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05/07/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Chronic First MPJ Pain
From: Don Peacock, DPM
Judging by the lateral x-ray, it appears that she may have a functional hallux limitless. It does appear that she has diminished first metatarsal declination angle due to hypermobility of the first ray. It would be interesting to know what her range of motion is with the first metatarsal loaded. Her deformity does not appear to be radiographically or clinically applicable for a joint implant. This appears to be more of a functional stage I hallux limitus. Your original concept of performing a decompression osteotomy would make more sense. This can be performed utilizing minimally invasive procedures.
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Pre- and Post-op X-Rays |
I recently had a similar case that I corrected by performing an 1.5 cm. incision medially and performing a decompression osteotomy on the first metatarsal phalangeal joint using a guide pin. This small incision also allowed me to reduce the dorsal exostosis, utilizing a power rasp. I was able to perform the surgery without the need for fixation. The patient is completely pain-free. Above are the pre-op and post-op x-rays. I angled the osteotomy to get plantarflexion of the first metatarsal and also addressed her equinus deformity by endoscopic gastroc recession. Addressing the equinus deformity will give you improved plantarflexion of the first metatarsal. Most of these deformities are associated with gastroc equinus, which should be addressed.
Don Peacock, DPM , Whiteville, NC, peacockdpm@gmail.com
Other messages in this thread:
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
09/12/2013
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
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
08/14/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Staged Procedures for Digital Deformities (Ivar Roth, DPM, MPH)
From: R. Kurt Meier, III, DPM, Jeffrey Kass, DPM
I have been in practice for 22 years, and I have done bilateral procedures and single procedures. Usually, if it's digital, I have no problem operating on both feet at the same time. I try NOT to do bunions at the same time. In my experience, patients tend to "favor" the less painful foot in the immediate post-operative period. It always seems that the "good" foot winds up with a clinically worse result, even though the same procedure was done on both feet. I present both options to patients, and will do bilateral bunions if the patient REALLY wants to get it done, but I, personally, would opt for one foot at a time if it were my feet. I treat patients like I would treat family members, and would suggest to family members to have one at a time.
R. Kurt Meier, III, DPM, Brick, NJ, icfeet@tellurian.com
I respectfully disagree with Dr. Roth regarding bilateral foot surgery. First off, I always have my patients' best interest in mind and don't base my operative decisions on financial gain. This is evidenced by my performing pro bono and capitated cases. I think it is common sense that one should have a "good foot to stand on."
The greatest surgeon could have unexpected post-op complications. Unless, of course, the greatest surgeon is always paired with the most compliant patients, who never have any allergic or foreign body reactions, etc.
I try my best to keep up on current literature. JFAS is full of unilateral forefoot complications - I could only imagine the problems the patients would encounter if those procedures were done bilaterally. I hope that those who have had success performing bilateral cases continue to do so. Some of us might prefer the conservative approach. Please don't insinuate that we all do this for monetary gain or that we are following old wives' tales. Some of us still have pure motives.
Jeffrey Kass, DPM, Forest Hills, NY jeffckass@aol.com
06/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2B
RE: Fissuring Under 4th and 5th Digits
From: James S. Scales, DPM, Lloyd Nesbitt, DPM
A similar thing used to happen to my daughter after swimming in concrete swimming pools. The base of her toes would crack open and peel. We finally figured out that it was the concrete causing abrasions in this area of the foot from pushing off the cement floors of the pools.
James S. Scales, DPM, Arvada CO, jdscales@comcast.net
05/24/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Fluoroquinolone Toxicity
From: Robert Kornfeld, DPM
I am presently treating both my 8th and 9th patients who are suffering with fluoroquinolone toxicity. Not just in the form of Achilles tendon rupture, but more a systemic toxicity syndrome with resultant severe peripheral neuropathy, pedal tendinitis, CNS, and digestive complications. Working with these patients has led me to the understanding that there are many patients out there with single nucleotide polymorphisms (SNPs). These patients may have a long history of medical problems, many relating to adrenal dysfunction.
The SNPs make them susceptible to methylation disorders, inability to metabolize sulfur-containing foods and medicines, inability to convert ammonia to urea, and many others. These are the high-risk patients who are sitting ducks for this horrible and life-altering toxicity syndrome. Many have died from the effects of these complications. There is a growing (and somewhat large) population of these patients due to the high number of fluoroquinolone prescriptions being written.
I think at this time it is imperative to write for this class of drugs only when a C&S confirms its efficacy and only when it is critical to prescribe such a potent antibiotic. The age of personalized medicine mandates a deeper understanding of our patients' unique physiology. I have been ordering genetic tests and have been both enlightened and amazed at the number of patients with homozygous mutations that explain much of their recurrent or recalcitrant pathology. Please give serious thought to this post. Writing for fluoroquinolones in a cavalier way will surely lead to more medical disasters.
Robert Kornfeld, DPM, Manhasset, NY, Holfoot153@aol.com
05/18/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Hallux Varus (Kel Sherkin, DPM)
From: Charles Morelli DPM
One way to address and successfully correct a hallux varus, in addition to what others have already posted, is to simply do a tendon transfer of the EHL into the lateral base of the proximal phalanx.
