BB&T Contributing Editor
NEW YORK – The New York State Podiatric Medical Association attracted about 2,000 attendees to its annual clinical conference in the latter part of January. The meeting, held at the Marriott Marquis hotel in Times Square, is one of the largest gatherings of this medical specialty. The program included a full day of lectures on the diabetic foot and on orthotic surgery. Exhibi-tors featured orthotics, surgical instruments and implants, diagnostic equipment, wound therapy products, prescription drugs, OTC formulations, and various office-based services.
The drug categories include antifungals for athlete’s foot (tinea pedia) and nail fungus (onychomycosis), anti-inflammatories, antibiotics and pain medications. Formulated products include emollients, lotions, creams, ointments and gels for diverse applications such as moisturizers and exfoliants for treating calluses and dry, cracked heels, and gels for removing discoloration of toenails and fingernails caused by keratin debris.
The American Podiatric Medical Association (Bethesda, Maryland) is the leading professional society for podiatrists. Podiatric subspecialties also are represented by professional associations that include the American College of Foot & Ankle Orthopedics & Medicine (Bethesda, Maryland), the American College of Food & Ankle Surgeons (Chicago) and the American Academy of Podiatric Sports Medicine (Walkersville, Maryland).
Profile of the podiatric profession
A four-year course of study and training at a podiatric medical college is required to become a podiatrist. This is typically followed by post-graduate training in a two- or three-year residency program to acquire the basic skills that are a combination of medicine, orthopedics and surgery on lower extremities. The three-year residency provides more advanced training in the rear foot and in reconstructive surgery. The majority of states will issue a license after one year of residency. There are eight schools of podiatric medicine in the U.S.
Fellowships after residency are generally in the areas of wound care, sports medicine, geriatrics and podopediatrics (podiatry for the pediatric population). There are two certifying boards: the American Board of Podiatric Surgery and the American Board of Podiatric Orthopedics and Primary Podiatric Medicine.
Professional requirements for podiatrists vary between states. In some states, podiatrists are considered like all other physicians and require 50 CME credits annually, whereas in other states, podiatrists are considered auxiliary healthcare providers and there is no requirement for CME credits.
The portion of the body that is considered the lower extremity on which a podiatrist may operate varies by state. Thirty-five states permit podiatrists to treat the foot and ankle. In some states, a podiatrist can operate on any structures below the knee.
An estimated 70% to 80% of podiatry practices are office-based. There are 15,000 office-based podiatrists in the U.S. About 5% to 10% of podiatry is performed in long-term care facilities such as nursing homes. Surgery also is performed in outpatient surgery centers and in hospital emergency rooms.
Reimbursement is the same as in any other field of medicine and is provided according to the CPT code that is based on what the licensure allows the podiatrist to perform.
Wound care products
A range of wound care therapies were on display at the conference, including equipment, bioactive dressings that release growth factors or silver, cellular matrices as skin substitutes and tissue regeneration products. Of particular significance are foot ulcers. They are a common complication of diabetes, affecting nearly 15% of all diabetics within their lifetimes, and can lead to amputations. The incidence of diabetes is growing and was described as an epidemic by health officials in New York City in a recent series of articles on diabetes that was featured in The New York Times.
Podiatrists make initial assessments of neuropathic disorders as an aid in predicting the formation of diabetic foot ulcers.
Tekscan (South Boston, Massachusetts) markets the F-Scan Mobile System. It records bipedal plantar pressures using paper-thin, conformable and high-resolution insole sensors to identify potential ulceration areas and for gait analysis.
Bailey Instruments (Manchester, UK) sells the PressureStat, a plantar pressure-measuring device that is used to determine if a patient presenting with neuropathy is at risk of developing a foot ulcer. It compares an impression of a patient’s foot to a grey scale calibration card. The company also markets a range of podiatric surgical instruments and or-thotics.
