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01/04/2017    

RESPONSES/COMMENTS (CLINICAL)



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:


09/28/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Elliot Udell, DPM


 


There are neurologists and podiatrists in my own geographic area who do not prescribe any of the varied vitamin compounds for diabetic neuropathy. I respect their right to their opinions.


 


The way I handle these compounds in my practice is that I give the patient a one-month supply of one of the compounds (and there are many) and tell him or her to try it for a month. If the patient feels that it helps them, they will come back every month for a new supply. If it does not help them, they won't buy it again. Some patients will want to run it past their neurologists, endocrinologists, or primary care doctors first; and in some cases, those doctors will give them a green light and in some cases they are told not to try it. I don't lose any sleep over either decision. 


 


Elliot Udell, DPM, Hicksville, NY

09/28/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



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

09/27/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Paul Jones, DPM, Lancing Malusky, DPM


 


Is it possible to get clarification as to this post? Why was the neurologist so adverse to Metanx? Was it the B6? The L-methyl folate? The B12? Why is Metanx “the worst thing you can take?” Is it the attitude of an all-knowing neurologist? Is it legitimate? What are the studies?  


 


Paul Jones, DPM, Portland, OR


 


I recently developed type 2 diabetes. My current A1c level went from 6.2 to 5.3. More importantly though, I requested Metanx for night time foot neuropathy from my PCP (who had never heard of it). The non-generic Metanx resolved my night pain. The A1c change may be coincidental, but the resolution of my neuropathy is not. 


 


Lancing Malusky, DPM, Kettering, OH

09/17/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Paul Clint Jones, DPM


 


I have had this issue as well. I found that using topical Silvadene cream 2-3 times daily is very effective to getting rid of them. Let us know how it works for your patient. 


 


Paul Clint Jones, DPM, Portland, OR

09/17/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Martin V. Sloan, DPM


 


It is difficult to tell, but those lesions look like pitted keratolysis. Have the specimens been analyzed for bacterial identification and sensitivity? Is Corynobacterium a possibility? Is the patient diabetic?


 


Martin V. Sloan, DPM, Abilene, TX

08/31/2018    

RESPONSES/COMMENTS (CLINICAL)


RE: Body Identity Integrity Disorder (BIID) 


From: George Jacobson, DPM


 


This is a rare disorder where the patient wants to get rid of a body part. In this case, amputate the foot. The patient gets happiness at the loss of a body part. To read more about this, look it up or click this link. Could you imagine having a patient that has this disorder and does everything they can to lose their foot or leg. 


 


George Jacobson, DPM, Hollywood, FL

08/29/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Joel Morse, DPM


 


This appears to be purpura due to a hypersensitive vasculitis due to the antibiotics. One can also see a transient rash from endocarditis. This does not appear to be embolic, which usually occurs at the tips of the toes. Ask the internist if they can put the patient on another antibiotic.


 


Joel Morse, DPM, Washington, DC

08/21/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Lawrence Rubin, DPM


 


The characteristic radiographic appearance of chronic gouty arthritis in the foot is the presence of clearcut, “punched-out” erosions with dense, sclerotic margins in a juxta-articular distribution, often with overhanging edges. What's going on in the proximal interphalangeal joint of the second toe and the distal-medial tuft of the distal phalanx in the great toe is highly suspicious.


 


Arthrocentesis with even just a couple of drops of synovial fluid enables microscopic examination which can make the diagnosis. If crystals are seen, their shape and appearance under polarized light are diagnostic. Way back when I taught in the classrooms and clinics of the Illinois College of Podiatric Medicine, when we saw this kind of arthropathy on an x-ray, we used to say, "When in doubt, think of gout."  


 


Lawrence Rubin, DPM, Las Vegas, NV

08/21/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



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.  


08/17/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Stephen Musser, DPM


 


It is not that uncommon for diabetics to experience gout attacks. After all, diabetes does/can affect the renal function in diabetics causing increase in uric acid. Regarding the radiographs submitted, there is not enough evidence in the pictures to suggest chronic attacks of gout in that particular toe. Obtaining labs is recommended. 


 


Stephen Musser, DPM, Cleveland, OH

08/16/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Elliot Udell, DPM


 


Two conditions that share clinical appearances are acute gout and acute bacterial infection. A sixty five year old diabetic patient could have acute gout or an infection, and missing the correct diagnosis could be problematic. It is not out of the question that the patient could even be presenting with acute gout combined with a bacterial infection.


 


This case calls for a needle biopsy of the affected joint and ask the lab to not only look for urate crystals but have them do a culture and gram stain. You will have to send the fluid tapped in two different types of media (Call your lab). In the interim, place the patient on a broad spectrum antibiotic and monitor the patient carefully for any signs of ascending cellulitis.


