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04/26/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Clifford Wolf, DPM
While Dr. Srivastava and her colleagues make this look easy, there are significant issues which need to be recognized before a team can start employing this technique. Training and experience of the Mohs micrographic surgery (MMS) staff in processing the nail unit tissue is paramount to produce the highest quality sections. Because of the unique anatomy of the nail unit, it is easy to create sections with either false negative or false positive findings. Additionally, for optimal histopathologic analysis, the operating surgeon would benefit from training and experience in leaving the nail plate in place, as opposed to avulsing it.
When at all possible, functional surgery for nail unit melanoma in situ is preferable over amputation to preserve digit functionality. The recurrence rate observed in this study was non-inferior to other published studies. How do podiatrists get the training and qualification to perform treatment and management of ungual melanoma in situ?
Clifford Wolf, DPM, Oceanside, CA
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08/08/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Paul Kesselman, DPM
A recently released article discussed this very interesting topic. For those who are dealing with a large diabetic patient population, it is certainly worthy of more review and discussions with the medical specialists managing the patient's glycemic control. The authors discussed their experiences in a 2-year retrospective analysis at 2 Level 1 Trauma Centers. Their conclusions were that in certain patient populations, the fructosamine levels were a better predictor of perioperative complications of infection, dehiscence, joint replacement failure, and others than HbA1C.
I am left wondering if other podiatrists, including Dr. Allen Jacobs, have had similar experiences with fructosamine levels in their patient population, including office-based and or other outpatient elective surgical patients. For more information, Please click here
Paul Kesselman, DPM, Oceanside, NY
07/31/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Paul Kesselman, DPM
Dr. Jacobs’ post is unfortunately true, despite similar posts, from many esteemed colleagues, many who have called for a re-emphasis of biomechanics. In the three or more years I personally have been posting on this issue, nothing in a positive direction has changed. Dr. Jacobs alludes to my review of charts not having sufficient biomechanical or basic gait data. That alone is bad enough! What he failed to mention is it’s far worse than that. In my role as advisor for a myriad of orthotic labs, the sheer volume of improperly completed order forms is staggering. And it’s not just limited to podiatrists.
Chiropractors, orthotists and pedorthists also somehow feel the orthotic lab can fix a bad scan or cast, or somehow figure out the right prescription for what ails the patient. That’s like leaving it to the pharmacist to know which hypertensive medication a patient should take. No ill will towards the pharmacist, but that’s not their responsibility. Just as it’s not the labs issue to repair a cast or predict how much posting or shell rigidity your patient can tolerate. Fabrication labs can do just so much. It’s up to the clinician to do a proper work-up!
Our residents need more time in clinical rotations in biomechanics and less time doing reconstructive trauma surgery. That should be left to post-residency fellowships. We need to spend more time educating the next generation of DPMs on in-office, everyday routine matters and less time-on the less frequent. If that means CPME or other acronyms make changes, so be it. I’m not involved in academia but sometimes it takes an outsider to see what’s wrong. I believe that Dr. Jacobs, I, and many others of our generation see the problems too well!
Paul Kesselman, DPM, Oceanside, NY
07/30/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Ben Pearl, DPM
I agree with Dr. Jacobs' assessment that commercial driven ideas are often passed off as vetted gait research. In addition to all the direct access “biomechanic solutions” that are directly marketed to patients at online and brick and mortar retail outlets, other specialties have begun to fill the void that has been created by many but not all residency programs and other podiatry seminars. Recently, a friend sent me a popular podcast that featured a chiropractor talking about gait and a strong pitch for the benefits of minimalist shoes. There are physical therapy clinics that have specialty run clinics that also fill the void. Another colleague sent me a course called Gait Gurus that reviews cases and is organized by chiropractors.
When I was consultant at NIH, we used to routinely have a biomechanics PhD, orthopedic surgeon, physical therapist, physiatrist, and me watch a patient walk and collectively make recommendations for treatment. I make it a point to try to video my patients’ gait as much as possible and review it with them.
Hopefully, our profession is past the recognition point that we are being superseded by other commercial entities and specialties and is now making active course corrections to remain relevant in the area of gait.
Ben Pearl, DPM, Arlington, VA
07/30/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Rod Tomczak, DPM, MD, EdD
Dr. Kesselman asks why a podiatrist has never led a team of researchers or published research concerning the correlation between gait and general health. Dr. Jacobs very succinctly states the reason is because we don’t perform a true gait analysis anymore. Besides, it’s difficult to perform a true evidence-based examination in the office. Experience-based maybe, but real objective data is hard to glean from the equipment most podiatrists have on hand. Most reputable journals would scoff at an article submitted with the title, “Too Many Toes Sign and…” or “Wet Foot Impressions on the Floor in Diagnosing Pes Planus and Pes Cavus.”
