The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

December 01, 2006 #2,754 Editor-Barry Block, DPM, JD

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WA Podiatrist Spends 10% of Time on Housecalls

For years, Spokane podiatrist Dr. Borys Markewych has done about 10 percent of his work out of the office, largely attending to the foot-care needs of people with diabetes.

Dr. Borys Markewych

"It's very important to make sure they don't end up losing their limbs," Markewych says.

Source: Heather Lalley, Spokane Review [11/28/06]

MS Podiatrists Use Infusion System to Reduce Pain Meds

Podiatrists Carey Craig Williams and R. Michael Whitmore of Oxford, MS have taken a step into the high technology future of podiatric surgery—and found it pain-free. Williams is the former Chief of Podiatry at the National Naval Medical Center in Bethesda, MD. He and Whitmore have served resident directors of podiatric surgery.

Dr. Carey Craig Williams

The state-of-the-art medical infusion pumps, named ambIT®, allow them to perform pain-free surgery on their patients and at the same time to significantly reduce the quantity of narcotic pain relievers necessary. "One hundred percent of the surgeries in which we use the Sorenson Medical ambIT pump are pain-free,” said Williams.

After surgery, the compact ambIT pump—which hangs from a belt pack and runs on two AA batteries—stays with the patient to ensure a comfortable recovery at home. "An important feature of the ambIT pump is that the patient is in control of their own pain medication. If they begin to feel pain, they can press a button on the pump and get more medication,” said Williams.

Medicare to Expand Diabetes Prevention Services in 2007

In 2005, Medicare expanded coverage for preventive services to include diabetes screening. Starting January 1, 2007, Medicare will provide more coverage for services that affect people with diabetes. Medicare is increasing payments to doctors for some of the most frequently billed face-to-face doctor/patient services, as well as
expanding access to rural and underserved areas.

http://www.cms.hhs.gov/partnerships/downloads/diabetesupdate.pdf

Source: CMS

Query: Non-Healing Stress Fracture

A healthy 35 y/o female presented after two years of treatment of a stress fracture of the second metatarsal. Palpation of the dorsal aspect of the bone was tender. Initial treatment by me was a surgical shoe with Plastazote to accommodate the bone. A bone scan demonstrates increased uptake at the tender area at the diaphysis of the metatarsal. Foot orthoses were made with a forefoot extension. A bone stimulator was instituted.

A recent MRI demonstrated mild inflammation at the site of the chief complaint, consistent with a healing stress fracture. Recent x-rays were compared to ones that I took when she first presented in June, 2006, and shows little to no changes: The x-rays demonstrate a remodeled cortex along one edge, consistent with a remodeled stress fracture. Labwork was WNL.

Current symptoms consist of pain after an hour shopping in the mall, with edema over the tender area, which resolves overnight. She has requested surgery to “solve” the problem for the past three months. Any suggestions?

Jay C. Goldstein, DPM, Portland, OR

Query: Reattachment of the Achilles Tendon

What is the proper code for the reattachment of the Achilles tendon with a washer/screw?

T.J. Miller, Office of Lawrence Gaston, DPM, Lawrence, KS

Response: The code for repair of an Achilles tendon would be CPT 27650 or CPT 27652 or CPT 27654 depending on whether it's a primary or secondary repair. The use of a screw/washer over any other fixation/attachment is included in the repair and not separately reimbursed or a code determining factor.

Tony Poggio, DPM, Alameda, CA

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

RE: James Levitt, DPM
From: Warren S. Joseph, DPM

I am devastated to learn of the death of Jim Levitt in the crash of his airplane. Jim was not only a former student of mine but a fellow pilot. He traveled all over the US in his Bonanza and we saw each other frequently at meeting where we would spend lots of time "hanger flying" (when pilots get together to talk airplanes and flying). He was a serious pilot who used his plane not only for personal enjoyment but also to the benefit of his patients, many of them being Native Americans at outposts that no other podiatrist could or would serve. I will sorely miss both his dedication to the profession and the times we had talking about a shared passion.

Warren S. Joseph, DPM, Huntingdon Valley, PA

RE: Closing 1st MP Pressure Ulcers (Robert Teitelbaum, DPM)
From: Multiple Respondents

The key to closure of these wounds lies in the etiology: “pressure”. Assuming the other wound healing parameters (diabetes control, nutrition, circulation, wound care) have been adequately addressed, these wound will not generally progress to full epithelialization without proper offloading of pressure. This may be as simple as a modified wedge healing shoe or it may require complete off-loading (I would typically use a short leg cast with a cast caliper attached). Offloading and lower extremity biomechanics has been Podiatry’s forte and what makes us the very best at treating these wounds.

