I wanted to share this article from Foot and Ankle International for all of you still using low % ethanol injections for treatment of Morton’s neuroma in hopes that you will consider some other treatment or at least just try Marcaine alone. The authors of this study found no difference at all when injecting rat nerves with plain Marcaine or with 4% ethanol solution. Patients do not like having a series of these injections.
This is clear evidence that using anything lower than 30% solution is essentially doing the same as injecting plain Marcaine, but can be more uncomfortable for the patient. If anything, add a little Decadron. I would like to hear from those of you who use this treatment on a regular basis who can refute clear evidence-based medicine.
It’s not the first appointment “no show” that I worry about. It’s the second, and if there is a third, the patient will not be able to be seen as a patient. We don’t spend the time and resources to track down a patient who simply does not show up. A note is made in the EMR and if and/or when they call back to reschedule that is the time a credit card is requested and to tell them that there will be a “no-show” fee automatically charged if they again do not show up without calling to cancel. No credit card, no appointment.
Every patient is called and/or emailed a reminder two days prior to their appointment. This is done automatically via our EMR software.
Like others who have commented, we use the time to catch up on all of the other work that is required to run a private practice like charting, MIPS, MACRA, quality measures, advanced care, marketing, and actually sitting down to eat lunch.
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.
When performing bunion surgery, there are two important caveats: Caveat #1. The sesamoid apparatus must be positioned in the correct anatomical alignment in relation to the first metatarsal head. There is very little tolerance to this rule. Caveat #1 is folkloric at best. I have a desire to hold Dr. Fellner to the same standards that you are asking Dr. Peacock to uphold. Is there any evidence or peer-reviewed literature proving that poor sesamoidal placement is of primary importance in selecting bunion procedures?
Caveat #2. the sagittal alignment of the first metatarsal must be balanced correctly with the lesser metatarsals. This requires of a surgeon a need to exercise due diligence intra-operatively to evaluate and adjust, as required. The sagittal plane alignment of the 1st metatarsal to the lesser mets is more than folkloric, but difficult to accomplish no matter what approach or procedure is selected to repair a bunion deformity. My questions here are: 1. Where does the evidence lead us in accomplishing this caveat? 2. is there evidence that we can balance the first metatarsal to the lesser metatarsals long-term?
Dr. Fellner, you are exactly right. This procedure has not been subjected to scientific evaluation. A modification of the Wilson has been performed MIS and it is in the literature. This particular modification has not been.
In order for us to truly back up what we are saying about this procedure, we are going to need to publish it. I would not go as far as to calling it a sound-bite because we do have some case presentations that have been published in non-peer-reviewed journal articles. However, from a purely academic standpoint...
Editor's Note: Dr. Peacock's extended-length letter can be read here.
I agree with Dr. Fellner that there is not a lot of information when you Google this MIS procedure and probably no published studies on this surgery. In contrast to this MIS bunionectomy, there are a lot published material and studies on the MIS Reverdin Isham bunionectomy, as that procedure is very popular around the world, especially in the orthopedic community. The three best sources for the MIS Katzen Wilson bunionectomy would be PM News, PM Magazine, and lectures sponsored by the AAFAS.
This procedure is a modification of a MIS Wilson bunionectomy made through a dorsal incision. You can view pre- and post-op pictures in the ads of these publications as well as occasional discussions and an article written by Dr. Katzen on the procedure in PM Magazine. The procedure is also demonstrated at the AAFAS cadaver meetings and you can usually find Dr. Katzen at these AAFAS-sponsored meetings. The fact that there are no published studies on this surgery does not mean that the procedure is without merit. It might be worth your time getting more information on this bunionectomy, especially if you have a large geriatric practice. The procedure is also very popular with patients who want to have bunion surgery and can't afford to miss a lot of work.
Has anyone else tried to Google the term "Modified Katzen-Wilson osteotomy." If so, are you as disappointed with the findings as I was?
It will be helpful, to the reader, to know the definition of terms applied to a discussion. And when a respondent justifies clinical practices with research evidence, to know those references. Otherwise, this is but a sound-bite.
