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03/18/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Michael J. Schneider, DPM
In today’s climate of gender equality/equity, can Dr. Mendoza’s claims of gender discrimination in podiatry residencies be substantiated?
Michael J. Schneider, DPM, Denver, CO
Other messages in this thread:
12/08/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Ivar E. Roth DPM, MPH
I completely agree with Dr. Laps that bunion surgery should be a last resort. I review far too many complications cases where the patient had no or little complaints and the doctor basically insisted they should have surgery. I remember when I was an extern at Kern hospital (where Dr. Laps was trained) that the reason not to do both feet at the same time was different. It was to do one procedure a day or week for the patient to exhaust their leave time, and for the doctor to milk the insurance company so they would get the full fee on each procedure rather than be paid the multiple procedure fee if all the surgery was done at the same time.
Ivar E. Roth DPM, MPH, Newport Beach, CA
12/08/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Philip Wrotslavsky, DPM
Dr. Laps discourages having both feet done together. This published study is worth taking a look at to help get a better insight into doing both bunions at once. Unilateral versus bilateral first ray surgery: a prospective study of 186 consecutive cases--patient satisfaction, cost to society, and complications. Robert Fridman, et al. Foot Ankle Spec. 2009 Jun.
Abstract: Many studies have evaluated bilateral versus unilateral surgery in large joints, but limited research is available to compare outcomes of bilateral staged foot surgeries versus synchronous bilateral foot surgery. In total, 186 consecutive cases of first metatarsal-phalangeal (MTP) joint surgery were prospectively included in this study; 252 procedures were performed: 120 were unilateral or staged bilateral operations, and 66 were synchronous bilateral operations. Patients were evaluated at 6 and 12 weeks for specific early complications and surveyed about their return to work, activities of daily living, footwear requirements, satisfaction, and reasons for choosing staged or synchronous surgery. In addition, a cost analysis was performed on all surgical scenarios. Student t test showed no statistical significance between groups in all clinical settings to a 95% confidence level.
Complication rates were similar and few in all situations. Patients were very satisfied when choosing bilateral synchronous surgery and would elect to repeat it the same way 97% of the time. The economic costs to the health system average 25% greater when patients undergoing first MTP joint surgery have the procedure performed one foot at a time. Combined with the time lost from work, this reveals a significant economic cost to both society and patient.
Philip Wrotslavsky, DPM, San Diego, CA
11/10/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Ivar E. Roth, DPM, MPH
Going barefoot at home is a bad idea. Sooner or later you’re going to suffer an injury due to that recommendation. I guess the older you get, the wiser. While going barefoot might sound like a great idea, experience has shown me that it is not. Additionally, the more often you support your feet, the better your feet will function with the extra benefit of less injuries and accidents.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
11/10/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Robert D Teitelbaum, DPM
Dr. Kuizinas' observations may have validity for many patients but I find that in my Florida practice, going barefoot is problematic. Many people move down from the Northeast where they commonly have wall to wall carpeting and fall in love with some tiles that are very common here. It's warm, airy, and sunny, and they go barefoot quite often. In a short time, they're in my office complaining of heel pain. They are middle aged, and it's America, so many of them are overweight. I have to straighten them out when it comes to this subclinical stress they're putting themselves under. I find that half of the cure for heel pain syndrome is 'between their ears'. I straighten them out by telling them, "You get away with everything when you're younger, and nothing when you're older."
To be sure, there are many Floridians who have gone barefoot their entire lives and get away with it, possibly from their intrinsic muscles getting a great workout from early in life. But I don't see many of them in my office for that condition.
Robert D Teitelbaum, DPM, Naples, FL
05/05/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Allen Jacobs, DPM
The suggestion that hyperbaric oxygen is the “nectar of the gods” is incredulous. The retrospective studies examining the utilization of HBO for the management of DFU are at best controversial. The largest published retrospective studies demonstrate no benefit to system HBO, and no benefit whatsoever to topical HBO. Such studies have demonstrated no reduction in amputation rates, or advantage of HBO to comprehensive wound care.
The International Working Group on the Diabetic Foot's most recent recommendations stated that the indications for systemic HBO were “weak”, and for topical HBO non-existent. HBO therapy is never performed in a vacuum, and is...
