08/24/2013
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Wart Treatments (Dusty McCourt, DPM)
From: Paul Kesselman, DPM
Over the last few years, I have stopped almost all surgical and office-based chemical care for verrucae (even mosaic). If a few treatments of OTC chemcals fail to make any headway, I send the patient to the pharmacy with an Rx for 1 ml of Candida antigen. The cost is '$125 and will last approximately ten treatments. The candida is mixed 0.1 cc, with an equal amount of lidocaine (with or without epi) and I inject this directly into the verrucae. As this may be painful, the area must first be anesthetized with lidocaine/epinephrine.
With mosaic verrucae, I choose the largest "mother" wart. The treated area is re-evaluated every two to three weeks. I have rarely had to inject a verruca more than three times. Your patients (and you) will be amazed at the results. Two little known articles can be read on this subject and may be found online at: altoonafp.org/full.htm and podiatryinstitute.com/pdfs/Update_2012/2012_05.pdf
Prior to embarking on this regimen, one should obtain a good medical history and be sure your patient has no history of yeast sensitivities or previous fungal infections.
Paul Kesselman, DPM, Woodside NY, drkesselmandpm1@hotmail.com
04/30/2013
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Non-Specific Bone Marrow Edema Syndrome
From: Erik Kenyon, DPM, Eric J. Roberts, DPM
Sometimes, the non-specific marrow edema in pediatric patients is normal. It is believed to be as a result of transition of the bone marrow from infancy to adulthood.
Here is a reference: Shabshin N, et. al. High-signal T2 changes in the bone marrow of the foot and ankle in children: red marrow or traumatic changes? Pediatr Radiol. 2006, 36: 670-676.
Erik Kenyon, DPM, Modesto, CA, Erik.Kenyon@kp.org
Note that the non-specific bone marrow edema seen on an MRI in children that are the age of your patient is a normal finding due to the hematopoetic cells. The pathology you are looking for is unlikely this non-specific finding. Over 50% of children have this finding bilaterally and is normal in growing bones. Focus on the ankle instability and continue your treatment.
Pal CR, Tasker AD, Ostlere SJ, et al. Heterogeneous signal in bone marrow on MRI of children's feet: a normal finding? Skeletal Radiol. 1999;28 (5): 274-8.
Eric J. Roberts, DPM, Tampa, FL, lordertz@gmail.com
04/06/2013
RESPONSES / COMMENTS (CLINICAL) - PART 2A
RE: Recalcitrant Heel Pain (Loren J Miller, DPM)
From: Paul R. Scherer, DPM, Mark Hinkes, DPM
I suggest that you work the patient up for sero-positive or sero-negative arthritis. The following diseases have been well documented as having unilateral persistent heel pain as the presenting symptom: sero-negative (HLAB27 positive) include ankylosing spondylitis, reactive arthritis (formerly Reiters), enteropathic spondylitis, psoriatic arthritis, anterior uveitis. Seropositive include rheumatoid arthritis, systemic lupus, and Sjogren’s syndrome. Custom orthotics sometimes don’t work. Who would have thought!
Paul R. Scherer, DPM, San Francisco, CA, pscherer@prolab-usa.com
When does the pain occur? Does the patient have AM pain upon arising or neuritic type pain in the afternoon? Does the patient have an unequal limb length? Is there pain to the calcaneus with medial/lateral compression? Is there a positive lamp cord sign to the medial calcaneal nerve? How about a bone scan of the calcaneus to R/O sub-clinical stress fracture? Does that patient have any history of lumbar spine trauma/surgery? Does the patient have any history of DVT? Have you tried a bone stimulator or casting the patient to be NWB for 6 weeks? Have you run any labs? ANA sed rate, crp, uric acid, bpm, rheumatoid factor?
