The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

September 09, 2009 #3,644 Publisher-Barry Block, DPM, JD

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CA/IL Podiatrists Provide Shoe-Buying Advice

Dr. John Pagliano

Your feet swell later in the day—as well as slightly when you run—so shop in the afternoon or after you've gone for a jog. Your feet will be about half a size larger, and that's the size you want to fit, says John Pagliano, DPM, a podiatrist in Long Beach, California, who specializes in sports medicine.

Dr. Marlene Reid

Grip the toe of a sneaker in one hand, the heel in the other. Bend toe forward. The sole should flex at the ball of the foot, where feet flex, says Marlene Reid, DPM, a podiatrist in Naperville, Illinois. If it buckles in the middle, it doesn't offer enough arch support.

Source: Karen Springen , Self [September 09]

NYCPM Alumni Association Donates Skeleton

Anatomy lecture and lab would not have been the same if we did not have our class skeleton, whom some of us so affectionately call “Gunther.” With the anatomy lab undergoing renovations, it had proved to be very challenging for many of the students to keep up with Dr. Bressler’s lectures without the proper visuals.

Judah Gomberg and Daniel Basalely (2012) study the upper extremity.

The NYCPM Alumni Association came to the rescue for the majority of us who could not afford to purchase a full skeleton model and could have used the extra help. With a more than generous donation of $880 the class purchased the high-quality 3B Scientific skeleton with ligaments and muscle attachments that arrived days before the first anatomy exam. It has truly been of great help and I’m positive that many of us will continue to use it throughout lower extremity anatomy.

Source: Oendrila Kamal (2012) NYCPM Alumni Report (Summner 2009)

Editor's Note: PM News is proud to present excerpts from Meet the Masters. Full versions of these interviews will appear in Podiatry Management Magazine.

Bret Ribotsky: What new ideas have you put into your practice in the last couple of years that have made a difference?  
 
Allen Jacobs: I sit down with these patients and I say, “look, these are the risk factors.”  By analogy, let’s say you go to a cardiologist. He does not just say have you had chest pains, and that is the end of it. He performs various blood tests, assesses your risk factors, and then he sits down with you and says, “Hey look, here is you cholesterol, here is your LDL, here is your HDL, here is your family history, here is your blood pressure, and we have to control all these factors.” 

For the diabetic, we as podiatrists, need to perform vascular testing and intra-epidermal nerve fiber density testing.  I think that we must get much more involved with these diabetic patients, everything from nail care to Charcot joint reconstruction.  I say that evaluation of that diabetic patient and total commitment and involvement in management of these risk factors has been the single biggest thing that has contributed to my office income, and has changed my practice substantially.

Meet the Masters is broadcast each Tuesday Night at 9 PM (EST). This week's guest is  , Ronald Lepow, DPM, former president of both the APMA and the Federation of International podiatrists . You can register for this event  by clicking here.

Query: Calcaneal Ostectomy and  Decreased Fat Pad
 
The x-ray shown is that of the left foot of a 70 y/o diabetic female patient who underwent a partial calcanectomy 2 years ago, secondary to osteomyelitis. The present issue is loss of fat pad, pre-ulcerative lesion, and significant pain, plantar calcaneus. Conservative measures have been exhausted, including custom accommodative inserts, shoes,  bracing, and pain management. Minimal relief has been achieved. She's not interested in further conservative treatment. She understands the risks of surgery, but wishes to pursue surgical intervention.  Her pain is severe enough that she is contemplating amputation, if all else fails.

Loss of Fat Pad, Post Partial Calcanectomy

I'm planning on contouring the plantar calcaneus, but I am wondering what my options are to address the loss of fat pad? Does anyone have any experience or success with autologous fat transfer, GraftJacket, tissue augmentation, or other modalities which would be effective in this setting?
 
Chris Seuferling, DPM, Portland, OR

Query: Weight-Bearing MRI

One of the imaging companies in my area has recently added a new device, a standing or weight-bearing MRI. I've had no experience with this. Any suggestions of when to use weight-bearing instead of the old non-weight-bearing images?

Larry Aronberg, DPM, Lake Worth, FL

Query: Destruction of Multiple Warts

How do I code destruction of multiple warts? I treated 7 warts on the right foot and one wart on the left foot. Do I use the CPT 17111 code several times or just once?

Samuel Rameas, DPM, Camillus, NY

Response: The code for destruction of multiple warts would be CPT 17110, which is described in CPT as destruction of "up to 14 lesions."

You would not use CPT 11711 (the only code billed; 1 unit) unless you were treating 15 or more lesions. The choice of codes is based on the collective sum of warts treated.

