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12/18/2009
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Osteomyelitis Case
From: Wm. Barry Turner, BSN, DPM This 24 y.o. IDDM young lady presented with neuropathy, but no wounds, just a complaint of a painful foot. Denies trauma. After initial x-rays, I ordered a WBC-tagged bone scan and I prescribed Flagyl, Doxycycline, and Cipro. The WBC-tagged bone scan was positive for osteomyelitis. I then had the local hospital radiologist do a needle biopsy for cultures. The patient had been on the antibiotics for two weeks by the time the needle biopsy was performed. The cultures returned-no growth for anaerobic and aerobic, but the gram stain revealed gram positive cocci. I left the patient on Cipro.
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Osteomyelitis of 2nd and 3rd Metatarsals (7/28/09 & 10/27/09) |
The patient had no insurance and limited financial ability. She could not afford to stop work. Her job would not allow her to work with a cast or a foot brace. Basically, I just kept her on Cipro for 8 weeks. The bone had no immobilization at all. She did commit to wearing a "stiff" shoe. I only saw her a few times. I just think it is interesting to see how this bone infection responded to very little care. She failed to come back for her last appointment.
Wm. Barry Turner, BSN, DPM, Royston, GA, claret32853@gmail.com
Other messages in this thread:
07/11/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: NaHCO3 with Local Anesthetic (Ivar Roth, DPM, MPH)
From: Jerry Falke, DPM
There have been numerous studies regarding buffering lidocaine, and all have consistently concluded a substantial decrease in burning at the injection site (i.e., greater than 50% improvement in tolerability). We did that for many years in our practice, mixing 10% NaHCO3 0.9% solution with lidocaine; i.e., remove 1 cc of lidocaine from a 10 cc. bottle and replace it with 1 cc. of 0.9% bicarb.
Lidocaine requires an acid medium for stable shelf-life, and it is that acidity that is thought to be the cause of injection discomfort. So be keenly aware that this will shorten the shelf-life of your mixture. Statistically, the lidocaine will retain approximately 90% strength at 2 weeks, if kept refrigerated, compared to about 60% in one week stored at room temperature.
We mixed our syringes in the morning and rarely used the ‘left-overs’ even the following day, mainly because we were uncertain of the shelf-life at that time. Google “buffering lidocaine” for some of the aforementioned studies.
Caution: This will NOT work with Carbocaine, as it will precipitate from solution almost immediately.
Jerry Falke, DPM, retired, Hagerstown, MD, falkeg@hotmail.com
07/05/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: DVT Prophylaxis Protocol (Yelana Barsky, DPM)
From: Larry Kollenberg, DPM, Pharm D
There are multiple 'guidelines' that exist for thrombophlebitis prophylaxis. See NIH, or orthopedic guidelines. In general, most institutions have specific criteria. Ask the nurse educator at your hospital. The guidelines are all essentially aimed at prevention. The risk for PE and DVT of the leg is relatively high with increasing co-morbidities. The individual patient should be evaluated based upon the given criteria and then graded or scored. If appropriate, minimal treatment should be compression stockings and local extremity exercises, such as NWB leg lifting and bending of knee for podiatric procedures (even with a BK cast). If the patient is at moderate or high risk, then you should consider unfractionated Heparin or LMWH.
Consider the need to bridge to warfarin. Consider and prescribe prophylactic treatment for ANY patient who it is indicated in ,especially if you have NWB home-bound patients.You are well within your scope to be prescribing these medications for short term use (i.e., 2-3 weeks). SQ Heparin bid is cheap, even if no insurance. If you have renal patients (CrCl <30ml/min) or are going to need long-term use, then you should include the PCP for monitoring, etc., as the patient should be closely watched, or bridged when appropriate to oral anticoagulants.
Larry Kollenberg, DPM, Pharm D, Baltimore, MD, lkollenberg@hotmail.com
04/15/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1 b
RE: Uric Acid Crystals, Post-op
From: Elliot Udell, DPM
Perform blood work on the patient and determine the uric acid levels. The recommendation is to bring those levels down to or below 6 ml/dl. If the crystals are all in the joints as described, the blood levels may have to be reduced even more. If the patient is an overproducer of uric acid, one drug of choice is allopurinol, 100 mg per day, but this can raise coumadin or theophyllin levels. A newer pharmaceutical is Uloric. It has a better safety profile, but is expensive. You can give between 40 and 80 mgs per day.
