07/11/2012
QUERY (CLINICAL)
Query: Recovery Time for Bunionectomy for Karate Artist
A potential patient called to make an initial appointment but wanted to ask a question before coming. She is a past Israel champion in tae kwan do, and she breaks wooden boards with her feet (forefoot!). Although she is now in her 50s, this activity is very important to her. She wanted to know, If she comes to me for bunion surgery, how long must she wait before she can go back to breaking wooden boards with her feet?
Richard Jaffe, DPM, Jerusalem, Israel
06/21/2012
QUERY (CLINICAL)
Query: Skimboarder's Toe
A 38 year old female came to see me 12/2011. Three months prior, she had hurt her foot while playing volleyball. She described a hyperextension of the 1st MPJ. There was soreness both plantar and dorsal, with palpable tenderness primarily at the dorsolateral aspect of the 1st MPJ, with no tenderness upon ROM of the joint. X-rays were negative for osseous pathology. Mild overlying edema was present. Anti-inflammatory measures (oral medication, heat, local steroid injection) were administered. The patient did not return for appointed follow-up, but was seen again recently.
The same symptoms and signs remained present, with no improvement reported from the previous measures. An MRI was ordered, and the conclusion was: "Sprain accompanied by probable tear to the lateral aspect of extensor expansion and lateral collateral ligamentous complex." The findings are compatible with so-called "skimboarder's" toe. I have searched the literature, and although the injury is adequately described, there seems to be no standard treatment. Have others had experience with this condition?
Peter M Mason, DPM, Largo, FL
04/30/2012
QUERY (CLINICAL)
Query: Botox or Iontophoresis for Hyperhydrosis
A 48 year old Caucasian male is completely healthy save the fact that he has severe hyperhidrosis. He has been evaluated and treated by a neurologist, endocrinologist, and dermatologist without success. His condition has been complicated by fissure formation with secondary bacterial infections concomitant with the hyperhidrosis (with use of aluminum topicals and with formaldehyde topicals). He is now considering Botox injections or iontophoresis. I am seeking input regarding these therapies and their success rates.
Catherine Ferguson, DPM, Euclid, OH
12/02/2011
QUERY (CLINICAL)
Query: Life-Long Maintenance Regimen for Onychomycosis
What is the suggested life-long maintenance regimen following Lamisil or laser treatment for onychomycosis.
Jay Kerner, DPM, Rockville Centre, NY
11/28/2011
QUERY (CLINICAL)
Query: Nitroglycerin Patches
I recently had a patient advise me that she had both feet saved last year with the application of nitroglycerin patches for an apparent PVD (unknown cause) problem that threatened loss of both feet. Does anyone have any information on the applicability for PVD and possibly peripheral neuropathy, and what would the dosage use and precautions be? I suspect that even though it is applied topically, there can be a significant impact on the heart, so there may be other precautions that are required to be taken.
Chuck Ross, DPM, Pittsfield, MA
10/28/2011
QUERY (CLINICAL)
Query: ACell
I recently had a patient come in for a bunionectomy pre-op consulation, and she requested that I incorporate ACell into her wound closure protocol. Has anyone used this product and with what kind of success?
Saera Arain-Saleem, DPM, Elnhurst, IL
09/23/2011
QUERY (CLINICAL)
Query: Lymphoid Aggregates in Cancellous Bone
I received a pathology report following a routine bunionectomy that stated: "There are several foci within the cancellous bony region of lymphoid aggregates. The aggregates consist of small compact lymphocytes No normal marrow elements are found. The possibility of a small cell lymphoma or other lymphoma-type is raised. The patient should have a CBC with differential to evaluate for CLL/SLL."
When I spoke to our hospital pathologist, I told him that I had never seen such an unusual pathology report in 30 years of practice. He agreed. The patient's recent CBC-differential on PAT was normal. The bone appeared normal at surgery. The patient has no related symptoms. Has anyone ever received a similar report? Does anyone have any insight as to the significance of such a finding with a normal CBC-differential?
Greg Caringi, DPM, Lansdale, PA
09/22/2011
QUERY (CLINICAL)
Query: Yellow Hands & Feet
A 77 year-old woman with Sjogren's syndrome, peripheral neuropathy, and a thyroid disorder came in recently with yellow hands and feet. Her arms and legs are not affected, and her eyes are clear. She has no symptoms and there has been no recent change in either her health status or her medications. Her internist and rheumatologist examined her and ran a wide variety of lab tests, all of which were negative. She does take several vitamin and nutritional supplements, but she has been taking them for several years with no previous problems. She has no unusual dietary habits. Any suggestions?