Tony Poggio, DPM, Alameda CA

Codingline subscription information can be found at:
http://www.codingline.com/subscribe.htm

RE: Leg Pain (Brent Rubin, DPM)
From: Lorraine Loretz, DPM

I work in vascular surgery and see this presentation occasionally, most recently last week: acute arterial stenosis mimicking DVT. Consider repeating venous duplex. If DVT is ruled out, then there may be compromised arterial supply (with a variety of possible etiologies). I would suggest a vascular surgery consult and order an arterial duplex - popliteal artery to check for velocities suggesting stenosis. Also get segmental pressures/pulse volume recordings which will help determine level of compromise, if present. If these are positive, she will need an angiogram.

Lorraine Loretz, DPM, NP, Worcester, MA, lloretz@juno.com
 

RE: Verapamil for Plantar Fibromatosis (Greg Caringi, DPM)
From: Richard M. Maleski,  DPM

I had a patient with bilateral plantar fibromas a few years ago. I excised them on the right foot, and I recommended Mederma cream for the scar. The patient, on her own, also used the Mederma on her non-operated foot. We were amazed at how much softening and reduction in the bulk of the fibromas occurred, so much so that she didn’t need the surgery on the other foot. I recommended the Mederma on my other plantar fibroma patients since then, and have had varying degrees of improvement. I tried to use the verapamil treatment, but never was able to get insurance coverage for it, and since my practice is in a very low income area, I have not been able to use it.

Richard M. Maleski,  DPM, Arnold, PA, maleski@zoominternet.net

RE: Non-Fixated Osteotomies (Arden Smith, DPM)
From: Ed Cohen, DPM

I was very interested in the discussion on non-fixated oteotomies. I have been using these procedures for 31 years and I feel this is an excellent procedure for treating a painful lesion that is caused by a plantarflexed metatarsal. The trick is to figure out if the lesion is caused or aggravated by the metatarsal head. This can be a very challenging problem as the lesion could be a wart or other pathology under a plantarflexed metatarsal.

If I have any doubts, I excise the lesion and then if the lesion returns I usually perform a metatarsal osteotomy. If I cannot get rid of the lesion, which is less than 1 or 2 percent, I perform a plantar condylectomy. If the lesion was caused by trauma, it may not be possible to get rid of the lesion. The pathology report can be very helpful in determining if the lesion has a mechanical component to it. I feel the success rate is 95 to 98 percent successful. The non-union problems are extremely rare, and I seriously doubt they are any more prevalent than with fixated osteotomies.

I believe the high incidence of failure or tranfer lesion associated with fixated metatarsal osteotomies is because the metatarsal is fixated at the wrong level. Free floating osteotomies seem to seek the right level by the patient ambulating on the foot after surgery. The AAFAS which is an international organization of podiatrists, orthopedists, and other medical doctors interested in minimally invasive foot surgery can provide an excellent opportunity for podiatrists to hear and see firsthand how effective non-fixated metatarsal osteotomies are. Another source might be orthopedist Mariano DePrado's book based on a fifteen-year study of minimally-invasive foot surgery.  

Ed Cohen, DPM, Gulfport, MS, ecohen1344@aol.com

RE: Standard of Care (Richard Boone, Allen Jacobs, DPM)
From: Vadim Glukh, DPM, Michael M. Rosenblatt, DPM

The comments from Dr. Jacobs and Mr. Boone are well receieved. However, all too many cases are tried with expert witnesses from the other specialty (e.g., orthopedics), or from far-away geographic areas and states. If the standard of care truly should depend on specific factors such as the ones above, then the argument about the standard of care in those cases serves only to dramatize the legal proceedings.

Vadim Glukh, DPM, Richmond Heights, OH, vadimglukh@gmail.com

Mr. Boone is absolutely correct about the issue of "standard of care." This is basically a red herring used by plaintiffs' attorneys to assign "culpability" of a particular treatment or lack of treatment.  This is one of the big problems with Government required "standards" for defining the pattern of treatment required under circumstances of a particular diagnosis. Government wants this desperately, so they can penalize providers for not following them, and even better, avoid paying them entirely.

The worst mistake any provider community can make is to fall into a pattern of required cohorts for treatment. I propose a more practical solution. A point value system can be assigned to specific diagnoses, and their relationship to the totality of the patient's condition. The points can be added up and a "qualification" program can be created out of the totality of points. Points are added or subtracted, depending upon the extent of the particular symptom or condition...and its effect upon life and limb.

