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December 24, 2008 #3,433 Editor-Barry Block, DPM, JD

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CA Podiatrist Fuels His Passion for Sports Medicine

For distance runner, mountaineer and adventure-seeker Dave Hannaford, his elite sports podiatry practice fuels his passions. Hannaford isn't sure what his next adventure will be. But there's a good chance the idea for it will come walking through his office door any minute now.

Dr. David Hannaford

Hannaford, a veteran ultra-distance runner and mountaineer, has climbed many of the world's tallest peaks and conquered some of the toughest footraces on the planet, including a remarkable third-place finish in the 2002 Badwater Ultramarathon - his first and only entry in the brutal, 135-mile race through Death Valley.

But as you sit in the waiting room of his sports podiatry office in Terra Linda, the walls covered with mementos of sporting accomplishments, it's clear that Hannaford's athletic feats almost pale in comparison to the amazingly self-sustaining ecosystem he's created for his passions and his profession. He treats elite athletes, having developed a reputation as one of the Bay Area's experts on running-related injuries.

Source: Jim Welte, Marin Independent Journal [12/21/08]

NY Podiatrist Wins Tim Gullikson Spirit Award

Dr. Albert Musella of Hewlett, NY has been selected as recipient of the Tim Gullikson Spirit Award. The Tim Gullikson Spirit Award is presented to a brain tumor patient, caregiver, volunteer, corporation or benefactor who embraces the fighting spirit and positive attitude that Tim used to battle -- and live with -- brain tumors, and in doing so, give hope to others. It recognizes someone who has shown extraordinary and unique courage, resourcefulness or ingenuity in battling the disease, or a person who shows an extraordinary effort to help fulfill the goals of the Foundation to assist brain tumor patients and their families as they cope with the illness.

Dr. Albert Musella

Musella is president of the Musella Foundation For Brain Tumor Research & Information, Inc, and webmaster of virtualtrials.com, an award-winning website for clinical trials and noteworthy treatments for brain tumors. Musella’s foundation has raised over a million dollars for brain tumor research. Additionally, he serves as webmaster for Podiatry Management Online and PM News.

Query: Brasseler Microline Hand Power Surgical Equipment

Does anyone know of a U.S. Company that either sells the Microline or fixes these units? The original Manufacturer, Brasseler, sold the line to a UK Company, DeSouuter. Are there similar handpieces made by another manufacturer that distributes their brand in the US?

David J. Freedman, DPM, Silver Spring, MD

Query: Coding Amputation and I&D

A patient with diabetes presented with gangrene and a deep space abscess. She required partial amputation of the 5th ray (toe and most of the 5th metatarsal), as well as extensive soft tissue debridement including I&D of a deep space abscess. How would this be coded?

Michael Fein, DPM, Bethel, CT

Response: With any amputation, there is some expected debridement of tissue. The question is how much would be included in the allowance for the amputation? The answer depends on the location, the independence of the debridement from the amputation, extent of debridement, and, of course, support for two separate procedures within your operative report description.

I would code the procedure CPT 28810-52 (amputation, metatarsal, with toe, single; reduced service since the entire metatarsal was not removed).

If you feel that significant debridement was required - beyond anything expected with the amputation - you could try to also bill CPT 1104x, but be ready for payer denial. No separate allowance would be warranted for an incision and drainage in the same site as the bone removal.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found here

RE: Severe Bromhidrosis (Birute Balciunas, DPM)
From: Multiple Repondents

Bromidrosis (bromhidrosis - both spellings are correct) results from bacterial action on footwear leather due to moisture from hyperidrosis. A patient can keep their feet meticulously clean, but as soon as the feet are placed into the shoe, the feet pick up the odor from the leather. The reason the odor is not as bad in the patient's sneakers is there is less bacterial reaction with canvas. The problem needs a two-fold approach. First, the feet have to be kept dry. Try Certain Dri Anti-Perspirant Pads or any OTC anti-perspirant. A very effective one is Mitchum Roll-On.

Next the shoes have to be attacked. The odor must be removed from the footwear. Try Bromi-Talc Plus Powder manufactured by Gordon Laboratories in Upper Darby, PA. It is by Rx only. It contains a substance called abscents, which is a potent deodorizing powder. This powder usually can get rid of most odors. If, after putting the Bromi-Talc Plus powder into the shoes and the odor in the shoe persists, the shoes must be discarded. Gordon Labs also makes another non-Rx powder called Bromi-Talc. It does not contain abscents and won't deodorize the shoes.

Mike Boxer, DPM, Woodmere, NY, mcbdpm@aol.com

I suggest you start patient with 20% aluminum chloride solution for twice a day. Patients need to also soak with diluted Bromo-Soak powder once a day. In this case, we should also look into the underlying problem causing this severe condition. Check for any excessive perspiration on other areas besides the feet, e.g., palm, underarm, groin areas. If other areas of the body have the same condition, work up for hyperactivity of sympathetic system by referral to a neurologist.

