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10/14/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Arthrosurface Hemi Cap for Frieberg’s Infraction.( William Sachs, DPM)
From: Alan MacGill, DPM, Jeffrey Kass, DPM Arthrosurface makes a larger implant (15 mm.), which is commonly used to resurface the first metatarsal, and a smaller size (12 mm.), which is what we have used to resurface the second metatarsal. The 12 mm. implant has worked great to re-establish a congruent articular face, all while maintaining the weight-bearing surface of the metatarsal.
We've performed this procedure in 4 cases. All cases involved the 2nd metatarsal and the patient age ranged from 29 to 68. Our follow-up has ranged from 10-19 months in this small sample size but results have been good. All patients have had increased joint range of motion, decreased levels of pain, and a return to desired activity level. These results have been promising but we'll have to wait and see how these implants hold up long-term.
Alan MacGill, DPM, Orlando, FL, alanmacgill@gmail.com I just recently had a discussion with a fellow colleague regarding this type of case. The thought for this type of procedure is that you have a damaged met head and the implant would take its place. The con is the met head is collapsing, this is the disorder. So, the concern would be whether or not the implant can hold due to the decreased strength and collapsing nature of the bone. I have not done a literature search on the topic, but decided the con was too much of a concern.
Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com
Other messages in this thread:
01/15/2009
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: AFO Brace/Shoe for CMT (David B. Arkin, DPM)
From: David J. Levine, DPM, C. Ped There are a variety of ways to provide the bracing this patient needs, but since the deformity is rigid, the bracing will not offer him as much help as modification of his shoes will. Accommodating the deformity and providing him with a wide base of support is the most important issue to address in this situation. Shoe modifications are an extremely under-rated and under-utilized way to help patients from a mechanical perspective.
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Shoe Modification for CMT (Courtesy Dr. David Levine) |
Above is an example of a shoe modification that would help this individual. My only conflict of interest is that I have a shoe lab in my office with a technician who does nothing but shoe modifications. They work! David J. Levine, DPM, C. Ped , Frederick, MD, Djldpm@fmh.org
01/06/2009
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Short-Term Coverage For Practice (Name Withheld)
From: Mark E Weaver, DPM, Jeffrey Kass, DPM It has been my policy (and several of the other podiatrists here in Fort Myers, FL) to cover for our colleagues in distress for a limited period of time free of charge. We try not to 'steal' a single patient, and would feel bad if we were forced to. Over a long period of time, we would try to cover our net expenses. I would say 30-40% depending on the patient mix and local expenses. Remember most of our expenses are fixed. I'm sure this could be found universally. Just ask.
Mark E Weaver, DPM, Fort Myers, FL, TCOPN@att.net I think Name Withheld’s suggestion is a good one. I have covered many of my colleagues practices, whether they were away on vacation, tending to an ill relative, etc. I think the more you are away and don't have coverage for your practice, the more trouble you will have (i.e., losing patients). I wish you a speedy recovery, and if by chance, you are in my vicinity please do not hesitate to call. Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com
12/24/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Benfotiamine Shown to be Efficacious in Treating Diabetic Peripheral Neuropathy (Michael Turlik, DPM)
From: Multiple Respondents With all due respect to Dr. Turlik’s analysis, I believe what matters is real life. I see results equal or better to prescription drugs for neuropathy using benfotiamine. I believe there is a place for both types of treatments. Really, there are few studies available for most treatments performed in our offices each day. However, we successfully treat patients and the studies have minimal relevance. As a matter of fact, I could take most studies and distribute them to 10 researchers and there would be multiple problems found. We should base out treatment on our expertise as physicians and what is best for patients. We can use studies for what they are worth, a guide. Just because insurance companies care about studies, this should not change our treatment plan. Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com I acknowledge Dr. Turlik for his critical evaluation of the paper on benfotiamine’s efficacy. He shows how we can be misled by poorly-written papers that have entered the literature. Without his critical analysis, many of us could be hoodwinked by sales reps and corporate-sponsored speakers who might try to convince us that evidence-based medicine supports the use of this dietary supplement in all cases of diabetic neuropathy.