Instead of getting a specific "standard of care...which can be easily manipulated to avoid payment or assign blame, you get a continuum. You will still have protagonists who complain about the point values, but the most egregious problems will be seen immediately, and are far less likely to be argued. It's amazing how many venues and systems respond to point value collection. And when hired experts on opposing sides scrupulously follow the "point collection rules", their results are astonishingly similar. It beats what we have now.

Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net

RE: Prescribing Pain Medicine to an Addicted Patient (Elliot Udell, DPM)
From: David E. Gurvis, DPM

I have got to wonder from Dr. Udell's post if there isn't something missing to this story of the doc prescribing pain meds to a sickle cell patient and having...

Editor's note: The full text of Dr. Gurvis' letter can be read at: http://www.podiatrym.com/letters2.cfm?id=28709&start=1

OFFICE SPACE/ MRI RENTAL – NYC, LI

Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, Hicksville and/or Plainview Long Island. JACHO-certified operating rooms available, as well as all surgical equipment and anesthesia. Extremity MRI Rental. Stark compliant. All exams read by board certified radiologist. Call for details. 516 476-1815

ASSOCIATE POSITION - DALLAS/FORT WORTH AREA

Seeking well-trained ABPS board certified/qualified foot surgeon for surgical practice with national foot/hand/orthopedic surgery group. Excellent salary/benefits. E-mail CV and cover letter to: slb99@pdq.net

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

HELP WANTED! NEW JERSEY
 
Busy podiatry practice located in northern New Jersey looking for a full time associate for an excellent opportunity for employment!
Please E-mail resume to njfootdoc@hotmail.com

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 – LONG ISLAND

Busy Wantagh, NY office. Motivated, preferably board certified, hard working, experienced in all phases of Podiatry. F/T, P/T hours available. excellent salary, call 516 242-7540 or Fax Resume 516 826-9036 or email jobke@aol.com

LOCUM TENENS POSITION – PHOENIX, AZ

Locum Tenens position available in West Valley Phoenix office beginning September 15th. Salary negotiable. One to two days a week in a friendly and casual office. Please direct all inquiries to drlaurel@cox.net.

ASSOCIATE POSITION – NORTH CAROLINA

Very busy practice in Western North Carolina, seeking Full-time Associate with hospital and surgical training. If interested please fax resume to 828-252-2272 or e-mail to mfas828@aol.com

EQIPMENT FOR SALE - ORTHOTIC FABRICATION SYSTEM

Amfit Orthotic Insole Fabrication System with Footfax SL Contact digitizer- For Sale Machine, Laptop, rolling bag, small inventory of shoes, insoles, all cords, parts and hardware Asking $10k.OBO! Please contact Jeff at Jhunt@psbank.net for further information, pictures.

ASSOCIATE POSITION - NY (MID-TOWN MANHATTAN & WESTCHESTER COUNTY)

Multi-office, well-established medical/surgical practice with on premises OR, digital x-rays, vascular testing, sonogram, F-scan, bone density testing, fluoroscopy & NCV. Additionally, EMR with voice recognition charting coming soon, and many other perks are available. We are looking for personable, well-trained & well-motivated individual. Patient base available for immediate in-office productivity. If you are new or ready to change locations, contact us ASAP to discuss opportunities. Send resume and cover letter to terri.bobson@verizon.net

POSITION AVAILABLE IMMEDIATELY - IOWA

Looking for Board Certified/Board Qualified Foot and Ankle Surgeon to join a very busy hospital-based practice. We see over 6000 patient visits per year in the county hospital and take all lower extremity trauma call. Must be 2yr residency trained minimum, with trauma experience or willingness to learn. You will be joining a group of 4 dynamic, hard working podiatrists who enjoy great benefits, pay for performance options and a great Midwestern lifestyle. Please send your CV and letter of interest to: Dr. Denise Mandi, Section Chief, Foot & Ankle Surgery, Broadlawns Medical Center, dmandi@broadlawns.org

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.

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

ALASKA- ANCHORAGE- IMMEDIATE OPENING – DON’T HESITATE

One of state’s largest podiatric providers is looking for an associate to join the practice with becoming a partner as part of plan. Practice has modern office on the campus of Alaska Regional Hospital and opportunities for surgery, in-office care and ancillary services. Great place to live for the outdoorsman. Three-year surgical residency preferred. contact: mcrosby@providerresources.com  AK03.

ASSOCIATE POSITION – CENTRAL FLORIDA

Growing practice east coast of central Florida looking for full or part-time associate willing to buy into practice. PSR 24/36 Please contact: pfk4@yahoo.com.

PM News Classified Ads Reach over 11,500 DPM's and Students

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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