Helene T. Nguyen, DPM, Hackettstown, NJ, htnguyen@feetnbeyond.com

You have addressed only the hyperhidrosis element of the problem but not the microbiological component. Add to his treatment regimen the use of an antibacterial soap such as Betadine or hexachlorophene twice daily. This should increase your chance for success.

Joel Lang, DPM (retired), Cheverly, MD, langfinancial@verizon.net

RE: Benfotiamine Shown to be Efficacious in Treating Diabetic Peripheral Neuropathy (Michael Turlik, DPM)
From: Multiple Respondents

With all due respect to Dr. Turlik’s analysis, I believe what matters is real life. I see results equal or better to prescription drugs for neuropathy using benfotiamine. I believe there is a place for both types of treatments. Really, there are few studies available for most treatments performed in our offices each day. However, we successfully treat patients and the studies have minimal relevance. As a matter of fact, I could take most studies and distribute them to 10 researchers and there would be multiple problems found.

We should base out treatment on our expertise as physicians and what is best for patients. We can use studies for what they are worth, a guide. Just because insurance companies care about studies, this should not change our treatment plan.

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

I acknowledge Dr. Turlik for his critical evaluation of the paper on benfotiamine’s efficacy. He shows how we can be misled by poorly-written papers that have entered the literature. Without his critical analysis, many of us could be hoodwinked by sales reps and corporate-sponsored speakers who might try to convince us that evidence-based medicine supports the use of this dietary supplement in all cases of diabetic neuropathy.

I have another question about the use of benfotiamine, which is a lipid-soluble form of thiamine or Vitamin B1. Why not take a simple blood test and see if the patient has a thiamine deficiency before giving the patient a thiamine supplement? Thiamine deficiencies definitely can cause peripheral neuropathy, but If there is no evidence that the patient has such a deficiency, putting the patient on benfotiamine is really practicing hocus pocus rather than evidence-based medicine.

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

I think this represents an over-simplification of the condition. Neuropathy is a complex, multi-factorial syndrome. It is more than the absence of a B vitamin derivative. I believe the best we can say is that benfotiamine may be one part of a complex protocol that shows efficacy in the treatment of neuropathy. It is important to identify and address all mechanisms whenever treating any pathology. For this reason, relying on one nutrient as "the treatment" for any condition is foolhardy. Likewise, evaluating one nutrient as a protocol and dismissing it as non-efficacious is short-sighted and unfair to the big picture.

Bob Kornfeld, DPM, Lake Success, NY, Holfoot153@aol.com

RE: Cuboid/Peroneal Pain (Mark Aldrich, DPM)
From: Ira Meyers, DPM, Jeffrey Trantalis, DPM

I see this a lot in runners. It usually occurs after a hard workout or race or after changing from old to new shoes. High dye strap with Elastoplast and Theraband exercises usually work within 1-2 weeks. If easily accessible, I'll add modality PT-elec stim, ultrasound. Massage and gentle manipulation help as well. For a first time occurrence, I only recommend orthotics if the biomechanical exam warrants it. This is strictly a history and exam diagnosis. I have had many patients (including myself on my first bout) think it was a stress fracture. However, there is usually minimal edema and only occasional pinpoint pain. But, ambulation is quite painful. X-rays are normal, and since pain usually resolves in 1-2 weeks, I rarely need to order other diagnostic studies.

Ira Meyers, DPM, Philadelphia, PA, idmrun@aol.com

I do not want to get involved with the didactic biomechanical dissertation presented by the previous doctors. One should consider the possibility of a hypermobile cuboid or subluxed cuboid. The pain across the arch with migrating symptoms are consistent with the diagnosis. There are occasions when plantar fasciitis diagnosis is made when it is the peroneal tendon involved The peroneal tendon is not tracking correctly in the peroneal groove. No orthotic or shoe will help if the cuboid is out of alignment. A very simple test is to have the patient make a circle with her foot both clockwise and counter-clockwise. If there is a limitation in motion, you have made your diagnosis. This is 100% for the diagnosis when presented.

Jeffrey Trantalis, DPM, Deerfield Beach, FL, Greek333@aol.com

ASSOCIATE POSITION - CHICAGO AREA

ASSOCIATE POSITION -SOUTHERN NEW JERSEY

I’m looking for podiatrist who wants additional practice hours. Perfect for combining your own practice with an additional income. Must be on Aetna Insurance, Horizon Blue Shield, Medicare, and most commercial carriers. I am looking for someone who has a desire to learn how a very successful practice is run, so that I will be able to have time away from my practice. The payscale is based on straight Commission. Could lead to partnership or sale. E-mail contact information, CV, and why you would be perfect for this opportunity. Contact foot.care@verizon.net

PODIATRISTS NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC

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

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds diagnostic and treatment dilemma’s and subtalar stenting from DPM’S. Full reporting with second opinion only, rapid return after care and assumption of care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com

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