The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

May 14, 2009 #3,545 Publisher-Barry Block, DPM, JD

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IA Podiatrist Breaks New Ground with Joint Grafts

Dr. Denise Mandi, section chief of foot and ankle surgery and chairman of the department of surgery at Broadlawns Medical Center, is using a new hyaline cartilage graft to give patients a better option for repairing damage to joints. Cartilage for the graft comes from juvenile donors. Mandi, who performed the first two surgeries with the graft in April, says she sees opportunities to combine the tissue graft with other technology to help more people.

Dr. Denise Mandi shows an x-ray of a foot. The arrow points to where a hyaline cartilage replacement could be made.(Photo: Doug Wells)

“In the past, we weren't able to replace hyaline cartilage with hyaline cartilage. As a general rule, hyaline cartilage in adults does not regenerate. When that cartilage wore out, the next best option was to replace it with something like fibrocartilage, which is not as strong. The reason this is something different is that it's actual hyaline cartilage that is able to grow once you transplant it.”, Says Mandi

Source: Des Moines Register [5/13/09]
 

TUSPM Holds Bates Memorial Reception at Region 3 Meeting

On Thursday, April 30th, the James E. Bates Memorial Reception was held at the Taj Mahal in Atlantic City during the Region III Conference.

(L-R) Drs. John Mattiacchi and Leonard Portnoy with Mrs. Bates

Many TUSPM alumni attended along with friends and family. Mrs. Bates was there as well, to thank everyone for their generous contributions to the James E. Bates Scholarship Fund.

Healthcare Reform Legislation Promised by Summer: Pelosi

House Speaker Nancy Pelosi pledged that healthcare reform legislation would be passed by July 31—before Congress takes its August recess. The comments were made from the White House where Pelosi, Majority Leader Steny Hoyer (D-MD) and key committee chairmen met with President Barack Obama and Vice President Joseph Biden to discuss the effort to reshape the health system. “That’s the kind of urgency and determination that we need to achieve what I believe will be historic legislation,” Obama said.

Members of Congress have repeatedly said they wanted to pass legislation before August, but few have done so in such a public manner. Democrats on the Energy and Commerce Committee, one of three in the House that will shape a reform bill, met to discuss a general list of ideas. “We’re trying to start off at the same outline, the same proposal,” said committee Chairman Henry Waxman (D-CA), who also met with Obama. “And then each committee will work its will.”

On Capitol Hill, Senate Finance Committee Chairman Max Baucus (D-MT), who’s spearheading the reform effort in the Senate, called Pelosi’s timeline “ambitious and aggressive,” but ultimately doable. The Finance Committee is expected to finalize a bill in June.

Source: Matthew DoBias, Modern Healthcare [5/13/09]

Improved Communication is a Worthwhile Investment

Inter-office communication costs so little – yet, the lack of it might lead to very costly missed opportunities. Lack of communication between back office (medical care, billing) and front office (receptionist) is perhaps the most significant example of where potential losses can occur.

The flow of accounts receivable information from back office to front should be a great concern to any medical practice. Yet in many practices, patients who have past due balances often arrive for their next appointment unprepared to pay. Effective communication between back office and front, supplemented by a proactive strategy to inform patients of their balance, could significantly boost over-the-counter collections.

This proactive strategy is certainly not flawless. It also adds to business expenses. But if your practice has large amounts in patient receivables, wouldn’t you invest a dollar to gain ten dollars? Simply communicate!       

Source: John V. Guiliana, DPM, MS.  For information about  the American Academy of Podiatric Practice Management, visit www.aappm.org

Query: Spider Bite Complications

I have a 44 y old patient who was bitten (or so he thinks) by a brown recluse spider about seven years ago. Once the wound was resolved (sx excision), the wound showed up on the other leg. The patient states the new wound had the same presentation as the original wound and he is sure he was not bitten again. Now he says every Spring the wound returns, most often at the original site. I am aware that most spider bites are in actuality infections and most commonly Staph infections, but I am just curious if anyone else has seen or heard of spider bite wounds returning or going to the other leg/foot? 

Spider Bite Complication

The patient  has venous stasis, but the wound is atypical for venous stasis, and it is not in the normal location (wound is anterior lateral calf, about mid shaft). The presenting erythema is not centered around the wound, but is usually more around the lower posterior calf, well above the ankle. The local temperature of the calf was 103.1. Ultrasound was negative for DVT, less than 1+ pitting edema. DP/ PT WNL. Systemic fever 101. Significant for varicose veins and chronic edema, but he wears support hose. No other health factors. He responded well to doxycycline. Work up for PG was negative.

