The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

February 08, 2007 #2,805 Editor-Barry Block, DPM, JD

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Heelys are OK With Precautions: PA Podiatrist

Dr. Joseph Gershey, a Dickson City podiatrist, said he has not treated any Heelys users for injuries. But because the shoes lack the ankle support of traditional roller skates, he sees the potential for more ankle sprains or fractures.

Heelys

Dr. Gershey said if children use Heelys with "sensible precautions," including helmets and other protective gear, they should be OK. "I think they are pretty much like anything." Dr. Gershey said. "If they are used incorrectly, they can pose a danger."

Source: David Singleton, The Times-Tribune [2/4/07]

Barry Named "Best Private University or College" by South Florida CEO Magazine

Barry University has been named "Best Private University or College," according to South Florida CEO magazine. The ranking is part of a South Florida "Best in Business" list compiled for the magazine's Jan. 2007 issue from an online reader survey. The listing calls attention to Barry's Catholic heritage and the number of programs offered. In addition, it highlights Barry's recent U.S. News and World Report ranking as No. 1 for student diversity among southern schools of the same size.

Dr, Chet Evans

Barry University was recently designated by the United States Department of Education as a Hispanic Serving Institution. According to Dr. Chet Evans, vice president for Medical Affairs for the Barry Division of Medicine, "Barry's School of Podiatric Medicine graduates
the highest percentage of Hispanic podiatrists than any other school in the country. We are living our community service mission everyday and this contributes to our positive reputation for delivering a high quality podiatric medical education," he added.

Seniors Can Prevent Falls by Fixing Painful Feet: ACFAS

Senior citizens can reduce their risk for dangerous and deadly falls by having painful foot and ankle problems treated. That's the message from experts with the American College of Foot and Ankle Surgeons (ACFAS).

"Reducing or eliminating foot pain in seniors improves their balance, coordination and stability when walking or standing," says Molly S. Judge, DPM, FACFAS, a foot and ankle surgeon in northwest Ohio. "Just one fall can permanently rob a senior of their independence and dramatically reduce their quality of life."

Dr. Molly S. Judge

Judge says foot and ankle surgeons can recommend simple, effective pain-relief measures such as stretching exercises or padding for painful corns and hammertoes. But when surgery is the most appropriate treatment for a senior's painful feet, simple surgical techniques often allow treatment to be performed on an outpatient basis. "It's just not true that foot pain is a normal consequence of growing older," she says. "No one should let pain hold them back from leading a full and active lifestyle."

Query: Building Staff Self-Esteem

People who feel their jobs are important are more apt to try their best, because they realize that it does make a difference how well the job is done What do you say (or do) to let your staff members know how important they are to the success of the practice?

Bob Levoy, Great Neck, NY

RE: Radiographs for Nail Pathology (Allen Jacobs, DPM)
From: Multiple Respondents

I agree with Dr. Jacobs. I obtain radiographs with nail pathology routinely. I feel you are doing your patient a disservice by not looking for the underlying cause of the nail pathology. Hey, this is Podiatry 101. Bone spurs, bone tumors, etc., can lift the nail and cause onychocryptosis leading to paronychias. Although the architecture of the distal tuft is irregular, osteomyelitis can be easily picked. And don't forget the infamous words of
radiologists, "clinical correlation recommended."

Performing these little surgeries is a definite way to increase revenue and at the same time, help your patient prevent further ingrown nails and possibly amputation. I am definitely one for diagnostic tests. They work!

Eugene A. Batelli, DPM, Naples, FL, ebatelli2001@yahoo.com

I have had a similar policy on taking x rays of infected nails. I always explain to the patient my concerns and I truly think they understand and appreciate our doing so. We have found an occasional osteo, not nearly the 15% that Dr. Jacobs relates which makes me concerned that we didn't look hard enough. I certainly concur with the findings of an exostosis being present commonly complicating or being causative of the nail deformity. Having these bits of information just make it much easier to plan for needed correction.

Michael Lawrence, DPM, Chattanooga, TN, ftdoc@joimail.com

I rarely take radiographs of nail pathology. I am amazed at the statistic of 15% occurrence of osteitis/osteomyelitis in patients with a nail infection of 10 days or greater. I also rarely use antibiotics with paronychia.

