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09/08/2020    

RESPONSES/COMMENTS (CLINICAL)



From: Keith L. Gurnick, DPM


 


You are already aware that the long-term prognosis for this patient, even after toe surgery done with the best techniques, is guarded at best, and recurrence over time is likely. The ligamentous laxity at the metatarsal phalangeal joints that is causing the symptoms of the 3rd and 4th toes is also causing lateral deviation of both 2nd toes and should be addressed at the same surgical time. Fusing the 2nd or 3rd MPJs would be a disaster, as these joints need to move. The use of double stem lesser metatarsal phalangeal joint implants will not provide enough stability in the transverse plane and will fail over time, and the lateral deviation will return. 


 


My suggestion is that you must address the 2nd and 3rd metatarsal phalangeal joints' lateral deviations using a "mini-tightrope" (Arthrex) or similar procedure placed/inserted medially at the MPJs and, in addition, your hammertoe correction procedure of choice to straighten the toes in the sagittal and transverse planes. You might need to lengthen the extensor tendons at the time of surgery (over the MPJs) and perform a lateral capsular release at the MPJs as well. Unless this patient has either metatarsalgia or plantar keratomas, I do not think Weil-type osteotomies of the involved metatarsals are necessary.


 


Keith L. Gurnick, DPM, Los Angeles, CA

Other messages in this thread:


11/24/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Jack Ressler, DPM


 



As the old saying goes - K I S S (keep it simple...).  First, check for a leg-length discrepancy. If nothing else is helping, start with a 1/4" thick felt or Korex rubber cork heel lift and cut a big enough hole to accommodate the painful area. Bevel the inside edges for comfort. The material you use should be rigid enough so it doesn't compress. This would at least isolate the area and eliminate a few other possible etiologies. Make sure you add the same thickness lift in the other shoe for balance unless there is a leg-length discrepancy. 


 


Jack Ressler, DPM, Delray Beach, FL


11/24/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Robert S. Schwartz, CPed


 


Eneslow has been successful in helping numerous healthy males who present with fat-grafting to the heel. To relieve impact forces and reduce pain, we use a heel rocker, often with SACH shock-absorbing material under calcaneus. The goal is to delay heel contact until the body is over the foot and increases forces to the midfoot.


 













Heel Rocker



 


Shoes that start with a thick (one inch or thicker) midsole/outsole can be modified. Otherwise, most walking shoes can have material added and modified by pedorthic technicians to accommodate this deformity.


 


Robert S. Schwartz, CPed, NY, NY

11/23/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Lance Malusky, DPM


 


I had a similar case years ago. The central plantar heel pain is likely a trauma to the plantar bursa, which is frequently ignored by the MRI radiologists or readers. I would take the disc of the MRI to a radiologist who specializes in extremity MRI readings. It may also require a fresh MRI with smaller slices to see the pathology. I would then consider a couple of lateral approach cortisone injections. Utilize the lidocaine pre-anesthesia to determine if a focal bursa pain site can be identified. In either case, I would surgically remove the bursa entirely.  


 


A central plantar, longitudinal or transverse incision with meticulous plastic-type closure (ala McGlamry), or a curved posterior junctional border incision with a peel-forward approach may be considered. The bursitis should be deep to the fat pad, which must be retracted, then preserved upon closure. 


 


Lance Malusky, DPM, Dayton, OH

11/23/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Judd Davis, DPM


 


Dr. Dananberg mentions "cuboid fixation, which can cause pain in the abductor hallucis muscle, often confused with plantar fascia pain." I was wondering if he or anyone else could expand on the cause and effective treatments for this. I occasionally see patients with abductor hallucis pain/edema or what I think may be cuboid syndrome and have had minimal success resolving these. These conditions were breezed over in podiatry school with very inadequate discussions and little clinical training for most of us, as they are not very common pathologies. As he mentions, they are often overlooked and misdiagnosed as PF.


