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January 25, 2008 #3,150 Editor-Barry Block, DPM, JD

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CA Podiatrist Has Misgivings About Barefoot Running

Running without a properly supportive shoe may lead to problems with tendinitis, according to Dr. Bob Baravarian, a podiatrist at the Foot & Ankle Institute of Santa Monica. In addition, landing on rocks, pebbles or rough material can cause wounds that may be difficult to heal. Not every runner needs supportive shoes, Baravarian adds, but most require some level of support for long runs in order to avoid problems, particularly if they have low arches.

Dr. Bob Baravarian

Baravarian has misgivings about the increasing popular practice of barefoot running. Yes, he says, it's done in some African tribes, but most of these practitioners have run barefoot since childhood and their feet have adapted to the running surface.

Source: Janet Cromley, Los Angeles Times [1/24/08]

Alleged Negligent Post-Operative Care (New York)

Facts: On Dec. 3, 2004, plaintiff Malvina Chambers, 49, a homemaker, underwent surgical repair of her left foot. The procedure was performed by defendant. It included removal of a bunion and repair of a hammertoe deformity of her left foot's second toe. Six days later, Chambers developed gangrene of her left foot's second toe. The condition ultimately necessitated amputation of the toe.

Chambers sued defendant. She alleged that he failed to provide proper post-operative care and that his failure constituted medical malpractice. Chambers' counsel claimed that the gangrene was a product of an excessively tight bandage that defendant had applied.

Defense counsel contended that gangrene is a known complication of the surgery that defendant performed. He also contended that the gangrene was not caused by the bandage. He claimed that the condition's cause was never conclusively identified, though he suggested that it could have been the result of a vasospasm or another bodily reaction to the surgery that defendant performed.

Injury: Chambers suffered gangrene of her left foot's second toe. She sought the evaluation of vascular surgeons, but the surgeons concluded that the toe had to be amputated. Chambers sought recovery of a total of $700,000 for her past and future pain and suffering. Her husband presented a derivative claim.

Result: Verdict-Defendant. The jury found that defendant's treatment satisfied accepted standards of medical care.

Plaintiff’s expert witnesses: Charles Passet, D.P.M., Forest Hills, NY
Defendant's expert witnesses: Edwin Wolf, D.P.M., New York, NY, Michael Trepal, D.P.M., Brooklyn, NY

Source: VerdictSearch New York Reporter Vol. 25, Issue 24

Query: S/P Talar OCD Arthroscopic Debridement And Continued Pain

56 y/o female s/p 12 months operative arthroscopic microfracture and curettage of a medial talar OCD. The original lesion was 0.5 cm x 0.7 cm, grade II Berndt-Hardy, and was accessible via arthroscopic portals. The patient is still symptomatic at one year post-op. She has had extensive PT, immobilization with a custom AFO, injections, NSAIDs, and rest. Physical exam reveals point tenderness along the anterior joint line of the AJ increasing over the medial gutter. She is had a negative anterior drawer and is painful with DF/PF at the AJ and INV/EVN of the STJ. There is no crepitus and the hindfoot/ankle are rectus. Recent radiographs (including DF stress views) show changes consistent with a medial talar OCD, a small amount of anterior tibial spurring, and an excess of 10 degrees of DF. A post-procedure MRI illustrates the OCD (now larger 1.0 cm x 1.1 cm) and mild/mod AJ osteoarthritis.

I have a surgical plan in mind but I would appreciate any insight or opinions regarding this challenging case.

David T. Taylor, DPM, Flint, MI

Query: When an Unhappy Post-op Patient Appears in Your Office

You operate on a patient and during her recovery she goes to another doctor. Let’s say the patient left because he/she thought he/she was not receiving the best care. Let’s also presume that the surgeon did nothing below the standard of care. Now let’s say that patient finds his or her way into your office. What would be the appropriate thing for the new podiatrist to do? Should the podiatrist contact the original podiatrist and say, “hey I have so and so in your office” and discuss it?

Peter Bregman, DPM, Tewksbury MA

RE: 20% Sclerosing Alcohol injections for Neuromas (Dan Methuselah, DPM)
From: Elliot Udell, DPM, Ed. Nieuwenhuis Sr., DPM

There are two issues here. One is what injection therapy might prove to be effective in the treatment of intermetatarsal neuromas. The other issue is what might be the cause of a surgical failure. In our practice we use either injections of 4% alcohol in Marcaine as per the protocol of Dr. Dockery, and if this does not alleviate the symptoms, we do a series of injections of consisting of 1 cc. of Sarapin, 1 cc. liocaine 2% with epinephrine, and .25 cc dexamethazone. We always apply a met pad after each injection. We often dispense a packet of adhesive-backed pads made for dispensing by Dr. Jills.

The greater issue is why so many neuroma surgeries fail. I don't have the answer, but Dr. Mark Decker, a radiologist who lectured at last summer’s APMA convention on this topic, is compiling data on certain MRI findings and he has thus found that removing neuromas that appear on MRI as ill-defined may lead to complications such as the one described by Dr. Methuselah. Dr Decker plans to lecture again on this topic at the 2008 APMA convention in Hawaii.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

When several treatments have failed to "cure" the patient’s symptoms, it is always wise to reconsider the original diagnosis. Over the years there have been many "neuroma's excised or injected, when in fact no neuroma existed. Even if the pathologist confirmed the presence of a neuroma you could have other conditions causing the patient pain. A stump neuroma is also a possibility. his will require revision surgery by burying the stump of the nerve in local muscle tissue.Consider treating the patient first for a capsulitis/bursitis with some appropriate biomechanical padding before you try more injections or surgery. You may be surprised at the results.

