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02/18/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: The Biomechanics of The First Ray in Dance (Stephen Pribut, DPM)
From: Dennis Shavelson, DPM
Dr. Pribut’s comment is well appreciated. It debates “who is the captain of the “en pointe” team." As the ballet cascade goes from rearfoot to forefoot, if the first ray is not stabilized as a unit to provide the necessary leverage to the flexor hallucis longus to take a dancer en pointe, the dancer’s career and performance will suffer.
In my opinion, the peroneous longus is the quarterback of the task. I used it in my dance analogy because it performs the same indispensible function in gait as well as in most biomechanical functions including the development of hallux valgus and varus. That was the “en point” I was trying to make.
Dennis Shavelson, DPM, NY, NY, drsha@foothelpers.com
Other messages in this thread:
09/13/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1B
RE: Recurring Lesions
From: Elliot Udell, DPM
What is disconcerting about this case history is that it appears that after futile attempts at debridement of the lesions, deep skin followed by tendon and osseous surgical procedures were chosen. Why wasn't a biomechanical exam performed along with an attempt at the judicious use of orthotics? The lesions are symmetrical and on weight-bearing surfaces and if abnormal biomechanics turns out to the culprit, short of amputation, no surgery will alleviate this patient's problems.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
09/12/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1B
RE: Recurring Lesions
From: Dan Klein, DPM, Jeffrey Kass, DPM
These keratotic lesions look like foreign body reaction to warts. The skin appears to be moist and there appears to be a small raised lesion proximal to the main lesion on the left foot. A biopsy may prove the culprit. I have seen similar lesions. Shaving the callus may disclose deeper mosaic lesions.
Dan Klein, DPM, Fort Smith, AR, toefixer@aol.com
I find the objective findings to be a bit puzzling. If intrinsic muscle i.e., the FDB, plantarflexed the head of the proximal phalanx, the distal portion of the toe would either be through the ground or dorsally subluxed. In the picture shown, the toe looks like an average hammertoe, other than the lesion. There does not appear to be any dorsal dislocation of the distal end of the toe. How exactly could the head of the proximal phalanx be plantarflexed otherwise? In traditional hammertoes, the head of the proximal phalanx are dorsiflexed.
Jeffrey Kass, DPM, Forest Hills, NY jeffckass@aol.com
09/12/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Recurring Lesions
From: Richard A. Simmons, DPM, Andrew Levy, DPM
Ask the pathologist to re-evaluate the slides and send them out for another opinion as a primary recommendation.
Andrew Levy, DPM, Jupiter, FL, rcpilot48@gmail.com
The concern is recurring hyperkeratotic lesions. The pathology report on biopsy stated: “Clavi x2.” I recommend another biopsy (2-3 mm punch) and send the specimens to a dermatopathologist for a more comprehensive report. My office utilizes the services of Bako Pathology.
Disclosure: I have no financial interest or relationship to Bako Pathology.
Richard A. Simmons, DPM, Rockledge, FL RASDPM32955@gmail.com
09/10/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Gangrene S/P Cast Complication
From: Ron Raducanu, DPM
Your idea of HBO is an excellent one. A vascular consult is highly recommended, if for nothing else than to have another name in the records, but more importantly to assess the level of potential outcomes. I think this young man/woman has a great chance of recovery. Young arteries and patients are extraordinarily resilient. Very interesting case. Please keep us posted on the outcomes. Serial photos would be amazing!
Ron Raducanu, DPM, Philadelphia, PA, kidsfeet@gmail.com
08/29/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1B
RE: PT Course After EHL Repair
From: Peter Bregman, DPM
If you feel great about the repair, then start active ROM at 2 weeks; if not, then wait 4-6 weeks. Fortunately, you do not need great ROM of the toe. It just needs to move and not be flail (even in an amateur athlete). One of the other things I like to do is throw a K-wire through the big toe to maintain the repair for however long you want to immobilize it. I always like to use amniotic membrane in these repairs, and it is never too late to inject some amniotic fluid around the repair. My preferred choice is Amnio FloGraft (Applied Biologics)
Disclosure: Dr. Bregman has been a paid lecturer for Applied Biologics.
