This week I found the responses to last week’s editorial about when to continue treatment and when to stop so interesting that I thought I’d let you do the talking. I always enjoy the responses to the Practice Perfect ezine, especially the varied interpretations of what I write. Add your comments to our discussion by either responding to the ezine or, better yet, writing to the eTalk section on podiatry.com.

Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine Western University of Health Sciences,
St, Pomona, CA

Letters to the Editor Edition:

***When is Enough, Enough?***

I’d really be interested in seeing a multi-centered study on the ultimate outcomes of doing tons of procedures on folks with Charcot and ulcerations to see if ultimately it really either a) gives them a better quality of life, or even b) avoids what often is the inevitable BKA!

Rick Robinson, DPM
USPHS Indian Health Service Whiteriver Hospital
PO Box 860
Whiteriver, AZ 85941

Editor’s Response:

A large multicenter cohort study would be fascinating to read. I did a quick Pub Med search using the MeSH terms “Charcot” AND “Reconstruction” AND “Outcomes” and only came up with one study (J Foot Ankle Surg. 2009 Jan-Feb;48(1):30-8.). Perhaps our lack of understanding of the long term outcomes is the reason why we see the pendulum swing so widely between aggressive and nonaggressive approaches from one year to the next. At the last ACFAS meeting I was struck by the number of surgeons who were starting to recommend primary BKAs, arguing the numbers of failures were pushing them to be more conservative.

The only problem with designing this type of study is the variability of surgical procedures and protocols. In my opinion, Charcot reconstruction is something that should be sent to a small number of centers regionally who would spend all of their time taking care of these patients. Only then would we be capable of standardizing procedures and protocols enough to see truly valid research results.

—Jarrod Shapiro, DPM

Hello there — I am not sure how I got on to this e-mail list, but I am glad that I did. I am not an MD, but a wound/ostomy nurse in an acute care hospital. It is so easy in our field to deal with lab numbers and procedures, that we forget the person that is involved. I try to see the person - by looking at and asking about pictures the patient may have, and my favorite topic is asking couples how they met (you hear such nice stories). I recently took care of a young man with gastric cancer. He was in the hosp. in June, but discharged first of July and then readmitted the 5th of July. He told me he had such delight in being able to see the fireworks over the 4th of July. He suffered many setbacks in the following days, and then was told he only had 2 months to live. He kept on going. I finally told him that he could stop all of this if he wanted, go home and spend time doing things that he wanted to do. After a few days that is what he did. He just wanted to see the fireworks again, and get the joy out of the few things that he wanted to do. Thank heavens that the doctors did not keep pushing to treat him, but saw the person and let him celebrate the end of his life. Keep up the blogs, as I learn a lot.

—Cheryl Royce, RN

Editor’s Response:

Cheryl’s comments make us stop and appreciate our health and remember how lucky we are just to wake up every day and see those we love. Her remarks also remind us of the complexity of treating sick people and the ever growing need for the team approach to patient care that has begun to pervade the wound care realm and also needs to grow for the rest of our patients. In modern times it’s become ever more difficult to really know our patients. We need to follow Cheryl’s advice and learn who they are, not just what disease they’re inflicted with.

—Jarrod Shapiro, DPM

WOW! All that enters my mind in this article is that there are some good people out there. Leonard Levy DPM once said that remember that there is a person at the other end of the foot. I twisted that statement and say often, I never met a foot that walked into the office by itself. There are all types of doctors out there, and I hear often doctors such as heart surgeons having a brashness that more or less tells patients what they are going to do. That's fine for some. But myself, I use compassion, and try to recruit patients to become active participants in their own fate. All I can do is share the pros and cons, on both side of every equation, and help them decide themselves. And do so with compassion of what would I do if this patient were my own mother.

Robert Colligan, DPM
Norfolk, NE

Editor’s Response:

Hear, hear!

—Jarrod Shapiro, DPM

Congratulations on your new position! The question of when enough is enough is very poignant for many reasons including the "selfish" reality that in the end our practices take both a significant financial hit for treating these conditions and at the same time get exposed to a very high medicolegal risk. Obviously, our patients have to endure the prolonged process and uncertainty; hundreds of office/home care visits, months of PICC line drugs and risks, a frame and its guaranteed issues, etc. etc. If all goes correct, they get to walk with a CROW for 6 months and then, braced custom shoes....and the beat goes on.

My employer of 11 years reminds me of this on a regular basis. So then, why do I do this? I know I'm not stupid - got lots of diplomas that refute that; insanity? I like to act crazy on occasion and when appropriate - but not here. For me, I think my passion for this work and desire to make a difference overshadow reason. Plus, its fun! I travel to Nicaragua every year to help the severely crippled and undeserved - they seek us out with the hope that they can be helped. I turn down mother's whose babies have club foot but because of their severe neurologic pathology, they are unable to walk - therefore will never use their new foot. I can't help them

But what about the Charcot patients and the evidence based amputation stats? I treat my share of Charcot patients and my schpiel goes something like this: The reason why your podiatrist has sent you here is that "as you know" you have a severely deformed foot. Your foot is not stable and no longer braceable and your leg is at high risk for amputation and a frame is needed, etc. to save your leg. They say, yes, I was told that I would need my leg amputated when I went for a second opinion and that is why I'm here. After I went through the list of complications, one patient said Doc, if there is only 10% chance for success, I'm in. His leg lasted 2 years. He thanked me, but I was bummed!

Nobody wants to lose their leg and if given an option, most patients want option B - keep the leg, inherit a frame. Have I lost legs? Of course. I'm not proud, but I have unfortunately seen just about every complication. The point is that hindsight is 20:20. Painting the bleakest picture I think is worth it in these cases. Charcot patient have so many co-morbidities - they are really sick despite their enthusiasm and getting medical clearance. I think one of our problems is that we might be trying to do too much with our reconstruction. I have relied on more closed reduction and external fixation and after my Ilizarov Russia experience; I now do gradual correction during the initial stages then beaming as a second stage. I have moved away from arthrodesis in 50% of my cases. My goal in not to open the skin except for the percutaneous TAL. For me, the gratitude from survivors outweighs the rare limb loss...10% limb loss perhaps. The more I do, the more I learn about myself and the more I respect the disease/deformity.

Editor’s Response:

Very thought provoking. Dr Siegel brings to light the complexity of the decision process with these patients. The only saving grace with Charcot reconstruction is that these patients are likely to lose the leg if we don’t try to fix them. It’s truly a limb salvage procedure. With appropriate consent and patient expectations that match the physician’s it’s easier to live with the consequences of our decisions. Charcot is likely to plague us for many years to come.

—Jarrod Shapiro, DPM

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Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. Best wishes, and I’ll see you at the ACFAS in Fort Lauderdale next year.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]