12/10/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: A1c and Elective Foot Surgery (Allen Jacobs, DPM)
From: Tip Sullivan, DPM
Dr. Jacobs has opened a very appropriate topic for discussion. I am not aware of any papers that specifically relate A1c to foot surgery success, elective or otherwise. The first thing that I asked myself after considering his question was: What is “elective” foot surgery? Certainly, we all agree that the current trend in “cosmetic” foot surgery is “elective.” I think the line one draws between elective surgery and necessary surgery can get grey.
Perhaps the terms emergent and non-emergent surgery would be...
Editor's note: Dr. Sullivan's extended-length letter can be read here.
12/08/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1 A
RE: A1c and Elective Foot Surgery (Allen Jacobs, DPM)
From: Pat Caputo, DPM
We all know that the hemoglobin A1C test measures the average blood glucose control for the past 2 to 3 months and is a good general measure of glycemic control during that period. Due to the nature and definition of glycosylated hemoglobin, it only needs to be performed 3 times per year. I am not so sure it should be considered or classified as standard of care to order a hemoglobin A1c prior to all elective foot surgery, unless it hasn’t been checked in over 3 months. It is, however, a very useful tool in predicting increased risk. Studies have shown that “Elevated pre-operative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery” (Halkos, M et al., Journal of Thoracic and Cardiovascular Surgery. 2008. 136(3) 631-640.)
The surgeon has to determine how extensive the planned surgery is and measure all other co-morbidities and factors (obesity, smoking, patient compliance, etc.). A HgA1c level of >9% represents an obvious high level of risk that I wouldn’t want to have my diabetic patient exposed to. A target A1c of under 7% is the most appropriate. As the A1c increases, so does the risk of complications. Like most everything we do, your medical decision is how much risk is worth the benefit.
Pat Caputo, DPM, Holmdel, NJ, capstops@aol.com
12/08/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: A1c and Elective Foot Surgery (Allen Jacobs, DPM)
From: Brian Crispell, DPM, Robert Wunderlich, DPM
Our hospital just covered this topic at our last department of surgery meeting on Tuesday December 4th. The chairman of surgery at Lankenau Hospital, Dr. Scott Goldman, advised that nothing above 7.5 should be allowed for elective surgery.
Brian Crispell, DPM, Ardmore, PA, bdcrispell@hotmail.com
Evaluating hemoglobin A1c every 3 months is the standard of care for diabetic patients, whether or not they are scheduled for elective surgery. In my community, the test is typically ordered by the patient's primary care physician (or whoever is actively managing the patient's diabetes). In their pre-operative assessment, if the primary care physician is satisfied that the patient's diabetes is stable and controlled, I wouldn't have a problem performing elective foot surgery (assuming there are no other contraindications to surgery). Generally speaking, these patients will have a recent HbA1c around 7% or less.
Robert Wunderlich, DPM, San Antonio, TX, rwunder@gmail.com
12/04/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: Verrucous-Looking Lesions on a Seven Year Old (Dennis Shavelson, DPM)
From: Neil Levin, DPM, Seth J. Steber, DPM
Blunt curette the lesion for biopsy; then laser the base as usual.
Neil Levin, DPM, Sycamore, IL, DRFEET1@aol.com
I use a high-temp cautery pen in the office setting to circumscribe the lesion and then evacuate it with a curette. This leaves the lesion intact for the pathologist to fully evaluate. It also allows preservation of the dermal layer so no scar tissue forms. Closure with sutures is not necessary and not recommended - let it heal by secondary intention. This method works as well as using CO2 and KTP/Yag lasers.
Seth J. Steber, DPM, Lehighton, PA, acpwc@ptd.net
Editor's note: To see the original note and photo, click on the subject line.
