The Voice of Podiatrists

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June 25, 2007 #2,970 Editor-Barry Block, DPM, JD

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IN Podiatrists Diagnose Rare Case of Gout Due to Hyperparathyroidism

In 2004, Walter Podguski visited Friendly Foot Care in Crown Point complaining of pain in his left foot and ankle. The Valparaiso man originally hurt his ankle playing softball and attributed the pain to his injury. But it was something else entirely. His doctor, Michael Nirenberg, with help from Friendly Foot partner podiatrist Michael Carroll, ran a number of tests on Podguski. It turns out he actually had gout in his foot due to primary hyperparathyroidism.

Drs. Michael Nirenberg and Michael Carroll

Podguski didn't even know he had hyperparathyroidism. Even stranger was that a podiatrist was giving him such a diagnosis. "You've just got to be on the ball for those one in a million things that walk into your office," Nirenberg said. "It probably saved his life." Nirenberg and Carroll wrote about their unique case, published in the latest edition of the Journal of the American Podiatric Medical Association, a 100-year-old publication serving as one of the definitive periodicals for podiatrists.

Nirenberg and Carroll see their paper as an important reminder to doctors that strange symptoms cause foot pain. "You have to look at the whole patient," Carroll said. "There are unique things doctors don't always look for."

Source: Piet Levy, Post-Tribune [6/22/07]

Kosinski Featured at Mt. Sinai Grand Rounds

Mark Kosinski, DPM, Professor in the Division of Medical Sciences at the New York College of Podiatric Medicine, was the featured speaker at The Mount Sinai School of Medicine's Department of Vascular Surgery Grand Rounds on Friday morning, June 22nd.

Dr. Mark Kosinski

Hosted by Victoria Teodorescu, MD, Associate Professor of Surgery, Dr. Kosinski spoke on the management of diabetic foot infections to the attending and resident staff. Dr. Kosinki's comprehensive discussion generated much interest and questions.

Two Thirds of States Now Have Apology Protection Laws

Thirty states and the District of Columbia have laws that make a physician's expression of regret or apology after an adverse event inadmissible in court. The laws differ about the precise kinds of physician communications protected.

These states have statutes: Arizona, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Utah, Vermont, Virginia, Washington, West Virginia, and Wyoming

Source: American Medical Association Advocacy Resource Center

Query: Leftover Apligraf

What are the rules regarding the use of the remaining Apligraf after application? Are physicians using it as a "free sample" to other patients, or must one dispose of the extra graft? Are there any specific rules relating to this? Obviously, one couldn't bill for another sheet or application, but is there anything wrong with applying it on another patient, as long as sterile technique is used and the time limit has not expired?

Joe Gonzalez, DPM, East Lansing, MI

RE: Alternatives to Anti-Fungal Cream (Norm Wortzman, DPM)
From: Paul Busman DPM, RN, Dave Schwartz, DPM, RPh

There are a lot of handicap aids available that might help her-- some sort of device with which she could grasp a gauze square and use that to apply the anti-fungal cream. If she can get close to her feet but not quite reach, she might be able to use an anti-fungal spray. I've occasionally used a short course of oral anti-fungals in stubborn tinea cases, but if she can't do regular foot hygiene the condition is likely to re-occur.

Paul Busman DPM, RN, Cohoes, NY, BREWERPAUL@aol.com

Can your patient take a short course of an oral antifungal? If there are no contraindications, I occasionally use oral fluconazole once weekly for two doses in addition to topical therapy.

Dave Schwartz, DPM, RPh, Rockwall, TX, txfootdr@yahoo.com

RE: Query: Venous Ulcer ICD-9 Code
From: Marc Katz, DPM

I believe the most appropriate codes for venous ulcers may be:
(454) Varicose veins of lower extremities
• (454.0) Varicose veins w/ ulcer
• (454.1) Varicose veins w/ inflammation
• (454.2) Varicose veins w/ulcer, inflammation
• (454.9) Varicose veins, asymptomatic

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

RE: High Heels Won’t Cause Permanent Damage (John J. Holtzman, DPM)
From: Howard Lepolstat, DPM

I do not believe that Dr. Holtzman's maintenance that high heels do not cause permanent damage is completely accurate. In terms of sound engineering principles, the degree and direction of the forces on the foot change as the orientation of the foot changes with the walking surface. Moreover, the size of those forces is impacted by the ratio of the height of the shoe's heel to the length of the foot (the shorter the foot and the higher the heel, the greater the effect).

The foot is a lever system and an argument could be made that a normal foot goes through all three lever classes during contact phase of a normal gait cycle. Given the enormous forces affecting the foot during that phase and their interaction with the tissue's adaptability (Wolff's and Davis' laws) it would be hard to make the case that there is no potential for permanent change. There are many variables in play: foot length, foot type, heel height and body weight to list a few. But, in my opinion, the most important factor is time. The less time in high heels, the less likely a permanent change will occur. There is a property that all materials have called "elastic limit." Simply stated it is the amount of distortion (stretch, compression, bending, etc.) that the specific material can undergo before it permanently changes its shape. Each material has its own peculiar elastic limit. Bone and connective tissue are no different. .

There are more esoteric variables such as the relative length of each bone or set of bones in the specific foot in relation to the entire foot. Imagine the change in forces applied at toe off from a size 10 women's foot with a 1.5" long second to the same size 10 foot with a second toe 3" long. The entire bone ratio will change and with it the applied forces.

Howard Lepolstat, DPM (Retired), Sun City West, AZ, TeachrComp@aol.com

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