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02/16/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Etiology of Hallux Varus (Dennis Shavelson, DPM)
From: Stephen M. Pribut, DPM
When I think of the muscle engine that drives a ballerina from plié to en point, I think of the flexor hallucis longus. This is the muscle that is driving the ballerina onto point. The peroneus longus is functioning as an important stabilizer of the ankle. Yes, it has a significant impact on the first ray in gait, let alone ballet, but let us not confuse the peroneus longus with the FHL which is the primary en point enabling muscle.
Stephen M. Pribut, DPM, Washington, DC, pribut@earthlink.net
Other messages in this thread:
09/13/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Recurring Lesions
From: Ed Cohen, DPM
I have seen about 10 of these lesions in the last 35 years. They are usually on the second toe and many times bilateral. I have had great success doing an MIS partial plantar proximal phalangeal head resections, and occasionally an MIS proximal phalangeal head resection. As far as I know, everyone of these surgeries has been successful in getting rid of these lesions.
Ed Cohen, DPM, Gulfport, MS, ECohen1344@aol.com
06/11/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Recurring Skin Lesions
From: Gino Scartozzi, DPM
Radiographs would be helpful to determine underlying factors contributory to the redevelopment of these lesions. However, I suggest it is possible that the third metatarsals are elongated relative to the adjacent second metatarsals. Such elongated metatarsal positions may be contributory to such biomechanically-induced lesions on the plantar aspect of the third toes seen despite toe arthroplasties being previously performed.
If the third metatarsals are elongated relative to the adjacent metatarsals, I suggest orthotic management, or shortening osteotomy of the third metatarsals if orthotics fail.
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
06/10/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Recurring Skin Lesions
From: Elliot Udell, DPM, Jon Purdy, DPM
I have seen many similar lesions. I like to keep things simple and work upward from there. With an unknown skin lesion step-one is biopsy and send the specimen to a dermatopathologist. If benign, it’s time to break the cycle of formation. I simply apply a high potency steroid under occlusion. It will resolve and may need to be performed from time to time. Many times, never again.
Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com
This patient might benefit from gait pressure studies in order to determine if there is excess pressure beneath those areas during gait. There are many products available that can perform this study. The one we use is the inexpensive carbon paper based device. The person walks over it and it determines where there is excessive pressure during ambulation. There are computer-based electrical plates that do the same thing. If it is determined that this is the case, then you can address the problem biomechanically and design a set of orthoses to correct the problem. Such information may also help if you intend to address the problem surgically.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
05/08/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Chronic First MPJ Pain (Don Peacock, DPM)
From: Charles Morelli, DPM
Not having seen this patient and basing these comment solely on the x-ray, I respectfully submit that this patient's condition was never addressed properly. Pre-op, there is an elevated first met and despite efforts to plantarflex the head, it is still dorsiflexed. Pre-op, there is a dorsal exostosis, and I would be surprised if there is any increase in hallux dorsiflexion. The dorsal bump was not removed aggressively enough and removing part of the dorsal aspect of the base of the proximal phalanx could have also been considered.
If you make a template and find the CORA, I believe you will see that this patient could have benefited from a Cotton procedure that would have required a graft and possible plate; depending on graft chosen. I don't want to, nor will I, get into a debate about MIS vs. open, but this case required more that a 1.5 cm incision and needed to be treated much more aggressively.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
04/19/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Wart Covered Foot (David Kahan, DPM)
From: David Hettinger, DPM, Elliot Udell, DPM
I would ABSOLUTELY get him on a regimen of cimetidine 400mg tid for twelve to sixteen weeks. (JAPMA, November 1, 1995 vol. 85 no. 11 717-718).
