The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

August 12, 2009 #3,620 Publisher-Barry Block, DPM, JD

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Biggest Challenge is Finding Cause of Diabetic Wounds: DC Podiatrist

In his practice as a doctor of podiatric medicine and surgery at Georgetown University Hospital in Washington, D.C., Dr. John Steinberg specializes in the diagnosis and treatment of complex lower extremity wounds. The 80 patients that he typically sees during a week are a varied group.  "We may have a U.S. senator or ambassador in one examining room and a homeless person in the other," he says.

Dr. John Steinberg

Dr. Steinberg notes that his biggest challenge is finding the cause of the wound. Diabetes, he says, is not the cause. "Diabetes does not cause foot ulcers and recalcitrant wounds," he emphasizes.  What does cause these ulcers and wounds in the feet and lower limbs of people with diabetes, he explains, is pressure on the feet and legs caused by ischemia, poor circulation, neurological problems, and infection - all complicating and attending factors of the disease. To heal the wound, the solution is to relieve the pressure, which Dr. Steinberg calls "the mechanics."  Sometimes, those mechanics may involve surgery to correct a bone or foot deformity, coupled with getting the patient into special shoes.

Source: Dennis McGrath, Diabetes Health [8/10/09]

OCPM Professor and Students Collaborate on Research Paper

Dr. Metin Yavuz, Assistant Professor in the Department of Basic Sciences, collaborated with Dr. Vincent Hetherington, Dr. Brian Davis of the Cleveland Clinic Foundation, and OCPM students David A Wood, Irene Nwokolo, Randy Semma, John Gerhard, Jalpa Patel, Megan Matassini, Trung Ky and Frank Luckino, to research and write a paper entitled, "Can plantar temperature be used to assess tri-axial loading under the foot?"  The research paper was submitted to the American College of Foot & Ankle Orthopedics & Medicine (ACFAOM) for a peer-reviewed process. The paper was not only accepted, but ACFAOM had asked that an OCPM representative present this paper at their clinical conference in Orlando, Florida in mid-July. 
 

Megan Matassini

2nd year OCPM student Megan Matassini (pictured above) presented the paper, which will be published in the November edition of "The Foot" Journal. 

Source: Footsteps, OCPM [July, 2009]

Angie's List

How did Angie and Craig (of Craig's list) get to be so influential? How did Robert Parker become the number one authority on wine? They all provide information that people need.  Well, Angie is now having people recommend and rate doctors. Be sure to go onto Angie's list and see if you're being discussed on there. If not, you can ask patients who are truly happy and satisfied with your services to stop by Angie's list and let her (and everyone in your community) know what a great doctor you are. By no means manufacture recommendations or have your family do them! Just ask real people to offer real advice about you and your practice. You'll be glad you did.

Source: Rem Jackson, CEO of Top Practices.  For information about  the American Academy of Podiatric Practice Management, visit www.aappm.org

Query: Surgical Options for Hallux IPJ Pain

I am interested in surgical treatment options for a 16 yo athletic healthy male with a history of a stubbing injury June 4, 2009. Initial x-rays noted equivocal fracture vs united apophysis. He was treated with cast boot, WBAT. He continues to have dorso-medial hallux IPJ pain, right hallux with inability to wear a closed shoe due to discomfort. X-rays have been unchanged over two months. Pain is dorsomedial rather than lateral.

Hallux Fracture

He has no prior history of injury but did have mild hallux interphalangeus prior to present injury, and this has worsened. He is developing a rigid hallux hammertoe with lateral deviation. Treatment options include resection of the lateral fracture fragment vs. hallux IPJ fusion. What would work best for this young gentleman?

Richard Frost, DPM, Spokane, WA

Query: Delighting Patients

What is the most compelling thing your staff (or a staff member) has done to delight patients and make your practice successful?

Bob Levoy, Great Neck, NY

Editor’s note: Bob Levoy will award a copy of his recent book, "222 Secrets of Hiring, Managing and Retaining Great Employees in Healthcare Practices" (Value = $59.95) to the PM News subscriber with the best answer.

