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04/30/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Nerve Compression Vs. Fictitious Injury (Jeffrey Smith, DPM)
From: Elliot Udell, DPM
Compression injuries can be extremely painful, and because they involve soft tissue inflammation around nerves, diagnostic modalities may not be too revealing. Interferential therapy has proven quite successful in the management of injuries described above, as well as with ankle sprains and others injuries where there is a great deal of pain and edema. This time-honored modality is a staple in most physical therapy centers. In the case described, rest combined with light compression and interferential therapy three times a week might make a great difference for this patient in a relatively short period of time.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
Other messages in this thread:
08/24/2013
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Traumatized Hallux Nail in 9 Year Old (David E. Gurvis, DPM)
From: Dan Klein, DPM
Unfortunately, when a heavy object drops on a toe involving the toenail, permanent soft tissue changes will occur. In this case, a young person's toe was involved with apparent soft tissue changes. I believe these changes are permanent, but over time as this person grows, the changes will become less obvious. With regard to the toenail, the growth plate may also have been permanently damaged, producing a permanent change. The analogy I have used in practice is to compare the trauma with a bowling ball dropping on a tomato. The tomato will never look the same.
Dan Klein, DPM, Fort Smith, AR, toefixer@aol.com
07/08/2013
RESPONSES / COMMENTS (CLINICAL) - PART 1a
RE: Surgical Intervention in a 12 Year Old with Flat Foot
From: Peter Bregman, DPM
The only thing I would do before making a surgical decision is do a neutral position x-ray and determine if a Cotton is really needed. Having said that, I recommend a Gastroc recession and a Hyprocure subtalar stent. Then add a Cotton, if needed, and then an Evans, if needed. In most cases, the Evans is not needed, but you can always tell the patient that they may need another procedure down the road.
If the clinical picture shows significant calcaneal valgus, then consider a calcaneal slide osteotomy instead of the Evans. I think Calc slide osteotomies are over-utilized because surgeons are not using enough arthroereisis implants which often obviate the need for these osteotomies.
Peter Bregman, DPM, Las Vegas, NV, drbregman@gmail.com
07/08/2013
RESPONSES / COMMENTS (CLINICAL) - PART 1B
RE: Surgical Intervention in a 12 Year Old with Flat Foot
From: Vincent Gramuglia, DPM, Mort Wittenberg, DPM
If there is no associated peroneal spasm, I would consider the TAL along with calcaneal osteotomy and plantarflexory medial column procedure like a Cotton or a Lapidus. Your philosophy should be to increase varus of rear foot and increase valgus of forefoot as taught by Dr. Dennis Shavelson.
Vincent Gramuglia, DPM, Bronx, NY, a2onpar3@optonline.net
In the “old days”, a TAL, followed with well-made custom orthoses, and at least a year of follow-up, would be done before all those extra surgeries would be considered.
Mort Wittenberg, DPM, Evans, GA, mwittenberg3@comcast.net
04/30/2013
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Wartabater (Greg Caringi, DPM)
From: Art Hatfield, DPM
Anyone who has been in practice for more than a few months knows that NOTHING is "virtually always 100% successful." Is the word "virtually" a subtle disclaimer? If the manufacturer is that confident, ask for 10 free treatments to evaluate how it does in your practice. If it is 100% successful as they claim, they should have no problem with your request. We all know that the "wart" is a dermal manifestation of a viral infection. Until a vaccine against the human papilloma virus is available, we as a human race, will be cursed with warts.
Art Hatfield, DPM, Long Beach, CA, afootjob@juno.com
11/14/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: Painful Stiff 1st MTP Joint After Bunionectomy with Implant (Mark Aldrich, DPM)
From: Joel Morse, DPM
The number one issue I see with implants is inadequate decompression. Of course it is not unusual to get 90 degrees of dorsiflexion on the table and then get 40 degrees 6 months Later. I walk my patients right after surgery. Therefore, I do not combine this with another surgery which requires immobilization such as a Lapidus or a Kalish, or even a fusion of the second toe. In the time it takes to fuse a Lapidus - the scar tissue sets in and you're back to square one.
Was there any elevation with the Lapidus? That would also result in jamming.
