One of the absolute worst feelings in the whole world is when you'd give anything not to have done something, and WISH you could turn the clock back. I'm going to grant you that wish! DON'T operate on the bunion with no symptoms. Patients with even the most trivial of post-op problems who were asymptomatic before surgery don't tend to be very happy and will make you miserable.
Carl Solomon, DPM, Dallas, TX
The decision to proceed with elective bunion correction for cosmetic or psychological purposes only, must be made following basic ethical principles similar to those employed for elective cosmetic surgical procedures. The principle of autonomy must be maintained. The patient should desire correction of the deformity absent any manipulation or coercion by the surgeon. The patient should make such a decision with true informed consent. The patient should understand that a painless deformity can become painful following surgery, and that complications can occur which may be gait altering and at times life-altering.
Over the years, I have personally reviewed several malpractice claims in which a patient died of a pulmonary embolism following bunion surgery. While I am not suggesting this is in anyway a common occurrence, the fact is that such complications do occasionally occur. More commonly, patient dissatisfaction following bunion surgery may occur due to pain, stiffness, swelling, delayed or non-union, infection, hardware related problems, or other complications with which the PM News readers are aware. In my opinion, good documentation regarding patient decision and awareness of complications should be in the medical record for elective bunion surgery as would be expected to be present in the medical record for any doctor-patient relationship.
I’m sorry and disappointed to see this kind of biased reporting on this site. CBD has been legalized in all 50 states for use in adult humans and pets (not children other than for seizures). There is far from a paucity of literature about its safety and efficacy. It has been well studied for years and there are still ongoing studies. Yes, there are unscrupulous companies out there. Selling to pregnant women is unethical since there are no teratogenicity studies. Putting it in food is a direct violation of FDA guidelines. It doesn’t belong in food no more than ibuprofen belongs in food.
Claims for its effects in advertising and on labels will always be an issue with the FDA since they don’t allow claims to be made for any natural substance. Putting in chemical additives is another issue. I’m all for removing companies like this from the market. However, this FDA release smacks of BIG PHARMA. There are NO studies to show it can do harm when...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
Congratulations to the Academy of Continuing Podiatric Medical Education. Unfortunately, I missed this last seminar. However, I have been attending these seminars with speakers such as Dr. Steve McClain and others. The Academy also offers additional learning opportunities. My thanks to the Academy, David George, DPM and Robert Marcus, DPM.
It’s been previously observed in this forum that a disproportionate number of cars are running into podiatry offices. Now we learn of a new one. I can certainly understand why many of these get reported in PM News…when we see a report of these stories in local media, we notice them and send them in. If the car ran into a 7-11, we wouldn’t see it here in PM News. But seeing this new report today made me wonder…do these incidents have more in common than just the fact that podiatry offices are victims?
These questions come to mind: Are the cars being driven by podiatry patients of those offices? Are they patients with neuropathy? Have their feet been anesthetized from a procedure? Are they wearing a bulky post-op shoe? Let’s collect this data where it is known and perhaps we can come up with some changes to our Policy and Procedures manuals in an effort to protect our office entrances!
I just don't get it? This type of promotion by companies is done in almost every business. I don't see anything morally or ethically wrong with it! I think companies should pay doctors like they do professional athletes to promote them to other doctors and the public. Give me a bunch of money and I’ll wear a scrub hat with your name on it or a set of O.R. scrubs with your company's name plastered all over it.
I am always pleased to see some discussion of gout. I am curious if the readership would care to comment on its cousin CPPD or calcium pyrophosphate disease? To my knowledge, there is no definitive test and the diagnosis is only by symptoms and x-ray.
According to statista.com, in 2015, there were nearly 1.1 million doctors of medicine in the U.S., and according to the sourced report cited by Dr. Jacobs, about 3,200 physicians received $500K or more for promotional talks and consulting. In addition, it is also reported that it does not include physicians receiving royalties for research and inventions. So, is this to criticize the right of any person, physicians included, to be paid a royalty or a salary for consulting services, research, or for their intellectual property from an invention?
Most of us in active practice have been invited to industry-sponsored lunches, dinners, and to the occasional sawbones or cadaver labs. Most of us have never been paid, nor will even dream of being paid, such amounts of money in salaries or gifts to even come close to the amounts in the cited report. While I do not necessarily agree with companies luring physicians to use their products with gifts, I do have to argue that the regulations issued by federal and state legislators to prohibit such transactions is plain and simple hypocrisy since most of them are "wined and dined" by industry lobbyists on a daily basis.
At the end of the day, we all agree that we are in this profession to care for our patients and provide them with sound, evidence-based treatment options. In an open market environment, many vendors will come to our door asking us to use their products. It is up to us to decide which one(s) will be appropriate or not to help our patients, not because of a dinner at a nice restaurant.