Editor's note: Dr. Jacobs' extened-length letter can be read here
05/05/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Steven Kravitz, DPM
The news story quoting Dr. Adams references the increase in diabetes and the need for advanced therapies. There is very good evidence that demonstrates that the commercial aspect of wound healing products (and medicine in general) has driven up wound healing costs tremendously without the need to do so. William Marston, MD did a good study on venous ulcers, demonstrating 96% healed with simple compression therapy care. However, the reality is that other studies demonstrate as much as 80% of the time providers utilize advanced healing products. Only a couple of years ago, a major wound healing company was forced to pay back fines in excess of millions of dollars due to over-utilization of HBO.
We have to start "practicing what we preach" and use the most cost-effective, efficacious treatment to handle patient care. Otherwise, the government will apply increasing restrictions on how we practice and treat patients. The government tends to do this anyway; there's no reason to give them fuel for more ammunition.
Steven Kravitz, DPM, Winston Salem, NC
01/04/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: David S Wolf, DPM
Kudos to Dr. Ivar Roth for his innovated treatment for both humans and dogs. What a positive marketing opportunity for our profession to educate the population of what a podiatrist aspires to.
David S Wolf, DPM (Retired)
10/11/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Tom Silver, DPM, Steven Finer, DPM
I was disturbed to read the article about Dr. Morris Stribling getting $1,000 of opioids stolen from his office and, as a result, he has added a physical security team on his property and urges others to lock up all controlled substances. I see no reason why any podiatrist should have opioids available in their clinic. You are just asking to be robbed at gunpoint or have your office broken into if patients that are seeking drugs know that you have them.
When narcotics are needed, they should only be prescribed through a pharmacy and on a very limited basis. The bigger question I would ask this doctor is why does he carry opioids in his office and how much is he prescribing to his patients?
Tom Silver, DPM, Minneapolis, MN
The storage policy for drugs may vary from state to state. However, it is expected that drugs should be stored in a safe and that there is a dispensing legend. The legend should show patient name, name of drug, and number of pills dispensed. Personally, why take the risk? If needed, write a prescription. The break-in may have been avoided as who knows what is stored in that office.
Steven Finer, DPM, Philadelphia, PA
07/07/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Elliot Udell, DPM
Dr. Rotwein asks the question as to whether podiatrists should teach non-podiatrists how to cast for orthotics. There is a bigger "elephant siting in the room." What we should really be asking is whether any of us have any problems doing business with certain orthotic labs that spend a lot of time, money, and effort teaching and marketing orthotics to chiropractors, physical therapists, and other non-podiatric healthcare professionals?
This issue came to my attention last year when a local chiropractor called me and asked for my opinion on whether she should take training and utilize a certain orthotic lab to make foot orthotics for her chiropractic patients. What was extremely bothersome is that same company advertises heavily to our profession and sponsors lectures at our seminars.
Elliot Udell, DPM, Hicksville, NY
07/07/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Irv Luftig, BSc, DPM
After 41+ years in practice, I've seen my share of colleagues, myself included, teaching podiatry students/residents/younger podiatrists the finer points of what makes our profession so specialized and necessary. Dr. Abe Plon took me under his wing and set me on a wonderful path back when I was a student in the 1970s and again after I started practicing in the early 1980s.
I've never had an orthopedic surgeon I work with show me how to do a hip, or a total knee or shoulder replacement. I've never had a nuclear cardiologist show me how to catheterize a heart. That would be a ludicrous expectation. Why are podiatrists like Dr. Overstreet teaching practitioners who never stepped inside a podiatry classroom to take our places. It makes no sense.
Irv Luftig, BSc, DPM, Hamilton, ON, Canada
07/06/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1C
From: Keith L. Gurnick, DPM
It is not at all surprising that some general practitioners, nurse practitioners, and others would feel comfortable performing similar foot care that podiatrists routinely provide, after sitting in on a lecture or watching and learning from a podiatrist performing procedures such as a toenail trimming, callus debridement, ulcer and wound care, toenail avulsions, or even a matrixectomy or a fluid cyst aspiration. After all, we podiatrists, with our four-year podiatry education and three-year residencies, were all educated and trained to do these same procedures. What is alarming, however, is when they think they are clinically competent after the brief "SODOTO" (See one, do one and teach one) method of teaching and learning skills. The fact is, if you don't know what you are doing as a healthcare provider, you are going to cause some problems. And guess who will be called to bail out these non-specialists? Any and all of these routinely provided procedures have the potential for adverse risks, complications, and bad outcomes.
