The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

April 10, 2010 #3,828 Publisher-Barry Block, DPM, JD

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In addition to Dr. Jaime Torres' other credentials in the story about his being appointed Region II Director of Health and Human Services (Yesterday's PM News), Dr. Torres is a member of the Board of Trustees of NYCPM’s clinical affiliate, Foot Center of New York.

 PM News Celebrates its 16th Year on the Internet

This issue marks the 16th consecutive year that PM News has published on the Internet. To date, we have published 3,828 issues to a podiatric audience of over 12,000 subscribers. We would like to thank all of our readers and advertisers for their support in making this on-going process possible.

PM Webmaster, Dr. Albert Musella

We also like to acknowledge those who work behind the scenes to enable this newsletter to be published: David Kagan, PM's associate publisher, who is in charge of Internet advertising, Al Musella, DPM, PM's Internet webmaster, Hermine Block, PM's managing editor, who copy edits each issue, Harry Goldsmith, DPM, of Codingline and, of course, all those who contribute by sending in queries and comments. These individuals are the key to PM News' success. 

MO Podiatrist to Receive Salute of Excellence Award

Dr. Robert Moore will be among the honorees at The St. Louis American Foundation’s 2010 Salute to Excellence in Health Care awards luncheon to be held Saturday, April 24 at the Ritz Carlton Hotel in Clayton. Moore is a podiatrist and foot and ankle surgeon at Betty Jean Kerr People’s Healthcare Centers in St. Louis, where he has worked for 28 years. His practice includes foot and ankle surgery, diabetic foot care, pediatric and geriatric foot care, as well as general and local foot care. Moore said, “It’s my epitome of gratification – so you can walk comfortably without pain.”

Dr. Robert Moore

He is board certified in reconstructive foot and ankle surgery by the American Board of Podiatric Surgery. Moore served as director of Podiatric Surgical Residency Training at Central Medical Center and continues to train podiatric residents in surgery at St. Mary’s Health Center. He is a member of the American Podiatric Medical Association and the National Podiatric Medical Association, and is a fellow in the American College of Foot Surgeons.
 
Source: Sandra Jordan, St. Louis American [4/8/10]

IL Podiatrists Return From African Medical Mission

Who would know better about small steps than a pair of podiatrists? Local Drs. Jennifer and Doug Paccacio, along with surgical nurse Jane Royalty recently spent two weeks practicing in Eretria, Africa, and returned April 2 for another two-week stint. The trio shared some of their experiences during a March 17 program at Valley West Community Hospital. Jennifer practices in Sycamore, Doug in Yorkville and Jane works at Kishwaukee Community Hospital.

(L-R) Jane Royalty, RN; Dr. Jennifer Pacaccio; and Dr. Doug Pacaccio (right) pose with their counterparts in Eritrea, Africa.

The local personnel were accompanied by another podiatrist, a surgical resident and two medical students. “This was a life-changing experience for all of us,” Jennifer said to nods of agreement from her colleagues. The mission trip was conducted as part of Physicians for Peace and the trio is helping to advance a newer arm of the organization, Limb Rescue International. Along with actually performing surgery and treating patients, the group provided education and training for staff at the hospital in Asmara. During their stay, they performed 59 surgeries, 34 on adults and 25 on children.

Doug called the medical personnel, and the citizens in general, very resourceful. “They make do with what they’ve got. And we learned as much as we taught,” he said. He said they often lost electrical power during surgery. “I no longer fear a power outage in OR,” he said. “You talk and talk about doing something like this and finally, one day, you just have to clear your schedule and go,” Doug said.

Source: Debbi Behrends, Midweek [4/7/10]

PA Podiatrist Expresses Concerns About Gas Drilling

Members of the state House of Representatives Environmental Resources and Energy Committee came to the Back Mountain on Wednesday to hear testimony on the impact of Marcellus Shale drilling and proposed legislation that would put additional environmental safeguards in place.

