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05/11/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Non-Union and Malunion of Metatarsals (Philip Graham, DPM)
From: Bret Ribotsky, DPM
While we all don't see this often, all of us with a little gray hair have had this patient walk into our offices. I believe your approach needs to be slow and methodical. Get a great history, do a calcium work-up (25 Hydro Vit D, 24 hr urine calcium level, and parathyroid levels). If she smokes, get her to stop or don't do the surgery. Check for equinus. Then, once you have all the information, plan a surgery with removal of all the hardware in the 1st and 2nd metatarsal.
Obtain a cortical/cancellous bone graft from the tibia and re-plate the metatarsals. This time, use BMP and or a bone stimulator and put the patient in an AK cast. I am sure everyone will appreciate the 3 hours of surgery, the hours of follow-up, and phone calls for maybe $1,200 dollars - but that's why we love what we do, helping people with real problems.
Bret Ribotsky, DPM, Boca Raton, FL, ribotsky@yahoo.com
Other messages in this thread:
10/05/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2B
RE: Vibration Anesthesia Device (Mark Johnson, DPM)
From: Elliot Udell, DPM, Robert Blaine, DPM
Blaine labs is not the first company to come out with a vibration device to help lesson pain associated with injections. I have tried several other devices and have found them to be successful. Dr. Amy Baxter, a pediatrician developed one shaped like a bee, and I have used it very successfully in my practice. I showed to my allergist who gives hundreds of injections to kids every day of the week and he immediately bought one and uses it all day long. The cost is $39.95 (buzzy4shots.com). You can also purchase one under "Buzzy pain relief system" at Amazon.com.
Elliot Udell, DPM, HIcksville, NY, Elliotu@aol.com
Regardless of whether users of the Vibration Anesthesia Device find it is efficacious or not, I would like to share why it was developed. Prior to its development, for twenty years, I was a frequent user of ethyl chloride spray with my injections. And like most of us, I never thought anything about what ethyl chloride actually was until roughly seven years ago when a patient, who happened to be a chemist, refused my use of ethyl chloride with his injection telling me that the spray was toxic and he did not want it on his skin.
I had never heard this prior from anyone. I checked the ethyl chloride bottle’s label which said nothing about the spray being potentially harmful let alone toxic as he had stated. However, the box the bottle came in did state the precautions, the potential adverse reactions, and the warnings for its use (“ethyl chloride is known as a liver and kidney toxin; long-term exposure may cause liver or...
Editor's note: Dr. Blaine's extended-length letter can be read here.
09/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2A
RE: Non-Union of Calcaneal Fracture
From: Zeeshan Husain, DPM
The fact that it has been 6 months with minimal healing is concerning. This is not a non-union (9 month) yet, just a delayed union. The use of a bone stimulator was a good choice. The real question is why is such a vascular bone slow to heal. Rushing into doing a revision whether it be ORIF or arthrodesis can only be disastrous without assessing the healing potential. Is the patient compliant with NWB? Is the patient a smoker? What is the vascular status? Consider evaluating the vascular perfusion to the foot as well as MRI with gadolinium (or bone scan) to make sure the bone has sufficient vascularity.
I have done a fair number of calcaneal fractures (ORIF and primary arthrodesis) and have never had one go to a non-union. I have treated malunions, but they eventually heal due to the rich vascularity. I have and would only consider going back in surgically at least 9-12 months after the initial surgery. I would be very reluctant to do anything now based on the x-rays which are acceptable-- just too soon. The K-wire can probably be removed at this time (to minimize risk for pin tract infection) and work-up the vascular perfusion issue. An MRI with gadolinium will give you better appreciation for any healing as well as if the bone is viable.
Consider medications such as Miacalcin (calcitonin nasal spray) or supplements based on blood work (coordinate with PCP). The worst case scenario - at one year, I would think about injecting bone substitute and/or platelet rich plasma percutaneously or making small incisions to pack in autogenous iliac bone (ideally) into the non-union areas.
Zeeshan Husain, DPM, Rochester, MI, zeepod@hotmail.com
09/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2B
RE: Non-Union of Calcaneal Fracture (Mak Yousefpour, DPM)
From: Jeff Mennuti, DPM, Sloan Gordon, DPM
You have not given much info on this patient other than 52, female. Does she smoke? Is she diabetic?