I read with interest Dr. Kaufman’s (no relation) breast cancer experience. The positive outcome is certainly good news. Concurrently, I would like to point out that as many as 30% of successfully treated early stage breast cancers may resurface over the span of many years as stage 4 cancers.
The conclusion is: successful treatment in early stage breast cancer is salutary, but ongoing awareness and prevention is necessary. Very little resources are afforded Stage 4 breast cancer at present.
David M Kaufmann, DPM, Nashua, NH
RESPONSES/COMMENTS (NEWS STORIES)
RE: Cambridge Foot & Ankle Associates Joins Upperline Health, Inc.
From: Lloyd Smith, DPM
Seeing Drs. King and DeSantis on the same team is a wonderful development. I have watched their respective careers develop over many years. Both have become great friends and inspirational leaders. I wish them well in their newly formed relationships.
It is always nice when our profession writes on the topic of plantar fasciitis for educational purposes to the public. I am noticing more and more that the FDA-Approved evidence Level 1, ESWT treatment is almost never mentioned in publications such as the one where Dr. John Giurini was quoted.
How can our profession not include FDA approved ESWT-treatments, when the ACFAS Preferred Practice Guidelines note that ESWT should be offered before surgery? The same guideline is noted in the Podiatry Institute Handbook, as well as many well-known published peered-reviewed podiatry journals, over the past twenty years.
Do you feel that your profession is short changing the public when an FDA-approved ESWT procedure with evidence level 1 studies are ignored? Anyone have any input on this subject? I always thought evidence-based treatments were important, especially treatments that are FDA-approved. I would like some feedback from the podiatry profession. Please note I hope it’s not because ESWT is typically not an insurance covered procedure.
Disclosure: I am the co-owner of Excellence Shockwave
Dr. Udell, I appreciate your response and I agree with you 100%. I also totally agree with Dr. Jacobs’ take. MIS surgeons cannot scientifically state that there is less swelling and lower infection rates with MIS HAV correction compared to traditional surgery. We can only state that MIS HAV correction with screw fixation yields better early VAS scores than open Scarf/Akin. For MIS HAV correction, we have scientific backing for the Reverdin-Isham, SERI, Bosch, Magnan, and the MICA/PECA. None of these procedures have established dominance over any other HAV surgery.
Some MIS procedures actually have significant pain and swelling after surgery. The non-fixated PMOs that MIS surgeons do for IPK and ulcers have significant swelling and dorsal pain for up to three months post-op compared to...
Editor's note: Dr. Peacock's extended-length letter can be read here.
Surgery has definitely improved over the years with both traditional and MIS surgery. A lot of the foot surgeries that were done forty years ago no longer require a cast or a hospital stay for several days. This trend to getting the patient out of the hospital and walking around as soon as possible can be seen in almost all surgery from gall bladder, heart, vascular, orthopedic, and most general surgery.
The trend in surgery seems toward smaller incisions using non-invasive techniques and equipment that allow...
Editor's note: Dr. Cohen's extended-length letter can be read here.
Thank you, Dr. Peacock, for your interesting references to MIS surgery for the correction of bunion deformity. However, the published statement by the author clearly fails to support the claim that MIS surgery is associated with less swelling, less pain, and a lower infection rate. The references you cite do not substantiate that claim.
The preferred practice guidelines published by the Academy of Ambulatory Foot and Ankle Surgeons contains references in the chapter on “MIS correction of Hallux Valgus”. Of the 54 references, over 50% are taken from literature on...
Editor's note: Dr Jacobs' extended-length letter can be read here.
Thank you, Dr. Peacock, for pointing out that a well-trained surgeon can decide whether a minimally incisional surgery or a completely open procedure is best for an individual patient. The days when podiatrists were divided into two classes, those who only did open procedures and those who only did minimal incisional procedures is thankfully coming to an end. A well-rounded surgeon could decide what is best for a particular patient and should not be guided by prejudice or lack of training.
Today, orthopedists are doing spinal and many other procedures using minimally invasive techniques. Podiatry was light years ahead of its time when minimally invasive procedures were invented but as with back surgery, foot surgeons have to know when to choose what procedure for a particular patient.
Dr. Jacobs, we do have peer reviewed literature to support the effectiveness of MIS HAV correction. Recently, a level 2 prospective comparative study was published titled "Hallux Valgus Correction Comparing Percutaneous Chevron Akin (PECA) and Open Scarf/Akin Osteotomies" (Lee, et al. 2017. Foot and Ankle International). Basically, the study showed lower VAS scores in the early post-op period for the MIS group. However, after 6 weeks, the VAS scores were identical. All other measures such as AOFAS HMI, IM angle, HV angle, etc. were statistically insignificant at mid-term results.