Of the estimated 250 paronychia I treat per year, according to Dr. Jacobs' statistics, 37 of my patients would have had osteitis/osteomyelitis. The vast majority of these are older than 10 days. Of the 250, I have taken about five x-rays for subungual exostosis, one for infective concerns, and placed two people on antibiotics. None of these cases have presented with continued adverse sequella. As far as exostosis is concerned, that is easily ruled out since the nail is usually tented and there is pain on D/P compression. If pain remains after I&D or matrixectomy then I would take the x-ray. Initially, x-rays do not change my treatment plan so I don't take them.

So far my infective rate is well below that of the national average of 2% infection rate post-operatively. What am I missing?

Jon Purdy, DPM, New Iberia, LA, jpurdy@mindspring.com

I believe the patient's clinical picture dictates when radiographs are needed. Erring on the side of caution (by taking the image) is obviously preferred to diagnosis delay by failure to perform. If a patient's paronychia doesn't fully respond to an I&D and appropriate follow-up management, or they suffer recurrences in the absence of additional trauma, then ruling out an occult OM, via x-ray, or bone scan (in the absence of a positive study) is certainly indicated.

As for using time as the major determinant on whether to take an x-ray for a persistent paronychia, I generally use 1 month as a guide. As for when I perform an x-ray when faced with a dystrophic toenail, if I am making the medical decision that a matricectomy is needed and the toenail is significantly dystrophic, or "pincered", I will generally perform an x-ray, as you described, to rule out a subungual exostosis, or osteochondroma (not uncommon on distal phalanges) well prior to the matricectomy's performance to ensure the digit doesn't require osseous intervention instead or in addition to the
matricectomy.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

The reason why I don't routinely take radiographs of infected and non-infected ingrown hallux toe nails is because the distal hallux is one area of the body where radiographs may often be misleading. There are naturally occurring irregularities in the distal phalanx of the hallux and in the presence of an ingrown toe nail, such radiographs could lead to a misdiagnosis of osteomyelitis and unnecessary treatment. Because these patients present after the infection is already present, it is generally not possible to compare pre-infection views to see if there are any changes in the bone. MRI would be more diagnostic.

In 29 years I have seen my share badly infected toe nails and to date all have healed with a proper treatment plan which included surgical removal of the offending spicule, soaks and a course of appropriate antibiotics. In the one case where I removed a total nail and it seemed to take longer than usual to heal, I did order an MRI and it was negative. Eventually the problem resolved. Almost all of the patients I am describing above, did not have any systemic pathology such as peripheral vascular disease, diabetes, Leprosy, etc. It is possible that the population that Dr. Jacobs is describing in Carville, Louisiana is quite different than mine and maybe that is why he is reporting such a high incidence of osteomyelitis associated with infected ingrown toe nails.

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

Dr. Jacobs brings up an extremely interesting point regarding radiographs for paronychias and his resultant findings of approximately 15% of some reactive bone findings suggestive of osteitis/osteomyelitis confirmed by bone biopsy. Dr. Jacobs' criteria is any infection/paronychia that is present greater than ten days.Although this is certainly clinically prudent, it can also be debated whether this is clinically necessary, since it's probably safe to say that this condition is treated multiple times on a daily basis in most offices without radiographs and without bone biopsies, and the majority of these cases go on to heal uneventfully even without antibiotics.

I believe that it's safe to say that most practitioners will take an x-ray to rule out an underlying osteomyelitis in an untreated paronychia of several weeks/months duration when there are suspicious clinical signs such as edema of the entire digit, erythema of the entire digit, etc., and not just a localized paronychia of the involved nail border.

I am not disagreeing with Dr. Jacobs or his approach to this condition, I'm just wondering if the localized reaction of such a short duration is basically self limiting in a healthy, non-compromised host. That would explain the reason why the vast majority of patients that present daily with this condition heal uneventfully once the offending border is excised and the paronychia is I&D'd, even if not placed on oral antibiotics. In the early stages in a non-compromised host, this problem may simply be self-limiting once it is treated palliatively, and if it is not responding during a follow-up visit, then I believe more aggressive treatment is warranted. However, for a long standing untreated paronychia with a suspicious clinical presentation, clinical judgment is always the final decisive factor.

