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From: Carl Solomon, DPM, Allen Jacobs, DPM


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.


Allen Jacobs, DPM, St. Louis, MO

Other messages in this thread:



From: Dennis Shavelson, DPM

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



From: Elliot Udell, DPM


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. 


Elliot Udell, DPM, Hicksville, NY



From: George Jacobson, DPM


The population figures are quite daunting and telling of the foreboding future. But what is important for us right now is the actual percentage of each age group that visits a podiatrist’s office now. I don’t want to be electronically attached to my patients 24/7. They can call me if they need me after hours but a social media type practice, good Lord. We are seeing numerous psychological and sociological effects on these generations from online, e-socialization.  I don’t want an e-physician relationship (though it’s coming). 


I treat and evaluate three dimensional patients. We still touch our patients, which can’t be done online. E-practice may be what’s needed for a successful business model, but I chose to give up some success for sanity. I know I’ve taken this discussion beyond communicating appointments, but we have had patients try to get us to e-mail and text them. I’m not opening that Pandora’s box.  


George Jacobson, DPM, Hollywood, FL



From: Harry A. Yankuner, DPM


The article states that the BSA Silver Beaver Award is the highest awarded for adults. I would like to clarify that statement. The BSA Silver Beaver award is the highest award at the BSA COUNCIL level.


In the BSA, the three highest levels of recognition for meritorious service are:

        The Silver Beaver awarded for outstanding service at the COUNCIL level.

        The Silver Antelope awarded for outstanding service at the REGIONAL level.

        The Silver Buffalo awarded for outstanding service at the NATIONAL level.


This year, 13 individuals were honored with the Silver Buffalo. In 2011, William M. Finerty, DPM, a podiatrist in Ohio was honored with a Silver Buffalo award for his service and contributions to BSA.


Harry A. Yankuner, DPM, Dallas, TX



From: Jeffrey Worman, DPM, Steven J. Kaniadakis, DPM


I was so happy to hear of Dr. Caldwell’s appointment to Dean of Students at Barry University. Dr. Caldwell was instrumental in my podiatric education and served as a mentor to me in Cleveland and when I got out into private practice. Early on in podiatry school, I had my struggles, and Dr. Caldwell went way above and beyond to assure my success. I am forever grateful and appreciative of all his efforts. Congratulations to Dr. Caldwell and his wonderful family. I wish them all the best moving forward.


Jeffrey Worman, DPM, Largo, FL


I have known Bryan since literally the day that he started at OCPM. I know that Bryan Caldwell will be the very best Dean that Barry University has ever had! He is very straight-forward and a 100% caring, gentle, and kind person. Needless to say, he is a super intellect. He is, without a doubt, the best person for our Barry school. I hope that he will be influential to all the podiatry staff and students. Congratulations Bryan!


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



From: Paul Busman, DPM, RN


I'd always worry about a patient who wanted an asymptomatic bunion surgically corrected strictly for cosmetic purposes. A person who was so concerned with appearance might well be dissatisfied with a correction which, while technically excellent, might not accord with their preconceived notion of what a perfect foot "should" look like. Despite perfect surgical technique, the patient might be left with a scar that they'd consider unsightly, a slightly shortened hallux, etc. No thanks! 


Paul Busman, DPM, RN, Frederick, MD



From: Bryan C. Markinson, DPM


This ongoing discussion presents an interesting set of opinions centering on the themes of medical necessity, complications, and litigation. We should all adhere to the same accepted ethical standards regarding full informed consent (as Dr. Jacobs has stated) no matter what the reason for the patient wanting the surgery. Even without any threat of litigation, all of us can appreciate the attendant frustrations and anxiety that accompanies a less than optimum result, and the wide divergence of patient opinion on what is optimum and what is not. We all know how one unhappy patient can make us forget the many happy ones.


Based on my review of cases alleging failure to adhere to accepted standards of care, once litigation comes into the picture, any establishment by plaintiff or defense that the procedure was for cosmetic purposes, or to fit in fashionable shoes, etc. NO MATTER HOW WELL INFORMED (also subject to wide interpretation about how well informed is well informed enough), puts the defense at a not insurmountable but definite disadvantage.


Bryan C. Markinson, DPM, NY, NY



From: Lawrence Oloff, DPM


This, of course, is a personal decision. My perspective is that my main job is taking patients who are symptomatic, and making them asymptomatic. If patients are pain-free, then they are already at my target goal.


The other complex aspect of these decisions is trying to project disease course. I really don't feel that any physician can accurately predict if and when a bunion will become symptomatic. How many times have we all seen an elderly patient come in with asymptomatic bunions? If we had an accurate crystal ball, then the decision to operate on asymptomatic deformities would be clearer.


My vote would be to leave it alone, and periodic visits to assess for symptoms or developing arthritis or other concerning criteria that would suggest the need for intervention.


