The Voice of Podiatrists

October 30, 2006 #2,727 Editor-Barry Block, DPM, JD

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C-Shaped Feet Best For Barefoot Running: Pribut

Foot shape could be the key to successful barefoot running. Dr. Stephen Pribut, American Academy of Podiatric Sports president, says "It's very safe for those with C-shaped feet, in which the ball, outside foot and heel all make good surface contact and provide adequate support. that foot type to run barefoot."

Dr. Stephen Pribut

Shoes, however, provide needed support to those who have flat feet, abnormally high arches, plantar fasciitis or Achilles-tendon problems, he says. Additionally, flat-footed runners who overpronate "usually need a shoe to guide the foot in proper directions." Shoes, however, do change the mechanics of the stride, he says. And too much cushioning can create balance issues.

A specialty running store should be able to determine your foot shape and what kind of shoe is appropriate, Pribut says. Or you can determine the shape by dampening your feet and stepping onto a wooden deck or a paper bag. A normal foot will have a C-shape with a wide band of contact on the outside. "A flat foot would be rectangular, like a brick." A foot with a high arch would show contact on the ball and heel, with a narrow band on the outside foot.

Source: Lisa Roberts, Baltimore Sun, [10/27/06]

Podiatrists Attend Global Onychomycosis Panel in Iceland

Jeffrey M. Robbins, DPM and Warren S. Joseph, DPM recently returned from Reykjavik, Iceland where they had been invited to attend a global onychomycosis panel to discuss new advances in the treatment of that disease. Robbins and Joseph were the only two podiatric physicians attending the invitation only event which brought together specialists from around the world.

Drs. Warren S. Joseph and Jeffrey M. Robbins

The meeting was held in downtown Reykjavik the first day and then moved to the Blue Lagoon, man-made geothermal mineral baths and spa whose mineral waters have been found, through clinical trials, to have curative effects on various skin conditions, especially psoriasis. After the meeting the participants were given a tour of the new Dermatology Center that has been developed at the site.

Healthcare Premium Increase Down, But Still Outpacing Inflation

Healthcare insurance premium increases have been slowing in recent years, but they still outpace inflation and wages, which jumped 3.5% and 3.8%, respectively, this year.

	Increase
1999	5.3%
2000	8.2%
2001	10.9%
2002	12.9%
2003	13.9%
2004	11.2%
2005	9.2%
2006	7.7%

Note: Percentages are reported in the spring of each year.

Source: Kaiser/HRET "Employer Health Benefits: 2006 Annual Survey," September

Query: Anti-Coagulation For Scleroderma Patient

I have a patient that must be anti-coagulated. She has scleroderma and has CREST. The last time she had surgery and was taken off her coumadin, she threw a clot and lost a finger. She is scheduled for an orthotripsy. I am planning on taking her off the coumadin and augmenting with Lovenox 40mg. Does anyone have any experience with this problem? Is there a chance of compartment syndrome?

Priti Lakhani, DPM, Leavensworth, KS, pjlakhani@hotmail.com

RE: Hookworm Parasitic Infection (Michael A. DeVito, DPM)
From: Jeffrey Ali, DPM

The question about hookworm and its "toxin" affecting the foot begs correction. It sounds as if the parasite described may be more like scabies. Hookworm breaks through the skin, enters the vascular system, and migrates to the gut. It does not normally remain in the area of the entry point. Before administering any additional anti-parasitic, it might be wise to explore the area superficially, and remove any worm found.

Jeffrey Ali, DPM, Cleveland, OH, dpmchamp@netscape.net

RE: Screening For Hypertension
From: Multiple Respondents

Marty Lynn, DPM states taking blood pressure can be dangerous and cited a woman who has had a breast removed and lymph node dissection. Just last week speaking to a general surgeon who regularly does these procedures stated that after 6-8 weeks there is no problem using the affected side for blood pressure or IV's. He said it is one of those unproven statements that are taken for gospel and should be disregarded. In a separate conversation, an anesthesiologist concurred. His example of someone who had bilat breast removal still would need to have her BP taken and an IV started.

John Clarke, DPM, Fremont, OH, jclarke2735@sbcglobal.net

Vital signs are not required for scoring E/M encounters using either the 1995 or 1997 guidelines. I believe that Drs. Ribotsky and Cosenza have missed the “point” of the 1997 E/M Guidelines. That point is that ONLY history and exam elements relevant to the patient’s chief complaint count when scoring E/M encounters. So when a diabetic presents with a draining wound, documenting vital signs is medically relevant and counts when scoring the E/M encounter.

