The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

February 11, 2009 #3,467 Publisher-Barry Block, DPM, JD

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Diabetes Amputation Spurs Increased Visits to UT Podiatrist

The complications from diabetes suffered by Utah Jazz owner Larry H. Miller have prompted a flurry of calls from people worried about similar complications. Surgeons amputated Miller's legs just below the knees two weeks ago. Since then, people have been calling doctors with concerns about their own condition. Podiatrist Dr. Scott Clark's patient load has increased about six fold over the past two weeks. He says they ask, "Am I going to be at risk of losing my feet, of losing my limbs like Larry Miller did?"

Dr. Scott Clark

It really hit home to Lynette Fisher, who narrowly escaped having a below-the-knee amputation. Her foot had deteriorated into multiple fractures and more. "She was walking right on the middle of her foot with no sensation. She broke down and had large wounds on her foot and the side of her foot," Clark said. Clark's group reshaped the foot and used a fixation device to stabilize it. They also used a regenerative tissue matrix called GraftJacket to hasten the healing of her wounds. "What happens is it's basically a scaffolding for her body to grow new skin in across that," Clark said.

For people who are threshold diabetics, or who have crossed that line into Type 2 diabetes, the feet become a major concern. With Larry Miller's ordeal, the blindfold is off. The message about awareness and prevention is being delivered and, based on calls at Dr. Clark's clinic and others, people are listening.

Source: Ed Yeates, KSL-TV [2/6/09]

SALSA's Armstrong Given APMA's Award of Excellence

In a ceremony following his keynote lecture at the Annual Meeting of the New Mexico Podiatric Medical Association,  David G. Armstrong, DPM, PhD, Professor of Surgery and Director of the University of Arizona's Southern Arizona Limb Salvage Alliance (SALSA) was awarded the American Podiatric Medical Association's Award of Excellence by APMA President, Dr. Ross Taubman.

Dr. Ross Taubman presents APMA Award of Excellence to Dr. David Armstrong

"I am honored beyond words to receive this award", noted Armstrong. I think, however, this is more of an award acknowledging the growth of a profession and a field of study more than it is that given to a specific person." Armstrong, who has published more that 260 manuscripts and lectured on six continents, last year became the 25th and youngest ever entrant into the Podiatric Hall of Fame.

"I think I'd like to dedicate this award to my pop, the late Dr. Leo Armstrong, who showed me what wisdom and doctoring can be. I hope someday to live up to be half the man he was."

FL/MA Podiatrist Runs for Town Council 

Appointed to fill an unexpired term, Councilman Don Clayman plans to run to keep his seat in the March 10 town election. The Town Council on Oct. 28 chose Clayman, 73, to finish the term of Robert Gottlieb, who stepped down Sept. 23, citing personal reasons. Clayman had previously served as an alternate member of the town's Planning Board and the Community Affairs Advisory Board. He resigned from both boards as a condition of serving on the Town Council.

At the time of his appointment, Clayman cited beach erosion as the top issue facing the town. "Beach erosion is still No. 1," he said this week. Clayman is a part-time podiatrist from Massachusetts with 40 years of experience in the field. He sees patients during periodic trips up North throughout the year. Clayman received his education at the Ohio College of Podiatric Medicine.

Clayman was the force behind the town's designation as a distribution site for pharmaceuticals during a catastrophic emergency, such as a pandemic or exposure to the anthrax toxin. South Palm Beach is the only municipality in the county designated as a distribution site. About two dozen volunteers are in training by local health professionals, learning how they would assist in getting medical and other supplies from the Strategic National Stockpile into the hands of those in South Palm Beach. "We are the only town that is prepared," Clayman said. "We will be able to keep our citizens, guests and employees safe."

Source: Margie Kacoha, Palm Beach Daily News, [2/5/09]

Query: Restoring Skin Tone/Color Post-op

I performed routine hammertoe corrections on an African-American female in September, 2008. It healed uneventfully with no pain or problems presently with the exception for her concern over the cosmetic issue that the skin on the dorsal aspect of her toes is still blanched where the corns were on the dorsal aspects of the proximal interphalangeal joints. Is there any topical medication that will restore normal skin tone or color to these areas?   

Mark H. Sugar, DPM, Hyattsville, MD
 

Query: Platelet Gel Application Code

What, if any, code is there for platelet gel application?

Harold Brem, MD, New York NY

Response: I believe there are several possible codes, while not specific for platelet gel applications, that *could* be used when using tissue derived platelet gel. These would include:

CPT 20926 - tissue grafts, other (e.g., para tenon, fat, dermis, etc.)
CPT 86999 - unlisted transfusion medicine procedure
CPT 20550 - injection(s) single tendon sheath, or ligament, aponeurosis (e.g., plantar fascia).

