|
|
|
|
|
Search
02/23/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Fixation Vs. Non-Fixation of Osteotomies (Ed Cohen, DPM)
From: Randall Brower, DPM
If a patient comes in to your office with a 3 mm or more displaced 1st metatarsal fracture, and has no medical problems, how would you surgically treat it? By and large, most surgeons would FIXATE it AND keep the patient non-weight-bearing.
So, to Dr. Cohen, why do we treat osteotomies differently than fractures? The bone doesn't know the difference. That's why I never understood why some podiatrists are having a patient walk on day one after a bunionectomy with an osteotomy, but cast and NWB a 1st metatarsal fracture.
I'd love to listen to Dr. Cohen on the stand defend to a plaintiff's attorney after a displaced osteotomy why (in the 21st century) he didn't fixate an osteotomy with rigid stable fixation options, why he didn't treat a displaced fracture, and why he isn't in keeping with the current community standard.
Austin's article won't save you in court. Technology has advanced since the '60s. Competing with their neighboring practitioners, some podiatrists have found themselves selling patients on MIS, bunionplasties, no fixation surgery, and walking out of bunion surgery the same day rather than properly educating a patient about stable rigid fixation and the need for a period of NWB of the surgical fracture. My advice: Trade boutique for sound and stable technique.
Randall Brower, DPM, Avondale, AZ, footdoctor33@yahoo.com
Other messages in this thread:
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 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 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
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
06/14/2013
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.
05/11/2013
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
05/04/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Post-Keller Complication (Gregory Caringi, DPM)
From: Tip Sullivan, DPM
The first question should be why did she have the original first ray deformity? One reason that I often see is hallux limitus, which creates enough DJD to make the joint non-salvagable. A dorsiflexed first ray in hallux limitus can certainly result in 2nd met overload and plantar plate rupture/dislocation. I would not be overly concerned with the cyst, but would discuss it in depth with the patient.
Over the years, I have moved more toward first MTPJ fusion and away from Kellers, except in those older sedentary people. Arthrodesis changes weight-bearing functional dynamics, and if done correctly, can off-load the second Met. If you are going to surgically address this, I would consider a Weil osteotomy (2nd). While you are there, remove the cyst. Along with a plantar plate repair, check out the Scorpion by Arthrex. Make sure that the post-op orthoses accommodate by getting the first ray down.
Tip Sullivan, DPM, Jackson, MS, tsdefeet@MSfootcenter.net
04/25/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Post-Op Hallux Varus (Kel Sherkin, DPM)
From: Robert Chelin, DPM, Steven Silvers, DPM
Dr. Sherkin, perhaps you might consider a medial capsular tightening and a medial Akin osteotomy as the simplest correction to bring the toe into rectus and address your patient's cosmetic concerns. It seems that the attending surgeon may have been overly aggressive with the metatarsal head resection and, as a result, a hallux varus has resulted.
Robert Chelin, DPM, Toronto, CA, ft-biz@rogers.com
with all due respect, what does the fact that the initial procedure was performed by an orthopedic surgeon have to do with anything? I have been fortunate to have acted as a defense expert for many podiatrists in malpractice actions. Most cases involve complications which can and do occur and do not indicate that treatment rendered was below the standard of care. Foreseen complications of hallux valgus surgery include under-correction and over-correction of said deformity.
Perform enough of these surgeries and all manner of complications of healing can arise. If they didn't, foot surgery conferences/seminars (be they podiatric or orthopedic) would not need to have lectures on correction of this complex deformity. Let's grow up folks, we're all foot surgeons, trying to do the best for our patients. Let's leave the petty professional jealousy and politics out of it. BTW, I'm guessing that the original procedure in this case was an opening base wedge.
Steven Silvers, DPM, Santa Monica, CA, drshs@yahoo.com
04/24/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Post-Op Hallux Varus (Kel Sherkin, DPM)
From: Keith L. Gurnick, DPM
1) It looks to me more like the surgery performed was an opening wedge with a bone graft, not a closing base wedge. The bone graft is still visible and looks like it was the patient's own bunion bone placed in the opening wedge which was most likely too much bone, and thus an overcorrection of the IM angle with resultant hallux varus. The osteotomy site at the base does not even look like the bone went on to union from the x-ray shown.
2) Your best chance of a correction to make the toe less straight without the potential ramifications of future surgeries would be a 1st MPJ fusion.
3) You could go back to the base and cut through and remove some bone at the base wedge site. Then also do some work at the head, but 1 1/2 years post-op, there will be joint changes. It is a much more difficult and exacting procedure to try to preserve the joint, and if this surgery fails, the patient will require a third surgery.
Keith L. Gurnick, DPM, Los Angeles, CA, keithgrnk@aol.com
04/20/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Bacterial Infection of Nail? (Jay Kerner, DPM)
From: Dennis Shavelson DPM
This patient’s biopsy reflects the repetitive microtrauma form of onychodystrophy, where there is a relatively normal nail plate competing with “additional” nail-like material being generated directly from the nail bed upward.
This nail unit (not matrix) hyperkeratosis eventually laminates to the nail plate forming a thick nail, but before then, a microscopic space exists between them. This space often contains bacterial growth as described here (although not usually fulminate). There can also be lint and other debris occupying this void under the microscope.
This “Ugly Toenail” classifies traumatic nail dystrophy in the Bakotic-Shavelson Classification System for Dystrophic Toenails (Bakotic B, Shavelson D: The Pathogenesis of Dystrophic Toenails; Podiatry Management, p133-140, August 2006) and needs a larger shoe and/or a foot centering orthotic, and not a laser or an antibiotic.
Dennis Shavelson DPM, NY, NY, drsha@foothelpers.com
03/08/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1A
RE: Numbness in Foot When Driving (Olga Luepschen, DPM)
From: Art Hatfield, DPM, Peter Bregman, DPM
My first question would be: Does this happen while driving all vehicles or just a specific vehicle?
Art Hatfield, DPM, Huntington Beach, CA, afootjob@juno.com
This is likely a positional entrapment of one of the peripheral nerves in the distal leg or foot. You need to do a systematic evaluation of the peripheral nerves by percussion until you find the entrapment site. It should be noted that EMG/NCV studies are not reliable for picking up this type of entrapment, especially if the studies are done when the patient is not symptomatic. There also may be a subclinical radiculopathy that is not showing up on MRI that is creating a double crush syndrome when the patient is in a seated position. So, look for the Tinel's sign in the nerve(s) of the affected dermatome, and when you find it, decompress it. Normally, you could try more conservative options, but at this point, they are unlikely to work.
Peter Bregman, DPM, Las Vegas, NV, drbregman@gmail.com
|
| |
|
|
|