I have another question about the use of benfotiamine, which is a lipid-soluble form of thiamine or Vitamin B1. Why not take a simple blood test and see if the patient has a thiamine deficiency before giving the patient a thiamine supplement? Thiamine deficiencies definitely can cause peripheral neuropathy, but If there is no evidence that the patient has such a deficiency, putting the patient on benfotiamine is really practicing hocus pocus rather than evidence-based medicine.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com I think this represents an over-simplification of the condition. Neuropathy is a complex, multi-factorial syndrome. It is more than the absence of a B vitamin derivative. I believe the best we can say is that benfotiamine may be one part of a complex protocol that shows efficacy in the treatment of neuropathy. It is important to identify and address all mechanisms whenever treating any pathology. For this reason, relying on one nutrient as "the treatment" for any condition is foolhardy. Likewise, evaluating one nutrient as a protocol and dismissing it as non-efficacious is short-sighted and unfair to the big picture. Bob Kornfeld, DPM, Lake Success, NY, Holfoot153@aol.com
12/11/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Latest Research on Subtalar Joint Axis Location (Kevin A. Kirby, DPM)
From: Simon Young, DPM, Dennis Shavelson, DPM Bravo. It is great seeing new research which can help us utilize biomechanical principles in our daily lives. This will help us understand pedal pathology better and help in guiding us to fabricate a more appropriate orthotic devices which will result in better patient outcomes. JAPMA published an article, although supported by a lab, which showed that custom-molded orthotics reduced our energy consumption during gait. Simon Young DPM, NY, NY, simonyoung@juno.com I read with great anticipation Dr. Kirby's posting announcing “some recent research that may greatly change the way we view the forces and moments that affect foot and lower extremity function” until I realized that it was authored by HIM! For years, I have had difficulty understanding what Kevin is saying. I have debated his STJ Sagittal Axis Theory vs. my Neoteric Biomechanics Theory, stating that his theory required engineering and research skills that mainstream podiatry doesn’t possess. Of my theory, he wrote that “your approach of foot biomechanics may suit many podiatrists very well and may allow them to progress to a better understanding of foot and foot orthosis function that they may not have been able to achieve otherwise” and then added, “You may use that quote as long as you use it along with my other quote, "Unfortunately, I see your model as a throwback to the Root model that I have worked so hard to get the profession to move away from for the past quarter century. Therefore, I simply don't see much benefit taking podiatrists back a step or two in sophistication, when they should rather be keeping more in step with the mainstream international biomechanics community and their prolific research on foot and lower extremity function." I read Dr. Kirby's article and for a moment, considered applying to a fellowship at The Penn State Biomechanics Lab but I had charts to fill out, pre-certs to dictate and call in, and toenails waiting to be cut in the next room. I will let the profession decide which way to go when looking for a new paradigm of biomechanics, upgrading and expanding Root or Dr. Kirby’s. Dennis Shavelson, DPM, NY, NY, Drsha@foothelpers.com
12/09/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Floroquinones and Tendon Injuries
From: Elliot Udell, DPM The 12/1/08 issue of the Medical Letter reports that studies have shown that the incidence of injury after taking quinolone antimicrobials is from .14% to .4%. The risk is higher for patients over 60 years of age and those taking corticosteroids. The article went on to cite a case control study in Italy involving 22,194 cases non -traumatic tendonitis and 104,906 controls. Relevant to podiatric medicine is the part of the study that reports Achilles tendon rupture occurred with fluroquinoline treatment in one of every 5,989 patents in general and one of every 1,638 patients who are over 60 years of age. Elliot Udell, DPMHicksville, NYElliotu@aol.com
11/27/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Orthotics and Bunions (Simon Young, DPM)
From: Dennis Shavelson, DPM I would like to pose these theoretical questions: 1) If an orthotic could be dispensed that reduced functional hallux limitus and allowed peroneus longus to leverage and power to the point that it produced renewed stabilizing power upon the first ray, locking it more securely in closed chain with every step, would the IM, HAA and Met primus elevatus of that patient's pathological medial column improve? 2) Could manual therapy, motor control, and additional vaulting of the dynamic arches of the foot then leverage and power the flexor hallucis longus and abductor hallucis, further reducing the development or advancement of a bunion deformity? Although Neoteric Biomechanics has not yet been double-blind studied, the podiatrists working with this new paradigm are doing just that, every day, in practice. Disclaimer: Dr. Shavelson is the inventor of Neoteric Biomechanics and has a financial interest in the paradigm. Dennis Shavelson, DPM, Medical Director, The FootHelpers Lab, drsha@lifestylepodiatry.com
11/17/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: CR vs. DR X-ray Systems (Mark K. Johnson, DPM)
From: Michael Fein, DPM, Marc Garfield, DPM I have had a 20/20 DR System for over 2 years and I am very satisfied with the system and their service. Last summer, there was a power surge which unfortunately resulted in "frying" my DR system. I called Reina and had a new system in my office the next day before 11am. I have no financial relationship with 20/20. Michael Fein, DPM, Bethel, CT, mzfein@gmail.com From the standpoint of speed and functionality, the 20/20 NAOMI DR System works well. Resolution is better than plain films. Laterals and upright ankle films have a grainy appearance along the plantar-most soft tissue margin. This can be corrected with a 1-inch foam spacer under the foot, and by focusing the beam just over the foot rather than what one would do with standard film. Images are readable within 10 seconds from the time of exposure. Software is trouble-free. The system can be used easily without an assistant as there is NO developing; it is essentially a big digital camera. Remember, even if the plates are digital, you can't take the next patient's films until you have cleared the films from the first patient. With the DR, I can take 10 views of both feet and not hesitate before filming the next patient. 20/20 is a great company to do business with. Tech support is unbelievable. I had a power outage and Cox changed my IP address in the same week. I didn't wait more than 20 seconds to have a tech help me re-establish network connections. They also included the setup/shipping and installation in their price quotes. Make sure you compare apples to apples.
