Providing the Algorithm for Wound & Podiatric Care at Ocean County Foot & Ankle Surgical Associates

Issue Number: 
Volume 12 Issue 4 - April 2018
Author(s): 
Joe Darrah

Toms River, NJ —As the longest highway in the state of New Jersey, the Garden State Parkway is truly a destination route despite its being defined as a “limited access” thruway. When traveling north from the southernmost point, the highway provides access to the state’s multiple (and popular) shore points, including Wildwood, Stone Harbor, Avalon, Sea Isle City, and, Cape May. Continuing into Atlantic County, the Parkway offers commuters the likes of Margate, Brigantine, Somers Point, and Atlantic City. And from Burlington County on through the length of the state, the parkway is a 172-mile jaunt that all told will take folks from the “shore section” into the “metropolitan section” that ultimately leads into New York by way of Montvale. 

For folks who reside in New Jersey’s Ocean County, an area that’s reportedly remained one of the state's fastest-growing regions since the 1990s and is positioned just 50-miles east of Philadelphia, PA, the parkway also serves as an access route to multiple locations that comprise one of the Garden State’s more comprehensive healthcare networks for patients who require chronic wound care, podiatric care, and other ancillary services: Ocean County Foot & Ankle Surgical Associates, P.C. With four office locations (Toms River, Toms River West, Forked River, and Whiting) and three hospital affiliations (The Center for Wound Healing & Hyperbaric Medicine at Community Medical Center, Toms River; the James Klinghoffer Center for Wound Healing and Hyperbaric Treatment at Deborah Heart and Lung, Browns Mills; and the Wound Treatment Center at Monmouth Medical Center’s Southern Campus, Long Branch), the network provides a host of services including limb salvage, vascular assessment and treatment, podiatric care and surgical reconstruction, and plastics. The algorithm that embodies the network’s treatment goals — to provide patients with a program that sees their care follow a 360-degree trajectory. 
“We offer multispecialty, comprehensive care,” said Russell D. Petranto, DPM, FACFAS,” a managing partner at the practice who helped launch the program in 1996 alongside Vincent J. Migliori, DPM, FACFAS. “And by ‘comprehensive,’ we mean vascular treatments all the way to medical management, orthotics, and reconstruction — it’s full circle.” 

Today, the staff has grown to a 14-member panel of podiatrists, orthotists, and surgeons who care for thousands of patients annually. The evolvement of the staff, as well the growth of the program’s services and location portfolio, was established through a strategy developed by Migliori and Petranto that has mimicked the full-circle suite of healthcare offerings afforded to each patient throughout the region. 

“Our vision, which started more than 20 years ago, promises to provide care to patients who suffer from the diseases of the foot, ankle, and leg,” said Petranto. “We knew we were going to follow through with that vision using every possible avenue of treatment.” 

And it all started, literally, from his own home.

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VIDEO: Click here for a video interview with Dr. Russell D. Petranto, DPM, FACFAS, as he discusses how he and his colleagues launched and have continued to grow the practice at Ocean County Foot & Ankle Surgical Associates, P.C.
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THE EARLY YEARS OF PRACTICE

It was the mid-1990s and Petranto, a native of Trenton, NJ, was not far removed from a two-year associateship performed in Lancaster, PA, and the completion of his residency (which he served at three Philadelphia-area locations: Bryn Mawr Hospital, Crozer Chester Trauma Center, and Metropolitan Hospital’s Springfield division). It was time to embark on the next step of his career. Through a small business loan, Petranto purchased a residence in Toms River, remodeled its two two-car garages into four separate treatment rooms, and initiated a private practice that would ultimately build a caseload of more than 100 patients per week. 

“And that’s where this wound care program started — in that house,” said Petranto. “When I came into the area, I brought with me a strong training program in wound care. I was treating patients in the hospital and in my practice who were living with chronic wound conditions.” 

Migliori, a graduate of the Pennsylvania College of Podiatric Medicine whose residency training specialized in elective foot surgery, had been operating his own practice in nearby Forked River, NJ, at that time. The two came into frequent contact during hospital rotations at the Kimball Institute in Lakewood, where Migliori serves today as medical director for the hospital’s wound care center. As they continued to work together, they felt a synergy happening beyond the hospital walls, Petranto said. 

