I was at a lecture years ago by Gary Gibbons, MD of New England Deaconess/Harvard who said "eschar-goes". Having also listened to a PhD nurse giving a lecture at an APWCA meeting on leaving stable eschar, I asked about the difference between what we docs are taught and what the nurses are taught.
The docs and the nurses are trained differently in how to treat stable eschar. The nurses are taught to leave it alone. We are taught to remove it. The fact is that you don't know what's going on underneath. You need to use your clinical judgment. If you think it's infected underneath or that this necrotic tissue is interfering with healing, remove the eschar. Dead tissue doesn't get better.
Myron Bergman, DPM, Bridgewater, NJ
Other messages in this thread:
RE: Orbactiv - A New Antibiotic Alternative
From: Ed Cohen, DPM
I treat numerous diabetic patients with gram positive bacteria, including MRSA-infected foot ulcers. Most of the digital ulcers can be treated successfully with a MIS flexor tenotomy and oral antibiotics. Some patients present with associated bone infection and frequently need IV antibiotics.
Until recently, this required a picc line and 6 weeks of daily IV infusions. Orbactiv is a new antibiotic featuring a once dose protocol that is as effective as 10-14 days of Vancomycin twice a day. Orbactiv is less...
Editor's note: Dr. Cohen's extended-length letter can be read here.
Get two 2mm punch biopsies. You need a deeper and more diagnostic sample. Don't treat without knowing your diagnosis first. This is dangerous. I'd recommend sending the specimens to Bako labs as they are experts in this area.
Disclosure: I have no financial relationship or interest with Bako Labs.
The International Association for Dance Medicine & Science has an excellent resource paper on the guidelines for beginning pointe work.
As medical director for a professional ballet company and the mother of a pre-professional collegiate level ballet dancer, I can assure you that age is probably one of the LEAST important factors to consider when beginning pointe training. Core and proximal muscle strength, alignment, flexibility and technical training has been determined to be significantly more critical.
Heather S. Snyder, DPM, Medical Director, Charlottesville Ballet
I have noticed the same relationship to smoking and IPKs as Dr. Thomas Nolen has observed. My thought is that the vasoconstrictive effect of nicotine reduces capillary and arteriolar blood flow. This will alter fibroblast function of the skin. I once treated the Marlboro Man; he was loaded with IPKs.
I completely disagree with the comments of Dr. Chaskin. Alcian Blue is not a conventional stain used for diagnosing fungi. If anything, GMS is a more standard stain than Alcian Blue. But using PAS with another stain does not make the diagnosis any more accurate than simply repeating PAS. The shortcoming in this kind of testing is not the stain itself, but the fact that in each section we stain, we may not be cutting the diagnostic area of the sample. So, the more sections we perform, the more likely we will make the right diagnosis. On the other hand, PCR will be much more accurate, although more expensive.
Joon Yim, MD, Pathology Director, Foot and Ankle Specialists of the Mid-Atlantic, LLC, Rockville, MD
RE: Alcian Blue Stains as an Alternative to Genetic Testing
From Daniel Chaskin, DPM, Ridgewood, NY
PCR assays or genetic testing are more expensive than Alcian Blue Stains. Many podiatrists do not order genetic testing because of cost. Alcian Blue Stains may not be as expensive and may with PAS yield a higher positive result. Alcian Blue stains combined with PAS is likely to result in more positive onychomycotic results. Thus, if you are concerned about cost and do not want to order genetic testing, consider Alcian Blue Stains. If cost is not a factor, my personal opinion is that genetic testing is the optimum choice for detecting onychomycosis.
Daniel Chaskin, DPM, Ridgewood, NY
RE: New Treatment of Osteoid Osteoma
From: Neil H Hecht, DPM
I just read an article where MR-HIFU (magnetic resonance–guided high–intensity focused ultrasound) is used in children to treat osteoid osteoma without incision, pain, or radiation, in contradistinction to CT-RFA (CT guided radiofrequency ablation). CT-RFA requires an invasive approach with drilling through muscle and soft tissue into bone of the patient and radiation exposure to the operator.