If others are going to do the procedures, they must be equally able to manage the patient afterwards, whether with good or bad outcomes. Non-podiatrists, those with extremely limited specialty specific education in the foot and ankle who perform these type of foot and ankle procedures, should never be held to a "lower standard" of care simply because they are not podiatrists.
Keith L. Gurnick, DPM, Los Angeles, CA
07/06/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Dennis Shavelson, DPM, CPed
Podiatry has forsaken evidence-based biomechanics, functional foot orthotics and their root causes that Dr. Root, et al. implanted into our profession in the 1970s. Subtalar joint neutral, pronation, hyperpronation and Root’s biomechanical examination are evidenced to be flawed and not useful to make biomechanical decisions. A 2017 study determined that “none of the deformities suggested by the Root method correlated with altered kinematics” and was “no longer valid for clinical practice.”
In the past, shoemakers, arch support fabricators, physical therapists, orthopedic surgeons, chiropractors, and orthotic labs openly brought us up to biomechanical speed. But currently, the exciting drive to elevate podiatry to be on par with MDs and DOs has supplanted non-surgical bio-architecture and biomechanics in importance as an acculturation of the DPM.
I gave warning about the future of biomechanics in a 1989 article. Using a 3 degree varus heel wedge and “posting to cast” is no longer the standard of care when it comes to biomechanics and custom foot orthotics. Instead, we are fast becoming the standard of care of orthopedic foot surgery, wound care, and regenerative sports medicine as we continue to acculturate podiatry. Should other professions draw a line in the sand to prevent that from happening?
Dennis Shavelson, DPM, CPed, Tampa, FL
07/06/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Jeff Root
Dr. Rotwein asks if you would teach a non-podiatrist how to cast for orthotics. I suggest that the answer to that question depends on who and why you might want to teach others to cast for orthotics. If the podiatrist is skilled at casting and is capable of training a non-podiatrist such as an office assistant to properly cast, then the answer might be yes. In this scenario, the podiatrist can personally evaluate the cast or scan of the foot and can prescribe an appropriate orthosis for their patient.
However, in my opinion it would be inappropriate to train a non-podiatrist to cast if that person was not qualified or was not working under the supervision of someone who is qualified to prescribe, dispense, and provide any necessary post-orthotic follow-up. Successful foot orthotic therapy requires both a quality cast or scan of the foot and an appropriate prescription that is specific to the individual patient’s condition and needs.
Jeff Root, President, KevinRoot Medical
07/05/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Allen Jacobs, DPM
I read with interest the decision in the state of Pennsylvania that a podiatrist may act as supervisor for a CRNA. Based on my prior experience, I suggest that one approach this with caution as an example of being careful for what you wish for.
Some years ago, I acted as a defense expert in a wrongful death case. In this particular state, absent the physical presence of an anesthesiologist in the operating room, the “surgeon“ was responsible for the actions of the CRNA. In this particular case, the nurse anesthetist gave a medication by bolus which was contra-indicated. The podiatrist was busily performing an excision of a ganglionic cyst. Unfortunately, the patient expired.
In addition to suing the anesthesia group, the podiatrist was also held liable due to the fact that...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
07/02/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Alan Ng, DPM
Interesting post by Marc Jones, interesting how he takes one year to post for open payments. He doesn’t understand that investing in a company when they start up is a risk. That money sits for years hoping that it does well and we get lucky. Every other year, the amount made on that site was a fraction of what was made in 2019. Most of those payments were from speaking and teaching. While someone like Marc is sitting at home, those of us who work with industry are away from our families designing or teaching other physicians new techniques or better ways to perform surgery.
