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05/16/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Soft Tissue Mass (Rob Lagman, DPM)
From: Gino Scartozzi, DPM
Since visualization of the tumor is poorly defined within the existing MRI study, I recommend repeating the MRI study with contrast in light of the radiologist's diagnostic impression of synovial sarcoma or giant cell tumor of the tendon. In this situation, wide excisional resection of the tumor would be indicated rather than incisional biopsy or partial excision. An inadequate or partial resection of a giant cell tumor of the tendon would predispose the patient to development of malignancy of this tumor type. Coordination with an oncologist is strongly advised.
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
Other messages in this thread:
09/11/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Pulse Vs. Continuous Terbinafine Therapy for Onychomycosis (Barry Mullen, DPM)
From: Stephen Gill, DPM
Thank you, Dr. Mullen for the response on evidence-based therapy for this daily practice challenge. I would appreciate more information on the +PAS D/D method and treatment protocol for other non-dermatophyte causes: saprophytes, Candida (infectious), lichen planus, and psoriasis (non-infectious).
I often wonder about mixed etiologies (skin/nails) and the clinical effectiveness of laser ablation and concurrent Rx therapy on non-dermatophyte causes.
Stephen Gill, DPM, Denver, CO, georgestephengill@gmail.com
08/16/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: APMA 5K Run/Walk
From: Shawna Shapero
Show your support for the APMA Educational Foundation Student Scholarship Fund. Click here to see the APMA 5K Run/Walk video. A new category has been added: Sleeper! Yes, you can donate as a Sleeper!
Shawna Shapero, Bako Pathology Services
08/15/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2B
RE: Verruca Treatment in an Immunocompromised Patient (Catherine Wu, DPM)
From: Charles Morelli, DPM
First of all, make sure it's a wart. As a transplant patient who is on many of the same meds as your patient, I have some experience with this, and I also recently had surgery. Basically, you do nothing different. These patients are at greater risk for infection, so you need to take greater care with sterility, antisepsis, and technique. If s/he gets an infection, the patient will need to contact their transplant nephrologist who will adjust their meds while the infection is treated with antibiotics. It's a delicate balance between fighting the infection and not rejecting the transplanted organ.
That being said, cimetidine in a 53 year old is usually not very successful, although I understand using it, as there is nothing to lose. I exclusively use canthranone (cantharadin). It is quite strong and quite effective. Be careful if using it for the first time as it very caustic, but it works. In kids or adults with very tender skin, use less. Have them back every 10 days for debridement and re-application, if necessary. There are other options (laser, bleomycin, etc.) but I will let others comment on those as I do not use them.
Tell your patient that these types of lesions, when left untreated for many years, can change into carcinomas. He just might decide to take off from work for a few days. Even with the topical meds, if he has a reaction to them, he may need to take time off anyway.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
08/15/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2A
RE: Verruca Treatment in an Immunocompromised Patient (Catherine Wu, DPM)
From: Stephen Musser, DPM
After three years, you need to biopsy the lesion to be certain that you are still dealing with a verruca. Once the diagnosis is established (by pathology), there are a variety of treatment modalities available. First, address the hyperhydrosis, if that is an issue. Second, conservatively, you may want to use sal. acid to be applied in the AM, followed by application of Efudex cream at night, and cover with a bandage. Check the drug interaction of Efudex with his current meds.
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
08/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Painful Bunion and Hammertoe (Mario Dickens, DPM)
From: Richard Gosnay, DPM
I completely agree with Dr. Sullivan's opinion that we need more information in order to conclusively propose a solution to this case. Information that we must know include the patient's medical history and med list, the active patient's goals and expectations with respect to activities and shoes, the patient's ability to go non-weight-bearing if necessary, possible hypermobility of the 1st metatarsal-cuneiform joint, possible pain at the site of plantar plate ruptures, possible 1st metatarsal elevatus, possible equinus, and any other gross foot deformity.
But we do know several important facts regarding this case. The A/P view shows...
Editor's note: Dr. Gosnay's extended-length letter can be read here.
