The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

February 10, 2007 #2,807 Editor-Barry Block, DPM, JD

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CA Podiatrist Uses Arterial Assist Pump to Save Patient's Feet

Kermit Skeie, 88, went through a number of doctors who attempted to save his feet. When a lower bypass failed, Kermit thought he was going to lose the battle. "I should have had my feet cut off," he said. After the last surgery, he was referred to Kaiser Permanente podiatrist Diane Barry in 2005, who took over Kermit's case. "His past injury set him up for bad circulation," Barry said. You can feel the effects (of poor circulation) as you age as circulation to the feet decreases, which is normal, but he felt more of the effects since he had previous damage to both feet," Barry said.

Dr. Diane Barry

Barry, realizing Kermit's heart may not be able to pull through another surgery, decided to try another approach to save Kermit's feet. "It was really hard for him to recover from the last surgery so we decided to loan him an arterial assist pump and it worked really well," she said. The device works to increase the flow of blood to lower limbs. The pump squeezes the area to increase blood flow. "It mimics the person exercising or running and increases the blood flow to the foot," Barry said. With the help of the machine, and visits to Barry who would remove the dead tissue and monitor the infected areas, Kermit's feet began to heal.

"Most doctors would have quit and said `take it' but Dr. Barry does not give up on her patients," Lorna said. "When it would get worse he would get very discouraged and she would say `no that's just a step backwards.' She is so positive in her thinking and doesn't give up." Once unable to move around the house on his own, and spending a day a week at the doctor's office, two years later, he is now able to walk short distances with a walker, and visits Barry once a month. "I think he is just amazing," Barry said.

Source: Ambrosia Sarabia, SGV Tribune, [2/8/07]

Diseased Toenails Can Predict Amputation: CLEAR Study

Nearly 3 in 4 people with diabetes at high risk for amputation have diseased toenails. These are the findings of a recent study presented at the Council of Nail Disorders in advance of the American Academy of Dermatology last week in Washington, DC. The study, co-authored by Drs. Stephanie Wu and David G. Armstrong of Scholl’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University, was the first to rigidly evaluate a controlled group such as this.

Dr. Stephanie Wu

“This study is something of a confirmation of what many have felt, but the ubiquity of the results is something of an eye-opener,” noted Dr. Wu. “It appears that if you have certain pre-existing risk factors for amputation coupled with a clinically diseased nail, chances are you have a significant fungal infection based on laboratory cultures. It is our hope that this study will assist us in making more rapid assessments and embark on much-needed therapy for these high-risk patients.”

Bush Renews Malpractice Debate But Reform Unlikely

President Bush has renewed his call for nationwide tort reform, but federal legislation addressing medical malpractice lawsuits is unlikely to pass while Democrats hold the majority in Congress, the Chicago Tribune reports. Bush in Illinois last week said, "I'm worried about frivolous lawsuits that are running up the cost of healthcare." He added that "when somebody gets sued all the time, they practice more medicine than is necessary and it runs up your costs." A day later in New York, he said that "excessive lawsuits will make it hard for America to remain the economic leader that we want to be."

In addition, during his State of the Union address last month, Bush asked Congress to pass legislation that would limit non-economic damages awarded in medical malpractice cases. However, Bush's legal agenda "is likely to be ignored" in the new Democratic-led Congress, according to the Tribune. Democrats generally oppose efforts to restrict the types of lawsuits people can file and the amounts they can recover.

Source: Chicago Tribune via American Health Line [2/8/07]

Query: Revision First MTP Joint Arthrodesis
From: David Arkin, DPM

I'm looking for suggestions for surgical revision of a fused first MTP joint at 45 degrees dorsi-flexion. The patient's original complaint was sub-second met head pain, with hallux valgus deformity. She underwent first MTP joint fusion with dorsal plate and a second hammertoe PIP joint fusion by a colleague. She now has dorsal hallux IP joint irritation, plantar first and second met head pain. My plan is for two-piece implant at the first MTP joint, and Weil osteotomy to shorten the second met. The alternative is re-arthrodese the first MTP in the corrected position. Any suggestions from anyone who has revised a first MTP joint fusion?

David Arkin, DPM, Big Flats, NY

Query: Ankle Scope Code

What code is used for billing an ankle synovectomy using a scope?