Without addressing Dr. Peacock's use of the Katzen Modified MIS Wilson procedure for HAV/Bunion correction in general, I'd like to address his pre- and post-surgery x-ray angle interpretation from the x-rays he sent us to review. I can't agree with his measurements of either the pre-op and 6 week post-operative x-rays. I am not trying to be critical, but to be honest here. Here is what I measured from his x-rays sent in.
Pre-Op IM Angle
His measurement was 13 degrees
My measurement is 11 degrees
Pre-Op HA Angle
His measurement was 22 degrees
My measurement is...
Editor's note: Dr. Gurnick's extended-length letter can be read here.
As I remember when I read the study concerning Betadine toxicity, it showed that there was a statistically significant correlation, but that was only a couple of percent to make it a positive study in an in-vitro study. In reality, there is nothing better than a wet-to-dry Betadine dressing. In my over thirty years in clinical practice, I have never been let down with using Betadine. When the rubber meets the road, I vote for Betadine.
Ivar E. Roth DPM, MPH, Newport Beach, CA
RESPONSES/COMMENTS (CLINICAL) - PART 2
RE: Betadine® and Silvadine® on an Open Wound Long-Term
From: David Secord, DPM
I’m always curious about the recommendation of using either povidone iodine (Betadine®) or silver sulfadiazine (Silvadine®) on an open wound, long-term, to promote healing. As you can see from the chart enclosed (from “The In Vitro Antimicrobial Activity of Wound and Skin Cleansers at Nontoxic Concentrations”, Betadine® is toxic to fibroblasts and keratinocytes. The other article(s) cited questions about the usage of Silvadene® (as opposed to nanocrystalline silver) on wounds.
From: Wound Cleansers and Toxicity. ADV SKIN WOUND CARE 2005;18:373-78: “Skin cleansers in the present study were most toxic to fibroblasts, showing toxicity indexes between...
Editor's note. Dr. Secord's extended-length letter can be read here.
I’ve read with great interest the multiple suggestions for repair of what used to be called a cocked-up 5th toe and an obviously deformed 5th metatarsal. I suggest a simpler approach, borrowing the skin Z-plasty idea from Dr. Pollack. 1. A PIPJ arthroplasty combined with an EDL lengthening done while the skin is open from the Z-plasty. 2. An angulated (lateral/proximal to medial/distal) simple osteotomy of the 5th metatarsal at the surgical neck will give you the ability to maintain or lengthen the metatarsal while also allowing for as much medial and dorsal placement as you wish to eliminate pressure in all directions.
A K-wire is driven distally through the metatarsal head and all phalanges, then retrograded back into the metatarsal shaft. This should give you correct alignment of all fragments with all the stability you need. Repair the now reversed positions of the Z-plasty skin flaps. If you are not familiar with how a Z-plasty works, ask your friendly neighborhood plastic surgeon to assist, as I did 25 years ago. They’re very simple to perform and you get more lengthening than from a V-Y.
Jeff Kittay, DPM (retired), San Rafael Norte, Costa Rica
I suggest a mini-MAU osteotomy on the 5th metatarsal. This will close down the IM angle to an anatomic position with little to no shortening and lends well to rigid fixation with 2 screws. My concern is the painful plantar lesion sub 5th met. Pain plantarly may recur, even with a tailor bunion correction. Your plan with a 5th toe approach (V-Y, MTPJ release, etc.) sounds good. I have also done plantar skin wedges and partial 4/5 syndactylies to ensure 5th toe anatomic position.
Joe Boylan, DPM, Ridgefield, NJ
I suggest dividing this surgery into two stages:1- soft tissue 2-osseous repair. In the first stage, I would lengthen the Achilles/ gastrocnemius, depending on where the equinus is originating. Then, I would do a z-plasty of the skin, lengthening of the extensor tendon, and a capsulotomy. For the second stage, I would do a base wedge procedure as the high 4-5th IM angle dictates.
Dr. Markinson, I agree with your point regarding not trivializing surgical correction and that was never my intent. I was trained in traditional surgery and definitely cut my teeth in surgical corrections lasting up to 45 minutes to correct a tailor’s bunion.
