at Oregon State University, vitamin D deficiency can cause muscle weakness and pain and low bone-mineral density in both adults and children. Studies have revealed a correlation between the incidence of traumatic injuries and vitamin D status.
Research suggests that vitamin D could play a role in the prevention and treatment of a number of different conditions, including type1 and type 2 diabetes, hypertension, glucose intolerance, and multiple sclerosis.

New research has connected vitamin-D deficiency to an increased risk of muscle injuries in athletes.

Researchers looked at 89 football players from a single NFL team and conducted lab tests of vitamin D levels in the spring of 2010. The mean age of the players was 25.The team gave the researchers data to allow them to determine which players had lost time because of muscle injuries.The results showed that 27 players had deficient levels of the sunshine vitamin, and 45 more had levels consistent with insufficiency. Only 17 players had levels within normal limits. Sixteen players had suffered a muscle injury—and the mean vitamin-D level of the injured players was 19.9 nh/mL, a deficient value.


Causes of Vitamin D Deficiency

Vitamin D deficiency can occur for a number of reasons:

IF

1. You don't consume the recommended levels of the vitamin over time. This is likely if you follow a strict vegetarian diet, because most of the natural sources are animal-based, including fish and fish oils, egg yolks, cheese, and beef liver.
2. Your exposure to sunlight is limited. Because the body makes vitamin D when your skin is exposed to sunlight, you may be at risk of deficiency if you are homebound, live in northern latitudes, wear long robes or head coverings for religious reasons, or have an occupation that prevents sun exposure.
3. You have dark skin. The pigment melanin reduces the skin's ability to make vitamin D in response to sunlight exposure. Some studies show that older adults with darker skin are at high risk of vitamin D deficiency.
4. Your kidneys cannot convert vitamin D to its active form. As people age their kidneys are less able to convert vitamin D to its active form, thus increasing their risk of vitamin D deficiency.
5. Your digestive tract cannot adequately absorb vitamin D. Certain medical problems, including Crohn's disease, cystic fibrosis, and celiac disease, can affect your intestine's ability to absorb vitamin D from the food you eat.
6. You are obese. Vitamin D is extracted from the blood by fat cells, altering its release into the circulation. People with a body mass index of 30 or greater often have low blood levels of vitamin D


Treatment for Vitamin D Deficiency

Treatment for vitamin D deficiency involves getting more vitamin D -- through diet, supplements, and/or through spending more time in the sun. Although there is no consensus on vitamin D levels required for optimal health -- and it likely differs depending on age and health conditions -- a concentration of less than 20 nanograms per milliliter is generally considered inadequate, requiring treatment.
Simple blood test can be obtained to determine if serum concentrations are within the acceptable normal limit, and those who are found to be deficient or on the lower end of normal with muscle aches, recurrent stress fractures, or other symptoms will be placed on some form of supplementary treatment protocol.
Guidelines from the Institute of Medicine call for increasing the recommended dietary allowance (RDA) of vitamin D to 600 international units (IU) for everyone aged 1-70, and raising it to 800 IU for adults older than 70 to optimize bone health. If you don't spend much time in the sun or always are careful to cover your skin, as sunscreen inhibits vitamin D production, you should speak to your doctor about taking a vitamin D supplement, particularly if you have other risk factors for vitamin D deficiency as mentioned earlier.

Many foods and drinks have fortified vitamin D as well, and also many doctor's offices are offering supplementations or at least recomendations for such in their offices.