Marc Garfield, DPM, Williamsburg, VA, mgarfield1@cox.net
11/12/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Painful Callused Heels (Shari Kaminsky, DPM)
From: Barry Mullen, DPM I've read the prior postings and tend to agree that the etiology is likely repetitive, mechanical microtrauma from long-standing open back shoe wear. However, this individual is overweight and has a history of pre-existing autoimmune disease. Therefore, with this setting, I'd recommend ruling out hypothyroidism. Do a thyroid assay because a percentage of those patients may present with various forms of thyroid acropachy (affecting the skin and nails). Locally, skin debridement with keratolytic ointment application under occulsion and rubber heel cups with closed back shoe wear generally helps. Systemically, your patient may be in need of thyroid supplements. Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
10/31/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: 4th Ray Resection or Transmet? (Jeffrey Kass, DPM)
From: Multiple Respondents I would do the TMA as a primary procedure. However, Dr. Kass's patient already has a BKA; so as an alternative option, in addition to a TAL and a 4th met. head resection, I would also resect the 2nd and 3rd met. heads in an attempt to equalize the length pattern and hopefully prevent further tissue breakdown. S. Jeffrey Siegel, DPM, Philadelphia, PA, Heeldoc1@aol,com A trans met with Achilles tendon lengthening would probably be your best bet. The patient will function well in a shoe with filler. I would maintain the metatarsal parabola and bias my cuts from dorsal distal to plantar proximal as to minimize the potential for further ulceration. Gerald Mauriello Jr., DPM, MA, Toms River NJ, mauriellodpm@gmail.com Based upon Hx and clinical status, a proximal TMA, with well-contoured parabola and appropriate reduction of any distal osseous "spikes" would be my goal. The base of the 5th presumably has the peroneal insertion and medial soft tissue insertions are also assumed to be non-disrupted. TAL, immediate post-op bracing, rehabilitation and surveillance for contractures with Botox, and consideration for release residual deformity have been very positive for many of our patients in similar scenarios. Alan Cantor, DPM, East Meadow, NY, ajcdpm@aol.com
10/29/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Plate System for Osteotomy (Jason Serpe, DPM)
From: Dan Waldman, DPM, Paul Bassi, DPM I have used Wright Medical's opening base wedge plate on a male mid-40's, marathon runner with great outcome radiographically and functionally. He is back to running without problems; of course the orthotics were part of the plan. Dan Waldman, DPM, Asheville, NC, DPMcareer@aol.com I am quite familiar with the Wright Medical BOW plate and have done several opening wedge procedures using this system over the past 8 months. I agree with Dr. Weiner in that you have to be extremely careful when performing the osteotomy. It is very easy to be overly aggressive and crack through the lateral cortex, thereby creating a very unstable distal fragment. I typically go no further than 2/3rds of the way across with my cut and then attempt to open the wedge. I then press from lateral to medial at the hinge to open the osteotomy site for plate placement medially.
