The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

March 09, 2009 #3,488 Publisher-Barry Block, DPM, JD

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We've just mailed the March 2009 issue of Podiatry Management. This month's Cover story is the Status of Women in Podiatry.  In addition, you'll  find our usual assortment of features, including our columns, and a CPME-approved CME.

March 2009 Podiatry Management

Self-Assessment is key to Prevention for Diabetics: TX Podiatrist

Diabetes and daily routines go hand in hand—eating balanced meals, monitoring blood sugar, getting some physical activity each day, and relaxing. But there’s another task doctors urge you to add to your busy schedule: examine your feet.

Dr. Lawrence Lavery

“Diabetic foot complications account for 20–25 percent of all diabetes-related hospital admissions,” says Lawrence Lavery, DPM, MPH, foot researcher and professor of surgery at Texas A&M Health Science Center College of Medicine in Round Rock, Texas.
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“So much of prevention and early diagnosis has to do with self-monitoring and self-assessment,” Lavery says. “Your feet are not talking back to you because of neuropathy—your feet are not telling you that your shoes are too tight or that the ball of your foot is swelling. Patients have to substitute other mechanisms to monitor their feet.”

Source: Chelsea Reynolds, Diabetic Living [Summer 2009]
 

NYCPM Student Accepts Award for Groundbreaking Video

Nicholas Giovinco, NYCPM Class of 2010, was awarded first place in the Multi-Media Student Research Competition held by the Foundation for Podiatric Medicine for his video, “Morton’s Neuroma Explained.” The contest awards prizes for the best original research in Podiatric Medicine. Mr. Giovinco strongly credits Shane Baker and Kelly Powers, both also of the Class of 2010, for their collaborative efforts on the video, and shares his award with them.

(L-R) Nicholas Giovinco, Shane Baker, and Kelly Powers

“Morton’s Neuroma Explained” is part of the Dr. Glass Project, a website and series of videos created as a repository for royalty-free content to help further understanding of podiatric issues among podiatrists and laymen alike. It was created by Mr. Giovinco, Mr. Baker and Ms. Powers, along with fellow students Brad Hart and Doug Doxey, also of the Class of 2010. The videos are available on the Dr. Glass Project website drglass.org, on the Dr. Glass YouTube channel, and as a podcast via iTunes University.
 

LECOM Appoints Evans as VP for Medical Education/Program Development

The Lake Erie College of Osteopathic Medicine (LECOM) of Florida has announced that Chet Evans, MS, DPM has joined the administration of the LECOM Bradenton campus as Vice President for Medical Education and Program Development. In his new role with the College, Dr. Evans will have multiple program responsibilities. As a senior administrator, he will work with the academic leadership of LECOM Bradenton to manage the College of Osteopathic Medicine and the School of Pharmacy. His role will be to provide leadership and direction for new educational programs.

Dr. Chet Evans

Dr. Evans is currently the chair-elect the Florida Governor's Diabetes Advisory Council. His Florida health care and medical education experience will allow him to connect with hospital leaders and others in the medical community around the state to build new clinical teaching affiliations for medical student rotations and pharmacy student clinical experience.

Query: Diagnostic Ultrasound

My office is interested in purchasing a new ultrasound machine for simple diagnostic evaluation and guided injections. We are looking for a unit which has USB-flash drive access for image transfer into an electronic medical record system. Are there any suggestions for a unit under 10K which produces quality images?
 
Jody McAleer, DPM, Jefferson City, MO
 

Query: Missing APMA Life Members

APMA has lost track of the following life members and would appreciate any information.  

Benjamin Feldman, DPM, Temple (1950)
Edward Giese, DPM, Scholl, (1959)
David Klinger, DPM, Long Island (1950)
Herbert Toll, DPM, Temple (1950)

Thank you.

Beth Shaub, Director, Membership Services, APMA , bshaub@apma.org

RE: Bunion Deformity with Severe Contracted Digital Deformities (Jim Giannakaros, DPM)
From: Multiple Respondents

When evaluating this radiograph, two things come to mind.  First, this foot, with its severe lateral dislocations at the MTPJs and large bunion deformity is reminiscent of a rheumatoid foot. Second, I am concerned about the contracted neurovascular structures with such a severe deformity. If surgical correction would consist of traditional bunion surgery with MTPJ release, percutaneous pinning, arthroplasty, possibly even flexor tendon transfer, etc, then spasticity and ultimate occlusion of the digital arteries may occur, possibly resulting in gangrene of the digit(s), even with normal distal perfusion. 