Dr. Thomas Jiunta (photo courtesy of the Wilkes-Barre, PA Times Leader)

Dr. Thomas Jiunta, a podiatrist from Lehman Township, where issuance of a drilling permit is expected to be approved next week, said that since he has been researching Marcellus Shale exploration, he has “gotten a lot of lip service from senators and representatives about how we need to do it right. Before I start, I just want to say that maybe, maybe – and this is the first time I’ve said this word – we need a moratorium to stop it until we get it right.” Audience members burst into applause and cheers at Jiunta’s suggestion.

After sharing his concerns about an inadequate number of treatment plants capable of removing hazardous chemicals from water used in hydraulic fracturing and risks associated with storing those chemicals underground, Jiunta made several suggestions for the bill. One is adding a requirement that recovered waste water from the fracturing process be stored in sealed tanks rather than in surface pits that have liners that he said could tear and overflow with heavy rain.
 
Source: Steve Mocarsky, Times-Leader [4/8/10]

Query: Piezogenic Papules

I have an elderly but very active woman with two severely painful piezogenic papules in the posterior heel. Conservative treatment via heel cup is completely ineffective. Are these lesions easy to locate at surgery to the point where the fascial defect can actually be repaired? Is there a favorite injection technique out there? They happen to be larger than the typical papules I have seen and they, of course, really accentuate on weight-bearing. Is any kind of enhanced imaging indicated?
 
Bryan Markinson, DPM, NY, NY

RE: Possible Tear of Lateral Plantar Plate and Lateral Collateral Ligament (Alan Berman, DPM)
From: Jeffrey Kass, DPM

Recently, there was a similar posting in PM News regarding plantar plate tears. The discussion included trying a short course of oral steroids (prednisone), and off-loading the area. In a 60 year old, I would always try conservative care before surgical intervention. One thing, I would add to the prior discussion - if there is no history of trauma, no significant bunion or hammertoe deformity, look for a hypermobile first ray or an equinus deformity as possible other etiologies.

Use custom-made orthotics with dispersion padding around the site met head while addressing any potential biomechanical entities mentioned above. A "turf toe plate" is another good idea which will prevent bending of the forefoot. Dr. Jill's sells these at a very reasonable cost.
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

RE: Stiff Joint, Post-op Bunion Surgery (Craig Breslauer, DPM)
From: Randall Brower, DPM

I have never understood the reasoning behind apost-op bunion patient walking immediately post-operatively in a sandal, of all things. Would we walk a patient with 5th metatarsal fracture or a stress fracture right after diagnosis? A bunionectomy with an osteotomy is a surgical fracture. It heals as any fracture repair heals. I think many podiatrists in general, in order to "sell" a patient on an easy post-operative recovery after bunionectomy have fallen into the trap of not treating this surgical fracture appropriately.  The soft-tissues around that violated joint will contract and thicken, with immediate post-operative weight-bearing in a sandal potentially causing long-term stiffness. 

Also, a sandal is inadequate as it doesn't stop the EHL from firing and contracting. I have patients wear a surgical fracture boot for six-weeks like I would any other fracture. They are non-weight-bearing for the first two weeks. After sutures come out at two weeks, I have them perform ROM exercises to the 1st MTPJ but remain in the boot. I'd rather a patient not choose surgery because of inconvenience of post-op course than be miserable with post-op contractures and other complications from too early and too little protective weight-bearing.
 
Randall Brower, DPM, Roswell, NM, randoman33@yahoo.com

RE: Stiff Joint, Post-op Bunion Surgery (Craig Breslauer, DPM)
From: Michael Rosenblatt, DPM 

When I was in practice, usage of such artificial joints was common. Now, there seems to be “reversal” in the standard of care, which suggests that such implants are contra-indicated unless there is significant, demonstrable bone damage pre-operatively, and visible on x-ray. More recently, Craig Breslauer, DPM, has pointed out (correctly, in my opinion) that damage, or more specifically, sagittal  plain surgical “corrections” can cause inadvertent disruption of the oblique orientation to the sesamoid crista while addressing the IM angle and PASA. This issue underlines the fact that it is not only “bony” hypertrophic or atrophic changes” that suggest the need for an implant.