Patient selection is the key with this procedure. I have had excellent results with younger patients, some of whom I’ve done both feet about 8 weeks apart. Despite the osteotomy site being very stable with the plate in most cases, I still recommend a period of immobilization. Cast immobilization seems to work best, as the patients I have placed in CAM-walkers have begun ambulating prematurely despite my strict NWB instructions. I also use the Allomatrix as a bone filler and have had excellent results with it. My correction has been about 1.5 to 2 degrees per mm of wedge, and I have used the 3 mm. and 4 mm. plates in most cases. Paul Bassi, DPM, Wichita, KS, Paul@ksfootdoc.com
10/28/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Corticosporin Otic Suspension Discontinued (Richard Rettig, DPM)
From: Hal Ornstein, DPM All the podiatrists in our practice stopped using Corticosporin otic solution when performing a matrixectomy several years ago due to the excellent results we got with use of AmeriGel wound dressing. It is much more convenient for the patient, with no soaking and once-a-day application. Outcomes are significantly improved with less redness, infections, pain and drainage. The Oakin in AmeriGel Wound Dressing provides the antimicrobial properties to fight off and kill the most common infections, and helps to remove debris. Amerx has packaged the AmeriGel nicely in a small box that includes gauze, Band-aids and wound wash. It is nice that we can add to the bottom line since Amerigel is not a prescription product and patients love that they save a trip to the pharmacy. Hal Ornstein, DPM, Howell, NJ, toetoe@optonline.net
10/24/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Mid-Arch and Met Pain (Kel Sherkin, DPM)
From: Philip H. Demp, DPM, MA, MS, PhD
Based on my published pilot study and an ongoing multi-research team funded by the NIH, the micromechanics of the metatarsal length pattern can be evaluated by a geometric configuration of the five metatarsal heads which corresponds to a unique equation. If this configuration turns out to be evaluated as a pathomechanical configuration, then shortening or lengthening by surgery or conservative therapy using the computer should produce precise information as to how to proceed in finding the appropriate toe(s) and amount to shorten or lengthen. Surgeons are already doing this. However, in the literature, they talk about obtaining a parabola configuration, which is considered to be pathomechanical and may produce a clinical problem in the long run.
If you email me a weight-bearing, dorso-plantar radiograph, I will analyze it according to my research and send you a report by mail which includes possible treatment which you can consider. We assume that the problem was caused by a pathomechanical metatarsal length pattern. Philip H. Demp, DPM, MA, MS, PhD, Cinnaminson, NJ, pdemp@dca.net
10/22/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Monofiliments Not an Accurate Test of Neuropathy (Peter J. Bregman, DPM)
From: Allen Jacobs, DPM, Peter J. Bregman, DPM PSSD is NOT the most sensitive means to detect small fiber neuropathy. Intraepidermal nerve fiber density testing is the most sensitive means to diagnose and quantitate small fiber neuropathy. PSSD remains contoversial and does have a CNS component. PSSD is not helpful for peripheral autonomic or motor neuropathy. IENFD testing may preceed positive EMG/NCV testing and PSSD testing for affirmartion of neuropathy by as much as 3-10 years.
The suggestion that retained 10 gram filament perception may be present in the presence of an ulceration is correct. That is why the examination should also include a 128 tuning fork, light touch, 2- point discrimination, reflexes, neuropad testing, manual muscle testing, questioning and observation. Small fiber neuropathy and large fiber neuropathy may cause symptoms without demonstrable office examination findings.
