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09/26/2013
RESPONSES/COMMENTS (CLINICAL) - PART 2B
RE: Unstable Scar
From: Robert S. Schwartz, CPed
It is possible to reduce heel contact shear and pressure to the heel using heel and toe rockers (See attached photo). Rockers are designed to delay contact with the floor until the body passes over the heel and lands on the midfoot. MBT is an example of a ready-made shoe that offers this feature. It has both the delayed heel contact and SACH heel to absorb forces. The insole has to provide added protection.
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Ankle Joint Rocker with SACH Heel |
A horseshoe-designed device with dispersion under the calcaneus using a combination of memory foam (PPT, for example) and pink Plastazote under the ulcer, and a firm frame for stability and support should help. Appropriate footgear is critical including appropriate shoe size and style, and heel height. What footwear is he wearing around the house? Maybe he’s wearing no shoes.
Other messages in this thread:
03/13/2024
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Robert Kornfeld, DPM
I have spent more than 30 years treating chronic foot and ankle pain and have had many cases of “recalcitrant” PT tendinitis. Once you come out of the “next best treatment” mentality and focus on the patient, you will find answers. Functional medicine teaches you to examine the patient's total health landscape to uncover immune burdens and any epigenetic and genetic issues (SNPs) which will create inefficiency in repair pathways. These underlying mechanisms are managed prior to any treatment. Once you have up-leveled immune function, you can heal these chronic cases via regenerative medicine injection therapies. This is how every doctor should be practicing. I have loved my practice all these years.
Robert Kornfeld, DPM, NY, NY
02/08/2019
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Allen Jacobs. DPM
The observation of Dr. Jones that activated folic acid may be helpful for the management of Reynaud's disease or phenomenon is not without a potential, although unproven, scientific basis. The utilization of l-methylfolate, B6, and methylcobalamin, increases nitric oxide levels. Nitric oxide is of course a well-established powerful vasodilator. It is also helpful in the reduction of homocysteine which is a non-essential amino acid inhibiting the coupling of nitrogen and oxygen to produce nitric oxide. It is now available in a generic form through EBM Phramacy.
Allen Jacobs. DPM, St. Louis, MO
12/28/2016
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Burton J. Katzen, DPM
I have been performing the MIS metatarsal osteotomy for correction of hallux valgus deformity since 1980, and let me first say that I appreciate the need for extensive scientific studies for any procedure that we want to classify as an accepted standard of care. Also, The Academy of Ambulatory Foot and Ankle Surgery is extremely fortunate to have members like Drs. Peacock, Nadal, and Isham who are very scientifically-oriented in their evaluations, and we are equally as fortunate to have someone like Dr. Block who is finally making the profession aware of the excellent work performed on a daily basis by our members here and all over the world.
That being said, my contribution to the discussion only comes from a vast amount of anecdotal experience involving thousands of cases over many years. I do look forward in the future to working with my esteemed colleagues in producing a scientific study on the procedure. The osteotomy is performed with four separate cuts at...
Editor's note: Dr. Katzen's extended-length letter can be read here.
08/31/2015
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Stephen Albert, DPM
Reading PM News exchanges from Drs. Richie, Udell, Kesselman, and Phillips, I am compelled to join them as President of the American College of Foot and Ankle Orthopedics and Medicine (ACFAOM). I wish to do so in a broader context rather than just Dr. Wrobel’s article. By the way, James Wrobel, an acquaintance of mine, is an excellent podiatric researcher.
ACFAOM believes that biomechanics and medicine are the cornerstones of contemporary podiatric practice. With that in mind, I wish to underscore the educational avenues available to practitioners and those still in training available from not only ACFAOM, but...
Editor's Note: Dr. Albert's extended-length letter can be read here.
08/28/2015
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Brian Kiel, DPM, Vince Marino, DPM
I have been perfoming these injections for years and would never give them up.. My success rate is at least comparable to surgical excision with fewer and less complicated complications. I have used the solution for other neuritic conditions such as painful keloids, nerve entrapments and injuries with a good success rate. Sure it's anecdotal, but it's not a placebo.
Brian Kiel, DPM, Memphis, TN
I agree whole-heartedly with Dr. Dockery’s observations about the article presented. I continue to use injections of 4% alcohol for nerve sclerosing purposes and NEVER have found my patients to have relief after a single injection. I have found that usually it takes three injection treatments for patients to begin to see any significant results. I also use the solution mixed with anesthetic with epinephrine to allow the solution to “sit” for a longer period of time around the nerve. I think the article as presented is not relevant to the clinical settings in which we utilize this modality. Therefore, its results cannot be relevant.