11/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
From: Joe Agostinelli, DPM, Michael Corcoran, DPM
I just had a similar patient. Remove the implant and perform arthrodesis, filling up the stem defect in the proximal phalanx with ground up bone graft.
The MPJ should have been fused to begin with. Take the implant out and fuse it.
08/25/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Recurring Forefoot Pain in a Cyclist (Mark Aldrich, DPM)
From: Brad Makimaa, DPM
As a triathlete, I have discussed this several times. Don't overtreat with orthotics. Take away all the excess pads and have him get a proper bike fit. Likely the fitter will adjust the position of the shoe clip. This alone should resolve the problem, but one should always go with a full bike fit for maximum comfort and performance.
Brad Makimaa, DPM, Key West, FL, drmak3@comcast.net
07/30/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: 2013 Boy Scout National Jamboree
From: Edward D Williams, DPM
The 2013 Boy Scout National Jamboree will be held from July 15-24, 2013 at the new Summit Becktel Family National Scout Reserve in West Virginia. The Jamboree is two weeks in length, but a one-week commitment as a volunteer is acceptable. Please contact me at 505-690-0266 or email me if interested.
Edward D Williams, DPM, Santa Fe, NM, Edward.d.williams@comcast.net
07/20/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: Botox for Over-active Tibialis Posterior (Sean S. Ravaei, DPM)
From: Robert Bijak, DPM
Dr. Ravaei states, "I would like to inject the muscle with Botox so he can walk better." May I suggest a diagnosis before attempting a treatment you have not performed before? If the foot is plantarflexing and inverting, perhaps the peroneals and/or extensors are weak and not that the other muscles are hyperactive. A nerve conduction study and/or MRI of the lower back (L-5,S-1) is indicated.
Any abnormalities around the common peroneal at the fibular head? A second opinion from a totally independent and different neurologist may be corrobative. Dr. Ravaei didn't give the patient's age or history. Is he hyper- hypo-reflexic, is there clonus, a positive Babinski, any loss of sensation? A stroke, brain tumor, or spinal cord compression are some of the more serious differential diagnoses to be considered.
Robert Bijak, DPM, Clarence Center, NY, rbijak@aol.com
07/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: Recovery Time for Bunionectomy for Karate Artist
From: Wenjay Sung, DPM
Dr. Jaffe, I am pleased that our international brethren are making headway into foot and ankle care overseas. For this patient, I would explain to her that it would depend on how bad her "bunion" or deformity is. If her deformity is severe, she may need to take a long time off before she can return to her sport. If her deformity is minor, she may take less time, but typically 3-4 months before returning to her sport.
Martial arts (breaking boards) is a high impact sport and, as with other professional athletes, I would only allow them to return to their sport after they can jump in a figure of eight on the post-operated foot comfortably and convincingly.
Wenjay Sung, DPM, Chicago, IL, wenjay.sung@gmail.com
07/03/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Congenital Adducto-Varus 4th Toe (Mark Ray, DPM)
From: Ron Raducanu, DPM
Dr. Ray states in his post that the deformity is "easily reducible". Hence, I think the best way to answer your question is to reduce it at the DIPJ first and see if the toe sits straight. Then, reduce it at the PIPJ and see what you find. After "easily reducing" at both sites, decide which gives the optimal correction.
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com
PIPJ is your best bet. A small plantar medial to lateral stab incision (my favored technique is with a Beaver blade) to release the tendon, and then use your bandaging to splint the toe in a corrected position. Since it's a very small incision, I usually will "close" the incision with a steri-strip to preclude your needing to remove a suture in a child with an incision that small.
Ron Raducanu, DPM, Philadelphia, PA, kidsfeet@gmail.com
06/25/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
From: Vincent Gramuglia, DPM, Michael Corcoran, DPM
I have had success in this situation by leaving the arthrosurface metatarsal cap in and performing a Keller procedure.
Vincent Gramuglia, DPM, Bronx, NY, a2onpar3@optonline.net
I've seen several cases of Arthrosurface removal. Of course, arthrodesis is probably the best option with the most predictable results. However, as your patient does not want arthrodesis, an alternative is to remove the implant and perform a Keller with folded GraftJacket interposition. A double-stemmed implant would be a challenge because of the way the first metatarsal head was reamed for the Arthrosurface.