Greg Caringi, DPM, Lansdale, PA
09/13/2011
QUERY (CLINICAL)
Query: MTPJ Stabilization with AVN
A couple of years ago, I performed an Austin bunionectomy on a 50 y/o female who had HAV and an AVN of her third met head. I remodeled the third met head. I chose not to replace the joint due to my less-than-stellar experiences with lesser MTPJ implants. I performed a chylectomy/exostectomy to get the third MTPJ moving and pain-free. This worked initially, but now the patient has laterally-deviated second and third MTPJs, mainly in the transverse plane. The hallux remains in an acceptable position. The third MTPJ is not really painful. There is limited but pain-free motion at the third MTPJ- it looks much worse on x-ray than it is clinically.
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AVN, Post-op Austin Bunionectomy |
I am leaning towards a lesser MTPJ joint replacement for the third met, and soft tissue balance procedures for the second and third mets. Are there any lesser met head replacements that don't stay swollen for years? How about a soft tissue interposition with about eight weeks of K-wire immobilization? Suggestions welcome.
Tip Sullivan, DPM, Jackson, MS
06/18/2011
QUERY (CLINICAL)
Query: Clinical Success with Poor Radiological Result
I saw this patient for a routine follow-up, one year post-op. Below are the pre- and post-op x-rays. I am not happy with the results, but she has no problems and is happy. She has no swelling, no pain, and is in unrestricted footgear without problems. Please note the correction of the IM angle but the remaining TSP abnormality. ROM is normal without pain or crepitus, but mildly tracking. The rear foot and midfoot complex are fairly stable.
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Pre- and Post-op X-Rays |
The main abnormality that I see is the tibial sesmoid position. There has also been a change in the position of her 2nd and 3rd toes at the MTPJ level. I am seeking constructive criticism from my colleagues regarding procedural choice, possible reason for the radiographically poor result, and clinical responses to similar situations.
Tip Sullivan, DPM, Jackson, MS
05/12/2011
QUERY (CLINICAL)
Query: Ultrasound-Guided Popliteal Infusion, Post-Bunion Surgery
An anesthesiologist at our surgery center has approached me about ultrasound-guided popliteal infusion, post-bunion surgery. Has anyone had any experience with this, and what were the results?
Brian Kiel, DPM, Memphis, TN
04/14/2011
QUERY (CLINICAL)
Query: Uric Acid Crystals, Post-op
I performed an MIS saucerization procedure. Although the patient has had no post-op pain, the tiny incision has uric acid crystals draining. I have seen this as the primary complaint in patients, but this is the first time I have had this complication to a surgery.
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Uric Acid Crystals, Post-op |
The culture is negative for bacteria. What is the best way to to approach this complication? Any ideas or experiences would be appreciated.
Name Withheld (CA)
04/11/2011
QUERY (CLINICAL)
Query: Orthotic for Golfer With Met Adductus Foot
My golf buddy is suffering from severe enthesiopathy of the peroneus brevis which is exacerbated by his golf swing. As he follows through and rolls up onto his left foot, he is experiencing a lot of pain at the base of the fifth metatarsal. The base of the 5th is prominent as one would expect in a Met adductus foot. His foot type is associated with moderate hypermobility of the medial column. The rest of his biomechanical exam is unremarkable.
He is in a CAM boot, takes NSAIDs, uses ice and rests. I would like some suggestions on an orthotic that will control his foot, but at the same time, not prevent him from supinating his left foot as he follows through.
Vincent Gramuglia, DPM, Bronx, NY
03/25/2011
QUERY (CLINICAL)
Query: Obesity and Foot Pain
We have a society that is overweight and getting worse. I see many patients every week who are 300–350 pounds and more, with foot pain, metatarsalgia, tendonitis, PTTD, stress fractures, plantar fasciitis, and heel pain. I think that most everyone would agree that many of these conditions would be dramatically improved with weight loss. I occasionally get individuals to lose weight, but for the most part, this is a wasted effort and I sometimes offend some patients.
How are my colleagues addressing this issue, and does this result in weight loss? Is there any consensus that this topic should be ignored or addressed?
Scott Shields DPM, Enid, OK
02/23/2011
QUERY (CLINICAL)
Query: Lichen Planus
I am treating a 52 year old Hispanic male who presented to my office with dystrophic toenails, 1-5, of both feet. He came to the office with a history of lichen planus, primarily involving his feet. Nail biopsies revealed changes consistent with the burnt-out phase of lichen planus. Any suggestions for treatment?