 


I have watched a few YouTube videos on the cuboid whip manipulation but have not found them very helpful or felt confident doing an aggressive manipulation myself. Any other pearls would be appreciated.


 


Judd Davis, DPM, Colorado Springs, CO 

11/20/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1C



From: Howard Dananberg, DPM


 



Considering that there is only minimal pain despite extensive palpation, but pain occurs with standing and/or walking, a herniated lumbar disk should be ruled out, particularly in light of the type of ski jump injury he incurred. A straight leg raise exam may reproduce symptoms. The other two problems may be 1) trigger points in the soleus which can cause referred pain to the inferior heel but would not exhibit symptoms on localized exam, and 2) a cuboid fixation, which can cause pain in the abductor hallucis muscle, often confused with plantar fascia pain.


 


In this situation, careful palpation shows limited to no pain with plantar fascia palpation, but when the abductor is palpated above the superior aspect of the plantar fascia, pain is acute. Manipulation of the cuboid creates spontaneous relief. I think that the disk herniation, considering the history of injury, is the most likely culprit.  


 


Howard Dananberg, DPM, Stowe, VT


11/20/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Don Steinfeld, DPM, Martin M Pressman, DPM


 



To me, an autologous transplant of fat under the heel is an exercise in futility. I recall, years ago, a new idea on the landscape. Collagen was injected to treat pressure spots and keratomas. We quickly learned that this material was pressed away with only a few steps. The only time it was of any use was interdigitally. The fat beneath the heel is held in place in honeycomb septae. You cannot replicate this situation. It sounds to me like there may be a nerve issue. The click may be a nerve which is now problematic due to the lack of fat. Consider that and take a fresh look.


 


Don Steinfeld, DPM, Farmingdale NJ


 


This is an interesting and difficult case. If you think this is a fat pad atrophy case and not the fascia and you can palpate the plantar tuberosity through the fat pad, you might take a lateral non-weight-bearing film to measure the fat pad thickness as compared to the contralateral side. If indeed there is atrophy, then a folded GraftJacket graft with plantar calcaneal condylectomy might be considered. This is from personal experience and not from EBM. I have done this only in select cases when I am sure the fat pad is damaged.


 


Martin M Pressman, DPM, Milford, CT


11/20/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Jordan DeHaven, DPM, Todd Lamster, DPM


 


I would consider a nerve entrapment or Baxter's neuritis. Often these are missed on MRI. I would revisit the MRI to assess for fat replacement to the abductor digiti minimi. I would also consider giving him a diagnostic injection at the branch of the lateral plantar nerve. If you have positive findings with MRI and/or diagnostic injection, then a Baxter's nerve release would be warranted.


 


Jordan DeHaven, DPM, Bristol, RI


 


I would look at nerve compression as the etiology of his pain. It is likely he traumatized Baxter's nerve with his initial injury, and is now suffering with a localized compression neuropathy. Try a nerve block of the tarsal tunnel or just directly underneath his heel and see how he responds and for how long. He may need a release of the distal tarsal tunnel and the abductor muscle/fascia. If the plantar fascia is significantly thickened or scarred on US or MRI, I would consider releasing that as well.


 


Todd Lamster, DPM, Scottsdale, AZ

11/16/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Robert D Teitelbaum, DPM


 



I use Castellani paint instead of gentian violet because it is less 'stainful'. It stains but it does clean up with an inordinate amount of isopropyl alcohol. If I suspect the maceration to be a chronic issue, I suggest (and dispense) MacerRx web gel from Darco.  


 


Disclosure: I have no personal or financial relationship to Darco Medical.


 


Robert D Teitelbaum, DPM, Naples, FL


11/16/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Richard A. Simmons, DPM


 


Bako Pathology has a PCR web space panel test designed to detect 1) Staph aureus, 2) Staph aureus mecA Gene (MRSA), 3) Gram negative bacteria, 4) Dermatophytic fungi, 5) Candida species and Corynebacterium minutissimum. The test is easy to collect specimens using a curette to scoop the suspicious tissue and then place it inside a special cardboard container for transport. The final specimen container is two business cards thick. What I appreciate is the ability to do a broad spectrum screen in one test and a quick turnaround for results.  