According to the guidlines of the ADA (January 2008-Diabetes Care), diabetic neuropathy can be diagnosed in 87% of cases WITHOUT the need for advanced diagnostic testing. Allen Jacobs, DPM, St. Louis, MO, allenthepod@sbcglobal.net Editor’s note: Dr. Bregman’s extended=length response can be read at: http://www.podiatrym.com/letters2.cfm?id=22654&start=1
10/21/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Monofiliments Not An Accurate Test of Neuropathy (Peter J. Bregman, DPM)
From: Lee Rogers, DPM, James J DiResta, DPM,MPH, Dr. Bregman's opinion is fundamentally flawed. The 5.07 monofilament is not advocated to diagnose neuropathy, but to diagnose loss of protective sensation (LOPS) from neuropathy. Also, it depends on the location and number of sites tested to produce the correct result. The monofilament test has been proven in many trials to predict ulceration in patients with diabetes. The PSSD machine is not an accepted method to diagnose neuropathy or loss of protective sensation. It is a proprietary instrument that costs 10's of thousands of dollars, versus pennies for a monofilament. There is a steep operator learning curve for the PSSD and it does not correlate with the most objective neurological test, the EMG/NCV. Furthermore, the PSSD is popular to determine the need and effectiveness of surgical nerve decompression in diabetes. Both the American Academy of Neurology(1) and the American Diabetes Association(2) have recently published position statements refuting the surgery as an effective treatment for diabetic neuropathy. There has only been 1 prospective trial of nerve decompression surgery at Grade IV (low level) evidence. The monofilament is not dead, it is alive and well. The combination of a monofilament test with a vibratory perception threshold (VPT) from a biothesiometer is more sensitive at detecting LOPS. 1. Cornblath DR, Vinik A, Feldman E, Boulton AJM. Surgical decompression for diabetic sensorimotor polyneuropathy. Diabetes Care 2007;30:421-422
2. Chaudhry V, Stevens JC, Kincaid J, So YT. Practice advisory: Utility of surgical decompression for the treatment of diabetic neuropathy: report of the American Academy of Neurology. Neurology 2006;66:1805-1808 Lee Rogers, DPM, Des Moines, IL, lee.c.rogers@gmail.com I felt compelled to respond to the recent comments of Dr. Peter Bregman on PSSD testing as a better screening tool for peripheral neuropathy. In his comments, he infers that this is the new "gold standard" in diagnosing peripheral neuropathy which is a dangerous assumption. While it is true that PSSD is a highly sensitive test and therefore more likely to "capture" more patients with neuropathy, it lacks specificity, thereby finding many false positives and potentially labeling sick people as "sicker" when they are truly not at any more risk. The added danger of the so-called "potential benefit" of finding patients for "early" surgical intervention with surgical decompression based on this testing is also disturbing. For us, as our country's leading foot healthcare providers, to promote such an algorithm of care with PSSD, a costly test compared with the simple and inexpensive monofilament testing in the process of screening for peripheral neuropathy is not the new standard of care. There is truly minimal gain and potential harm with PSSD use as a screening tool which is just not supported by the present literature and cannot justify the cost to our healthcare system at this time. Use of PSSD testing is for pre-surgical assessment and even at that, questionable, as it promotes intervention in a manner that is still in dispute. James J DiResta, DPM, MPH, Newburyport, MA, jsdiresta@comcast.net
10/11/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Nail Dust Inhalation (Steve Bennett DPM)
From: Multiple Respondents I use the HP-Sani Vac from Moore Medical. It is independent of the Dremel, but has an adjustable hose. It really works well. Jennifer Ryder, DPM, Rapid City, SD, jenbenryder@yahoo.com I recommend reading a series of three articles on this topic published in APMA Journal years ago by Carl Abrahamson, PhD, from Temple University College of Podiatric Medicine.. Joan Williams, DPM, Seattle VAMC, Joan.Williams@va.gov Dr. Nicola McLarnon at Glasgow University in Scotland has carried out extensive research on the effects of nail dust. See: World at work: Evidence-based risk management of nail dust in chiropodists and podiatrists. J G Burrow, N A McLarnon, Occup Environ Med. Oct 2006 (Vol. 63, Issue 10, Pages 713-6). Lorraine Jones, London, England, lorraine.jones@gmail.com
10/10/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Nail Dust Inhalation (Steve Bennett, DPM)