Initially, either drug can cause other gouty inflammatory attacks. If the patient's kidneys are under-secreting urate, probenecid is the drug of choice, however, if the person is excreting less than 800 mg/dl...
Editor's note: Dr. Udell's extended-length letter can be read here.
04/15/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1 a
RE: Uric Acid Crystals, Post-op
From: Charles Morelli, DPM
This is trauma-induced hyperuricemia, and the best way to treat this is to be your patient’s doctor and treat him as you would any patient with gout. If it's acute, treat the acute manifestation (steroid injections, analgesics, anti-inflammatories, colchicines, etc). If it’s chronic, either do that yourself too, or refer the patient back to his internist, whichever you are more comfortable doing. The goal of treatment in acute gout attacks is to end the "flare up" and convert the patient's condition to the chronic state. Going on a low purine diet can help prevent recurring attacks.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
03/21/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
Query: Pain in Hallux Interphalangeal Joint (Jordan Sheff, DPM)
From: Multiple Respondents
It's likely that the MPJ is not dorsiflexed sufficiently to allow for propulsion and as a result, there is now jamming and increased mobility at the hallux IPJ. While this may sound radical, I had a similar case sent to me a number of years ago where I recut the MPJ and inserted a total silastic implant. Since the fusion appears solid, you can determine at what level you wish to recreate the MPJ so that the first metatarsal length can be preserved.
The surgery has placed abnormal forces on the distal joint. Try injection of steroid with rigid soled shoes and NSAID if tolerable. If this fails, I recommend an arthrodesis of the joint.
David L. Nielson, DPM, Roanoke, VA, pampantla@hotmail.com
A rocker-bottom shoe will work.
Dwight L. Bates, DPM, Athens, TX, dlbates04@yahoo.com
03/19/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: White Tipped Toes (Gregory Mayer, DPM)
From: G Dock Dockery, DPM
This condition of white tips of the toes after water exposure looks very much like keratolysis exfoliativa (also known as "lamellar dyshidrosis). In most of the cases that I have seen, the palms of the hands are also involved. Treatment is to use topicals and daily use of emollient creams containing urea, silicone, or lactic acid. Steroids typically are not very helpful.
G Dock Dockery, DPM, Seattle, WA, gdockdockery@aol.com
03/12/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Painful 1st Metatarsal-Cuneiform Joint in Runner (Harry Cotler, DPM)
From: Gino Scartozzi, DPM
The patient, in my opinion, places an unreasonable condition to providing definitive and informed care decisions. For the patient to decline an MRI or CAT scan to ascertain the presence of an occult stress fracture, joint osteoarthrosis, chronic tendinopathy of the extensor hallucis longus tendon, ligamentous injury of the first metatarsal-medial cuneiform articulation, tibialis anterior tendinopathy or injury, etc. places the practitioner in a position of achieving a clinical failure outcome. Whether the patient's condition is treated conservatively or surgically, the liability of failure to the practitioner will be the same, despite the patient being provided a "no guarantees" warning.
The patient should be strongly advised that the MRI or CAT Scan is ESSENTIAL to determine the etiology of his symptoms and his prognosis for recovery. I would explain to the patient, "I wouldn't expect my mechanic to diagnose a car malfunction without the ability to look under the hood." If the patient refuses, I would advise the patient (sarcasm here folks!) to seek a practitioner with the ability for "x-ray vision."
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
03/11/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Painful 1st Metatarsal-Cuneiform Joint in Runner (Harry Cotler, DPM)
From: Tip Sullivan, DPM
Does the pain change with hills? In flats? Look for an anterior tibial enthesiopathy. Does the pain correlate with any particular nerve distribution? or dermatome? I have found that diagnostic blocks with straight Marcaine (not cortizone) is helpful in delineation of the source of pain, intra-articular vs. extra-articular. Have the patient come into your office ready to run and keep blocking areas, having him run until you can identify the origin--process of elimination.
If you have an ultrasound, you might avoid an MRI--If you are not experienced in ultrasound, send the patient to a colleague who is.
Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net
01/22/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Homeopathic Injections? (Robert Bijak, DPM)
From: Randall Brower, DPM, Jonathan Purdy, DPM I have asked PICA and my attorney regarding this very issue. Homeopathy is not allopathic, proven by scientific method or FDA standards. While treatments may work, they are indefensible in court. We live in a litigious world. My attorney will refuse to represent me if I use unapproved remedies or therapies with no scientific backing. Yes, some homeopathic remedies work well...but we, as a profession, must hold our specialty to a higher scientific standard. Otherwise, we risk not only appearing as "foot chiropractors" by mainstream medicine, but risk legal challenges that will not be defensible in court. Read the bottom of every homeopathic medication, "not intended to diagnose, treat, cure, or prevent any disease." In my state,... Editor's note: Dr. Brower's extended-length letter can be read here. In my opinion, “alternative” medicine or homeopathy does not adhere to current scientific medical principles, and as such, does not uphold the Hippocratic Oath to which we all have pledged ourselves. It states “…I will respect the hard-won scientific gains of those physicians in whose steps I walk,…avoiding those twin traps of overtreatment and therapeutic nihilism.” Homeopathy is not being used based upon compelling scientifically evidenced research, FDA regulated or not. At best, it employs the placebo effect as an aid which,... Editor's note: Dr. Purdy's extended-length letter can be read here.
10/04/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Wound VAC with HBO (Doug Mason, DPM)
From: Frank Lattarulo, DPM We see this scenario all the time. In a 12-person, multi-place chamber we rarely have a treatment without a patient on a VAC. By the very nature of what HBO does, you are expected to get vasoconstriction on decent (Boyle's Law) to 2.4 ATA (45 FSW). There is also some hyperemia during the 90-minute treatment and some vasodilation on ascent. If the wound VAC is applied properly, sealed effectively, and enough skin prep applied, this should not be a concern. Your wound VAC or NPT machines should not impact HBO treatments. Of course, remember to disconnect the tubing and cover the end prior to loading the patient. Simply reconnect after treatment, turn the machine on, and this will be fine.
Frank Lattarulo, DPM, New York, NY, doclatt@aol.com
09/06/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1 b
RE: Cortisone Injection in Second Trimester? (Mark Stempler, DPM)
From: Multiple Respondents I would be concerned with that course of treatment as a first line therapy because of the potential medical-legal ramifications. Why not a course of supportive and/or physical therapy as a first-line approach? Perhaps consider PRP. I suggest that the dose of cortisone that is typically used is not enough to significantly disturb her endocrine function, but I would not want to take that chance without the written recommendation of her Ob/Gyn for that specific course of therapy.
Arnold B. Wolf, DPM, Sterling Heights, MI, omnifootcare@prodigy.net You might want to consult with her Ob/Gyn, but if he's okay with it, I'd say go ahead and give the injection. I can't imagine that a single shot of a repository steroid would be much of an issue, assuming your patient had no other health issues. Paul Busman, DPM, RN, Clifton Park, NY, paul@busmanwhistles.com With all the speculation and allegations about certain preservatives such as mercury in some medications, I would certainly urge to pass on the injection. You theoretically could be dragged into a lawsuit years from now. You should carefully weigh your options. Jim Lentini, DPM, Norwich, NY, JPLENT@aol.com
09/06/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1 a
RE: Cortisone Injection in Second Trimester? (Mark Stempler, DPM)
From: Lawrence Kollenberg, DPM According to the package insert from triamcinolone suspension, the following will be found: "Pregnancy Teratogenic Effects - Pregnancy Category C corticosteroids have been shown to be teratogenic in many species when given in doses equivalent to the human dose. Animal studies in which corticosteroids have been given to pregnant mice, rats, and rabbits have yielded an increased incidence of cleft palate in the offspring. There are no adequate and well-controlled studies in pregnant women. Corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Infants born to mothers who have received corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism." Essentially, most of those drugs that are listed as category C have no significant studies to say that the drug is either safe or unsafe. Hence, the comment about benefits vs risks. I can tell you from a practical perspective that OB-GYN's do administer betamethasone on a routine basis when indicated in our hospital to pregnant patients. A similar comment is found in the package insert of betamethasone. Lawrence Kollenberg, DPM, Pharm D, Baltimore, MD, Lkollenberg@hotmail.com
09/04/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Manipulation Videos (Howard Dananberg, DPM)
From: Robert Bijak, DPM I found Dr. Dannenberg's videos frustrating and offensive. For many years, we have seen podiatrists claiming they are the kings of the foot. In Dr. Dannenberg’s video we see him working on the poplitieus and the leg. Not that I oppose podiatrists doing more, but the reality is most of us in the U.S. can't do this by law. I'm sick of seeing treatments we can't do. On the other hand, we are told to be proud that we are the specialists of the foot. It's obvious to me that foot treatment without a license to work on the leg makes us an inefficient practitioner. Podiatry has to decide where it stands. Just the foot, the foot and leg, or what? The laws in this country are non-standard and podiatrists don't know what they are. The profession is, excuse the truth, screwed up. Licenses are different, residencies not available. This is what our leadership has given us. Dr. Dannenberg shows what chiropractors have been doing for years. We don't learn manipulations of the fibular head in school; and it's not legal for most of us. Podiatry has to address the main problem, our limited license and limited training. Try manipulating the fibular head and popliteus in New York. Bye, Bye license. Full scope answers all our problems, and that's all we should be addressing. Robert Bijak, DPM, Clarence Center, NY, rbijak@aol.com
06/21/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Integrative Podiatric Medicine
From: Arnold B. Wolf, DPM I find it interesting whenever anyone tries to "reinvent the wheel" by copying the original design premise and then ultimately "spitting out" the same product that originally existed. I see this with "integrative podiatric medicine"...in other words, "same stuff, different wrapper". Call it for what it is and in common parlance what it is normally referred to: "alternative medicine". For those who practice it, have the "stones" to embrace it for what it is...an alternative...don't create a euphemism to make it sound different than what it is.