Anita Patel, Office Manager, Whiting, IN

Response: There is a listing in CPT of the various available codes to use when ankle arthroscopy is done. In your case, you would bill CPT 29895 (arthroscopy, ankle, synovectomy, partial). If you did more than the synovectomy, i.e., debridement, you could, instead, bill either

CPT 29897 (arthroscopy, ankle; debridement, limited) or CPT 29898 (arthroscopy, ankle; debridement, extensive).

Howard Zlotoff, DPM, Camp Hill, PA

Codingline subscription information can be found at
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RE: Charles Bradley, DPM - DSC Award

I had the splendid opportunity of working with Dr. Bradley at CCPM while I was a student and resident. Whenever I was assigned to scrub in one of his cases, I was always excited. He always made me feel at ease. Thank you and congraulations, Dr. Bradley.

Mitchell Moser, DPM, Roseville, CA

RE: Exertional Compartment Syndrome (Cory Pilling, DPM)
From: Multiple Respondents

It might be helpful to re-assess your diagnosis. Often times it is helpful to have the patient perform rigorous exercise in the office, such as running, repetitive stair climbing just to reproduce the symptoms. An examination with the patient symptomatic would confirm your diagnosis.

FYI, the soleus is in the superficial posterior compartment. Using a Stryker compartment pressure-measuring device, you could measure the compartment pressures pre and post exercise. If a significant rise in pre and post exercise pressures is documented, this would confirm your diagnosis. Your local hospital ER will likely have the Stryker probe needed. I am not aware of any conservative treatment options. Fasciotomy is usually necessary and effective.

John Levin, DPM, Atlantis FL, John.Levin@OCPBC.com

My primary question to this patient would be how serious a competitor is she. If she is expecting to be drafted by a college or get a scholarship, this situation must be treated more seriously. If she is a serious athlete than she should be referred back to her orthopedist or a physiatrist for compartment pressure testing for exercise-induced compartment syndrome, while inducing symptoms on a treadmill. If her compartment pressures are not elevated than further investigation with MRI would be prudent.

If her pressures are elevated consideration for ice therapy prior to initiating her workouts, as well as, during and afterwards. In lieu of utilizing orthotics in her shoes while in competition, will she be allowed to use a Campbell's rest strap with a longitudinal arch to control her pronation?

Unfortunately, oftentimes these problems require surgical intervention to get some relief. But most importantly, make sure the diagnosis is correct.

Simon Young, DPM, NY, NY Simon Young@juno.com

For this patient, exertional compartment syndrome is plausible, but uncommon. I suggest obtaining an MRI to r/o an accessory soleus muscle.

Jeffrey Siegel, DPM, Philadelphia, PA, heeldoc1@aol.com

RE: Podiatry Internet Journal
From: Al Kline, DPM

The Podiatry Internet Journal or PIJ is an open-access, on-line resource journal introduced in January 2007 to enable rapid access information of case study articles relevant to the field of Podiatry. I began this project with the help of my fellow colleagues in an effort to establish an internet journal that will allow rapid access to information when submitted. The journal online can be accessed at www.podiatry.wordpress.com

The Podiatry Internet Journal began accepting articles in January 2007. The journal will accept articles and publish them online, usually within 1 to 2 weeks of submission. The concept of open-access availability of information is a unique switch from online, subscription-based articles. The journal also will publish a PDF version of submitted articles in a journal-like format very similar to what you see in your favorite podiatry journal. The PIJ is directing its article content to case study presentations and information relevant to podiatry as we practice. A major advantage is its speed of delivery in information.

Just last week, the journal received an article from an orthopedic doctor recently published in the JFAS. His article was edited and uploaded within one week of submission. It is this kind of fast access to information that will likely enhance our need for rapid information and knowledge in our field. We are actively seeking support of active podiatrists, residency directors, and residents to add and share case information through our unique site.

Al Kline, DPM, Corpus Christi, TX, al@kline.net

Editor’s comment: Through an agreement with PIJ, selected articles from PIJ will be reprinted in Podiatry Management.

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

Editor’s note: This discussion continues at: http://www.podiatrym.com/letters2.cfm?id=12692&start=1

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 -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

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