The Voice of Podiatrists

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June 16, 2007 #2,963 Editor-Barry Block, DPM, JD

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Wood’s Lamp Useful in the Detection of Odor-Causing Bacteria: CA Podiatrist

According to Dr. Michael Zapf, a podiatrist in Agora Hills, CA “For the most part, our skin does not have much of a smell all by itself. Sweat itself probably has only a minor smell, not enough for you to notice, but enough that your dog knows it is you coming in the door. But adding a little sweat to your body does create a wonderful bed for the growth of bacteria and fungus that can lead to some real problems.”

Dr. Michael Zapf

Some foot odors are made worse by bacteria and fungus. Topical antifungals can be very helpful if you notice that there is redness and peeling around the toes. Start with the over-the-counter varieties and see if they work for you. Zapf says “The really powerful odors are caused by a particular species of bacteria. These bacteria do not cause any disease, but they do leave a lot of offended noses in their wake. Because it is a bacterial problem, antifungal medications will not touch it. Some people have suffered with this condition for years.”

Zapf say “This condition is diagnosed in the office using a special ultraviolet light called a Wood's Lamp that causes the critters to actually glow coral-red. It is a sight to behold. With the right diagnosis, a prescription for the correct antibiotic will clear this up in just a day or two.”

Source: The Acorn [6/14/07]

93% of Nurses Experience Pain, Yet Only 16% Seek Foot Help: UK Study

Nearly two thirds of nurses find it hard to concentrate because of their painful feet, reveals a new survey. This June, the Society of Chiropodists and Podiatrists is launching their "Working Feet" campaign as part of "Feet for Life Month." The campaign hopes to raise awareness about the dangers of working feet too hard and offers helpful foot care advice.

The society says that 93% of nurses commonly experience problems with their feet, knees or back due to long shifts. Of the nurses surveyed, 93% said they also suffer from hot, swollen and painful feet after their shift. Despite these complaints, only 16% of nurses said they had visited a chiropodist or podiatrist in the last year.

Nita Parmar from the Society of Chiropodists and Podiatrists says: "Protect your feet at work. Feet can spend hours in the same shoes and if your feet hurt it can affect your concentration, efficiency and attitude to work. "Ignoring painful feet could also lead to problems in the long-term."

Source: Nursing in Practice [6/13/07]

Edwards Outlines Cost-Saving Measures

Democratic presidential candidate John Edwards today announced the cost-saving measures in the universal healthcare plan he released in February. Edwards claims his plan would save an average family $2,000 to $2,500 annually and eliminate $130 billion a year in wasteful spending.

Se. John Edwards

The plan seeks to bring down costs by setting national accounting standards; requiring insurers to spend at least 85% of their premiums on patient care; creating patient-centered “medical homes” and requiring healthcare markets and public plans to proactively monitor the health of patients with chronic ailments to reduce complications and hospitalizations.

In addition, his plan would support safe re-importation of prescription drugs from Canada and would create a central organization within the Institute of Medicine to test new devices and drugs and disseminate best practices nationally. Like fellow Democratic presidential candidates Barack Obama and Hillary Rodham Clinton, Edwards would seek adoption of electronic medical records.

Source: Jennifer Lubell, Modern Healthcare [6/14/07]

Query: Gamma Graft

I am researching a wound coverage product called gamma graft. It is a cadaveric allograft that is touted for its apparent ease of use. It has a 2 year shelf life. It is self-adherent to a good vascular bed (no sutures needed) and the most amazing thing to me is that it is costs from $80 for 3 sq. cm. up to $350 for 50 sq. cm.. Does anyone have any experience or thoughts about this graft?

Tip Sullivan, DPM, Jackson, MS

Query: MBT Shoes

I recently received an invitation to attend a seminar at a local pedorthoic company to discuss the MBT shoe and how it can "improve weak and injured muscles, improve walking, posture, balance and gait." I like this shoe and have used it in the past for post-op recovery following a first MPJ fusion and for an arthritic patient whose gait is less than propulsive. I have wondered what effect this shoe has on not only the musculature, but also the knee and hip, as the foot is now forced into functioning in a manner it was never meant for. How it improves balance is also a concern, as you are standing on a rocker bottom and some patients (not all) have had a difficult time dealing with this particular feature of the shoe. I have yet to receive a satisfactory answer and look forward to hear what our biomechanics gurus have to say.

Charles Morelli, DPM, Mamaroneck, NY

Query: Neuropathy Coding

If a patient presents complaining of "burning, tingling, numbing sensations," but generally the neurologic exam is unremarkable, would that be coded as ICD-9 782.0 (disturbance of skin) based on the patient's complaints?

If the neurologic exam reveals "decreased sensation" along with the burning, tingling sensations, would that then be ICD-9 356.9 (hereditary and idiopathic peripheral neuropathy, unspecified), or is that code only for patients with absent sensation?

Patti Smith, Lake Havasu City, AZ

Response: I, too, would code a complaint of "burning, tingling, numbing sensations" as ICD-9 782.0 (disturbance of skin). These are subjective findings, so you would base their presence on the statements of the patient (and document it as such).