Mobilize the tendon, drill a hole perpendicular to the long axis of the phalanx, and follow the same protocol for any tendon transfer. Insert the tendon from the lateral side of the phalanx and keep pulling until the hallux is in the desired position. Insert your choice of interference screw and close. No fusion, no osteotomy.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
05/02/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Wartabater (Greg Caringi, DPM)
From: Ted Cohen, DPM
Dr. Caringi, do you remember that long river we spoke about in 1980 at OCPM? It had that long structure over it that was for sale. Well, it's still for sale!
Ted Cohen, DPM, Las Vegas, NV, doctor@viawest.net
04/29/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2 (CLOSED)
RE: Post-Op Hallux Varus (Kel Sherkin, DPM)
From: Stephen Musser, DPM, Cosimo Ricciardi, DPM
A first MTP fusion, in my opinion, would be your best choice.
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
If you think that this is the result of a closing base wedge, you probably should not entertain doing surgery on this patient. This is an opening wedge procedure, the joint is subluxated at best, and the patient is not having pain. Pandora's box is sitting in your treatment chair.
Cosimo Ricciardi, DPM, Fort Walton Beach, FL, basewedge@yahoo.com,
04/26/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Post-Op Hallux Varus (Kel Sherkin, DPM)
From: Ed Cohen, DPM
Some of the most important factors to consider are: the patient's chief complaint was a shoe problem, the 1st MPJ is pain-free, the 1st metatarsal head is fine, and the cause of the problem was an over-corrected IMA. I consider this to be a mild hallux varus compared to the usual hallux varus that presents to my office. My procedure of choice would be a reverse Akin osteotomy (lateral wedge osteotomy of the hallux base) which would also reverse some of the soft tissue deformities. This would make the big toe straight and allow the patient to wear a nice shoe and add quality to her life.
I have used this procedure many times and...
Editor's note: Dr. Cohen's extended-length letter can be read here.
04/22/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Wart Covered Foot (David Kahan, DPM)
From: Jerry Langford, DPM
This would be a good patient to treat with the off-label use of cimetidine to kick-start the immune system to get rid of the warts. The dosage for a child is 20-40 mg/kg a day in three divided doses. Children 10 years old or younger usually respond in 7-30 days; ages 11-18 years usually respond in 4-12 weeks. The dosage for adults is 20 mg/kg up to 1600 mg a day, and it may take 6-12 weeks for the warts to resolve. For the average adult, I usually prescribe 800 mg b.i.d.
Jerry Langford, DPM, Collierville, TN, jlangforddpm@bellsouth.net
04/20/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Wart Covered Foot (David Kahan, DPM)
From: Stephen Musser, DPM, Barry Mullen, DPM
Treat the underlying hyperhydrosis. Continue current treatment for 4-6 weeks including debridement along the way. If there is no clinical improvement/resolution, try adding Efudex cream covered at night time, followed by morning application of a Sal acid medication. Let them know Efudex is not cheap!
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
Consider Tagamet 25 mg/kg P.O. in divided doses. This is the perfect indication. It's affordable and often effective for recalcitrant multiple verruca. For additional information, see: Cimetidine as a First Line Treatment for Pedal Verruca; Mullen et al; JAPMA Vol 95, No. 3; May/June 2005
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
03/09/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Numbness in Foot When Driving (Olga Luepschen, DPM)
From: Gino Scartozzi, DPM, Stephen Doms, DPM
In light of the fact that lower back issues were ruled out by means of MRI and nerve conduction velocity tests, I suggest a complete arterial vascular work-up including arterial ultrasonography to rule out any stenoses. Particular points of interest for study of these stenoses may be about the femoral-popliteal and aorto-femoral regions. When in a seated position, these stenoses can develop a clinical manifestation, and are relieved while leaving such position.
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
When I was a student at PCPM (class of 1980), we had a similar case in clinic. We discovered that the male patient drove a car with a center console. He would rest his right leg against the console when driving. He was developing neuropraxis of the common peroneal nerve. The nerve was compressed from the console to the fibular head. He adjusted his driving technique and it resolved.
Stephen Doms, DPM, Hopkins, MN, sdoms@aol.com
02/26/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Proper Biopsy of Melanoma (Mark Schilansky, DPM)
From: Bryan C. Markinson, DPM
I wish Dr. Schilansky had contacted me prior to his posting in the last issue of PM News. First of all, the Codingline Seminar he refers to was well-received, and it was a pleasure to work with him and the other panelists. However, his accounting of the case I presented does not even resemble the case I presented, making it difficult for me to comment on his comments. The chronology is wrong, the facts are wrong, and the questions as to the standard of care are wrong. In fact, in his earnest attempt to provide you with good information, he supplied information which is controversial at best, and not in line with current best practice.
I presented the case true to my feelings and experience, and was very honest in admitting at the presentation that, in the future, I would not shave such a large lesion. However, this was not at all a deviation from the standard of care, which Dr. Schilansky intimates. Since each point of his post is built on an incorrect foundation, the only way to set the record straight would be for me to present the full case, with teaching points, in the pages of PM News, which I will do as soon as possible.
Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org
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