 


Disclosure: I have no financial or other connection/association to Bako Pathology.


 


Richard A. Simmons, DPM,  Rockledge, FL

11/13/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Elliot Udell, DPM, Pete Harvey, DPM


 



We have had similar cases over the years. For starters, you need to rule out a bacterial infection and treat it accordingly. After that, separate the toes with strips of gauze and teach the patient to do the same daily. One medication that we have used with great success is Formula 7 Gel. It’s a bit pricey but does the job. 


 


Elliot Udell, DPM, Hicksville, NY 


 


Over many years of practice, I have had similar situations a few times. If a C&S shows no growth for fungi, yeast, or bacteria, I have recommended to the patient to buy a spray can of Arrid Extra Dry antiperspirant and spray a small amount between the toes at bedtime and in the morning after shower. This has worked several times.


 


Pete Harvey, DPM, Wichita Falls, TX


11/13/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Estelle Albright, DPM, Jack Ressler, DPM


 


Please consider taking swab culture(s) to rule out bacterial and fungal infections.


 


Estelle Albright, DPM, Indianapolis, IN


 


You should take a C&S. I have found on several occasions when antifungals agents aren't working, it is usually an underlying bacterial infection. Erythromycin lotion twice daily for a couple of weeks seems to help. 


 


Jack Ressler, DPM, Delray Beach, FL

11/09/2020    

RESPONSES/COMMENTS (CLINICAL)



From: Charles Morelli, DPM


 


Depending on the foot type and how extensive the amputation is (whether or not it may include a partial ray resection as well), these procedures will often cause the patient to lose medial stability with potential subsequent collapse of the medial column, again depending on the patient and their foot type. In most cases, I will insert a subtalar implant or stent (depending on  preference) and have found that these work well in stabilizing the foot in these particular cases, and will also augment off-loading with a custom orthotic. 


 


Charles Morelli, DPM, Mamaroneck, NY

10/27/2020    

RESPONSES/COMMENTS (CLINICAL)



From: Judd Davis, DPM 


 


I have always had good success with the full thread Synthes 2.0mm screws. Do a long dorsal arm chevron osteotomy and fixate it with 2 screws to prevent rotation.


 


Judd Davis, DPM, Colorado Springs, CO

10/26/2020    

RESPONSES/COMMENTS (CLINICAL)



From: Greg Cohen, DPM,  Stephen Kominsky, DPM


 


I’ve been using a percutaneous .062 inch K-wire for “mini Austins” for many years with great success. I leave the K-wire in for 6 weeks and remove it with topical anesthesia in the office.


 


Greg Cohen, DPM, Brooklyn, NY


 


For the past several years, I have been using the snap-off screws from In2Bones. For the fifth metatarsal, the 2.0 screw, 11 mm is the perfect size. I typically use two of them to prevent a rotation at the osteotomy site. They are so simple, I have often said that I wished that I had developed them.


 


Stephen Kominsky, DPM, Washington, DC

09/21/2020    

RESPONSES/COMMENTS (CLINICAL)


RE: Safety of Lidocaine Ointment


From: Jonathan Michael, DPM


 


I have been writing lidocaine ointment and cream for many years with great results for management of foot and ankle pain. Last week, one of our doctors received a grievance complaint from Aetna Medicaid from a patient that Aetna denied medication and sent a letter to the patient stating the reason for the denial ‘’Lidocaine ointment is not SAFE and effective for treatment of plantar fasciitis.”


 


That comment from the insurance company made the doctor look bad and caused the patient to file a complaint. I am not aware of any literature that cites lidocaine as not safe to be used, especially since we inject lidocaine every day in patients' heels. The only thing I see is that the insurance company does not want to pay for the medication and made it the doctor’s problem. Any thoughts are appreciated. 