12/04/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: Verrucous-Looking Lesions on a Seven Year Old (Dennis Shavelson, DPM)
From: Elliot Udell, DPM
If you are not sure of the nature of the lesion and it is too large to do an excisional biopsy, why not do one or two 2 mm. punch biopsies of the lesion and send them to a dermatopathology lab? If it comes back indicating that it is indeed a verruca, then there are many non-surgical choices that you can employ. One treatment we use that is "kid friendly" is called cryoprobe. There are many others.
On the other hand, if the pathology report indicates that the lesion is something other than a benign lesion, then surgical excision might be necessary. If removal would leave a "crater" too large to close, you might need to do a graft, and it would probably be best to call in a plastic surgeon as a consultant.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
12/03/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: 1st MTPJ Fusion or Lapidus for Severe HAV (Gino Scartozzi, DPM)
From: Barry Mullen, DPM
I couldn't agree more with Dr. Scartozzi's logic and sentiment. I simply fail to understand the rationale that supports fusing a salvageable 1st MTP. Proponents of 1st MTP fusion claim excellent functional results post-operatively. Really? What does that mean to a healthy, young, active individual who wants to retain the same activity level post-operatively as they enjoyed pre-operatively? When you have a pre-operative functional 1st MTP, a surgeon's goal should be to retain joint motion, even increase it when possible, not eliminate it.
In this case, while the PASA and IM angles are significantly elevated, a clear joint space exists which indicates...
Editor's note: Dr. Mullen's extended-length letter can be read here.
11/30/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: 1st MTPJ Fusion or Lapidus for Severe HAV (Mark Aldrich, DPM)
From: Gino Scartozzi, DPM
The utilization of a 1st MTPJ fusion for severe hallux abducto valgus deformities WITH the presence of pronounced degenerative joint disease in a young active patient with good bone stock certainly has a surgical indication. In many cases that I have seen, the indication for arthrodesis of the first metatarsal-phalangeal joint is associated more with late Stage II or Stage III joint manifestations in hallux limitus pathology. With these deformities, the intermetatarsal angle deformities tend to be normal to near normal in measurement.
The indications for a Lapidus as a medial column stabilizing procedure is considered with any...
Editor's note: Dr. Scartozzi's extended-length letter can be read here.
11/30/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: 1st MTPJ Fusion or Lapidus for Severe HAV (Mark Aldrich, DPM)
From: Edward Cohen, DPM
Fusing a pain-free, non-arthritic MPJ for a high and severe HAV deformity should rarely, if ever, be done as almost all of these bunions can be corrected with a reasonable functional and cosmetic result.
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Reverdin-Isham-Akin Bunionectomy |
The Reverdin-Isham-Akin bunionectomy is an excellent procedure for correcting this problem, which will occasionally need a closing lateral base wedge osteotomy. The orthopedist from Spain, Carlos Pique Vidal, has a terrific video on his website illustrating this point.
Edward Cohen, DPM, President of AAFAS, ecohen1344@aol.com
11/17/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1 A
RE: Pea-Sized Plantar Fibroma (David Kahan, DPM)
From: Evan F. Meltzer, DPM, Barry Mullen, DPM
I have found that small (<2-3 mm) plantar fibromas often respond to 1 intralesional injection of corticosteroid of your choice. This would seem to be an ideal treatment for your patient.
Evan F. Meltzer, DPM, San Antonio, TX, Evan.Meltzer@va.gov
Are you sure about your diagnosis? While a post-traumatic fibroma is conceivable from a foreign body penetration due to the relative lack of adipose tissue along the plantar surface of the foot and the fascia's anatomic proximity to the dermis, the history of this chief complaint is more highly suggestive of either an epidermal inclusion cyst or foreign body granuloma. In either case, Verapamil is unlikely going to influence this mass. Excision is the treatment of choice. Try pressure dispersing the mass during the athlete's season, and if painful enough to hinder athletic performance, excise it during the off-season.
