The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

December 30, 2006 #2,778 Editor-Barry Block, DPM, JD

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PM News wishes all our readers a Happy & a Healthy 2007!!!

We ask all our subscribers to make one of your New Year's Resolutions to add bblock@podiatrym.com to your address books. This will help ensure that you receive all your 2007 issues. Our next issue will be date January 2, 2007.

Preventing Diabetic Foot Ulcer Recurrence in High-Risk Patients

Use of temperature monitoring as a self-assessment tool

Lawrence A. Lavery, DPM, MPH, Kevin R. Higgins, DPM, Dan R. Lanctot, BS, George P. Constantinides, MS, Ruben G. Zamorano, MSW, MPH, Kyriacos A. Athanasiou, PHD, PE, David G. Armstrong, DPM, PHD and C. Mauli Agrawal, PHD, PE

Dr. Lawrence Lavery

Objective—The purpose of this study was to evaluate the effectiveness of a temperature monitoring instrument to reduce the incidence of foot ulcers in individuals with diabetes who have a high risk for lower extremity complications.

Research Design and Methods—In this physician-blinded, randomized, 15-month, multicenter trial, 173 subjects with a previous history of diabetic foot ulceration were assigned to standard therapy, structured foot examination, or enhanced therapy groups. Each group received therapeutic footwear, diabetic foot education, and regular foot care. Subjects in the structured foot examination group performed a structured foot inspection daily and recorded their findings in a logbook.

Subjects in the enhanced therapy group used an infrared skin thermometer to measure temperatures on six foot sites each day. Temperature differences >4°F (>2.2°C) between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized.

Results—The enhanced therapy group had fewer foot ulcers than the standard therapy and structured foot examination groups. Patients in the standard therapy and structured foot examination groups were 4.37 and 4.71 times more likely to develop ulcers than patients in the enhanced therapy group.

Conclusions—Infrared temperature home monitoring, in serving as an "early warning sign," appears to be a simple and useful adjunct in the prevention of diabetic foot ulcerations.

Source: Diabetes Care [January 2007]

Wake Forest Orange Bowl Tackle Plans to be Podiatrist

Wake Forest's 6-4 302 pound offensive tackle Louis Frazier spent yesterday afternoon visiting the Joe DiMaggio Children's Hospital in Fort Lauderdale.

Louis Frazier

The visit was particularly meaningful to Frazier, a junior from Clearwater, FL. He is a biology major, plans to go to medical school, and is hoping to be a podiatrist.

Source: John Delong, Winston-Salem Journal [12/29/06]

Query: DMERC 2007 Medicare Fee Schedule

I was recently asked this this question: What website do you go to for fee codes for DMERC/Medicare services, in general, for 2007?

Response: You may view the fee and codes for your individual carrier on its website. You can find the links for all the DME carriers at:

http://www.cms.hhs.gov/DMEPOSFeeSched/Downloads/DMERC_and_DME_MAC_Contacts.pdf

If you wish to view the fee/codes for all DMERC jurisdictions on one file, this can be obtained on the CMS website,

http://www.cms.hhs.gov/home/medicare.asp

Find the Medicare fee for service link on the right side of the page, and look for the DME Supplies fees link. Upon entering this site you will see a link on the left side for DMEPOS fee schedule. This area will then provide you with numerous files to chose from. The zipped file you need is "D07_JAN.zip" [Excel, Txt, MS Word ZIP, 16MB]. You will need to understand how to use Winzip and Excel to access the one file you need, D07 Jan_xls.

Paul Kesselman, DPM, Woodside, NY

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

RE: Medicare Denial (Daniel Cohen, DPM)
From: Michael Grant, DPM

I went through this same problem back in 1998. I performed multiple surgeries on a limb-threatening infection. I did several aggressive debridements leaving my well-vascularized patient with a nice granulating bed the entire dorsolateral and plantar lateral aspect of his foot. At my hospital, I documented training in harvesting skin grafts, and I was granted these procedures. I harvested a thigh full- thickness graft, applied it, sent to hyperbaric, healed with a partial 5th amputation.

I had the same denials. I had a choice of telephone review or in-person one. I demanded in-person, sent records along with photos. I never heard again for a while. I called for the status and was informed that to have an in-person review I had to have a denial. Their denial was withdrawn and I was paid. .