Michael Corcoran, DPM, Belvidere, IL, corcoranm@gmail.com
06/18/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Chronic Calcaneal Apophysitis (Jeffrey Kass, DPM)
From: Steven J. Kaniadakis, DPM, Ron Raducanu, DPM
Is there any limb-length descrepency in this case?
The pain seems somehow out of proportion with what is usually seen with the run-of-the-mill calcaneal apophysitis. Any temperature differences between the limbs? Swelling on one side? Discoloration of one foot over the other? Complaint of tightness to the foot?
I've seen several patients with similar presentations that were eventually revealed to have pediatric CRPS. If the child would tolerate it, perhaps perform a popliteal block to see if the symptoms resolve or lessen. I would also consider a referral to a pediatric neurologist for evaluation, just to be sure.
05/23/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Lamisil, Tamoxifen Drug-to-Drug Interaction (Craig Herman, DPM)
From: Charles Morelli, DPM
This topic is a perfect one to segue into one closely related and that is "anti-rejection drug-to-food" interaction. Having recently received a kidney transplant, I am acutely aware of these hazards and, as podiatrists, we all need to be aware of them.
Being that we treat thousands of diabetics each and every year, I can guarantee you that a substantial number of them have had, or are in need of a kidney transplant and if that is the case, they are undoubtedly taking meds that need to be taken not only at a specific time interval, but also not in the presence of any foods that can inhibit the P450 enzyme.
For kidney patients, grapefruit juice and...
Editor's note: Dr. Morelli's extended-length letter can be read here.
05/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Non-Union and Malunion of Metatarsals (Bret Ribotsky, DPM)
From: Elliot Udell, DPM
While ordering a vitamin D 25 OH on such a patient is a no-brainer before ordering a parathyroid test, one might consider serum calcium levels first. Most labs will this include as part of a "SMAC". The parathyroid test is expensive and might need to be justified by being able to show elevated serum calcium levels first.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
02/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1A
RE: Nail Dystrophy (Tip Sullivan, DPM)
From: Bryan Markinson, DPM
Dr. Sullivan presents a very interesting photo which demonstrates very symmetrical nail lysis changes. The pattern of lysis appears to be proximal to distal and beginning just beyond the level of firmly attached nail which appears to be just at the level of the distal lunula (from what I can see on the left hallux). Interestingly, the distal lysed segments seem to remain adherent to the lysed nail behind it. There is a green tinged discoloration of the left hallux nail plate. At first look, due to the symmetry, I would assume bilateral trauma from some activity or footwear or both together.
I remain curious as to why the distal portions stay attached, but assuming that the entire plate is indeed intact but lysed from the bed, then I would have to assume a matrix issue causing a nail plate alteration, coupled with a separate reason for the lysis. I would debride the lysed portions completely to the firmly adherent proximal nail and send them for culture, and PAS stain. If there are any visible changes in the nail bed/lunula areas, a nail bed biopsy can also be considered and may be helpful in ruling out an inflammatory process. An x-ray of the toes may also be revealing. Occupational history may also be helpful. These nails look like cases of severe water immersion that I have seen, but the patient's other nails are normal.
Bryan Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org
02/11/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Nail Dystrophy (Tip Sullivan, DPM)
From: Dwight L. Bates, DPM, Jefrey Kass, DPM
There appears to be an extensus deformity of the IPJ right and left hallux. As the fifth toe also has a similar nail, I bet on repetitive trauma as the cause. There may be an associated bacterial infection to account for the green discoloration.
Dwight L. Bates, DPM, Athens, TX, dlbates04@yahoo.com
I would have sent the nails for pathology to rule out presence of fungus. If they came back positive, I would have put the patient on oral Lamisil. (or you could try a laser if you have access to one.) Will the nail grow back normal? I have no idea. But, it is certainly worth a try. BTW, I would avulse the contralateral nail as well and do the same thing. The toenails are obviously not normal, and the way they are growing appears to be causing more pathology.
Jefrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com
01/28/2012
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Achilles Tendon Problem (Richard I Polisner, DPM)
From: Geoffrey Bricker, DPM
Ruptures can occur spontaneously as we all know, so with an 8-week interval, I don't think the Sarapin is to blame. I always mix in 50% dextrose as this stimulates blood flow to the area. I have never had a rupture with this injection; the only complications are pain after the injection and some (15%) treatment failures necessitating surgery (I mostly use the Topaz microtenotomy). After the injection, when the pain subsides, add calf-strengthing (low weight, high reps) to increase tendon strength, which should be done thrice weekly for a year, then at least twice weekly to maintain strength.
Geoffrey Bricker, DPM, Springfield, MO, geoffreybricker1@msn.com
09/10/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Professional Attire (Alan Mauser, DPM)
From: David M. Schofield, DPM, Frank Lattarulo, DPM
My opinion will probably be in the minority. We should not think of our attire in the office as being professional or not. It does not matter what you wear if you do not live your life as a professional. Being a professional doesn't stop at the office door. It means volunteering in your civic and medical communities. It means always being a good representative and advocate for our profession of podiatry. If you don't (and I am not inferring that any of this is about Dr Mauser) act professionally all of the time, it will not matter what you wear in your office. AND if you do act professionally all of the time, it will not matter what you wear in your office.
David M. Schofield, DPM, Sarasota, FL, Elmira, NY, david.schofield@yahoo.com
For the first 15 years in practice, shirt and tie was deemed by public opinion (as well as my father) to be "more professional" than anything else. The next five years, I wore slacks and a polo shirt. A white coat depended on the time of year and the temperature of the office.
The last five years have been strictly scrubs and a white coat. There are several factors leading into my decision. One was my dry cleaning bills. Another is the overall appearance of those dress clothes after a particularly busy day where several patients requiring casting...
Editor's note: Dr. Lattarulo's extended-length letter can be read here.
08/30/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Brachymetatarsia (Eric Edelman, DPM)
From: Gerald Mauriello, Jr., DPM, MA
I believe using a bone graft in this case (2 cm) is a mistake. Distraction osteogenesis with ex-fix is the technique I would consider. A bone graft of that size is likely not to incorporate, not to mention the acute stretching of the neurovascular bundle. A gradual stretch of soft tissue and callus distraction with a mini-rail is the way I'd go.
Gerald Mauriello, Jr., DPM, MA, Freehold, NJ, drmauriello@gmail.com
08/16/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1b
RE: ESWT & NSAIDs (Paul Kesselman, DPM)
From: David Zuckerman, DPM
The only study that I have read regarding use of NSAID and ESWT with low energy repetitive ESWT is by Jan Rompe MD. FDA studies withheld NSAIDs up to 12 weeks because they would then be a factor in the effectiveness of ESWT. The end point was 12 weeks or three months. That being stated, here is what we have used over the past 12 years with shockwave therapy. The use of NSAID along with high-energy ESWT ISN'T contraindicated. Our protocol with the Dornier Epos Ultras is 0.21 mj/cms for Achilles tendinosis. This is considered low energy even with a regional nerve that is typically necessary. Any energy over .028mj/cms is high energy, anything below is low or medium energy
I wait in most cases at least 14 days so that the inflammatory stage of wound healing has passed. To be on the safe side, wait 21 days. There still are no studies or proof that prove NSAIDs do interfere in vivo except for one low-energy study by Jan Rompe MD.
You need to consider the overall patient and his needs and other pain and joint problems. If I felt that it would help the patient overall, I would give NSAIDs at any time. We have avoided this entire issue with the use of high energy lasers (nexus 30 watt ) for pain and inflammation.
David Zuckerman, DPM, Cherry Hill, NJ, footcare@comcast.net
08/10/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Recalcitrant Wound (Samuel Rosenwald, DCh)
From: Chris Browning, DPM
I had a similar patient who had fallen from a height and suffered a calcaneal fracture. A local orthopedist performed ORIF and the patient eventually developed osteomyelitis, wound infection, and dehiscence. The orthopedist removed the hardware, and the patient developed an open wound/sinus extending down into the calcaneus. The patient saw another doctor who treated him with HBO, wound care, and VAC. When the patient came to me, he had been walking around for one year with a piece of foul smelling calcaneus exposed in the base of the wound. MRI revealed chronic osteomyelitis. Sed Rate/CRP was negative. I took the patient to the OR and debrided all of the bone out and then took a rotary burr and roughed up all of the area down to healthy bleeding bone. I mixed Wright Medical Osteoset beads but instead of making individual beads, I put the hardening solution in a syringe and squirted it into the calcaneus to fill the void in the bone. I had already added Vancomycin and Tobramycin. I also took a bone culture PRIOR to this. The solution hardened nicely, and I excised the ulcer out and performed flap closure of the skin.