Peter Bregman, DPM, Las Vegas, NV, drbregman@gmail.com
08/29/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: PT Course After EHL Repair
From: Marc Mizrachy, DPM
I had a very similar case a few years ago. A 23 year old woman had dropped a large piece of glass on her foot. Following primary repair, I waited 6 weeks before sending her to physical therapy, and she ended up with an excellent result.
Marc Mizrachy, DPM, Hillsborough, NJ, marcmiz@comcast.net
08/27/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1B
RE: Metatarsalgia Post-op Hammertoe Surgery
From: Ed Cohen, DPM
The contracted 2nd toe and a HAV with bunion is a common problem seen in our office. I usually start off with an MIS proximal phalangeal osteotomy at the base of the 2nd toe; then a flexor tenotomy and possibly a PIPJ capsulotomy. A 2nd extensor tenotomy and 2nd MPJ capsulotomy should also be done. Another osteotomy at the neck of the 2nd proximal phalanx and a 2nd metatarsal osteotomy should straighten the toe, and it should purchase the ground. A Reverdin- Isham bunionectomy would correct the HAV bunion deformity. The fixation would have to be removed at the start of the surgery. This should also help correct the metatarsalgia.
Based on the length of the metatarsals, it is unlikely that a 3rd and/or 4th metatarsal osteotomy will need to be performed. I would like to see the plantar aspect of the foot to see which metatarsals are plantarflexed, and then I would palpate the heads of the metatarsals to see which ones are painful. If this patient didn't have metatarsalgia, a 2nd metatarsal osteotomy would probably still need to be performed to get the toe to purchase the ground. The advantages of using MIS surgery is that the procedures are relatively atraumatic and there is immediate ambulation, which is good for any patient, especially a 72 year old. The cosmetic and functional results are usually excellent.
Ed Cohen, DPM Gulfport, MS, ECohen1344@aol.com
08/27/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Metatarsalgia Post-op Hammertoe Surgery
From: Peter Bregman, DPM
If you're looking to achieve surgical correction to give this patient a pain-free ambulatory foot, this is what I recommend. You can determine if the plantar plate is ruptured on the second digit which is likely detected by getting an MRI. If the plate is ruptured, then you have to perform a repair of the plate by any number of methods in order to help keep the second toe down, which would include a shortening osteotomy of the second metatarsal. Fix the hallux valgus with a proper osteotomy, and check and fix equinus if needed.
Peter Bregman, DPM, Las Vegas, NV, drbregman@gmail.com
08/19/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Bulbous Toes Bilaterally (David Kahan, DPM)
From: Steven J. Kaniadakis, DPM
This appears to be a result of inflammation. After changing the patient's shoes, consider an IM corticosteroid, as you might use for neuritis, such as when a nerve becomes scarred down from a Morton's neuroma. This diagnosis might be considered, especially if the "bulbous" distal toe pulps are slightly erythematous.
Steven J. Kaniadakis, DPM, Saint Petersburg, FL stevenkdpm@yahoo.com
08/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Bulbous Toes Bilaterally (David Kahan, DPM)
From: Stephen Musser, DPM
First, wait and see how she responds to the buttress pad treatment. Second, ask her if she has been in a pool a lot this summer. I've seen similar presentations when patients have been in a pool that has a rough bottom finish.
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
08/15/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Non-union Following a Lapidus Procedure (Barry Francis)
From: Tip Sullivan, DPM, Andrew I. Levy, DPM
As we say down here in the South, “Don’t you be kicking that skunk!” The patient is happy and is well aware of the issues. She knows her options – let her kick the skunk if she so chooses.
Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net
Caccio, et al., in J Bone Joint Surg Am. 2010 May;92(5):1241(ncbi.nlm.nih.gov/pubmed/19884432) presented the use of extracoporeal shockwave to treat non-unions. Dr. Rompe presented the paper at the International Society of Medical Shockwave Treatment meeting in Chicago in 2011 as a level-1 study showing a faster return to union and better short-term clinical outcomes than traditional open surgical repair in long bones. At 12 and 24 months, the outcomes were equal, but the patients did not need surgery.
I also use ultrasound bone growth simulators for slow healing fractures and osteotomies. To me, it is also critically important that the patient does not smoke and avoids secondary cigarette smoke.
Andrew I. Levy, DPM, Jupiter, FL, rcpilot48@gmail.com
08/14/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)
From: Dan Klein, DPM, Daniel Waldman, DPM
I suggest evaluation for medial calcaneal nerve injury. Perhaps RF treatment may give relief. Radio-Frequency treatment has proven to be successful in these cases.
Dan Klein, DPM, Ft. Smith, AR, toefixer@aol.com
Many of my patients with acute and chronic plantar fasciitis have benefited from MLS laser therapy. I have been using the MLS Laser from Cutting Edge for 8 months and am impressed with its efficacy in many challenging cases. I have my patients come in 2 to 3 times a week for a month for the laser treatments. Understanding proper laser settings and area(s) treated is critical for a successful outcome whether treating plantar fascia, tendonitis, neuromas, or other anatomic regions.
Daniel Waldman, DPM, Asheville, NC, dpmcareer@me.com
08/13/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Staged Procedures for Digital Deformities (Barrett E Sachs, DPM)
From: Ivar E. Roth DPM, MPH
While Dr. Sachs' claims that he would get better results by performing surgery one foot at a time, that is a wives' tale. It all comes down to training and doing a proper surgical repair in the first place. I have been doing bilateral forefoot surgery since the beginning of my career, thirty years, and have not had any problems whatsoever. Of course, I perform it only where and when it is appropriately indicated. I have observed and heard through my podiatry contacts that the most common reason to operate on feet at separate times is purely financial.
The results of staging surgery is not what is best for the patient, having them pay twice for services and go through anesthesia twice, etc. Let’s be honest - most podiatrists use this story about patient safety for one purpose only, and that is to make more money. Those doctors who really believe one foot should be done at a time either are not doing adequate surgical correction or believe a wives' tale that just is not true.
Ivar E. Roth DPM, MPH, Newport Beach, CA, ifabs@earthlink.net
08/08/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1B
RE: Diagnostic Ultrasound (Thomas Graziano, DPM, MD)
From: Ira Baum, DPM
I agree with Dr. Graziano’s summation regarding the use and abuse of diagnostic ultrasound. However, I want to address the myth of the “series of 3 steroid injections” for plantar fasciitis. As an initial treatment of acute plantar fasciitis, I provide the patient the option of a steroid injection. I also address the biomechanical etiology (if it is a biomechanical etiology). If the patient’s response is a reduction of symptoms, my focus is directed at the etiology, and phasing out of treatment of the inflammation and incrementally increasing their activity level. I know Dr. Graziano, and I know he follows a similar path of treatment, but I don’t think a series of steroid injections has any rational basis as a protocol.
Ira Baum, DPM, Miami, FL, ibaumdpm@bellsouth.net
08/03/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Freiberg's Infraction in a 14 Year Old (B. Lee, DPM)
From: Robert Baron, DPM, Dennis Shavelson, DPM
Are you sure it is a Frieberg's infraction? Marrow signal changes of the metatarsal head on MR tend to be non-specific but could represent a stress response (contusion) or even a subchondral fracture which can be easily overlooked. How long was she symptomatic before seeking professional care? I recommend a follow-up MR in 6-8 weeks or before allowing her to resume any strenuous physical activity.
Robert Baron, DPM, Willowbrook, IL, robert4261@aol.com
Without seeing x-rays or vascular studies, biomechanically, the logical thing to do is to reduce the load, function, and responsibility of the 2nd ray in the weight-bearing life of this young girl so as to optimize her potential and reduce the need for invasive procedures.