Query: Coding Bone Cyst & Fracture Treatment

I excised a bone cyst from a left fifth metatarsal that had resulted in a pathologic fracture of the metatarsal at that site. The repair included windowing of the bone cortex, curettage of the material, and packing with a synthetic bone grafting material. The window was replaced, and the fractured portion stabilized (without internal fixation). Soft tissue was closed over the area, followed by skin closure.

I believe that the coding options include open repair of a metatarsal fracture (CPT 28485) and/or curettage of a bone cyst (CPT 28107-59). Are these codes correct? How does the procedure coding affect the global post-operative period?

Howard J. Bonenberger, DPM, Nashua, NH

Response: It's my opinion that the correct coding for this procedure would be using the CPT 28104 (excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus).

The fracture was not reduced, fixated, or grafted. Therefore, the bone cyst repair was the procedure actually performed. I would feel differently if there was additional work done that was unique to the fracture.

Howard Zlotoff, DPM, Camp Hill, PA 
 

Codingline subscription information can be found at:
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RE: Tingling and Burning of Toes Under Bedcovers (Bob Hatcher, DPM)
From: Greg Aposperis, DPM

Although her vascular and neurological exams were WNL, more information is needed. Does she have low back problems?  What is her typical sleep position--back or sides? If she sleeps on the back or stomach, the symptoms may be low back issues. Sleeping with pressure on the toes may produce microvascular ischemia, resulting in her symptoms. Are all toes/both feet affected equally?

Any history of collagen disease such as Raynaud's? Does she note color or temperature changes in her toes at the time of the symptoms? Does she just remove the covers, or does she also get up and walk around to get relief? Does she normally get good sleep, or does she wake up un-refreshed?

The list goes on, but do not consider her "a head case" until the above questions can be answered to your satisfaction. The fact that she only has the symptoms with sheet pressure is the key to your diagnosis.

Greg Aposperis, DPM, Santa Barbara, CA, santabarbarafootclinic@yahoo.com

RE: Oral Lamisil Use in Children (Bruce N. Block, DPM, Brian, Kashan, DPM)
From: Bryan C. Markinson, DPM, Maurice W. Aiken, DPM

The use of terbinafine is not approved in children. Gupta. et al., established in several large series that use of terbinafine in children is safe. In one study of almost 1000 children, there was a 10% adverse effect incidence, of which only 8 out of 100 such incidences actually led to cessation of the treatment.

See Gupta, et al., Onychomycosis in children: prevalence and treatment strategies. J AM Acad Dermatol. 1997;36:395-402, and Gupta AK, Cooper EA, Lunde CW. The efficacy and safety of terbinafine in children. Dermatol Clin 2003;21:511-20.

The dose is by body weight as follows: Less than 25 kg. - 62.5 mgs per day; 25 - 40 kg. - 125 mgs per day; >40 kg. - 250 mgs per day.

The parents should be informed that the drug is not FDA approved for use in children. I always inform the pediatrician.

Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org

Dr. Kashan urges utmost caution regarding use of terbinafine in children. In fact, he states clearly that he would not do it. He does not say, however, what he would do with a child who clearly is distressed at having onychomycosis. In general, I would not argue that his position is too rigid, as he is being true to his own level of tolerance and experience in this situation. However, I would argue that advancing the position that off-label use of anything in children should absolutely be avoided (which I do not think Dr. Kashan intended) may be the wrong message to take away from his post.

For example, the use of Marcaine is not approved in children, but I welcomed the ENT surgeon's injecting it into my own kids throats post-op when they had their tonsilectomies. When I eventually get my own case of prostate hypertrophy, I may welcome the off-label use of Nizoral to help shrink it. Now, one might point out that the risk severity in using terbinafine in children is much greater than my two examples, but the scientific evidence, in well done large sample size studies, states otherwise.

Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org

I have had several pediatric patients in this age range who I have used oral Lamisil successfully. Prior to its use in this population, I contacted Novartis and obtained several articles on its use in Great Britain. It is extensive and has been used in ped populations for many years.

As usual, you do your pre-treatment liver function studies and a CBC w/diff, and do a monthly repeat of those labs if you are more comfortable then the recommended 6 week repeat. As far as dosing is concerned, I have used the usual 250 mg dose each day as per the articles that I have referred to previously. Call Novartis or ask your rep to inquire about this subject. They have been very responsive in the past.

