Diabetes is the most expensive chronic disease our nation faces, costing the United States over $400 billion in combined medical costs and loss of productivity. Yet, with this knowledge, one must wonder if enough is being done to solve this epidemic and what we, as medical professionals, can do to improve outcomes.

As we prepare for National Diabetes Awareness Month in November, we may want to consider how we can ensure that every patient with diabetes receives optimal care for their lower extremities, which could improve productivity for patients and the organizations they work for, as well as decrease associated astronomical costs.

This is no easy task, as we have to look at this medical crisis from several angles:

• How can we collaborate with other medical providers to increase awareness of our valuable role and ensure that they include referrals to our offices as part of their treatment plans for their existing patient base?
• When we bring these patients into our offices, how can we improve their ability to be compliant, enabling us to provide effective treatments and support healthy lifestyles?
• Finally, how can we improve our "footprint" in the public's eye to increase awareness of the role we play as podiatrists and decrease the number of amputations that many of us must perform?
  

Here are six strategies the podiatric community should consider to address and improve the diabetes crisis that we are faced with:

1. Podiatrists should unite together as one voice and represent our local community in Pennsylvania, and participate in community outreach events that present a comprehensive message about managing diabetes, providing community-based education, raising awareness of diabetic foot care, the risk of diabetic foot complications, and the preventative podiatric treatments necessary. Our active presence and engagement will improve our position in public forums.

2. Strengthen the podiatric brand and its role in diabetes management on social media as an educational sounding board for followers to increase their awareness of the importance of podiatric care in diabetic patients. Social media is a resource that allows us to break boundaries and "speak" to our target demographic, share educational content, and highlight success stories, which may help increase awareness of podiatry.

With millions of people regularly accessing the internet to improve their medical knowledge, developing and sharing educational content on social media that resonates with individuals seeking or receiving treatment could be beneficial.

Furthermore, a series of social media posts developed throughout November for Diabetes Awareness Month, utilizing hashtags such as #NationalDiabetesMonth and #DiabetesSupport, may reach a wider audience.

3. Seek opportunities to reach other medical providers in a setting such as a clinical conference that may allow for time to devote to collaborating with different providers, such as vascular surgeons, endocrinologists, and dietitians. Increasing our presence in venues such as clinical conference settings will enhance our ability to develop relationships within the broader medical community and foster effective collaborations with key players in the diabetic medical community. This can lead to increased awareness of the importance of our role and direct referrals from these providers.

4. Share testimonials from patients to be impactful and relatable. As many of us work with diabetic patients and showcase their efforts to comply with treatment plans, we may want to consider asking for a release to be signed and for a patient to provide a testimonial that a diabetic patient may find relatable and learn from.

5. Creating and distributing marketing assets tailored to patients and the medical community would expand our reach and improve outcomes in both attracting and treating diabetic patients.

6. Implementing strategies to treat noncompliant patients to improve treatment outcomes can support both patients who want to do well and doctors who experience low job satisfaction and burnout when they are unable to engage patients in the manner in which they desire.

Noncompliance among patients with diabetes is associated with increased emergency room visits, frequent hospitalizations, and high treatment costs. The mortality rate among patients who do not adhere to their treatments is significantly higher than that of other patients. Reducing noncompliance can have a significant impact on the overall medical costs our country is experiencing.

Noncompliance is a complex issue and is usually not a deliberate refusal. Patients may have low health literacy, and they may not understand their diagnosis or the importance of follow-up care. Assessing patients' goals, capabilities, and barriers puts them at the center of the interaction about diabetes management.

Noncompliant patients may not fully understand their condition or the potential consequences of noncompliance. While the patient is responsible for the majority of diabetes care, doctors must recognize that they have little control over how patients manage their condition between office visits. It would benefit the doctor-patient relationship if time were taken to investigate the reasons for noncompliance.

Some of these common reasons include:

• Lack of understanding - Providing resources to enhance patient education through written materials (and making these materials available in Spanish and other languages) and using plain, concise language instead of medical jargon have been known to improve compliance.
• Unaffordability of medical treatment - The high cost of medication and medical supplies can prevent a patient from adhering to their treatment. Practices that offer a wide variety of medical supplies at lower costs compared to pharmacies and retail stores can be appreciated by patients who need to reduce their medical expenses, thereby decreasing noncompliance by providing solutions to financial barriers.
• Overall forgetfulness - Providing patients with weekly pill organizers can help simplify their complex medication regimens, improving their ability to stay organized and complete self-care tasks.
• Transportation concerns - Providing patients with information about local transportation services may help ensure they receive follow-up treatment.
  