From: Multiple Respondents As a resident, I spent a fair amount of time providing nail care in an office without a vacuum system. During this time, I went to an optometrist for an evaluation regarding my contact lenses. He immediately asked me if I spend time working in a bakery since my lenses were saturated with fine white dust, to a degree where all of the oxygen channels were plugged in the lenses, rendering them useless. A few years later, I went to an ENT for sinus problems. After examining my sinuses he said, in a somewhat perplexed way, that my passages had a very odd appearance; one that is seen in individuals that work in very moldy environments such as those who are in the mold removal business. After I told him that we burr nails, he fully understood the clinical appearance of my sinuses. Both doctors were astonished that we expose ourselves to this significant medical risk just to achieve smooth nails for our patients. Since the ENT visit, I only use a Dremel to refurbish guitars. Ironically, Lamisil is not only an option for patients with onychomycosis, but may become necessary for the doctors who treat those opting not to take it! Nicholas Taweel, DPM, PT, Philadelphia, PA, drtaweel@hotmail.com Having tried a variety of vacuum extractors in the past, I decided to try a liquid spray electric nail grinder. It was expensive (about $1,300) at the time so I purchased one unit only. I found it to be far superior in reducing dystrophic toenails, significantly reducing nail dust,operates quietly, and has a small handpiece that is easy to hold. Within a year, I purchased a second unit, and now have four! For those who may have been disappointed with vacuum extractors, I would recommend you consider the Micromat 3000 from Med-Pro Corp. They can be contacted at 1-800-633-7761. I've had these units for over six years, with no significant problems. I have no financial or personal interest in this company or product; I simply wanted to share a good quality drill. David Arkin, DPM, Big Flats, NY, docarkin@stny.rr.com For 20 years, I have been a representative of a company in Tennessee that manufactures electronic air cleaners. In my research, I have found it is the best product sold bar-none. It works by ionization and ozination of indoor air. I did quite a lot of research on whether it would take airborne nail dust out of the air in podiatrists offices. Indeed it will. The units are sold according to the sq. footage they are to accommodate. The average office is probably 2,000 sq. feet and would require a unit about the size of a small electric heater that would run 24/7. There are no filters. The air is electronically cleaned, causing absolutely no harm to humans. The units can be purchased at an average cost of about $700. James Steinberg, DPM, Tampa, FL, footmedicine@yahoo.com
09/22/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Hyperbaric Oxygen Chambers
From: Multiple Respondents
I stand corrected. As we all know, our scope of practice varies wildly from state to state, and I was not aware that DPMs can be reimbursed for CPT 99183; "supervision of HBO treatment." Nonetheless, considering Dr. Gonzalez's orginal inquiry, I would like to re-iterate that he should work with his hospital-based WCC, as opposed to opening an HBO clinic himself. I also suggest consulting with a wound care center management company (diversifiedclinicalservices.com/ and nationalhealing.com/) are two leading companies in the US), which can provide expertise, chambers, technicians and up-front investment in opening up an HBO clinic. To my knowledge, HBO clinic can be very profitable for the hospital, If they have multiple chambers and WHEN they have full-ulitization of the chambers. HBO will save limbs and lives for your patients. Kazu Suzuki, DPM, Los Angeles, CA, kazu88@gmail.com Three years ago, there was a scenario where the MD's in our hospital attempted to forbid me from "supervising" HBOT dives. Their "argument" was it was "out of scope" for a DPM. I contacted every expert/educational/governing body......obtained case laws....excellent Supreme Court verdict in Texas...and: "so long as the problem falls within the scope of practice of the DPM, then the supervision of systemic HBOT is no different from prescribing any "systemic medication." As a major multi chambered unit, supervising osteoradionecrosis of the face/jaw, failed grafts on the "non foot region" of the body, not permitted to be supervised by myself as an Attending HBOT. I had no disagreement. Many patients indeed experience diverelated illness and it is not a recognized medical matter for a DPM to be "in charge of complications of a patient with a cancerous-related jaw issue". There is very clear opinion from courts, state educational departments and the Underwater Hyperbaric Society. Indeed, attempting to not allow a certified DPM to supervise foot-related dives is cause for legal recourse for any colleague: I fought this and won. Alan Cantor, DPM, East Meadow, NY, ajcdpm@aol.com Dr. Long's letter concerned me in respect to podiatrists not being paid for a service that they are legally allowed to perform, especially in regard to insurance. Can insurance carriers refuse to pay a physician, just because he is a podiatrist?
I have been paid for supervising full body hyperbaric oxygen therapy for lower limb pathology since 2002 by every insurance carrier that I participate (that provides HBO coverage). Please be aware, that having your patient take penicillin is more dangerous and potentially life-threatening than HBO therapy. Hyperbaric oxygen therapy needs to be more available to wound care patients and it can be offered cheaper and more efficiently in free-standing wound care centers. I am not paid an exciting amount when you look at the overhead cost, but I do get amazing results with my wounds.