Wm. Barry Turner, DPM, Royston, GA

Query: HIPAA and ID Theft

We all have multiple computers and store backups appropriately off-site. HIPAA addresses the private information in those computers. However, where does the doctor stand legally if there is an office break-in, the computers are stolen, and the thief uses names, birthdates, and SSN to obtain credit cards, etc?

Pete Harvey, DPM, Wichita Falls, TX

Editor’s Note: PM News does not provide legal advice. Under HIPAA, doctors are required to take “reasonable” steps to prevent such security breaches. Examples of acting reasonably would be to have adequate locks on your doors and having password protection for all your computers. These are simple steps which help prevent theft. As long as your computer or flash drive are password-protected, the data cannot be easily accessed.

RE: Diabetic Ulcer Sub-met 3
From: Multiple Respondents

I had a very similar patient. He had a history of a catastrophic infection which was resolved with a 5th ray resection and 4th toe amputation in Italy. Completely insensate, he would frequently break down under the 3rd or 4th metatarsal heads and acquire frightening infections. He wasn't the best surgical candidate because of his general health and his inability to go full non-weight bearing.

Before Photo of Ulcer

I performed a variation on a pan met-head resection by resecting the remaining lesser met heads with a Keller on the first ray. I reduced forefoot pressure with a tendo-Achilles lengthening. I used total contact casts during his recovery to protect the TAL while allowing him to bear weight.

After Photo of Ulcer

He regularly returns home to Sicily, where he walks everywhere. He is also the host at a restaurant here in Danbury, which requires him to stand and walk all the time. He has yet to develop even a blister on the foot.

Richard Gosnay, DPM, Danbury, CT glabroushead@gmail.com

To keep things on the simple side, I would consider an Integra graft and VAC dressing. Once the ulcers have closed, I would try to place the patient in a custom-molded foot orthosis with the FF valgus corrected and the area balanced. This should be combined with a full-length rocker sole with apex proximal to this area of maximum pressure. The shoe may require a reverse Thomas heel or lateral clip since the rearfoot varus will still remain.

On the surgical side, I believe the residual 3rd digit is creating retrograde pressure and will likely need to be amputated. The four metatarsal can be addressed with a Weil osteotomy. Finally, a 1st mpj arthrodesis can be used to create a more stable forefoot and a gastroc recession or TAL to reduce the equinus and forefoot pressures.

Craig Breslauer, DPM, Palm City, FL, cbdpm@bellsouth.net

You can off-load her all you want, and it will heal, but when she walks again (even with the best off-loading inserts) for any given length of time, (as patients often do), the lesion will break down again. I would recommend  x-raying again with monofilament wire around the ulcer to see exactly where it's located because I would almost venture a guess the lesion is more sub met 4 than 3. Two approaches:
 
Quick approach: Try a percutaneous TAL to help off-load the forefoot, but be careful of over-lengthening, which can result in a heel ulcer. Posterior splint can be used afterwards to hold correction.
 
Long approach: No age was given but if she has good healing potential, then I would recommend a Pan met head resection using a 2 or 3 dorsal linear approach. With the 3rd met head removed, the transfer lesions have started and to try and balance the pressures will be difficult.  1st MPJ arthoplasty vs. fusion has always been debatable and might be considered but may be age-dependent.
 
Unfortunately,  both of these approaches may require some time off from work depending on what type of work she does, but that’s what temporary disability is for. 
 
Khurram Khan, DPM,  Assistant Professor, NYCPM,  khankhurram@hotmail.com
 

RE: Coding a Brace Adjustment (Mark Schilansky, DPM)
From: Paul Kesselman, DPM

I would like to issue a clarification to Dr. Schilansky's discussion of the L4205 and L4210 HCPCS codes which recently appeared in Codingline. The original question posed on Codingline was related to the initial adjustment of a new device by the practitioner who dispensed it. Any fitting, repairs or adjustments made during the first 90 days are covered under the global period for the HCPCS. Therefore, there is no additional allowed amount unless:

1) The practitioner dispensing the device is not the supplier who ordered it. An exception to this would be if one doctor in a group orders the device and another doctor in the same group dispenses the device. In this situation, an additional allowance would not be allowed.

2) The device has been used for greater than 90 days. In this case, an allowance can be made for repairs and adjustments under codes L4205 and L4210 if not otherwise described by a separate HCPCS code. Under these circumstances, the labor charges are billed in units of fifteen minutes per unit and the repair charges would need to be itemized. An example would include replacing a screw or pin on a device. Replacement of a hinge or soft tissue supplement would be coded only by their HCPCS code, and use of L4210 or L4205 would be inappropriate.