High–intensity focused ultrasound therapy uses focused sound wave energy to heat and destroy the targeted tumor under MRI guidance. This precise and controlled method does not require a scalpel or needle, greatly reducing the risk of complications like infections and bone fractures.
There was a mention in the article that MR-HIFU was also used here in the U.S. to treat uterine fibroids and painful bone metastases from several types of cancer in adults, but had not previously been used in children. I thought this was interesting and wondered if our podiatric brethren have used this for adult osteoid osteoma or any other bone tumors. Also, I wondered if there was any possible use in osteomyelitis.
I have had the opportunity to treat over 30 patients with multiple IV infusions of Krsyrtexxa at the Gout Institute of America in Belleville, NJ. I agree with Dr. Udell that the efficacy of pegloticase is tremendous. In each patient I have infused, the patient's serum uric acid levels have dropped after the first infusion to almost undetectable levels and the process of dissolving the tophi begins.
This is due to the fact that pegloticase is the enzyme that turns uric acid into allantoin, a water soluble end product that is excreted via the kidneys. Pegloticase also mobilizes crystals out of...
Editor's note: Dr. Cozzarelli's extended-length letter can be read here.
Gouty tophi consuming a digit like the one depicted in the photo often actually replace the bone. The best course of action (providing the patient is a candidate) would be a distal amputation, especially if the tophi are emanating from the wound.
James Nuzzo, DPM, Fox River Grove, IL
Pegloticase is a possible option. It lowers serum urate levels more than any of the oral medications. The problem as Dr. Lenz pointed out is finding a rheumatologist who is trained and comfortable with administering this drug via infusion. The drug has a lot of potential system side-effects and the administering doctor has to be very knowledgeable and prepared to manage any of these potential problems. The rheumatologist must also be willing to examine the patient in order to make sure she has no other medical risk factors that would disqualify the patient from having this treatment.
Surgery on a non-ambulatory, 80-year old is not the best approach for your patient. The surgical risks of flare-up, infection, and the fact that your patient will still have numerous other tophi still causing pain elsewhere, are not worth it. Instead, get him to a rheumatology practice that offers IV infusions of Krystexxa (pegloticase). The tophi will resorb without the inherent risks of surgery.
Consider pegloticase, which is an infusion that will dissolve gout crystals in the body. This is infused every two weeks under the order of a rheumatologist. The hardest part is finding a rheumatologist who knows about and uses this drug.
This case presentation screams for a biopsy. You can't treat it unless you know what it is.
Sherwin Tucker, DPM, Hartford, CT
The history of your patient would suggest this is a pressure lesion. The patient may or may not be a candidate for correcting the equinus resulting from the CVA. An easy correction would be to perform a percutaneous FHL tenotomy in the office setting. It is not likely that this has a neurological pathology with respect to the skin. The procedure is outlined in this video.
A painful problem indeed. With a history of CVA and dropfoot, in combination with wearing an AFO, has anyone checked to make sure she's wearing the correct size shoe? Perhaps she's being pushed too forward into the toebox of the shoe and whammo! That, coupled with the dropfoot, the flexor tendon to the big toe is probably over-powering the weak extensors and causing a hallux malleus when she walks. If the shoe size is correct, then consider fusing the IP joint to keep the hallux rectus.
Gary Docks, DPM, Beverly Hills, MI
RE: Treatment of Plantar Scar
From: Robert S. Schwartz, C Ped
Excavate a channel in an orthotic and either leave it empty or fill it with foam or a gel cushion, depending on what the patient finds most comfortable. Add a double rocker to control sagittal plane forces and midfoot motion. A rocker can have an added channel to unweight the area with scarring.
As a lifelong runner and tennis player for most of my 76 years, I can personally relate to your tennis coach’s problem. I’ve had most of the described symptoms for most of my adult life. Some suggestions: look at the wear patterns of his tennis and other shoes for clues. Check for possible plantarflexed first ray, resulting in lateral forces during propulsion.
