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05/03/2019
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Adam Landsman, DPM, PhD
As soon as I saw Dr. Levy's post, I knew it was just a matter of time until somebody came forward to declare that based on this one study, lasers don't work for treatment of onychomycosis. It only took one day. As doctors, we should look at some facts (not sound bites) before deciding what is best for our patients.
FDA: correct that FDA cleared lasers for cosmetic improvement of nails, however this was not due to the fact that laser can't kill fungus, but rather because, they also deemed that onychomycosis is...
Editor's note: Dr. Landsman's extended-length letter can be read here.
Other messages in this thread:
07/30/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Ben Pearl, DPM
I agree with Dr. Jacobs' assessment that commercial driven ideas are often passed off as vetted gait research. In addition to all the direct access “biomechanic solutions” that are directly marketed to patients at online and brick and mortar retail outlets, other specialties have begun to fill the void that has been created by many but not all residency programs and other podiatry seminars. Recently, a friend sent me a popular podcast that featured a chiropractor talking about gait and a strong pitch for the benefits of minimalist shoes. There are physical therapy clinics that have specialty run clinics that also fill the void. Another colleague sent me a course called Gait Gurus that reviews cases and is organized by chiropractors.
When I was consultant at NIH, we used to routinely have a biomechanics PhD, orthopedic surgeon, physical therapist, physiatrist, and me watch a patient walk and collectively make recommendations for treatment. I make it a point to try to video my patients’ gait as much as possible and review it with them.
Hopefully, our profession is past the recognition point that we are being superseded by other commercial entities and specialties and is now making active course corrections to remain relevant in the area of gait.
Ben Pearl, DPM, Arlington, VA
07/30/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Rod Tomczak, DPM, MD, EdD
Dr. Kesselman asks why a podiatrist has never led a team of researchers or published research concerning the correlation between gait and general health. Dr. Jacobs very succinctly states the reason is because we don’t perform a true gait analysis anymore. Besides, it’s difficult to perform a true evidence-based examination in the office. Experience-based maybe, but real objective data is hard to glean from the equipment most podiatrists have on hand. Most reputable journals would scoff at an article submitted with the title, “Too Many Toes Sign and…” or “Wet Foot Impressions on the Floor in Diagnosing Pes Planus and Pes Cavus.”
But Dr. Kesselman’s question addressed why a podiatrist hasn’t authored the study. I posit there are a few reasons. One, a biomechanics paper is simply not as sexy as a supramalleolar osteotomies manuscript. Secondly, podiatry is primarily an action profession, not an...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
04/29/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2
From: Richard Jaffe, DPM
I have been watching the movement to MIS foot procedures for well over 40 years. I always hoped that I could rationalize the negatives and include the technique in my list of available procedures. Now that we have a serious study to help evaluate the efficacy of the technique, I am as steadfastly opposed to it as ever. Twice the complication rate? Twice the rate of a second surgical procedure? And for what? Has it eluded our practitioners that recovery from foot surgery takes much longer for bone than for soft tissue? Pain and swelling come from bone healing, and not much from skin. And the sum of 3 small incisions is almost as long as a scarf incision. So, what are the advantages of MIS?
In the early years, it took only a few minutes to perform the procedure. Indeed, I noticed the first comments made by orthopedists who tried it always...
Editor's note: Dr. Jaffe's extended-length letter can be read here
04/29/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1
From: Ben Pearl, DPM
While the results of the survey are a little surprising, there is an inherent selection bias in that only runners that were not suffering with debilitating knee arthritis would be participating in the Chicago Marathon.
Ben Pearl, DPM, Arlington, VA
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1C
From: Robert Kornfeld, DPM
I graduated NYCPM in 1980. Back then, there was a huge divide between “closed” and “open” surgeons. I did lots of MIS bunionectomies with a Shannon #44 burr in those years. There was no question that the x-rays weren’t always pretty but the patients were happy. But applying MIS to certain levels of deformity was not satisfying. While I spent most of my surgical career doing mainly traditional open surgery, I always found MIS preferable for certain cases.
To be honest, this many decades later, it is surprising to me that there are still “evaluations” of MIS being reported. It has been around for a really long time. It is being performed all over the world. I say let each surgeon choose the technique that is most satisfying in his or her hands. If it did not produce positive outcomes, it would no longer be a surgical option for thousands of surgeons around the world.
