In the borough of the Bronx, New York, approximately 550 of every 100,000 adult Medicaid enrollees are hospitalized due to complications from diabetes, according to a 2015 report from the Office of the State Comptroller. Frequently these are conditions affecting the foot. The podiatrists at Bronx-Lebanon Hospital Center’s Department of Foot Surgery/Wound Management, Orthopaedics provide those patients as well as patients who have a wide range of other conditions convenient access to the complete spectrum of care.
Joanna Ayoub, DPM, Co-Director, Department of Foot Surgery/Wound Management, Orthopaedics at Bronx-Lebanon Hospital Center, and Charles Lee, DPM, Attending Surgeon, Department of Foot Surgery/Wound Management, Orthopaedics at Bronx-Lebanon Hospital Center, assist each other in a surgical case.
From surgical correction of foot deformities and management of complex foot fractures and wounds, to a full array of non-operative podiatric care, the specialists at Bronx-Lebanon comprehensively cover the medical foot care needs of the Bronx community.
“Our foot surgical team has created a Center of Excellence for both simple and complex foot care that has helped many patients for many years and will continue to do so,” says David Wong, DPM, Co-Director, Department of Foot Surgery/Wound Management, Orthopaedics at Bronx-Lebanon Hospital Center. “We work very closely with the hospital’s medicine/family medicine, vascular surgery, plastic surgery and infectious diseases teams. We get everyone on board in treating complex cases.”
This multidisciplinary emphasis, coupled with attention to the community’s unique needs, defines the department’s approach to ensuring that area residents have access to its expansive services.
David Wong, DPM, Co-Director, Department of Foot Surgery/Wound Management, Orthopaedics at Bronx-Lebanon Hospital Center, examines a patient’s foot for bunion surgery.
“In addition to our hospital team, we have three non-operative podiatrists who work at clinics outside the hospital. They offer a broad range of conservative treatments and let us know immediately if one of their patients needs surgery. We’re also available to these patients to treat ulcers or open wounds.”
— David Wong, DPM, Co-Director, Department of Foot Surgery/Wound Management, Orthopaedics
Foot Health in the South Bronx
The South Bronx community has a greater-than-average need for advanced foot care, with many residents at increased risk for foot wounds. More than a third of residents live below the poverty level.
“The primary issues in an area with this socioeconomic makeup are the systemic problems that can cause foot conditions, such as diabetes,” says Joanna Ayoub, DPM, Co-Director, Department of Foot Surgery/Wound Management, Orthopaedics at Bronx-Lebanon Hospital Center. “Recognizing that there is a strong correlation between socioeconomic level and medical compliance, we focus on accessibility of care. We hold a clinic every day, with multiple physicians involved. We either have a physician in our practice, or we have one on call 24/7 for emergency room, inpatient and surgical consults.”
In addition to making themselves available, the podiatrists understand that patients in the community may face considerable financial and logistical constraints. That makes the wide variety of services the department offers all the more important.
“The Bronx is a community of hardworking people, and sometimes people who would benefit from surgery can’t take an extensive amount of time off work,” explains Charles Lee, DPM, Attending Surgeon, Department of Foot Surgery/Wound Management, Orthopaedics at Bronx-Lebanon Hospital Center. “We have to help these patients, so if a patient needs a non-surgical care plan that will still allow him or her to continue with daily activities, we take that into consideration and offer alternative treatment plans.”
HIV is another factor that increases the need for advanced podiatric care in the Bronx. The area has a disproportionately high HIV mortality rate compared with that of other neighborhoods in Metro New York that have a greater number of annual HIV diagnoses. As a result, they may suffer from more complications.
“The South Bronx has a high concentration of immunocompromised patients who have HIV, hepatitis and/or diabetes,” Dr. Wong says. “Many of these patients come in with ulcers and gangrene, so we tailor care to those types of infections and focus on limb salvage.”
Dr. Lee demonstrates how the foot functions while explaining his treatment plan with a patient.
Having local podiatric care available is an economic as well as medical benefit to the community. A 2011 study published in the Journal of the American Podiatric Medical Association found that patients who had visited a podiatrist in the year before developing a foot ulcer saved thousands of dollars — $4,271 for Medicare patients and $19,686 for patients with commercial insurance — over a three-year period compared with those who had not visited a podiatrist before ulceration.
Jason Lacher, DPM, Attending, who plays an important role with conservative podiatric management, applies a cast on a patient.
“We consider the patient as a whole. We determine if the patient has other comorbidities that contribute to the initial cause of injury and how they may affect healing and treatment. We work with other specialties to optimize the patient’s ability to heal.”
— Charles Lee, DPM, attending surgeon, Department of Foot Surgery/Wound Management, Orthopaedics
The breadth of patients’ podiatric needs has shaped the identity of the Department of Foot Surgery/Wound Management, Orthopaedics as a locally focused program providing the full range of advanced podiatric care, including surgery.
“We are an all-inclusive department that treats all foot pathologies,” Dr. Ayoub says. “We employ all aspects of conservative care. For patients who require additional levels of care or in cases of trauma, such as an Achilles rupture or displaced fracture, we deliver acute surgical intervention.”
Dr. Ayoub describes a flatfoot reconstruction case as an example of the department’s methods. A patient presents with painful flatfoot deformities. The podiatrist begins treatment with orthotics, bracing and/or physical therapy, but these interventions may prove to be insufficient. The patient may require surgeries on multiple parts of the foot, such as calcaneal osteotomy to realign the heel, tendon lengthening, repair or augmentation to undo any imbalances resulting from the deformity, and treatment for bunions or hammertoes, which can develop consequently. In some cases, joint fusions may be required. After the procedure, the podiatrists may promote early weight-bearing to help the patient recover mobility at a faster rate and benefit from an earlier return to work.