KCI (Kinetic Concepts; San Antonio) markets to podiatrists a leading product for chronic wounds., especially for treating diabetic foot ulcers. Its V.A.C. System provides negative pressure wound therapy and utilizes T.R.A.C. (therapeutic regulated accurate care) technology for monitoring and maintaining pressure at the wound site. The company also markets specialty wound dressings under the V.A.C. brand, such as the V.A.C. GranuFoam heel dressing and V.A.C. Vers-Foam dressings.
Johnson & Johnson Wound Management (Som-erville, New Jersey), a subsidiary of Johnson & Johnson (New Brunswick, New Jersey), featured Regranex Gel (becaplermin) that releases a growth factor for treating diabetic foot ulcers, Promogran, a matrix wound dressing that combines collagen and oxidized regenerated cellulose for promoting granulation tissue formation and epithelialization, Promogran Prisma Matrix that delivers silver to the wound site, and Silvercel, a silver-releasing antimicrobial dressing.
Integra LifeSciences (Plainsboro, New Jersey) featured its Dermal Regeneration Template and the Bilayer Matrix wound dressing for partial and full-thickness soft tissue trauma and chronic wounds. It is comprised of a semi-permeable silicone membrane and collagen-glycosaminoglycan biodegradable matrix.
The company also markets a line of extremity fixation devices from its acquisition of New Deal, a French company. They include compression staples and screws, arthodesis plate, nerve guide and peripheral nerve protector, reamers and an Achilles tendon suture system. .
Healthpoint (Fort Worth, Texas), a subsidiary of DPT Laboratories (San Antonio), markets the Oasis wound matrix that is prepared from the small intestinal mucosa of pigs. It is used for the repair and reinforcement of damaged tissue. The 3-D extracellular matrix serves as a host for tissue remodeling. The company also markets Accuzyme (papain-urea) ointment, the leading enzymatic debriding agent.
Organogenesis (Canton, Massachusetts) sells the Apligraf bi-layered cell therapy that expresses multiple growth factors and cytokines found in human skin. It is used for the treatment of venous leg ulcers and diabetic foot ulcers.
Smith & Nephew Wound Management (Largo, Florida) markets Dermagraft, a human fibroblast-derived dermal substitute, Versajet, a hydrosurgery system for wound debridement, and Profore, a four-layer bandage with graduated compression for treating venous leg ulcers.
Promethean LifeSciences (Pittsburgh) sells GammaGraft, irradiated human skin allograft wound dressing which is storable at room temperature.
Spenco Medical Corp. (Waco, Texas) markets a diverse line of products. Its 2nd Skin branded products include a scar therapy gel, dressing kit, blister pad, self-sealing cut closures, Quick Heal first aid cream and moist burn pads. Spenco also sells PolySorb insoles and arch supports. Its Silicore padding products (e.g., bed pads and foot pillows) are sold to nursing homes.
Custom footwear and orthoses
A proliferation of companies sell accommodative and custom-made footwear for people with toe and foot irregularities, and orthotic products which include insoles, heel cushions, arch supports and ankle braces.
Med-Dyne Healthcare Products (Colleyville, Texas) featured its line of arch supports, insoles, ankle braces and gel heel cups for shock absorption and foot protection. Its insoles are fabricated from Poron microcellular urethane foam from Rogers Corp. (Rogers, Connecticut).
Langer (Deer Park, New York) is a provider of medical products for lower extremity care, including custom orthotics, gait-related products, sandals and soft goods. In September 2004, Langer acquired Silipos (Niagara Falls, New York), a manufacturer of gel-based products focused on the orthopedic, orthotic, prosthetic and skin care markets.
Gel for skin protection is used in over 200 Silipos products such as bandages, wraps and pads. The gel incorporates mineral oil that gradually diffuses onto the skin to reduce friction and pressure, improve elasticity and minimize scarring. Silipos’ products are sold in more than 60 countries.
The Stone Podiatry division of Henry Schein (Melville, New York) featured its new HealthStrides polyester sock knit from polyester fibers containing copper oxide from Cupron (Greensboro, North Carolina) for imparting antifungal and antibacterial activity.
Potential applications include protection against tinea pedis, erythema, vesicular eruptions and malodor. The socks are manufactured by Renfro (Mount Airy, North Carolina). Cupron is evaluating the use of its material in surgical sponges and dressings.