Of course, there are complications associated with their use. Sometimes they must be removed, for various reasons. There is also a concern about their ability to withstand weight-bearing usage, if they have been installed or used for that. A joint implant is not designed to maintain an angular surgical correction that will not by itself remain congruous. Rather it will “assist” in that goal.

In most cases, joint implants are not designed to bear weight, but rather to substitute for a damaged surface or dysfunctional movable system. But my point is that it is time to look beyond x-rays when you determine the necessity for using them. X-rays may or may not serve as your only arbiter. I think we are now seeing this over-dependence on pre-op x-rays result in a lot of post-operative stiff joints.

Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net

RE: MASS Theory  (Tyler Brahm, DPM)
From: Patrick J. Nunan, DPM, Keith Gurnick, DPM

I believe what Dr. Richie was pointing out was that Dr. Glaser was not a mechanical engineer. While his MASS theory has some merits, it is nothing new as recently pointed out by Kevin Kirby. Royal, Whitman and many others talked about moving the arch up with rigid beams (steel orthotics). The importance of the 1st ray and the windlass mechanism was described by Hicks and  then popularized by Dananberg. So is it new and revolutionary? Not really; that is why some people object to Dr. Glaser’s lectures.  
 
Patrick J. Nunan, DPM, West Chester, OH, pjndpmrun@aol.com

In the past two weeks, I have seen three patients who came to me for second opinions regarding their feet. All three patients were women and had orthotics made at a podiatry office practice by a respected and experienced podiatrist  who now uses Sole Supports Lab and orthotics made with the Ed Glaser, DPM "mass theory." One patient had plantar proximal insertional plantar fasciitis, one patient had a symptomatic bunion with symptomatic functional hallux limitis, and one patient had a sub-2nd metatarsalgia secondary to pre-dislocation syndrome of 2nd MPJ with a pronated foot and mobile 1st ray.

All three patients had …

Editor’s note: Dr. Gurnick’s extended-length letter can be read here.

RE: Metanx and Folast (Alan MacGill, DPM)
From: Robert Lagman, DPM, Patrick J. Nunan, DPM

I have also had patients come back and report that they were taking Folast. I first noticed it when I got a refill from the local pharmacy to substitute this for Metanx. I then did research online about the differences and realized that the medication isn’t really the same. Metanx is made local to me (within 5 miles of my office) and I know a fair amount about the company. I had great results with the company over the last few years. I have noticed a lower result with the prescriptions than in the past and this may be why. 

I have recently started doing epidermal nerve fiber density tests to validate my results on Metanx and have been getting less than optimal results, and now I am questioning if this due to the medication not doing what I had thought it would, or if my patients have been on the Folast medication instead over the last 4-6 months. I’m making sure that I now mark name brand necessary on my Rx when I write it.  I too am curious as to what everyone else is experiencing.

Robert Lagman, DPM,  Mandeville, LA, rlagman@drlagman.com

Pharmacists are being told by suppliers and their corporate bosses that Folast is the same. Folast is an inactive form of the B vitamins, not an active form that is in Metanx. We have had them try to change it even when we write, "Dispense as Written." We tell the patient they are not the same thing. I even write now on prescriptions, "there is no generic substitute in the active form."  That has stopped the substitutions. 
 
Patrick J. Nunan, DPM, West Chester, OH, pjndpmrun@aol.com

RE: Accountability of Expert Witnesses
From: Adam Cirlincione, DPM

I have on multiple occasions (most recently PM News of April 09, 2010) noted that the same podiatrists are listed as plaintiff's expert witness on cases within New York. I have also noted that typically, these experts lose the case in question. In this day of decreasing reimbursement, poor economy, and the increase in litigious patients entering all of our practices, how do we justify the fact that these same doctors who continually testify against their peers maintain membership in the same professional societies that I have worked hard to become a part of?