“Dr. Migliori was always acquiescent to observe me when I needed it, and we also had a loose connection because both of our families were from Trenton,” he added. “Our relationship really came together nicely. Being that it was the mid-1990s, some managed care organizations were looking at reimbursement patterns that were dictated by the number of patients you had in your practice. The more patients you had, the better the reimbursement patterns would be. That’s when we decided to merge our two practices, so the number of patients would be greater and we would have a greater reimbursement pattern for managed care. Ultimately, we decided to develop a joint practice, but managed care didn’t get a real stronghold in this area right away. But we were well on our way to having additional doctors.”  

The trajectory for additional providers was born out of Petranto’s and Migliori’s vision to offer a viable, complete approach to care for patients in need of a foot-and-ankle medical program. In 1996, Jose R. Ruiz, DPM, was hired as the company’s first associate. Robert Floros, DPM, FACFAS was also recruited to assist on the more complex surgical procedures that patients required and to perform reconstructive surgeries for the two existing office locations as well as the wound center at Kimball, which marked the program’s first foray into establishing itself as a visiting panel for chronic wound patients. “At that point, we started to look into the possibility of additional locations, and we were really starting to grow,” Petranto added.

In 2008, the practice expanded into Whiting, NJ, following an invitation from administrators at Kimball who suggested that the group fill a vacancy in a local medical building that would position its providers in a nearby location to care for hospital patients in both an inpatient and outpatient capacity. Over the next five years, the group opened wound centers at Community Medical Center, Monmouth, and Deborah Heart and Lung before enveloping a Toms River-based practice owned by Michael J. Felicetta, DPM — an endeavor that now gave the group two separate locations in town. Felicetta later joined the practice in March 2016. As plans for potential expansion continue, Petranto said the program may also soon be enveloping another location in Whiting. “These practices are happy to have us be a part of their groups because we allow the physicians to do what they are trained to do — see patients and take care of patients — without having to worry so much about the bureaucracy and paperwork that needs to be done in order to be sustained and solvent,” he added. “We were noticing a trend, and so we were going to continue to explore practices in key areas that have the right practice motto and possibly entertain relationships with them.”

STAFF AND SERVICES
As the company’s presence in more towns and hospital centers has continued to grow, so too has its staff and programs. The expansion focus eventually turned to limb salvage and vascular care. Enter the likes of Girish Nair, DPM; Michael Plishchuk, DPM; Matthew Regulski, DPM, ABMSP, FASPM, FAPWH(c); Valarie Beck, DPM; Robin Lenz, DPM; Kerianne Spiess, DPM, and Amanda Crowell, DPM. 
“We had the general podiatric specialists and the reconstructive specialists, but we needed the limb-salvage specialists,” Petranto said. “We also needed a vascular surgeon and a surgical center, as well as an endovascular program, an orthotist, and a pedorthist.”
That’s when Darelle Pfeiffer, DPM, and Davison de Queiroz, CPed, BOCO, CO, LO joined the team.

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VIDEO: Click here for a video interview with Dr. Matthew Regulski, DPM, ABMSP, FASPM, FAPWH(c), to learn more about how his career led him to Ocean County Foot & Ankle Surgical Associates, P.C. and how he sees his practice evolving with wound care science and technology.
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“These were the areas of care that were part of our early vision and were necessary for patient care in foot-and-ankle medicine,” Petranto continued. “The plan was to take things piece by piece so that we could assemble and create an entity that would allow the patients to stay with us through the entirety of their treatment and rehabilitation.”
A core component of the service structure is the vascular program, which features multiple noninvasive labs onsite throughout the practice. These labs are certified by the Intersocietal Accreditation Commission, a nonprofit organization based in Maryland that evaluates and accredits facilities that provide diagnostic imaging and procedure-based modalities for purposes of improving the quality of care provided in private offices, clinics, and hospitals where such services are performed. 

“These labs are equipped with certified registered vascular technicians who do our lower extremity vascular studies and focus on the arterial and venous side of the disease process,” Petranto said. “We also have endovascular specialists who come in to see the patients and have their procedures done — angioplasties, atherectomies, venous ablations, and sclerotherapies. All these procedures are conducted here at our surgical centers.”