Lawrence Oloff, DPM, Burlingame, CA



From: Todd Lamster, DPM


This is one area that I have to respectfully disagree with Dr. Morelli. First and foremost, in my opinion, the foot is a functional structure. No matter the morphology, no matter what lumps or bumps are present, if it is pain free, then it is working properly for that patient. Performing surgery on a pain-free structure is ill-advised, as there are too many potential complications. Even a slight amount of pain, scarring, or swelling will most likely be viewed as a failure in a patient who was asymptomatic prior to surgery.


I am sure we have all seen the second opinions following a bunion surgery "that wasn't too painful or wasn't causing pain to begin with." "Did the doctor do it right?" "Why is it still swollen?" "Why is my toe stiff?" Don't let the patient decide if surgery is the right course of action. You are the surgeon; you decide.


Todd Lamster, DPM, Scottsdale, AZ



From: Scott L. Schulman, DPM


An 82 year old unhealthy patient presented with a horribly painful bunion, with an infected ulcer, and asked me to fix the bunion and end his pain.  I found him not to be a surgical candidate and could offer little help other than standard ulcer care and off-loading. He responded, "Why the heck didn't that other guy tell me this could happen and why didn't he fix it 10 years ago?


Bunions are hereditary, PROGRESSIVE deformities that WILL in most cases get worse. I do not think it is "Just cosmetic." Doctors don't just treat pain, they treat conditions and potential problems. High blood pressure does not hurt. Neither does melanoma or even dental cavities, but we treat these conditions to PREVENT bigger problems down the road. How many bunions end up causing bigger problems later?  I think we owe it to our patients to at least educate them on the progression and likelihood of bigger issues, increased pain, and more extensive surgery down the road if left untreated. 


Scott L. Schulman, DPM, Indianapolis, IN



From: Elliot Udell, DPM


When I entered practice, over 35 years ago, I had two offices. One was in a suburban area in Long Island and the other was in a specific Chassidic community in Brooklyn. I found the patients’ reaction to bunions, hammertoes, and other foot deformities to be radically different in each community. I found that on Long Island, if a forefoot deformity was slightly painful or deemed "ugly", most but not all of my patients were more inclined to seek surgical corrections. In Brooklyn, where religious life and raising large families consumed family members from dawn to dusk, unless the deformity was extremely painful to the point of being incapacitating, or interfered with other aspects of their life, most but not all of my patients optioned for conservative management of their deformities.


Elliot Udell, DPM, Hicksville, NY



From: Charles Morelli, DPM


Dr. LaFata is correct when he says that "unsightly bunions all have something in common: They're a pain." They are not only a pain physically, but also emotionally and cosmetically as well which should not be discounted. A new report from the American Society of Plastic Surgeons reveals that Americans spent more than $16.5 billion on cosmetic "plastic" surgery, and minimally invasive procedures in 2018. Why should podiatry be any different?


Many of us have had countless patients who present to our offices with bunion concerns that are not always painful. These are mostly young women and some men who are socially embarrassed by the appearance of their feet including both bunions and hammertoes, not to mention nail infections. There is a place for cosmetic foot procedures in this profession and to make a blanket statement to a patient that s/he should not have surgery due to the lack of pain is short sighted. Explain the risks of such a procedure including pain, swelling, and scarring, and let the patient be the ultimate arbiter. Refer them to a surgical colleague and allow them to be treated. 


Charles Morelli, DPM, Mamaroneck, NY



From: Rem Jackson


I encourage Dr. Lim to reconsider retiring his iconic Happy/Sad Foot Sign. There is no marketing device ever invented that can beat a great sign on a busy road. This is a great sign. 


Rem Jackson, CEO Top Practices 



From: Tom DeBenedictis, DPM


Is this similar to what lobbyists do with Senators and Congressmen? Is it possible that these same companies try to influence our legislators? Should we be as concerned? 


Tom DeBenedictis, DPM, Union City, NJ



From: Wenjay Sung, DPM


Congratulations to Dr. Barry Block who been a mainstay in podiatric professional news and interest pieces. I look forward to what he has in store next!


Wenjay Sung, DPM, Arcadia. CA



From: Tim Shea, DPM


It was wonderful to see my old classmate (CCPM class of 1973) Dr. Jim Flynn featured again in the Oklahoma press. In school,  Jim was not only well respected as a student, but a really nice guy. For those who may not remember, Dr. Flynn was also noted for his contributions to the Oklahoma City Bombing first responders many years ago. In all instances, he has been a caring doctor with a great sense of charity and humor. Our profession is lucky to have a member like Jim Flynn, DPM.


Tim Shea, DPM, Concord, CA



From: Arthur E. Helfand, DPM


Speaking of the past, a check of the records will indicate that Temple University School was founded in 1915. Let us not lose our history.