I know I will receive e-mails/responses telling me that perhaps these doctors are out to better our profession in some way, or that these doctors are "great people," but please explain to me how we allow these doctors to continue to be a drain on the system we are all asking to be fixed? We know very well that these doctors are paid for their opinions, and these opinions depend on how much they are paid and by whom they are paid.

I am sure there are correct procedures to follow to remove someone from a professional membership, but I get the feeling that perhaps we may fall short in this area. How does one find out a history of actions that an ethics committee of APMA/NYSPMA/ACFAS has taken in the past? Is there a transparent database of actions these professional societies have taken in regard to what they consider false or misleading testimony? It may make it easier for me to decide where I spend my money and which professional societies I support.

Adam Cirlincione, DPM, Glen Cove, NY, pittpod@gmail.com

PRACTICE & BUILDING FOR SALE - MIDDLE TENNESSEE

Two locations each with 3 exam rooms, x-ray room, large waiting room, and ample parking. Excellent locations and growth potential. All equipment and furniture included. Website and marketing material included. Seller happy to assist with transition. Priced to sell with financing available 250k. Call 931-446-5724.

PRACTICES FOR SALE – BOSTON SUBURBS

Two established part-time practices. 2009 Gross 150K. Turn-key opportunity with low overhead. Diverse payer mix & loyal patient base. Currently open 2 days a week, but can expand to increase revenues. Personnel to remain, seller will assist transition. Asking 65K for both offices. Contact david@transitionconsultants.com (800) 416-2055.

ASSOCIATE POSITION – NEW YORK

Podiatrist Needed Immediately - RFC only. $45/hr working for the state prison system. Clean and safe. Easy money to help pay the bills. Several shifts available. If interested, E-Mail hansfeet@aol.com.

ASSOCIATE POSITION – CALIFORNIA

Looking for a motivated Podiatrist to join a rapidly growing practice in Los Angeles. Excellent compensation. Please reply to coasttocoastpodiatry@yahoo.com

PRACTICE FOR SALE IN HOFFMAN ESTATES, IL NEXT TO SCHAUMBURG

Established 16 year old practice, great Payer mix, no HMO. Fully equipped, updated 1253 ft2, Class A space. Excellent Suburban location just west of Chicago. Great Start-up opportunity - Tremendous expansion potential! Email to: ILDPMpractice@aol.com for more information.

EQUIPMENT FOR SALE - X-RAY ORTHOPOSER

SXR-15 floor model X-ray Orthoposer unit for Sale. Great unit for primary or second office. $1500.00, shipping not included. Reply to: robertnunberg@me.com 617-974-3338

ASSOCIATE POSITION – HUDSON VALLEY, NY

Lower Hudson Valley (Carmel area) Tuesday & Wednesday mornings 9-1. Surgical privileges at hospital available for any cases booked. Compensation dependent on experience. 25 year old practice. Podiatric references will be needed. Reply to PodAssociate@aol.com

CANADIAN PODIATRISTS COME BACK HOME!

An Edmonton, Alberta group of DPM’s requires an additional Podiatrist. Interest in biomechanics essential. Given Canadian visa restrictions, this position is open only to Canadian Citizens or permanent residents. Very attractive compensation package. Fax C.V. or letter of interest to: (780) 483-5796.

ASSOCIATE POSITION FULL-TIME - SUBURBS OF CHICAGO

PSR 36 - month-trained podiatrist needed for busy suburban Chicago practice. Full benefit package included. If interested, please email your curriculum vitae to foot1st@yahoo.com

ADVANCED RESEARCH AND SURGICAL FELLOWSHIP

Boston University Medical Center has two unique fellowship positions Become an expert in Limb Preservation, Tissue Repair and Regeneration. Be part of this unique Fellowship at a major teaching facility. During this time, he/she would be expected to become a knowledge expert who will contribute significantly to research, surgical procedures, teaching, and innovations in limb preservation and tissue repair. Requirements: Completion of a two or three year surgical residency; Candidate must possess a commitment to an academic career in podiatric medicine and surgery. Annual Salary: Year 1 $61,000, Year 2 $66,000. Submit a CV and letter of interest to: erin.springhetti@bmc.org

