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04/27/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Bryan C. Markinson, DPM
I am not sure if Dr. Levy's intention on paraphrasing the article on Mohs surgery was informational only or if he was recommending that podiatrists employ it. Clearly, Dr. Wolf interpreted it as the latter and asks how one could "get the training and qualification" to do it. I am also confused about his point on leaving the nail plate in place, but that point is moot when it comes to excising a melanoma for which surely a preliminary biopsy has been performed, and total excision is now the reason for further surgery. Mohs surgery is not at all new.
The short answer to Dr. Wolf's question involves multiple steps towards getting the training and qualification to perform this surgery. Step one: Graduate from an accredited MD/DO program Step two: Complete a ACGME-approved dermatology, surgery, or plastic surgery residency. Step three: Complete a certified dermatopathology fellowship since Mohs surgery requires...
Editor's note: Dr. Markinson's extended-length letter can be read here.
Other messages in this thread:
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Hopefully, our profession is past the recognition point that we are being superseded by other commercial entities and specialties and is now making active course corrections to remain relevant in the area of gait.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
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.
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
05/06/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Bryan C. Markinson, DPM
Dr. Roth says, "since most pods can operate on soft tissue to the knee, it makes sense that one day a podiatrist will get this training and act as a referral for these lesions of the foot and leg. WHY NOT? He goes on to ask, ”Why not think big?" If this represents deep, considered thought about why podiatrists should be offered training in Mohs surgery, or interventional radiology, I believe it to be embarrassing should a dermatologist or interventional radiologist see it. However, if a DPM that Dr. Roth mentors and encourages to think big wants to be a Mohs surgeon or interventional radiologist, I have laid out exactly how one thinking big can get that done in my last two PM News issues.
Bryan C. Markinson, DPM, NY, NY
05/03/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Pete Harvey, DPM, Ivar E. Roth DPM, MPH
I agree with Dr. Markinson. What might be overlooked here is practicality. If a person requires heart surgery, he/she wants a surgeon who has performed hundreds per year and not one or two procedures. The odds of any surgeon in the country performing hundreds of Mohs surgery on a great toenail are very slim. I would be surprised to hear of any surgeon who has performed hundreds on a toe.
Pete Harvey, DPM, Wichita Falls, TX
I have read what both Dr. Levy has said and what Dr. Markinson has responded. My take is as follows: I believe Dr. Levy was just saying that this type of training and fellowship should be offered to those podiatrists who want to specialize in this area. Since most Pods can operate on soft tissue to the knee, it makes sense that one day a podiatrist will get this training and act as a referral for these lesions of the foot and leg. WHY NOT? I recently tried to get a fellowship going for a podiatrist to do an interventional radiology program. I can see the day when this will happen and we will be the best at clearing blockage of the foot and lower leg to save these limbs. Again, why not think big?
Ivar E. Roth DPM, MPH, Newport Beach, CA
04/30/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Steven Finer, DPM
A few years ago, I had the procedure done on the tip of my nose. It was done at a major teaching hospital in Philadelphia. The surgeon had the MD degree, dermatology residency, and a fellowship in dermatopathology. He also had the resources of the institution, including all the complicated machines and stains necessary to do the procedure. It is self-evident, as pointed out by Dr. Markinson, that a podiatrist must have the same.
Steven Finer, DPM, Philadelphia, PA
04/29/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Steven Kravitz, DPM
I read with interest the post written by Dr. Markinson regarding ungual melanoma and his comments on treatment thereof, including the Mohs procedure. They were professional, well stated, and point to the decisions we make each day with the patients that we treat and the ethical aspects related thereto.
We all seek to be the very best professionals we can be and we all believe that podiatrists, among all healthcare professions, should represent those who are best educated in this anatomical area and concurrently provide the very best care. But that does not mean providing all care necessary. It means, in addition to providing the treatment that we deliver, that we also utilize good judgment and refer to other professionals when appropriate to ensure that each patient is treated as a family member would be, getting the best care each of them deserves.