Vince Marino, DPM, San Francisco, CA
03/27/2014
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Bret Ribotsky, DPM
Having just returned from the American Academy of Dermatology's annual meeting in Denver, this is what I learned. None of the lasers currently available work to cure onychomycosis. I asked a few questions to drill down on this topic. The result is that they (the collective masters) feel we're still a few years away from having a laser or a light source that works. The feeling was that photodynamic therapy (medication + light source) would be the first to the market with good results. Two new topicals (from Anacor and Valeant) have some good data, but nothing so far is a home run.
03/26/2014
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Dennis Shavelson, DPM
My position is that dystrophic toenails present a complex diagnostic and treatment scenario that will never be solved by one magic bullet like a pill, topical, laser, or orthotic. To start with, eyeballing dystrophy as fungal must end, as repetitive microtrauma may be as or more important than whether hyphae are etiological. Shoe scuffing from tight toe boxes and underlying biomechanical foot type-specific pathology plays a major role as a precursor to both primary disease and recurrence.
An initial history gathering health state, biomechanical, vascular, and neurological data followed by a biopsy sent to a lab seeking multiple etiologies, and a custom treatment plan will lead to better short- and long-term outcomes. I have a prescription pad, a dispensary, a laser, a biomechanical compensation plan, and a guarantee to my patients that I will try my best to affect short- and long-term cure for their “ugly toenails” if they are willing to assume a role in their care.
Anecdotally, I find that my success rate before and after I had 1064 lasers in my practice has improved, but the number one addition to my pathogenesis-oriented care these past years has been foot centering orthotics, muscle engine training, and shoe wardrobe and lifestyle adjustments, especially when it comes to reducing recurrences.
03/25/2014
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Paul J Maglione, DPM
I have been using a laser for treatment of mycotic toenails for close to three years. I have found it to be an effective modality. Does it cure all? No. You will see cures in some and improvements in many, if not all. Recently, I have been using it in combination with Genadur liquid.
None of my patients ever reacted like the one in the previous posting. They realize it is part of a treatment plan which includes improved pedal hygiene and prevention of tinea. You don't have to use a laser, you can use oral medication if you wish, or use laser with a topical. Use something. Bi-monthly debridement by itself is not a treatment plan.
02/20/2014
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Tip Sullivan, DPM
I had a similar case that had me scratching my head. Aappropriate cultures and allergy tests were done. There was no metabolic reason for the problem. After two failed closures and a wound that just continued to granulate, I discovered that she had gone to the MS gulf coast shortly after her original surgery. I requested a special stain for mycobacteria. Result: mycobacterium marinum.
I think we are making a simple problem very complicated. The likely cause is aggressive retraction, which often results in this type of post-op incisional issue. This is very common in an anterior ankle approach. A very wise man turned me onto this fact when I was at Temple. Thank you, Dr. Laporta. Expensive wound healing modalities have their place. In this case, I'm not sure we need thousands of dollars of diagnostic testing, etc.
02/19/2014
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Ross B Feinman, DPM, Elliot Udell, DPM
My first recommendation is to cease all surgical intervention. It appears that there is a reason that the wound is still open. Get an ID consult as soon as possible. Get a culture and sensitivity, arterial Doppler and vascular consult, and an MRI per ID recommendation. It appears that there is probably a deeper reason than just localized dehiscence, and that there could be a deep abscess or infected hardware or suture and possibly a more serious vascular complication.
In cases where there is post-operative dehiscence and all other factors such as poor vascularity have been ruled out, take a fine hemostat and probe for buried sutures. You might be surprised that either remnants of non-absorbable sutures or even those that are supposed to be absorbed may be causing an idiosyncratic reaction and preventing post-operative healing. Once these are identified and removed, you will be surprised as how rapid the wound closes.
02/08/2014
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Barry Mullen, DPM
Since the fracture is 18 months old, intra-articular, exhibits sclerosed, smooth ends with no evidence of periosteal remodeling, and considering its poor blood supply to begin with, this likely represents an atrophic non-union, or pseudoarthrosis. This can be confirmed by bone scan or MRI. However, if there is any residual activity (unlikely), then a bone stimulator is certainly worth a try, but would not be expected to work in the absence of non-viable bone (which is likely what the patient has).
Assuming symptoms warrant, and IF he fails conservative treatment (an orthotic with kinetic wedge and dancer pad accommodation is worth a 3-month trial), then TOTAL removal of the sesamoid makes the most sense since it is unlikely one would prevent the hallux drift from a partial sesamoidectomy anyway.
Post-op, I'd likely still place him in an accommodative orthotic with the same accommodations anyway, so it makes sense to try it pre-op. I think the KISS approach makes the most sense here.