This case sounds like vaculopathy. Get an arterial Doppler. She may have injured the vascular supply to the calcaneus. Before you go straight to surgery that may never heal, check her arterial flow first. Or, she may have a chronic ischemia causing the delay in union.
Jeff Mennuti, DPM, Orange City, FL, dr.mennuti@gmail.com
The fracture is still comminuted and any attempt to perform an ORIF will be a failure, in my opinion. I believe that the best course of action would be to remove the hardware and fuse the hindfoot, along with implantation of an internal bone stimulator. I don't think any of the excellent calcaneal fracture plates would be valuable in light of all the bone callus you will encounter. An ex-fix might be an option, but will be quite challenging.
Additionally, I encourage you to add growth factors (PRP, DBM, Incite, Stimublast - whatever your preference) to enhance the fusion.
Sloan Gordon, DPM, Houston, TX, sgordondoc@sbcglobal.net
08/25/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Treating a Diabetic with an Inversion Sprain (Philip McKinney, DPM)
From: Jeffrey Kass, DPM
I believe the diabetic inversion case treatment was good medicine, and if someone wants to claim the doctor was overzealous - well, "better safe than sorry." Good job.
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com
08/10/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Pruritic Lesions, Arms and Legs (Jim Fisher, DPM)
From: Joel Morse, DPM
I would not use a super high potency steroid on the legs of an 84 year old. I would start with a mid-strength one and monitor it. When in doubt, think eczema. Eczema can also turn into cellulitis easily in an older patient, so if it is worsening, put the patient on Keflex (as long as she has no allergy).
Joel Morse, DPM, Washington, DC, Foxhallfoot@aol.com
07/14/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Recovery Time for Bunionectomy for Karate Artist (Richard Jaffe, DPM)
From Stanley Beekman, DPM, Charles Morelli, DPM
This all depends on the kick that she uses. The most common kick for breaking boards is the side kick, which contacts with the calcaneus or the side of the foot. Either way, this will not matter. If she uses a round house kick or a front kick, she should contact with the metatarsal heads (however, in the round house kick, the instep is used occasionally, especially with higher kicks). In this case, I would use the same criteria as I would for runners, which is 3 months. You also would want her to work on returning the digital flexor strength to normal. Remember, it is the muscles that convert eccentric loading to concentric loading.
Stanley Beekman, DPM, Cleveland, OH, sbkmn1@gmail.com
It depends on the age, medical history, type of wood, bone stock, history of osteoporosis, the technique used when breaking the board (side kick, ball of foot, heel, roundhouse, back kick), type and severity of bunion procedure (Silver, head osteotomy, base osteotomy, midfoot fusion, Cotton, etc), and fixation (K-wire, screws, plates, implants, etc.), stability of Aiken if also performed, level of compliance, degree of immobilization that may require physical therapy for muscle re-education, and other things I am sure I am not mentioning. Combine clinical judgment, x-ray evaluation, CT scan, signed consent form, and gut instinct, and still wait 10-12 weeks.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
07/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Recovery Time for Bunionectomy for Karate Artist (Richard Jaffee, DPM)
From: Barry Mullen, DPM
Unfortunately, Dr. Jaffe's question is far too generic to accurately answer at this time. A myriad of parameters exist that affect bone healing. For instance, what type of bunionectomy is contemplated? Will an osteotomy be performed? If so, which bone (metatarsal? phalanx? both?), how many, and where within the anatomy of that bone will the osteotomy be performed (distal metaphysis, proximal metaphysis, midshaft)? How will it be fixated? Is your patient's physiologic age commensurate with her chronological age? Just because she is a karate expert, can we automatically assume 100% health with no co-morbid fracture healing factors such as post-menopausal osteoporosis, etc.? ALL of these parameters affect bone healing rates.
As one example, a healthy 50 year old female, with no co-morbid fracture healing factors, who undergoes a distal metaphyseal 1st metatarsal osteotomy with AO fixation, should heal that osteotomy via primary bone healing between 4-6 weeks. At 8 weeks, assuming no setbacks occur, and radiographic evidence confirms primary fracture healing, then I'd likely have little qualm about allowing this patient to re-stress the forefoot. Keep in mind that following any immobilization (for me, in this example, typically 3-4 weeks in a pneumatic cam walker), patients will experience some disuse atrophy and regional, pedal osteoporosis. So, I'd want her back in flexible shoes, propelling off her forefoot and re-establishing full blood flow throughout her operated foot for several weeks prior to allowing the stress of board-breaking.
