The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

September 06, 2010 #3,950 Publisher-Barry Block, DPM, JD

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MO Podiatrist Discusses Causes and Treatments of Hammertoes

A hammertoe, says Dr. John Holtzman of Missouri Foot and Ankle, may be on any of the second to fifth toes, but occurs frequently on the second toe. The majority of hammertoes are hereditary, like bunions, but they may arise from trauma. Secondly, if you drop something on your toe or kick something and injure the ligament, you can develop a hammertoe. The third cause is long-term bad footwear, years of wearing high heels with pointy toe boxes that squash the toes. But more often than not, Holtzman says, shoes simply irritate an existing problem.

Dr. John Holtzman

“Options for treating hammertoes include wearing shoes with extra depth, padding, or surgery to realign the toe,” Holtz­man notes. “If it’s in the second toe, and that is longer than the first and third toe, we can address that, but I would do surgery only if it was at least four or five millimeters longer. The only time I operate on hammertoes at all is if they are painful and have failed conservative measures. There is no sense in taking a surgical risk for a cosmetic effect.”

Source: Mary Jo Blackwood, RN, MPH, Ladue News [8/26/10]

OCPM Receives NIH Grant

The Ohio College of Podiatric Medicine (OCPM) has been awarded a research grant  from the National Institutes of Health (NIH) to study the clinical implications of plantar shears and stresses in diabetic ulceration. Dr. Metin Yavuz, Assistant Professor and Research Associate at OCPM, will lead the research  project.

Dr. Metin Yavuz

The project will take three years with an approved budget of $150,000 plus indirect costs. Over 100 diabetic patients will be recruited, and their 3-D plantar loading pattern will be assessed.

Source: MD News [September/October 2010] via Dr. Richard Hofacker

TN Podiatrist Writes Book on Homeless Survival

How to Live Homeless In Style: 50 Ways to Survive on Plastic Bottles in These Economic Times. This is the real title of a real book that was recently really published. The author is Dr. Robert Spalding, a podiatrist practicing in Tennessee. Spalding treated several homeless patients who were referred to him from the Chattanooga Community Kitchen, a local homeless services agency. Over time, he gained their trust and began to talk to them about surviving without a home.

Dr. Robert Spalding

What resulted was over a year of research and the published book. Inside, readers will find pictures of the subjects and the means they use to survive. There are also discussions on how mentally ill homeless individuals are mistreated in this country, survival tips and techniques, resources on food banks and other emergency services, and ways to cope with stress.

Source: Rich & Elizabeth Lombino, Change.org [9/4/10]

Editor's Note: PM News is proud to present excerpts from Meet the Masters.

Bret Ribotsky: What advice can you offer for treating wounds in diabetics who don't respond to treatment?

Dr. Michael Miller

Michael Miller: I can’t tell you how many diabetic foot ulcers I have seen that just were not getting healed because the leg above was just massively swollen and inflamed and rife with chronic venous insufficiency. The wound care specialist or podiatrist is cutting felted foam and adding extra layers, and recreating the boot to try to figure out why the off-loading is not working. In the meantime, they are trying to heal the wounds for this stagnant cesspool of venous disease on the proximal aspect. Re-assess, re-assess, and the most important thing is dare to be different.

Dr. Larry Kosova

Meet the Masters is broadcast each Tuesday Night at 9 PM (EST). The next segment  will feature computer guru, Dr. Larry Kosova. You can register for this event by clicking here 

Insurer Expense Exclusions

The National Assn. of Insurance Commissioners has approved proposed medical-loss ratio guidelines that would limit what kind of spending insurers can consider as going toward patient care and quality improvement. If the federal government approves the recommendations, insurers will not be able to count spending as a quality improvement expense if it goes toward:

• Retrospective and concurrent utilization review
• Fraud prevention
• Development or execution of provider contracts
• Establishment or management of provider networks
• Establishment or maintenance of claims adjudication systems
• Provider credentialing
• Marketing
• Accreditation
• Calculation or administration of individual enrollee or employee incentives

Source: The National Assn. of Insurance Commissioners' proposed form for insurers to report financial information to state regulators via AMNews [8/31/10]

Respond to the Pressure of Forced Commitment

Apply brakes when someone urges you to make a hasty commitment.