Mark Hinkes, DPM, Murfreesboro, TN, drhinkes@gmail.com
01/16/2013
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: The Self-Esteem of Podiatry 2013 (Gino Scartozzi, DPM)
From: Jack Sasiene, DPM
Dr. Scartozzi states: "The solution is quite simple, the decision to provide treatment procedures for a patient should not be contingent on where the source of payment will be coming from. It is not the practitioner who is responsible to routinely write-off services that are not covered by insurance carriers." This is my point exactly. Medical care in this country has been dictated by the insurance carriers. Medicare sets our fee payments, private insurance uses it, and have brainwashed patients into the concept that everything is covered and we are the guilty parties when we aren't. Why be put in the middle of that?
I wonder what "smart business doctors" like Jon Hultman, David Helfman, and Hal Ornstein would say about...
Editor's note: Dr. Sasiene's extended-length letter can be read here.
11/14/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Painful Stiff 1st MTP Joint After Bunionectomy with Implant (Barry Mullen, DPM)
From: Dennis Shavelson, DPM
Appreciating the biomechanical demands of this case must begin with a diagnosis of this patient’s foot type. Dr. Mullen hits the mark by discussing planal dominance on the sagittal plane in most hallux rigidus cases. Yet, we continue to focus our non-operative biomechanics on the frontal plane of the rearfoot with subtalar neutral casts with RF varus wedges and RF medial skives as the dominant modifications.
Collapse in the rearfoot, the vault, and the forefoot, is foot-type specific and exists mostly on the sagittal and transverse plane from the midtarsal joint distally. We will get better surgical results when we address this undeniable biomechanical fact.
Most of us are dispensing devices that have been constructed without any casting, and/or prescribing modifications directed to reduce or reverse the forefoot biomechanical pathology on their dominant planes where they exist. You wouldn’t fix a problem in your dining room by correcting the walls and floors of your living room.
We need sagittal and transverse plane dominant non-operative biomechanics to complement our sagittal and transverse plane surgeries before we begin aggressive PT and rehab, so aptly suggested by Dr. Mullen’s posting. That’s the future of biomechanics.
08/14/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Partial Thickness Torn Ligaments (Ivar E. Roth DPM, MPH)
From: Barry Mullen, DPM
The short answer to Dr. Roth's query is that I believe the best approach to repairing plantar plate tears is by the performance of a primary repair utilizing the "Arthrex Quick Fix" complete plantar plate system. This procedure is a relatively new technique that I first learned at the May, 2011 Civic-Kern Hospital Residents Alumni Association (CHRAA) annual meeting in Orlando, Florida. It was presented by Dr. Paul Goldsmith from Chicago, Illinois who provided an excellent synopsis of the technique and his short-term results. Dr. Goldsmith likely has some of the longest follow-up and most extensive experience utilizing this technique.
Hopefully, he reads this reply and elaborates upon my various comments...
Editor's note: Dr. Mullen's extended-length letter appears here.
07/02/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Implant Exchange (Alan Spector, DPM)
From: Steve Goldman, DPM, MBA
The HemiCap will pretty much pop out. The stem of that implant has a corkscrew pattern and will unscrew easily. I suggest looking at the Primus implant (tornierdx.com/futura/primus.php). I've been using it with some degree of success from both a cosmetic and patient relief perspective.
Steve Goldman, DPM, MBA, NY, NY, stevegoldman@att.net
06/25/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
From: John J. Hickey, DPM
I've had luck using transdermal Verapamil 15% gel from PDLabs- it's a non-invasive treatment also used for Peyronie's disease, but I'm not treating that with a ten-foot pole.
John J. Hickey, DPM, Levittown, NY, jhickeydpm@earthlink.net
05/25/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Lamisil, Tamoxifen Drug-to-Drug Interaction (Charles Morelli, DPM)
From: Elliot Udell, DPM
Dr. Morelli, I have a powerful request for you. Since most of us are not up on each and every drug and food interaction regarding the transplant patient, perhaps you can research and write a comprehensive paper on what all of us need to know when treating patients who have had organ transplants. Since you are personally close to this matter, you would most likely include important things that a person just glossing over the literature might overlook.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
05/18/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Soft Tissue Mass (Bryan Markinson, DPM)
From: Robert Lagman, DPM
I do appreciate the answers to my original post on this soft tissue mass. The patient is extremely hard to deal with and has yet to follow up on the repeat MRI with contrast as recommended. At his last visit, he said he feels that the tumor is a result of trauma from kicking against the side of the pool when making turns.