Robert Kornfeld, DPM, NY, NY
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Keith L. Gurnick, DPM
A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 months. All used the Shannon burr and performed distal metatarsal osteotomies which needed screw fixation. This review found a 16.6% complication rate with MIS hallux valgus correction, which is higher than that reported in the literature for open procedures of 7% to 8%. Many reasons for this increase in complication rate with MIS hallux valgus surgery can be considered. The hardware removal rate accounted for almost 40% of all complications as is likely due to screw prominence after swelling resolves given the entry point on the medial border of the first ray.
1) The review of 17 studies on MIS bunion using a Shannon 44 burr and screw fixation showed twice the complication rate of...
Editor's note: Dr. Gurnick's extended-length letter can be read here.
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Neal Blitz, DPM
As you know, MIS bunion surgery is a hot topic, game-changing, and no longer the mark of an "inferior surgeon." You might particularly appreciate the parallels I draw between new MIS bunion repair to the history of laparoscopic surgery, which was once considered an "unethical procedure" and now is the global gold standard.
Neal Blitz, DPM, Beverly Hills, CA
01/03/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Elliot Udell, DPM
There is a question that all readers of the abstract will invariably ask. How does the complication rate of the Scarf procedure compare to complication rates of other first ray osteotomy procedures? Has this group done met analyses of other bunion procedures? Does the Scarf procedure have more or less complications as compared to other bunion procedures that utilize an osteotomy?
Another problem which relates to the Scarf procedure and similar types of osteotomies is whether the skill of a particular surgeon plays a role in complication rates. The study of 1,583 cases was not able to determine if the complications they listed applied to all surgeons or to only a handful.
Elliot Udell, DPM, Hicksville, NY
07/20/2022
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Keith L. Gurnick, DPM
This is a wonderful piece of literature to help defend doctors who end up in a lawsuit after Achilles tendon ruptures associated with repeated cortisone injections. They reported no "severe" adverse effects in their study. All patients were injected with either (1) 1 mL of methylprednisolone acetate (40 mg/mL) and 1 mL of lidocaine (10 mg/mL) (corticosteroid injection) or (2) 1 mL of lipid emulsion and 1 mL of lidocaine (10 mg/mL) (placebo injection). No severe adverse events were observed in either group, and there was no deterioration in the long term (2-year follow-up). Patients were offered up to 3 injections with an interval of at least 4 weeks between each injection.
All adverse events, defined as any negative or unwanted reaction to the intervention, were recorded at each physician visit, with special focus on fat atrophy, skin depigmentation, infections, and tendon ruptures. Furthermore, during the intervention period, the patients were asked to register any adverse events in their patient diary, including pain beyond a few days after the injections.
A total of 215 injections were administered (87 corticosteroid and 128 placebo). Injection pain was indicated in the patients’ diaries, with a mean (SD) pain score of 12 (14) of 100 in the corticosteroid group and 14 (17) of 100 in the placebo group, with no significant differences between groups. No severe adverse events (e.g., infection, tendon rupture, subcutaneous depigmentation, or atrophy) were recorded in either of the groups.
Keith L. Gurnick, DPM, Los Angeles, CA
07/20/2022
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Doug Richie, DPM, Elliot Udell, DPM
It is important to recognize that the corticosteroid injections were not administered directly into the Achilles tendon in this study. As noted in the manuscript, the injections were "placed peritendinous anterior to the tendon in the Kager triangle as close as possible to the thickest part of the tendon, or, in the case of neovascularization, as close as possible to the intratendinous vessel(s)."
Doug Richie, DPM, Long Beach, CA
Thank you, Dr. Kass for sharing this article with all of us. What is most interesting is that the paper not only documented "immediate" relief of symptoms but studied the Achilles tendon with ultrasound, and documented that there was no deterioration over two years.
This would seem to give us a green light to treat Achilles tendinopathy with one injection of a steroid. One question that this paper did not cover was whether there is danger to the Achilles tendon by giving multiple, weekly injections of a steroid.
