With reference to the "newest and latest", be it
surgical instrumentation, a pharmaceutical,
whatever, the best question I have heard was from
Jack Schuberth DPM. He will listen and ask, "Well
Doctor, what is the problem that you are solving".
It is a basic and brilliant question that I ask
every time I read about a new wound care product,
fixation device, pharmaceutical, anything.
Industry informs us of a "problem" they have
solved.
As Dr. Marino correctly-notes, many of these
solutions are expensive and may not provide
significant if any benefit to the patients we
treat. And yes, sometimes the oldies are goodies.
For example, plate fixation vs. two screw fixation
for 1st MPJ arthrodesis. Digital implants vs.
simple K-wire fixation. Complex Lapidus fixation.
The use of orthobiologics for everything to
"enhance healing". Perhaps most pervasive CTP's in
wound management. Frequently, the corporate
sponsored studies demonstrate clinical equivalence
but no superiority.
Last week, I performed a minimal incision 5th
metatarsal osteotomy for a bunionette fixated with
a percutaneous .62 K-wire. I fixate my 1st
metatarsal distal metaphyseal osteotomies with a
single screw, no plates on IM nails. Frankly, here
too I believe a K-wire is likely sufficient for
this also. In fact, I know that studies
demonstrate this conclusion is correct. When is
the last time you utilized a Cartiva implant? Used
a Pegasus implant for 1st MPJ interpositional
arthroplasty? Used a two component 1st MPJ
implant? Did a Young tenosuspension? The IWGDF
diabetic ulceration review suggests that many of
the CTP's and therapies advocated and sold by
industry lack robust studies showing superiority
or even at times efficacy.
My old insightful professor Dr. James Ganley
warned us all back in 1973 of the technologic
imperative. Corporations define a non-existant
problem and offer solutions to these problems.
Recency bias, newer is better, "free CME programs
unregulated by CPME, corporate purchases of
lecture time at our CME programs with so called
"unrestricted educational grants", unregulated
access of corporations to our residents and
students, contribute to the irrational use of
these products.
The ethical issue is whether surgical or medical
products which lack evidence supporting their use
should be presented for consideration at our CME
programs. In part, our colleagues who present and
advocate such products should be ashamed. The
"free CME" and "free CECH" infomercials disguised
as education must be interdicted or regulated by
CPME.
Dr. Marino is in my opinion correct. Newer does
not always mean better. There may be good reason
that seasoned (old) practitioners are sometimes
not so fast to incorporate the latest. I suppose
its time to stop using Herbert bone screws or
absorbable allograph pins for my bunionectomies
huh?
Allen M. Jacobs, DPM, St. Louis, MO
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