Respond: “If I have to decide right now, my answer is ‘No.’ If you give me time to review the facts, my answer may be different. Do you want me to answer now?”

Source: Adapted from Success for Dummies, Zig Ziglar, IDG Books Worldwide via Communication Briefings

RE: Cortisone Injection in Second Trimester? (Mark Stempler, DPM)
From: Lawrence Kollenberg, DPM

According to the package insert from triamcinolone suspension, the following will be found: "Pregnancy Teratogenic Effects - Pregnancy Category C corticosteroids have been shown to be teratogenic in many species when given in doses equivalent to the human dose. Animal studies in which corticosteroids have been given to pregnant mice, rats, and rabbits have yielded an increased incidence of cleft palate in the offspring. There are no adequate and well-controlled studies in pregnant women. Corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Infants born to mothers who have received corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism."

Essentially, most of those drugs that are listed as category C have no significant studies to say that the drug is either safe or unsafe. Hence, the comment about benefits vs risks.

I can tell you from a practical perspective that OB-GYN's do administer betamethasone on a routine basis when indicated in our hospital to pregnant patients. A similar comment is found in the package insert of betamethasone.

Lawrence Kollenberg, DPM, Pharm D, Baltimore, MD, Lkollenberg@hotmail.com

RE: Cortisone Injection in Second Trimester? (Mark Stempler, DPM)
From: Multiple Respondents

I would be concerned with that course of treatment as a first line therapy because of the potential medical-legal ramifications. Why not a course of supportive and/or physical therapy as a first-line approach? Perhaps consider PRP. I suggest that the dose of cortisone that is typically used is not enough to significantly disturb her endocrine function, but I would not want to take that chance without the written recommendation of her Ob/Gyn for that specific course of therapy.
 
Arnold B. Wolf, DPM, Sterling Heights, MI, omnifootcare@prodigy.net

You might want to consult with her Ob/Gyn, but if he's okay with it, I'd say go ahead and give the injection. I can't imagine that a single shot of a repository steroid would be much of an issue, assuming your patient had no other health issues. 

Paul Busman, DPM, RN, Clifton Park, NY, paul@busmanwhistles.com

With all the speculation and allegations about certain preservatives such as mercury in some medications, I would certainly urge to pass on the injection. You theoretically could be dragged into a lawsuit years from now. You should carefully weigh your options.

Jim Lentini, DPM, Norwich, NY, JPLENT@aol.com

RE: Manipulation Videos (Howard Dananberg, DPM, Robert Bijak, DPM)
From: Stanley Beekman, DPM

Thanks Dr. Dananberg. I appreciate your going "out of the box" and contributing to podiatric knowledge. I can understand Dr. Bijak’s frustration in not being able to do more for his patient due to the limitations imposed in his state. I recommend that he reads his state's scope of practice and make sure that he uses all that is legal.

I respectfully disagree that podiatrists do not know where they are. I am sure that every podiatrist knows the limitations in his state. In Ohio, the scope is: “The practice of podiatric medicine and surgery consists of medical, mechanical, and surgical treatments of ailments of the foot and muscles and tendons of the leg governing the functions of the foot: and superficial lesions of the hand other than those associated with trauma.”

Podiatrists are permitted the use of such preparations, medicines, and drugs as may be necessary for the treatment of such ailments. The podiatrist may treat the local manifestations of diseases as they appear in the hand and foot, but the patient shall be concurrently referred to an MD or DO for the treatment of the systemic disease itself.

