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From: Don Peacock, DPM


I agree with most of the post Dr. Rosenblatt has eloquently described. It is essential that surgeons address gastrocnemius equinus when the deformity presents. It’s equally vital that we incorporate bio-mechanical exams in our surgical endeavors. 


I do take some exception with his conclusion that performing a MIS bunion correction without fixation will always lead to second metatarsal transfer pain. The research in this area contradicts this statement. Non-fixated first metatarsal osteotomies such as the landmark research Dr. Dale Austin gave us is a...


Editor's note: Dr. Peacock's extended-length letter can be read here.

Other messages in this thread:



From: Paul Clint Jones, DPM


I 100% concur with Lancing Malusky, DPM. I use Metanx as my frontline in treatment of neuropathy. I actually prefer Metanx’s sister formulation of Deplin. It’s labeled for depression, but it’s the same stuff – just pure 15mg L-methyl folate. I typically prescribe it as 1/2 tablet qd to 1/2 bid. I then supplement with Jarrow-Brand methylated B12 to prevent anemia. Aside from being contra-indicated in history of cancer or history of seizure, patients can take it with any of their meds. If anything, they are able to take lower doses of their other neuropathy meds.


Anecdotally, I noticed that their Raynaud’s symptoms also resolves. Therefore, I use it with good success as a front liner in treating my Raynaud's patients, without the side-effects of calcium channel blockers. One can use it on children as well as adults. You can start and stop on a dime and use it seasonally. I would love to know why the neurologist thinks it’s so bad.


Paul Clint Jones, DPM, Portland, OR



From: Steven Kravitz, DPM


There have been a number of posts dealing with gout and diabetic patients, most recently that by Dr. Udell on the differential between gout and infection.


Strange as it may seem, gout has been misdiagnosed when the actual pathology is early onset of Charcot foot disease. This is more common than might otherwise be recognized and most often [misdiagnosed] by family practice type physicians who are not educated enough for the index of suspicion needed to diagnose early onset of this osteoarthropathy.


In particular is a case that was seen by a family practice physician for several months, referred back to radiology, then to orthopedics, all of which has confirmed gout without supportive serological testing, etc. With the patient apparently not improving, the family practice physician... 


Editor's note: Dr. Kravitz's extended-length letter can be read here.  



From: Amira Mantoura, DPM


I have used EMLA for my kids when they were young, prior to injections and blood draws. I then used it for electrolysis. If used as directed from a fresh tube, it is very effective and leaves the skin completely numb. I suggest applying a liberal amount under occlusion for 30 to 45 minutes. This is all my personal experience. I have never used it on patients prior to nail debridement.


Amira Mantoura, DPM, Stamford, CT



From: Donald Blum, DPM, JD, Simon Tabchi, DPM


According to, a "fair price for the drug (2 injections) is $8618.11. This is approved (on label) for Dupuytren's contracture.


Donald Blum, DPM, JD, Dallas, TX


Dr. Jeffrey Lehrman and I have done a case study on Xiaflex for a patient with recurrent plantar fibroma. It was very successful for the patient, and she is still pain-free with no recurrence. We were able to obtain a donated vial from the manufacturer. We are currently in the process of getting our article published.


Simon Tabchi, DPM, Allentown, PA



From: David Zuckerman, DPM 


I am surprised that ESWT hasn’t been mentioned as a  treatment for Achilles tendinosis with or without posterior calcification. Typically, the pain is caused by degenerative fibers of the insertional Achilles tendon. John Furia, MD published a peer-reviewed article in the American Journal of Sports Medicine titled, "High-Energy Shock Therapy as a Treatment For Insertional Achilles Tendonpathy." ESWT is non-invasive, office-based, with none of the disability and complications typically known with surgical approaches to this difficult clinical problem. 


David Zuckerman, DPM,  Cherry Hill, NJ



From: Robert Greenhagen, DPM


Similar to plantar enthesophytes, too much credence is given to the presence of the spur. The majority of the pain is due to the soft tissue contracture/tendon irritating the boney insertion. This is the nature of all enthesopathies.  


Tallerico, et al. demonstrated that an isolated gastrocnemius recession addressed the condition regardless of the presence or absence of a posterior spur. AOFAS scores were demonstrated to be equal to that of our double row fixation (suture bridge) study that was published in 2013. This treatment option provides a low risk of complications and allowed the patients to be weight-bearing as tolerated in a walking boot immediately after surgery.


I was fortunate to assist in both studies and have used the isolated gastrocnemius recessions for treatment of posterior pain for the majority of my patients. The origin of the gastrocnemius study was an elderly patient who was not a good candidate for the suture bridge repair of the Achilles. More recently, I have also used PRP injections to the insertion in combination with the gastrocnemius recession.


Robert Greenhagen, DPM, Omaha, NE



From: James Nuzzo, DPM, Matthew Andrews, DPM


I have been successful on a number of occasions entering the area laterally and incising the tendo-Achilles longitudinally, removing the spur without detaching the tendon completely, maybe sometimes partially, It negated the potential for using an anchor to re-attach the tendon Achilles. It is of course important to make sure that the intrinsic presence of the spur is causing the pain.