Involving a patient in planning their treatment makes it more effective, as they are more likely to adhere to a plan they helped create. Collaborating with other podiatrists to learn what solutions have worked for them to improve noncompliance can also be helpful.

Podiatrists working collectively as one voice within our Pennsylvania Podiatry Medical Association position us as a powerful force. Leveraging our position in the medical community to be "present" is key. Together, we are a powerful collective force that can support one another, other medical professionals, and the patients we treat. Operating as one unit to fight the diabetes crisis is the only way we can reverse our current medical emergency.

Matthew Sowa, DPM, is a podiatrist practicing in Fleetwood, Pennsylvania. He serves on the PPMA Board of Directors.

As a podiatrist, clinical awareness of sun damaged tissue is a vital portion of our dermatological assessment for it has been shown that the dorsum of the foot is one of the most neglected regions of the body when applying sunscreen. ²  Squamous cell carcinoma, basal cell carcinoma and malignant melanoma are all common cancers that can be found on the dorsum of the foot.  While basal cell carcinoma is the most common skin cancer for anatomical sites such as face and trunk, it is squamous cell carcinoma that is found to be most common in the feet.²

The following paragraphs will discuss the common pigmented lesions that can be seen in the lower extremity.

ACTINIC KERATOSIS

On exam, these present as reddish-brown macules or papules that are poorly circumscribed. They can be scaly and range from 2-5mm in diameter. They are considered pre-cancerous and can be considered an early form of squamous cell carcinoma.

Diagnosis: as with all lesions, if it is raised, perform a shave biopsy or 2-4mm punch for flat lesions.

In some cases, AK can sometimes resolve on their own only to return with sun exposure.⁵ In most cases however, the lesions are removed as a precaution. Some modalities for removal include cryosurgery, curettage and desiccation and laser surgery

Topical creams, gels and solutions are prescribed for use in patients with numerous or widespread actinic keratoses.

Approved medications

• 5-fluorouracil (Carac®,
• Efudex®,
• Fluoroplex®)
• Diclofenac (Solaraze®) and hyaluronic acid Imiquimod (Aldara®, Zyclara®)
• Tirbanibulin (Klisyri®)

BASAL CELL CARCINOMA

This is the most common form of skin cancer and accounts for more than .5 million cases diagnosed in the United States annually.  These can present as papules, plaques, nodules and pigmented lesions. These can also appear as a smooth papule with a central erosion or crust. BCC typically invades locally and rarely metastasizes.  Because they can growth in size, referral to dermatology is recommended for removal.

Some therapeutic interventions for more superficial basal cell carcinoma (BCC) include cryotherapy, topical chemotherapy, and photodynamic therapy.

More commonly, surgical intervention is utilized and this includes curettage, shave excision and standard excision. For larger and recurrent lesions, Mohs surgery will be employed.

SQUAMOUS CELL CARCINOMA

SCC typically arise from actinic keratosis as the result of exposure to UV radiation. Once actinic keratosis cells expand into the dermis they are then referred to as squamous cell carcinoma.

Squamous cell carcinoma most commonly appears as firm, smooth, or hyperkeratotic papule or plaque, often with central ulceration. Patients may describe a nonhealing lesion that bleeds with minimal trauma.

DIAGNOSIS

Shave biopsy if the lesion is raised, or 2-4mm punch if the lesion is flat

TREATMENT

Most SCC can be treated with curettage and electrodesiccation, cryotherapy, and excision. When recurrent, Mohs surgery is utilized.