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
06/22/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Is This MTPJ Salvageable? (Alan Berman, DPM)
From: Richard Gosnay, DPM
This is obviously a complex breakdown of the forefoot that requires several considerations if Dr. Berman and the patient are to expect a successful outcome. Those are quite impressive periarticular erosions! I believe a rheumatology consult is in order.
The second ray must be corrected. As noted previously, the plantar plate is almost certainly disrupted. The second metatarsal is quite long, so I suggest a Weil osteotomy, a second toe arthrodesis, dorsal capsulotomy with extensor tenotomy, and a Girdlestone tendon transfer.
Although hypermobility of the first metatarsal was not noted, such transverse plane deviation and second ray degradation usually indicates that...
Editor's note: Dr. Gosnay's extended-length letter can be read here.
06/20/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Is This MTPJ Salvageable? (Alan Berman, DPM)
From: Estelle Albright, DPM, Michael Theodoulou, DPM
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Is This MTPJ Salvageable? |
Does this patient have gout?
Estelle Albright, DPM, Indianapolis, IN, estellealbright@hotmail.com
One does not treat a radiograph. Unfortunately, the clinical history and limited x-ray does not provide us with enough information to give a valid response. But if we can extrapolate from what is given and seen, this is an individual with severe hallux valgus. There is notable metatarsal primus varus and a subluxed joint. Of concern are the erosive changes of the first metatarsal head which suggests potential rheumatic process; high on the list would be gouty arthropathy or rheumatoid arthritis.
This is of concern as joint sparing reconstructive osteotomies will not resolve the underlying pathologic process, with potential for continuation of disease. Arthrodesis of the joint is a truly acceptable alternative for such severe deformity in light of the subluxed joint and potential rheumatic process. However, without visualization of joints more proximally, this cannot be completely advocated. Arthrosis of the first tarsometatarsal joint is a relative contraindication to distal fusion.
It has been my experience, that if one does fuse the first metatarsophalangeal joint, there is seldom need for proximal re-alignment osteotomies as the joint is decompressed and the first ray re-aligns. Finally, please do not overlook the completely dislocated 2nd MTPJ with probable plantar plate disruption given the longstanding transfer loading.
Michael Theodoulou, DPM, Cambridge, MA, michaelhtheodoulou@msn.com
06/19/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Chronic Calcaneal Apophysitis (Jeffrey Kass, DPM)
From: Stephen Musser, DPM, Ed Wiebe, DPM
You don't want to 'out-smart yourself', but if you think it's a true case of Sever's disease, start aggressive PT, NSAIDs, orthotics for any biomechanical pathology. Looking at the lateral radiograph of the left heel, the growth plate actually has more sclerosis than the right. Secondly, re-examine your other x-ray views (AP, obliques). There is something that looks pathologic around the talus and STJ.
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
X-rays show more closure of the epipheseal plate, right side, and a hint of decreased bone density. RSD is possible - Pain ALL the time, way out of proportion to injury. Linear scleraderm deep scarring, fibrosis, lots of pain. Both of these have essentially a clinical diagnosis. Scleraderma may have tissue pathology in the skin if a scar forms. I hope it's just re-injury apophysitis!
Ed Wiebe, DPM, Flagstaff, AZ, elw520@hotmail.com
05/23/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Hyperpigmentation of African-American Women After Using Corn Remover Pads (Janet McCormick, MS)
From: Shelley Gath, DPM
Links to cancer were published after rats were given high doses of hydroquinone. Hydroquinone does show dramatic results and is still prescribed by many dermatologists and plastic surgeons on a limited basis. With all products, results may not become evident for several months, if at all. Also, if results are seen, continued maintenance of the product is necessary to prolong the desired look. So yes, hydroquinone use would be limited to 8 weeks.
Kojic acid as well as alpha hydroxy acid have caused irritation and redness in some patients, which may cause the area to become darker than the original pigment. With all products, a test area is recommended first. Like my mother used to tell me, put lemon on it, which has natural bleaching properties and VItamin C which regenerates the skin. Avoid sun exposure to the area when using.