07/03/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Severe Metatarsalgia (Judd Davis, DPM)
From: Simon Young, DPM
Unfortunately, you might need to consider a Hoffman-Clayton type procedure.
Simon Young, DPM, NY, NY, simonyoung@juno.com
Editor's note: To see the x-rays for this case, click on underlined subject heading.
06/23/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2B
RE: Non-Surgical Approach to Plantar Fibromas (Terry L. Spilken, DPM)
From: Marc Katz, DPM
Cryosurgery is an excellent treatment option for patients with plantar fibromatosis. It is an ambulatory procedure performed in the office. It requires one day of rest and elevation after the procedure. Within one week, the patient is back to full activity. It is important that the patient is informed that the cryo unit is not FDA cleared for fibromas. Patients must understand that this is an off-label procedure.
Fibroma cryo can lead to serious medial plantar nerve damage. It is essential that you map out the neurovascular bundle with ultrasound and make sure you stay within the fibroma using ultrasound. Even that does not guarantee success. This is also a cash procedure and there can be no justification using nerve codes for reimbursement.
The success rate is at best 50-60% realistically, and it is rare for the fibroma to resolve. Success typically occurs when the procedure is performed multiple times. Single treatments rarely resolve a fibroma.
Marc Katz, DPM, Tampa FL, dr_mkatz@yahoo.com
06/23/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2A
RE: Non-Surgical Approach to Plantar Fibromas (Chuck Ross, DPM)
From: Richard M. Maleski, DPM
Try using Mederma cream. A number of years ago, I had a patient with bilateral plantar fibromas and did a fasciectomy on one foot. I had her use Mederma for the surgical scar. On her own, she also used it on her other foot and the fibromas reduced dramatically. I subsequently "lost" the surgery on the other foot because of this, but learned of a possible treatment option. I have tried this on other fibroma patients since then with varying degrees of success. Off hand, I can think of at least one other patient who had similar results and avoided surgery.
Richard M. Maleski, DPM, Pittsburgh, PA, maleski@zoominternet.net
06/21/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Chronic Calcaneal Apophysitis (Jeffrey Kass, DPM)
From: Gino Scartozzi, DPM
The immediate concern is that there is a consolidation of the calcaneal apophysis in a 12 year old male when such a process is expected in a male at 15-17 years of age. Such a process may indicate an occult Salter Harris Fracture (Type V) or an infection, as eliciting factors that created such a premature closure of the growth plate. I am concerned by the pain elicited out of proportion with any attempt at weight-bearing and regional osteopenia as compared to the contra-lateral view in the rearfoot region.
My recommendation is that a neurology consult be obtained to determine underlying complex regional pain syndrome. Pain management, along with aggressive treatment of CRS/causalgia, is imperative so that the condition does not become chronically disabling.
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
05/17/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Stabilizing the Medial Column (David Weiss, DPM)
From: Douglas Richie, DPM
I am curious how Dr. Weiss determined that this patient had "hypermobility" of the 1st ray? Furthermore, I am not aware of any published study, using modern biomechanical measurement techniques which have demonstrated that any surgical procedure can correct this presumed "hypermobility". How do static relaxed stance weight-bearing x-rays demonstrate function of the human foot, and specifically the 1st ray, during dynamic gait?
Douglas Richie, DPM, Seal Beach, CA, DRichieJr@aol.com
05/10/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Marfan's Syndrome and Bunions (Tip Sullivan, DPM)
From: Howard J. Lepolstat, DPM
Going back to basic physics and without overdoing the analysis, this appears to be a class-1 lever system --- fulcrum (1st MPJ) in the middle with the force and resistance at either end. There is tremendous joint laxity that maximizes the effects of the pathological forces on that joint, thereby increasing the tendency and reality of the deformity. As in any mechanical system, the forces are going to accumulate at the weakest link in the chain, which is probably the MPJ and secondarily the MCJ. Changing the orientation of the bones (via surgery) will not change that.