I suggest utilizing your current paradigm; maximize the care that you offer her with a multifaceted plan including foot beds, muscle engine training, along with activity and lifestyle adjustments. Refer her to a dedicated, skilled biomechanically-oriented podiatrist if you are not so specialized.
Dennis Shavelson, DPM, NY, NY, drsha@foothelpers.com
07/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Repair EHL Rupture? (Joe Gonzalez, DPM)
From: Dan Klein, DPM
All things work in concert, including tendons and bones. You should repair a ruptured tendon when possible. The result of not repairing the tendon will be realized later and most likely regretted. Early repair and return to function should be the rule.
Dan Klein, DPM, Ft. Smith, AR, toefixer@aol.com
07/16/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Repair EHL Rupture? (Joe Gonzalez, DPM)
From: Daniel Pollack, DPM
Get a stat MRI to see how far the proximal end of the EHL retracted, and then primarily repair it if possible, or else it may need a graft augmentation. Worst case scenario, it is a tenodesis, but it needs to be repaired.
Daniel Pollack, DPM, Flushing, NY, dpollackdpm@gmail.com
06/22/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1B
RE: Tibial Torsion and Femoral Anteversion
From: Edmond F. Mertzenich, DPM, MBA
In my experience, many children are still learning to walk at age two. When they get distracted, they will often trip and fall. However, one must keep in mind other issues which can cause these problems; for example, neuromuscular disease, eg. CP. Assuming no major problems are found, frequently I can only tell parents that the patient will usually grow out the problem and offer to see the patient periodically to make sure the patient is progressing positively. Most children will develop normally by age 5, however, it can take up to age 8 to get a complete resolution. If there is a serious problem, appropriate treatment per protocol is needed.
Edmond F. Mertzenich, DPM, MBA, Roscoe, IL, doctoreddpm@frontier.com
06/22/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Tibial Torsion and Femoral Anteversion
From: Russell G. Volpe, DPM
First, I would beg to differ that serial casting and night splints are “no longer considered acceptable.” I routinely use serial casting for a variety of congenital deformities in the pre-walking child. As for night splints, there are a number of splints (Dobb’s brace, Tibial Torsion Transformer, Wheaton Brace) that I employ in the infant and young toddler to help increase the bimalleolar or metatarsus adductus angles in moderate to severe cases, particularly those with “symptoms” associated with tripping and falling.
As for functional change, there is some objective evidence that gait plates improve the angle of gait based on a small cohort study by Anthony Redmond that reported a 6 degree average improvement in angle of gait with the use of a gait plate orthosis. So, this is a good option after a heel-toe gait is established at around age 2 1/2, provided there is some available external hip rotation, and that it is worn in a shoe with adequate flexibility for a light-weight child across the break in the shoe (at the ball). Also, be sure your lab makes the gait plate of adequate length. It will fail to exert the desired effect if it ends proximal to the lateral MPJs.
In more severe, or recalcitrant cases pelvic bands and other similar elastic band therapies can help to increase the external position of the leg in gait.
Russell G. Volpe, DPM, NY, NY, RVolpe@nycpm.edu
06/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Considerations of Re-using a Bone Screw (Joshua Kaye, DPM)
From: Don R Blum, DPM, JD
The manufacturer's specifications are for one-time use. There are companies that will recertify hardware, like getting a used program car, and certify that it meets the specifications as well as repackage the hardware, sterile if required. This is why once a screw is put in and then one decides a different size is necessary, there is a charge for the extra hardware.
What is not seen are microscopic changes occur to the screw. The threads could be damaged "slightly (minimally)", perhaps not observable to me, but...
Editor's note: Dr. Blum's extended-length letter can be read here.