Therefore, I would recommend 1st MTPJ fusion, with metatarsal head excision of rays 2-5 combined with digital arthroplasties as needed with pecutaneous K-wire fixation for approximately 4 weeks. One may decide to resect the 2nd and 3rd only if little pathology exists in the 4th and 5th toes, but this may produce lesser metatarsalgia and/or transfer lesions of the 4th and 5th metatarsals. If the surgeon feels that metatarsal head resection is too radical, or if the surgeon feels that preservation of the joint is key, then one needs to shorten the metatarsals in order to allow reduction of the toe deformities and prevent arterial spasticity. I would then recommend some type of osteotomy to shorten the lesser rays, specifically the 2nd and 3rd metatarsals. A Weil osteotomy or sagittal Z osteotomy may work well, but this too carries risk of non-union, further instability of the forefoot, as well as possible issues with fixation.

Todd Lamster, DPM, Phoenix, AZ, tlamster@gmail.com

Initially, I would recommend a custom-molded shoe. If that does not work or the patient wants surgery, I would recommend a Hoffman-Clayton with arthroplasties fixated with K-Wires and a fusion of the first MPJ. Prior to the surgery, make sure a vascular exam is done.
 
Joel Morse, DPM, Washington, DC, foxhallfoot@aol.com

Depending on the patient’s activity level, and if the goal is pain relief, I would treat this like a rheumatoid foot. I would perform a 1st MTPJ arthrodesis, pan met head resection, PIPJ arthrodesis 2,3,4, and arthroplasty 5th with pinning.
 
Chris Lotufo, DPM, Newnan, GA, chris_lotufo@hotmail.com
 

RE: Nerve Blocks and Nitroglycerin (Michael M. Rosenblatt, DPM)
From: Kazu Suzuki, DPM, Wm. Barry Turner, RN, DPM

I agree with Dr. Rosenblatt that PT block or nitro paste has no clinical evidence on wound healing, to my knowledge. I'm afraid you may be putting yourself liable by treating your ischemic leg patients with "unproven" and "anecdotal" methods.

We screen all of our new wound patients with handheld Doppler and/or laser-Doppler (SPP/PVR monitor). If we suspect ischemia, we make immediate referrals to vascular specialists; namely vascular surgeons, interventional cardiologists, and interventional radiologists. This IS the standard of care delineated by the ACC/AHA guideline and TASC-II guideline for the management of PAD.

Kazu Suzuki, DPM, Los Angeles, CA, kazu88@gmail.com

I wholeheartily agree with Dr. Rosenblatt. Every chronic wound-regardless of presentation, in my practice, gets a vascular consult. The nitroglycerin is only a Band-aid. A temporary measure at best. Your body, over time, will develop resistance to the nitroglycerin effects. But using nitroglycerin before and after a vascular bypass or per cutaneous intervention is not necessarily contraindicated and usually helpful. Remember to control the resulting lower limb edema. I would use support hose, Jones compression dressings, Unna boots, and sometimes just bed rest with slight leg elevation. You need to be creative to keep the pressure off the wound site and careful to avoid applying too much pressure on the arterial system.

During my nursing career, we applied the nitroglycerin paste to a piece of paper and taped the paper over the chest for acute MI. Because of frequent calcification of the arterioles in the interdigital and intermetatarsal space, I rub the nitroglycerin in, looking for a more of a surge effect in attempt to break up the calcification. Does it work? I am not sure, but I know nitroglycerin will almost always get me some blood. That is another reason we do a trial application in the office, to make sure the patient can tolerate the rubbed in technique. Again, in almost 20 years, I have had only one patient become hypotensive. I use nitropaste on 90% of my wounds. 
 
Wm. Barry Turner, RN, DPM, Royston, GA, claret32853@gmail.com
 

RE: Intra-op Use of Kenalog 40 (James Hetfield, DPM)
From: Ivar E. Roth DPM,MPH

I have read the angry responses to my statements about Kenalog use. Read the package insert carefully and I think you will have a different opinion as this is FDA-mandated language and it is there for a reason.

The cases that I have reviewed are not hiccup cases, these are cases where massive problems have occurred. I am only one reviewer of claims, yet I have had multiple cases where Kenalog was used in a post-op wound with disastrous results. If you multiply the number of cases out there by my observed percent of incidence, this adds up to a big problem.

My intent is to get the word out there that this is a potential problem area that podiatrists need to know about. When you are in trial, it is very hard under oath to say that you deliberately went against the package insert warnings for a product that you used for the benefit of your patient.