Alan Ng, DPM, Denver, CO
07/01/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Marc Jones, DPM
Dr. Ng expressed his frustration in hospitals beginning the trend that was started by ASCs of making physicians use “cost-effective” implants. Why is he concerned with this? You don’t have to look any further than openpaymentsdata.cms.gov. In 2019, Alan Ng made $661,755.13 from biomedical companies, including Paragon 28, Zimmer, and Wright among others. 83% of that money came from ownership or investment interest in the companies and another 13% in consulting fees. If this trend continues, he himself will stand to lose a lot of money if the expensive implants cease to be used in the hospital setting. It is hard to believe that he is concerned about patient outcomes.
Marc Jones, DPM, Spokane, WA
05/21/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Dennis Shavelson, DPM
Dr. Ellman, by leaving out underpinning, inherited biomechanical pathology as the number one trigger of foot pain, foot deformity, performance issues, and degenerative joint disease from his list, is missing a great public service opportunity to educate the public of the importance of lower extremity biomechanics.
If you are having foot pain living life on hard surfaces while comfortable living on carpet, that is pathognomonic of one's endogenous structural collapse in some part(s) of the foot that needs to be supported, stabilized, or balanced rather than be dampened.
Cushioned shoes, shock absorbing surfaces, and reduced pounding lifestyles mask and defer the predicable bunions, pedal collapse, muscle engine atrophy, and back pains that develop over time in most of us that can be diagnosed, treated, compensated, and controlled using modern biomechanical technology.
Dennis Shavelson, DPM, Tampa, FL
05/11/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Patrick J Nunan, DPM
I want to add to Dr. Kominsky’s comments on cost. Many hospitals are contracted with maybe 2-3 suppliers of surgical hardware. Before getting approval, you have to submit a request and possibly present before a hospital committee on why and how the new equipment is better than what they have negotiated already with other companies. The new technology must be usable to most of the podiatrists and orthopedic surgeons on staff. It must be the same cost or less expensive than what is already on the shelf. The equipment needs to be unique and there is NO other way to fixate the procedure. The days of getting any equipment we want is over!
Patrick J Nunan, DPM, Beaufort, SC
05/11/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Don Peacock, DPM, MS
This post is of interest to me because I know both parties involved. I rotated through Dr. Kominsky’s program as a podiatry student. I was impressed by his surgical talent and his willingness to teach. Likewise, I know Thomas Bembynista, DPM and I met him at minimally invasive academy seminars. He is a superbly trained foot surgeon with stellar surgical skills.
Like Dr. Kominsky, I shy away from claims of better when it comes to techniques. There are too many variables. One of these is who does the surgery. The post reminds me of one of the best foot surgeons I have ever known who practiced in NC for years. He did not have hospital privileges for most of his career. He performed large foot surgeries in the office under local with perfectly skilled outcomes. He often used K-wires for large rearfoot fusion cases performed under local anesthetic in his office. His name was Barry Johnson, DPM and his surgical skills were amazing. There was something almost magical with his abilities.
The truth is some surgeons are just good at what they do. Drs. Kominsky and Bembynista would fall in this category. Whatever technique they do, it's likely to have good results. It ain’t the car (technique), it’s the driver (surgeon).
Don Peacock, DPM, MS, Whiteville, NC
04/15/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Burton J. Katzen, DPM
In response to Dr. Loshigian's post about there being no significant evidence that there is faster recovery time with minimally invasive surgery, I will agree that the long-term results of traditional vs. MIS might be the same depending on the procedure and surgeon. I assume what Dr. Loshigian calls “significant evidence” means evidence-based medicine. Unfortunately, it would be extremely difficult to satisfy surgeons who require level 1 or 2 evidence.
At level 1, you would have to have patients agree to have one foot performed traditionally and one foot using MIS techniques. At level 2, you would have to have patients sign up for surgery and randomly...
Editor's note: Dr. Katzen's extended-length letter can be read here.
04/15/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Don Peacock DPM, MS
The comparative studies between traditional and MIS HAV corrections have shown some slight differences in VAS scores in the early recovery period. However, the VAS scores even out fairly quickly at 3 weeks or so. Trying to answer the question as to which is best is not easy to conclude. Scientifically, there seems to be no difference between the disciplines with respect to HAV correction.