Bone growth stimulators
dj Orthopedics (Vista, California) markets the OL 1000 bone growth stimulator which uses an electromagnetic field for healing of nonunion fractures. It requires only a 30-minute daily treatment, as contrasted with competing stimulators that require 8 to 10 hours of daily treatment such as the stimulator from EBI (Parsippany, New Jersey), a subsidiary of Biomet (Warsaw, Indiana).
The Exogen 2000+ fracture healing system from Smith & Nephew Orthopaedics (Memphis, Tennessee) also was on display. It uses a low-intensity ultrasound signal that is applied daily for 20 minutes and is approved for use on nonunion fractures as well as immobilized fresh fractures.
SanuWave (Marietta, Georgia), recently spun off from HealthTronics (also Marietta), markets the Osssatron equipment that uses high-energy extracorporeal shock wave therapy (ESWT) for the non-invasive treatment of lateral epicondylitis (tennis elbow) and plantar fasciitis, an intense heel pain caused by overstretching of the plantar fascia ligament, the muscle that extends from the heel to the ball of the foot and also supports the foot arch. Spark gap technology is used to generate the shock waves, the same as used in lithotripsy for treating kidney stones.
Orthometrix (White Plains, New York) recently introduced Orbasone, a competing ESWT unit for treating plantar fasciitis.
Toe and foot implants
Nexa Orthopedics (San Diego) markets implants used in reconstructive foot surgery that came with its acquisition of Futura Biomedical, such as the Memi Toe, a cobalt chrome implant used in arthroplasty of the metatarsal phalangeal joint (the base of the big toe), a conical subtalar implant for correcting flatfoot deformities, and the Primus flexible great toe implant fabricated from silicone elastomer.
The company also markets the OsteoCure brand of resorbable calcium sulfate beads and polylactide-co-glycolide resorbable scaffolds and plugs used as bone graft substitutes for filling bone voids.
Kinetikos Medical (Carlsbad, California) specializes in products for small-bone surgery, including its MBA subtalar implant, K2 Hemi and KGTI great toe implants and compression screws.
OsteoMed (Addison, Texas) markets surgical implants for podiatrists and foot and ankle specialists. These include the ReFlexion implant, a three-piece system for the reconstruction of the 1st meta-tarsal phalangeal joint (MPJ), needed as a result of osteoarthritis or rheumatoid arthritis, InterPhlex flexible stabilization rods for correction of hammer toe, Talar-Fit subtalar arthroereisis implants, and a line of cannulated screws.
BioPro (Port Huron, Michigan) sells a range of implants and associated products used in podiatric surgery which include MPJ Hemi implants for the great toe and the lesser toe, subtalar implant, digital compression screws, a screw extractor and a bunion osteotomy guide.
Endoscopic and surgical equipment
Instratek (Spring, Texas) markets instruments used in endoscopic procedures such as its Endotrac system for endoscopic plantar fasciotomy for treating heel pain and the Edintrak II system for neuroma decompression for treating a condition known as Morton’s neuroma (perineural fibroma) that is caused by an enlarged nerve in the metatarsal space between the second and third toes. The company also sells titanium cannulated bone screws.
Wallach (Orange, Connecticut) recently introduced to the podiatric specialty its PainBlocker cryoanalgesia instrument for freezing nerves (neuroablation) to stop pain from Morton’s neuroma and plantar fasciitis. The product has been used for many years for ob/gyn applications.
Cryosurgical Concepts (Boynton Beach, Florida) sells the hand-held CryoProbe for the controlled destruction of unwanted tissue (e.g., warts and skin lesions) by the application of a high-pressure jet of liquified nitrous oxide gas (minus 127 degrees Fahrenheit).
Ellman International (Oceanside, New York) man- ufactures the Surgitron dual-frequency and low-temperature generator for cutting and coagulating tissue. The 4.0 MHz frequency minimizes heat dissipation and cellular alteration, yielding reduced scar formation. It is used for surgically correcting ingrown toenails and for removal of skin lesions.