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
09/13/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 3
RE: Gangrene S/P Cast Complication
From: Jeffrey Kass, DPM
I agree with all the previous excellent advice. I suggest considering the Artassist device. One may also consider L- argentine in topical or oral forms in lieu of nitroglycerin.
I think it is irrelevant that this occurred under the care of an orthopedist. The same outcome could of easily occurred to a podiatrist. I think the case is horrible and pray the patient gets better.
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com
09/13/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Effective Treatment for Hyperhidrosis (Billie A. Bondar, DPM)
From: Michael Forman, DPM
Bromhidrosis is caused by bacteria forming on the skin of the foot. One of the protocols we have worked out for our office is as follows.
1. Soak both feet in a 50/50 solution of rubbing alcohol and water for ten minutes twice a day.
2. Purchase Certain Dri pads (or like product) and apply to feet every morning.
3. Follow the Certain Dri with a spray deodorant.
4. Apply an absorbent powder to feet and shoes. We recommend Zeasorb-AF powder.
Michael Forman, DPM, Cleveland, OH, im4man@aol.com
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 3
RE: Gangrene S/P Cast Complication (Nanme Withheld)
From: Paul Kesselman
It sounds like you have done all you could. Referring this patient to a vascular surgeon at the outset was absolutely the correct (and possibly the only thing) you could do. Unfortunately, this patient will have to live with this situation for his entire lifetime. Nature undoubtedly will take its course. I have no doubt.
So will the legal system. While you are to be admired for taking on this case, Beware! Any sharp attorney handling this case, will no doubt look to spread the wealth, naming as many parties as possible to include in any legal case.
Paul Kesselman, DPM, Woodside, NY, drkesselmandpm1@hotmail.com
09/12/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Effective Treatment for Hyperhidrosis (Billie A. Bondar, DPM)
From: Elliot Udell, DPM, Don R Blum, DPM
Blaine laboratories has a product called Revitaderm Sweat Stop Foot Soak Tablets. We have dispensed them in our office and have had very promising results.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
After you have exhausted topical OTC products, find a physician who will do or does Botox injections to the feet, or radio frequency ablation to the sympathetic ganglion. I have had patients previously who have had the Botox therapy. The Botox injections will have to be repeated 6 or so months later. For RFA, I have only read about.
Don R Blum, DPM, Dallas, TX, donrblum@sbcglobal.net
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 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
09/10/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 1B
RE: Gangrene S/P Cast Complication
From: Wm. Barry Turner, BSN, DPM
It may already be too late, but I would try to instigate the use of oral and topical vasodilators. Using HBOT is a great idea, but keep in mind that O2 is a vasoconstrictor. The blood fluid will be richer in oxygen. If you couple the oxygen therapy with a vasodilator, you will see a much quicker and maximized response. I do not like the response quoted from the ortho doctor. I hope his licensing organization is aware of his callous concern for this patient. Topically, I would rub in 1/2 inch of nitroglycerin pasted to the affected foot's arch, tid. Hold for SBP under 100mm. Discuss with the patient's PMD about using oral medication, like Procardia.
My question to the patient's parent, "how did the child tolerate the significant pain that would accompany this travesty?"
Wm. Barry Turner, BSN, DPM, Royston, GA, claret32853@ymail.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 2
RE: Metatarsalgia Post-op Hammertoe Surgery (Ed Cohen, DPM)
From: Don Peacock, DPM
I agree with both Drs. Cohen and Bregman regarding how to approach this surgical entity. My only input in this particular case would be to avoid removing the fixation which is now in place. I would approach this patient with a minimum invasive correction of the bunion deformity by an Isham-Reverdin and percutaneous Akin osteotomy in the way Dr. Cohen explains.
In lieu of a simple way to perform an osteotomy on the proximal phalanx, I recommend a biplane correction osteotomy of the 2nd metatarsal by percutaneous metatarsal osteotomy (in the Weil-Johnson style). In addition to this correction, the plantar plate concerns that Dr. Bregman discussed could be alleviated by adding the percutaneous version of the Haspel procedure to your correction.
Also, correcting any equines present would be advantageous to the patient with his overall metatarsalgia pain. If you live in a state where this is not possible or he does not have equinus, I would follow the Leventen formula and perform percutaneous osteotomies of the 2nd and the 3rd metatarsals.
Don Peacock, DPM, Whiteville, NC, peacockdpm@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
08/28/2013
RESPONSES / COMMENTS - (CLINICAL)
RE: Metatarsalgia Post-op Hammertoe Surgery
From: Mike Piccarelli, DPM, Jon Purdy, DPM
Either the interossei were cut during the neuroma or the original problem was attenuated by a plantar plate tear. The neuroma was possibly an incidental finding. His activity level would dictate the repair.
Mike Piccarelli, DPM, Staten Island, NY, mcpdpm@verizon.net
Although “see bone – cut bone – fix bone” works well in active young patients, it is not always the best choice in all patients. Prior to a major work-up for capsulitis, I have had very good success giving it time to heal with a simple off-loading insert with other anti-inflammatory therapies. I inject one, and only one, short-acting steroid, if needed. After a few weeks, it is either working or it is not. If not, work up and repair is indicated. If it is, then it will resolve and periodic off-loading, or permanent (correction) with a custom orthotic is a much better option than a life-long fix in an elderly patient.