I have tried to express the importance of identifying and treating this soft tissue mass and hope he will follow up with the MRI. I am a little disturbed though when advice is given stating that if you have to ask the question on PM News, then you probably aren’t the best person to handle the patient and refer him to someone else. I feel that this is a terrible answer. Should this be our standard answer now when a clinical question is asked on this forum?
I pride myself on always putting the patient first and never getting in over my head. I feel that I am exceeding the standard of care with this patient and trying to get all opinions prior to moving forward. I will absolutely refer this patient if...
Editor's note: Dr. Lagman's extended-length letter can be read here.
03/20/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Do First MTP Joint Fusions Reduce the IM Angle? (Ed Davis, DPM)
From: Carl Solomon, DPM
I support Dr. Davis’ contention that the degree of hypermobility at the Met-cuneiform joint does have some bearing on this, which is why I commented anecdotally that hypermobility seems to make 1st MTP fusions even more capable of reducing IM angles. But my position that the procedure effectively reduces the IM angles is NOT just anecdotal. I tried to illustrate that and was criticized both here as well as in personal emails. So instead of taking my word for it, look at some studies (both orthopedic as well as podiatric) on your own. Please search key words “1st MTP joint arthrodesis + metatarsus primus varus.”
Among the many results is the following, which makes a rather compelling statement: “A separate proximal osteotomy for...
Editor's note: Dr Solomon's extended-length letter can be read here.
03/02/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Podiatric Physicians Practice Podiatric Medicine: RIP Podiatry (Leonard Levy, DPM)
From: Bryan C. Markinson, DPM
I will borrow a line from an old comic strip (Motley’s Crew) that I used to read. In the first frame, a character is frantically looking through the Yellow Pages. He is asked, “what are you looking for?” He replies that he hurt his foot and needs a foot doctor. He is told that, “they call themselves podiatrists.” In exasperation, he replies, “well, the first one who calls himself a “foot doctor” will become a millionaire!
That about nails this dilemma perfectly!
Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org
02/17/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Disposing of Old X-Ray Machines (Neil H Hecht, DPM)
From: Edmond F. Mertzenich, DPM, MBA
About two years ago, I had that dilemma. In Illinois, I contacted the Department of Nuclear Safety on how to dispose of the machine. Their requirement was that the glass of the x-ray tube be broken so that it could not be used by other people. As for the oil situation, after the bulb is broken, if your community has a program to collect hazardous waste, see if you can dispose of the part through them.
Edmond F. Mertzenich, DPM, MBA, Rockford, IL, doctoreddpm@frontier.com
01/10/2012
RESPONSES / COMMENTS (CLINICAL) - Part 2
RE: Doppler Study for Diabetics (Ron Werter, DPM)
From: Gerald Mauriello Jr., DPM
Simply, micro-vascular disease in a diabetic with palpable pulses is a very common occurrence. I am sure that many of us have had similar experiences, performing a TMA on a diabetic with a gangrenous forefoot in the presence of bounding pedal pulses. Dopplers are unable to assess microvasculature. Perhaps, consider transcutaneous oxygen pressures.
Gerald Mauriello Jr., DPM, Freehold, NJ, drmauriello@gmail.com
01/06/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Orthotic Therapy for Hallux Rigidus (John Scholl, DPM)
From: J.C. (Chris) Mahaffey, MS
The American College of Foot & Ankle Surgeons (ACFAS) recently completed its first multicenter trial research study, titled “A Multi-Center Retrospective Review of Outcomes for Arthrodesis, Hemi-Metallic Joint Implant, and Resectional Arthroplasty in Surgical Treatment of End-Stage Hallux Rigidus.” The study’s results will be published in the January/February 2012 volume of the Journal of Foot & Ankle Surgery.
