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December 06, 2006 #2,758 Editor-Barry Block, DPM, JD

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Medicare Cuts Will Affect Practice: TX Podiatrist

Podiatrist Paul Valenza said Medicare cuts also affect his practice. Because his patient mix only includes about 50 percent Medicare patients, he’s able to diversify, provide additional services, and treat younger patients, most whom have health insurance.

Dr. Paul Valenza

With more than 24 percent of the county’s population age 65 or older, this issue should be a concern in the Kerrville area, Valenza noted.

Source: Alison Beshur, Kerrville Daily Times, [12/2/06]

Scholl’s CLEAR Impact at International Neuropathy Symposium in South Africa

Scholl’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science played a significant role at the 7th International Symposium on Diabetic Neuropathy in Cape Town , South Africa , last week. “The advances being made in this area are picking up pace and are verging on the breathtaking,” noted Professor David G. Armstrong, Director of CLEAR and Associate Dean at Scholl College.

Prof. Andrew Boulton, Univ of Manchester. Prof. Aaron Vinik, symposium chair, and Prof. David Armstrong

The Symposium featured speakers from five continents, and covered cutting-edge topics ranging from gene transfer therapy to the genomics of nerve damage. Prof. Armstrong was honored with one of only five plenary lectures at the symposium and the only on wound healing and prevention. “What really energized me," noted Armstrong, "was to see other podiatrists from the USA , such as Andrew Rader and Tim Barry, attending and presenting. I think it further highlights the migration that we are seeing in this area of study, specifically, and this profession in general.”

Stark Describes P4P AS ‘Offensive’

Rep. Pete Stark (D-CA) called pay-for-performance initiatives “offensive” and said Medicare should boot hospitals and physicians from the program if they don’t meet the highest standards of care, rather than reward them when they do. Stark, who is likely to become chairman of the House Ways and Means health subcommittee, was speaking at the National Committee for Quality Assurance’s policy conference Dec. 1.

Rep. Pete Stark

In contrast, acting CMS Administrator Leslie Norwalk said pay-for-performance efforts are an important part of the CMS’ plans to pay for care more intelligently. Norwalk also touted increased Medicare coverage of preventive services, like cancer and diabetes screenings.

Source: Matthew DoBias, Modern Healthcare [12/4/06]

Query: Cutaneous Fibromatosis Considerations

I have a patient w/multiple cutaneous fibromatosis and MVP. She has severe hallux valgus and 2nd hammertoes bilateral. Due to her deformities she requires custom-molded shoes, but would refuses to wear them. A few weeks ago I performed a deep I&D on her second toe which had a deep infection, which healed uneventfully. I am planning to perform an arthroplasty of her second toe. At some point in the future she will also require a bunionectomy with metatarsal osteotomy.

I am planning to stage these procedures because I wish not to open a closed sterile area. She has been cleared for surgery with the usual requirement for pre-operative antibiotic prophylaxis for her MVP. Is there any medical contraindications to surgery due to her fibromatosis and/or any additional post-operative treatment she should receive?

Paul Kesselman, DPM, Woodside, NY

2007 Medicare Fee Schedule Posted

The 2007 Medicare Physician Fee Schedule was published on Friday in the Federal Register. You can access the Federal Register at:

http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/06-9086.pdf

This is a very large file, and will take several minutes to open - have patience.

I would strongly suggestion when it opens (in a pdf format) you click on the "Save a Copy" button (and save the file to your Desktop) allowing you "instant" access to this valuable information.

All the 2007 RVUs for services and procedures are listed, as well as their assigned global days.

Harry Goldsmith, DPM, Cerritos, CA

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

RE: “Floating” Toe Post-op Osteotomy (F. Don Chantiles, DPM)
From: Lowell Weil, Jr., DPM, MBA, David Secord, DPM

For sure, the most common complication follow the Weil osteotomy is the "floating toe." The literature has identified this condition anywhere from 15-25%, depending on the surgeon. When we presented our long-term studies of the WMO at the Orthopedic Foot and Ankle Society Summer Meeting several years ago, we related a 12% incidence of this problem. There are many different theories as to why this happens from excessive shortening to plantar translation of the capital fragment which puts the intrinsic musculature into a disadvantageous position to scar tissue formation/capsular adhesions at the dorsal MPJ.

Barouk recommended modifications to the osteotomy in cases of shortening greater than 2-3 mm. whereby one takes out a proximally based wedge of bone to elevate the capital fragment and plantarly rotate the capital fragment to put the toe in a more weight-bearing position.

Preventatively, we use early and aggressive PT started at 1 week post op. When the problem occurs (now about 5-8% of the time), manipulation under IVA of the MPJ usually sufficiently eliminates the problem with an occasional T&C of the joint being necessary.

Lowell Weil, Jr., DPM, MBA, Fellowship Director, Weil Foot & Ankle Institute, WeilJr@aol.com

Although I do the procedure and have never seen this happen, a good explanation of the cause and effect of this is explored in the June, 2006 issue of Techniques in Foot & Ankle Surgery (Vol. 5, No. 2). In this volume is an article entitled “Lesser Metatarsal Osteotomies in Metatarsalgia”, by Christopher W. Hodgkins, MD, Martin J. O’Malley, M.D., Andrew J. Elliott, M.D, and John G. Kennedy, M.D. In this article they cover (among other things) the Weil osteotomy for metatarsalgia treatment.