James Nuzzo, DPM, Mount Prospect, IL


The radiograph demonstrates a calcific density which is likely enshrouded by the Achilles tendon. I have had good success with detachment of the tendon with tendon debridement, remodeling of the posterior heel, and re-attachment using the Stryker sonic anchor with immediate weight-bearing in a CAM boot. We use the sonic anchor with #2 braided suture (included in the kit) with excellent results. For significant tendon degeneration, we also augment with a Stravix graft.


Matthew Andrews, DPM, Sterling Heights, MI



From:  Ira Baum, DPM


The cause of the dystrophy of this nail will never be found. If it was present at birth, maybe the trauma was intrauterine or it's even possible that the nail matrix was oxygen deprived; whatever the exact cause, the nail matrix now outputs an abnormal nail plate. The nail plate is not only abnormal in appearance but in all probability is and always will be susceptible to fungal, saprophytic, and bacterial infections. 


In my experience, the use of systemic or topical antifungal agents will not cause a normal appearing nail to grow. There may be some who advocate steroid injections into the nail matrix, but in my experience, they are of little benefit. I understand the psychological effect that an abnormal nail may have on her, but the only solution would be to remove the nail and use cosmetic nail replacements periodically, or routinely file the nail to a normal thickness and paint the nail. Sometimes, conditions are not resolvable.


Ira Baum, DPM, Naples, FL



From: Charles Morelli, DPM


I am not sure why a bone stim was used for sesamoiditis, but I will let others comment on that as I don’t see the correlation, nor do I understand physical therapy for this. She has a “rigid pes cavus” which gives you the possible etiology of her condition. Address the cavus and her pain may also go away. Certainly a gastroc, TAL, Bauman needs to be considered for the equinus as well as a DFWO of either the first met, or cuneiform, or a Cole midfoot osteotomy if it's global, but I have no idea how severe her cavus is. 


Rather than removing the sesamoid(s), you can consider removing just the plantar 50% of the sesamoid by planing with a sagittal saw, and leave the articular cartilage. Brace with proper orthoses. 


Charles Morelli, DPM, Mamaroneck, NY



From: John F. Swaim, DPM


Does the lateral and/or sesamoid view show hypertrophy of the tibial sesamoid? If so, I would plane that off and immobilize the foot in a post-op shoe with 1/2" felt extended out under the met heads to eliminate ground-reactive force under the toes for 4 weeks, then transition back into footgear with an orthotic. The constant overload from a cavus foot type can cause hypertrophy of the bone here. Also consider a TAL if this is a factor.


John F. Swaim, DPM, Red Bluff, CA



From: John J. Brummer, DPM


The painful rash on the hands and feet of a two year old likely represents a Cocksackie A 15 viral infection, otherwise known as hand, foot, and mouth disease. He should be seen by the pediatrician and have his throat and mouth examined. This infection is generally self-limiting and extremely common in that pediatric age group.  


John J. Brummer, DPM, NY, NY



From: David Secord, DPM


I've used the Bleomycin treatment for verrucae for about 15 years now and think of it as my primary treatment course for adults with normal immune systems. With this treatment, I've seen an approximately 98% success rate with the added benefit that if the person has multiple verrucae, treating just the one lesion will allow resolution of all of them in the course of 5-6 weeks. 


The procedure entails using the body’s own immune system to kill the wart and follows the path of driving some of the warty material into the dermis, where the body will identify it and raise killer T-cells to the HPV (I, II, IV). As these circulate throughout the body, any place with a wart will...


Editor's note: Dr. Secord's extended-length letter can be read here. 



From: Stephen Musser, DPM,  Neil Barney, DPM


Use a local anesthetic with epinephrine (1:200,000) and pack it well with a post-op dressing.


Stephen Musser, DPM, Cleveland, OH


I have had success using 5% 5 fluorouracil daily with adhesive tape occlusion for those very stubborn verruca. It can take many weeks but is painless. Check on the patient every 2-3 weeks. In most cases, you do not even have to debride the lesions as it shrinks on its own. Pain from the lesion subsides quickly after a short time of use. I gave up excisions long ago as it is too painful and can cause scarring and severe disability while healing.


Neil Barney, DPM, Brewster, MA



From: Bryan C. Markinson, DPM


It is a little bit unsettling to ponder the original query by Name Withheld and the response by Dr. Samimi. It is true that metastatic cancer to the foot (generally considered rare) usually indicates a poorer prognosis, but so does all metastatic disease. MORE IMPORTANTLY, in metastatic disease to the foot, and specifically the nail unit, it is the first knowledge that any cancer exists in the patient anywhere in a way more than casual percentage of cases. In nail units, it approaches 50%. This puts us in a position to get the patient diagnosed and a chance at treatment for the original tumor, even though prognosis is naturally poorer. 


When a patient with a known history of cancer (as stated in original post) presents with a foot complaint or lesion, a ...


Editor's note: Dr. Markinson's extended-length letter can be read here.