Try excavation to the heel counter at the site of the Haglund’s, use a longer shoe size (our feet grow as we get older), and double layer socks to relieve shear forces. A custom semi-rigid (pelite/cloud) orthotic with deep pocket/excavation under the first met head and a heel lift to accommodate equinus influences and an equinus rocker modification are worth a try.
Given the long pain history of your patient, it’s doubtful that continued conservative care will benefit. The x-ray indicates multiple issues related to posterior heel pain. There is a Haglund’s deformity, insertional tendinosis, Achilles calcification, and most likely retrocalcaneal bursitis.
Additional x-ray findings seem to complicate the use of orthotics in this case. Orthotics help posterior heel pain by limiting abnormal motion and decreasing stress and/or twist of the Achilles, etc. Unfortunately, this patient has a medium...
Editor's note: Dr. Peacock's extended-length letter can be read here.
This osteochondroma is best removed by direct excision en mass using bone-cutting forceps until you see normal looking bone, and allow it to heal by tertiary intention. Over the last fifty years, I have removed many of these lesions with the typical cartilaginous "cap" and since they are primarily seen in very young people, healing is uneventful...a method taught to me by Lyle McCain, DPM. This constitutes an excisional biopsy.
I commend Dr. Graziano and others who have offered comments on this subject. Patients with true gouty Tophi have been the most frustrating of all the surgeries I have done in my career. These patients take hours in the OR with the surgeon using a small curette carefully removing piece after piece of tophi, and the reimbursement has always been incredibly poor. A patient I operated on noticed that my comments about payment were true (incredibly small). As this patient was out-of-network for my care, he paid my fee for the 2.5 hour surgery. He expected his reimbursement to be much greater than it was.
As a result, he is suing his insurance company for how low they are paying surgeons to treat his condition. I was deposed in this case in February, and it was interesting that it was my first deposition with 6 attorneys in the room (three from the patient’s firm, and three representing the insurance company). For hours, I talked about the disconnect between surgical fees and what those who pay for insurance think they are. I’m excited to cheer for this case, and maybe a 60 Minutes episode.
Bret Ribotsky, DPM, Boca Raton, FL
RE: Surgery to Remove Gouty Tophi
From: Thomas A. Graziano, DPM, MD
I agree with some of the posters here that at times tophaceous deposits can be managed effectively with medication. However, in some instances surgical intervention is necessary.
Pre- and Post-op photos of Tophi Surgery
Above are pre- and post-op photos of a very interesting case I had many years ago. It was necessary to create a large flap off the hallux, debride the tophi and degenerative bone, and then repair the flap.
I am not a fan of operating on tophi. These cases either precipitate gout, breakdown, and/or get infected. It is often impossible to get all of the crystals out.
It may be worth referring this patient to a rheumatologist, or infusion center, for treatment via Krystexxa (pegloticase). I have seen huge tophi resorb with this infusion, without the risk of surgery.
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.
In my office, if a new patient doesn't show up for a first appointment and then calls to apologize and reschedule, the patient is told that the visit will need to be pre-paid in full and is non-refundable. We send a contract to sign and return via email. Once they pay, their visit is confirmed but they must provide 24 hours notice to change the appointment. If they don't, the fee is forfeited. This has worked well for me since I run a cash practice.
I'm not aware of any changes in the standards of care. Over the years, I have only had 2 or 3 patients who couldn't take oral terbinafine because of abnormal liver function. With the advent of e-prescribing, I have found many patients who can't take an oral antifungal due to interactions, mainly with some hypertension, hypercholesterolemia, and antidepressant medications. Oral terbinafine can displace those meds that are metabolized in the liver and significantly raise their blood levels. Some meds will require close monitoring and adjustments in dosage if you still decide to prescribe. E-prescribing eliminates the guesswork or trying to remember all drugs that can interact with pop-up warnings that appear if there are any interactions, with details and degree.
So, before even starting the conversation with a patient regarding oral antifungals, I always check for interactions with other medications through e-prescribing. When there are no drug interactions, if the patient wants to take the oral antifungals, then we do the KOH and liver profile and tell them to wait for our office to call with the results before picking up the prescription.
Tom Silver, DPM, Minneapolis, MN
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