But Dr. Kesselman’s question addressed why a podiatrist hasn’t authored the study. I posit there are a few reasons. One, a biomechanics paper is simply not as sexy as a supramalleolar osteotomies manuscript. Secondly, podiatry is primarily an action profession, not an...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
07/29/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Allen Jacobs, DPM
Some years ago, tapentadol was released as an alternative for the treatment of post-operative pain. Bunionectomies were selected for the study. No podiatrists were authors. Dr. Kesselman, if you speak to students on outside rotations and particularly residents, you will find that patients seldom if ever are subjected to weight-bearing examinations. Of course ABPM and CPME will quickly raise the requirement for a limited number of so called “biomechanical examinations” as a requirement. However, this is an examination that should be ongoing daily for 3 years. This includes patients being evaluated and treated for conditions undergoing surgical decision-making.
The fact is that gait analysis is not a routinely observed part of the podiatry evaluation observed by many podiatry residents. Therefore, it is not surprising that an evaluation of the relationship between gait and general health did not include podiatry...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
07/26/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Paul Kesselman, DPM
In a recent publication entitled, "What Your Gait Says About Your Health", the author(s) went into great detail about some issues every person experiences during their lifetime. As podiatrists, we should be on the forefront of monitoring these issues, documenting them, and referring patients to a variety of other practitioners as deemed medically necessary. A question to ask is why wasn't a podiatrist lead team or institution performing this study?
Paul Kesselman, DPM, Oceanside, NY
09/06/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Ivar E. Roth, DPM, MPH
Tip, here is the answer. I have studied intensely nail pathology for over 20 years. I have a 98% success rate to CURE any fungus toenail. I mean the worst of the worst. Regularly with the same success rate, I can get nails to re-attach and grow normally. The answer is to treat the nail bed.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
09/04/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Nail Biology and Nail Science
From: Tip Sullivan, DPM
I have always wondered why no one has ever figured a way to entice a nail to re-attach to the nail bed after trauma. I have finally found a great source of information and would like to share it.
Tip Sullivan, DPM, Jackson, MS
04/29/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2
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
04/29/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1
From: Ben Pearl, DPM
While the results of the survey are a little surprising, there is an inherent selection bias in that only runners that were not suffering with debilitating knee arthritis would be participating in the Chicago Marathon.
Ben Pearl, DPM, Arlington, VA
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1C
From: Robert Kornfeld, DPM
I graduated NYCPM in 1980. Back then, there was a huge divide between “closed” and “open” surgeons. I did lots of MIS bunionectomies with a Shannon #44 burr in those years. There was no question that the x-rays weren’t always pretty but the patients were happy. But applying MIS to certain levels of deformity was not satisfying. While I spent most of my surgical career doing mainly traditional open surgery, I always found MIS preferable for certain cases.
To be honest, this many decades later, it is surprising to me that there are still “evaluations” of MIS being reported. It has been around for a really long time. It is being performed all over the world. I say let each surgeon choose the technique that is most satisfying in his or her hands. If it did not produce positive outcomes, it would no longer be a surgical option for thousands of surgeons around the world.
Robert Kornfeld, DPM, NY, NY
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Keith L. Gurnick, DPM
A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 months. All used the Shannon burr and performed distal metatarsal osteotomies which needed screw fixation. This review found a 16.6% complication rate with MIS hallux valgus correction, which is higher than that reported in the literature for open procedures of 7% to 8%. Many reasons for this increase in complication rate with MIS hallux valgus surgery can be considered. The hardware removal rate accounted for almost 40% of all complications as is likely due to screw prominence after swelling resolves given the entry point on the medial border of the first ray.
1) The review of 17 studies on MIS bunion using a Shannon 44 burr and screw fixation showed twice the complication rate of...
Editor's note: Dr. Gurnick's extended-length letter can be read here.
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Neal Blitz, DPM
As you know, MIS bunion surgery is a hot topic, game-changing, and no longer the mark of an "inferior surgeon." You might particularly appreciate the parallels I draw between new MIS bunion repair to the history of laparoscopic surgery, which was once considered an "unethical procedure" and now is the global gold standard.
Neal Blitz, DPM, Beverly Hills, CA
02/15/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: AFOs and PAD
From: Paul Kesselman, DPM
The effectiveness of community-based walking programs for patients with peripheral artery disease (PAD) can be limited by calf claudication during exercise. Recent evidence finds adding carbon fiber ankle foot orthoses (AFO) to a walking program can result in improvements in patient mobility and delay claudication onset when walking.