From: Steven J. Kaniadakis, DPM


Question the patient as to whether she ever had acupuncture or that sort of oriental "medicine". I have seen this on x-rays. If this was not some other sort of artifact, then consider this. Call the patient. Some patients will not recall until later, because some of those oriental providers do not inform patients that they have implanted the "pins" or wires into the patient's foot/leg. It is important to document this in the patient's record, and to inform the patient. The object(s) may be a problem with MRI or real surgery. I have seen these near the posterior tibial nerve with patients having tarsal tunnel syndrome.


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



From: Robin Lenz, DPM


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. 


Robin Lenz, DPM, Toms River, NJ 



From: Gary Docks, DPM


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



From: James Nuzzo, DPM


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.


James Nuzzo, DPM, Mount Prospect, IL



From: Keith Gurnick, DPM


1) Make a dorsal medial incision, and make it long enough for visual exposure so you are working in a tunnel.

2) Schedule more intra-operative surgical time than you might expect.

3) Have lots of  moist 4x4s handy for scrubbing out the tophi where they're attached or embedded into the soft tissues in the site (lots of blunt dissection).

4) Also use lots of flushing of the site. And when you have flushed it out, flush some more.

5) Inform your patient in advance that you will likely not be able to remove 100% of the abnormal tophaceous chalky deposits, but you will get as much out as possible.


Keith Gurnick, DPM, Los Angeles, CA



From: Sarah Goldberg, CPed


Based on the outsole wear shown on your patient's boots, I suggest that, in addition to orthotics, you should look into modifying the soles of his boots. We have found that patients who show faster than usual extreme lateral heel wear benefit greatly from lateral heel flares and, depending on the patient's range of motion, lateral wedging. When a flare is added to the outside of the shoe, you increase the surface area of the shoe which improves the patient's stability and frontal plane positioning.


Sarah Goldberg, CPed, Eneslow, NY, NY



From: Ira Baum, DPM


Based on the intra-operative information, a choice was to be made. Resect what you judged to be infected bone, or flush and pack the wound and follow the standard course of antibiotic therapy directed by an infectious disease specialist.  It was not an easy decision, but I think your decision was correct and appears to be done in the best interest of the patient. The pathology report does not include the clinical appearance at the time of the operation, and therefore has limitations as evidence of wrongdoing. Having said that and your concern of a malpractice incident, the obvious now comes into focus: Impecable progress notes and photographs demonstrating progress.


Ira Baum, DPM, Naples, FL



From: David Samuel, DPM


I appreciate Dr. Boylan's post and non-disparaging thoughts regarding treating other doctors' complications. I can't agree more. We all see them, do them, and understand that we usually don't see bad surgery but bad outcomes. That can happen to all of us. 


However, if I saw one of my post-op x-rays with the capital fragment teetering on a 2-4mm area on the met shaft with what appears to be a first met angle easily 18 deg, if not more, I WOULD BE VERY WORRIED. Dr. Boylan is correct. My residents are not taught this, will never be taught this, and I hope when they move on to their own careers, I will never see a post-op film like this, with a very large IM angle, and...


Editor's note: Dr. Samuel's extended-length letter can be read here



From: Don Peacock, DPM, MS


I agree with all the points made by Dr. Fellner. I have also performed the SERI procedure and what I find most desirable about the procedure is the ability to rotate the distal fragment in the frontal plane, allowing for better repositioning of the sesamoids. 


That being said, I am not fully convinced that we should position the sesamoids back to proper placement in all cases. Let me explain. I found that in some instances, trying to reposition the sesamoids under the metatarsal head resulted in...


Editor's note: Dr. Peacock's extended-length letter can be read here. 



From: Gino Scartozzi, DPM


It appears on the clinical photograph that has been submitted that the distal middle-lateral portions of both hallux nails are in a state of onycholysis (loosened from the nail bed) with the halluces impinging onto the second toes of both feet. The patient appears in the limited photograph to have a bilateral hallux valgus deformity. 


The loosened or onycholytic portions of the hallux nails are the result of biomechanical trauma from shoe wear which may accentuate the hallux valgus deformity. The nail biopsies and fungal nail cultures are negative for psoriatic disease or dematophytic infection. It should be noted, however, that these regions of nail that are loosened from the nail bed are susceptible to secondary fungal colonization, and proper foot hygiene should be stressed to the patient.


Gino Scartozzi, DPM, New Hyde Park, NY 



From: David Secord, DPM


"Current American College of Cardiology/American Heart Association guidelines suggest one month of dual antiplatelet therapy and a six-week wait before noncardiac surgery following bare-metal stent placement and at least 12 months of clopidogrel and aspirin after a drug-eluting stent is used and before noncardiac surgery. Data from 899 patients were included in the researchers' analysis of bare-metal stent outcomes. The drug-eluting stent study included outcomes data from 520 patients."



Explain to interested patients that this study suggests that patients treated with bare-metal stents should wait three months before having elective noncardiac surgery.

Note that for patients treated with drug-eluting stents, the study suggests delaying surgery for more than 12 months.

Explain that current guidelines suggest a six-week wait following bare-metal stent implant and at least a 12-month wait for elective surgery following drug-eluting stent placement.



David Secord, DPM, Corpus Christi, TX