For my particular paradigms, I never tell patients that their recovery will be quicker than a potential traditional surgery. A fifth metatarsal osteotomy is, in fact, a surgical break and will heal in the same amount of time whether we perform that through a...
Editor's note: Dr. Peacock's extended-length letter can be read here.
I rarely disagree with Dr. Markinson, but his comments reflect the views and morays of “maximal” incision foot surgeons that need discussing. Dr. Peacock is an ABPS-certified surgeon who has become a “hybrid” surgeon by adding minimally invasive procedures to his toolbox. These procedures with rare exceptions, when well selected, take less time to perform (his point), allow ambulation earlier than traditionally recommended, heal faster, rehab functionally, and infect less often. In addition, the ability to control the post-op course biomechanically utilizing external biomechanical fixation apply Wolf’s and Davis’ Laws of adaptation better than rigidly fixated osteotomies and plated joints.
The worldwide acceptance on minimally invasive foot surgery because of reduced cost, shorter op time and the comparable results in many instances to procedures performed open are evident to those with an open mind to those moments when a new paradigm may actually be an advance to what “we have been fed for the last 35 years.” To quote Eric Hirzel, “The strength of one’s opinion should not exceed their knowledge on the matter.”
While I can understand Dr. Gurnick's rationale for treating the deformity, my son was born with the same condition. You are correct That taping was unsuccessful. I chose not to correct the deformity. My son is 27 years old and ran cross country in high school and college, with no problems. To this day, he is comfortable.
I think Dr. Bergman gave some sage advice "use your clinical judgment" regarding dry eschars. While the fact "dead tissue doesn't get better," removing it can also potentially open a can of worms. Hence, I like the sage advice better.
Any wound should remain viable with the use of materials and topical treatments, and by essentially maintaining a moist environment. It has been my experience that using topicals, including topical antibiotic ointment, is a key way to help promote the advantages of healing. I think reports about such ointments preventing damaging enzymes and other proteins and other wound byproducts from leaving the wound are wrong. The benefits outweigh these reported risks.
I would use copious amounts of topical ointment and Adaptic. The Adaptic is placed first in intimate contact with all wound boundaries. Then the material is weighed down with the application of the ointment. It is unlikely that the ointment is going to last that long anyway. Any products should be allowed to wick off the wound. Ointments last longer than cremes or lotions. This maintains a longer viability of growing healthy tissues and red granulation from the margins and borders of the wound, rather than the growth of yellow fatty fibrosis, which turns into scar tissue.
Eschar is better than this type of tissue formation, and the ointment will help any developing eschar more easily slough off instead of adhering to the wound longer. Remember to bevel all edges of the wound. The eschar (dried blood) has valuable proteins and products of the platelets.
I have a 50 year old patient whose next treatment option for a plantar plate tear is surgery (we have been through all conservative measures). She has asked about PRP injections. I'm looking for opinions on the use of PRP for this condition.
I would not expect PRP to be effective in the case of a plantar plate tear causing an unstable joint. Even if the tear were to heal, the ligament is still attenuated and will not provide the saggital plane stability necessary for the joint to function properly. The long-term consequence of joint instability is usually arthritis.
Michael Loshigian, DPM, NY, NY
RESPONSES/COMMENTS (CLINICAL) - PART 2
RE: Forefoot or Rearfoot Reconstruction? (Estelle Albright, DPM, Andrew I Levy, DPM)
From: Tip Sullivan, DPM
If I get this straight, the doctors responding to the rearfoot vs. forefoot post believe that one should only fix what hurts. The problem is that if one only reconstructs a forefoot in the face of an obviously unstable MTJ complex, I can tell you from experience, the forefoot deformities will eventually recur.
A significant percentage of my 27 year old surgical practice has been spent repairing previous surgeons' work who did not recognize this truth. I do my best to explain this to patients with the disclaimer that if we do "the easy" forefoot surgery, experience has taught me that there is a greater chance of recurrent problems as compared to the more difficult surgery. I wish we had some solid research in this area and not just anecdotal evidence.
