05/29/2019    Allen Jacobs, DPM

What Are Clinical Practice Guidelines? (Donald Peacock, DPM)

The “standard of care” is variously defined as
that which the average podiatrist would do under
the same or similar circumstances. In reality, we
are all generally familiar with the manner with which the “average podiatrist” evaluates and treats commonly
encountered foot and ankle pathology. The public
and profession are not well served by multiple
self-declared authoritative bodies setting self-
declared standards of care.

Case series reports, particularly without long-
term retrospective evaluation, do not justify
percutaneous tenotomy of the EHL for
hyperextension deformity if the hallux IPJ. If I
wish to provide temporizing relief of
positionally-induced pain or deformity, I’ll
start performing peroneus breves tenotomy for
PTTD, Achilles’ tendon tenotomy for non-
neurologic equinus, and PT tenotomy with deltoid
ligament release for supination deformity.

MIS represents an area of increased focus in the
profession both at the practitioner and corporate
level. We have witnessed expanded opportunities
for MIS in a wide range of interventions from
bunionectomy to ankle fracture and ankle
arthrodesis. Specialized instrumentation for MIS
is now increasingly available.

The issue is not whether MIS is potentially
appropriate for some patients. The issue is when
and how such procedures are utilized. The issue
is why there is the need for “board
certification” in MIS. The issue is why the MIS
surgeons require their own standards of care. The
issue is a clear paucity of long term outcome
studies.

Bias? I do not maintain an anti-MIS bias. It is
my opinion that MIS should be incorporated into
APMA, ACFAS, and other educational conferences.
Present the MIS procedures, and long-term
outcomes. Publish the same in legitimate peer-
reviewed journals. Establish MIS credibility
through accepted scientific means, not through
litigation or non-ABFAS certification. And not
through case reports and case series with no long
term outcome studies. There is a difference
between can do it and should do it.

With all that said, I continue to believe that
tenotomy of the EHL for “spoon toe“ is not the
manner in which most podiatric physicians manage
nail deformity or toenail pain from a hallux
hyperextension deformity.

Allen Jacobs, DPM, St; Louis, MO

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