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
11/17/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: Pea-Sized Plantar Fibroma (David Kahan, DPM)
From: Brad Makimaa, DPM
I clearly would not first assume fibroma. I certainly would not jump to verapamil on a 17 year old. I also would not have a surgical discussion without a proper diagnosis. I would get an MRI. This will give better insight to the diagnosis which can direct the best treatment. I am much more inclined to think more of inclusion cyst or scar tissue as the primary diagnosis. Diagnosis must be established first, i.e. Is this mass attached to the fascia or arising from it? Is there a metal or organic fragment? I assume that an x-ray was done. This vastly changes your surgical planning and discussion with the patient on outcome and post-op scenario.
Brad Makimaa, DPM, Key West, FL, drmak3@comcast.net
10/22/2012
RESPONSES / COMMENTS (CLINICAL) - Part 1A
RE: Chronic Interdigital Maceration (John Scholl, DPM)
From: Robert K Hall, DPM, Robert Bijak, DPM
An effective adjunct to wicking moisture/maceration may be by utilizing Lamb's wool "rope" threaded between the affected toes. While not sterile, topical antibiotics (I prefer cream) or antifungals (like Naftin Gel) may be used. Appropriate bacterial C&S or fungal culture helps ID organism(s) or lack thereof. Use of "prophylactic" antibiotics may trigger a super-infection.
Robert K Hall, DPM, Ft Lauderdale, FL, robertkhalldpm@bellsouth.net
The maceration is due to the biomechanical overexertion of the muscle engines, causing hyperhidrosis, maceration, and infection. A custom foot orthosis, controlling pronation and varus, will restore efficiency, reduce sweating, and allow healing. Orthotics are the answer for most foot problems.
Robert Bijak, DPM, Clarence Center, NY rbijak@aol.com
10/22/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: Chronic Interdigital Maceration (John Scholl, DPM)
From: Vito J Rizzo, DPM, Barry Mullen, DPM
Recently, I have begun to offer treatment with laser for this resistant contamination. The half dozen cases performed to date have all resolved with a maximum of 3 treatments.
Vito J Rizzo, DPM, vjrizzo@optonline.net
I'm miffed by responses employing empiric therapy for a common condition that arises from a myriad of etiologies, and amused by the "secret weapon"comment. Presuming the lesion has not arisen from a skin cancer (open wounds not responding to therapy w/in 6 months = biopsy), then determine the etiology BEFORE you treat. This eliminates empiric therapy and provides a basis for evidenced-based medical treatment. In the case of macerated web spaces, how is this accomplished? Well, my "secret weapon" is the Wood's Light = color of florescence = etiology i.e. red = corynea bacteria minitismun = mycins; green = pseudomonas = quinalones; white = psoriasis or...
Editor's note: Dr. Mullen's extended-length letter can be read here.
10/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1 A
RE: Chronic Interdigital Maceration (John Scholl, DPM)
From: Michael J Felicetta, DPM, Sloan Gordon, DPM
I have found that this is sometimes related to a gram negative bacterial infection and responds readily to oral antibiosis and daily BID local care with Domeboro's solution, gentamicin cream, and antifungal topical therapy.
Michael J Felicetta, DPM, Toms River, NJ, DrMFoot@aol.com
My secret weapon for this condition is to start a regimen of Metornitazole gel (Metrogel) nightly x 1 month. Often the culprit is corynebacterium mintissimum and this eradicates it well. Of course, I imagine you are controlling sweating and footgear, etc. Of course, if nothing works, biopsy - as is evident in Dr. Carl Solomon's patient.
Sloan Gordon, DPM, Houston, TX, sgordondoc@sbcglobal.net
10/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: Chronic Interdigital Maceration (John Scholl, DPM)
From: Eric M. Hart, DPM
I have seen benefit to using lamb's wool between the toes in addition to the drying agents you have already used. It can be used as a preventive measure for life. Just make sure that the patient doesn't wrap it circumferentially around the toes.