Bowens disease (squamous carcinoma in situ) a more superficial version of SCC

Verrucous carcinoma is a more invasive, rare, variant of squamous cell carcinoma that commonly arises on the feet.  It is most common in the soles, but it can develop even on dorsal surface in areas of recurrent friction^. First-line treatment is complete surgical excision with wide margin; however, amputation may need to be performed due to local tissue destruction and late intervention.³

MALIGNANT MELANOMA

Melanoma accounts for only about 1% of skin cancers but causes a large majority of skin cancer deaths.⁴

The American Cancer Society’s estimates for melanoma in the United States for 2025 are:

• About 104,960 new melanomas will be diagnosed (about 60,550 in men and 44,410 in women).
• About 8,430 people are expected to die of melanoma (about 5,470 men and 2,960 women).⁴

Despite the statistics, melanoma is mostly curable if diagnosed and treated before reaching later stages. When diagnosing pigmented lesions, it is fundamental to be acquainted with “A,B,C,D” criteria for evaluation of pigmented lesions.

A (asymmetry)- lesions with irregular shapes and asymmetry are more unsettling. Whereas lesions that are round or oval are likely to be benign

B (border irregularity) irregularity to the border of the lesion is more concerning for malignancy while even and symmetrical borders tend to be benign

C (color) multiple shades of brown, black or blue black, red or white colorations are more troubling compared to less irregular pigmentation

D (diameter) Lesions greater than 6 mm warrant further evaluation, however earlier stages of melanoma may not precisely adhere to ABCD criteria.

Treatment

Surgical management is necessary and should likely be referred to a dermatologist.

Visual representations can be found by visiting The American Cancer Society.

Bibliography:

1. Gordon ML, Hecker MS. Care of the skin at midlife: Diagnosis of pigmented lesions. Geriatrics 1997; 52(Aug): 56-68

2. Jackson N, Allen T, Wagner R, Understanding Ultraviolet Radiation Dorsal Foot Injury at the Beach JAPMA Vol 109.No3. May/June 2019

3 D Nagarajan ¹, Malarvizhi Chandrasekhar ¹, Jim Jebakumar ¹, K Aravind Menon ^1,✉ Verrucous carcinoma of foot at an unusual site: Lessons to be learnt .Letter ,South Asian J Cancer

. 2017 Apr-Jun;6(2):63

4. Melanoma Skin Cancer | Understanding Melanoma. (n.d.). Www.cancer.org; American Cancer Society. https://www.cancer.org/cancer/types/melanoma-skin-cancer.html

5. Firnhaber J Diagnosis and Treatment of Basal Cell and Squamous Cell Carcinoma Am fam Physician. 2012;86(2):161-168

Todd Zeno, DPM is a podiatrist practicing in Hanover, Pennsylvania. He is a Past President of PPMA.

It is rewarding to treat patients and provide them with foot and ankle care that can make them feel their best.

There are times when patients may not always display a cheerful demeanor. A hostile and uncooperative patient can put a damper on your day and make it challenging to treat the next patient with the spirit they deserve.

In practicing podiatric care for 25 years, I have learned the importance of being positive and calm when listening to my patients and providing care.

Here are five tips to help podiatrists who are dealing with a difficult patient:

1. In treating patients who may not act their best, I have learned that just listening and letting them vent is the best way to abate their anger eventually. Not everything is about their care or your office; it can be just frustration with life or something at home. If it is about their care, they feel better getting their say, and then we work on coming up with solutions to their frustration and an apology from me for any office issue.
2. In dealing with them, it is essential to create boundaries to ensure that patients treat us respectfully and that nurses and medical assistants are treated well. As attracting and retaining employees continues to be challenging, employees who come to work in environments that are more stressful than they need to be are at risk for increased turnover. Having a policy and procedure for how staff can respond to these cases can better prepare them to ensure they are treated with dignity and can continue to come to work and engage positively with patients.
3. Understanding patients' moods may not have anything to do with you but more about them. Perhaps they are having a bad day. Learning not to take a poor attitude personally may not change the situation, but it may help change your perspective when patients come to the office in a less-than-ideal mood. I have no problem with a patient yelling at me, but I will not tolerate them treating the staff that way. I have learned to let their anger bounce off and not take home any patient issues. My staff knows that I have their back, and they can report any patient problems to me without engaging with the patient.
4. Validating the patient's feelings may be all they need to change the dynamics and continue with a positive appointment so the patient can receive care. I have found that just listening can often de-escalate most situations. For many older patients, their appointment may be their only outing for the day/week, and the only time they get to engage with other people.
5. Know your boundaries and establish a system for reacting to negative behaviors. Understand when it may be necessary to end an appointment and dismiss a patient. I feel that doctors need to take the reins and handle disruptive or angry patients, especially if we need to end the appointment or refer them somewhere else.
   