In this case, is the hallux affecting the toe position? If not, I wouldn’t fix it. If it is, a simple Akin that can be managed weight-bearing in a CAM walker could solve that issue. Is the toe position painful, or just the capsule? Regardless of whether the toe is causing the problem, if off-loading keeps the patient ambulating pain-free, that is the best solution. If not, then an intra-operative progression of resolution should be taken. This would consist of capsulotomy/repair, tendon lengthening, and a Weil-type osteotomy, which can be managed in a weight-bearing status.
Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com
08/27/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: I Want to Work as a Podiatrist (Juliet Burk, DPM)
From: Steven Gershman, DPM
Amen to Dr. Burk. A completely well-reasoned argument about how podiatry has lost its way. If you want to be just a foot and ankle surgeon, be an orthopedist. Three-year residencies create orthopedist wannabees.
Podiatry is the total care of the foot and ankle, including dermatology, neurology, medicine, endocrinology, biomechanics, surgery, and general palliative care. It was never meant to be just surgery. And yes, women often do have to deal with different pressures than men.
Steven Gershman, DPM, Auburn, ME, obsidianom@aol.com
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
08/20/2013
RESPONSES / COMMENTS - (CLINICAL)
RE: Diindolylmethane for Verrucae (Todd Lamster, DPM)
From: Jeffrey Kass, DPM
I use "DIM" for verrucas. The dosage is 6mg/kg twice daily. There was a study published showing a very high cure rate (greater than 90 percent) in approximately 2.4 - 5 months. There was a recent article on recalcitrant verrucae in Podiatry Today (latest issue) which referenced this. I started recommending it to patients after reading the article, so I can not give any feedback on its effectiveness as I have not yet seen the patients back.
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com
08/19/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2B
RE: Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)
From: Michael Rosenblatt, DPM
Whenever you have a patient with severe localized pain, you might find benefit in looking for a cause that is not necessarily inflammation-related, like nerve damage or a conduction defect. Patients like that benefit from nerve conduction studies, which you can then have a physical medicine consultant read and consider. We always worry about treating these patients with any form of narcotic because they are highly likely to become acclimatized and possibly addicted to them. The irony of narcotic analgesic therapy for chronic pain is that the pain itself becomes how the addiction is expressed.
This is why some pain specialists use...
Editor's note: Dr. Rosenblatt's extended-length letter can be read here.
08/19/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2A
RE: Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)
From: Peter Bregman, DPM
In order to rule out or rule in nerve pathology, I recommend doing a diagnostic block using no more than one cc of lidocaine plain in the medial calcaneal nerve and lateral plantar nerve separately. This may or may not be assisted by ultrasound. You can also look for a Tinel's sign with both these nerves as well. This will help make the diagnosis of a nerve problem versus something else.
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 4 (CLOSED)
RE: Staged Procedures for Digital Deformities
From: Vincent Gramuglia, DPM
I have never had a problem performing bilateral podiatric surgery on my patients. Even the most complex rearfoot and reconstructive forefoot procedures are amenable to this surgical philosophy in my hands. Of course, these patients must meet strict pre-op criteria. First and foremost, they all must be able to do a handstand and walk this way for three blocks minimum. If they pass this simple test, then they are a candidate.
It also helps if they are Olympic gymnasts, astronauts, or yoga instructors. One rule of thumb is to instruct these special individuals not to wear loose fitting clothes (especially a dress) post- operatively.
I think its time to take a stand against the old tired axiom of "do no harm." Our patients today are much more compliant than those cave dwellers, and by the way did Hippocrates have the kind of internal fixation that we have today? I doubt it. Roll the dice...see what happens.
Vincent Gramuglia, DPM, Bronx, NY, a2onpar3@optonline.net
08/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Popliteal Block for Forefoot Surgery (Tip Sullivan, DPM)
From: Philip McKinney, DPM
I routinely use a posterior tibial block, followed by a field block of the surgical area for forefoot surgery. If doing a rearfoot procedure, I do a common peroneal block with a surgical site field block. If the case involves the ankle, or an Achilles tendon location, then I use the popliteal block with a surgical field block.
Philip McKinney, DPM, Eugene, OR, opodiatry@oregonpodiatry.net
08/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 3
RE: Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)
From: Jeffrey Kass, DPM, Michael Forman, DPM
Consider a neurogenic origin; at a local level, a nerve entrapment from the plantar fascial release, perhaps a tarsal tunnel or radiculopathy from the back.
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com
I have seen several of these cases, one of which was of my own doing that resulted in a trip to court. The culprit was a neuropraxia of the first branch of the medial plantar nerve (Baxter's nerve). Diagnosis is made on MRI, which will show atrophy of the abductor digiti minimi. Clinically, you will see an adducto varus fifth toe due to the loss of this muscle. For this reason, you should always note the position of the fifth toe pre-operatively. It is in an adducto varus position pre-op. The Baxter's n. may have been damaged prior to surgical intervention.
If you Google Baxter's nerve, you will find an excellent article from our Atlanta colleagues that describes this syndrome and the surgical approach to its care.
Michael Forman, DPM, Cleveland, OH, im4man@aol.com