David Hettinger, DPM, Wheaton, IL, davidhett@msn.com
I have often seen cases of verrucae, especially mosaic verrucae spread all over the bottom of a persons' foot. It is rare but possible to see it spread to the hands. There might be more going on with this patient than verrucae. You might wish to do a "scoop out" procedure on one or two of the warts and send them to a dermatopathology lab in order to be certain that you are indeed treating verrucae. You might also want to send this patient to an immunologist in order to rule out the possibility of a deficiency in his immune system.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
04/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Unresponsive Vesicular Dermatitis (Mark Aldrich, DPM)
From: Bryan C. Markinson, DPM
It may be time for an IM injection of 40 to 60 mgs of Kenalog. However, before you do that, the patient should be patch-tested for shoe chemical allergies. It is quite possible that with the bazooka treatment the patient is getting, exposure to the primary allergen continues unabated. That should be addressed. You can send the patient to an allergist or do the testing yourself with the T.R.U.E. Patch testing kit.
Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org
04/08/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Recalcitrant Heel Pain (Loren J Miller, DPM)
From: Stephen Musser, DPM, Edmond F. Mertzenich, DPM, MBA
Although the pain is unilateral, I suggest ordering a rheumatoid profile to rule out any seronegative arthropathies. In addition, I would also order a Tc99 triphasic bone scan and look for a possible stress fracture. Keep us posted, this sounds like an interesting case.
Stephen Musser, DPM Cleveland, OH, ly2drmusser@gmail.com
I recommend looking into the possibility that the patient has some back-related issues, i.e., bulging disc, lumbar arthritis, spinal stenosis, radiculopathy, and sciatica-type problems. I have frequently seen patients complain of heel pain and by asking a few more questions, it turns out that the problem was related to a more proximal issue.
Edmond F. Mertzenich, DPM, MBA, Rockford, IL, doctoreddpm@frontier.com
04/05/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Recalcitrant Heel Pain (Loren J Miller, DPM)
From: Andrew Levy, DPM, Corey Fox, DPM
What does the MRI show about the inferior calcaneal bursa?
Andrew Levy, DPM, Jupiter, FL, rcpilot48@gmail.com
I applaud Dr. Miller's approach to the stubborn heel pain patient. At this point, I recommend an ankle MRI to rule out a partial rupture of the plantar fascia near the insertion, most likely involving the central band. If so, then it's 4-5 weeks of immobilization in a cast, WB or NWB, depending on severity. Use a cast as opposed to Cam-Walker, because" removable cast" means the patient will do exactly that - remove it. This is a good treatment, even for fasciitis with no rupture. Then, for fasciitis or fascia rupture, try TOPAZ (Arthrocare) coblation. It's an 8 minute percutaneous procedure with excellent outcomes and minimal complications.
Corey Fox, DPM, Massapequa, NY, fox.corey@gmail.com
04/03/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Post-op Varus (Joshua Kaye, DPM)
From: Gary W. Docks, DPM
I see Dr. Kaye's dilemma, but the negative IM angle was never addressed in the first place. A reverse Austin osteotomy would have corrected it nicely. Over the years, I have run into this many times. Assuming this 74 year old female is amenable to another surgery, I would follow the "keep it simple, stupid" rule and perform a double-stemmed Swanson implant and do soft tissue releases on the 2nd and 3rd MPJs (medial capsulotomies and release of medial tendinous structures) to provide room for the straightened hallux.
Performing a lst MPJ fusion without doing anything to the 2nd and 3rd MPJs will result in a "sore" in the lst interspace post-surgery. The double-stemmed implant will provide stability and, at her age, will suffice for the rest of her lifetime. I'm sure you're going to encounter a good amount of scar tissue from the two previous surgeries, which will require that you create a new tissue plane and shell out a good portion of the fibrous tissue from the inside of the capsular structures. If you leave all that scar tissue there, it will definitely hinder motion at the lst MPJ post-op. Much good luck with the re-do.
Gary W. Docks, DPM (RET), Chardon, OH, gwdocks@aol.com
03/12/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Efficacy of Lasers for Onychomycosis (Burton Katzen, DPM)
From: Burton Katzen, DPM
In response to the storm of e-mails I have received (many from laser companies and collegues associated with laser companies), I never said that lasers were not one of several effective methods for treating onychomycosis. I’m sure they would have not received FDA approval if they weren’t. However, that being said, I was never promoted a laser by a company showing me copies of pre- and post-laser lab reports, only pre- and post-laser nail photographs.