Also, clearly his problem is more an issue of uncontrolled edema rather than a physical therapist placing gauze between his toes. It will likely recur. I would work with his primary care provider to ensure that diuresis management is maximized in addition to your standard care.
Eric M. Hart, DPM, Bismarck, ND, erichartdpm@gmail.com
10/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: Chronic Interdigital Maceration (John Scholl, DPM)
From: Robert J Snyder, DPM, MSc,
This condition is likely a mixed gram negative bacterial and fungal infection. A combination of Cipro 500 mg and Lamisil 250 mg po, daily for 7-10 days along with continued local care may be of benefit.
Robert J Snyder, DPM, MSc, Miami Shores, FL, drwound@aol.com
10/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: Chronic Interdigital Maceration (John Scholl, DPM)
From: Joe Gonzalez, DPM
Cut a little strip of Aquacel (or Aquacel Ag) and wick it in between the toes. Change every 2 days initially, and it will turn to a gel and not stick, but it will absorb the moisture.
The key is to control the edema. So continue with multilayer compression or simply use tubigrips (and extend the tubigrips over the toes). Then cover the toes with a hospital sock as the secondary dressing.
Joe Gonzalez, DPM, East Lansing, MI, gonzalez.joe@gmail.com
10/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1C
RE: Chronic Interdigital Maceration (John Scholl, DPM)
From: Carl Solomon, DPM
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Interdigital Squamous Cell Carcinoma |
Dr. Scholl's picture is very reminiscent of my patient who didn't respond to oral and topical antifungals, oral and topical antibiotics, and whose biopsy came back as squamous cell carcinoma.
Carl Solomon, DPM, Dallas, TX, cdsol@swbell.net
10/09/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: "Near Complete" Tear of PT Tendon (Robert Schwartz, CPed)
From: Dennis Shavelson, DPM
Mr. Schwartz, alerting us to what pedorthics has prescribed for Grade II or IV PTTD since 1925 is a testimony to where our profession has come. Have you ever tried to walk or live life in one of the shoes Mr. Schwartz promotes?
Instead of forcing our patients to wear orthopedic shoes with wedges and external fixes that are obvious to public scrutiny and pathological lifestyle, podiatry has developed more towards internal fixes involving semi-rigid foot orthotics, gauntlets, and foot surgery that are housed in an OTC, conventional shoe.
The continued use of “vestigial” protocols that encompasses much of the pedorthic community by podiatry is why I am upset with us allowing CPeds to take our casts and dispense our orthotics as we abandon biomechanics in many of our hospitals and group practices.
Dennis Shavelson, DPM, NYC, drsha@lifestylepodiatry.com
10/08/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: "Near Complete" Tear of PT Tendon (Larry Aronberg, DPM)
From: Robert S. Schwartz, C Ped
At Eneslow, the most often prescribed pedorthic protocol for PTTD with partial or total tear is high top orthopedic shoes to help control (support and stabilize) ankle motion in sagittal and frontal planes; extended medial counter to help control frontal plane motion and allow an internal orthosis to remain anchored; an orthotic device that has maximum heel and arch stability and control with accommodation for bony prominences and rigidity; shoe shape (last) that accommodates and matches foot shape, whether it is a foot that still has supinatory ROM or one that is adducted and fixed; medial flare and buttress to the shoe to further control frontal and sagittal plane motion; rocker sole designed with its apex perpendicular to the line of progression to help control transverse and sagittal plane motion; heel elevation to balance functional LLD and reduce dorsiflexion demand.
The contralateral side is also managed to provide more weight distribution since it has to work harder. As a house shoe to get off the bed, we have had best success with an orthopedically-designed sandal that has a contoured footbed to match patients' needs. Most often, we are modifying ready-made shoes, boots, and sandals rather than making them from scratch. We call it “Shoe Makeover.” This has been an effective treatment modality since 1926.