In Georgia we are allowed to perform full history and physicals, including ears and lungs. At Barry University School of Podiatric Medicine, we were trained to examine the entire body. Wm. Barry Turner, RN, DPM, Royston, GA, claret32853@gmail.com
09/19/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Risks of Prescribing Opiates For Chronic Pain
From: Barry Mullen, DPM Just as I am a staunch proponent that our specialized license precludes us from treating systemic disease (like hyperglycemia, hyperurecemia etc.- not talking about their pedal manifestations), I'm also an advocate that chronic pain sufferers, whose etiology is incurable, should be managed by...pain management specialists. Their expertise and overall knowledge base in all aspects of patient care is far superior to ours because they deal with these individuals every single day of their practice lives. So, why wouldn't you, in the best medical interests of your patient, refer your patient to the specialist best positioned to manage a chronic, incurable medical issue? That said, my observation over 25 years is that the vast majority of specialists who treat patients with acute painful conditions grossly UNDER-prescribe pain medication during the acute pain management phase of treatment. I suspect one can also be held accountable for under-prescribing medication that leads to pain and suffering, as well as over-prescribing. If your expertise and experience pales in comparison to a specialist in that discipline, consult them. You're much more apt to be sued by hanging on to a patient, delaying diagnosis or treatment, or worse, mismanaging them.
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
08/27/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Standard of Care Soft Tissue Masses (Bryan C. Markinson, DPM)
From: Erik L. Kenyon, DPM, Allen Mark Jacobs, DPM The number of malignant masses that are removed from the foot is extremely small. I have removed hundreds of masses and found only one malignancy. To have an MRI on every mass, much less a frozen section on every mass, when you look at the probability of a malignancy, is not really a cost-effective or even required. A lot can be made from the history, location and physical exam. Large, quickly enlarging masses or masses in unusual locations benefit from a pre-operative MRI for assistance in planning and diagnosis. I don't think that you can find fault in not obtaining a frozen section during the routine excision of a mass, but if there is a malignancy, it absolutely needs to be referred to someone who specializes in the treatment of malignancy.
Erik L. Kenyon, DPM, Modesto, CA, ekgoal@yahoo.com Malignant soft tissue lesions of the foot are uncommon. That is a statistical fact. The suggestion that MRI with contrast is REQUIRED prior to surgical intervention for extirpation of ANY soft tissue mass is NOT representative of the standard of care, and such comments only serve to provide inaccurate representation of daily practice. This situation is analagous to the "everybody should recieve DVT prophylaxis assertion."
Clearly, atypical lesions deserve greater pre-biopsy/excision diagnostic evaluation or possibly referral to more experienced healthcare providers. The suggestion that typically presenting ganglionic cysts require pre-excision MRI with contrast is a total waste of healthcare resources.
The only location wherein the philosophy of "a complete work-up for everything" is supported is in the office of plaintiff lawyers, not the offices of the average healthcare provider. With all due respect, perhaps Dr. Markinson needs to step away from the world of academic medicine and not tell those of us in daily practice what the "standard of care" requires.
Allen Mark Jacobs, DPM, St. Louis, MI, allenthepod@sbcglobal.net
08/14/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Chiropractic Adjustment before Casting for Orthotics? (Jeff Root)
From: Howard J. Dananberg, DPM, Elliot Udell, DPM Jeff Root questioned the outcome of manipulation prior to orthotic impression casting and queried whether it would change the plantar contours of the foot. My experience has found that the foot contours do change, most particularly the forefoot to rearfoot relationships. Forefoot supinatus can be almost immediately resolved via manipulation, and thus the entire posting strategy altered. When coupled with the technique for manipulating ankle equinus, the changes are so profound, I find it hard to imagine trying to solve complex biomechanical issues without using manipulation. Last week, I saw a 23 yo Down's Syndrome male for the first time. He was in high top boots and UCBL orthotics. He could barely walk down the hallway and his feet were almost 45 degrees abducted! On exam, the forefoot was very sloppy and hypermobile, but there was a negative 4 degrees of ankle joint dorsiflexion with the knee extended. He had a large keratotic lesion sub medial/inferior navicular where it abutted the UCBL. After manipulating his equinus and basically grinding his UCBL to a standard orthotic design with a 1st ray c/o, he was able to stand and walk w/out pain. His abducted position decreased to near normal as well. His smile was ear to ear....and I think explains the value of manipulation procedure when combined with foot orthotic therapy. Howard J. Dananberg, DPM, Bedford, NH, howiedbpg@aol.com
08/13/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Fracture of Medial Sesamoid (Barrett E Sachs, DPM)
