The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

December 13, 2006 #2,764 Editor-Barry Block, DPM, JD

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Holiday Shopping Can Lead to Foot Pain: NH Podiatrist

“This time of year, arthritic conditions are exacerbated by holiday shoe wear,” said podiatrist Dr. Howard Bonenberger of the Ankle & Foot Center in Nashua. “In January and February, there’s a rise in the number of stress fractures from walking, 10 a month to 18 to 20 a month.”

Bonenberger, whose specialty is treating bone, joint, muscle and nerve problems in the foot and ankle, said walking in high heels on a hard surface for extended periods may lead to stress fractures, small cracks in the inner part of the bone, typically the metatarsal or long bone at the base of a toe, near the ball of the foot. If the stress continues, it may affect the stronger, outer part of the bone.

The sufferer generally experiences pain and swelling over the top of the forefoot, a condition that requires professional attention, the doctor said. To avoid stress fractures, common in women who wear high heels for long periods, Bonenberger offered a simple strategy: change shoes and heel heights during the day and wear sneakers to the mall.

“On the way to the party, or at home, alternate shoes,” the physician said. “If you’re going shopping after work, take your walking shoes. At the end of a long day at work, take five or 10 minutes and put up your feet at your desk.” To relieve aching feet, apply cold compresses and take over-the-counter anti-inflammatory drugs, Bonenberger said, reminding anyone with an aspirin allergy to avoid those drugs.

Source: Hattie Bernstein, Nashua Telegraph [12/11/06]

Alleged Misdiagnosis - Cancer Wrongful Death (Michigan)

FACTS: The estate of a patient who died from a rare form of cancer alleged the man's death was due to negligence of the man's treating podiatrist. Plaintiff claimed defendant violated the standard of care, but the jury disagreed with that argument and returned a verdict in favor of defendant.

Plaintiff's decedent, 59 year old Walter Chapton, presented to defendant podiatrist in May 2000 with a 3 cm. lump on the top of his right foot. Defendant diagnosed the lump as a ganglion cyst and was able to aspirate only a small amount of fluid from the lump. Defendant injected the lump with corticosteroids. Chapton returned to see defendant two weeks later. Defendant's notes indicated the cyst was somewhat decreased in size and he told decedent there was no need to undergo further treatment unless the cyst got bigger, became painful or changed in color. On May 17, 2001, Chapton returned to defendant as the lump had grown to 4" to 5" in length and 3" in diameter over the previous several months. Defendant recommended its removal, which was not accomplished until July 18, 2001. Pathologists identified the mass as a high-grade myxoid chondrosarcoma (cancer), for which surgery was futile as the cancer had already metastasized to Chapton's lungs. Chapton died in May 2002.

Plaintiff's experts opined that, had the cancer been diagnosed in or around May 2000, Chapton's chances of survival were 80% to 90%. However, when the diagnosis was made in July 2001, his survival chances were zero. Plaintiff alleged that, because defendant was unable to aspirate much fluid from the mass in May 2001, the standard of care required further testing, such as an MRI, ultrasound, or CT scan, or referral to an orthopedic surgeon.

Defendant contended that, despite retrospective knowledge that the diagnosis was incorrect, it was not a violation in the standard of care to miss the cancer. He claimed he was not negligent because primary cancerous lesions to the foot, , particularly chondrosarcoma, are extremely rare.

RESULT: Defense verdict

PLAINTIFF EXPERTS: Jonathan A. Haber, DPM, Caldwell, NJ, Charles F. Fenton, III, DPM, JD, Atlanta, GA, J. Sybil Biermann, MD, Ann Arbor, MI, Michael J. Kraut, MD, Southfield, MI

DEFENDANT EXPERTS: Charles G. Kissel, DPM, Warren, MI, Marshall Solomon, DPM, Farmington Hills, MI

Source; The Michigan Trial Reporter

Some Raise Concerns About Quality-Of-Care Reporting

The approval by the 109th Congress of a bill (HR 6408) that would maintain the current level of Medicare reimbursements to physicians for 2007 and provide a 1.5% increase in reimbursements to physicians who agree to report data on certain quality-of-care measures "immediately raised concerns among some doctors and lawmakers who specialize in health issues," the New York Times reports.

Under the bill, physicians beginning July 1, 2007, would qualify for a 1.5% bonus if they report to the government certain data on the quality of their care, such as how often they prescribe certain medications to heart attack patients or how well they manage blood pressure in patients with diabetes. Medicare officials say the data will allow the
government in the "near future ... to reward doctors who follow clinical guidelines and perhaps penalize those who flout such standards without justification," the Times reports.

According to the Times, the passage of the bill has raised concerns among lawmakers from both parties, including some Republicans who "support the general idea of pay for performance." Critics of the legislation are concerned about the idea of "federal agencies setting benchmarks for care," as well as the "feasibility of developing standards for hundreds of thousands of doctors within six months," the Times reports.

Source: NY Times Via American Health Line [12/12/06]

Query: Billing Software for Mac

We are currently using an old, unsupported Mac-based billing program: SoftFoot. We will need to upgrade soon in order to support the new HCFA claim deadline April 2, 2007. Can anyone recommend a billing program that can support this change?