On page 105 is a depiction of the osteotomy and the text explains the work of Trnka, et al. on cadaver studies of the Weil and the change in the center of rotation of the metatarsal/phalangeal joint and the resulting action of the intrinsics at dorsi-flexors rather than plantar-flexors and resulting ‘floating toe’ syndrome. To prevent this, they recommend:
1. extensor tendon lengthening
2. making the osteotomy parallel with weight-bearing
3. considering a flexor to extensor tendon transfer
4. insertion of a temporary K-wire across the digit and into the metatarsal head at 5º of plantar-flexion.

Also mentioned are the studies by O’Kane and Kilmartin and Migues, et al. on the incidence of ‘floating toe’ with the Weil. No hints were given as to the approach or treatment if you get a 'floating toe' after the Weil, but certainly, a Girtlestone would approach this well.

David Secord, DPM, David5603@pol.net, Corpus Christi, TX

RE: A Picture is Worth 1,000 Words (Kevin Kirby, DPM)
From: Multiple Responses

Unfortunately, that image in Dr. Kirby's photo is the cruel reality. The doctors design a perfect orthotic and the main point is that plates are not going to go in a perfect foot. So what we do orthotics?. Maybe we must to plan an ortothotic inside a terrible shoe...

Dr. Marta Losa Iglesias (Spain) marta_losa_iglesias@hotmail.com

We, as podiatrists, have argued against the use of high-heeled shoes for a considerable amount of time. Despite these efforts, over 800,000,000 of these type of shoes will be sold in 2006 worldwide, with approximately 300,000,000 of these purchased in the US. Since women continue to buy these shoes in huge numbers regardless of the health hazards, the need to make these less deleterious would be a reasonable compromise.

Insolia®, a product developed by a company I co-founded in 1998, is a new insole which can be used in any women's higher heeled shoe, boot or sandal to improve comfort. It functions by creating a weight shift within the shoe, balancing the center of force rearward and off the ball of the foot. Insolia was granted the APMA Seal of Acceptance earlier this year. It has been available from the company via the www.insolia.com for over a year and has received very positive response by women. The product will be at retail in most CVS stores nationwide in early January, 2007.

Howard J. Dananberg, DPM, Bedford, NH, howiedbpg@aol.com

Even though I don't agree with Dr. Shavelson's "trademarking" of foot types, I do agree with his point that "we should be seeking a paradigm change in biomechanics that exists outside of the Root box." From attending many of Dr. Root's lectures during my early career, it was never my impression that Dr. Root wanted his podiatric colleagues to stop thinking about biomechanics and stop creating new ideas after he coauthored his last book in 1977. I believe he felt that he was laying a foundation for the growth of a scientific discipline, podiatric biomechanics, which would improve the ability of podiatrists to effectively treat mechanically-based pathologies of the foot and lower extremity.

With that in mind, I strongly disagree with Dr. Mullen's comment that "the classic bio-mechanics textbooks do not require re-invention." That would be like saying that “the classic surgical textbooks do not require reinvention." In fact, my biggest problem with this comment is that it reminds me of the embarrassing fact that a large proportion of the podiatric profession has stopped trying to learn about biomechanics since they feel that they have "already learned it all" by reading the works of Root and coworkers nearly 30 years ago. They can’t seem to accept the fact that many of the theories taught by our podiatric biomechanics forefathers are not supported by research, are not theoretically coherent and, as a result, are less frequently being taught in podiatric educational institutions around the world. It is about time that the podiatrists of this great country started opening their minds to the wonderful world of scientific research of the international foot and lower extremity biomechanics research community so that we can remain as leaders in the treatment of foot and lower extremity mechanical pathologies for generations to come.

Kevin A. Kirby, DPM, Sacramento, CA, kevinakirby@comcast.net

Editor's note: This topic is now closed

ASSOCIATE POSITION--PHOENIX SUBURB

Attractive opportunity for enthusiastic, proficient, and personable associate. Well-established modern practice with multiple newer spacious offices, technology and equipment. Solid referral base, close to hospitals, knowledgeable certified staff. 22% MCR. Practice and surgical center partnership potential opportunity. Prefer 24-36+ PSR. Send CV: AZpodassociate@aol.com

ASSOCIATE POSITION - LOS ANGELES/SOUTH BAY AREA

Multi-office, multi-doctor, well-established practice near the beach cities. Seeking a board eligible/certified PSR-24 or PSR-36 trained foot and ankle surgeon. Well-rounded practice requiring knowledge in biomechanics, pediatrics, sports medicine, diabetic wound care, trauma, and reconstructive foot and ankle surgery. Full-time position available immediately with generous compensation and benefits, including malpractice, and health insurance. Two-year commitment required with partnership opportunity. Send CV to akemfoot@sbcglobal.net or fax to (310) 838-0027.

ASSOCIATE POSITION - CENTRAL CALIFORNIA

Central California multi-location 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- MEMPHIS, TN

30 year-old, high volume, multi-office practice in Memphis, looking for 24-36 PSR trained individual. Good opportunity for reconstructive surgery and wound care. No nursing homes or weekends. Potential partnership opportunity. Contact Footdok4@gmail.com.

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