Paul Kesselman, DPM, Oceanside, NY
01/19/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Aspirin or Low - Molecular-Weight Heparin for Thromboprophylaxis After a Fracture
From: Elliot Udell, DPM
In the January 19, 2023, the Journal of the New England Journal of Medicine, a paper titled: "Aspirin or low - Molecular-Weight Heparin for Thromboprophylaxis After a Fracture" was published by the Major Extremity Trauma Research Consortium. The paper studied post-operative management of lower and upper extremity fractures and this included fractures of the foot as well as the hands.
It showed that placing a patient on low dose aspirin if the fracture was reduced surgically, was as good as giving heparin in preventing thrombosis. The paper studied patients starting at age 18. The paper did not indicate a need for prophylaxis if the pedal fractures were reduced, non-surgically.
Elliot Udell, DPM, Hicksville, NY
01/05/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Robert D. Phillips, DPM
I note the discussion in the last couple of days about recurrence rates after hallux valgus surgery. This discussion makes me reflect on some recent actions in our profession's residency education standards.
The question has to be asked, what is an acceptable recurrence rate? If it is 1/1000 or 5/100? If I am one of the patients in which it occurs, I don't care what the recurrence rate is. The fact that it happened to me is of primary importance and I want to know why. I also expect that the person who performed the surgery also wants to know why. Did that person do any type of exam before surgery besides take a couple of x-rays on...
Editor's note: Dr. Phillips' extended-length letter can be read here.
01/04/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: David Secord, DPM
I appreciate the post from Dr. Udell on the Scarf osteotomy and the call for a wider examination of bunion procedures and surgeon skills, skewing results. I have amended my approach to 1st ray pathologies to just three procedures: Primarily, the Scarf; Secondarily, the Lapidus (in cases of either an IM over 18 degrees, or a gorilliform or diseased 1st metatarsal/medial cuneiform articulation; and the Fowler (in cases where the IM angle is over 18 degrees and the 1st metatarsal/medial cuneiform articulation is normal). I commonly graft my Lapidus procedures to avoid over-shortening of the 1st ray and transfer to the 2nd met head. I’ve corrected as much as a 45 degree IM angle with the Fowler.
Although a major undertaking, a comparison of complications between commonly employed techniques would be monumental in scope and...
Editor's note: Dr. Secord's extended-length letter can be read here.
01/04/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: 3D Bioprinted Scaffolds for Diabetic Wound-Healing Applications
From: Leonard A. Levy, DPM, MPH
Effective treatment and healing of diabetic foot ulcers (DFUs) is a complex process, often unsuccessful, and resulting in significant clinical and economic burden as well as lower-limb amputation. A rapidly growing field is the use of 3D bioprinted drug-loaded scaffolds to treat DFUs. These bioprinted scaffolds are fabricated with different designs for the delivery of the antibiotic levoflocixin. The scaffolds utilize a variety of techniques that demonstrate excellent mechanical properties and provide sustained drug release for four weeks.
With the global incidence of diabetes (DM) rapidly increasing, it is estimated that 700 million people will have the disease by 2045, increasing the incidence of DFUs in the absence of improved, effective, and simpler treatment. It is forecast that the cost of DFUs which was $7.03 billion in 2019 will increase to $11.05 billion by 2027. To overcome this social and economic burden, new and innovative treatments such as 3D bioprinted scaffolds are needed to overcome restrictions of current treatment options.
Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL
01/03/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Elliot Udell, DPM
There is a question that all readers of the abstract will invariably ask. How does the complication rate of the Scarf procedure compare to complication rates of other first ray osteotomy procedures? Has this group done met analyses of other bunion procedures? Does the Scarf procedure have more or less complications as compared to other bunion procedures that utilize an osteotomy?
Another problem which relates to the Scarf procedure and similar types of osteotomies is whether the skill of a particular surgeon plays a role in complication rates. The study of 1,583 cases was not able to determine if the complications they listed applied to all surgeons or to only a handful.
Elliot Udell, DPM, Hicksville, NY
01/03/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Douglas Richie, DPM
Thank you, PM News for posting the findings of a recent study published in the Journal of Foot and Ankle Surgery which showed a 5.1% recurrence rate after 1,583 Scarf osteotomies were performed for correction of hallux valgus deformity. These findings reinforce other quality studies which also show low recurrence rates after standard osteotomy procedures used for hallux valgus surgery. A systematic review of 229 published studies found a 4.9% recurrence rate after standard hallux valgus surgery. (Barg, et al. J Bone Joint Surg. 2018:100(18), 1563-1573.)
This begs the question: Why is one particular medical device company advertising to the general public via the Internet and warning that standard bunionectomy surgery has a 70% recurrence rate?
