The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

August 08, 2007 #3,008 Editor-Barry Block, DPM, JD

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Aging Feet, Like Car Tires, Can Be Repaired: NJ Podiatrist

Question, baby boomers: Ever think of your feet as a pair of tires? It's time that you do, now that you're walking/jogging/stiletto-heeling your way through middle age, according to some foot experts.

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Dr. Terry Spilken

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"Over the course of a lifetime, the tires start to wear down and your feet start to wear down," says Terry Spilken, a podiatrist who has worked with the Alvin Ailey American Dance Theatre and the New York Islanders hockey team.

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"It's part of the natural process. As we get older, things change and we start getting pains where we never had pain before," adds Spilken, of Livingston, N.J. "Just as tires need to be repaired, your feet do, too."

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Source: Meg Nugent, The Star-Ledger (Newark, NJ) [8/4/07]

OCPM Student Wins Miss Plus America Pagent

Jenna Vaught is a single mother, a third-year student at the Ohio College of Podiatric Medicine and an ongoing dieting success story (she has lost 170 pounds). Last month, the 30-year-old found time to compete in the Miss Plus America pageant and came home with a crown on her head.

Jenna Vaught

During her one-year reign as Miss Plus America Elite, the Louisville, KY native plans to promote a platform of diabetes awareness and prevention.

Source: John Campanelli, Cleveland Plain Dealer [8/5/07]

New TN Law Makes Doctor Shopping a Felony

The new Tennessee law makes it a crime for people simply to knowingly deceive different medical providers by getting prescriptions for a controlled substance without disclosing that they've already been given a similar prescription within the past month. Controlled substances are drugs that have the potential for abuse or addiction, such as pain relievers OxyContin, Dilaudid and Lortab.

The state recently sent letters to 30,000 doctors, nurses and pharmacists letting them know about the new law and that they can now report people they suspect of doctor shopping. Enrollees did not receive a similar letter. "We sent the letters to providers because that was where the cry was coming from," Faulkner said.

It's now a felony for TennCare enrollees to doctor shop and carries a penalty of one to six years in jail, depending on a person's prior record, said state Rep. Gary Odom, D-Nashville, one of the bill's sponsors.

Source: Claudia Pinto, Tennessean [8/6/07]

Query: Plantar Fascial Pain

I have a 46 yo healthy male with chronic heel pain. He sustained an eversion injury playing basketball in Mar 2003. He was unable to bear weight a few days, but it was left untreated and pain subsided to point that he was able to run a few marathons. He experienced some chronic pain and numerous conservative treatment attempts, including injections, orthotics, night splints, immobilization; all without improvement. MRI revealed some fasciitis with no other pathology. In early 2006 ESWT was performed (Dornier) in-office with no improvement six months later. EPF releasing medial 1/2 of fascia was performed. Pain of fascia insertion resolved, but he continued to have medial heel pain.

X-rays revealed slight spurring of medial calcaneus, which corresponded to clinical area of pain. The heel spur was resected, which resolved the medial calcaneal pain. Now six months post heel spur resection, he continues to have pain about 2-3 cm. distal to fascia insertion plantarly. MRI reveals a 9 mm. wide ovoid area of fascial enlargement in area of question, with no insertional fasciitis. I've adjusted his orthotics countless times. Any thoughts are appreciated.

Steven Block, DPM, Owensboro, KY

Query: UV Therapy

Has anyone been using UV therapy, CPT 96900 (actinotherapy [ultraviolet light]) for skin conditions (eczema, tinea pedis), and getting paid?

David Sands, DPM, Jamaica Estates, NY

Response: CPT 96900 is specific for actinotherapy (ultraviolet light therapy) used to treat certain skin diseases, such as

Atopic dermatitis; Chronic urticaria; Eczema; Lichen planus; Mycosis fungoides (cutaneous T-cell lymphoma); Pityriasis lichenoides; Pityriasis rosea; Pruritus of renal failure or hepatic disease; Psoriasis; or Vitiligo.