Maurice W. Aiken, DPM, Baltimore, MD, mwaiken@comcast.net

RE: Duty to Disclose Audit? (Name Withheld)
From:  Barry H. Block, DPM, JD

It’s clearly a close call on the ethics of disclosing a Medicare audit of four years ago which resulted in repayment. Hopefully, in the following years, the seller would have reformed and improved his/her Medicare billing practices. The take-home message is that any potential purchaser should ask questions like, “Have you ever been audited by Medicare or any insurance company?” By asking such a question, you are obliging the seller to reveal such information (at the risk of being sued for misrepresentation).

Additionally, before purchasing a practice, you should review some patient charts and look at the associated billing records. A certain amount of caveat emptor is necessarily present.

Barry H. Block, DPM, JD, Forest Hills, NY, bblock@podiatrym.com

RE: Yellow Pages Parity (Frank DiPalma, DPM)
From: M. W. Aiken, DPM

I can certainly understand the frustration of having an orthopedist encroach into the territory of podiatry. The competition is real, and if the Yellow Pages will not stand by its policy of equal treatment to allow you to advertise in the M.D. ortho section, then try a letter from your attorney accusing them of restraint of trade and unfair business practices. At least, file a complaint with the Better Business Bureau and your local Chamber of Commerce to make some much-needed noise.

Accordingly, you could attempt to place an ad in the urology section of the Yellow Pages. In your ad, simply state...."If it measures 12 inches in length, it's technically a foot.....and I can treat that." See what they say.

M. W. Aiken, DPM,  Baltimore, MD, mwaiken@comcast.net

ASSOCIATE POSITION - FREDERICK, MD

Well-established and growing 2 office state-of-the-art practice located in medical/professional buildings. EMR, Digital X-ray, Ultrasound, DME provider, etc. Competitive Base Salary plus bonus, malpractice, health insurance, etc. PSR 24 minimum/Board Qualified or Certified with ability and desire to take ER call. If interested, forward CV to DOCSBNB@aol.com

ASSOCIATE POSITION - BOSTON, MA 

Very busy office near Williamsburg. Currently, a satellite office 2 days a week. Great opportunity to make office full-time. Grosses approx. 130,000/year. The office has everything needed to start practicing. All included. Must sell. If interested, e-mail totalfootcareva@hotmail.com

PRACTICE OPPORTUNITY - CINCINNATI, OH

Well-established practice located in medical/professional building minutes from hospital. Many referrals, three satellite clinics and two assisted living facilities to keep you busy. Associate leaving due to family emergency-need to either find an associate or sell ASAP. Contact bjadpm@hotmail.com for more details.

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

ASSOCIATE POSITION - FLORIDA

Busy practice in East Central Florida in search of full-time podiatrist to perform routine foot care in office and nursing home. Competitive salary and full benefits available. Reply to jrdpm@bellsouth.net

PRACTICE FOR SALE - ALABAMA, GULF COAST

 Established 26 year old practice. Owner desires to sell and relocate. Operated 25 hours per week. Mixture of surgery and general podiatry. MD referrals. Surgery center and hospitals in close proximity. Highly profitable. Priced to sell. Will lease office to buyer. Call Mike Crosby at 888-776-2430 or email mcrosby@providerresources.com

ASSOCIATE POSITION - MARYLAND

Harford County, Bel Air, est. 1991, seeking PSR24/36, strong ethics, friendly demeanor. Associate or partnership opportunity for the right applicant. We provide onsite ambulatory surgical center, patient base, strong referral resources, billing, scheduling, and many technologies. Visit our website. e-mail your CV to drhoward@hlsfootcare.com.

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 fmassuda@footexperts.com

FOR SALE: MICROVASC UNIT

Excellent Condition, Never Used, New 14K, BEST OFFER. All-Pro 2010 X-Ray processor, used, great condition, Includes cassettes BEST OFFER
NYCPodiatry@gmail.com

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.

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Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 11,500 DPM's. Write to  bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451 Ext 110

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