That being said, it seems the first step is to stabilize the forces as much as possible, which is the function of orthotic devices. From my perspective, the degree to which those forces can be stabilized is the degree to which long-term surgical success can be hoped for. The choice of surgical procedure is a function of the osseous deformities. I may be wrong, but I don't think it is a function of ligamentous laxity, and I don't think a recurrence can be forestalled by surgically correcting the unstabilized foot.
Getting this patient stabilized for a significant period of time in the most rigid orthosis he can tolerate can only increase the chance of surgical success. Certainly there can be no downside.
Howard J. Lepolstat, DPM, (Retired), Sun City West, AZ,TeachrComp@aol.com
04/14/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: No More Paper Medicare Remittance Advice
From: George F Jacobson, DPM
We were just notified from CMS (First Coast) that in 20 days we will no longer have paper explanations of benefits (remittance advice). We will have to contact our Medisoft vender for instuctions as to how we can access the ERA, which will be sent to Capario, the clearinghouse for our data. CMS will send the data to them.
Twenty days is insufficient notice to entirely change a system! Has anyone else received this letter? Has anyone been granted access to look up and print out your patients' RA from the ERA? There is free software available, but you need a separate ERA receiver ID. There is a form to request an ERA receiver ID, but I'm afraid that it might cause problems with our clearinghouse's ID and authorization to receive and send data on our behalf. CMS is making practice tiresome! What's next?
George F Jacobson, DPM, Hollywood, FL, fl1sun@msn.com
02/15/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2B
RE: Gouty Tophi, 3rd Digit (Charles Baik, DPM)
From: Stephen Pirotta, DPM, Keith Gurnick, DPM
I have dealt with a few of these and think the best, most effective, least expensive, and long lasting resolution is amputation of the digit. I do them in my office. It's a 15 minute good solution that best serves the patient. Managing future episodes is then the next goal for their PCP.
Stephen Pirotta, DPM, Bentonville, AR, iwillctrnow@yahoo.com
Since the toe does not appear to be infected, you could leave it be and suggest shoe modifications or open sandals (when appropriate) so that there is less pressure against the toe. I would caution you to be very careful administering additional cortisone shots into the toes of elderly diabetics.
A peripheral vascular study to assess small vessel circulation would be prudent to help guide your surgical decision. If you choose to open the toe and remove the gouty deposits, be aware that the chalky material will be invested all over the area, including the dorsal tendon and all the surrounding tissues and you will be scraping, dissecting and curetting that small area for 30 minutes. Removing this gouty material may further devascularize a toe that could be already somewhat compromised, and if the toe does go on to heal, the gout and tophi deposits could return in the future.
Obviously, it goes without saying that you should also...
Editor's Note: Dr. Gurnick's extended-length letter can be read here.
02/15/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2A
RE: Gouty Tophi, 3rd Digit (Charles Baik, DPM)
From: Elliot Udell, DPM
Addressing gouty tophi from a surgical perspective without addressing hyperuricemia is not doing the patient any favors. Unlike localized osteomyelitis, which some of us choose to address surgically, gout might be a local, pedal condition today, but if the hyperuricemia is not properly managed, it can affect other joints tomorrow. The patient's eating habits also need to be addressed. We have all had patients who we have seen in the emergency room who are willing to take uric acid lowering drugs but are also willing to walk into a restaurant and eat a red juicy steak.
The two oral drugs most commonly used to lower serum urate levels are allopurinol and Uloric (feboxustat). Renal status will affect if and how much allopurinol you can give. Many diabetic patients have renal problems. Uloric, on the other hand, is not affected by renal status but is not FDA-approved for the treatment of tophi even though it may prove to be effective. One drug which might be a choice is called Pegloticase which is administered IV for refractory cases of gout. It is highly effective, but I would caution anyone contemplating its use to work with a good physician who has experience with this drug.