From: Vince Marino, DPM, Rich Bouché, DPM I have treated a professional dancer/ballerina with the exact same symptoms as described. She not only had a fractured medial sesamoid, but also had a bipartite medial sesamoid with fractures in both pieces confirmed by MRI. She failed 12 months of conservative care because she injured it at the beginning of her season and was treated conservatively with the group’s trainers and therapists. I excised all the pieces of the medial sesamoid through a medial approach with the incision just below the medial condyle of the 1st metatarsal I shelled out the fractured pieces of the sesamoid and then reinforced the medial capsule suturing “pants over vest” similar as to a Brostrom. She was non-weight-bearing for 3 weeks with post-op ROM the P.T. beginning 5 days post-op. She did great and was back dancing in 12 weeks at full bore. Vince Marino, DPM, San Francisco, CA, drmarino@marinofootandankle.com When all conservative treatments have been exhausted, then a surgical approach is viable. I would recommend a 3 cardinal plane CT scan to assess the quality of the medial sesamoid fracture segments and to assure there is no other pathology involving the 1st MTPJ or the 1st metatarsal head. If the pathology is localized to the tibial sesamoid and one or both segments are of good quality, then I would recommend removing only one segment of the fractured sesamoid (hemi-sesamoidectomy) through a medial incision. It is key to preserve the FHB slip to the great toe by meticulous dissection. By preserving the medial FHB slip and only removing one of the segments of the fractured sesamoid, the mechanics of the great toe joint will be preserved. The moment arms of the FHB and FHL are negatively affected when one or both of the sesamoids are removed. I recommend two weeks NWB followed by at least 2 weeks in a SLW boot- 6-8 weeks for return to sports. Please refer to the following article for specifics of the aforementioned recommendations: Bouché RT, HeitEG: Surgical approaches for hallucal sesamoid excision. J Foot Ankle Surg 41(3):192-196, 2002. Rich Bouché, DPM, Seattle, WA, spmrtb@earthlink.net
07/21/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Post-op Pitting Edema (Nicholas Taweel, DPM, PT, DPM)
From: Barry Mullen, DPM I completely agree with Dr. Taweel. Obtain a stat venous duplex scan to rule out DVT. Pitting edema within the first 2 post-op days above and beyond one's usual post-op presentation should be considered a DVT until proven otherwise.
In hindsight, review this particular patient's DVT risk factors to see how many were present pre and peri-operatively (e.g., obesity, smoking, BCP's, past personal and family hx, polycythemia, thigh tourniquet use, etc) so that your future surgical candidates with similar risk factors might be DVT prophyllaxed pre-op. Is there any history of post-op trauma?
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
07/11/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: APMA Wins Medicare Victory
From: Paul Kesselman, DPM In my thirty years of involvement in the podiatry profession, I am hard pressed to find a day where I was prouder than I am today, to be a member of APMA. The passage of HR 6331 by a veto proof margin in.... Editor's Note: To read the complete text of this extended letter see : http://www.podiatrym.com/letters2.cfm?id=20666&start=1
07/04/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Protocol for NAOH (Marta Losa Iglesias)
From: Marc Katz, DPM, Name Withheld Marta, I did reflect on your words and conclude the following. All patients are different and unique and all doctors are different and unique, that's a fact. We all commented on the same basic procedure and they all were very similar with minor modifications to accommodate the unique patient and the unique Dr. We are all doing the right thing. Or do you believe that the procedures explained by Rounding and Bloomfield are the only answer? I believe that matrixectomies are proven straightforward procedures that do not require any new extensive research. Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com I applaud Ms. Inglesias' suggestion that our profession would benefit from investing in evidence-based medicine. I feel much more comfortable offering treatments based on solid research and hard science. Institutions like Scholl's CLEAR center are the future of our profession. Cochrane Data Base is an excellent suggestion for finding the most up-to-date information available on clinical questions. Registration is free. Thus, I recommend to other doctors considering a switch to a new method of treating ingrown nails the following:
Sodium Hydroxide Chemical Matricectomy for the Treatment of Ingrown Toenails: Comparison of Three Different Application Periods Viewed at: http://podiatrym.com/go.cfm?n=210 Frankly, I get a great deal of value out of hearing the experiences of my colleagues. Some opinions offered are based on many years of clinical experience. I feel the criticism offered was both harsh and unnecessary. Please continue to provide a forum for practitioners to seek advice and benefit from the experience of others.
Name Withheld
06/25/2008
RESPONSES / COMMENTS (CLINICAL) ACTIVE - PART 2
RE: Removing a Stayfuse Device (John L Etcheverry, DPM)
From: Robert M. Przynosch, DPM These can be very difficult. I have had to cut a dorsal window in the phalanx to remove the "female" component. Robert M. Przynosch, DPM, Asheville, NC, rprzynosch@hotmail.com
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