Also, in my opinion, patients would not be overly impressed with negative post-laser cultures after spending the money if their nails are still thick and “ugly.” Whether the companies or my colleagues care to agree, the patient’s perception is that they will come in with an ugly nail and leave with a pretty nail. My only point was that I believe it would be unethical not to tell patients that this may not be true in the majority of cases. Once again, my only warning to colleagues contemplating purchasing a laser is to not promise your patients with thick nails “beautiful nails” in six months.
In my experience, it’s not going to happen, and both of you will be disappointed. It was frustrating enough in the past explaining to patients that if you take Lamisil pills, all the “little fungus people” won’t run out in horror from underneath your nails.
Burton Katzen, DPM, Temple, Hills, MD, DrburtonK@aol.com
03/11/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Efficacy of Lasers for Onychomycosis
From: Scott Day, CEO
Managing patient expectations is paramount to any successful medical practice. All legitimate laser companies that have gained FDA clearance to market their laser in podiatry can officially state "temporary increase in clear nail." Nowhere in that statement do we claim "new pink nail" or "thinner nail." Although these two claims would be nice, they are not necessary to maintain satisfied laser patients. It is enough to offer your patients hope to improve the appearance of their nails.
Most established and successful laser practices have effectively managed their patients' expectations. Those expectations are based on "improvement in the appearance." The key is improvement from the baseline, which is recommended to be documented with photographs. Surprisingly, often these patients see positive change before the podiatrists do, but photographs serve as a helpful reminder.
Patients, who are willing to pay cash, often are embarrassed about how their nails look. Most of your current patients are resigned to live with a personally disgusting condition for which their foot specialist has no viable solution. The laser gives your patients new hope to look and feel better. The fact that you have invested in a technology that gives your patients an alternative treatment option speaks volumes about you as a medical practitioner. How effective you manage your patients' expectations will determine your patients' satisfaction with your laser service. As a medical practitioner, the laser you purchase (or not) is only one variable in your ultimate success.
Scott Day, CEO, Hyperion Medical, sday@hyperionmed.com
03/09/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Efficacy of Lasers for Onychomycosis (Tip Sullivan, DPM)
From: Michael B. DeBrule, DPM
There is a great review article from Jennifer Ledon from Miami looking at evidence for laser and light therapy for toenail fungus, "Laser and light therapy for onychomycosis: a systematic review." Ledon JA, Savas J, Franca K, Chacon A, Nouri K., Lasers Med Sci. 2012 Nov 20.
There are a lot of variables to consider: which laser to purchase, optimal laser settings, number of treatments, time between treatments, marketing, etc. Most studies are glorified case series (excluding the recent study by Landsman). Landsman, et al. found most patients improved with regard to appearance, but only about one third of patients had both clear nail growth and negative cultures. Laser is a good treatment option without the side-effects of oral therapy, but we need more studies!
Michael B DeBrule, DPM, Richfield, MN, innovativefootcare@gmail.com
03/02/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A (CLOSED)
RE: Fixation Vs. Non-Fixation of Osteotomies (Gino Scartozzi, DPM)
From: Charles Morelli DPM
I too echo Dr. Scartozzi's comments regarding a met head "seeking" its own level. With the exception of some salvage procedures and some specific neurological deformities, there are very few metatarsal osteotomies that I would ever do without fixating them in some manner. All you need is one or two complications early on in your career to teach you that lesson, regardless of what the literature says or what orthopedists have been doing for years with the "V" osteotomy.
Another life lesson learned early on is that there is one thing you never want to mess with and that is the metatarsal parabola. Once that is done, you have other problems that can last years (transfer lesions, ulcerations, bursitis, stress fractures, lawsuits, etc.), and there are few things worse in private practice than to have the same patients come back to the office month after month, year after year, so you can manage the problem you just caused.
Do yourself a favor. When in doubt, fixate it. You will sleep better and so will your malpractice carrier.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
Editor's note: This topic is now closed and no further letter will be accepted or published.
02/21/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A (CLOSED)
RE: Etiology of Hallux Varus
From: Vincent Gramuglia, DPM
The current debate over the biomechanics of the post-operative bunion has left me longing for a simpler time in PM News when we debated the intricacies of mycotic nail billing in nursing homes. Boy do I miss the good old days!