PRACTICE FOR SALE: TENNESSEE

Established 30-year full-scope podiatry practice. Excellent hospital and surgery center privileges with investment opportunities. Fully equipped 2200 sq.ft. office across from hospital. High volume of new patients, DME, and local referral base. Great community for a family and the outdoorsman. Reply to tnfootdr@gmail.com

ASSOCIATE POSITION-BERKELEY, CALIFORNIA

We are seeking an energetic individual to join our multi-office practice in Northern California. PSR 24+ with a California license is required. Partnership position is possible with an excellent long term business opportunity for an enthusiastic and motivated individual. Please send resume to Mwolpafootdoc@yahoo.com

ASSOCIATE POSITION - CONNECTICUT

Associate needed full or part-time for Nursing homes in Connecticut. Need hard-working, ethical individual. Must have CT license. Excellent salary. Please call Zina (347)307-4333 for additional information.

ASSOCIATE POSITION – CALIFORNIA

Looking for a motivated podiatrist to join a rapidly growing practice in Los Angeles. Will hire immediately. Excellent compensation. Please fax CV to: 310-652-3669.

PART-TIME POSITION - CHICAGO AREA 

Immediate opening to provide podiatric services in nursing homes within 30 miles of downtown Chicago 2 to 3 half days a week.  Competitive package and $500 signing bonus paid after 6 months of service. Contact Dr, Brian Aronson at 773-775-0300 or BA@podiatryplus.net

ASSOCIATE POSITION - SOUTHWESTERN PA

Suburban Pittsburgh. To work in an established practice and also a new office scheduled to open in August 2010. Future partnership buy-in possibilities. Rearfoot credentials needed to expand the established practice, and to maximize the potential in the new practice. Competitive salary, benefits. 724-337-4433.

FULL-TIME PODIATRY OPPORTUNITY - BOSTON, MA

HealthDrive is seeking a caring podiatrist to join our group practice. We currently have a FT non-surgical opportunity available in the Boston, MA area. We offer a competitive salary, Paid malpractice Insurance, health and dental Insurance, long & short term disability, flexible schedule (No weekends), established patient base, equipment, supplies and complete office support provided. If interested in this opportunity, please call Maria Kelleher (toll free) at 877-724-4410 or email caring@healthdrive.com

ASSOCIATE POSITION - SW FLORIDA, BEACHES

Well-established podiatry practice with excellent mix office/surgery seeking full-time associate PSR 12-36. Excellent salary & benefits for the right hardworking, personable candidate. Email resume to capecoralpodiatry@live.com or fax to 239-573-9201

PM News Classified Ads Reach over 12,000 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 12,000 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451

RE: Stiff Joint, Post-op Bunion Surgery (Craig Breslauer, DPM)
From: Michael M. Rosenblatt, DPM

I have never understood the reasoning behind having a patient walk immediately post-operative bunion surgery - in a sandal, of all things. Would we walk a patient with a 5th metatarsal fracture or a stress fracture right after diagnosis? A bunionectomy with an osteotomy is a surgical fracture.  It heals as any fracture repair heals. I think many podiatrists in general, in order to "sell" a patient on an easy post-operative recovery after bunionectomy have fallen into the trap of not treating this surgical fracture appropriately. The soft-tissues around that violated joint will contract and thicken with immediate post-operative weight-bearing in a sandal, potentially causing long-term stiffness. 

Also, a sandal is inadequate as it doesn't stop the EHL from firing and contracting. I have patients wear a surgical fracture boot for six-weeks, like I would with any other fracture. They are non-weight-bearing for the first two weeks. After sutures come out at two weeks, I have them perform ROM exercises to the 1st MTPJ but remain in the boot. I'd rather a patient not choose surgery because of inconvenience of post-op course than be miserable with post-op contractures and other complications from too early and too little protective weight-bearing.
 
Randall Brower, DPM, Roswell, NM, randoman33@yahoo.com

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