Medicine, by its current design, is based on science and the dreaded "double-blind" investigational protocol. Manufacturers of homeopathic and naturopathic products purposely avoid the "medical product" claim because of the heightened demands that that classification would place upon their product(s). Personally, I prefer scientific medicine over "anecdotal" medicine (perhaps that may be a better name than "integrative podiatric medicine", i.e. less confusing). It is scientific knowledge that makes us better, not "anecdotal evidence". Let's see the integrative podiatric medicine people do the science and then, maybe I'll become a believer.
Arnold B. Wolf, DPM, Sterling Heights, MI, omnifootcare@prodigy.net
06/07/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Charcot STJ Complete Dislocation (Tip Sullivan, DPM)
From: Tim Vogler, DPM First: CT scan to evaluate the actual position/fractures of the bones (3D reconstruction is helpful). Second: Send the patient to an experienced Charcot reconstructive surgeon. Don't try to "get by" with a less than ideal procedure; it will fail every time. There are no short cuts to Charcot reconstructive surgery. Tim Vogler, DPM, Advance, NC, tav@yadtel.net If you can heal the wound, a tibiocalcaneal or tibiotalocalcaneal fusion could be accomplished with retrograde intramedullary nailing. This is an excellent stable construct for such Charcot situations. Daniel J. Tucker, DPM, Orange, CA, reekat@aol.com
04/12/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Piezogenic Papules (Bryan Markinson, DPM)
From: Multiple Respondents Dr. Bryan Markinson asks if piezogenic papules are easily identifiable on film, and/or under surgical exposure. These fatty papules will show on imaging, but they are not generally symptomatic unless there is an underlying lesion causing their protrusion, and/or a ruptured muscle belly and/or torn tendon. Based on the large size of this patient, I would think the issue is a ruptured muscle and one would see that on surgical exposure. I would consider an MRI prior to surgery. Steve Berlin, DPM, Baltimore, MD, drstevenberlin@yahoo.com These lesions are easy to locate. That being said, they are not effectively resected. The fascia is not easily repaired. In my experience, you cannot remove the herniated papules. They are not localized and the result is lobulated fat continuing to be removed. You can try to close the defect but I believe you will end up at the same point prior to surgery, if not worse. You now may be dealing with painful papules with a possible symptomatic scar. Imaging is a waste of time and money. I have used ultrasound on these lesions to confirm they were fat. This did not change the treatment options. Carlo Messina, DPM, Weston, FL, cmacna@yahoo.com I have used the Topaz co-ablator for piezogenic papules with really good results. I use an 18 gauge needle to penetrate the skin, insert the Topaz and ablate say 7 times for 3-4 pulses. You will actually see them shrink in front of your eyes. My longest patient is two years out now and he has no pain. There is a slight recurrence but he is pain-free. For a simple procedure with no sutures and a relatively short post-op course, I think it’s worth a shot. On the negative end, I had to use an unlisted code and got paid pretty poorly. I think of it as free advertising.