Shelley Gath, DPM, Arcadia, CA, footdoc.gath5@gmail.comshellgath@hotmail.com
05/22/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Soft Tissue Mass (Bryan Markinson, DPM)
From: Anna Olvera, DPM, Jeffrey Manway, DPM
First, I would like to applaud Dr. Lagman for his question as I am sure MANY of us do not have ALL the answers, but it takes a good podiatrist to ask for help instead of not admitting that one requires assistance, and a botch job winds up being the end result. As my podiatric surgery professor told me a few years ago, there is no such thing as a dumb question when a patient's life is in question. That always stuck with me. I think it's important for ALL podiatrists to remember that, even the ones who consider themselves "seasoned", because no one has all the answers.
Second, Dr. Markinson's comment, "But I am positive that the patient could be in better hands" is inappropriate and unnecessary. Belittlement has no place here. If you have something constructive to add to the subject, the responder should do so with a modicum of professionalism and sensitivity. We are all professionals and should conduct ourselves in that manner and not resort to this pettiness. Instead of chastising a fellow colleague for a perfectly legit question, we should throw our energies into uniting our profession which, quite frankly, has always been fractious, with this comment being a pertinent reminder of it.
Anna Olvera, DPM, TX, annathefootdoc@yahoo.com
Just to echo Dr. Markinson's thoughts, I believe if there is any doubt in treatment plan, diagnosis, or technique, suspected malignancies should be referred out. I believe the possible morbidity of performing a biopsy is significantly understated. We should not have the mentality of, "I'll biopsy it and if it's malignant, then I'll refer it out." As he states, these are not skin lesions and should not be treated as such. This is a well documented problem in the literature and biopsy is not without its risks. Poor technique and improper surgical planning can leave the patient with suboptimal results - including additional (and sometimes unnecessary) treatment, more aggressive amputation, increased risk for metatastasis, and possible increased risk of mortality.
Further, when biopsies are performed in community facilities, they are generally reviewed by pathologists with lesser experience with rare oncologic issues (as any primary or secondary malignancy to the foot and ankle would be). This leaves the patient open to further harm as well. This is described in two landmark classic articles by Dr. Henry Mankin. They are both free articles at this point and I've listed the links below. I encourage everyone to read these. jbjs.org/article.aspx?volume=64&page=1121 jbjs.org/article.aspx?articleid=23264
Jeffrey Manway, DPM, Pittsburgh, PA ,jeffrey.manway@gmail.com
05/21/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Soft Tissue Mass (Bryan Markinson, DPM)
From: Narmo L. Ortiz, Jr., DPM
I was reading with interest the discussion and opinions concerning Dr. Lagman's original query, and I feel compelled to say this: Dr. Markinson does not need to apologize to anyone for writing what I think was wise, professional, and educated advice, and no one should take it is a criticism on their ability or amount of care and concern for their patient.
It is what it is: Dr. Markinson gave, as always, an accurate description of what should and needs to be done for the patient in question. I know that I am not alone in thanking him for his invaluable contributions to this forum, and to our profession at large.
Narmo L. Ortiz, Jr., DPM, Marietta, GA, nlortizdpm@embarqmail.com
05/15/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Non-Union and Malunion of Metatarsals (Philip Graham, DPM)
From: Jeffrey Kass, DPM
I respectfully ask all those responding to Dr. Graham's query why they feel their choice of surgical revision would actually work? Dr. Graham stated that 3 prior surgeries failed, "all due to non-compliance." The pain the patient has now is from a nucleated lesion/callus submet 2. Why not just debride the callus and enucleate it? Place a dispersion pad on it.
Is the AK cast that was recommended going to make the surgical revision work this time? So what if the screw is palpable? That wasn't the complaint. And while I understand there are many things wrong with the x-ray, I also understand she failed multiple surgeries before and likely she is not a good surgical candidate - so why put both yourself and the patient at further risk? Why would the non-compliance stop this time?