Since the patient described has multiple medical conditions, it is highly advisable that you co-manage this patient with a good internist or rheumatologist. If the patient is resistant to diet modification, referral to a mental health professional trained to work with food addictions should also be considered.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
02/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: The Use of Uloric vs. Allopurinol in the Management of Gout (Jeffrey Kass, DPM)
From: Elliot Udell, DPM
The problem with colchicine is a loophole in the law that enabled a private drug company to do research and patent a drug that has been on the market for ages. The same law enabled them to take generic colchicine off of the market. Shame on the FDA.
Drug plans take the path of least payment. When colchicine went from less than a dime per tablet to close to ten dollars a tablet for brand name Colcrys, the companies started dropping it in favor of uric-acid lowering drugs and NSAIDs. This alone should change the way we as podiatrists view the treatment of acute and chronic pedal gout. We need to revisit our injection techniques as well as the use of newer and less toxic NSAIDs. We need to take a fresh look at the use of allopurinol and Uloric as part of the podiatric armamentarium in the management of this extremely painful and disabling condition that we see so frequently.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
02/11/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: The Use of Uloric vs. Allopurinol in the Management of Gout (Frank Lattarulo, DPM)
From: Jeffrey Kass, DPM
Colchicine is readily available - it is just expensive - and now only available as a brand name. Additionally, it has been dropped from many drug plans. What is fascinating about this is that the drug company that received the FDA patent received it because they did a study and showed the FDA that there was an indication for gout. So here is a case of a company proving a medication works, and it was good enough for the FDA to approve it, yet the drug gets bumped off of drug plans. I guess evidence-based medicine is not so good afterall. Lesson to be learned: money talks, evidence-based medicine walks.
Jeffrey Kass, DPM, Forest Hills, NY jeffckass@aol.com
02/09/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: The Use of Uloric vs. Allopurinol in the Management of Gout (Peter Vannucchi, DPM)
From: Arnold B. Wolf, DPM
I always take pleasure in seizing the opportunity when treating patients, to give them more than what they bargained for. Gouty arthropathy (and enthesopathy) provides such an opportunity. Often, when patients come in with arthropathic symptoms, I don't hesitate to "grab the reins" to initiate the appropriate diagnostic and treatment protocols. Often times, I find that the PCP may "miss" the possibility of gout in the differential diagnosis because the pain doesn't involve the 1st MTPJ.
As far as choosing between allopurinol (Zyloprim) or febuxostat (Uloric), allopurinol is still (typically) the first-line drug as both are xanthine oxidase inhibitors, but generic availability is a driving force in the decision. Nonetheless, febuxostat should strongly be considered in cases where diminished renal status is a concern. Of course, therapeutic institution of either of these drugs should be delayed until the acute symptoms have resolved.
Arnold B. Wolf, DPM, Sterling Heights, MI, omnifootcare@prodigy.net
12/14/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Life-long Maintenance Regimen for Onychomycosis (Bryan Markinson, DPM)
From: M. Turlik, DPM
It was with great anticipation that I read Dr. Zaias’s study as referenced by Dr. Markinson in an earlier post. With all due respect to Dr. Zaias, an international expert on nail disease, and Dr. Markinson, a noted the podiatric expert in dermatology, I do not think that the authors' conclusion in the study is supported by the methods used to gather and analyze the data. The authors describe the design of the study as “a prospective, non-randomized, open study of sequential groups of office patients.” This type of study design does not allow for control of several types of biases which are encountered in therapeutic studies.
In general, this type of study lacks validity and results in an over-estimation of treatment effect. Case reports and case series are seen as hypothesis-generating rather than hypothesis-confirming studies. The correct conclusion should be that terbinafine may be an effective treatment for DSO when pulse-dosed for 7 days every 3 months, but not every 4 months. This needs to be confirmed in a more rigorous trial design.
Medicine has moved away from an expert-based system towards an evidence-based system. This movement will only increase in the future. Therefore, it is important for podiatric physicians to critically analyze the data which experts and opinion leaders utilize to make treatment recommendations. This becomes even more imperative when the expert declares a financial conflict.
M. Turlik, DPM, Cleveland, OH, mmturlik@aol.com
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