Elliot Udell, DPM, Hicksville, NY
06/03/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2
RE: Peripheral Neuropathy and Sleep Apnea
From: Richard Mann, DPM
Summary: Obstructive sleep apnea (OSA) is a common, independent, and often-overlooked cause of peripheral neuropathy. Additionally, in type 2 diabetics, OSA has been shown to significantly increase the odds of developing peripheral neuropathy as well as increase the intensity of neuropathic symptoms. Treatment of OSA by continuous positive airway pressure (CPAP) may diminish neuropathic symptoms. Physicians should consider ordering sleep studies on those patients suffering from peripheral neuropathy in which OSA is suspected of being a contributing factor.
OSA is a common disorder characterized by recurrent upper airway obstruction during sleep, resulting in intermittent hypoxemia. Its prevalence increases with age. Lajoie, et al. recently reported OSA to have a prevalence of nearly 60% and 40%, respectively, in...
Editor's note: Dr. Mann's extended-length letter can be read here.
06/03/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1
RE: Efficacy of Calcium Phosphate Cementing in the Surgical Treatment of Sanders Type II and III Calcaneal Fractures Using Screw Fixation with Sinus Tarsi Approach
From: Leonard A. Levy, DPM, MPH
Calcaneal fractures are the most common fractures of the tarsal bones and are generally categorized into intra-articular and extra-articular fractures. Non-surgical treatment of displaced intra-articular calcaneal fractures is generally associated with poor results. Therefore, surgical treatment is generally recommended for displaced intra-articular calcaneal fractures.
Open reduction with internal fixation is the most used technique for displaced intra-articular calcaneal fractures. A study was conducted to determine the effectiveness of calcium phosphate cementing (CPC) in the surgical treatment of Sanders type II and III calcaneal fractures using screw fixation with sinus tarsi approach. It was ...
Editor's note: Dr. Levy's extended-length letter can be read here.
05/06/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Bryan C. Markinson, DPM
Dr. Roth says, "since most pods can operate on soft tissue to the knee, it makes sense that one day a podiatrist will get this training and act as a referral for these lesions of the foot and leg. WHY NOT? He goes on to ask, ”Why not think big?" If this represents deep, considered thought about why podiatrists should be offered training in Mohs surgery, or interventional radiology, I believe it to be embarrassing should a dermatologist or interventional radiologist see it. However, if a DPM that Dr. Roth mentors and encourages to think big wants to be a Mohs surgeon or interventional radiologist, I have laid out exactly how one thinking big can get that done in my last two PM News issues.
Bryan C. Markinson, DPM, NY, NY
05/06/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Jeffrey Kass, DPM
The discussion of Mohs surgery has been going on for a few days. Some podiatrists have chimed in that this is something beyond the scope of podiatrists where other colleagues have disagreed stating you should be able to if you have the training.
The NYSPMA apparently appears to side with the camp that podiatrists should NOT be able to perform Mohs surgery. This is evidenced by the podiatry scope bill that is currently trying to be passed. This bill which makes “technical corrections” to the bill specifies podiatrists are NOT allowed to perform Mohs surgery.
Jeffrey Kass, DPM, Forest Hills, NY
05/05/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2B
From: Bryan C. Markinson, DPM
Dr. Berlin is correct when he states that in situ melanoma may be misdiagnosed. The literature has several citations detailing how on review of previously diagnosed in situ lesions. After special staining, they result in an interpretation of the lesion as invasive due to the presence of errant melanocytes deeper in the dermis. Additionally, there is a field effect where malignant melanocytes are discovered at considerable distance to the bulk of the observed lesion under the microscope.
However, his proclamation that three dimensional surgery is not the treatment of choice is definitely subject to heated debate globally with support on both sides of the issue. The reason for this is that "a simple amputation of the distal portion of the digit," as he describes it, offers NO LONG-TERM survival advantage, even for invasive lesions. At the Council for Nail Disorders Meeting, this is a perennial subject for discussion still waiting for consensus. But the brightest and most experienced minds in digit melanoma surgery are increasingly supporting digit sparing surgery for this exact reason. The situation is analogous to the early resistance by breast surgeons to accept that radical mastectomy did not offer any survival advantage over lumpectomy. In both cases however, data is continually being looked at to define the exact clinical scenarios that support conservative versus radical surgery.