Eugene A. Batelli, DPM, Clifton, NJ, eabdpm@gmail.com
03/23/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Plantar Plate Tear (Brent Rubin, DPM)
From: Multiple Respondents Plantar plate tears are most often caused (in the absence of acute injury) by attrition of the plate due to propulsive phase metatarsalgia (an elongated metatarsal "pole vaulting" over the plantar plate for many years). Once the plate has a partial or complete tear, conservative measures include the use of a Budin-type splint or "toe prop" type pad that has been around for years. The condition often, but not always, is accompanied by a hammertoe deformity. Orthoses with a metatarsal pad are also helpful but things tend to get bulky for shoe wear. One new device on the market that has promise for non-operative care in those patients who may be better served by non-op care is the new "Bioskin aftr brace" (just released at AAOS) with the Weil osteotomy strap that was designed to reduce the complication of a floating toe following the Weil osteotomy. We have used this strap successfully, post-operatively following a repair of the plate and also non-operatively for the selected patient. The strap acts as a night splint and holds the toe in plantar-flexion, and can also be used as an exercise device when placed dorsally. Of course, surgical options are available as described by Lowell Weil, Jr. and Jeff Christensen, utilizing a Weil osteotomy with a plantar plate repair performed through the same incision. A partial metatarsal head resection is always an option as is the flexor transfer procedure. Disclosure: I am the father of the designer of the Weil Strap used by Bioskin. Lowell Scott Weil, Sr., DPM, Des Plaines, IL, weil4feet@aol.com It sounds as though a very appropriate conservative care regimen has been employed while pursuing diagnostic studies to confirm the diagnosis. Just a couple more conservative options to consider would be the addition of a "toe-down" splint or Budin splint, the use of a carbon fiber insert beneath padded shoe inserts, and possibly the addition of an external metatarsal bar upon the sole of a sturdy shoe...all efforts to reduce forefoot pressure and diminish motion at the 2nd MPJ.
Christopher L. Hendrix, DPM, Memphis, TN, hendrix333@msn.com This is one of those cases where I feel there is a tremendous difference between suing an OTC orthotic and a custom made device. Most prefabs orthotics are "arch supports". In this particular case a custom made device can have a met pad and a dispersion around the second MPJ. A nice deep dispersion being the key. In a similar vein, "a poor man's version" would be using either a felt "U" pad or a reusable Dr. Jills "purple pad" under the second MPJ. A third option would be an MBT type shoe or the cheaper (in price) copy Sketcher "shape ups" with a rocker-type bottom which keeps the forefoot pressure minimized.
Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com
02/05/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Poor Surgical Result (Tip Sullivan, DPM)
From: Multiple Respondents I think this can be approached two different ways: 1) Use an Akin-type osteotomy on the phalanges to "cheat" the toes rectus. 2) Do a Weil osteotomy and shift the heads, and reef redundant tissue, and pin it after for 3 weeks. This is a bit difficult, but possible, when fixation is in the way. Peter Bregman, DPM, Tewksbury, MA, footguru@comcast.net These results are unfortunate but also common. Might I suggest Weil-type osteotomies of the 2nd, 3rd and 4th metatarsals. Start with the 4th, and use a small 2.4 mm cannulated screw. (I prefer the Osteomed 2.0/2.4mm system.) Then remove the previously-placed K-wire. Using the Osteomed “head-less” 2.4 cannulated system, drive a guide pin from the middle phalanx out of the toe, and then retrograde to the base of the proximal phalanx. Squeeze the PIPJ together to facilitate arthrodesis. Make a stab incision at the tip of the 4th toe and measure the appropriate size 2.4 head-less, lesser digital arthrodesis screw (it’s an intramedullary screw). Back off your measurement by 2-4mm, so that the screw does not enter the MTPJ. Place the screw from distal to proximal over the guide pin. Then, drive the guide pin retrograde into the metatarsal just off to the side of the MT screw (it acts as a K-wire). Check for a straight position with a C-arm. Repeat these steps for the 3rd, and then the 2nd rays, in an effort to keep the parabola anatomic. I have had excellent success with this combination of procedures. Godfrey Viegas, DPM, Crystal Lake, IL, gviegas1234@sbcglobal.net In order to "stabilize the transverse plane of the lesser MTPJs", I would simply perform mini-Akins at the base of phalanges 2 and 3. Osseous procedures always produce a more stable and definitive correction as compared to a soft tissue attempt. Next time, use a threaded K-wire to reduce the chance of proximal migration. I don't understand why you did not use the MMI smart toe implants on all of the hammertoes. It appears as if she has a clinical hallux varus. If not, and the patient is pleased with the result, leave it alone. Otherwise, consider a reverse Akin there as well. The 5th toe is a tough call. You may need to consider a re-do, combined with a syndactylization. Leave the broken implant alone and try to remove the broken K-wire. If it has already migrated as far as it has, and if you are taking her back to the O.R. anyway, get it out of there (and do another Akin if needed). It may migrate even more as she continues to weight-bear. Dr. Sullivan said it is "plantar to the joint" which does not sound good. I don’t see how that would not be symptomatic. Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