02/07/2014
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Paul R. Scherer, DPM
Ever since Kogler published his article in 1999, our profession understands that plantar fasciitis has a mechanical origin, the majority of times. Most organizations' “best practices” literature recommend mechanical control of the midtarsal joint with orthoses as the first line of treatment. The literature supports the positive outcome with orthotics (Scherer 1991, Lynch 1998, Landorf 2006, Roos 2006) in as high as 86% of the cases, and in all cases greater than with the use of oral or injectable anti-inflammatory meds.
Your particular case of a 42-year-old female with twice as thick plantar fascia on the symptomatic side might indicate a systemic origin of her plantar-fasciosis. This is an actual change in the collagen matrix from either a previous tear, if the symptoms are long-term, or a seronegative spondyloarthropy (SpA) in which orthoses would be symptomatically supportive until the diagnosis is made.
Paul R. Scherer, DPM, Owner ProLab Orthotics, Napa, CA, hpoc@aol.com
12/10/2013
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Keith L. Gurnick, DPM
The obliquity and spreading at the 2nd metatarsal-1st cuneiform joint is indicative of her joint instability. She also has a larger semi-facet at the lateral aspect of the base of the 1st metatarsal than might normally be found, even as a normal variant; but there is early x-ray evidence of splaying at that joint site. In addition, she has a rounded 1st metatarsal head and an increased metatarsus adductus angle (normal range 10-20). I do not agree with your lesser tarsus bisector line and reference points placement, look at the base of the 2nd metatarsal as an indicator of the elevated metatarsus adductus angle.
Options: A head osteotomy may still be the procedure of choice due to the fact that the post-op recovery should be easier and shorter than a Lapidus or whatever else you might be contemplating more proximally, which has a longer healing period, 2 incisional sites, and also more potential complications. No guarantees can be made that either procedure will yield a permanent correction, or will lead to recurrence; however, I would discuss the options with the patient ahead of time, discuss your reasoning for each option, and then tell the patient what you feel is the best option at this time for her situation.
11/04/2013
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Jeffrey Root
I believe Dr. Batelli made an important point when he implied that other deformities (i.e., conditions) may be creating an additional pronation moment that is acting at the subtalar joint and therefore on the implant. From the x-rays, it appears that the patient may have a metatarsus primus elevatus and/or a forefoot varus (forefoot supinatus?) position of the forefoot. If the implant successfully limits the range of subtalar joint pronation, then it could create an uncompensated or partially compensated forefoot varus condition.
In other words, the patent may need...
Editor's note: Mr. Root's extended-length letter can be read here.
10/14/2013
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Ralph Graham
It is no surprise that the manufacturers have no response as they indicate in their literature that this has never happened. As with all implants, the user has the duty of care to remove such fragments as may be causing pain, but this may not be all the pieces.
My own view is that any manufacturer that has no mechanism for removal of implants should be rejected as a supplier. We all know from experience that whatever you place in a foot may have to be removed, and a method for removal should be an absolute requirement before use.
10/12/2013
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Frank Lattarulo, DPM
This looks like a hammer lock digital implant by Orthofix (if not please check with the manufacturer of the implant itself for removal advice). Having recently spent a lot of time with my local rep and having put several of these in, I asked that very same question.
According to the company, since the implant comes frozen in dry ice and the "wings" in the "contracted" position, they recommend using Normal Saline Solution (getting it as cold as possible) and irrigating the area around the implant to try and contract the wings once again. Once the wings have contracted, the implant will hopefully (therein lies the operative word) slide out with some pressure. If not, I would take the same approach as you would normally use to take out any fractured internal fixation device.
03/20/2013
RESPONSES/COMMENTS (CLINICAL) - PART 2B
RE: Forefoot Surgery on an 84 Year Old (Joseph Borreggine, DPM)
From: Scott Hughes, DPM, George Jacobson, DPM
How about a 2nd toe amputation? - problem solved.
Scott Hughes, DPM, Monroe, MI, dr.hughes@comcast.net
If your patient has gotten around for 84 years and his chief complaint is that he can't wear a closed shoe, there are still custom-molded and extra-depth shoes available as an option. If that fails, then I'd still be cautious.
I wouldn't want to depend on primary bone healing, fixated or not. If there is a place for keeping it simple, this may be it. I don't know your patient. A simple Keller, with or without a 2nd toe arthroplasty or amputation, requires only soft tissue healing. I wouldn't "over-surgerize" an 84 year-old foot no matter how great your surgical skills are. What is the patient's social situation? Can he be compliant with your post-op instructions? The patient may need transportation and domestic help, etc. If those are discussed and planned as well as the surgery, and are consented non-issues, then you only have to worry about healing.
George Jacobson, DPM, Hollywood,FL, FL1SUN@MSN.COM
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