We all have bad days, and we do not have to allow others' bad days to impact our good days. Having a plan to react to less-than-ideal patients can establish boundaries and ensure that when a less-than-ideal circumstance occurs, a plan of action is there so that unnecessary stress does not happen. Your staff will also appreciate that you will stand up for them and they don't have to deal with unhappy patients on their own.

Dana Dober, DPM, is a podiatrist in Broomall, Pennsylvania, practicing at Podiatry Care Specialists. Dr. Dober serves on the board of directors of PPMA.

As a first-year podiatric surgery resident, the first consult I evaluated was a patient with opioid use disorder who had been injecting drugs into their lower extremities.  The wounds were deep and foul-smelling, with extensive necrosis of the subcutaneous tissues. My attending related that the wounds had a different appearance than the wounds we had seen in our previous opioid disorder patients who injected themselves with substances such as Heroin or Fentanyl.  Podiatrists who have not commonly encountered this type of pathology may not understand how the substances being injected may change the appearance of the wound and the treatment plan.  

To provide some background knowledge, prescription opioids were the leading cause of drug overdose deaths from 2007-2013, which eventually progressed to heroin from 2014-2015. From 2016 to the present day, Fentanyl is the leading cause of drug overdose deaths [1]. Xylazine (primarily used as a horse anesthetic) is found to be a common adulterant in the fentanyl supply due to its low cost, availability, and effects. Philadelphia is believed to be the forefront location of the Xylazine drug supply crisis. According to a most recent study by the Philadelphia Department of Health, 90% of street opioid samples had Xylazine detected within the sample [3]. The patient population in Philadelphia commonly refers to Xylazine as “tranq.”

Xylazine is an alpha-2 adrenergic agonist that decreases sympathetic nervous system activity, thus leading to a sedative effect. It has a synergic with other drugs, such as Fentanyl or Heroin, and is theorized to extend the duration of the sedative effects [2,4]. In addition to the psychological impact of Xylazine, dermatologic manifestations leave patients with debilitating pain and sizeable soft tissue deficits. The exact mechanism by which Xylazine causes dermatologic manifestations is not proven. However, many hypotheses exist, and more specific investigation is needed. Xylazine is deemed cytotoxic, which can cause dermal necrosis. Xylazine has vasoconstrictive effects on peripheral vessels, ultimately leading to hypoxia and subsequent tissue damage/death. Fentanyl, being commonly adulterated by Xylazine, has a short-lived manifestation, thus requiring a shorter period between injections to maintain psychoactive effects and leading to a higher concentration of xylazine within the soft tissues. [4]

Xylazine wounds commonly manifest on the extensor surfaces of the lower extremity. The wounds start as blisters with intact skin that develop at or around the injection sites. The blisters often harden into dry eschar (the most identifiable feature) or can develop into ulcers, which can be extensive and lead to exposed tendons, muscles, and bones [5]. Based on the experience of the two authors, these wounds are very extensive in terms of depth and exposed structures; however, most often, the wounds are not infected. 

Caring for these wounds in the at-risk population provides an extremely difficult task. In the proper setting, local wound care will suffice for treatment. Dressings such as xeroform, collagenase, or hypochlorous acid wound solution have been used for local care [6]. Xeroform, followed by gauze, is often used for local care upon initial consultation. The ability to perform local wound care following hospital discharge proves difficult for this patient population, given unstable housing scenarios and limited access to adequate wound care supplies. Secondly, the patient’s ability to refrain from further injecting is often the most significant barrier. Relapse with opioid use disorder is not uncommon, thus starting the cycle over again. Another complicating factor is that drug treatment (detox) centers may reject patients who need medical management, such as local wound care, and skilled nursing facilities may reject patients with opioid use disorders [5]. 

Most of these patients at our institution are seen by the wound care service. Given the large volume of patients seen with this pathology daily, the surgical services (orthopedics, podiatry, general surgery) are only consulted when clinical evidence of infection is present, such as cellulitis, abscess, or radiographic evidence of infection. The Burn Surgery team is our institution's leading service in performing operative debridement. Initially, our tentative treatment plan is to perform a surgical debridement. Surgical debridement may be ill-advised, given the uncertainty of adherence to postoperative recommendations. Recent publications regarding managing these wounds suggest that debridement may also impair wound healing by exposing deeper underlying structures such as tendons and bones. Therefore, aggressive local wound care should be the initial mainstay treatment for this pathology.  Surgical debridement should ultimately be saved when the patients are active and stable in substance use treatment [4] unless operative debridement is needed for infection eradication.