The latter code, I believe, may be used when injecting the gel into the plantar fasica for treatment of plantar fasciiitis, and not necessarily for wounds. Medicare and many others do not cover procedures involving platelet gel for wounds or other soft tissue pathologies as they are considered "investigational." There are, however, non-Medicare carriers that may cover the procedure on a policy by policy basis. The above codes are a starting point for your facility to use when inquiring on coverage.

I  suggest your facility compose a detailed report outlining the exact procedures to be performed. This will need to be sent to the carriers for pre-determination of benefit and pre-authorization of the procedures.  As these procedures are often required to be performed multiple times and are expensive, your facility should be prepared to document to the carrier the rationale for use, efficacy, exhaustion of other more conservative procedures, costs for these procedures and alternatives (e.g., amputation and its associated costs).

Paul Kesselman, DPM, Woodside, NY

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RE: Tendon for Gastrocnemius Paralysis (Mark Aldrich, DPM)
From: Multiple Respondents

Dr. Alrich asked what would be suggested to address the gastroc paralysis, if anything?  There is no muscle belly of the lower leg that develops the force and shortens the distance that gastrocs do.  For a muscle attached to the posterior calcaneus to plantar-flex the ankle more than a few degrees the tendon will have to slide more than an inch.  A muscle used to plantar-flex the ankle should be attached as far posterior as possible to give the muscle as much lever arm at the ankle joint.  Most of the muscles of the lower leg move less than that distance and produce insufficient force to create enough plantar-flexion moment to add significantly to activities of daily living.  In addition, there is usually a loss of muscle strength with a tendon transfer and you would lose the function of the transferred muscle.  So, there is no way for a muscle transfer to replace the loss of the gastroc and soleus muscles.

Eric Fuller, DPM, Berkeley CA, fullerpod@lmi.net

Presumably, the paralysis is caused by damage to the nerve roots innervating the sciatic nerve (L5-S1-S2). As such, only a muscle/tendon transfer not innervated by those nerve roots can be considered (assuming the remaining lower lumbar nerve roots aren't similarly affected). Is there another tendon strong enough in the LE to replace gastroc?...I doubt it, plus you'd also lose one grade of strength in the transfer and still need difficult out of phase biofeedback coordination.

Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

Posterior group muscle weakness due to over-aggressive TAL, CVA, or in your patient's case, gastroc partial paralysis always presents a challenge. Is there clinical evidence of a progressive cavus foot deformity? If secondary changes present, you may need to stabilize the foot first with cavus procedure of choice and 3-4 weeks later, tendon transfer. 

My primary choice is a p. brevis transfer anchored via drill hole in the posterior calcaneus lateral to medial. This muscle is much stronger vs FHL and therefore does a much better job. However, there is always a trade-off since now, the inverters are now dominant.  You will obviously need to attach the pb stump into the PL and then it is a waiting game. I videotape a patient’s gait throughout the pre and post-op course and follow closely to see if that is enough.  If not, tib. ant to the cuboid (the whole tendon) is next. And that should be it.

S. Jeffrey Siegel, DPM, Long Beach, CA, heeldoc@verizon.net
 

RE: Concierge Podiatry Services (Alan Mauser, DPM)
From: Ivar E. Roth DPM, MPH

I believe I am one of the first practitioners in the United States to be a concierge podiatrist.  The practice is, of course, different than the typical concierge doctor, whereby a front-loaded fee is required to become a patient and receive treatment. In my modified concierge practice, I accept NO insurance of ANY type and I am NOT a provider for any insurance company. I opted out of Medicare three years ago.

To be a concierge physician, you must think quality of care and be VERY service-oriented. I see a maximum of 15 patients per day. New patients receive up to one hour of time and returning patients are allocated ½ hour. All appointments are on time and I can usually see a patient the day of their call or within 24 hours. Coming in early or staying late is part of the service aspect of a concierge physician. I base my fees on what an hour of my time is worth, etc. and so should you.  Surgeries and all services are paid for upfront and we bill the insurance company as a courtesy to the patient so that they can receive reimbursement.

I have a very fulfilling practice and am satisfied that I took the path that I have. I would recommend a concierge type practice to any podiatrist who has the desire and ability.

Ivar E. Roth DPM, MPH, Newport Beach, CA,ifabs@earthlink.net
 

RE: Healthcare Networks of America, LLC (David Zuckerman, DPM)
From: Paul Rosen, DPM

Health Care Networks of America is a scam.  For years they have sent letters and faxes to my office, first asking me to join the network, then telling me that I am in the network, then telling me that I am getting patients from their networks that I either dropped out of (how do you spell Multi-Plan?) or were never in them.  And of course, all for the bargain price of $125.00  I have forwarded their faxes to the Fax Police to try and stop them from clogging my fax machine, but even they cannot stop them from sending faxes. A waste of paper, ink, time, and money. These faxes are supposed to have a number so you can opt-out of receiving them, but of course they do not. Does anyone know how to stop these frauds?