Bryan C. Markinson, DPM, NY, NY
05/05/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2A
From: Bret Ribotsky, DPM
I read with some interest the “debate” between Drs. Levy and Markinson. There are two different roads to training for Derms. 1) The Mohs fellowship, which is a one-year approved training program. 2) The Mohs college which allows certification after completion of 40 cases. I’ve been fortunate that over a dozen years ago, I went with my wife (a dermatologist) for training in Mohs surgery. We did this training outside of the U.S. over a few weekends. I was lucky to be allowed to receive this training and yes it did include surgery on the face, learning how to do flaps, etc. The microscopic training was not that difficult, once the principles of doing a frozen section were studied. Thus, I am a DPM with full certified training as a Mohs surgeon.
Now back to reality, I never did this on a patient in my practice. I never had the volume to even consider it. As a DPM, there is so much we are outstanding in, why even try to do something that is not in our wheelhouse? I remember going as a resident for microvascular surgery training, where we learned to sew rat carotid arteries with 9-0 and 10-0 sutures under microscopic view - I never used this in practice, but it did increase my surgical skill, and if that is the real goal, great.
I know most DPM residents have learned during training how to do hip surgery and many other procedures, but should we be allowed to do this? Of course not. To me, it takes a great surgeon to repair a 2nd hammertoe.
Bret Ribotsky, DPM, Boca Raton, FL
05/05/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1
From: Robert S. Schwartz, C. Ped.
The use of a hard-soled shoe for avulsion and other base of 5th injuries has to include a rocker profile design to transfer forces from the base of the fifth metatarsal. More importantly, the internal base of the shoe must be wide enough to accommodate the lateral column and prevent vertical and lateral forces from pressing and shearing the 5th base.
Robert S. Schwartz, CPed, NY, NY
05/04/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2B
From: David Secord, DPM
One of the items that hasn't been presented on the discussion of being trained in Mohs surgical techniques is who would write malpractice for you. I did two months rotation with one of the top orthopedic oncologists (Richard Schmidt) in the area, who is now with Cancer Centers of America, but was at Fox Chase when I knew him at The Graduate Hospital. He could tell that I was very interested in orthopedic oncology and offered to have me do the same fellowship as he if I wanted to extend my training past residency. When I looked into it, I discovered that no podiatric malpractice carrier would write a policy which would cover oncology surgeries.
Ignoring the fact that only a small number of orthopedic oncology cases occur below the knee and would likely end up in the hands of someone other than a DPM, I turned down the possible opportunity to be a fellowship-trained podiatrist in orthopedic oncology as the parchment and $4 would get you a regular coffee at Starbucks, as no one would cover my liability. Even if someone were allowed the chance to do a Mohs surgical fellowship, would that individual also not find malpractice coverage and end up not doing the procedures even if trained?
David Secord, DPM, McAllen, TX
05/04/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2A
From: Clifford Wolf, DPM
Dr. Levy's suggestion, "the manufacturer that makes the materials to perform Mohs surgery be contacted (e.g., Henry Schein Medical). Perhaps they may also have the resources to train or arrange for the training of DPMs interested in becoming proficient in this now commonly performed procedure. The profession should make whatever arrangements are needed for DPMs to acquire the required skill set for this potentially invaluable procedure." This made me laugh.
Dr. Markinson said, "Therefore when Dr. Levy asserts that DPMs 'should not be denied the opportunity to acquire the knowledge, skills, and training to perform Mohs surgery,' he is doing nothing more than cheerleading..." However, I love this cheerleading. It has led us to this discussion.
Dr. Levy believes "podiatric medical education and training will become more and more complex as medical science continues to evolve. The difference between the podiatric physician of the 1950s and 1960s and those who will be entering the profession in the late two thousands will be dramatic, bringing much more complex medical and surgical care to patients and solving problems that were not solvable." Podiatry... we are trending in the right direction.
Clifford Wolf, DPM, Oceanside, CA
05/04/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1
From: Keith L. Gurnick, DPM
Avulsion fractures of the 5th metatarsal base are not the equivalent to a Jones fracture and are not treated in the same manner. The article does not equate an avulsion fracture with a Jones fracture, and I would hope that any PM News reader would not infer from the reference to the article or after reading the article that a Jones fracture should be treated with a hard sole shoe and you will get the same outcome, because you will not. The classification for proximal 5th metatarsal fractures are divided into three zones each with their prospective management and potential complications.