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com
05/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Marfan's Syndrome and Bunions (Tip Sullivan, DPM)
From: Jerry Peterson, DPM
I learned different numbers than Dr. Sullivan did. 0-8 degrees of IM angle was considered normal. Neck osteotomy was performed from 8-14 degrees, and 15 and up was base wedges and Lapidus territory. So, I agree with Dr. Mullens on this one. However, this is NEVER a hard and fast rule as I do a lot of base wedges and even Lapidus procedures on patients with lower angles, and neck osteotomies on higher angles, depending on age, bone quality, foot function, and desired outcomes. Anyone who states that a certain angle of measurement entirely determines the procedure we do needs to wake up from dreamland. These are too broad statements, and I believe were not intended to be dispositive.
Jerry Peterson, DPM, West Linn, OR, DRP@ifixft.com
05/01/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Nerve Compression Vs. Fictitious Injury (Elliot Udell, DPM)
From: Peter J Bregman, DPM
Certainly, conservative therapy such as Dr. Udell suggests is a great idea, but if and when it fails, the sooner you decompress the affected nerves, the sooner the patient will get better. This is a local CRPS injury, which means a peripheral nerve is involved and needs to be repaired. I will not go into the neurochemistry here, but suffice it to say, a decompression can only help not hurt if done properly in the right hands. I suggest going to aens.us and find a surgeon near you who can treat this problem.
Peter J Bregman, DPM, Las Vegas, NY, drbregman@gmail.com
04/30/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Recent Research Confirms Therapeutic Effect of Foot Orthoses for Anterior Knee Pain
From: Kevin A. Kirby, DPM
A recently published single-blind randomized control trial has demonstrated the clinical efficacy of foot orthoses in the treatment of anterior knee pain (i.e. patellofemoral pain syndrome). 40 subjects with anterior knee pain of at least 6 weeks duration who had not been treated with foot orthoses in the previous 5 years were divided into a control group (n = 20) that received no treatment and an intervention group (n = 20) that received foot orthoses. The clinical observation period was 6 weeks.
Results of the study showed that there was a significant global improvement (i.e. subjective pain reduction) with foot orthoses when compared to...
Editor's note: Dr. Kirby's extended-length letter can be read here.
04/14/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Excisional Biopsy (Joe Borden, DPM)
From: Gino Scartozzi, DPM
The lesion as described by the practitioner as "pulsatile" concerns me as to whether there has been adequate pre-operative planning. The fact that the lesion easily bleeds and has developed after trauma strongly suggests a granuloma or hemangioma of some variety. A lesion of this size and clinical presentation may be a possible cavernous hemangioma.
I recommend prior to performing an "excisional biopsy" on the region of the heel, an MRI be obtained to determine if there is a larger arterial-venous malformation plexus present beneath the skin that may be hidden to the practitioner. If such vascular etiology is found, a vascular consultation may be requested pre-operatively. In addition, the skin coverage on the heel of a lesion as described as 2 cm x 5 mm may require plastics consultation pre-operatively to determine which method of closures are available, since skin mobilization for closure in this region of the foot is more difficult than in other regions of the foot. An "incisional" biopsy, dependent on the MRI results, may be obtained and would be more beneficial to determine the etiology (malignant vs. benign.) When the determination of the lesion's malignancy potential is found, the lesion's skin closure and treatment with an oncologist can be better planned.
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
04/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2A
RE: Excisional Biospy (Robert Snyder, DPM, MSc)
From: Bryan C. Markinson, DPM
Dr. Borden plans an excision of a 2 cm. lesion on the plantar heel. Dr. Snyder’s response was dead-on in recommending biopsies before excision. The size of the lesion alone mandates this approach. Excising the lesion, only to find out a few days later that it was malignant creates a horrendioma, which is totally unnecessary and, in fact, poor practice.
In such a scenario, the removal of the lesion before knowing what it is would then make the field of wide excision required much larger than it had to be. In the right circumstances, this may change the final approach from a simple skin graft to an amputation. Do you want to be the reason for that?
In general, it is good practice to ALWAYS biopsy first before excision for lesions where there is considerable suspicion. This will ensure good care and that you never make a bad situation worse. Lastly, depending on the “bulk” of the lesion, or suspicion of a vascular tumor, imaging may be the first thing you want to do.
