Podiatry Management Online


Podiatry Management Online
Podiatry Management Online



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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: 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



From: Joe Boylan, DPM, Jeffrey Kass, DPM


I believe this wound will heal with local wound care and collagenase, and lots of time. If the wound culture is negative, stop the oral antibiotics. Let's see another picture in 12 weeks.


Joe Boylan, DPM, Ridgefield , NJ


The clinical picture is obviously concerning. It is good that the patient is on oral antibiotics. This is going to be one of those cases that you will sweat out and no doubt second guess yourself a million times. I would consider bringing this to the OR for pulse lavage with antibiotic in the lavage, and then applying an amniotic membrane graft (Not that there is anything wrong with Amerigel, as I use it myself), but in a burn wound, my preference would be for SSD cream. If the wound was not cultured, this is prudent to do to make sure your antibiotic coverage is appropriate.


Jeffrey Kass, DPM, Forest Hills, NY



From: Stephen Musser, DPM


What was her pain level when you she was initially seen by you? Was a culture of the purulent drainage taken? There may be a possible colonization vs. a true infection. After two weeks, you may not have significant noticeable nail regrowth. Pending your answer to the first questions, I would treat locally (mupirocin/ steroid/soaks) for 6-12 weeks (patience is a virtue).


Stephen Musser, DPM, Cleveland, OH



From: Andrew Carver, DPM, Steven E. Tager, DPM


I recommend the Covidien-Kendall A-V Foot Pump be used evenings during sleep for 1-2 months. You can purchase used pumps through for around $150. The patient puts on the Velcro foot sleeve, which intermittently compresses the 'venous arch' during sleep. If the edema has not moved to fibrosis, this should reduce it. Follow up with Coban compression or Tommie Copper foot sleeves for a few months.


Andrew Carver, DPM, Washington, DC


This patient may be in the early stages of CRPS. Complex regional pain syndrome does not necessarily have to have pain associated with the condition in the early stages. 


Steven E. Tager, DPM, Scottsdale, AZ



From: Michael M. Rosenblatt, DPM


The doctor who has a patient with "unrelenting metatarsalgia" has relief with a wheal raised just over the posterior tibial nerve. This relief lasts about 5 days. 


Whenever I had a patient who experienced unrelenting nerve pain, I recommended looking for a systemic condition that causes the pain. There can be many of them, and usually they require a work-up combined with a referral to a neurologist to help look for that explanation. It is sometimes too easy to get caught up in local podiatry without keeping a necessary wider perspective. 


All specialists have a tendency to do this, not just "limited licensed" doctors. Systemic conditions like lupus, MS,...


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



From:  Andrew Levy, DPM


This case presents several unfortunate red flags to me as you go forward in your treatment choices. The 3 major red flags: 1) the patient is a smoker, 2) you indicate he stated the screw was stripped during surgery; how could he possibly know that? To me, that raises concerns of a litigious patient. 3) The surgery has left a wide gap at the IPJ.


If it was a fusion for trauma. There is a fair chance that the IPJ sesamoid ligament was torn from its insertion and is incarcerated in the IPJ. You stated that there is DF & PF with one grade of weakness. What are the goals of the surgery or treatment you want to accomplish?

Andrew Levy, DPM, Jupiter, FL



From: Bill Greco, DPM, Kent Biehler, DPM


Avulsion will effectively drain and remove the foreign body (nail). If you have a healthy patient with no contraindications to local anesthesia, removal of the offending nail will often be curative. An onychia present since March or before, unresponsive to antibiosis, requires proper surgical drainage. The chronic onychia is capable of damaging the matrix as well as increasing the risk of acute osteomyelitis. 


Bill Greco, DPM, New Rochelle, NY


I would like to see the toe x-rays. From the photo, it looks like the patient might have a dorsal exostosis on the distal phalange of the big toe, causing the problem.


Kent Biehler, DPM, Orange Park, FL



From: Thomas R. Komp, DPM, Joel Morse, DPM


You have to avulse the nail to get the infection to clear. There is no other way. Believe me, I have tried.


Thomas R. Komp, DPM, Green Bay, WI


This appears to be retronychia which was mentioned at one of the past Dermfoot Seminar lectures by C. Ralph Daniel, MD. Treatment is avulsion of the nail plate. I recommend that you send the plate in for biopsy to be sure that nothing else is there.


Joel Morse, DPM, Washington, DC



From: Tip Sullivan, DPM


Consider staging this repair:


Stage 1- resect duplicate fourth metatarsal.

Stage 2- (which can be delayed perhaps until skeletal maturity) If non-symptomatic, re-orient the 5th metatarsal.


Tip Sullivan, DPM, Jackson, MS



From: Michael Cohn, DPM


I have found Efudex, 5 fluro-uracil, cream to be highly effective in patients with poor immune response. It simply takes a rapidly dividing wart cell and puts in a false amino acid and kills the cell on division. You put it on the lesions under an occlusive dressing and it works very well in most cases.  


Michael Cohn, DPM, Albuquerque, NM



From: Michael M. Rosenblatt, DPM


Any patient with recalcitrant pain that is not "well managed" by the usual patterns of podiatric care should be evaluated for a general medical condition. For example, hyperuricemia is usually thought of as resulting in pain that affects joints, and for the most part that is true. But there can be atypical presentations of pain caused by hyperuricemia, and this includes heel/plantar fascia pain. 


A common pattern for patients with gout is excessive use of ETOH. This causes dehydration and major shifts in uric acid metabolism. Sometimes, patients with extremely high cholesterol and fatty acid lab reports see "unexpected and not usually connected" symptoms. I have seen patients with...


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



From: Richard Adams, DPM


Try evaluation with diagnostic ultrasound. Steve Barrett has performed exhaustive studies regarding recalcitrant heel pain evaluation utilizing MSK ultrasonography. If MSK ultrasound is negative, the patient is likely suffering from medial calcaneal neuritis. Try a diagnostic block of the medial calcaneal nerve with simple Xylocaine plain. The patient will think you are a genius when, five minutes later, he is able to stand without pain. The experience will be rewarding and positive for the patient and physician alike. 


Richard Adams, DPM, Granbury, TX



From: Jeffrey Kass, DPM


I am sure many of my astute colleagues will be able to identify this condition based on the picture and information provided. I am just curious why an unknown dermatological lesion wouldn't get a skin biopsy as part of the work-up? The skin biopsy would lend more information than the blood work-up. 


Jeffrey Kass, DPM, Forest Hills, NY



From: Jeffrey Kass, DPM


Regarding bloodwork, psoriatic arthritis is often a diagnosis of exclusion. Having skin lesions and or radiographic changes consistent with the disease, i.e. pencil and cup deformities, makes the diagnosis easier. Biomarkers in the blood should be considered. MMP3 (metalloproteibase-3) and hs-CRP (high sensitive C-reactive protein) as well as VEGF (vascular endothelial growth factor) have been shown, for example, to be useful in early detection of psoriatic arthritis and to monitor disease progression. 


Jeffrey Kass, DPM, Forest Hills, NY



From: Michael L. Rahn, DPM


Consider psoriatic arthritis. Since treatment may require long-term anti-inflammatories, either older ones such as sulfasalazine or plaquenil, or newer disease-modifying anti-rheumatic drugs (DMARDs), all requiring periodic lab monitoring. Why not let the rheumatologist treat this patient and perhaps become your best referrer?


Michael L. Rahn, DPM, McLean, VA