In the case of "decreased sensation along with the burning, tingling sensations," I believe it would be appropriate to use ICD-9 356.9 (hereditary and idiopathic peripheral neuropathy, unspecified) in the case of any manifestation of peripheral neuropathy, including absent sensation, if the actual cause of the neuropathy is unspecified.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found at
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RE: Short 1st Metatarsal, Status Post, Joint Implant (Name Withheld by Editor)
From: Multiple Respondents

Without seeing the patient and knowing anything about him/her, activity level, job etc. I would say that a one step procedure that would help this patient would be to remove the implant and perform an arthrodesis of the 1st MPJ with bone graft as needed. This would effectively address the short first ray and the likely unstable 1st MPJ.

I often perform 1st MPJ procedures as primary procedure for hallux limitus/rigidus and for deformity secondary to failed bunionectomy procedures (recurrence/varus,RA). I find the procedure to be extremely effective and well tolerated by patients.

Alec Hochstein, DPM, Great Neck, NY, Ahochstein@aol.com

If you are not attempting any IM correction and are only looking to Plantar-flex and elongate the first metatarsal, you may want to consider a sagittal plane "Z" osteotomy. This allows for both elongation and plantar-flexion and easy fixation utilizing two 2.0 or 2.7 cortical screws. This will heal much faster and allow for weight bearing much sooner than a bone graft with a Lapidus.

W. Kevin Pearson, DPM, Stockbridge, GA, pearsondpm@bellsouth.net

It may be easier to remove the implant, fuse the 1st MPJ (which probably should have been done in the first place), lengthen the gastrocnemius to decrease the forefoot load, and shorten the 2nd and 3rd metatarsals, if necessary.

In my opinion, it is too risky to attempt a Lapidus/distraction arthrodesis of the area to gain length. Particularly when the joint implant will fail in 4-5 years anyway and the salvage will be MPJ fusion. Then the whole medial column will be fused and usually too rigid.

Erik Kenyon, DPM, Modesto, CA, ekgoal@yahoo.com

I have seen this on several occasions and have treated this with various methods. Several ways to approach this are with decortication and external fixation, Lapidus fusion with grafting, and z-plasty lengthening of the metatarsal if you can make a long enough cut without disturbing the implant if you wish to leave it in place. If the surgery is far post operative, you could run the risk of devascularization with a lengthening procedure.

Another alternative which works well is sequential Weil-type osteotomies of the lesser metatarsals. Although patients perceive this as a more radical approach, in my opinion is offers a more controlled outcome.

Alternatively, is to fuse the MPJ with insertion of a graft to increase length as well although this usually requires Iliac crest graft.

Ira Weiner, DPM, Las Vegas, NV, vegasfootdoc2005@yahoo.com

OFFICE TO SHARE AND RENT LONG ISLAND & MANHATTAN

3 treatment rooms, JACHO certified operating room, MRI extremity unit and x ray equipment on premises, turn-key operation -no investment- Space also available on East 22nd street to share Manhattan. Call 516- 4761815 or email podo2345@aol.com

ASSOCIATE PODIATRIC SURGEON – TEXAS

We are looking for an exceptionally trained podiatric surgeon to work in the Houston, Texas area. Candidates seeking this opportunity need to be dynamic, people friendly, and have current licensure in Texas . Future licensure in Arizona will be required. Exceptional opportunity, with attractive benefits, and excellent starting salary. The successful candidate will find a rare opportunity to integrate into a specialized lower extremity practice with emphasis on peripheral nerve surgery, endoscopic and arthroscopic surgery, and other special surgery of the foot and ankle. Please submit a cover letter with current curriculum vitae via email to: Slb99@pdq.net Stephen L. Barrett, D.P.M., MBA

ASSOCIATE POSITION - MIAMI BEACH, FL

Seeking well trained PMS 36 / PSR 24+ for Full-Time associate position. Leading to partnership for the person. practice is 50% hospital based. Must have strong Sx skills, including Limb Salvage & Trauma. Competitive Salary & benefits Package. Fax 305-652-6672 or Call 305-785-2559 Email: doctorsole@aol.com

ASSOCIATE POSITION – SOUTHEAST MICHIGAN

Very busy home care and office practice looking for associate/s for full time position. offering great benefit packages, very competitive salaries. excellent opportunity for right individual PM&S 24/36 preferred. partnership possibility significant for right person. please call 248-303-3736 or fax CV to (248)996-1023 poda1@aol.com

PRACTICE FOR SALE - CENTRAL FLORIDA

Practice, all phases, including wound care and hyperbaric, with excellent building and location in central Florida, in 21st fastest growing county in U.S. Outstanding place to live and work; low penetration by managed care. Excellent exposure, and parking at 2000 sq. ft building near hospital and on busy highway. Great price and opportunity to grow large practice. windnwave@earthlink.net

ASSOCIATE POSITION SANTA FE, NEW MEXICO

We are looking for a highly trained, personable, ethical, and caring podiatrist, to work in a two doctor, three office practice, of thirty years. Send CV to sfpodiatry@ aol.com

PRACTICE FOR SALE: SAN DIEGO, CA (LAJOLLA) PRICE REDUCED!

Gross $289K in '06. Asking $120K. Possible finance. 5 y/o practice, affluent community with excellent schools. Selling due to age and health. Wish to consummate sale by summer's end. www.SDFootDoctor.com DrRDWorley@yahoo.com for stats and other info.

PRACTICE FOR SALE - NORTHERN CALIFORNIA

This podiatric practice is located near downtown Berkeley. The practice has been established in Berkeley for 15 years and focuses mainly on biomechanics and conservative care, but would do well with a practitioner who wants to expand the surgical component. The terms of the transition are negotiable. Serious offers only inquiry at : foot4sale@sbcglobal.net

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