David Wander, DPM, Philadelphia, PA, dldjwander@comcast.net

ASSOCIATE POSITION -MINNESOTA – PRIME MINNEAPOLIS SUBURB

Busy, well-established, full-scope podiatry practice, seeking highly motivated podiatrist for a full-time position with potential partnership opportunity. Looking for PSR 24+ individual. Excellent opportunity for long-term growth with unlimited income potential. E-mail CV to employment@associatedpodiatrists.com or fax to (612) 866-5875 Attn. Jennifer.

ASSOCIATE POSITION- KANSAS CITY, MO

Excellent opportunity for a hard working, ethical podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Dedicated, supportive staff with strong marketing and medical knowledge. Must be board eligible/certified. PSR/24. Partnership opportunity. Competitive salary, bonus structure, benefits. Wonderful place to raise a family. Fax CV to 816-455-8901

ASSOCIATE POSITION – MISSISSIPPI

Well established, busy, 3-doctor practice seeks PSR 12 or 24 trained podiatrist for associate position to fill vacancy of retiring member. East central location is a great area to raise a family and is a prime location for accessibility to several major cities. Competitive salary, benefits, and incentives. Partnership possible in 2 years to right individual. June - July start date. Applicant must be ethical, personable, and motivated. Please E-mail CV and letter of intent to shanegan@bellsouth.net

ASSOCIATE POSITION – NEW YORK & CONNECTICUT

Opportunity to be a part of a prestigious and well-established large Orthopaedic and Rehabilitation practice, with locations in Stamford, CT and West Harrison, NY. Looking for a podiatrist to join an already busy practice with opportunity to build. We have state-of-the-art offices with MRI, digital x-ray, paperless charts, physical and occupational therapy. Applicants should be Board Certified or Board Eligible. Competitive salary and benefits. For further information on the practice, log onto WWW.NYCONNORTHO.COM Interested candidates should forward their C.V. to: Cliff Katz, Executive Director ckatz@nyconnortho.com

ASSOCIATE POSITION- WEST CENTRAL FLORIDA

Position available for PSR 24/36 trained DPM to join the Podiatry Service of the largest multi-specialty Rural Health Group Practice in Florida. Good salary/incentive compensation and excellent fringe benefits plan, which includes paid vacation days, CME dollars and much more. EOE/DFWP Send CV and letter of interest to: MCRHS, P.O. Box 499, Parrish, FL 34219 or fax to (941) 776-4013.

ASSOCIATE POSITION - SOUTH CENTRAL PENNSYLVANIA-PM & S 36

Large, busy podiatry group looking for associate interested in future partnership. Practice facilities and technologies include: Surgical Center, Physical Therapy Department, six appointment locations, EMR, MRI and Digital X-ray. Full compensation and benefit package offered. Mail CV to Martin Foot and Ankle, 1203 S. Queen St. York, PA 17403 or email business administrator, johnreitzel@comcast.net

ASSOCIATE WANTED - NORTH CAROLINA , CHARLOTTE AREA

Incredible opportunity to join a busy, well-established group practice. Looking for a self-motivated, hard-working individual seeking to become a partner. Hospital and surgery center privileges. Salary plus percentage, 401k and real estate opportunities. Send CV to universityoffice@ bellsouth.net

ASSOCIATE POSITION - CENTRAL CALIFORNIA

Central California multi-location practice looking for PSR-36 associate leading to partnership. PSR-36 trained podiatrist with great opportunity for reconstructive surgical practice. Practice has Medicare-approved surgery center. Must have excellent interpersonal skills. Excellent salary and incentive. Respond to: westsidefoot@yahoo.com

ASSOCIATE POSITION LEADING TO PARTNERSHIP - TAMPA BAY AREA-FLORIDA

Immediate position available in growing multi-office/multi-physician practice. Looking for a highly motivated psr24/36 trained podiatrist. Must be board qualified/board certified ABPS physician and be highly enthusiastic, motivated, with excellent patient/ social skills. Excellent benefit package including salary/bonus, health ins, paid time off, paid CME, and much more. Please e-mail CV to drdad94@aol.com or contact (727) 944-2522 for more information.

ASSOCIATE WANTED FOR SOUTH MIAMI AREA

Large group, busy, multi-office, partner potential. Motivated applicants only. Mail resumes and letters of intent to 999 N. Krome Avenue, Homestead , FL 33030. July start time OK, sooner preferable. E-mail lianadpm2@aol.com

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