The findings show all three of these surgical interventions are viable options for successful treatment. Radiographic and clinical evaluation cited the metatarsalgia as the most common finding for the arthrodesis group (9.8%), bony overgrowth into the joint for the hemi-implant group (28.3%), and floating hallux for the resectional arthroplasty group (30.9%). It was noted that surgeons may want to use this evidence to think about the patient who has failed conservative therapy, and use that knowledge to choose the surgical procedure with the best long-term outcome.
Currently, ACFAS is conducting a research study on subtalar arthroereisis for the symptomatic flexible flatfoot to be completed by early 2013. ACFAS members interested in becoming clinical sites or learning more about the study should see acfas.org/2012study/
J.C. (Chris) Mahaffey, MS, Chicago, IL, Mahaffey@acfas.org
12/07/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Life-Long Maintenance Regimen for Onychomycosis (Evan Meltzer, DPM)
From: Robert A. Kornfeld, DPM
What I believe is missing from the discussion of life-long management of onychomycosis is "why does this patient have it?" Since we know that these organisms are ubiquitous and everyone has potential for exposure, why do some have chronic tinea pedis and onychomycosis, and others do not?
Answering this question will establish life-long management, and it goes way beyond Lysol spray or preventing athlete's foot. One must look at mechanisms. A burdened immune system is at the core of chronic infection. Once you identify the mechanisms and control them, you have a more reliable life-long management protocol. To do this, you need to study this particular patient's epigenetic influences on inefficient immune response, and do functional/molecular lab work to establish the causative diagnosis.
Robert A. Kornfeld, DPM, Manhasset, NY, Holfoot153@aol.com
12/02/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Laser Treatment of Onychomycosis
From: Michael H. Simons, DPM, MS
I agree that there is little scientific basis for the claims of a "cure" and I feel that most claims are based on anecdotal information. Having over 15 years experience either chairing or serving on Institutional Review Boards (IRB's), I decided to become a Principal Investigator (PI) for Biolase Lasers in Irvine, California. I and my sub-investigators have constructed a protocol for an investigational study that has been approved by Western IRB and will include pre- and post-treatment cultures and photographs. This will be a year-long study and we treated our initial 35 subjects this month.
We have approval to enroll up to 100 subjects. Inclusion criteria calls for bilateral involvement and positive culture results. 8% Ciclopirox will be used in conjunction with the laser treatment on one side only to evaluate if this enhances the laser treatment. We will publish our results when the study is completed.
Michael H. Simons, DPM, MS, Vice-Chair, Memorial Health Services IRB Fountain Valley, CA, msimons@memorialcare.org
11/30/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Laser Treatment of Onychomycosis (George Stephen Gill, DPM, MBA)
From: Alan Silverstein, DPM
Dr. Gill published an excellent letter concerning his laser treatment of onychomycosis. I have no issue throwing everything there is, including the kitchen sink, all at once to help resolve a problem. Of course, this treatment regimen could never be subject to rigorous analysis. I also have no issue asking the patient to do three separate treatments at the same time.
My belief is that topical therapy is of limited usefulness except in the very early stages of nail infection. I just wonder how Dr. Gill 'sells' the laser for additional fees at the same time he is prescribing oral therapy? Again, I think this can be an acceptable approach. If most people opt for laser because of their concerns about systemic effects, I just wonder how he broaches this with the patient. Can he elucidate?
Alan Silverstein, DPM, NY, NY alel@optonline.net
11/11/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: IACS Physician Quality Reporting
From: Joseph Borreggine, DPM
I thought PM News readers would be interested in this item from CMS: What is the IACS (Individuals Authorized Access to the CMS Computer Services system) and how does it relate to the Physician Quality Reporting System (Physician Quality Reporting, previously called PQRI) and the Electronic Prescribing (eRx) Incentive Program?