01/22/2010
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Hallux Limitus/Rigidus Implants (Craig Aaronson, DPM)
From: Multiple Respondents I suggest removing the hemi and insertion of the Primus Flexible Great Toe implant. Primus Flexible Great Toe implant is a double-stemmed prosthesis, and is constructed from UltraSil medical grade silicone elastomer and is provided with titanium grommets. Offered in four sizes, the primus is supported by a custom instrumentation set. Use the grommets for better long-term results. You will need to remove additional bone at the metatarsal head area to avoid too tight of an insertion. Usually, a 58 year old woman who underwent a hemi implant for the first surgery, will choose a total implant vs. a fusion option for the second surgery because she wants to be able to wear shoes with some amount of heel elevation. A fusion is certainly an option as well and should also be offered, discussing the expectations, possible complications, and limitations of both procedures. Then let the patient decide. Keith Gurnick, DPM, Los Angeles, CA, e-mail keithgrnk@aol.com My analysis shows a pathomechanical configuration of the metatarsal heads which includes a microtraumatic reaction within the metatarsal length pattern. One can change this configuration into a smooth, healthy configuration by shortening the second metatarsal by two millimeters. Philip H. Demp, DPM, Cinnaminson, NJ, pdemp@dca.net The Cluffy Wedge provides enough clearance to "unlock' a jammed 1st MPJ. This OTC device restores normal ROM immediately for most individuals diagnosed with functional hallux limitus and many other compensations and deformities that are the byproduct of a 1st MPJ that "locks" prior to toe-off. Cam White, Austin, TX, camwhite.shoes@gmail.com
12/19/2009
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Osteomyelitis Case? (Wm. Barry Turner, BSN, DPM)
From: Jeffrey Kass, DPM, Simon Young, DPM Based on the information given, I would not have kept the patient on Cipro for 8 weeks. To my knowledge Cipro has very little to no Gram (+) coverage; it is more a gram (-) drug. Hence, if your culture revealed gram (+) cocci, I think you would have been better off with doxycycline, or even the Flagyl. The fact that the patient denies trauma could be misleading as you state she presents with neuropathy, hence, she may not realize it. The x-rays to me look like a neurotrophic fracture which are healing via bony callus. If the distal part of the met head was indeed osteo, I would have to think that bone would die and be resorbed faster than I would think it would incorporate via callus with the proximal segment of bone. An Interesting case, indeed.
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com First and Foremost do not treat the pocketbook! I am truly sensitive to this patient's issues but, from a malpractice point of view, whether you treat an indigent patient or a patient with insurance, the outcomes must still be the same and your liability doesn't change. In my experience, Cipro is not the best gram-positive modality. Based on your prescription after the white blood cell-tagged bone scan, you emphasize more gram-negative coverage than gram-positive coverage. Infectious disease referral should have been sought. Even though the patient is without insurance, the patient could have been referred to her local hospital clinics. In these kinds of situations, MRI and white blood cell-tagged bone scans increase the probability of making an appropriate diagnosis for osteomyelitis, but can still have difficulty differentiating between Charcot foot and osteomyelitis. They should not be the sole source. Consideration for blood studies, such as white blood cell with differential, and sedentary rate/ CRP, would further confirm the diagnosis of osteomyelitis if it existed. Although the hospital radiologist performed a needle biopsy, pathology should have been performed, and it would've indicated either no osteomyelitis, an acute osteomyelitis process, or a chronic osteomyelitis process. Reviewing the x-rays and the patient outcome, I am still not certain that this was not due to a stress fractures as a result of Charcot foot changes rather than osteomyelitis. Simon Young, DPM, NY, NY, Simonyoung@Juno.com