In conclusion, with a large amount of street drugs containing Xylazine, there is a noted increased prevalence of extensive lower extremity wounds associated with injection drug use. Treating providers should resist the urge to perform debridement and continue with local wound care. Ultimately, surgical intervention is reserved for patients who have demonstrated continued ability to participate in substance use treatment and are most likely to follow up with postoperative care. When social circumstances are not optimal, local wound care is the treatment choice for xylazine wounds in the absence of infection. 

References

[1] Malayala SV, Papudesi BN, Bobb R, Wimbush A. Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA. Cureus. 2022 Aug 19;14(8):e28160. doi: 10.7759/cureus.28160. PMID: 36148197; PMCID: PMC9482722.

[2] D'Orazio J, Nelson L, Perrone J, Wightman R, Haroz R. Xylazine Adulteration of the Heroin-Fentanyl Drug Supply: A Narrative Review. Ann Intern Med. 2023 Oct;176(10):1370-1376. doi: 10.7326/M23-2001. Epub 2023 Oct 10. PMID: 37812779.

[3] Philadelphia Department of Public Health Substance Use Prevention and Harm Reduction. Health Update: Xylazine (tranq) exposure among people who use substances in Philadelphia. 8 December 2022.

[4] Perrone J, Haroz R, D'Orazio J, Gianotti G, Love J, Salzman M, Lowenstein M, Thakrar A, Klipp S, Rae L, Reed MK, Sisco E, Wightman R, Nelson LS. National Institute on Drug Abuse Clinical Trials Network Meeting Report: Managing Patients Exposed to Xylazine-Adulterated Opioids in Emergency, Hospital and Addiction Care Settings. Ann Emerg Med. 2024 Mar 15: S0196-0644(24)00080-5. doi: 10.1016/j.annemergmed.2024.01.041. Epub ahead of print. PMID: 38493376.

[5] McFadden R, Wallace-Keeshen S, Petrillo Straub K, Hosey RA, Neuschatz R, McNulty K, Thakrar AP. Xylazine-associated Wounds: Clinical Experience from a Low-barrier Wound Care Clinic in Philadelphia. J Addict Med. 2024 Jan-Feb 01;18(1):9-12. doi: 10.1097/ADM.0000000000001245. Epub 2023 Nov 29. PMID: 38019592; PMCID: PMC10967264.

[6] Carroll JJ. Xylazine-Associated Wounds and Related Health Concerns Among People Who Use Drugs: Reports from Front-Line Health Workers in 7 US States. Subst Use Addctn J. 2024 Apr;45(2):222-231. doi: 10.1177/29767342231214472. Epub 2024 Jan 2. PMID: 38258791.

Podiatric surgery is constantly evolving, and so are the methods and tools used by podiatric surgeons. Advancements aim to reduce surgical complications, post-operative pain, and recovery time, leading to better patient experiences. Innovative advancements in medical technology and surgical methodologies have ushered in improvements in patient results and abbreviated recovery periods.

There has been growing interest in minimally invasive surgery (MIS) to correct foot and ankle deformities. Although minimally invasive surgery for the foot and ankle has been around for many years, improvements in tools, implants, and surgical training have inspired the renewed popularity of these surgeries. A wide array of new shifters, guides, jigs, screws, and other devices have helped to improve foot and ankle MIS.  External jigs may aid in osteotomies and facilitate accurate placement of internal fixation.  Advancements in burr technology are another reason MIS of foot and ankle surgery has become more effective in recent years. Low-speed, high-torque burrs allow a surgeon to make an osteotomy without disrupting the soft tissue. Small incisions are cosmetically pleasing to the patient, avoid dissection and soft tissue stripping, which can result in postoperative swelling, and preserve blood flow to the surgical site, which allows for improved bone and tissue healing and faster recovery.  Another benefit from any MIS foot and ankle surgeries includes early weight bearing on the patient’s postoperative foot. There is a steep learning curve associated with foot and ankle MIS, and some factors may help to lower the learning curve.  These include attending saw bone and cadaver labs to practice techniques and spending time with well-versed MIS surgeons. To date, many MIS techniques have been developed to treat deformities such as hallux valgus, hammertoes, and bunionettes.  However, even more complex conditions such as Charcot are being addressed increasingly through a MIS approach. Percutaneous, minimally invasive techniques are being used to repair Achilles tendon ruptures. Historically, open techniques have been used to repair an Achilles tendon rupture, but they can be complicated by wound-healing issues and infection. This minimally invasive technique is ideal for middle-aged patients, where there may be a heightened concern for wound-healing issues.