“We perform all surgeries in the foot,” Dr. Lee says. “We treat simple problems, from ingrown toenails, soft tissue masses, plantar fasciitis, hammertoes and bunions, to more complicated issues such as infections, tendon ruptures/laceration, fractures, osteoarthritis, bone cysts, brachymetatarsia, flatfeet — anything necessary for the improvement or correction of our patients’ foot condition.”
The podiatrists also treat heel spurs, ulcers, bunions and dermatological disorders. Bunions may require either simple or complex surgery, so the podiatrists may select one of a variety of techniques, including osteotomy, exostectomy and/or fusion.
Being part of the Department of Orthopaedics, the Foot Surgery/Wound Management team takes a whole-person/holistic view of patients, recognizing that issues such as arthritic pain of the foot or fractures have far-reaching effects on the musculoskeletal system. This comprehensive approach with the orthopedists allows for improved health care and satisfaction for patients.
Additionally, non-operative podiatrists from Bronx-Lebanon provide community-based practices for patients who do not maintain a relationship with a podiatrist. These practices offer treatment when surgery is not mandated and provide a first step for patients who need surgery to begin their workup with specialists.
This foot X-ray reveals midfoot breakdown that may require surgical reconstruction.
“We recommend all patients with diabetes follow up with podiatric care at least once a year. During these visits, we evaluate their neurological, vascular, orthopedic and dermatological status and check for anything abnormal that may require more regular follow-up or treatment.”
— Joanna Ayoub, DPM, Co-Director, Department of Foot Surgery/Wound Management, Orthopaedics
Serving Patients with Diabetes
“As soon as patients are diagnosed with diabetes, they need to develop a relationship with a podiatrist,” Dr. Lee says. “How often do people check the bottoms of their feet? Many patients simply don’t know about the likelihood of developing diabetic neuropathy. By educating patients, we can help them be aware of the need to check their feet more often, to control their blood sugar levels, to maintain a healthy diet and to follow up with their primary care physicians.”
When medical intervention is necessary for patients with diabetic foot conditions, the Department of Foot Surgery/Wound Management, Orthopaedics offers a range of services tailored to the individual patient.
“For diabetes-related issues, we commonly provide wound care of the foot and care of dermatological and nail disorders, such as mycosis, warts and ingrown toenails, and if more advanced care is required, all of our foot surgeons are highly trained in wound care and limb salvage,” Dr. Wong says. “However, we help patients avoid these more invasive procedures whenever possible by encouraging those with neuropathy or peripheral vascular disease to see us every three months for nail care and an updated diabetic foot evaluation.” Those checkups are of paramount importance. According to a 2015 literature review published in World Journal of Diabetes, no complication of diabetes mellitus is more financially burdensome to patients than diabetic foot ulcer. For patients of limited means, these checkups not only prevent the devastating loss of tissue or even limbs that can result from ill-maintained diabetic foot ulcer, but also protect their savings. As the literature review notes, “early effective management of [diabetic foot ulcer] can reduce the severity of complications such as preventable amputations and possible mortality, and also improve overall quality of life.”
Co-Directors Dr. Wong and Dr. Ayoub discuss day-to-day matters that affect their department.
Complex Wound Care
“For patients who come in with ulcerations, we are ready with a variety of wound care modalities. We also work closely with vascular surgeons, medicine physicians and infectious disease physicians to make sure we are taking care of a wound from all sides,” Dr. Ayoub says. “Wound care can involve sharp debridement, applications of different creams or skin grafts, as well as therapies designed to accelerate wound healing.”
When a wound is no longer superficial and is probing into soft tissue or bone, or when an infection sets in, the podiatrists consider more aggressive modalities. In cases with the possibility of osteomyelitis, the podiatrists take a bone culture to determine the type of organism infecting the bone and the most effective antibiotic for treatment. The team maintains excellent referral relationships as well, so patients who need hyperbaric oxygen therapy can receive prompt treatment. By employing non-surgical therapies, the Department of Foot Surgery/Wound Management, Orthopaedics reduces amputation rates significantly.
The presurgical stage is notable for its multidisciplinary collaboration, as the podiatrists consult with their colleagues at Bronx-Lebanon to ensure there is enough vascularity for the wound to heal from surgery. The team also works with patients’ primary care providers during follow-up to ensure medical optimization.
(From left) Jason Lacher, DPM; David Wong, DPM; Joanna Ayoub, DPM; and Charles Lee, DPM, work closely together via a multidisciplinary approach within the department, offering conservative and surgical options for patients.
A Medical Home for Non-operative Foot Care
While serving as a destination for advanced procedures, diabetic foot management and complex wound care, the Department of Foot Surgery/Wound Management, Orthopaedics also provides a stable community option for non-operative treatment of foot injuries and abnormalities.
“If patients can resume typical activities without surgical treatment, and if conservative treatment more closely aligns with their needs and desires, we always prefer non-surgical options. Only when necessary do we consider surgical intervention,” Dr. Lee says.
Plantar fasciitis is a common complaint for which the podiatrists offer a variety of non-surgical treatment options. They may start by educating patients about stretching exercises they can perform at home to relieve heel pain, and some patients benefit from injections. Freedom from current pain is not the only goal of treatment. The podiatrists also educate patients about preventing future development of plantar fasciitis, focusing on stretching and footwear.
The London-based College of Podiatry estimates that 75–80 percent of adults have a foot condition. The Department of Foot Surgery/Wound Management, Orthopaedics is leveraging exceptional expertise and close collaboration with referring providers to help patients in the region access the care they need.
For more information about services available at the Department of Foot Surgery/Wound Management, Orthopaedics, visit www.bronxcare.org/our-services/orthopaedics/foot-surgery.