Deep infection was not seen in either group. Basically, a well performed MIS HAV procedure is just as good as a well performed open correction from a comparative statistical point. Advantages of MIS HAV are less scarring with shorter operative times. The overall results for MIS vs. traditional are identical in midterm results in the literature so far.
A quick Google search will yield three level 2 MIS HAV reports and four or more level 3. The research has been published and will continue to unfold. I was board certified in open foot surgery before I ever did a MIS foot surgery. My experience has been satisfactory with most MIS procedures. There are some I have abandoned, just like there are some open procedures I have abandoned. Knowing both open and percutaneous techniques and performing them well is the most ideal armamentarium to possess.
On what basis (studies published in peer-reviewed journals) does Dr. Goolsby support his claim that MIS bunion performed with "three small incisions" is associated with a lower infection rate, swelling, and less pain?
Thank you PM News, for bringing Richard Willner's accomplishments to our attention. Even more importantly, thanks for mentioning there is someone available to defend podiatrists and physicians against a sham peer review.
I agree with Dr. Branks and would like to offer an aside anecdote. Many years ago, I removed a 3-R neuroma from a lady’s foot. During the procedure, I heard an abnormal “click” at the tip of the 15 blade. The neuroma was out and further dissection revealed a hard cartilaginous material deep in the space. Removal of the “object” revealed itself as the skeletal remains of the dorsal fin of a fish. Upon questioning, she actually recalled an incident of sharp pain in her foot while walking on a Galveston beach many years prior. She healed well.
Pete Harvey, DPM, Wichita Falls, TX
RESPONSES/COMMENTS (NEWS STORIES)
RE: Illinois Podiatrists Publish a Rebuttal to Insurance Companies in FAI
The need for such a study became apparent when an APMA member contacted APMA for assistance in challenging an insurance company’s prior authorization policy on elective bunionectomy surgery. APMA’s Health Policy & Practice and Clinical Affairs Departments worked closely with our member podiatrists to challenge the insurance company’s flawed policy. Recognizing the need for data to further demonstrate the inaccuracies in the policy, APMA Clinical Practice Advisory Committee Chair Adam Fleischer, DPM, spearheaded this study with his colleagues. Their published work has been used to challenge the insurance company, and APMA along with its member podiatrists continue our advocacy efforts. Once again, I congratulate the Weil Foot and Ankle team, and I encourage APMA members interested in conducting similar studies to reach out to APMA’s Clinical Affairs Department.
Congratulations to two brilliant leaders in our profession who continue to inspire the next generation of podiatrists. I look forward to hearing more of their accomplishments and those of their future students.
Congratulations to Arthur Helfand for his amazing accomplishment of continuing to author medical literature primarily dealing with geriatrics and diabetes in allopathic interdisciplinary publications. His outreach through numerous (more than 400) publications in textbooks and medical journals, etc. (particularly in allopathic publications) continues to make great strides for podiatry. He is in the true sense a real "pioneer". In the 1960s, he was unique, as most podiatric authors were writing primarily for podiatric publications. He continues to be a mentor for all podiatric physicians.
The American Society of Podiatric Medicine congratulates our executive board member, Dr. Arthur Helfand, on having a chapter published in a text on gerontology. Because of Dr. Helfand's teachings, The American Society of Podiatric Medicine has now dedicated itself to advancing the cause of geriatrics within our profession. To this end, all future lectures and conferences sponsored or co-sponsored by the ASPM will contain lectures on podo-geriatrics.
It’s true that Zero Drop Shoes are the opposite of Stilettos. Unfortunately, in a civilized society, both are biomechanically unhealthy. “Pawing around in bare feet” on hard ground is bad for most feet. Living life barefoot (or in Zero Drop Shoes) causes pedal collapse, develops forefoot spread, wider feet, and more protective callus in time.
Murray and Drillis published that as we age, we imperceptibly walk slower and take smaller steps (Haywood K, Getchell N: Lifespan Motor Development; sixth edition, Page 131). They called this “pre-senile and senile walking”. This suggests that Zero Drop Shoes will age us functionally and reduce activity level over time as if we had aged.
The evidence confirms that it is our muscle engines that ultimately stabilize, support, and balance the foot when weighted. Since muscle engines leverage and power best in a 1-1.5” heel from the ground up, this translates to mean that if you have been over-active, have heel pain, postural symptoms, or an injury, a small heeled shoe is a better choice than either a flat or a stiletto. Ask yourself why work boots, hiking shoes, cowboy boots, dance shoes, cross-fit shoes, and most sport shoes played on hard surfaces all have a heel?
Dennis Shavelson, DPM, NY, NY
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