In summary, most replacement or repairs performed on devices prescribed or dispensed by podiatrists would not be described by the use of L4205 or L4210. Of course, exceptions do exist.

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net

RE: DVT Risk in Podiatric Surgery? (Lee C. Rogers, DPM)
From: Richard W. Boone, Sr., Esq.

I have no idea what the standard of care for DVT prophylaxis in podiatric surgery is or what it should be clinically. I'm a lawyer and it's not my job. I can tell you, however, and with a very high degree of certainty, that malpractice claims from grieving relatives of deceased foot surgery patients who died from a PE are terrible to defend. The injury to the patient is obviously catastrophic and the impact upon the patient's next of kin may even be worse, if you can imagine that. I find the defendant doctors don't take it very well either.
 
In DVT cases, the Plaintiff's lawyer always hits you with the "Coulda-Woulda-Shoulda" gambit (the Doctor could have done something which would have prevented the horrible outcome and, therefore, he should have done it) which, while not necessarily legally viable, is hard as heck to refute.
 
So, from my point of view, which is totally NON-CLINICAL, the degree of suspicion for DVT and/or PE following any pedal surgical procedure should be a lot higher than it is and, admittedly, higher than it probably needs to be from a clinical point of view. If I could make the rules, ANY otherwise unexplained post-operative complaint, not just a painful calf muscle, is a DVT until proven otherwise. And a negative Homan's sign alone DOES NOT rule out DVT in the eyes of any jury that I have ever met. 
 
If I could make the rules every unexplained post-op complication would get referred out to some other appropriate health care provider for a workup on an urgent basis. An ambulance ride is a lot cheaper than a funeral. I will cheerfully defend (for free) anyone who gets sued for having wrongfully referred a patient with possible DVT symptoms for an urgent workup .
 
Richard W. Boone, Sr., Health Care Attorney, Fairfax, VA, RWBoone@aol.com
 

BIOMECHANICS FELLOWSHIP – NEW YORK CITY

Neoteric Biomechanics 3-6 Month Fellowship: At The Foot Typing Center in New York City. Practice, Research, Publish and Credentialize Yourself In This New Paradigm. $1,000 a Week Stipend. New York License Required. Fax Interest to: 212 288 3034 or apply to Dr. Shavelson @ drsha@lifestylepodiatry.com.

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

PRACTICE 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 – TUCSON, ARIZONA

Full-time position which involves all phases of podiatry. Compensation based on training and experience. Must have current Arizona podiatry license. Send Resume to Transcription697@aol.com

PODIATRISTS NEEDED – DALLAS/ FT WORTH – TEXAS AREA

Texas Home Footcare Associates, a podiatry exclusive company specializing in house calls and visits to facilities for the elderly, is looking to hire podiatrists. We are located in the Dallas area. Full and part-time positions are available. Immediate Openings Available. Must have a Current Texas license. Competitive Compensation Package. If interested fax curriculum vitae to 972 931-4819 or e-mail gjmdpm@tx.rr.com. For further information, call 972-380-8028.

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                            

ASSOCIATE POSITION - HENDERSON, NEVADA

Associate wanted for thriving, well-mixed 3-doctor digital office, leading to partnership. Surgery, diabetic, pediatric, and general podiatry. Great office and location, fun area to live. Need 2+ years surgical residency. Must be energetic, self motivated, great patient skills. Salary plus bonuses. Email CV to gtorgesen@yahoo.com

ASSOCIATE WANTED - FLORIDA

Associate needed for a dynamic multi-doctor practice in the Tampa Bay area. Partnership opportunity for the right candidate. Preference given to a PSR 24+ resident completing their education this spring/summer, and must have a Florida license. Well-established practice, high tech with EMR and digital x-rays, with specialties in sports medicine, surgery and wound care. No nursing homes or HMO's. Excellent hospital privileges available. Choose an area of practice concentration that you are passionate about and enjoy a lifestyle for yourself and your family that is second to none. E-mail: kimvelez@tampabay.rr.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 – ILLINOIS 
 
Quality Podiatry Group provides quality services to residents at long term care facilities. We are currently offering full-time or part-time positions for motivated ethical podiatrists. Immediate openings available. If interested, fax curriculum vitae to 312 225-9366 or e-mail feetwork@aol.com

PM News Classified Ads Reach over 11,500 DPM's and Students

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