 


Jonathan Michael, DPM, Bayonne, NJ

09/14/2020    

RESPONSES/COMMENTS (CLINICAL)



From: Charles Morelli, DPM


 


If and when you decide to treat this condition in a 2 year old, you are treating the parents and not the patient. There is no reason to consider some of the options that have been suggested at this time especially since the baby is asymptomatic. Stretches, taping, toe spacers, and orthotics on a 2 year old for an overlapping toe? Although fine thoughts in theory, this is a 2 year old, and I doubt a parent has the time to stretch their child’s toe for hours a day over many months or years to address this. Taping and toe spacers? This is a 2 year old. How long do you think that would last before s/he pulls them out? Taping toes that are 2-3cm in length is more difficult than it sounds and would have to be done over and over and over again. “Custom pediatric-sized double or triple Budin splints”? Did not know a Budin splint could be custom made but again, this is a 2 year old. It might last a day or two and I can hear the screaming already.


 


This child has a hallux interphalangeus, R>L, that is exacerbating this. It is the possible etiology of the deformity and is preventing the toe from coming down. Wait for this baby to reach osseous maturity, ask again in 10–12 years if it is still a problem and consider a distal Akin, 2nd MPJ capsulotomy and/or any other procedure that will address this at that time. For now, leave it alone. 


 


Charles Morelli, DPM, Mamaroneck, NY

09/11/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 3



From: Don Peacock, DPM, MS


 


I have performed numerous corrections on patients with transverse hammertoe deformities using both traditional and minimally invasive techniques taught by the Academy. In my experience, the MIS techniques are better and longer-lasting when compared to traditional procedures. We have hundreds of patients out for many years with continued rectus correction following digital transverse plane hammertoe deformity corrected by MIS techniques. 


 


I do respectively disagree with my colleagues Drs. Nadal and Cohen and their requirement for metatarsal oseotomy. For patients that do not present with subluxed MPJ deformity, the metatarsal osteotomy is not necessary. Basing the technique on metatarsal length has never been proven to be a reliable indicator for metatarsal osteotomy. Here is a video showing correction of a severe transverse deformity without the use of a metatarsal osteotomy. 


 


Don Peacock, DPM, MS, Whiteville, NC

09/11/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1



From: Neil Barney, DPM


 


I have found that if you are doing bony repair such as an osteotomy at the phalanges, that as the bone shortens, the flexor tendon in essence gets longer. I rarely release the flexor tendon and that saves the purchase power of the toe. Maybe that's too simple an answer but it has worked in my hands. (A nod to Don Peacock, DPM who told me to do the bone work first, then see if tendon procedures are necessary).


 


Neil Barney, DPM, Brewster MA

09/10/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 2A



From: Stephen Musser, DPM, Richard M. Maleski, DPM RPh


 


An additional x-ray view would be helpful. Addressing the contracture at the MTP is critical either with a Weil and/or soft tissue release. Equally important is the the use of a toe splint(s), Darko, used afterwards to keep the digits in a corrected alignment for the soft tissue to heal/scar down the toe in the desired position, with proper alignment until scar tissue and adhesions are formed.


 


Stephen Musser, DPM, Cleveland, OH


 


I agree that transverse plane deformity of the lesser digits is very hard to correct and have always tried to avoid surgery for these. In one case that was successful, in addition to PIPJ fusions of the 2nd and 3rd toes with pin fixation across the MTPJs, I performed capsulotomies and capsulorraphies of the MTPJs as well as base wedge osteotomies of the 2nd and 3rd metatarsals to correct for the small amount of met-adductus that was present. I also freed up the extensor tendons from the insertion to about the metatarsal neck area, and sutured the tendon sheath apparatus in a more medial alignment, to try to relieve the lateral pull of the tendon across the MTPJ.


 


I followed the patient, who was very active, for 4 years until I retired. At least until then, the correction held up very well and the patient was happy. I can only hope that the correction will continue to last. This is the only time I performed this combination of procedures and I think that the correction of the met-adductus, although seemingly minimal, was key.


