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From: Robert S. Steinberg, DPM, Joe Boylan, DPM


Alireza Khosroabadi, DPM, stated, "As with any surgical procedure, once you perform enough of them, you start encountering complications." I challenge that statement. That's not how I practice. Don't we all want to get better, with each and every procedure? The more you do a procedure, the better you are supposed to get at doing them, unless you get careless and sloppy.


Robert S. Steinberg, DPM, Schaumberg, IL


I appreciate Dr. Khosroabadi's candid case presentation. If I saw one of these post-op patients, I would treat the patient without disparaging the surgeon. I am a strong believer in surgeon preference. That being said, in my opinion, MIS surgery has very narrow indications in foot surgery and is not well suited for hallux valgus surgery.


Open hallux valgus procedures offer much better and stable constructs, lending well to internal fixation. In the 1980s-early 90s, the NJ & NYC area had a lot of MIS DPMs - most who seemed to have ridden off into the sunset. I discourage today’s residency-trained DPMs from the widespread performance of MIS, especially for hallux valgus.


Joe Boylan, DPM, Ridgefield, NJ

Other messages in this thread:



From: George Flanagan, FCPodS


I am very interested to hear the replies following this query. In the UK, despite common usage of Xiaflex by hand surgeons, we have still only just had NICE (National Institute for Health and Care Excellence) approval for its use in hands. Effective use for Ledderhose disease would be off-license. I have used it once, with minimal benefit. In the hand, it largely improves contracture. As the contracture rarely develops in the foot, I wonder if collagen breakdown alone is sufficient to reduce the mass.


Luck’s (1959) work on pathogensis of Dupuytren’s would suggest it will only be beneficial for ‘mature’ lesions. I am only aware of Ziyad Hammoudeh’s brief 2014 article in Plastic & Reconstructive Surgery which highlights its use in one patient, without success. I look forward to hearing readers' experiences.


George Flanagan, FCPodS, Podiatric Surgeon & Medical Advisor to the British Dupuytren’s Society, UK



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: Ira Baum, DPM, Cindy Resnick, DPM


I refer you to the dissection technique of Luke D Cicchinelli, DPM: Another Approach to the Posterior Heel Surgery. Podiatry Update 2002. His approach, if done meticulously, many times spares the majority of the AT insertion. It may give you the option of simply reinforcing the AT insertion, if necessary.


Ira Baum, DPM  Miami, FL


I have successfully used plantar fascial night splints for the treatment of chronic Achilles tendonitis. It effectively stretches the Achilles and its usage often precludes the necessity for surgical intervention.


Cindy Resnick, DPM, Staten Island, NY



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: Steven J. Kaniadakis, DPM


On this weight-bearing lateral view, there appears to be the very subtle anterior break in the Cyma line, because the sinus tarsi is essentially obliterated, and there is a decreased calaneal inclination angle. These findings give rise to a decreased metatarsal declination angle, perhaps the etiology of the clinical presentation of a tyloma. Is it bilateral, because she may be compensating from one foot/ankle and a contralateral condition? Does she have flexible pes cavus foot or feet?


Try conservative measures, including carefully aligning and placing a "dancer's" pad or metatarsal pad in the shoe, placed slightly proximal to the metatarsal heads. Better yet, have any padding built into the forefoot extension of an orthotic. Make the extensions and padding bilateral. There appears to be an incidental finding of an accumulation of fat rather than a "bursa sac". I noticed what appears to be some early stages of anterior spurring in the talar beak or some variation of the typical beak. She may need a peg in the sinus tarsi.


Steven J. Kaniadakis, DPM, St. Petersburg, FL



From: Bryan C. Markinson, DPM


In the case presented on dermal sarcoma, it would have been better to first do a biopsy on a portion of the lesion. As presented, primary excision before knowing the biology of the lesion is not optimal. Histologic findings not only identify that the neoplasm is malignant, but a biopsy can give important information as to the aggressiveness of the tumor. As such, it is better left in the patient until that info is known. When excised primarily, only to find out it was malignant afterwards, this presents problems for wide excision planning. What may have been a conservative but complete excision now has to be expanded to a much wider surgical field as the tumor margins are now not reliably identifiable. On feet, this may create the need for an otherwise unnecessary amputation or need for free flap.