I personally have been indirectly treating popliteus syndrome in runners since 1978 via the use of orthoses, as I am treating the foot. The treatment of the popliteus syndrome is a fortuitous side-effect. However, as soon as I can relate the tibial manipulation to a foot muscle, then I will be using it.

Stanley Beekman, DPM, Cleveland, OH, sbkmn1@gmail.com

RE: Keller with Chondroplasty (Barry Mullen, DPM, Jeffrey M. Kittay, DPM)
From: Martin M. Pressman, DPM

With all the attention to evidence-based medicine, perhaps we should look at some of the recent literature with regard to arthritis of the first MPJ. Dr Mullen mentions logic as a rationale for surgical procedure choice and opines that the head of the metatarsal is the source of the arthritic pain and that the base is the "healthy side" of the degenerating joint. While I agree that silicone hemi-joints did not fare well in the long-term, there is ample evidence that metallic hemi-joint arthroplasties are successful and have good survival rates.

Our recent study of Biopro implants (Level-2 evidence) in the July JFAS documented  86% good to excellent results after a mean of 2.9 years (1.6-4.5years). Townley reported several hundred cases, starting in 1954, with no implant removals. I agree that concomitant deformities must be considered or addressed, e.g., elevatus or length issues, but I disagree that arthritis is a one-sided phenomenon. The rationale to replace the base of the proximal phalanx is that the base is just as significant as the head in the generation of an arthritic first MPJ. While the head cartilage often looks worse than the base, both are involved and neither is "healthy". The long history of successful Keller procedures with or without implants also speaks to the usefulness of this procedure. That being said, fusion, osteotomy, arthro-resurfacing (see JFAS 49 (2010), and silicone totals are all useful and have their place as well.

References : (Townley CO, Taranow WS. A metallic hemiarthroplasty resurfacing prosthesis forthe hallux metatarsophalangeal joint. Foot Ankle Int 15(11):575–580, 1994.Roukis TS, Townley CO. BIOPRO resurfacing endoprosthesis versus peri-articular osteotomy for hallux rigidus: short term follow-up and analysis. J Foot Ankle Surg 42(6):350–358, 2003.) (Salonga, Novicki, Pressman, Malay: A Retrospective Cohort Study of the Biopro Hemiarthroplasty Prosthesis J Foot and Ankle Surgery 49(2010)331-339).

Martin M. Pressman, DPM, Milford, CT, pressmandpm@gmail.com

POSITION AVAILABLE - NEW YORK

Well-established, multi-doctor podiatry practice with offices in Putnam and Westchester counties. Compensation based on productivity. Excellent opportunity for recent residency graduate to build skills and learn practice management. Full-time preferred but right part-time candidate will be considered. Email cover letter and CV to: podiatry2011@gmail.com

IMMEDIATELY AVAILABLE- ASSOCIATE POSITION -CT (FAIRFIELD AND NORTH HAVEN)

Great opportunity. Join one of the largest podiatric groups in Connecticut. Well-established and progressive offices. Electronic medical records, digital x-ray, diagnostic ultrasound, Padnet vascular studies, nerve conduction studies, pinpoint and CO2 lasers, electrical stimulation and ultrasound therapies. Seeking a well-trained, personable, and highly motivated individual. Please send resume and current photo to dr.kassaris@yahoo.com

PODIATRY POSITION AVAILABLE – WISCONSIN

Affinity Medical Group, an integrated health care organization in East Central Wisconsin, is seeking a BC/BE Podiatrist for our Appleton location. This is a General Podiatric practice opportunity including routine care, sports medicine, and surgery. The Appleton area offers a unique quality of life, combining a family centered, university community with all season recreation, a nationally acclaimed educational system, and a diverse and growing economy and population. For information, contact or send your CV, to: Sara Roth, Affinity Medical Group, Physician Recruitment, Phone: 800-722-9989; Fax: 920-727-4350; E-mail: sroth@affinityhealth.org Visit our website at: www.affinityhealth.org EOE.

