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
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.
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
05/04/2021
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
05/12/2020
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2
RE: Higher Risk of Incident Heart Failure in Older Adults with Gout
From: Leonard A. Levy, DPM, MPH
MedPage has (May 6, 2020) reported a study by Lisandro D. Colantonio, Kenneth G. Saag, et al., indicating that 4% of the U.S. population ('6 million men and '2 million women) are affected by gout. Furthermore, older individuals with gout were at increased risk for incident heart failure, but not for incident coronary heart disease or stroke or all-cause mortality.
Leonard A. Levy, DPM, MPH, Fort Lauderdale, FL