Additionally, patients need to be staged before complete excision. Definitive local surgery planning will often change if the patient has been found to have metastases. Lastly, some tumors require local radiation and/or chemo before definitive surgery is performed. The best way to go in a case like this is an initial biopsy. If benign, planning for excision is easy and straightforward. If malignant, referral to a university/hospital-based sarcoma treatment team with tumor intact is optimal.


Bryan C. Markinson, DPM, NY, NY



From: Brian Kiel, DPM, Dave Williams, DPM


I have had good results using Topaz on the Achilles as well as plantar fascia. Over a period of time, I have devised a technique that works well. 


Brian Kiel, DPM, Memphis, TN


Surgery may still be an option, and you do not have to transect the Achilles tendon for good results. O.A. Mercado, DPM made a series of surgical instructional DVDs entitled, “The Art of Surgery.” He has 2 specific DVDs dedicated to Haglund’s deformity and calcified tendo-Achilles. I  recommend the series. He is a wonderful teacher.


Dave Williams, DPM, El Paso, TX



From: Andrew Cassidy, DPM


I have found that not all physical therapy is the same. For a small spur like this, I suggest PT do aggressive soft tissue mobilization (it’s supposed to hurt but not be worse the next day) combined with phonophoresis (ultrasound with 10% hydrocortisone in the ultrasonic gel that can be compounded), as well as stretching protocols and eccentric loading exercises, maybe combined with a CAM walker.


If this fails, I would surely consider trying a growth factor, or stem cell injection in lieu of surgery. I have had many patients that failed conservative measures get complete resolution of pain with the use of biologics, which I would use in the form of PRP intra-operatively as well. The spur has been around longer than the pain. Be sure to treat the patient, not the x-ray.   


Andrew Cassidy, DPM, Austin, TX



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: Paul Clint Jones, DPM, Thomas Graziano DPM, MD


The quick way to triangulate the intra-tendinous ossicle is to use a 25 gauge needle to probe the tendon intra-operatively to locate the mass, then dissect the mass free. If there is too much of the tendon missing following the ossicle removal, then doing a split tendon autograft works nicely. This is a technique developed by John Mozena, DPM. I made an animation that shows the technique nicely.  


Paul Clint Jones, DPM, Portland, OR


I recommend you refer this patient out to someone who regularly performs this procedure. No magical mystery cures for this condition. The Achilles tendon needs to be detached, ostectomy performed with Achilles tenodesis. The newer fixation techniques for Achilles tenodesis are excellent and provide exceptional stability and repair.  


Thomas Graziano DPM, MD, Clifton, NJ



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 Robert S. Schwartz, CPed


The most important consideration in footwear selection in this case is to accommodate the lateral column. Most shoes become narrower at the midfoot, both medially and laterally. In this case, it increases pressure and shear both laterally and plantarly. Certain styles have a broader base of support inside and outside the shoe. Birkenstock has the right shape for met adductus. Finn Comfort and New Balance SL2 last (#1540, #928 are two styles in that last) may relieve shear and pressure to the base of the 5th. A new footwear option that has a broader shank area is KyBoot. 


Almost no shoe fully accommodates the styloid process at the base of the 5th in this foot. A shoe modification in which the lateral column inside the shoe is opened up and extended laterally is the best option since it can be done to most shoes. 


 Robert S. Schwartz, C Ped, NY, NY



From: Robert S. Schwartz, CPed


Memory foams are foams that have “memory” to rebound to their original thickness and density when non-weight-bearing. The higher durometer ones, such as midsoles and outsoles of footwear (40 durometer and above on the ‘Sure A’ scale) do not pack down, or bottom out. Most memory foams we use for insoles are made of 15 to 25 durometer polyurethane such as PPT and Poron.