A number of payer plans I have reviewed include actinotherapy as a benefit, but with certain conditions (e.g., http://medpolicy.bluecrossca.com/policies/MED/UV_skin_disorders.html, http://www.empiremedicare.com/newsupda/2001-08/ultroaviolet.htm). The most important issue appears to be the specifics of the conditions/diagnoses being treated.

While eczema (under some circumstances) might be payable for a set course (determined by the plan) of treatment, tinea pedis would not. Before investing in UV therapy equipment, I would recommend you strongly consider

- your practice's ability to attract patients with the above (and other) conditions needing to be treated (or are you planning on trying to attract patients with the above conditons of the
foot and/or ankle looking for treatment?);
- your specific payer mix, and, at least the major players, policies on actinotherapy payment; and
- investigating what will be required in order to perform actinotherapy - equipment, training, staff, space, and time - as well as the liabilities.

Harry Goldsmith, DPM, Cerritos, CA

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RE: Vancomycin Beads (Will Godfrey, DPM)
From: Christopher Formanek, DPM, Marc Katz, DPM

I have had great success with using Osteoset resorbable antibiotic beads manufactured by Wright Medical. The resorbable nature often obviates the necessity for a second procedure in taking out the beads. The beads provide a longer term elution to fight the infection and also have the advantage of repairing bony 64% in osteomyelitis and 98% in non osteomyelitic bone. I had great results in using them in a case where I nearly completely resected an osteomyelitic cuboid bone. In fact the beads filed in some of the defect!

You can choose between 3.0 or 4.8 mm beads which you make on the spot in the OR. Contact Wright medical for a booklet in steps for preparing the beads. I find that 0.5 g Vancomycin powder works best although you can also use Tobramycin. It takes about 5 minutes to prepare completely, using the fast cure set. A drain is optional.

Christopher Formanek, DPM, Baton Rouge, LA, BRpodiatrist.com

Here is what I use for osteomyelitis after appropriate bone resection. Start with the Osteoset Resorbable Mini-Bead Kit. Get rid of the liquid supplied with the product. In the cup provided add the calcium sulfate powder plus 1 gram of Vancomycin powder. Instead of the liquid supplied, you will be using 3 cc. of Gentamicin liquid. I use 2 Gentamicin 2ml. vials and waste 1 cc. The other 3cc.'s are added to the powder and mixed well and then smoothed into a plastic form that is provided with the kit. Let dry well. I usually make the beads while the scrub tech is setting up and before I start the surgery.

A few tricks. More is not better. If you put too many beads in the wound you will have excess fluid leaking from the area and a lot of maceration. So use a reasonable amount. If you are working with a metatarsal shaft or hole within a bone, push the beads into the bone canals or create some small areas to put the beads. You can also scatter a few in the soft tissue void. I will typically close the wound. If the patient requires several debridements over several days or a week, finish the 2 or 3 debridements and then apply the beads and close.

You can experiment with the medications. I had a patient with osteomyelitis which did not respond to the typical antibiotics. I did a bone culture which grew heavy growth of Aspergillus. In that case, I used Voriconazole(VFEND) and mixed it with the beads. This was in addition to IVAB.

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

Arthrex’s Mini TightRope Hardware (Bruce Williams, DPM)
From: David Secord, DPM, Bruce Williams, DPM

I’ve been approached by the Arthrex rep here in my area about this product and found it a nice adjunct in an ankle fracture repair instead of a transmalleolar screw that has to come out, but have hesitated to consider using it for a bunion. My reasons follow the thought that if you have that large an intermetatarsal angle, you probably should be considering a Lapidus procedure or a Fowler procedure or perhaps even a closing base wedge if your typical Austin/Akin won’t get the job done. If any of the more proximal procedures are done adequately, you will get the intermetatarsal correction you seek and correct the hypermobility at the 1st metatarsal base/medial cuneiform area as well.

The second thought is that the picture I was shown of the placement of the tightrope was just about where the perforating artery to the 1st metatarsal is usually located and that can’t be a good thing. The last question was on scarring around the tightrope and the possible entrapment of the afore-mentioned perforating artery and the deep peroneal nerve. The rep in this area for Arthrex really didn’t have any other suggestions, but that the tightrope could get you potentially high intermetatarsal correction without the proximal procedure, setting the patient up for quicker return to weight-bearing. This is nice, but unless I had answers to my other two questions, I don’t think I’d consider it in a bunion. Works nicely in the ankle, however.