I left this in place for about six weeks. Commonly seen with these beads, there was moderate serous drainage from the wound, and I applied the VAC. Much of the bone healed in and on x-ray, the patient's calcium sulfate plug was getting smaller and resorbing. After about six weeks, I went back in, removed the plug, roughed up the bone again, and had an orthopedic colleague harvest fresh iliac crest graft. I then packed it into the defect. The wound and BONE healed rapidly and uneventfully. Get a bone biopsy and/or MRI. There is dead or infected bone in the wound. The calcaneus heals very well under the right conditions.
Chris Browning, DPM, Temple, TX, chrisbrowning@att.ne
08/09/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1a
RE: Recalcitrant Wound (Samuel Rosenwald, DCh)
From: Robert Thiele, DPM
Something is not allowing the wound to heal. Assuming all medical and nutritional reasons including cessation of smoking have been addressed, remove the hardware. Biopsy and culture the bone to rule out osteo. Also biopsy and culture the soft tissue. If biopsies are clean, then a delayed primary closure should not be a problem with reported size of this wound. Non-weight-bear the foot until it heals. If osteo, treat accordingly. You either have an osteo or possibly a reaction to the hardware, assuming also that you have a healed fracture. You did not mention anything about a non-union. Update us on the outcome.
Robert Thiele, DPM, Hillsborough, NJ, drthiele@comcast.net
08/09/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1b
RE: Recalcitrant Wound (Samuel Rosenwald, DCh)
From: Thomas Graziano, DPM, MD
You can assume your 42 y/o patient with a chronic open calcaneal wound that probes to bone has osteomyelitis. These patients are very difficult to manage and resistant to closure for a number of reasons. The first is that the local soft tissue and osseous structures (the nidus) are relatively avascular. Because of this low vascular perfusion, antibiotics, intravenous or otherwise, cannot adequately penetrate the tissue, let alone any topical treatments. The second reason has to do with the lack of soft tissue coverage over the bone. The patient continues to ambulate on an unprotected area and therefore continues to exacerbate the problem.
If you review the literature, you will find numerous articles on the subject. A partial calcanectomy is one option. This can be combined with a local muscle transposition which addresses the issues mentioned above. Applying a well-vascularized muscle flap over a well debrided osseous and soft tissue structure accomplishes two things. It allows for improved perfusion, thereby increasing antibiotic penetration, and at the same time provides well needed soft tissue coverage over the defect. The abductor digiti minimi muscle is an excellent choice by virtue of its wide base of origin and proximal neurovascular supply, as well as other intrinsic muscles depending on the location of the defect. I recommend that you search the literature for a more complete description and philosophy behind the technique.
Thomas Graziano, DPM, MD, Clifton, NJ, TGrazi6236@aol.com
08/08/2011
RESPONSES / COMMENTS (CLINICAL) - PART 1
RE: Hallux Extensus in a 2 Year Old (Arthur Gudeon, DPM)
From: Robert Bijak, DPM
If a 2 year old has hallux extensus, and so does the mother, a possible anatomic, genetic correlation is screaming out to be found. The child (and possibly the mother) should be examined and imaged for spina bifida, cauda equina, or spondylolysthesis, etc. with nerve compression involvement in the S1,2, tibial nerve distribution of the flexor hallucis (which is apparently weak) allowing for the extensus,and secondary to EHL overpowering. After the correct diagnois is made, then you can consider treatment options.
If the podiatrist is uncomfortable with this exam, a referral to a pediatric neurologist or pediatric orthopedist would be a good idea.
Robert Bijak, DPM, Clarence Center, NY, rbijak@aol.com
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