If I had the unfortunate experience of having an ungual melanoma, I would seek a specialist who had the most experience with Mohs procedure, especially with a historically challenging and potentially life-threatening diagnosis. We all gain by acquiring as much knowledge as we can on any topic related to the treatment that we provide.
Steven Kravitz, DPM, Winston-Salem, NC
04/28/2021
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Clifford Wolf, DPM
Dr. Markinson might be confused about leaving the nail plate in place. Dr. Divya Srivastava and her colleagues use this technique for primary biopsy. MART-1 immunoperoxidase staining was used to define the melanocyte density in the specimens. I agree with Dr. Markinson on the multiple steps he describes towards getting the training and qualification to perform this surgery.
For me, the message is that just because the pathology involves the foot and ankle, we (most of us) are not qualified to perform the standard MMS technique. The implications determining the tumor is malignant are horrific. Identify a team capable of doing this surgery in your area and use it as a resource for referral.
Clifford Wolf, DPM, Oceanside, CA
05/06/2019
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: David Zuckerman, DPM
I appreciate Dr. Jacobs pointing out that lasers shouldn’t be used for the treatment of mycotic toenails where there is PVD and lack of sensation. I have taught hundreds of doctors over the past 15 years and always pointed out that a detailed physical and history need to do done, as last time I looked, we are well trained podiatric physicians.
There is a role for lasers in the treatment of mycotic toenails. Lasers work by the mechanism of photo-biostimulation with heat playing little to no role in...
Editor's note: Dr. Zuckerman's extended-length letter can be read here
03/30/2018
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Elliot Udell, DPM
Dr. Kesselman and others, including me, have questioned why we do not have ongoing research studies in the area of foot orthoses and biomechanics. What fuels our frustration is that just as we know fish live in water and birds fly, we know that properly designed foot orthoses can help many patients with many foot conditions including some that cause heel pain. Just today, a patient came in to my office to have me make a new set of custom orthotics because the old ones wore out and his heel pain was returning. He would not be willing to pay hundreds of dollars for something that was not helping him. This is a common scenario for all of us.
The answer is that the podiatry labs should meet with the research people at our schools and together fund research on biomechanics and foot orthotics. I would donate to that cause. It’s an investment, and if enough papers show that orthotics are helpful, then we can begin to ask insurance companies to pay for them.
Elliot Udell, DPM, Hicksville, NY
03/26/2018
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Dennis Shavelson, DPM
Dr. Young comments without reading the paper. Dr. Udell presumes podiatry research will prove the value of our orthotics versus shams or OTC products. In fact, the meta-analysis conceived from the nil included orthotics developed eight (8) different ways. More fact: Subtalar joint neutral cast orthotics don’t place subjects into subtalar joint neutral weight-bearing. That’s because collapsing feet cast STJ neutral produce devices that are collapsed.
In 2012, Lee, et al. proved that the subtalar position has little to do with controlling arch height or protrusion. They cast non-weight-bearing, a cohort with subtalar joints aligned at 4° eversion, 2° eversion, neutral, and 2° inversion. Digital scanning analyzed the shape of each negative. They found that the changes in arch height, navicular height, and protrusion were insignificant and very small between groups.
There is no (anecdotal) doubt that podiatry $200-1200 custom cast foot orthotics work and make patients happy. Dr. Richard Schuster said, “well placed tissue paper in a shoe will work and make patients happy.” To produce peer-reviewed literature, you must research from the nil. Most important, you must have cohorts, products, and services that can be proven valuable and applicable in practice. In the case of podiatric custom foot orthotics, my opinion is that we do not.
Dennis Shavelson, DPM, NY, NY
01/23/2018
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Steve Spinner, DPM
First, let me congratulate Dr. Steinberg on his remarkable post-op infection rate. Secondly, let me remind the resident audience reading this that there in an enormous body of literature out there, including CDC recommended protocols, that set guidelines for antibiotic usage in surgery. In a nutshell, you would be within current practice guidelines if you were anywhere between a single pre-op dose and stopping within 24 hours post-operatively. The literature would not support administration of antibiotics for a period of 5-7 days post-op in a clean elective foot operation.
Steve Spinner, DPM, Plantation, FL
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