Larry Dorman, DPM, Miami, FL
02/21/2011
QUERY (CLINICAL)
Query: Foot Lift
I recently had a patient go to NYC for a "Foot Lift." She is very satisfied with the outcome. She had Sculptra injected into her atrophic metatarsal pad. I would like to offer my patients the same option rather than a metatarsal osteotomy. What are the risks/benefits? What are the doctor and patient costs? What is the technique?
John Moglia, DPM, Berkeley Hts., NJ
01/18/2011
QUERY (CLINICAL)
Query: Scarf Complication
A Scarf bunionectomy was performed on a 52 y/o female. The patient gave every inclination that she understood the post-op instructions of non-weight-bearing, but has admitted to being a "bad patient". The incision dehisced one week post-op w/distal screw loosely protruding from wound over the first metatarsal.
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Scarf Complication, 16 Days Post-op |
There were no signs of infection, so the skin edges were debrided and re-approximated. Above is an x-ray taken 16 days post-op. What should be the next course of action?
Name Withheld
01/04/2011
QUERY (CLINICAL)
Query: Achilles Procedure With Distal Incision
Does anyone have a literature reference for an Achilles lengthening or repair being performed without making an incision proximal to the level of the talus?
Daniel Chaskin, DPM, Ridgwood, NY
12/21/2010
QUERY (CLINICAL)
Query: Radiesse or Other Injectable Implants
Is anyone using Radiesse or other injectable implants in the feet? If so, how much is typically injected for metatarsal fat pad atrophy? Do you first do posterior tibial blocks? I would appreciate any information regarding anesthesia, amounts injected, placement, frequency, best products, etc.
Peter Schaffer, DPM, Birmingham, MI
12/16/2010
QUERY (CLINICAL)
Query: Neuroma in 14 Year Old
I have a 14 year old patient who appears to have a neuroma at the third interspace of the right foot. In 15 years of practice, I've never seen a patient have a neuroma at such an early age. Orthotics, injections, and met pads have not alleviated the pain. Any suggestions?
Michael Levy, DPM, Santa Monica, CA
12/13/2010
QUERY (CLINICAL)
Query: Video on Austin Bunionectomy?
I have tried using the medial incision approach for Austins, but have had more problems with wound closure/separation post-operatively. Also, I find it difficult to transpose the head laterally due (I assume) to incomplete dissection of the lateral joint capsule off the met head. That being said, I do find that the patients recover with less swelling and greater ROM after surgery. Is there a video or other teaching resource available to help me correct my technique on this approach?
Peter Smith, DPM, Stony Brook, NY
12/08/2010
QUERY (CLINICAL)
Query: Kidner for Flexible Flatfoot
My patient is an 11 year old boy on whom I performed flatfoot surgery two years ago. The surgery consisted of a gastroc recession, Cotton procedure, and subtalar implant. Alignment generally was good, although not as corrected as I would have liked. The implant displaced several months ago and was causing pain so I removed it. His foot has subsequently pronated more and more since then. My plan is to go back in and replace the implant now that scar tissue has formed to help stabilize the implant in place.
Also, I am planning on doing an Evans procedure to help bring his foot back around in the transverse plane. Because I feel that he needs something even more aggressive to help hold his foot under his leg, I thought about doing a Kidner-type procedure or simply cut the posterior tibial tendon (maybe in a z-plasty fashion) and shorten it to tighten it up to help supinate his foot. It is that last procedure that I wanted some opinions on. I would appreciate any experience in that regard if anyone is doing that kind of procedure or something like it on kids to help in fairly severe cases of flexible flatfeet.
Stephen Pirotta, DPM, Bentonville, AR
12/06/2010
QUERY (CLINICAL)
Query: Sharp Pain in Hallux
I have a patient with a suspected neuroma, in the second interspace, which we are treating with sclerosing injections and orthotics. He is also reporting a sharp pain at the tip of his hallux of the same foot, especially when sitting or driving. He feels this pain worse when wearing the orthotics. Any ideas on cause and/or treatment?
Michael Warheit DPM, Buffalo Grove, IL
12/02/2010
QUERY (CLINICAL)
Query: Dehydrated Alcohol Sclerosing Injections
Can anyone please help me with the proper dosing of dehydrated alcohol to add to 30cc 0.5% Marcaine with epinephrine? I was told to remove 4cc from the Marcaine bottle and replace it with alcohol. Is this correct?
Michael Kaye, DPM, Anna, IL
11/26/2010
QUERY (CLINICAL)
Query: Unusual Fungal Nail Cultures
On a fungal nail culture, I recently obtained the result irpex lacteus. Researching it quickly on the Net, it appears to be some form of plant pathogen. Is anyone familiar with this fungus, and if so, do they know if terbinafine, itraconazole, or fluconazole will work on it.
Edmond F. Mertzenich, DPM, Rockford, IL