I do believe the increased popularity of MIS HAV correction will continue and will be patient driven. People like small scars, especially in the case of percutaneous procedures. There is psychology involved here as well; similar to the well-known placebo effect. It is likely that percutaneous scars are going to be well received by the patient and better results reported because the wounds appear smaller. If it looks like less trauma is done, then it will be perceived as such.
These questions are just as much answered by psychological effects imparted by a perception of less invasive techniques. These effects cannot be understated. If the patient thinks it is less invasive, it probably will be perceived as such. The placebo effect is well documented in medicine and patients can even get better with sham surgery. We have only scratched the surface on understanding how we heal and how our patients perceive healing.
Don Peacock DPM, MS, Whiteville, NC
03/30/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Lisa M. Schoene, DPM
Like Dr. Galluzzo, I have been performing 4% alcohol sclerosing injections for neuromas for about 12 years. I wish I had started using them earlier. I too have also had fantastic success with the regimen of 7-10 injections. I have a large sports medicine practice and my patients are thrilled with the success as there is no downtime and no reduction in their athletic activities. There are few to no side-effects, so this is better than using corticosteroids.
I utilize an outside ultrasonography doctor who works with many DPMs in the Chicago area. We have discussed that utilizing the 4% alcohol causes no damage to the fat pad (which is almost always too thin) nor to any of the surrounding muscles or other soft tissues. I have performed only 1-2 surgeries on neuromas since I have started using the solutions. I have also used this injection for injuries to the plantar proper digital nerve which gets caught under the sesamoid and can cause quite a bit of pain. This eliminates removing the medial sesamoid, which I prefer not to do.
These solutions have been long utilized for bladder and cardiac procedures, so the dehydrated alcohol has been around for a very long time. Maybe it is time to do a multi-center/office study utilizing this treatment protocol as an alternative to surgery, especially with the limited availability of corticosteroids, so we can "prove" the success that we are already achieving.
Lisa M. Schoene, DPM, Chicago, IL
03/30/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Brian Kiel, DPM
Dr. Bregman, you are correct in your statement that it takes at least 20% alcohol to cause nerve destruction. The purpose of sclerosing, however, is to have an effect that is not destructive. I feel that there is a desensitization of the nerve rather than destruction. Of course I have no studies to prove it and I think that would be an excellent project. In the meantime, my patients respond and those who have developed neuroma pain in another area, several years later, return to my office as a result of successful treatment.
Brian Kiel, DPM, Memphis, TN
03/29/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: David Secord, DPM
As Dr. Kiel is commonly using sclerosing injections on patients, I’m curious as to what code he is using and what solution he is using for “sclerosing” a nerve (Sclerodex, polidocanol, sodium tetradecyl sulfate [sotradecol] or phenol). I have to assume that it is one of these agents, as these are actual sclerosing agents, whereas 4% absolute alcohol is not (as evidenced by the fact that you are doing more than one injection). Clearly, if you have “sclerosed” the nerve, you don’t have to do it multiple times.
David Secord, DPM, McAllen, TX
03/29/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Charles Morelli, DPM
What is not being mentioned, and has not been mentioned when deciding whether or not to excise the neuroma or address the deep transverse intermetatarsal ligament (DTML), is the actual size of the neuroma. All neuromas are not created equal. If the neuroma is quite large and fills the interspace, a DTML procedure is doomed to failure and you will eventually need to go back again and excise it. That has been my experience. Conversely, if the lesion is small and the patient's symptoms are mild to moderate you should realize success by only addressing the ligament. I can’t tell you where to draw the line, but that comes with experience.
I also discuss both procedures with the patient and let them know that we may have to do a second procedure if the DTML is not successful. Some are okay with this and some are not. Some don’t mind rolling the dice, and some will say "just take it out doc" as they don’t want to go through a second procedure. I also will consider an invasive procedure after attempting sclerosing or steroid injections on small to moderate sized neuromas, and I have stopped injecting larger ones as for me, that has not been successful. Nor have pads or orthotics as patients do not wear them 24/7 and have pain barefoot. As always, evaluate your patient and do what is in their best interest.
Charles Morelli, DPM, Mamaroneck, NY
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