09/10/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1C
RE: Gangrene S/P Cast Complication
From: Khurram Khan, DPM
What type of procedure was performed? Is it a possible compartment syndrome after the surgery? Sickle cell? Vasculitis? All these need to be worked up.
1- Given the proximal aspect of the incision site, refer the patient to vascular to assess the PT artery - it may have been injured in the surgery both at the ankle and its branches in the midfoot.
2- PT nerve block for sympathetic blockade.
3- Nitro paste/patch for vasodilation in the area.
4 - Warm compress behind the knee.
5 - An anecdotal suggestion would be to use Metanx to help NO production.
Khurram Khan, DPM, NY, NY, khankhurram@hotmail.com
03/12/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1C
RE: Efficacy of Lasers for Onychomycosis
From: Dale Feinberg, DPM, CPed
The conversation here is really between efficacy and reality. If one performs a bunionectomy with less than desirable results, you do not refund your fees. If you invest in the most advanced ultrasound technology and get reimbursed at 20% of the golden day fees, you do not complain. You have invested in and practice retail medicine, yet accept wholesale reimbursements.
You are a pawn in the game. Imagine bringing home a shiny new BMW and telling the dealer to bill some random car payment company who randomly decides if, when, and how much to reimburse the dealership. When I turn on my Cool Breeze laser several times a day, I have already been paid MY pre-determined professional fee and feel like the king of the world. So, if there's something wrong in the neighborhood, who ya gonna call- "Fungus Busters."
Dale Feinberg, DPM, CPed, Yuma, AZ hd5bl@aol.com
03/11/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1C
RE: Efficacy of Lasers for Onychomycosis
From Michael Turlik, DPM
Therapeutic efficacy is best determined from level-1 evidence to include: randomized, controlled trials and a systematic review of pooled trials. Laser therapy for onychomycosis is promoted as an alternative to oral therapy. I am unaware of any valid level-1 evidence which demonstrates laser to be equivalent or superior to oral therapy.
Landsman and associates published a placebo-controlled trial in JAPMA evaluating the efficacy of laser in the treatment of nail fungus. I am unaware of any other comparative trials of laser for nail fungus. The Landsman study is an industry-sponsored study. The reader should carefully read the article to assess the validity and relevance before accepting the conclusions.
With the paucity of valid published trials, I am amazed anyone would be confident enough to use laser in the treatment of nail fungus. It may be an effective treatment, but in my opinion, there is no level-1 evidence to support the use of this expensive therapeutic option. This is what healthcare critics would suggest as costs which do not show an improvement in patient-centered outcomes.
Michael Turlik, DPM, Cleveland, OH, mmturlik@aol.com
03/09/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1C
RE: Efficacy of Lasers for Onychomycosis (Burton Katzen, DPM)
From: Marc Katz, DPM
I can understand Dr. Katzen's frustration and difficulty having to deal with telling patients that laser did not work. Well many of our colleagues really don't care if it works; it pays their Lexus payment. The other issue is that we listen to salespeople who don't know anything about onychomycosis. They only know how to sell lasers and do what is in their best interest. They may tell you that their laser is so amazing that it will kill all fungus in just one treatment! And it will also clean out your garage for you too!
Laser is an excellent option to treat the chronic nail condition known as onychomycosis. Laser treatment is not a cure. It is part of a comprehensive treatment plan for fungal nails. Patients require maintenance treatments to keep the chronic condition controlled. They require lifetime topicals and should use a Steri-shoe. Does anyone complain to their dentist that they need to have their teeth cleaned multiple times per year? Do they complain that their teeth aren't 100% white and that they still need to pay? No! Because dentists explain the real story to their patients as we should be doing with ours. They are not afraid to treat chronic mouth infections and make you pay cash each time forever.
Adopt the dental hygiene model like I do, and let's make podiatrists the experts for treating this chronic nail condition! All it takes is honesty.
Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com
03/01/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1C
RE: Fixation Vs. Non-Fixation of Osteotomies (Randall Brower, DPM)
From: Sheldon Nadal, DPM
What Dr. Brower is missing is that a minimally invasive surgical first metatarsal osteotomy differs from a post-traumatic fracture in that it is a planned osteotomy, not an accident.
Minimally invasive sagittal plane V-osteotomies such as that used in a modified Wilson or Austin bunionectomy, or a first metatarsal head osteotomy such as the Reverdin-Isham bunionectomy, when performed properly, are designed to be much more stable than a post-traumatic first metatarsal fracture. In most cases, these bunion surgeries can be fixated adequately by impacting the capital portion of the osteotomy onto the first metatarsal shaft, followed by appropriate post-operative bandaging and footwear. If the situation calls for it, osteotomies can even be fixated percutaneously.
If Dr. Brower is really interested, I invite him to attend the next conference of the Academy of Foot and Ankle Surgery at the Louisiana State University in New Orleans June 20-22, 2013. We will be happy to teach him the procedures in the cadaver lab.
Sheldon Nadal, DPM, Toronto, Ontario, Canada, shel14@rogers.com
02/21/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1C (CLOSED)
RE: Etiology of Hallux Varus (Dennis Shavelson, DPM)
From: Jeffrey Root
I appreciate Barry Mullen, DPM’s supportive words about the value of "Rootian" biomechanics. I don’t necessarily understand Dr. Shavelson’s explanation of his own theories or some of his attempts at describing the biomechanical theories of Merton L. Root, DPM, et al.
In his reply to Dr. Mullen, Dr. Shavelson stated “Discussing a re-alignment of the hindfoot in the same breath as hallux valgus and varus reveals an American podiatry fixation that is...
Editor's note: Mr. Root's extended-length letter can be read here. This topic is now closed and no further letters will be posted.