Michael Grant, DPM, Ft. Wright, KY, DocMikeDPM@cs.com

RE: Orthotics For Skier with Achilles Tendinitis (Edward Orman, DPM)
From: Jack Glick, DPM, Kevin A. Kirby, DPM

Properly made orthotic plates can ease the Achilles tendon strain. Consider the position of the skier as usually tilted forward. Also realize that the ski boot (also the skating boot, and sometimes the biking boot) are usually rigid to help the foot, boot and ski function as a solid unit. The leg is controlled by the position of the torso.

Ask your lab to make a full foot length firm orthotic that will maintain the foot in a heel vertical to the ball of the foot and a 12 degree pitch in the midfoot position when it is in the boot. A well fit boot will not allow room for posting and creating a surface that is inclined (varus or valgus) may be conducive to additional problems. Heel lifts will reduce the Achilles strain. There is no method of measurement, so you will have to "experiment" until you reach the correct amount of lift.

Jack Glick, DPM, AFO LAB, jglick@afo-lab.com

In order to initiate and hold a turn in downhill skiing, the medial edge of the downhill ski must be able to "bite" into the snow to be able to generate sufficient side-ways directed force on the skier's body that allows the skier to make the desired change in direction across the fall line of the ski slope. If the skier's right foot is unable to generate sufficient force from the medial side of his plantar forefoot and then transmit this force through the boot sole, ski binding and onto the medial aspect of the ski, then he will be unable to optimize his left turns.

In general, these skiers will use a relatively mechanically inefficient method of downhill skiing turn compensation by internally rotating and adducting their hip excessively to cause an increased valgus angle of their tibia to the snow surface so that they can then generate adequate medial ski edge pressure to make their turns. A 3/16" polypropylene orthosis with a flat rearfoot post, minimal arch fill, medial heel skive, slightly inverted balancing position, full-length neoprene topcover and slight varus forefoot extension will probably greatly aid this skier in initiating and holding his left hand turns during downhill skiing.

In addition, check for excessive tibial varum on the right leg which may require either an adjustable cuff boot or a varus binding cant. As for the Achilles tendon pain, using heel lifts and three times a day gastrocnemius and soleus stretching exercises, along with twice daily icing therapy generally helps most skiers with this mild to moderate cases of this relatively common disorder.

Kevin A. Kirby, DPM, Precision Intricast Orthosis Laboratory, kevinakirby@comcast.net

RE: Warm, Red Toes (Art Lukoff, DPM)
From: Multiple Respondents

Since the problem is unilateral I would rule out a venous blockage and the order an MRI on the lumbar spine. My money is on a bulging disc.

Gary S. Smith, DPM, Kane, PA, Penndoc@verizon.net

Be sure to rule out cold exposure? I've seen toes with frostbite match that description.

M. Schuh, DPM, Lakewood, NJ, emptyshoe@hotmail.com

In the cases that I have seen, they were all caused by gout or chondrocalcinosis. Pain out of proportion to the stimulus, hypalgesia, is the real clue to the diagnosis. Try colchicine 0.6 mg, three tabs, Sig: one q hour; after 24 hours the erythema will remain, but the edema and most of the pain should subside if it is gout. If you can get joint fluid from a toe joint, you are a better doc than I am; yet it would be the definitive diagnostic tool. If you
have some revelation or x-rays show something diagnostic, I would be glad to read it here.

Jim Fisher, DPM, Eureka, CA, jim.fractal@gmail.com

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 WANTED FOR SOUTH MIAMI AREA

Large group, busy, multi-office, partner potential. Motivated applicants only. Mail resumes and letters of intent to 999 N. Krome Avenue, Homestead, FL 33030. July start time OK, sooner preferable. E-mail lianadpm2@aol.com. I can also be reached at 305-331-4501.

ASSOCIATE POSITION - CINCINNATI, OHIO

One of the largest podiatry practices in the United States is again in need of a PSR 24-36 Associate. All present doctors are in their thirties with similar training. Everyone is treated equally and there is definitely no limit to your success. Please submit resume or contact Karen Roesch via email or phone. Kroesch4poh@aol.com (513) 729-4455

ASSOCIATE POSITION- KANSAS CITY, MO

Excellent opportunity for a hard working, ethical podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Dedicated, supportive staff with strong marketing and medical knowledge. Must be board eligible/certified. PSR/24. Partnership opportunity. Competitive salary, bonus structure, benefits. Wonderful place to raise a family. Fax CV to 816-455-8901

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) 838-0227.

POSITION AVAILABLE - NEW YORK AND/OR NEW JERSEY

Part-time and full-time positions available for any or all of the following office, assisted living facilities, hospitals, and house calls. Please Fax CV to (212)473-8563.

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