Robert S. Schwartz, C Ped, NY, NY, rss@eneslow.com
10/02/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: Mixing Carbocaine with Dehydrated Alcohol (Alex Terris, DPM)
From: Ken Hatch, DPM
When I was a student, an anesthesiologist told me that the issue of Lidocaine allergy per se did not exist. The issue was the preservative in the lidocaine. The issue was about amides and esters. The preservative may be the allergen and NOT the local. Get more info about what type of non-preservative locals are available. Consider a skin test with non-preservative local anesthetics and consult with an allergist.
Ken Hatch, DPM, Annapolis, MD, KLHDOC@aol.com
10/02/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: Mixing Carbocaine with Dehydrated Alcohol (Alex Terris, DPM)
From: Sloan Gordon, DPM
Although the patient has a lidocaine allergy (one of the "amide" type locals), switching to an "esther" type makes sense for local anesthesia. However, in this instance, the local anesthesia is simply a vehicle for the alcohol. Perhaps it's unnecessary? I have used alcohol injections with saline as a vehicle as well as diphenhydramine or promerhazine (which has mild local anesthetic properties).
I would just avoid the locals since the patient has had such a severe reaction.
Sloan Gordon, DPM, Houston, TX, sgordondoc@sbcglobal.net
09/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: Non-Union of Calcaneal Fracture (Mak Yousefpour, DPM)
From: Tip Sillivan, DPM
First, what type of pain is she having? Is it from the non-union? Is it neurological? What are her expectations/goals? Make sure she understands that her foot will most likely never be like it was before her accident.
If she is actually having problems with her daily activities and you have no doubt that it is from her non-union, fuse it! Make sure that you determine why the other attempt failed. It appears from technique from what I see on the x-ray provided.
I suggest reading articles by Dr. Sanders in JBJS. Typically, intra-articular posterior facet fractures are VERY hard to anatomically reduce. In cases like this –in the acute setting – I try to reduce it, but if I cannot get it within a couple of mm, I will do a primary fusion. In cases where it is 6 months old, I strongly doubt that you can reduce it adequately to avoid future problems.
Tip Sillivan, DPM, Jackson, MS, tsdefeet@MSfootcenter.net
09/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: Non-Union of Calcaneal Fracture (Mak Yousefpour, DPM)
From: Tip Sillivan, DPM
The hardware needs to be removed, the non-union debrided, and the STJ fused. There is no point in an ORIF at this time as the joint is almost certainly destroyed.
Mike Piccarelli, DPM, Staten Island, NY, mcpdpm@verizon.net
09/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Strong Association Exists Between Obesity and Foot Disorders
From: Paul Kesselman, DPM
A recent review by Medscape of several studies and articles over the last decade makes the case for podiatrists to either weigh their patients or take it as part of the medical history. Common disorders such as arthritis, heel pain, and others are noted in this study as having a higher incidence among patients who have an increased BMI. Several studies pointed out in this review suggest that having patients lose weight would reduce their foot pain.
So much for the sole pundit who previously suggested that podiatrists had no business discussing weight loss with their patients. While podiatrists may not be trained in weight loss education and techniques, neither are most other physician specialists. Referring patients to a weight loss center, nutritionist, or another physician specialty is certainly well within our purview. The complete article may be read here.
Paul Kesselman, DPM, Woodside NY pkesselman@pol.net
09/11/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Eliminate Nail Recurrence Following Chemical Cauterization
From: Frank J. DiPalma, DPM
I'm sure many of our patients suffer from this problem and, even though we warn our patients before performing a chemical matrixectomy, they have to deal with recurrence.
For many years, I have cut the deformed toenail straight back, just the width of correction, back beneath the eponychium. I have used a curette to remove any remaining portion of nail or tissue that would interfere with the destruction process. I have used a Crile-wood needle holder since it has a fairly fine point and a robust construction, and continued to have had to deal with recurrence.
This process has been refined, so that only...
Editor's note: Dr. DiPalma's extended-length note can be read here.
