Valley Presbyterian Hospital: Diabetic Foot Global Conference

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – Practitioners treating Charcot foot have little evidence to guide them in selecting the right medicine, according to an international task force offering guidance on diagnosis and treatment of the condition.

Reporting on its January 2011 Paris meeting, task force cochair Lee C. Rogers, D.P.M., said the group of 18 experts from six countries took hours just to arrive at a definition of the syndrome. Ultimately, they decided that Charcot foot is an inflamed foot in a person with neuropathy.

The official report of the task force, convened by the American Diabetes Association (ADA) and the American Podiatric Medical Association, will be published in the journals of those organizations. Dr. Rogers of the amputation prevention center at Valley Presbyterian Hospital, Los Angeles, cautioned that he was offering only his personal observations on the proceedings.

"The major thing you’ll see in this task-force document is that there is very little evidence for any of the pharmacological treatments ... [But] that doesn’t mean we don’t use them in clinical practice," he said at the Diabetic Foot Global Conference, which was presented by Valley Presbyterian Hospital.

Although there are no good prevalence studies on Charcot foot, the task force estimated that 0.15%-1% of patients with diabetes suffer from the syndrome, said Dr. Rogers. There are 40,000 new cases a year in the United States. Patients with Charcot foot are more likely to suffer amputations, and may have a higher mortality rate, he said.

Having Charcot foot increases the risk of a foot ulcer 36 times, and 30% of patients with one Charcot foot have two Charcot feet. "It’s known that Charcot foot impacts the lifestyle of the individual, and often ... leads to permanent disability and premature retirement," Dr. Rogers said.

The syndrome appears to start with a traumatic event, which the patient may or may not remember. The trauma sparks inflammation. A patient with autonomic neuropathy may continue walking on the foot without feeling pain, leading to a cycle of fracture, subluxation, dislocation, and deformity.

"One of the things that is very important that came out of this meeting is that inflammation is the key to the pathogenesis of Charcot foot, and is also the key to diagnosis," said Dr. Rogers.

Charcot foot is often misdiagnosed, or diagnosed late. If clinicians can recognize the inflammation early on, they may be able to prevent the chain of events that leads to such conditions as rocker bottom foot later on.

The panel agreed that a Charcot foot should be classified as "active" if inflammation is continuing, or "inactive" if the inflammation has subsided. They thought this was more useful than the terms "acute" and "chronic," which only suggest how long the condition has been present.

The first step after suspecting Charcot foot is imaging, Dr. Rogers said. "What’s important when you’re trying to make a diagnosis based on imaging is that you have to incorporate a lot of the clinical findings to determine which type of imaging to perform: whether or not you suspect osteomyelitis, [or] whether there’s the presence of an ulcer."

He recommended starting with an x-ray to see whether there is bone destruction. MRI can’t be specific for Charcot foot vs. osteomyelitis unless you consider secondary signs, said Dr. Rogers, who noted the following:

• More than 90% of cases of osteomyelitis in diabetic foot are from contiguous spread, and the spread can be traced from an ulcer to the bone on MRI.

• Osteomyelitis primarily affects only one bone, whereas Charcot may affect multiple bones.

• Deformity is more common in Charcot foot than in osteomyelitis.

• Charcot foot is more often in the midfoot, whereas osteomyelitis is more common in the toes and forefoot.

Turning to medical treatments, Dr. Rogers said, "The most important thing you can do is offloading."

He recommended educating "other members of the team," such as emergency room physicians who may treat Charcot patients presenting with an injury and a swollen foot that has not yet been x-rayed. "Offloading and immobilization can avoid the later sequelae," said Dr. Rogers.

There is little research to compare a cast walker or a total contact cast, he said. Some on the panel recommend complete avoidance of weight bearing, he said. A Roll-A-Bout walker offers another alternative.

In one study, patients took a mean of 18.5 weeks of casting to quiescence (J. Am. Podiatr. Med. Assoc. 1997;6:272-8). "This is not something where you can tell the patient, ‘We’ll have you out of the cast and walking in 3 weeks,’ " said Dr. Rogers. "You have to explain to the patient [that] this is a long process."

After taking the load off a Charcot foot, practitioners can try bisphosphonates to treat the condition, Dr. Rogers said.

The two agents that have been studied for Charcot foot are pamidronate (Aredia) and alendronate (Fosamax). Pamidromate can be given in a single 90-mg intravenous dose. (You may have to answer questions from the pharmacy because of dosing requirements for patients with renal insufficiency, but there are no dosing requirements if you are giving the dose only once, because the half-life doesn’t really matter in that case, Dr. Rogers said.) Alendronate was given in oral doses of 70 mg weekly in one study in which it was compared with pamidronate for Charcot foot, and it took longer to achieve normal foot temperature.

Another drug studied for Charcot foot is intranasal calcitonin (Miacalcin), which "might make more pathological sense," said Dr. Rogers. It is sprayed once per day in alternating nostrils. It should be given in combination with vitamin D and calcium.

How do you determine whether any of these therapies is working? By using a contact thermometer, you can compare the Charcot foot to the non-Charcot foot. A difference between the two that is greater than 4° F (2° C) is considered significant for inflammation. "Make sure this gets back to [within a] 4° difference before you put them back in their normal footwear," said Dr. Rogers.

Thermal imaging is helpful with patient compliance because it helps the patient see the difference, he said.

After getting the patient into an inactive state, make sure the foot stays protected so it doesn’t develop an ulcer, Dr. Rogers said in conclusion.

Dr. Rogers said he had no conflicts of interest to disclose.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."