Paul Rosen, DPM, NYC, NY, paulfxfeet@aol.com
 

RE: Carl Abramson, PhD
From: Larry Zonis, DPM, Pat Caputo, DPM

I was saddened to hear of the passing of Dr. Carl Abramson. He was an inspiration to many of us who had the opportunity to study under his guidance.  Dr. Abramson was an advocate for our growing profession. His enthusiasm for microbiology was as infectious as his smile, his humor and his desire to advance our profession into mainstream medicine. He believed in podiatry as he believed in us as his students. He will be truly missed.

Larry Zonis, DPM, Scottsdale, AZ

I was so happy to read the tribute to Dr Carl Abramson by no one less than Dr. Helfand.  I say this because Dr. Helfand brought to light a personal, humorous and humanistic portrait of Dr Abramson that many of us students in the early 1980s at PCPM thought was “Urban Legend.”  My roommate, Dr Doug Finkel, was a microbiology work-study student for Dr. Abramson, and he would tell me of his Pocono and Catskills resort stand-up routines and WW II military account with Gen. Patton.  It was hard to believe because neither experience matched the persona of the kind, friendly professor in class.  Dr. Abramson (and his legend) will be missed by the wide range of people who he touched in his very full life.

Pat Caputo, DPM, Holmdel, NJ
 

PRACTICE FOR SALE - CENTRAL FL

ASSOCIATE POSITION NORTHERN CALIFORNIA

Need associate in busy office in two locations. Hospital privileges
available. Emphasis on wound care. All aspects of Podiatric Medicine and Surgery. Associate position to lead to partnership and buyout. Please contact jimf@humboldt1.com

POSITION WANTED In NY or NJ AREA

Board certified podiatrist seeks part-time position in NY/NJ area. Experienced in all aspects of podiatry, including Diabetic Foot, Surgery and in patient care. I'm available Tuesdays and Thursdays. Please contact me at nyraider1@yahoo.com

OFFICE SPACE FOR RENT - SEATTLE, WA

Full-service, state-of-the-art podiatry office is offering office space for an independent podiatrist or podiatry group. We have digital X-ray, PADNET, physical therapy equipment, all podiatry equipment and staff to assist you to make the most out of your podiatry practice. Our office is conveniently located close to North West and Stevens Hospital right across from North Gate Mall. You can send your letter of interest to: seattlefootdoctor@yahoo.com or call 425-223-9588

ASSOCIATE POSITION-- METRO NEW YORK AREA

Part-time/Full time. Must be HIP Par Provider. Excellent opportunity for partnership. Must have surgical privileges at area hospitals. E-mail CV to rrranch7@yahoo.com

ASSOCIATE POSITION – CINCINNATI, OHIO

This is your once-in-a-lifetime opportunity to join one of the most successful practices in the United States. No seniority system. If you are motivated and have completed a PSR24-36 residency, your income is limited only by your enthusiasm and desire to achieve. Fax resume to: 513-577-7261 or E-mail resume to Kroesch4poh@aol.com

ASSOCIATE POSITION -SOUTHERN NEW JERSEY

I’m looking for podiatrist who wants additional practice hours. Perfect for combining your own practice with an additional income. Must be on Aetna Insurance, Horizon Blue Shield, Medicare, and most commercial carriers. I am looking for someone who has a desire to learn how a very successful practice is run, so that I will be able to have time away from my practice. Payscale to be discussed. Could lead to partnership or sale. E-mail contact information, CV, and why you would be perfect for this opportunity. Contact foot.care@verizon.net

PODIATRISTS NEEDED  CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC 
 
Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

FOR SALE - FLORIDA—CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

ASSOCIATE POSITION - VIRGINIA IS FOR LOVERS

Immediate full-time amd part-time associate positions 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 tofixafoot@cox.net or fax to 757-397-5889

ASSOCIATE POSITION – ST. LOUIS, MISSOURI

Excellent opportunity for PSR 24-36 foot and ankle surgically-trained physician. Looking for hard-working, personable, highly-motivated individuals to join our group and build their own practice. Position leading to partnership. Great opportunity with excellent salary and benefits. Please e-mail CV and references to cavallinig@foothealers.com

ASSOCIATE POSITION MONTANA

Great opportunity for a PSR-24 or 36 residency trained individual to join a dynamic two doctor group with physical therapy. Needs good FF surgical skills, RF a bonus. Beautiful office and great area of the country for outdoor recreation minded individuals. Opportunity for partnership after employment. Reply to: jclough@sofast.net

PODIATRY ASSOCIATE WANTED – NJ

Northern NJ. Bergen County Must be well-trained. No nursing homes or house calls. Modern well-equipped office. Digital x-ray and ultrasound. Excellent pay and opportunity. Must have NJ license. Call 973-472-4700.

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to f-massuda@footexperts.com

 
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