In the context of this academic discussion, none of us should diminish the honor and respect we all have for you and many of our other esteemed colleagues who keep biomechancics and foot orthotics on the front burner at our conventions. When I went to school at NYCPM, back in the 1970s, there were conflicting opinions between the late great Drs. Schuster and Dr. Root. Both men taught all over and had their myriads of followers as well as labs that produced their orthotics. These pioneers of biomechanics were respected more because of who they were rather than on well written academic papers published akin to what Wrobel and his team wrote.
As Dr. Kesselman points out, the opinions of podiatrists with high stature is not enough in this century to convince insurance companies to pay for orthotics. These people want to see current, well-written research papers. Unless we continue to invest in these studies, we cannot and should not expect anyone either in the insurance industry, orthopedics, or even well educated patients to believe that when we cast or scan patients in our offices for custom foot orthotics, we are not doing any more for them than what Dr. Scholls does when it has people stand on scanners at Walmart and take home pre-fabs.
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.
All of Dr. Udell's comments are correct, and his philosophical stance toward the purveyors of theoretical concepts is a cause for us to have natural skeptical attitudes. Science and art definitely coexist in the field of medicine, and to a great degree in the implementation of orthotic design. Where I disagree with Dr. Udell is the notion that this intermingling is a bad thing. Of course, differing concepts and opinions will surface and that's completely natural.
The theoretical prophets all make up their theories and they do this through the creative imagination. These artists/scientists are a gift to us. I find it fascinating when someone challenges an...
Editor's note: Dr. Peacock's extended-length letter can be read here.
We can wait forever for high level evidence to surface that would defend biomechanics in open court. Dr. Sackett, the father of EBM, opined that medicine is more than meta-analysis and level I literature; it depends on expert opinion. Walking down the hallways of any great medical school, you are invited to respect the portraits of its esteemed “self-declared experts” who are the foundation of its bloodline. Dr. Udell’s explanation of biomechanics can be equally applied to other fields of medicine.
To adhere to Dr. Udell’s logic, the acknowledged theorists, lecturers, publishers, and superstars of biomechanics and the very science itself will spiral into non-existence. Wait, Isn’t that what podiatry has done to biomechanics?
I agree with Dr. Dockery and would like to thank him for his expertise on this subject. I have been using 4% alcohol injections for over 14 years and wish I would have started sooner. I mostly use them for neuromas and Baxter's nerve entrapment. I believe this treatment should be offered as another form of conservative treatment as most patients prefer to avoid surgery. I have heard patients tell me that they have gone to other podiatrists and were told that it doesn't work or that the podiatrist didn't believe in the treatment. I'm not sure how you can believe in something you don't utilize!
We are doing a disservice to our patients by not offering all forms of conservative treatments. I don't need studies to tell me this procedure works when I can see the results and I get referrals. If you don't use this treatment for whatever reason, send your patient to someone who does. I'd be more than happy to treat your patients. In the worst case scenario, it may not work (unlikely as it has an 80+ % success rate), and then surgery may be indicated.
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
RESPONSES/COMMENTS (CLINICAL) - PART 2
RE: Are We Still "Kings" of Orthotics? (Doug Richie, DPM)
From: Elliot Udell, DPM
True, the paper by Wrobel, et al., did not show that custom orthotics were the be all and end all in the management of all symptoms caused by plantar fasciitis. Yes, it showed a 125% improvement in spontaneous activity over three months as compared to pre-fabricated orthoses. It did not show improvement in pain. This is why all of us use injections, physical medicine, NSAIDs, etc., in addition to custom orthotics in the management of plantar fasciitis.
What is most significant with Wrobel's paper,however, is that it is a good attempt at bringing evidence-based medicine to one aspect of biomechanics and foot orthoses. Up until now, education in biomechanics has been, by and large, in the domain of self-declared experts. They occupy bully pulpits at conventions where they espouse their own theories of how an orthotic should be made and why it works.The obvious problem is that if you attend five lectures by five different individuals on this topic, you will hear five different sets of conflicting theories and recommendations. This is because the information given by these speakers has not stood up to the scrutiny of solid university-based research. We need more papers like that of Wrobel, et al. Then biomechanics and custom orthoses will graduate from pet theories into actual science.
Elliot Udell, Hicksville, NY
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