After being seen by the intake clinician, patients receive a vascular study and undergo any needed vascular or endovascular procedures prior to consultation by an on-staff orthoptist. The patients are then referred back to the general podiatric physician. It’s the type of full-circle, comprehensive care that Petranto and Migliori envisioned when their practice launched and represents a significant achievement among the protocols that the group has developed over the years.

FROM BLAZING TRAILS TO TRIALS

Today, the practice is also well known for its propensity to be involved in multiple ongoing clinical trials, many of which are coordinated by Regulski. At the time of the visit by Today’s Wound Clinic,Regulski and his colleagues were enrolling patients in an 18-month, phase 3 venous leg ulcer (VLU) trial with a New Zealand-based company seeking to market a frozen-gel product that utilizes a topical growth factor cocktail of the vitronectin protein and insulin-like growth factor 1. 
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VIDEO: Click here for a video interview with Dr. Matthew Regulski, DPM, ABMSP, FASPM, FAPWH(c), who discusses some of the recent and current trials being conducted at Ocean County Foot & Ankle Surgical Associates, P.C.
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“They’re doing about 12 trial sites across the country, and they want each site to have 6-8 patients,” Regulski explained. “The inclusion criteria are very strict. If you have a patient who has a wound between 2-5 cm2, it has to be older than six months, but less than one year old; or if the wound is between 5-15 cm2, it has to be less than six months, but greater than 30 days. It’s a dosing trial — some will get high dose, some will get low dose, and we expect the trial to run sometime until this coming spring or summer.”

The sophistication of the vascular program has made it a prime candidate for recruiting patients for these types of trials, said Regulski. “The venous leg ulceration is probably the most prevalent chronic wound you are going to see, and venous leg ulcer trials have traditionally not worked out well due to the inflammation, the chronicity, and the dependency,” he continued. “The leg is always in a dependent position because most people who are living with VLUs are working people who can’t sit around for eight weeks waiting to heal. And as our cells get weaker and we get older, it’s harder to recover. So the costs for treatment of VLUs are astronomical. But we’re the only podiatry group that I know of that has its own vascular center. And you’re going to get better reviews here than you do in the hospital. Whether it’s a new patient or a recurrent patient with a new wound, they get their testing done — arterial duplex, toe pressures, skin perfusion pressure — and if there’s a problem with vascular disease, they get an evaluation. We have access to everything right here and we are able to risk-stratify patients.”

On the podiatric side, Regulski said the practice was also recently approved by a local company to participate in a trial that will use an amniotic fluid injection for Achilles tendonitis. “It is one of the first such trials going in the country and is going through independent review board approval at this time,” he continued. Additionally, the group is in conversations with a Maryland-based company related to a proof-of-concept trial for a cryopreserved graft that is freeze-dried and reportedly has a shelf life of six months at room temperature. “It’s something that would normally have to be kept on ice and thawed, but it keeps the same cell viability and same cell count,” said Regulski. “It is fascinating. And we’re going to be one of the first people to do a proof-of-concept trial.” 

As of press time, the trial had not yet started, yet it remains an example of the type of work that Regulski, Petranto, and their associates believe will help the practice remain innovative as wound care (and the healthcare industry as a whole) evolves. 

“We as an industry need to do a better job of identifying the algorithmic pathway by which our wound patients need to be treated, and with that algorithmic pathway be able to provide the appropriative adjunctive therapies,” Petranto said. “We, as an industry, know that the algorithm is a linear progression to the appropriate treatment pathway to the chronic wound patient. But when do each one of those benchmarks get achieved at different benchmarks of the algorithm? If it’s a medical-management standpoint, when is that patient optimized? If it’s a vascular-status assessment, when is that patient optimized? If it’s biofilm and bacterial counts, when is that patient optimized? That’s where we need the research. And we have already started that research here. This practice is already going down that road.”

Joe Darrah is Managing Editor of Today’s Wound Clinic.

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VIDEO: Click here for a video interview with Dr. Russell D. Petranto, DPM, FACFAS, who discusses some of the challenges that exist regarding the emotional and mental health effects facing chronic wound care patients, as well as some of the strategies that he and his staff employ when caring for this patient population.
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