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

RE: What to do in the Face of the Projected Medicare Cuts? (Neal Frankel, DPM)
From: Jeffrey Kass, DPM

I don't know about anyone else, but I am terrified about the Medicare cuts the current Obama administration has proposed. If we were complaining about insurance issues before, this will magnify those problems many times over.

I also think we as a profession need to be proactive, as Dr. Frankel suggested. Dr. Frankel speaks of ways of dealing with non-Medicare payers. I think the "brains" of the profession needs to scramble and come up with a plan to get rid of the idea of this twenty-something percent paycut. I don't think many of us can survive such a cut. 
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

ASSOCIATE POSITION – HOUSTON, TX

Associate needed for 30 Year Houston practice. 2 offices, each located in growing medical center. Heavy surgical/office practice with minimal RFC. Tremendous opportunity for personable self starter. English & Spanish would be a big asset.PM&S-24 and PM&S-36 graduate welcome. Texas license required. Reply to ssssmosk@aol.com

PRACTICE FOR SALE or ASSOCIATE WANTED – SOUTHEAST OHIO 

Well-established, two-office practice in Southeast Ohio for sale. Seller currently works 3.5 days per week. Gross >$300K, Net ~$140K.  Excellent locations and growth potential. All equipment and furniture included. Seller is willing to help with transition, Ohio Licensure. Contact seller at bjadpm@hotmail.com for more information.

ASSOCIATE POSITION- CALIFORNIA

Associate needed for coverage in the office, nursing homes and facilities in Orange County Southern California. Surgical as well as C&C. Will help to get on staff at St. Jude Medical Center. Please contact Dr. Lee for more information at (714) 333-5837 or by e-mail to chinuklee@yahoo.com

ASSOCIATE POSITIONS – CALIFORNIA

Three podiatrists needed for busy North Hollywood office. Full-time Monday-Friday 8am-2:30pm.  No weekends and no call. Pay negotiable. New podiatrists are encouraged to apply. Please email resume and salary request to Coasttocoastpodiatry@yahoo.com

ASSOCIATE POSITION – NAPLES, FL

Great opportunity for PSR- 24/36 BE/BC podiatrist with strong surgical skills to join multi-office practice. Hospital privileges available at 648 bed hospital system, 200 bed hospital system and multiple surgical centers. Florida has a great scope of practice law and we rotate for ER call at all 4 hospitals. Candidate needs to be ethical and motivated. Established practitioner or new practitioner OK. Base salary, percentage, benefits including 401K. Fax CV to (239)566-8778 or Email CV to Drgordon@gulfcoastfootcare.com

PRACTICE FOR SALE-SOUTHEAST MICHIGAN-BRIGHTON
 
Outstanding opportunity. Eleven year established. Excellent location in mid to high income growth area. Must sell due to illness. Turn-key, all equipment and furniture included. Beautiful 1,350 sf build-out. Great visibility and parking. Priced low to sell immediately. Call (248) 565-5266. Docpod@aol.com 

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

PRACTICE FOR SALE - CENTRAL FL

Practice sale, in beautiful, high quality of life, growing area; 2000 sf bldg. fully equipped/ designed for podiatry; excellent location, features & exposure; near hospital, wound and HBO center. Great opportunity for expansion; good insurance climate. 352-357-7499 / E-mail: windnwave@earthlink.net

NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS

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

SPORTS MEDICINE/ PODIATRY FELLOWSHIP

The Palo Alto Medical Foundation has a 12-month Fellowship beginning Aug 1, 2009 and ending July 31, 2010. APPLICANTS MUST BE ABLE TO OBTAIN A CALIFORNIA LICENSE.  Interviews will be at the American College of Foot & Ankle Surgeons Annual Meeting and Midwest Podiatry Conference. Candidates will be chosen by mid-April. 24-month surgical residency training is a pre-requisite .Send a letter of interest, CV and three letters of recommendation to: Amol Saxena, DPM, FACFAS, Fellowship Director, Dept. of Sports Medicine, PAMF, Clark Bldg. 795 El Camino Real, Palo Alto, CA 94301 Ph: 650/853-2927 Email: HeySax@AOL.com

OFFICE SPACE/ MRI RENTAL – NYC, LI   
 
Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, and Plainview Long Island. JACHO-certified operating rooms available, as well as all surgical equipment and anesthesia. Extremity MRI Rental. Stark compliant. All exams read by board certified radiologist. Call for details. 516 476-1815

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

 
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