ASSOCIATE POSITION – KENTUCKY 
 
Very well established podiatry practice in Louisville, KY seeks a motivated, ethical practitioner trained in all phases of podiatry including routine care, surgery and wound care to join 2 other podiatrists. By joining our practice you will receive a competitive salary with a bonus structure and benefits. Our practice is equipped with DME, PadNet, Gait Scanner and on site retail store. There is a huge potential to grow your practice with our ideally located facility that has strong affiliation with leading area hospitals as well as 2 local residency programs. For immediate consideration, please forward CV to Samuel10530@yahoo.com

ASSOCIATE POSITION - BLOOMFIELD, NEW JERSEY

Part-time office, part of larger practice looking for associate with well-rounded podiatric skills. Board qualified a must. Ground position leading to partnership. Please email CV to doccapo@yahoo.com

ASSOCIATE POSITION - SW FLORIDA GOLF, BOATING & BEACHES 
 
Great opportunity to join a well established podiatry practice.  Excellent mix office/surgery, motivated experienced staff. Seeking full-time Associate PSR 12-36. Salary $100 Thousand + bonus package with benefits, early buy-in available to right candidate. Email resume to capecoralpodiatry@live.com or fax to 239-573-9201

MANHATTAN - FULL-TIME POSITION

Available for a Board certified/qualified podiatrist (PSR-24, PM&S-36 ). Located in Downtown Manhattan in a multi-specialty Orthopaedic office. We have a high-volume practice that treats routine care, trauma, sports-related injuries, hospital consults, and ER Consults. Contact fscudese@seaportortho.com

ASSOCIATE POSITION - FREDERICK, MARYLAND

Fredericks premier group practice is located only 45 minutes from both DC and Baltimore. Immediate opening for a minimum PSR 36 Podiatrist for full time position. We have it all: EMR, digital x-ray, ultrasound, ASC, etc. Excellent salary with bonus structure and benefits. Please email resume to docsbnb@aol.com

FULL-TIME ASSOCIATE NEEDED FREDERICK/HAGERSTOWN, MARYLAND

Reconstructive Foot & Ankle Institute, LLC needs full-time DPM at least PMS 36 to join premier group in Frederick/Hagerstown, MD. ASC, EMR, DR-digital radiography and ultrasound, Vascular/nerve testing, DME, retail store, strong hospital affiliations, salary, bonus and benefits. Respond to drmichaels@rfainstitute.com

PRACTICE FOR SALE – MASSACHUSETTS

Solo Practice Grossing over $700K yearly 4 days a week. Mostly surgical with heavy emphasis on peripheral nerve patients and pediatrics. General bread and butter podiatry as well. No Medicaid very little Medicare. Very modern office. 30 minutes north of Boston. Modern new equipment (digital x-ray, ultrasound, computer network, etc.). Great referral network. Website included. Option to buy the condo 3500sq ft. Have PICA practice evaluation to show you. Call 978-944-7789 for details.

PRACTICE & STATE LICENSED ASC FOR SALE (MARYLAND, DC SUBURB)

Full-time 38 yr old podiatry practice with state licensed surgical center. Fully equipped with digital x-ray, diagnostic ultrasound, 2 orthotic scanners, computer network, and well-equipped surgical suite. Retiring owner will stay on as needed for transition. Email dpmpracticeforsale@yahoo.com

MEDICAL SPACE AVAILABLE- MANHATTAN

Multispecialty Medical Building with 24/7 doorman. Prime Luxury Building and Location, Gramercy, Stuyvesant, Peter Cooper Area. 305 Second Avenue (17th-18th). Prior tenants past 23 years; podiatrist, dentist (plumbing/electric intact), internist. Ideal for podiatry, co-share with dentist, MD, etc. (flexible lease terms). E-Mail; jbdrun@aol.com Phone; 480-951-2480.

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