Keith L. Gurnick, DPM, Los Angeles, CA
05/03/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1C
From: Leonard A. Levy, DPM, MPH
Bryan Markinson, DPM, says, “The simple truth is that no podiatrist is denied the opportunity to perform Mohs surgery, he or she just has to go to medical school, get trained in dermatology/dermatological surgery, fellowship in dermatopathology, then fellowship in Mohs surgery. Simply put, Mohs surgery on the foot is not podiatric medicine and surgery.” A few decades ago, DPMs would not, for example, dare to perform rearfoot bone surgery, and rightly so, nor would they even put bone screws into a metatarsal. As our pre-doctoral education changed and residency training became a requirement rather than just an experience that an occasional podiatrist would complete for 6 months or a year, reconstructive foot surgery became a standard for DPMs who completed a 3-year podiatric surgical residency.
I am very aware of the training a dermatologist receives, having been...
Editor's note: Dr. Levy's extended-length letter can be read here.
05/03/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Pete Harvey, DPM, Ivar E. Roth DPM, MPH
I agree with Dr. Markinson. What might be overlooked here is practicality. If a person requires heart surgery, he/she wants a surgeon who has performed hundreds per year and not one or two procedures. The odds of any surgeon in the country performing hundreds of Mohs surgery on a great toenail are very slim. I would be surprised to hear of any surgeon who has performed hundreds on a toe.
Pete Harvey, DPM, Wichita Falls, TX
I have read what both Dr. Levy has said and what Dr. Markinson has responded. My take is as follows: I believe Dr. Levy was just saying that this type of training and fellowship should be offered to those podiatrists who want to specialize in this area. Since most Pods can operate on soft tissue to the knee, it makes sense that one day a podiatrist will get this training and act as a referral for these lesions of the foot and leg. WHY NOT? I recently tried to get a fellowship going for a podiatrist to do an interventional radiology program. I can see the day when this will happen and we will be the best at clearing blockage of the foot and lower leg to save these limbs. Again, why not think big?
Ivar E. Roth DPM, MPH, Newport Beach, CA
05/03/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Steven J Berlin, DPM
I have been reading about podiatric training with the use of Mohs surgical therapy. It is fine for basal and squamous carcinoma and often very successful even though I would prefer the complete surgical excision of the lesions. However, when it comes to subungual melanoma, it is not the treatment of choice. Too often even in situ melanomas can be misdiagnosed and be in a class of acral lentiginous melanomas that often act very irrational. The treatment of these melanomas are a simple amputation of the distal portion of the digit. After all, subungual melanomas have one of the highest incidents for metastasis of the foot.
Steven J Berlin, DPM, Baltimore, MD
04/30/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Steven Finer, DPM
A few years ago, I had the procedure done on the tip of my nose. It was done at a major teaching hospital in Philadelphia. The surgeon had the MD degree, dermatology residency, and a fellowship in dermatopathology. He also had the resources of the institution, including all the complicated machines and stains necessary to do the procedure. It is self-evident, as pointed out by Dr. Markinson, that a podiatrist must have the same.
Steven Finer, DPM, Philadelphia, PA
04/30/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
RE: Treatment for Ungual Melanoma in Situ (Leonard A. Levy, DPM, MPH)
From: Bryan C. Markinson, DPM
Dr. Levy’s persistence on the issue of podiatrists performing Mohs surgery on the foot is perplexing. He is supporting his opinion based on advances podiatry as a profession has made over decades regarding residency training and practice act changes. Dr. Levy asks, "Are we or are we not physicians?" Personal feelings aside, including mine, the fact is that this question is still a raging debate closer to question than consensus, and has nothing to do with performing Mohs surgery.
He states, "We should not be denied training to perform any kind of surgery on the foot and ankle." Really? Sorry Dr. Levy, when it comes to many kinds of surgery involving the foot, others may be more endowed with the requisite knowledge, training, and experience. Would Dr. Levy support removal of a malignant nerve sheath tumor by a ...
Editor's note: Dr. Markinson's extended-length letter can be read here.
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