 


Elliot Udell, DPM, Hicksville, NY

08/15/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Elliot Udell, DPM


 


I had a similar case many years ago. What was most annoying is that the patient would come in every four weeks to have the lesions debrided and enucleated. Can you imagine what it was like debriding and enucleating 30 or 40 punctate lesions every four weeks. What finally worked was that I casted the patient for fully functional rigid foot orthotics. After using the orthotics, the lesions all went away. That was 25 years ago. Today, I would have done a punch biopsy first and sent the specimen to the Derm Path lab. 


 


Elliot Udell, DPM, Hicksville, NY

08/06/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Steven J. Kaniadakis, DPM


 


EMLA works best placing it under occlusion. I tried it in practice on young apprehensive teens, some younger children, and apprehensive older patients. My experience is it takes too long to work. Also, the patch or occlusion preparation seems to work on certain areas better than others. When I tried it on the plantar foot, forget it. The flexor side (anterior) surfaces are somewhat better. EMLA takes too long in any case. Use the freezing sprays instead.


 


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

08/03/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Mark K Johnson, DPM 


 


In clinical practice, I have in the past recommended EMLA cream topically BID over small surface areas of the tarsal tunnel, sural, or deep peroneal nerve trunks for neuropathic pain reduction, especially in diabetic patients or those with radiculopathy. Pre-treatment topically of younger patients, or the use of vibration devices, often lessens apprehensive fear of local nerve blocks. Finally, we have had patients with hypersensitive feet or reduced pain thresholds benefit from topical EMLA under occlusion 45 minutes prior to the office visit for sharp debridement of IPKs.


 


Mark K Johnson, DPM, Bakersfield, CA

07/31/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 2



From: Donald J. Adamov, DPM


 


In my 13 years of clinical practice, I estimate that 2-3 people out of every 100 experience the metallic taste in the mouth with oral terbinafine. Most of these patients were able to deal with it. I do recall one patient several years ago to whom it became very bothersome. It took a couple of weeks to resolve after stopping the medication. 


 


At the time, I did a Google search on this and found a case of a gentleman, in I believe the UK, who was actually hospitalized because he didn't want to eat due to the taste disturbance. In my experience, the taste disturbance with oral terbinafine is rare and to become a big problem is incredibly rare. 


 


Donald J. Adamov, DPM, Spring Hill, FL 

07/31/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Steven Finer, DPM


 


I have used EMLA on some patients with diabetic neuropathy. Mainly, I used it on patients' toes, with some improvement. I have never used it as a pre-injection nor procedure anesthetic. 


 


Steven Finer, DPM, Philadelphia, PA.

07/31/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



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

07/30/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1



From: Robert L. Baron, DPM


 


I see this type of lesion on occasion. It appears to be ossification of a bursa, most likely due to repetitive, low grade trauma to the area.


 


Robert L. Baron, DPM, Willowbrook IL

07/30/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 2



From: Allen Jacobs, DPM, Neil Barney, DPM


 


I must admit to “shock and awe" at the recent discussion regarding loss of taste with oral terbinafine. Loss of taste is one on the most common adverse sequels of this medication, occurring in greater than 1/50 patients. Although typically reversed with discontinuation of terbinafine, loss of taste may be permanent. I suggest that in the future, practitioners might familiarize themselves with the FDA package insert before prescribing medications, or offering commentary regarding potential medication side-effects.


 


Allen Jacobs, DPM, St. Louis, MO


 



After over writing 200 scripts for terbinafine, I have seen 3 cases of taste disorder that caused the patient to stop its use. Taste came back within days of stopping. No ill effects were noted thereafter. As an aside, not one case of elevated liver functions was found in those patients tested.


.


Neil Barney, DPM, Brewster, MA


07/27/2018    

RESPONSES/COMMENTS (CLINICAL)



From: David Secord, DPM, S. Jeffrey Ali, DPM


 


Dysgeusia with Lamisil is not common as far as I know, but I have always let my patients know that it is a possibility. In the large number of prescriptions I’ve written for this medication, I’ve had one patient suffer from dysgeusia. I’ve also had one patient suffer from fulminant hepatic failure, so you get an idea of how my luck runs. This one patient suffered for about half a year before regaining normal taste. Until then, he stated that “everything states like cardboard.” Because I warned him of the possibility, he wasn’t upset with me. His wife likes it because he stopped eating so much and eventually went on to lose 45 pounds. 


 


David Secord, DPM, Houston, TX


 



That is about the only side-effect that I have never had a patient complain about in my 20 years since podiatry school. Nausea, sight disturbances, and even anxiety after reading about the drug, yes, but no taste disturbances. I have had to limit Lamisil use due to elevated hepatic enzyme levels.


 


S. Jeffrey Ali, DPM, Broadview Heights, OH


07/12/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



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

07/12/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



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


 



According to GoodRx.com, 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


06/27/2018    

RESPONSES/COMMENTS (CLINICAL)



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

06/26/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



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


06/25/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1



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
Spenco