Bryan C. Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org
04/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2B
RE: Excisional Biospy (Joe Borden, DPM)
From: Jeffrey Kass, DPM
If you feel the lesion may be malignant, I recommend performing two 2 mm. punch biopsies first. Dr. Borden stated that he would refer it out if it was malignant, and hence if he finds through the biopsy that there is malignancy, he can refer it out, and the operating physician will have a better picture of what he is dealing with. He will know his margins. Once you go and cut something out..the "puzzle" becomes a little harder when the second doctor has to go back in.
You also don't have to worry so much about bleeding with a 2mm biopsy - you can always throw a suture in it.
Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com
04/11/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Bunionectomy Complication (Alan Berman, DPM)
From: Juliet Burk, DPM
I have successfully used EPAT treatments to break up post-operative adhesions and improve post-op ROM. It doesn't take many treatments - sometimes as few as two. You can contact the company to find a provider using the machine in your area. It's a great conservative option.
Juliet Burk, DPM, Muskogee, OK, julietburk@gmail.com
04/09/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: S/P Fracture Left Ankle (Philip Graham, DPM)
From: Jeff Mennuti, DPM
This is a high ankle fracture, i.e. above the ankle joint. Therefore, what you are dealing with is a syndesmosis repair. I recommend ankle stress views under flouro. Once you prove syndesmotic injury, you would have to consider thorough curettage of the syndesmotic ligament, and adequate reduction using a very large bone clamp. Keep the foot in extension, and place at least 2 trans-syndesmotic screws. Preferably, use a straight plate, and at least 2 trans-syndesmotic screws, and at least 3 cortices of purchase.
Jeff Mennuti, DPM, Orange City, FL, dr.mennuti@gmail.com
04/07/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Hyperkeratotic Tinea (Name Withheld)
From: Martin T. Girling, DPM, Stephen Musser, DPM
I have had great success with Sal. acid and sulfa soap (bar soap) (if you can get a local pharmacy to order it for you).
Martin T. Girling, DPM, Plant City, FL, mgirling@pol.net
I would treat your dermatological patient with a topical high potency steroid ointment x 2 weeks (in the evening), followed concomitantly with a topical urea cream (50%) daily (AM) until the follow-up appointment. If you already treated the patient with both PO and topical antifungals, I would repeat your cultures. I'm not sure tinea is the main issue at this time.
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
04/06/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Hyperkeratotic Tinea (Name Withheld)
From: Simon Young, DPM, Alec Hochstein, DPM
This looks like an acute dermatitis. Use a class-1 steroid, e.g., Temovate in conjunction with a keratolytic agent such as urea.
Simon Young, DPM, NY, NY, simonyoung@juno.com
It seems that you have thrown everything at it for tinea and hyperkeratosis that you could without significant results. It might be time to change the diagnosis or dig a bit deeper. My first impression is that this is a form of dermatitis, likely psoriasiform spongiotic dermatitis. I have had several patients with a similiar presentation and had excellent results with a combination of topical keratolytics and oral as well as topical steroid preparations. I would certainly recommend a full thickness biopsy be sent to a dermatopathology lab for diagnosis and documentation.
Alec Hochstein, DPM, Great Neck, NY, greatneckfootdoc@me.com
03/16/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Lapidus or Fusion (Carl Solomon, DPM)
From: Dennis Shavelson, DPM
I would like to comment on Dr. Solomon’s case. His procedure reduces the IM, but if one looks closely, the first metatarsal position and the girth of the foot have not changed post-op. In reality, the IM angle is reduced due to a 2nd met adductus deformity. His procedure will not produce shoe fit improvement as would be expected from a reduced IM angle.
Also, the fusion eliminates first ray function, increasing lesser metatarsal tissue stress (and the 2nd ray deviation) and prevents selection of varied heel heights in shoes, while shortening stride. In cases like these, when I was operating, I would perform a Keller bunionectomy with an aggressive EHL “Z” plasty and a purstrung capsular “soft tissue plasty”, along with post-op compensatory rehab and optimal functional positioned orthotics, foot type-specific. The removal of the proximal phalanx base allows the IM angle to reduce. The 1st MP joint remains functional, and often stride length, step length, and cadence are upgraded, not reduced.
Since there is minimal lateral transfer of tissue stress and a level of 1st ray function, patients can wear more stylish, higher heeled shoes. They can upgrade their lifestyle habits, not reduce them.
Dennis Shavelson, DPM, NY, NY, drsha@lifestylepodiatry.com
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