06/14/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Recurrent Ganglion Cysts
From: Eric Edelman, DPM
I have a technique I've used maybe a half dozen times for larger ganglion cysts over a midfoot or hindfoot joint, or recurrent ganglions. Once I find the hole where the joint fluid is leaking from, I use a small Mersilene patch which I cut to fit the area, and sew over the fascia or joint capsule using non-absorbable suture. Mersilene is commonly used as a hernia repair patch. It's thin, cuts easily, and is perforated so it's easy to stitch down (It is also inexpensive.) Mersilene is popular in hernia repair because you get a thick, dense scar tissue - sounds perfect for sealing up a recurring ganglion, right?
Eric Edelman, DPM, Syracuse, NY, ericedelman@gmail.com
05/18/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Painful Bunion in a 12 Year Old
From: Sloan Gordon, DPM, Ed Cohen, DPM
First, I believe showing partial x-rays are not the way to go. For example, I can't see the hindfoot:forefoot relationship, and the TN joint looks uncovered to me. So there may be more to correcting this bunion than just a forefoot procedure. The child may need an arthroresis procedure.
That said, I believe your options are an opening wedge of the first metatarsal vs. an epiphysioidesis. Are you sure the metatarsal protrusion is +, as it looks - to me.
Sloan Gordon, DPM, Houston, TX, sgordondoc@sbcglobal.net
Most painful bunions are aggravated by shoes. I find that it can be a big problem for young active people 12 years and older. I generally will not do bunion surgery on patients under 12, but I feel that these young patients over 12 do as well or better than the other age groups that have bunion surgery.
These painful bunions that appear on young people can get dramatically worse with time and can also cause significant...
Editor's note: Dr. Cohen's extended-length letter can be read here.
05/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Difficult Post-Trauma Case
From: Judd Davis, DPM, Peter Bregman, DPM
The history, aspirate, and MRI all indicate this is a hematoma. Assuming adequate vascular status and healing potential, I recommend incising it, drain all fluid/thrombi, explore the dead space and cauterize any vessels bleeding into it. Leave at least a portion of the incision open without sutures so it can continue to drain as it heals, and let it heal by secondary intention. This way you can manually compress out any thrombus that accumulates later. The pain usually resolves almost immediately and the incision should heal in a month or so with adequate wound care.
Judd Davis, DPM, Colorado Springs, CO, jtdavisco@yahoo.com
It appears as if one or more of the branches of the intermediate dorsal cutaneous nerve were damaged with this, which is often overlooked in most blunt traumas. Start applying some type of topical compound pain medication with anti-inflammatory medication in it as well. See how the patient responds. Performing a more proximal block with Marcaine in the superficial peroneal nerve may be helpful as well. Surgical repair may be needed if the patient does not improve over the next few months. The cysts may just be adding extra compression to the affected nerves.
Peter Bregman, DPM, Las Vegas, NV, drbregman@gmail.com
05/11/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Overlapping 2nd Digit Status Post Bunionectomy
From: Barry Mullen, DPM
Assuming this 77 year old patient is very active, and that considerable 1st MTP joint pain exists, the "KISS" approach calls for either a 1st MTP fusion or Keller arthroplasty, coupled with a partial 2nd metatarsal head resection and plantar plate repair, if torn (likely).
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
05/09/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1
RE: Brachymetatarsia
From: Thomas Graziano, DPM, MD, Sam Bell, DPM
This is an interesting case. You would use external fixators on the 3rd and 4th metatarsals. You also have local access to and can harvest an autogenous bone graft from the osseous bridge between the 1st and 2nd metatarsals. In an attempt to better balance the length pattern, you might consider shortening the 2nd metatarsal and performing an IPJ arthrodesis on the 2nd toe. Stage the procedure and make sure the patient is well aware of the rather cumbersome post-operative course involved.
Thomas Graziano, DPM, MD, Clifton, NJ, TGrazi6236@aol.com
Wouldn't the problem the patient is having determine how you would treat the short metatarsals? We need more information.
Sam Bell, DPM, Schenectady, NY, dpmbell@aol.com
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