12/15/2009
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Strengthening the Feet Will Not Correct Biomechanical Problems (Ray McClanahan, DPM)
From: Bruce Williams, DPM, Stephen Pribut, DPM Dr. McClanahan, states that, “there is no evidence for any of these assertions” in reference to ”Athletic footwear is healthy for runners, and some runners need shoes to guide them, and correct their pronation.” He then goes on to state, but not cite, the large amount of published literature that states, “Faulty gait patterns, overpronation, foot weakness, and chronic injuries in runners are caused by footwear, not corrected by footwear." The paper that Dr. McClanahan chose to reference, the only paper, was primarily authored by someone with a vested interest in the sale of “barefoot” running shoes. You can follow this link to where it is discussed in more detail. Unfortunately for Dr. McClanahan, it appears that his primary interest is in selling a product as well. I look forward to his citing published works or studies that will ratify his claims. Bruce Williams, DPM, Merrillville, IN, bwilliams@airbaud.net A journalist writing a few sentences from a two year old, 40 minute interview does not constitute a "published opinion". Nor can a few sentences adequately cover complex issues. Ray McClanahan, jumped to the conclusion that my opinion and standard podiatric thought is that less than ideal biomechanics and improper shoes create running injuries. Studies have not... Editor's note: Dr. Pribut's extended-length letter can be read at: http://www.podiatrym.com/letters2.cfm?id=31187&start=1
11/18/2009
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Article on The Use of Dietary Supplements in Diabetic Peripheral Neuropathy By Robert G. Smith DPM, MSc, RPh (Lawrence Kollenberg, DPD, D Pharm)
From: Richard H. Mann, DPM, Jay Kerner, DPM I would like to compliment Dr. Smith on his recent CME article The Use of Dietary Supplements in Diabetic Peripheral Neuropathy. I found it to be highly informative and well written. I would specifically like to compliment him on the manner in which he explained the mechanism by which benfotiamine, the active ingredient in Neuremedy, safely and effectively reduces the symptoms of diabetic peripheral neuropathy. I would point out that Neuremedy is not a dietary supplement. It is a medical food. Medical foods are held to much higher safety and efficacy standards by the FDA than are dietary supplements. Disclosure: Dr. Mann’s Company, Realm Labs Distributes Neuremedy. Richard H. Mann, DPM, Realm Labs, CEO, rhm123@gmail.com I'd like to recommend a book titled Snake Oil Science - The Truth About Complementary and Alternative Medicine by R. Barker Bausell. It provides an excellent look at the scientific evidence for complementary and alternative medicine (CAM), and the psychological and physiological pitfalls that lead patients, doctors, and researchers into mistaken assumptions. It's certainly eye-opening how we, as doctors, can easily be misled by false positive results for treatments which may involve nothing more than a placebo effect. Also explained in-depth are the deficiencies of many studies promoting CAM. Are CAM therapies more effective than a placebo? The Next time that your patient brings up the subject, you'll be properly prepared. Jay Kerner, DPM, Rockville Centre, NY, Aikiman44@aol.com
04/23/2009
RESPONSES / COMMENTS (CLINICAL) - PART 1 (CLOSED)
RE: Chronic Achilles Tendinitis (Alan Mauser, DPM)
From: Geoffrey Bricker, DPM, Jan David Tepper, DPM I have been using prolotherapy for tendinosis for over 2 years now with a greater than 90% success rate, even in cases where surgery was contemplated. Inject 1-2 cc each of 50% dextrose, Sarapin, and 0.5% Marcaine along the tendon every 1-2 weeks for up to 7 injections. Sarapin is optional. The effects seem to be cumulative so you can space out as desired. There may be some injection soreness for 2-3 days after the injection. Use adjunctive therapy as indicated. It is cheap and easy with few compliance issues. I First heard about this on PM News, researched it and perfected it. It should definitely be taught in the schools. If there are questions contact me by e-mail or phone (I'm still old school). Geoffrey Bricker, DPM, Springfield, MO, geoffreybricker1@msn.com When all else fails for chronic Achilles tendonitis (the fusiform swelling is classic for greater injury), I cast for 6 to 12 weeks, or as long as they are responding to therapy, and treat this as a partial tear. Once no longer symptomatic, I consider bracing (orthotics, AFO ) to whatever extent is necessary to remove the deforming forces. If the condition is resistant to this form of care or if it fails this form of care, I use further diagnostic testing such as MRI to determine the extent of the injury and treat appropriately. Jan David Tepper, DPM, Upland, CA, jdtdpm@aol.com Editor's note: This topic is now closed.
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