June 05, 2006 #2,597 Editor-Barry Block, DPM, JD

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Diabetics With Foot Infection at Very High Risk For Hospitalization: Landmark Study

Persons with diabetes who develop an infection are at a 55-fold greater risk for hospitalization, and an alarming 154-fold greater risk for amputation. These are some of the startling figures emanating from the first population-based study on diabetic foot infection. Researchers from Texas A&M University, Rosalind Franklin University of Medicine and Science, and the University of Washington collected data on nearly 1,700 patients over a two-year period.

"The results strongly suggested that foot infections are common and complex. They are also costly in terms of morbidity," noted Dr. Lawrence A. Lavery of Texas A&M, the lead author on the study.

The study also found that nearly 9 in 10 amputations performed are instigated by an infection. "This was perhaps the most interesting figure in the study," noted David G. Armstrong, DPM, PhD, Professor of Surgery and Director of Scholl's Center for Lower Extremity Ambulatory Research at Rosalind Franklin University and one of the study's principal investigators.

Source: Medical News Today [6/2/06]

Newman to Keynote BUSGMS White Coat Ceremony

Jay Newman, DPM will be the keynote speaker at Barry University's School of Podiatric Medicine "Rite of Passage" for junior class members beginning clinical rotations. Dr. Newman will be the keynote speaker and present a "white coat" to his daughter, Laura Newman, who is a junior at Barry University.

Source: Barry University School of Graduate Medical Sciences

“It Makes No Sense Not to Pay for Podiatrists” - Sen. Hillary Clinton

Acknowledging she "still (has) the scars" from her failed attempt to reform national healthcare more than a decade ago, Sen. Hillary Rodham Clinton on Thursday promised a Poughkeepsie audience a future "conversation" about healthcare in America.Clinton's visit to Poughkeepsie involved a tour of Vassar Brothers Medical Center, Although she avoided specifically mentioning national health care, the senator said the country is headed toward a crisis with the costs of care, climbing numbers of uninsured and underinsured patients, and the often byzantine structure of health maintenance organizations.

Clinton criticized health-care insurers for plans that cover patients only in the event of medical emergencies or necessities, and said a shift is needed toward plans that provide more coverage for preventative treatment. "It makes no sense for insurance companies to pay to amputate a diabetes patient's foot, but not pay to send them to a podiatrist" or for nutritional aid, Clinton said, drawing applause from the assembled doctors and nurses.

Source: Nik Bonopartis, Poughkeepsie Journal, [6/2/06]

Query: Gastrosoleal Equinus

I request input on the case of a 12 y.o. otherwise healthy white female w/ profound gastrosoleal equinus. She is a toe-walker and lacks heel contact throughout gait cycle and walks w/ slightly bent knees. In static stance, she has a mild genu recurvatum and moderate posterior calf group muscle hypertrophy (almost Egyptian column). She is negative for hamstring contracture. In her case, there is no apparent underlying neurologic disorder, or family history of such.

I need some guidance or referral to references as to procedure(s) of choice for child this age. I was researching it and found, among others, the McGlamry Institute described a procedure: proximal 1/3rd (6 cm from myotendinous junction) medial and lateral and then
proximal central tenotomy slide procedure w/ suturing.

Will Godfrey, DPM Leesville, LA, williamtrekkie@earthlink.net

Query: Primary vs Secondary Tendon Repair

What defines a primary versus secondary repair of a tendon?

Example: CPT 27664 - repair, extensor tendon, leg; primary, without graft, each tendon versus CPT 27665 - repair, extensor tendon, leg; secondary, with or without graft, each tendon. What makes something a primary repair and something else a secondary repair? Also, If I am using a MaxForce Graft for the repair, I assume I can only bill CPT 27665, with nothing extra for the use of the graft material, correct?

Paul Kesselman, DPM, Woodside, NY

Response: Generally, the definitions of primary, [delayed primary] and secondary tendon repair are as follows:

Primary repair: Any repair of an acute injury completed within the first 24 hours after the injury.

Delayed primary repair: A repair performed within 24 hours to two weeks of the injury.

Secondary repair: A repair performed after two weeks of injury.

Primary repairs usually involve direct surgical correction of the injury, while secondary repairs may include tendon grafts or other more complex procedures.

Harry Goldsmith, DPM, Cerritos, CA


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RE: The VA Data Debacle
From: Robert Teitelbaum, DPM

I believe that the nimrod who had the veterans' data disk stolen from his home has done a small favor for all health professionals who have to accommodate HIPAA regulations in their practices. To begin with, he has put into perspective the nature and severity of the type of misappropriation of PHI that we would even be capable of doing as individual practitioners.

We are likely to allow information to be seen from the wrong side of a divorce proceeding, or having information about patients' conditions viewed by strangers that may cause embarrassment. Our employees may speak out of turn (i.e. publicly) about patients' personalities or conditions. What prison term would, or should result from 26 million counts of jeopardizing economic identities?

Secondly, he has put a good scare into all of us who carry the practice-on-a-disk everywhere they go. Not good. That needs to be re-thought by many of us. Cars can be broken into and people can be mugged. Encryption need to be top notch.

Finally, this sorry soul has reminded me that I too, work for the federal government. I and my colleagues have done a fine job implementing the particulars of federal laws, making all the deadlines, signing up for new identifier numbers, and being meticulous in avoiding fraud and suspect business liaisons, as well as reading the tea leaves of proper coding and billing. But this gentleman (and countless others like mailmen and bureaucrats in myriad government agencies) will not face a five percent cut in pay next December, (or every December). And other income streams they have will not be affected by cuts in their federal pay---like private insurances pegged to Medicare fee schedules. We are government employees and Rodney, you were right--we get no respect.

Robert Teitelbaum, DPM, Naples, FL, mfvandange@aol.com

RE: Familial Keratoderma (Al Musella, DPM, Dennis Shavelson, DPM)
From: Elliot Udell, DPM

When I looked at the photo my thinking was along along the same lined as Dr. Shavelson. "Could there be a biomechanical component?" Could there really be a biomechanical cause if the problem developed at age 5? Is this not too early for this type of pathology to develop?

There are dermatologic and rheumatologic conditions that cause hyperkeratosis on te feet and have no biomechanical cause. In the photo of the right foot there is some keratotic tissue on the lateral aspect of the fifth met base. This does not appear to be on a high pressure area and this is not present on the opposite foot. Does this factor enter into the equation?

What might yield interesting results is to take a "Pressure Stat" test. This is a simple, inexpensive throw-away method of determining if there is excessive pressure on certain parts of the foot during gait.

Elliot Udell, DPM, Hicksville, NY,Elliotu@aol.com

Editor's note: PM News subscribers are reminded that photos or x-ray of cases can be submitted along with queries. Please be sure, however, that patients' name do not appear.

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