I also believe if a new patient presents to the podiatric physician’s office with a history of HTN, documenting vital signs would also be relevant. If however, that same patient presents 1 week later for a heel pain follow-up, and had a normal BP at the initial visit , one would be hard pressed to make a case for counting vital signs towards the E/M encounter. On the other hand, if the BP recorded one week previously for this new patient with HTN was abnormal , or the patient had a change in HTN medications during the previous week then documenting their vital signs makes sense.

Dr, Levy is correct - we want to be considered physicians so recording vital signs can be a routine part of our care. Make sure you have the appropriate sized blood pressure cuffs for all patients and use the measurement of an abnormal BP as an avenue to communicate with the patient’s primary care physician. But do let us not confuse quality medical care and reimbursement as they are not always synonymous.

Ken Malkin, DPM, Caldwell, NJ, drmedicare@aol.com

We as podiatrists should be more medically oriented and this is an excellent way to do that. Patients often see us on a more regular basis than their primary and we deal with many sick people that could benefit from this. Also, as a profession, podiatry should be taking a more wholistic approach.

However, you can't just take vitals so you can bump your E&M code up. That's how our profession looks bad. The other pitfall is taking vitals and not acting on them. If you don't plan on calling their PCP if the BP is 190/100 then don't do the vitals just to bump the E&M.

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

RE: Lapidus on Down's Patient (David Gurvis, DPM)
From: Multiple Respondents

I have performed a Lapidus on a 40 y/o Down's syndrome male. He mostly used a wheelchair to get around his home and I am sure he probably bared some weight while transferring during the post op period. We also did not have a chance to throw two screws across the joint due to a stress riser intra op, so we used a 4-0 screw from distal to proximal and a .062 K-wire from distal medial 1st met base through the medial and middle cuneiform and cut it flush to bone. This pt is now 12 wks and is starting to WBAT and his osteotomy is fully healed.

David Ellenbogen, DPM, New York, NY, dellenb@nycpm.edu

Have you considered first MTP joint fusion? There is abundant literature to support first MTP joint fusion as a primary procedure for severe hallux valgus without the need of a proximal osteotomy. Furthermore, a non-weight bearing cast is not always required post-operatively. The apex of a hallux valgus deformity is the 1st MTP joint and in the presence of a spastic neuromuscular condition, 1st MTP arthrodesis is a good choice.

David T. Taylor, DPM, Flint, MI, dttaylor_19@yahoo.com

I use an Acumed lazy L plate and accompanying titanium screws from their extremity congruent plate set; they have great pictures, technical papers, and video on their website. There's also the locking plate & screw sets from Wright and others. Solid fixation construct is the key; then one can sleep better.

My post-op protocol is 2 wks splint w/ wheelchair & crutches + 3-4 wks NWB or heel posted or shod SL cast + 3-4 wks cam/Bledsoe/pneumatic boot/walking cast of choice. Add 3-4 more wks NWB cast if the patient has poor bone stock.

Osteomed has some great non-/very slow resorbing and well incorporating DBM allograft; and as I’m sure you well know, be certain to drill and feather out both sides of fusion site.

Will Godfrey, DPM, Fort Polk (Leesville), LA, williamtrekkie@earthlink.net

RE: Bariatric Surgery Referrals
From: Paul Busman DPM

The increased mortality from morbid obesity is so great that I feel it's almost morally wrong to NOT at least bring up the subject of bariatric surgery with our obese patients. When a podiatric surgeon contemplates performing any invasive procedure, he or she does their due diligence and if all of the work up indicates that the benefits of the surgery outweigh the risks, they proceed with the operation with the conviction that they are doing it in the patient's best interests. Certainly, there are negative outcomes from time to time, but hopefully in the balance they help far more people than they harm.

The same is true of bariatric surgeons. The reputable ones have an exhaustive battery of tests and evaluations that they require before a patient goes under the knife. Again, some patients have less than perfect results and some even die (as they may for any internal surgery) but in the balance the benefits of losing large quantities of excess body weight outweigh the risks if the patient is properly screened and selected. If we refer a patient to an endocrinologist to control diabetes or an oncologist to treat a skin cancer that we discover during examination, we may be saving their lives. Referral to a bariatric surgeon may do no less.

Another point is that if you refer a patient to a bariatric surgeon, you are only making a suggestion that this patient be evaluated, not that they SHOULD have the surgery. The burden of making the surgical decision is on the surgeon.

Paul Busman DPM, Troy, NY, BREWERPAUL@aol.com

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