Arthur E. Helfand, DPM, Narberth, PA



From Ron Werter DPM


Just a reminder of things past: Stony Brook, part of the State University of New York had a college of podiatry in the 1975. It graduated one class. Also, NYCPM was part of Long Island University from 1948 to 1955. It was called the Long Island University College of Podiatry. 


Ron Werter, DPM, New York, NY



From: Elliot Udell, DPM


It would be interesting to compare these statistics to areas in Europe where there is no economic benefit for either the surgeons or the hospitals involved. In my geographic area, it does not take too much prodding for certain surgeons to remove bones beneath ulcerations or entire digits. For some doctors, if there is any suspicion of osteomyelitis, antibiotic therapy is never an option, instead the patient is taken directly to the OR. 


I have a number of patients who still have all ten toes, when other surgeons wanted to remove one or two of them without giving antibiotic therapy a chance to work. These surgeons defend their way of practicing by saying that it is better to amputate immediately rather than keeping a patient on antibiotics and risking the development of resistant strains of microoganisms. The patient, however, is rarely given the choice.


Elliot Udell, DPM, Hicksville, NY



From: David Zuckerman, DPM  


Dr. Jacobs makes a good point, but I believe the point made by Dr. Horowitz makes a more important point. Podiatrists should play a major role in the assessment of risk falls which includes gait and biomechanics. Saying that every fall is probably due to an inner balance middle ear problem is robbing our patients of comprehensive fall assessment  


Podiatric medicine is needed and should be part of the initial fall assessment  Sending patients just for etiology assessment that doesn’t include podiatry is robbing our seniors of complete comprehensive care


David Zuckerman, DPM, Cherry Hill, NJ


Editor's note: This topic is now closed.



From: Allen Jacobs, DPM


Dr. Horowitz’s statement that people fall ONLY as the result of foot or gait abnormalities is not correct, and exemplifies the very problem of fall risk assessment. The etiology of falls in senior citizens includes an eclectic variety of factors, such as medication effects, inner ear pathology, neurological disorders, visual difficulties, environmental hazards, footwear. Complete fall risk evaluation must include assessment of all such factors, not just podiatry-related pathology. 


Allen Jacobs, DPM, St Louis, MO



From: Allen Jacobs, DPM


You can view a podiatry friendly fall risk evaluation at the Center for Podiatric Education. It reviews the CDC guidelines for fall prevention. Or go directly to the CDC fall risk prevention site for appropriate guidance. The CDC guidelines (the STEADI guidelines) may be easily incorporated into your practice. 


Allen Jacobs, DPM, St. Louis, MO



From: Earl R. Horowitz, DPM


The role of podiatric services must be fully developed and recognized in preventing falls in the senior population. Seniors fall only when their foot leaves the ground improperly during the gait cycle. Multiple and common foot problems that cause pain lead to abnormal sway action that causes senior to fall. Biomechanical dysfunction, arthritic changes, and loss of sensation may easily lead to sway and gait changes that cause falling. Senior foot and ankle problems may not seem significant in importance even to the senior themselves only because they do not realize the significance of the foot to controlling falling.


Foot and ankle pathology should be classified as one of the main causes for senior falls. Most podiatrists treat senior foot complaints not understanding their potential role of preventing seniors from falling that a full foot and ankle examination would indicate. Podiatrists must become more knowledgeable in examining gait and sway problems that lead to falls in seniors. They must develop examination, treatment, and preventive protocols for this life-threatening problem. Foot and ankle problems can change from year to year very quickly as seniors grow older. A yearly full foot and ankle examination should become a part of senior health plans. The opportunity for podiatry to be in the forefront in geriatric medicine and fall prevention is now!


Earl R. Horowitz, DPM, Jacksonville, FL



From: Shari Lewis Kaminsky, DPM


It would be very useful for all podiatrists working with the elderly to have access to a well thought out approach to assessment and documentation of fall risk. My practice has attempted to get the exact requirements and documentation needs from CMS with only vague answers such as "Just try to make an attempt." If we are going to do this, we would like to make sure it is an exact fit with what is required and not a "best attempt."


Shari Lewis Kaminsky, DPM, Florissant, MO



From: Ira Baum, DPM, Donald R Blum, DPM, JD


Dr. Levy’s recommendations to reduce the risk of seniors falling and risking severe injury is a responsibility that all podiatrists should honor.  I add the importance of gait aides to mitigate falls, when necessary, for the aged and not so aged, with neurological impairment to the lower extremities. Our concern for the whole person is what makes us physicians.


Ira Baum, DPM, Naples, FL


Thank you, Dr. Levy, for comments about "Falls" related to "Seniors". One more item that needs to be considered, for all ages, is injuries resulting from walking the dog. People are out walking the dog or walking for exercise and paying more attention to a telephone conversation, a text, or a social media post than the squirrel or rabbit that your dog wants to run after; or they are just not paying attention to the curb or the debris on the sidewalk.


Donald R Blum, DPM, JD, Dallas, TX


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