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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:


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

03/26/2021    

RESPONSES/COMMENTS (NEWS STORIES) - PART 1B



From: Peter J. Bregman, DPM


 


I have heard anecdotal information about this treatment for many years, very similar to how you described it. In fact there will be an article coming out shortly where I am on the opposite of the side of sclerosing injections. The reason being is if you read the literature, it takes a minimum of 20% alcohol to effectively cause chemical destruction of the nerve. So while I understand that there is a success rate for your injections, I would proffer that it is not the alcohol that is responsible for the success rate but it is the anesthetic itself. 


 


I venture to say if you switched out the alcohol with 4 mg of Decadron, you might even get better results not having to do so many injections. It is conceivable that somehow the alcohol has some sort of chemical physiological effect that enhances the anesthetic or vice versa but I think it’s more likely than not that it’s just the anesthetic that’s doing the job. There needs to be a study done using saline, local anesthetic, local anesthetic with 4% alcohol, and local anesthetic with 4 mg of Decadron. This would answer the questions above.


 


I also think that the patients that you think were cured by your 7 to 10 injections probably went somewhere else for different treatment. This is likely about the same number who had a neurectomy and did not do well and went somewhere else, which caused the surgeon to believe it was a success.


 


Peter J. Bregman, DPM, Las Vegas, NV

03/26/2021    

RESPONSES/COMMENTS (NEWS STORIES) - PART 1A



From: Paul A. Galluzzo, DPM


 


Dr. Cox and Dr. Roth are right on track regarding neurectomy. I have been doing alcohol sclerosing injections since 2001. My father, Dr. M.A. Galluzzo, was doing these injections even before that. I haven't had to remove a neuroma in over 15+ years due to the high success rate of this treatment. I have done in-office DTL release only when the injections have failed which is less than 10 % of the time. I also have great success with neurolysis for stump neuromas. For those who say the success is anecdotal, I would like to know how many patients you have treated with alcohol injections. 


 


When those patients who have undergone this treatment come back for other services and/or refer friends and family, I call that a success. If anecdotal equals success, then I'll keep providing this excellent level of care. And for those of you who don't do neurolysis with alcohol and may be located close to my practice and are thinking of neuroma excision for your patient, you can refer them to me. If it doesn't work, I'll refer them back to you for the procedure. 


 


Paul A. Galluzzo, DPM, Rockford, IL

03/24/2021    

RESPONSES/COMMENTS (NEWS STORIES) - PART 1B



From: Ivar E. Roth, DPM, MPH


 


I have to agree wholeheartedly with Dr. Bregman concerning neuroma surgery. RARELY does there exist a reason to do a neurectomy. It has been at least ten years since I have removed a neuroma surgically. Between steroid, alcohol injections, and orthotics, rarely is anything else necessary. However, recently I had one very stubborn case and I did a release only, with full success. 


 


Just like it is now accepted that we only do a fascial release for heel spurs, meaning we no longer remove the bone, the same situation exists with neuromas; they just do NOT need to be removed. The standard of care should be NON-removal for us and for the benefit of the patient. That should be a point of distinction between DPMs and the MDs.


 


Ivar E. Roth, DPM, MPH, Newport Beach, CA

03/24/2021    

RESPONSES/COMMENTS (NEWS STORIES) - PART 1A



From: Peter J. Bregman, DPM, Brian Kiel, DPM


 


Dr. Cox, I am glad that you are doing the procedure although you’re not doing the open more definitive procedure. It also seems from your response that you were concerned about reimbursement. However, our goal is to give the patient the best result and while an endoscopic-type procedure is very good, I am a proponent of the open procedure using the appropriate microsurgical techniques. 


 


Peter J. Bregman, DPM, Las Vegas, NV


 


In-office release of DTL and osteotomies of 2 metatarsals with anecdotal success is a recipe for malpractice. Our obligation is to do the best for the patient, not what is best for us, whether it be our time or pocketbook. If surgical excision is the "best" treatment for a particular patient, then you are obligated to do that procedure or refer them to someone who will do it. I have maybe 3-4 neuroma surgeries per year as we perform sclerosing injections, a minimum of 6 every week or two weeks, with excellent results. We tell the patient that the usual course is 6-8 injections but occasionally there are 1 or 2 more. 


 


Brian Kiel, DPM, Memphis, TN

03/23/2021    

RESPONSES/COMMENTS (NEWS STORIES) - PART 1


RE: FL Podiatrist Discusses Morton's Neuroma (Peter J. Bregman, DPM)


From: Sanuel Cox, DPM


 


I read the response from Peter J. Bregman, DPM and agree I would love to never do another neurectomy. That said, I have tried first cutting the deep transverse ligament (DTL) with an #18 needle with poor success. Then I went to an MIS technique of using a #67 or #64 blade and hugging the metatarsal and cutting the ligament with only slightly better success. More recently, I have been doing about a 1.5 cm incision, then using a Freer elevator to locate the DTL. I then use a tenotomy scissor to cut the ligament, and use a hemostat to spread the interspace, with better success.


 


With this type of procedure, there is very little post-op pain and no bleeding. I use a few simple sutures and it is quickly done; however, there have been some of those procedures that have...


 


Editor's note: Dr. Cox's extended-length letter can be read here.

03/22/2021    

RESPONSES/COMMENTS (NEWS STORIES) - PART 1



From: Peter J. Bregman, DPM


 


I read the news item highlighting the coverage of Morton’s neuroma by Dr. Kushner, and not surprisingly he mentions neurectomy as a end-point solution. When will this profession understand and adopt decompression as the first surgical option for a patient? It has a very high success rate when done properly and has zero chance of stump neuromas. I have treated too many stump neuromas from neurectomies, which can ruin people’s lives for a long time. 


 


I don’t think our profession understands the damage that can be done by performing a neurectomy. I recommend everyone look deeper into doing decompression instead, and receive proper training if necessary and certainly the Association of Extremity Nerve Surgeons would be the place to do that. Having performed over 400 nerve decompressions with around  90% success and zero stump neuromas, I cannot advocate neurectomy. I hope there will be an end to neurectomies as a first line surgical treatment. 


 


Peter J. Bregman, DPM, Las Vegas, NV
ASPMA


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