Tisha Ragsac, Office Manager, Salinas, CA

Query: Neuroma Etiology/Diagnosis

Could one developed a" neuroma" from trying on and walking in a pair of high shoes for just 5 minutes, and if so, would the pain of the neuroma be immediate or could it arrive two days later? Would ultrasound show if the neuroma is present?

Holly Xerri, DPM, Oceanside, NY

RE: Mosaic Verrucae (Steven Schutzbank, DPM)
From: Jennifer Ryder, DPM, Randall Brower, DPM,

I use Adapelene qd to help with hyperkeratotic buildup and Aldara (imiquimod) every other evening for 16 weeks with good results. If there is a lot of hyperkatosis then this combination doesn't work as well.

Jennifer Ryder, DPM, Rapid City, SD, jenbenryder@yahoo.com

I debride verrucae to pinpoint bleeding, if the patient can tolerate it. I then apply trichloracetic acid, followed by duct tape. The patient is instructed to remove the duct tape 2-3 times/week and apply over-the-counter salicylic acid then reapply the duct tape. I see patients back in 2 week intervals. If after 6-8 weeks we see no improvement, I take them to the OR, resect the verucca(e) and use a Holmium/YAG laser to ablate the basement membrane and rim. I have 100% success rate with this laser (not CO2 laser). The only downside is the fact that the patient has to undergo outpatient surgery. Usually kids respond better to the duct tape/acid treatment.

Randall Brower, DPM, Roswell, NM, randoman33@yahoo.com

RE: Neuroma Release Vs. Excision (Marc Katz, DPM)
From: Peter J. Bregman, DPM, Barry Mullen, DPM

The surgical use of neurolysis or decompression has been around since the dawn of carpal tunnel surgery treatment as has proven to be safe and effective. For Dr. Katz to surmise that by super freezing a piece of tissue adjacent to a small nerve which theoretically should damage the adjacent nutrient artery is safer then cutting a ligament is a stretch to me. There are a plethora of papers discussing the use of decompression for treatment of nerve entrapments which is what a Morton's neuroma is.

If it were a true neuroma, then I might be inclined to try cryotherapy for a truly damaged nerve. Since there is only one person who has predominantly wrote about this (Dr. Goldstein) who I understand has a financial interest in this therapy, I would need more convincing.

As for cortisone being a noxious substance, that is hyperbole! It is used everyday by thousands of doctors in every specialty. When used judiciously and wielded properly, it is a great tool. I never implied that endoscopic nerve decompression was non-invasive, however, it is minimally invasive. If properly performed the complication rate is low and success rate high. As for AM surgical, I am not saying that you need to do the release endoscopically open is just fine but has slight increase in morbidity. Also, to be fair I have been paid to speak for AM surgical on one occasion as Region One conference. I happen to think their equipment is the best.

Peter J. Bregman, DPM, Wilmington, MA, Footdoc@PAINFREEFEET.COM

Endoscopic release for interdigital neuroma = 90% success? Comparing this technique physiologically to the decompression techniques utilized for other peripheral nerve entrapment syndromes, ie. TTS? Am I missing something here? A major flaw exists with this logic? In true peripheral nerve entrapment syndromes, like TTS, isn't it extremely rare that the involved peripheral nerve, i.e., PT, and its branches, have undergone obvious macroscopic damage through excessive fibrous tissue engulfment?

However, isn't this almost always universally observed with true post- traumatic inter-digital neuromas, whether post acute trauma vs. the more common chronic repetitive micro-trauma? If this "theory" is accepted, how could one then expect a return of normal nerve function and elimination of neuritic pain via endoscopic release? Releasing the inter-metatarsal ligament, in this case, still leaves one with a fibrous encased, permanently damaged digital nerve, while potentially creating long term inter-metatarsal/digital instability.

Conversely, decompression of an entrapped peripheral nerve, which still has retained its normal architecture, should be expected to yield consistent positive results. Physiologically, simply releasing the inter-metatarsal ligament and expecting a damaged digital nerve to respond just doesn't make sense to me. Therefore, I must question those who claim such high success rates and welcome input from other colleagues with extensive experience utilizing this technique for this pathology. I believe endoscopy certainly has its place in podiatric surgery, I just don't see working consistently for this pathology.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

Editor’s Note: This topic is now closed

o Coding Toe Fillers for Shoes
o Coding a Lateral Hemiphalangectomy
o CPT 64450 Denial
o Criteria for Non-Invasive Arterial Testing
o Post Surgical Follow-Up Billing

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EQUIPMENT WANTED – USED X-CELL X-RAY UNIT

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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 - 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) 838-0227.

PRACTICE FOR SALE – NEW YORK

20 Year practice by-the-sea in beautiful Long Beach, NY. Excellent Terms. E-mail seashell554@aol.com or (516) 432-7300.

ASSOCIATE POSITION – NEW YORK CITY

Looking for an enthusiastic well-trained foot and ankle surgeon to join busy Manhattan/Brooklyn practice leading to partnership. Candidate must have completed a minimum two-year surgical residency program, demonstrate qualities of self-motivation and have impeccable skills in forefoot and rearfoot surgery. Package includes malpractice ins. health ins. plus salary. Terms negotiable. Email Manfootcare@aol.com or call 917-756-3686

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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