 


Richard M. Maleski, DPM, RPh, Pittsburgh, PA

09/10/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1



From: Andrew I. Levy, DPM


 


First, we need to see x-rays. But all things being equal, I suggest custom pediatric-sized double or triple Budin splints. Use these until the deformity is stable and then at least half again as long.


 


Andrew I. Levy, DPM, Jupiter, FL

09/09/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Sheldon Nadal, DPM


 



Abducted lesser toes are often associated with long adducted metatarsals. The toes then go in the opposite direction. This is usually most noticeable with the third metatarsal and third toe, and is often associated with second and third toes that are splayed apart. Consequently,  in order to get satisfactory reduction of the transverse plane deformities, it is necessary to perform osteotomies at metatarsal necks two and three, in addition to toe surgery (toes 2 and 3 need to be shortened). I would not fixate the lesser metatarsal osteotomies and I would splint the second and third toes to each other with 1/16 inch or 1/8 inch felt between the two toes while holding them as straight as possible in the transverse plane.


 


When the foot heals, the toes should be less abducted and the metatarsal heads will have shifted slightly laterally. If the fourth metatarsal head is prominent plantarly, you may consider doing the fourth metatarsal osteotomy at the same time. Otherwise, I would tell the patient that she may need a fourth metatarsal osteotomy in the future if she develops pain under the fourth met head.


 


Digital surgery performed in the presence of long adducted metatarsals without lesser metatarsal osteotomies can, in some cases, result in subluxed metatarsophalangeal joints, especially if soft tissue work is done at the MPJs. The transverse plane deformities originate at the metatarsal phalangeal joints. It is more effective to correct a forefoot deformity by performing surgery proximally than distally to it.


 


Sheldon Nadal, DPM, Toronto, Canada


09/09/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Edward Cohen, DPM


 


Crooked and deviated toes are one of my main interests. I learned correction techniques attending MIS cadaver meetings at LSU Medical School. These problems can usually be corrected by doing non-fixated  proximal phalangeal and metatarsal osteotomies. In severe MPJ dislocation cases, you can combine these with a Haspel MIS decompression metatarsal head osteotomy. 


 



 


Above are photos of a 78 year old patient pre- and post-op. The patient was able to resume his three mile walking regime just two days after the surgery.


 


Edward Cohen, DPM, Gulfport, MS

08/28/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Dennis Shavelson, DPM


 



My anecdotal experience is that COVID-19 affects endothelial cells by creating an hypoxia and Dr. Jacobs article supports my stochastic hypothesis. In Cuomo and Coppola, et al.'s article, pro-inflammatory cytokines activate hypoxia-inducible factor 3α via epigenetic changes in mesenchymal stromal/stem cells, they determined that “hypoxia activates the expression of nuclear factor-kappa B (NF-κB), which in turn stimulates the release of pro-inflammatory cytokines, as interleukin 6 (IL6)” as discussed in Allen’s referenced article.


 


Dennis Shavelson, DPM, NY, NY


08/28/2020    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Elliot Udell, DPM


 


Thank you Dr. Jacobs for giving us a link to an article which shows an association between arthralgias and myalgias and COVID-19. It is advisable that we all read this paper. What is different, however, between the query I posted and what was discussed in the paper is the timing. The patients who are presenting to us with painful soft tissue pathology are presenting six months after being symptom free of COVID-19. It is now the end of August and the majority of the patients I am seeing with these symptoms had COVID-19 in early March when the disease was rampant in our geographic area.


 


I am trying to gather information from all of our colleagues and the data gathered might be "meat" for another paper.


 


Elliot Udell, DPM, Hicksville, NY

08/27/2020    

RESPONSES/COMMENTS (CLINICAL)



From: Allen Jacobs, DPM


 


This article might assist Dr. Udell and other posters inquiring about musculoskeletal pain associated with or subsequent to COVID-19 infection.


 


Allen Jacobs, DPM, St. Louis, MO
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