IACS is the CMS enterprise Identity Management and Authentication system which implements the security requirements of Federal legislation, Federal Standards, and CMS policy. An IACS account is required to access TIN-level feedback reports. The IACS Quick Reference User Guides can be found on the Physicians and Other Health Care Professionals Quality Reporting Portal at qualitynet.org/pqri. The QualityNet Help Desk is available to assist eligible professionals with: general IACS questions; registering/creating an IACS account; accessing an IACS account; changing an IACS account; and approving users into an organization. They are available from 7:00 a.m. - 7:00 p.m. CST Monday through Friday at 1-866-288-8912 or TTY 1-877-715-6222 or via e-mail to Qnetsupport@sdps.org
Joseph Borreggine, DPM, Charleston, IL, footfixr@consolidated.net
10/21/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Plantar Fibromas
From: William B. Crawford, DPM
Plantar fibromas and fibromatoses are solid, fibroblastic, benign lesions of the plantar aponeurosis. Painful lesions are the result of trauma from plantar pressures or mass effect. I fail to understand the rationale of steroid injection, needling, or the like, into a non-inflammatory solid mass. If it is asymptomatic, leave it alone. If it is chronically painful, remove the lesion. Window the aponeurosis with margin, leaving the subfascial fat, and it will not return in that location. Multi-nodular fibromatoses may require large windowing or resection of most of the aponeurosis slip. Results are uniformly good. Sometimes conservative treatment is surgery.
William B. Crawford, DPM, Ocala, FL, wcrawf1052@embarqmail.com
10/19/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: TightRope for Hallux Valgus (Michael B. DeBrule, DPM)
From: Joseph Menn, DPM
Dr. DeBrule asks how he can minimize complications with this procedure. Yeah. Don't do it. Seriously, do you really think that we can overcome the structurally abnormal forces of an HAV deformity by WIRING the metatarsals together? Do you really think that it has any chance at all of withstanding the force of a 205 pound patient in full stride of a run....held together by a little tiny wire?
Where oh where do these crazy ideas come from? Oh yeah, someone lectured about how freakin' great it was. And the masses believed. Procedures like these remind me of...
Editor's Note: Dr. Menn's extended-length letter can be read here.
10/18/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Mini TightRope for Hallux Valgus (Michael B. DeBrule, DPM)
From: Zeeshan Husain, DPM
Arthrex has a newer system that came out over a year ago with a small plate that you put on the lateral side of the 2nd metatarsal. The suture is passed through the same way and the buttons fit into slots on the plate. The idea is to disperse the stress over a larger surface area to minimize stress risers at the drill sites. Talk to your Arthrex reps, and they will provide you with the newer system.
Zeeshan Husain, DPM, Rochester, MI, zee@alum.mit.edu
10/11/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Painful 1st MTPJ (Brian Timm, DPM)
From: Greg Caringi, DPM
I have always been very interested in both the surgical and non-surgical treatment of painful hallux rigidus. When the joint is unable to be salvaged, I generally perform an interpositional arthoplasty - Keller procedure with modifications shown to me by Dr. James Ganley. In my hands and with 30 years of practice, I have had excellent short and long-term results. There are, however, times when an arthrodesis is more appropriate.
What is the consensus opinion for the best surgical technique - fewest complications and best durability - for arthrodesis of the 1st MTP Joint?
Greg Caringi, DPM, Lansdale, PA, drgregc@msn.com
08/09/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Medial Malleolus Screw Removal (Gary Bjarnason, DPM)
From: Neil A Burrell, DPM
All the comments on removing a screw from the medial malleolus reminds of the time a well respected orthopedist in our community went in to remove a screw from a patient's hip. The patient had her original surgery in another state. When he got to the screw head, he realized that he had never seen anything like it before. He called maintenance and had them bring up every screw driver they could lay their hands on. He found the correct screw driver, had it sterilized, and successfully removed the screw with no complications, short-term or long-term.
Neil A Burrell, DPM, Beaumont , TX, nburrell@gt.rr.com
08/08/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Medial Malleolus Screw Removal (Gary Bjarnason, DPM)
From: James E. Rogers, DPM
Make a stab incision near the head of the screw with a #11 blade (no more than 1/4 inch). Clean any bone debris out of the screw head with a #64 blade or micro-curette, if necessary. Use an appropriate hex head screwdriver - counter clockwise twist (rightie - tightie; lefty - loosie). One stitch should take less than five minutes. Done!
James E. Rogers, DPM, Nashville, TN, drjimbob@comcast.net