David Secord, DPM, Corpus Christi, TX, David5603@pol.net

My thought is that the higher the IM angle in these patients with a flexible deformity, the better it would be to utilize the more proximal placement of the tightrope. In the more proximal area I would expect less use of wire for greater overall distal closure. Then, if necessary, use of a distal osteotomy to finish the job. It makes perfect sense to me that use of a distal tightrope could lead to stress fracture of the second metatarsal, if indeed that is where the wire was placed.

I am not so much concerned about the 2nd metatarsal pulling away from the 3rd metatarsal. I am very interested in how much IM angle closure would be allowed with use of the proximal closure and whether others feel as I do that this would not only be more stable but would tend to be more sound structurally and mechanically over time.

Bruce Williams, DPM, Merrillville, IN, bwilliams@airbaud.net

Editor’s Note: This topic is now closed.

ASSOCIATE WANTED - PHOENIX, AZ AREA

A well established, ethical solo podiatry practice wishes to expand its current surgical services in the near future by hiring a full-time associate with PSR 24-36 training which includes very strong surgical rear-foot and ankle reconstruction, diabetic limb salvage and ER trauma. Successful association may lead to partnership. ABPS Board qualified/certification is required. Applicants must be personable and caring to patients. Practice in an office base within a new state-of-the-art orthopedic surgical hospital environment and plenty of future expansion capabilities for a bright, eager, reliable associate. Email complete CV with current references & photo to footdoc352@cox.net

PRACTICE FOR SALE OR SHARING- CENTRAL FLORIDA

Practice all phases. Wound care, hyperbaric privileges nearby. Excellent building, location, and exposure on busy highway. Outstanding place to live and work; low penetration by managed care. Ample parking and accessibility with 2,000 sq. ft building designed and equipped for podiatry (lease or buy) 7 minutes from hospital. Great price, terms and opportunity to grow. 352-357-7499 - windnwave@earthlink.net

A.S.A.P.! Excellent opportunity for well-trained, highly motivated PSR 24/36 or experienced practitioner leading to partnership in one year and complete buy out in five years. Generous salary/benefits first year. Large well rounded practice, heavy in forefoot and rearfoot surgery. Send C.V. - FAX (901) 396-5335 or Email drjoelcook@comcast.net

ASSOCIATE POSITION – MISSOURI

One of our long-term associates needs to relocate due to family reasons. Step into full schedule. Five locations in growing population area without HMO's. Partnership available. Missouridpm@yahoo.com

ASSOCIATE POSITION - NORTHWEST PENNSYLVANIA

Multi-specialty group is looking to add another Podiatric Surgeon or General Podiatrist to our well-established group. Office locations in northwestern Pennsylvania. Unlimited opportunities exist for the right Associate, wound care experience is a plus. Please forward your CV to adminsec@ips-mso.com

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City. Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

ASSOCIATE POSITION SANTA FE, NEW MEXICO

Immediate opening for PSR 24/36 individual in three office practice. We are looking for an ethical, hard working, well trained Podiatrist. Partnership available. Please Fax CV to sfpodiatry@aol.com

ASSOCIATE POSITION -CONNECTICUT-NORTH HAVEN

Seeking a part-time associate for a busy, well-established, respected, growing practice. Desiring an ethical, motivated, personable, well-trained PSR12/24/ or 36 podiatrist. Our practice is well-rounded and diverse with a good mix of sports medicine, diabetic care, surgery, podopediatrics, and general podiatry. Email information and CV to Pedy7@aol.com with subject heading “Podiatry Associate.”

POSITION AVAILABLE - SOUTHEAST TENNESSEE/ NORTH GEORGIA

Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. Full and part time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-292-4800. Fax 773-486-3548 ---------------------E-Mail sschneider@homephysicians.com -- www.homephysicians.com

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