These are highly successful in distributing cushioning over the entire foot in proportion to forces from above and below. Skechers markets their “memory foam’ shoes that do not fulfill the above criteria. They use a much softer material than described above.


Robert S. Schwartz, CPed, NY, NY



From: George Jacobson, DPM


I agree with Dr. Shea. Shoes with memory foam insoles bottom out quickly. Some that are new just flatten out. They don't seem to have the resilience or density needed for ambulation. It is not the same as a memory foam mattress, where the weight is distributed over a large surface (our body). The weight distribution to the foot needs more resilience through the "gait cycle", which memory foam doesn't seem to provide. I tell patients that they make good house slippers to soften the hard tile floors but don't have the qualities of a running shoe. I cut several running shoes longitudinally to demonstrate those qualities and then discuss orthotics.  


George Jacobson, DPM, Hollywood, FL



From: Keith L. Gurnick, DPM


Alas, Dr. Shea, you are not alone. I too have seen an increase in the number of patients I am diagnosing, specifically with either plantar fasciitis, and/or associated peroneal tendinitis in non-athletic patients who either walk for exercise, walk their dogs, walk the grandchildren, or just do their activities of daily living, wearing the shoes you are alluding to. 


It seems to be almost always women in my practice who purchase these types of shoes and have these specific issues. However, I relate the issues more to the "non-structured" outer soles of the shoes, rather than...


Editor's Note: Dr. Gurnick's extended-length letter can be read here



From: Joel Morse, DPM, Dan Michaels, DPM, MS


This appears to be Radiasse as the filler in question. It has calcium hydroxyapatite and is the only filler that shows up on x-ray. I have not used a filler in this location. It appears that there is a lot of filler in a small space and that may have caused the complication. For a fifth toe corn, I suspect you would use a very small amount of filler and it appears that too much filler was used. I suspect you can use too much and that may affect the vessels to the toe. We generally use fillers on the plantar aspect of the feet under the metatarsal heads.


There is a very good paper on complications with dermal fillers, which I reference: Clinical,Cosmetic and Investigational Dermatology 2015:8 205-213


Joel Morse, DPM, Washington, DC


This is lollipop toe syndrome (LTS) caused by 1. too much Restylane injected into the toe (way too much in this case) and   2. not padding the injected site with an aperture pad post-injection. All of the Restylane migrated to the tip of the toe instead of staying over the lateral head of the proximal phalanx. It may take 6-12 months to absorb. 


Dan Michaels, DPM, MS, Frederick/Hagerstown MD



RE: Cell Phone Causes Toe Fracture


A patient came in with a swollen erythematous distal 2nd toe. Last night, her cell phone fell vertically onto her toe. There is small avulsion/chip that was sheared off the lateral condyle of the base of the distal phalanx of the 2nd toe. 


Cell Phone Causes Toe Fracture


Since she has a Morton's type foot, she is getting more pain than usual at toe-off.



From: Michael M Cohen, DPM


Regarding Dr. Callarman's query about Hyalgan in the ankle... I co-authored an article we published in Foot and Ankle International regarding the efficacy of Hylgan in the ankle joint. The article was published with Dr. Roy Altman, our former Chief of Arthritis and University of Miami faculty member. Drs.  Altman and Moskowitz published one of the original multi-center trials of Hyalgan for osteoarthritis in the knee and is a gold standard article.


Please also note that there is another fine article published in JBJS regarding the same by Dr. Tom Chang. I hope this helps answer some of the questions raised.


Michael M Cohen, DPM, Miami, FL



From: Elliot Udell, DPM


Has Synvisc been approved for joints other than the knee? If not, it is an off-label use which is 100% legal; however, insurance companies may not pay for it and this is an expensive injection. Does anyone have any experience with injections of Synvisc in joints other than the knee with regard to insurance re-imbursement?