Tim Vogler, DPM, High Point, NC, Timothy.Vogler@cornerstonehealthcare.com

Robert Teitelbaum, DPM, Naples, FL

Be sure to check to see if the patient has an equinus. Even a small degree of equinus can cause a forefoot ulceration to stay open, irregardless of interventions. A percutaneous tendo-Achilles lengthening usually does the job nicely, with minimal surgical intervention. Jeff Johnson, MD and David Sinacore, PT out of Washington University in St. Louis wrote about it in the mid-90s and I believe David Armstrong wrote about it as well.

Kathleen Satterfield, DPM, San Antonio, TX, VKSatterfieldDPM@aol.com

I found at time what works the best for sub 1st MP joint ulcer is a gastronemius recession or an Achilles lengthening. These neuropathic patients have acquired equinus and place a significant amount of pressure under the forefoot. There have been numerous studies done on equinus and the increase risks of forefoot ulcers in diabetic patients. I prefer a gastrocnemius recession and cam walker for 6-8 weeks minimal weight-bearing with crutches and a walker.

Francois M. Harton DPM , Holland, MI, fharton@chartermi.net

If equinus is present, consider a TAL to reduce the forefoot pressures. A pecutaneus TAL procedure can easily be done in the office under local anesthesia in the presence of neuropathy. There are several published studies to support this treatment, if indicated.

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

Two plausible causes of the problem are 1)An underlying pathology which prevents healing in that area such as peripheral vascular disease or a certain form of neuropathy. 2) Abnormal biomechanics or osseous pathology resulting in abnormal pressure beneath the first MP. Both are most likely present.

I had a patient with an ulceration in the same location The patient’s vascular specialist adequately addressed the circulatory problem. We ruled out osteomyelitis via appropriate testing and yet we could not get the ulcer to totally close. We then approached the pressure beneath the first MP in two phases. We first dispensed one of the shoes with inserts with plugs that could be removed to accommodate the area of ulceration. There are at least two companies that make these devices. When the ulcer was almost closed we switched the patient to a bulky accommodative orthotic with a cut out beneath the first met head and a build up behind it. We also added a rear foot valgus post to further offload the area. This combination worked however the area healed and ten reulcerated and this was attributed to the fact that the patient was not totally compliant with the use of the orthotic. My secretary saw him walking outside with sandals and he even came to the office without the orthotics and load of excuses. Tough love counseling which consisted of graphically conveying the worst possible scenario eventually convinced the patient to comply and the ulcer closed.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

First I would suggest coming up with a reason for the ulcer—neuropathy, nutritional, structural, etc Of course one should treat the underlying cause as well as you can and use the “team” approach---BUT---When I have been faced with this problem it has usually been –in a large part due to patient compliance. In this case, my rule is to protect the patient from themselves. I have found a multilayered adhesive felt pressure off pad applied directly to the entire plantar aspect of the foot, offl-oading the area to be quite effective. You can apply a Coban or other cover and leave a window for wound care.

Tip Sullivan, DPM, tsdefeet@msfootcenter.net

RE: Post-op Nail Care (Gene Graham, DPM)
From: Jeffrey A Petrinitz, DPM

Iodosorb gel a Healthpoint product is excellent at drying wounds. This is a bead similar to Debrisan beads that have the ability to absorb drainage, many times greater than its own weight. As it absorbs drainage it emits elemental iodine, killing any localized bacteria. Another inexpensive option is Polysporin in powder form. Just have the patient sprinkle on the wound bid after cleansing with soap and water.

Jeffrey A Petrinitz, DPM, Greensboro NC, jpgroks@yahoo.com

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ASSOCIATE POSITION - CENTRAL CALIFORNIA

Central California multilocation practice looking for PSR-36 associate leading to partnership. PSR-36 trained podiatrist with great opportunity for reconstructive surgical practice. Practice has Medicare-approved surgery center. Must have excellent interpersonal skills. Excellent salary and incentive. Respond to: westsidefoot@yahoo.com

ASSOCIATE POSITION – VANCOUVER CANADA

Associate superb opportunity- beautiful Victoria, BC, Canada- multi office ,future buy-in. Full scope Podiatry Write Dr.Cole@shaw.ca.for further details. Exam given in June 2007.

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