Douglas Richie, DPM, Long Beach, CA
07/21/2022
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Steven Kravitz, DPM
This is an interesting study, but not necessarily a "green light" for cortisone injection in the treatment of Achilles tendinitis. It still should be used only after conservative treatment, when heel lifts, stretching, etc. are not effective. If cortisone injection is used, it should be applied judiciously, not repeated on a regular basis for a long period of time, and short-acting steroids are preferred. Additionally, the degree of tendon disruption should be considered prior to the use of cortisone therapy.
Finally, what is the lifestyle and the degree of stress the individual is expected to apply to the Achilles tendon apparatus post-injection therapy? The two extremes would be a ballet dancer and a librarian. The long-term potential negative impact on the structure intended is of much more concern with a ballet dancer and others who are extremely...
Editor's note: Dr. Kravitz's extended-length letter can be read here.
07/20/2022
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Keith L. Gurnick, DPM
This is a wonderful piece of literature to help defend doctors who end up in a lawsuit after Achilles tendon ruptures associated with repeated cortisone injections. They reported no "severe" adverse effects in their study. All patients were injected with either (1) 1 mL of methylprednisolone acetate (40 mg/mL) and 1 mL of lidocaine (10 mg/mL) (corticosteroid injection) or (2) 1 mL of lipid emulsion and 1 mL of lidocaine (10 mg/mL) (placebo injection). No severe adverse events were observed in either group, and there was no deterioration in the long term (2-year follow-up). Patients were offered up to 3 injections with an interval of at least 4 weeks between each injection.
All adverse events, defined as any negative or unwanted reaction to the intervention, were recorded at each physician visit, with special focus on fat atrophy, skin depigmentation, infections, and tendon ruptures. Furthermore, during the intervention period, the patients were asked to register any adverse events in their patient diary, including pain beyond a few days after the injections.
A total of 215 injections were administered (87 corticosteroid and 128 placebo). Injection pain was indicated in the patients’ diaries, with a mean (SD) pain score of 12 (14) of 100 in the corticosteroid group and 14 (17) of 100 in the placebo group, with no significant differences between groups. No severe adverse events (e.g., infection, tendon rupture, subcutaneous depigmentation, or atrophy) were recorded in either of the groups.
Keith L. Gurnick, DPM, Los Angeles, CA
07/20/2022
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Doug Richie, DPM, Elliot Udell, DPM
It is important to recognize that the corticosteroid injections were not administered directly into the Achilles tendon in this study. As noted in the manuscript, the injections were "placed peritendinous anterior to the tendon in the Kager triangle as close as possible to the thickest part of the tendon, or, in the case of neovascularization, as close as possible to the intratendinous vessel(s)."
Doug Richie, DPM, Long Beach, CA
Thank you, Dr. Kass for sharing this article with all of us. What is most interesting is that the paper not only documented "immediate" relief of symptoms but studied the Achilles tendon with ultrasound, and documented that there was no deterioration over two years.
This would seem to give us a green light to treat Achilles tendinopathy with one injection of a steroid. One question that this paper did not cover was whether there is danger to the Achilles tendon by giving multiple, weekly injections of a steroid.
Elliot Udell, DPM, Hicksville, NY
07/19/2022
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Ultrasonography-Guided Corticosteroid Injection vs. Placebo Added to Exercise Therapy for Achilles Tendinopathy
From: Jeffrey Kass, DPM
Jeffrey Kass, DPM, Forest Hills, NY
06/14/2022
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Study Shows Relationship of Diabetic Foot Ulcers to Vitamin D Deficiency
From: Leonard A. Levy, DPM, MPH
A retrospective study was done on 339 hospitalized patients with type 2 diabetes, aged 60-90 years (mean age 67, nearly two-thirds were men) . They were seen between January 2020 and March 2020, including 204 with and 135 without diabetic foot ulcers. Overall, 80.5% had vitamin D deficiency (defined as < 50 nmol/L or < 20 ng/mL). Factors that independently linked with an increased diabetic foot ulcer risk were prolonged diabetes duration and elevated systolic blood pressure.
While the relationship between diabetic foot ulcers and vitamin D levels has been controversial, the study showed that among the people with a diabetic foot ulcer, only 3% had vitamin D levels that were sufficient (> 75 nmol/L or > 30 ng/mL), 24% had levels defined as insufficient (50-75 nmol/L or 20-30 ng/mL), and 73% were deficient. The differences between these rates and those among the people without a diabetic foot ulcer were significant. Elderly people with diabetes were recommended to have routine vitamin D screening or receive vitamin D supplementation to prevent the onset or improve the prognosis of diabetic foot ulcers. (Source: Miriam E. Tucker, Medscape, Low Vitamin D Links With Increased Diabetic Foot Ulcers, June 03, 2022)
Leonard A. Levy, DPM, MPH, Fort Lauderdale, FL
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