Elliot Udell, DPM, Hicksville, NY



From: Mark Dreyer, DPM


I have no experience with Hyalgan, but I used Synvisc One in the military population for ankle and 1st MPJ osteoarthritis. It’s a single injection instead of a series. It comes pre-loaded in a 6cc syringe, I use 6cc into the ankle via a 22 gauge needle every 6 months. Use 1cc for hallux rigidus/limitus.


Mark Dreyer, DPM, Newport, RI



From: Elliot Udell, DPM


Whether HIV or meds that are used to treat HIV cause a lack of resistance to the virus that causes warts is a good question. Unfortunately, asking that question to most readers of PM News might not give us the answers we are looking for. Why? Many people will not tell a podiatrist or dentist in private practice that they have AIDS. Only on rare occasions do patients tell me that they are being treated for AIDS. I suspect that many more have the virus but don't want to divulge that aspect of their medical history.  


The same holds true for other sexually transmitted diseases. In the last 20 years, not a single new patient has told me about any medical history of having being treated for a sexually transmitted illness. Am I to think that these diseases do not exist in my community? Podiatrists working in hospital settings where "the truth" cannot be hidden might be in a better position to answer Dr. Sullivan's question. 


Elliot Udell, DPM, Hicksville, NY



From: Keith Sklar, DPM


I had a previous patient with similar clinical findings. The patient was 12 years old. Both he and his parents were educated on what I believed to be a fungal condition. The patient was treated with PinPointe laser as well as oral terbinafine, and topical anti-fungals. The patient and his parents were reminded about the importance of parent/patient compliance.


Pre- and post-treatment photos


I  rarely remove a nail plate. I’ve improved so many dystrophic nails very simply. As I tell all my patients, it just takes time, patient compliance, and good physician care.


Keith Sklar, DPM, Schaumburg, IL




From: Jeffrey Kass, DPM


I would like to thank Dr. Shavelson for sharing with the readers the condition of "disappearing nail bed (DNB)". It was a condition I was previously unaware of. Having said that, I do have concerns regarding some of his statements. 1) He states for this condition that the etiology is not primarily infection. In the study he linked us to, I don't see where it stated that. I did see that 36% of DNB in toenails did indeed have fungus, 17% had nail trauma, and 18% a history of prior surgery. 


2) Shavelson continues that "continuing to treat as fungal or saprophytic is 'reckless'." If a nail biopsy or culture reveals fungus or mold, then it would NOT be reckless to include this in your treatment paradigm. 3) Shavelson continues to point out the great toe is especially long and parenthetically mentions shoe etiology. The original posting revealed the child was born with the problem. 


Jeffrey Kass, DPM, Forest Hills, NY



From: Paul T Slowik, DPM


Referral to a dermatologist would be my first course of action. Pending that consultation result, I would consider a total simple avulsion with regrowth expected. Although we are generally taught to the contrary, I've seen many nails grow back much improved without any medicinal intervention. 


Paul T Slowik, DPM, Oceanside CA



From: Dennis Shavelson, DPM


I’m sure that this almost teenager and her family are desperate for a diagnosis and  treatment that will work. This is known as disappearing nail bed syndrome in the literature (Daniel R, Babaev M, Avner S: An Update on the Disappearing Nail Bed; Skin Appendage Disord. 2017 Mar; 3(1): 15–17) and the etiology is not primary infection. Continuing to diagnose and treat this problem as a fungal or saprophytic problem with terbinafine is reckless at best, especially in a twelve year old.


Notice that her toenail is short and the distal digital soft tissue is bulbous (pathognomonic). You should notice that her hallux is especially long (shoe etiology). I also detect signs of a flexible forefoot foot type that is serving as underpinning etiology needing treatment that need to be confirmed. If the patient has peroneus longus atrophy or a weakness in the lateral compartment of her legs, the diagnosis will be made.


These toenails need debridement in addition to attention to the other factors mentioned above. A referral to a dermatologically-dedicated DPM is an option. The patient and her parents will thank you.


Dennis Shavelson, DPM, NY, NY
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