Ed. Nieuwenhuis Sr., DPM, Wycoff, NJ, edfeet@aol.com

RE: Painful Erythematous Toes (Judd Davis, DPM)
From: Barry Mullen, DPM

Editor’s note: This extended-length note appears at: http://www.podiatrym.com/letters2.cfm?id=17621&start=1

RE: Bromidrosis (Melissa Gaffney, DPM)
From: Marc Klein, DPM, Hal Ornstein, DPM

Consider the use of hexachlorophene. I used to use it for this condition, but got out of the habit when it was no longer available in the late 1980's. I have never seen it fail (wash feet every morning with it).

Marc Klein, DPM, MAILKlein@aol.com

In our office, we often approach bromidrosis as follows. First, the shoes are treated with Mycomist and placed in a plastic bag overnight. Second, the foot is treated with either Bromi-Talc Plus or Abscents deodorizing powder on a daily basis.

The treatment of hyperhydrosis should be approached in the following manner. First, treat the shoes as above. Second, the foot is treated with Formadon. Have the patient apply the Formadon twice a day for four days then twice a week only. By the sixth week the foot will stop sweating (For more severe cases use Forma-Ray). In addition, have the patient use Bromi-Talc Plus on a daily basis. These products are made by Gordon Laboratories and can be purchased from your podiatry supplier.

Hal Ornstein, DPM, Howell, NJ, toetoe@optonline.net

RE: Reimbursement for Topaz Procedure (Allen Jacobs, DPM)
From: David E. Gurvis, DPM, Mitchell A. Barber, DPM

I agree entirely with Dr. Jacobs regarding billing for the Topaz procedure. It is unlisted, and anything else is fraudulent. Period.

As for evidence-based medicine. I do have a question for my more erudite colleagues. For obvious reasons, it would take sham surgery to really do a single-blinded study and no double-blinded studies could ever be carried out in this case. This is something none of us in the field in day-to-day practice would undertake (sham surgery), nor would we be competent to. For a surgery to be proven to work, in EBM, besides large numbers in follow-up, what exactly is considered evidence? Any takers?

David E. Gurvis, DPM, Avon, IN, deg1@comcast.net

I performed the TOPAZ procedure via the percutaneous method for plantar fasciitis. After researching the procedure and possible CPTs, I agreed that CPT 28899 is the best code since there is no code for tenolysis of the plantar fascia. I was expecting a clear denial from Aetna that I would later appeal, but to my surprise they paid me...but here is the kicker...they paid an incredible $148 total. They stated it was according to my "fee schedule." I almost had a heart attack when I read that. Of course, the whole point of the "unlisted code" is that it isn’t a scheduled fee, rather a case per case assessment (as I understand it).

Next, I sent the Op note, literature and a letter to their clinical nursing review. After nearly 30 days, I called back and they said it was denied by the provider team and never made it to "clinical review," to which I asked if I could call or speak to them, and of course they said they do not have a direct line (I then asked that if the sky was falling and the clinical review team were the only people who could save us, could we call them..to which she replied calmly, "no." I tried to explain to them that they currently pay $202 for an ingrown toenail, but are paying me less for an outpatient procedure that requires anesthesia, a tourniquet, and specialized TOPAZ equipment...so as it stands now they put it through to the clinical review department. I would appreciate any suggestions on how to get this paid at a better, normalized surgical rate

On a side note, I feel the procedure is an excellent, minimally-invasive choice for chronic heel pain. The patient reported 65% improvement after 3 weeks and was able to ambulate immediately.

Mitchell A. Barber, DPM, Laurel, MD, mitchbkid@hotmail.com

SEEKING ASSOCIATE WITH POTENTIAL TO FULL PARTNER

Busy multi-physician podiatric group with 2 locations seeking BQ/BC surgically trained doctor. Applicant should be well-trained in all aspects of surgical and conservative care. Seeking ethical, hard working and outgoing physician to join our 4-physician group. Excellent quality of life in suburban Houston, near NASA and the Gulf of Mexico. Email CV and cover letter to Dr. M. Rockett at Mrockettman@comcast.net.

Busy multi-dimensional practice; 70 miles north of New York City . Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

ASSOCIATE POSITION- CONNECTICUT

Established Practice looking for PSR 24/36 trained surgeon. Must have experience and be responsible for all surgical cases for the practice. EMR and digital x-ray in new 6-treatment room office. Hospital privileges available. Connecticut has a new ankle law for the Properly-trained DPM. Competitive salary, benefits, and bonus. Great area to raise a family. Fax resume to 860 243-5790

ASSOCIATE POSITION - VIRGINIA (SOUTHERN)

Immediate full-time and part-time associate position available. Unlimited income potential. Busy, diverse, 40+ yr Hampton Roads practice. Must be compassionate; energetic; and motivated; PSR24/36. Looking for long-term arrangement. Please send letter and CV to dcarrone@cox.net fax to 757-397-5889

Excellent opportunity for ethical & personable hard-working individuals to join a busy multi-office two physician practice. Looking for one podiatrist with interest in conservative care, including sports medicine and one podiatrist trained in rearfoot surgery. Rearfoot surgeon must be board eligible and working toward board certification. Competitive salaries, 401-K, health insurance, paid vacation and more. Please forward CV with references to nrussell@neondsl.com

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