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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
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
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
08/08/2013
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
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
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