Regenerative medicine, including platelet rich plasma (PRP), is becoming more commonly used in podiatry. Regenerative medicine therapies, sometimes called orthobiologics, use biologic tissues, such as blood or bone marrow, to improve symptoms of certain conditions and have the potential to enhance healing in musculoskeletal tissues. Platelets release growth factors play a critical role in tissue healing. PRP is produced by obtaining a small sample of a person’s own blood. The blood is centrifuged (spun down) to isolate and concentrate platelets that assist in natural tissue healing processes. PRP, which is depleted of red blood cells and granulocytes, including neutrophils, which are associated with inflammation, is then injected back into the site of the injury or surgical site. The injection contains proteins that can potentially decrease inflammation, reduce pain and improve tissue healing. PRP can be used to aid in healing tendon repairs, augment arthrodesis sites, and hydrate various bone grafts, such as demineralized cortical and cancellous grafts.

Autologous chondrocyte implantation is being used to repair full thickness cartilage defects of the ankle joint. Arthroscopic, single stage cartilage restoration is now available for foot and ankle surgeons. Autologous chondrocytes are harvested arthroscopically with a shaver and then mixed with PRP to make a cartilage-scaffold paste and an autologous fibrin glue to fix the chips in the cartilage defect. BioCartilage® extracellular matrix (ECM), from Arthrex, contains the ECM that is native to articular cartilage, including components such as type II collagen and additional cartilaginous growth factors. After processing, the dehydrated allograft cartilage has a particle size of 100 µm-300 µm. The small particle size improves its injectable nature after it is mixed with an autologous blood solution, allowing easier delivery to the defect site. PRP is productive when it comes together with cartilage. It has proliferative properties, can control inflammation at the joint repair site, and is pro coagulation which means less bleeding and quicker rehabilitation.

3D printing, also known as additive manufacturing, has revolutionized the treatment of challenging foot and ankle pathology. Treatment options for patients with large structural defects of the foot and ankle have typically included bulk allografts, autografts, and bone transport.  These options may be susceptible to donor site morbidity, nonunion, infection, and can require several surgeries to complete.  Bone allografts can also collapse over time.  Avascular necrosis of the talus is a disease process occurring when the blood supply to the talus is damaged either by trauma or systemic condition.  With advanced stages of AVN, removal of all avascular bone followed by arthrodesis was routinely the only surgical option.  Failed ankle arthroplasty is also difficult to manage.  If the native talar components erode and collapse, tibiotalocalcaneal arthrodesis and a bulk allograft can be performed, but the graft can collapse over time. A potential solution to improve management of large defects is the use of custom, 3-D printed porous titanium implants. 3-D printing technology has allowed for the development of custom metal implants that provide superior mechanical stability while also conforming to the patient’s anatomy.  Titanium alloy implants are designed with an interconnected porous architecture to encourage bony ingrowth. The implants can be made in a variety of sizes and footprints to reconstruct deformity and fractures across several anatomic indications. While 3D printing technology offers immense potential in orthopedics, there are several challenges. Cost-effectiveness and accessibility are key concerns, as implementing 3D printing infrastructure and materials can be expensive. Healthcare costs are a tremendous burden on hospitals and patients, and the use of expensive implants may be denied in favor of more traditional implants. Additionally, the long-term durability and biocompatibility of 3D printed materials need further investigation.

Numerous companies dedicated to foot and ankle surgery have emerged over the past several years.  The foot and ankle market are one of the fastest growing segments in the orthopedic industry. We are in the initial stages of harnessing the full therapeutic potential of biologics, and there are plenty of opportunities to advance the standard of care in foot and ankle surgery.