Vincent Gramuglia, DPM, Bronx, a2onpar3@optonline.net
Editor's note: We agree, and we will be closing this topic with today's notes.
02/15/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Etiology of Hallux Varus (Eric Fuller, DPM)
From: Dennis Shavelson, DPM
Hallux valgus occurs in the flexible forefoot functional foot types, with few exceptions. As Dr. Fuller mentions, this foot type characteristically is attached to an inhibited (exhausted), poorly leveraged, poorly trained peroneus longus muscle engine that cannot oppose the increased dorsiflectory stiffness of the first ray that exists in this foot type.
Wellness biomechanics addresses this problem by vaulting the foot, utilizing foot type-specific casting and lab corrections and modifications that allow the PL to be trained stronger and become better-leveraged and motor-controlled. This innovative, evidence-based biomechanics platform replaces subtalar joint neutral biomechanics with one that actually puts the DPM in the driver's seat.
Think of the peroneus longus muscle engine in a ballerina who has trained it so well that she can stay en pointe. In addition, the number one injury in ballet is to the 1st MP joint when there is underlying foot type pathology or poor training technique. This confirms my claims, as this is the same mechanism for bunion formation in the average Joe or Jane.
Dennis Shavelson, DPM, NY, NY, drsha@foothelpers.com
02/11/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Etiology of Hallux Varus (Jordan Sheff, DPM)
From: Edmond F. Mertzenich, DPM, MBA
I recommend looking into some form of rheumatological problem or some form of neurological problem. I did a Web search on spontaneous hallux varus and Pubmed came up with an abstract of 5 cases by Grandberry on "Idiopathic Adult Hallux Varus" in Foot Ankle Int. (1994 Apr; 15(4): 197–205). Jahss published two cases of spontaneous hallux varus in Foot and Ankle International, January 1983. In Jahss' article, one of the patients had a past history of polio. Look at these articles. They may assist you.
Edmond F. Mertzenich, DPM, MBA, Roscoe, IL, doctoreddpm@frontier.com
12/22/2012
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Displaced MBA Implant
From: Zeeshan Husain, DPM
The arthroereisis implant allows the soft tissue to remodel and sustain the correction after removal beyond 6 months. When I was a resident, we were investigating the corrections achieved by the use of the MBA implant and also tracked a few patients after they had them removed. The removals included patients who had the implants in for at least three years. Once the implants were removed, radiographic angles were unchanged, and correction was maintained.
There is enough scar tissue that forms that seems to allow the subtalar joint to stay in place. I suggest a wait and see approach to what happens to the foot after removal. Otherwise, it is not possible to predict what will be needed to maintain the correction.
Disclosure: I have no financial relationships with any implant company.
Zeeshan Husain, DPM, Rochester, MI, zee@alum.mit.edu
12/11/2012
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: A1c and Elective Foot Surgery (Tip Sullivan, DPM)
From: Dan Klein, DPM
I define elective surgery as any surgery that is not limb- or life-threatening. My understanding is that when a diabetic exceeds 160mg/dl, the WBC cells do not function, thereby increasing the risk for post-op infection. I have always required all my diabetics who are undergoing elective surgery to keep their blood sugar to less than 160. I prefer an A1C of less than 7.
Dan Klein, DPM, Fort Smith, AR, toefixer@aol.com
12/10/2012
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: A1c and Elective Foot Surgery (Allen Jacobs, DPM)
From: Gino Scartozzi, DPM, Neil A Burrell, DPM
The standard that I have used within my practice for elective procedures in diabetics has been 7.5 mg%.
Gino Scartozzi, DPM, New Hyde Park, NY, gsdpm@aol.com
The Texas Diabetes Council, Texas Department of State Health Services in 10/29/2009 adopted new guidelines for physicians in the state of Texas. The recommendation of an A1c between less than 6 up to 8 was adopted based on type of diabetes, age of the patient, duration of diabetes, and of course co-morbidities. This information as well as all the TDC algorithms can be found at tdctoolkit.org/algorithms_and_guidelines.asp
Neil A Burrell, DPM, Beaumont, TX, nburrell@gt.rr.com
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