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05/10/2021
RESPONSES/COMMENTS (NEWS STORIES)
From: Steve Kominsky, DPM
Any time that a surgeon makes a comment like “it allows for a faster healing time” typically means that up against a more traditional approach to the “same procedure”, the procedure being touted is the better of the two for the reasons listed. Unfortunately, in too many cases, this is mis-information being touted as either for monetary gain (either paid by the manufacturer, OR direct marketing to consumer) or it is simply because the surgeon has “drunk the Kool-Aid”.
The Lapiplasty procedure, of which I have done several, is a place looking for a home for well-designed surgical instrumentation. I am not speaking against the concept, nor the instrumentation in terms of its function. It works well. It does, however, add substantial cost to the procedure. Does one NEED to use it - well I see it similar to riding a bike with training wheels, or skiing with poles. It may be helpful during the initial phase to learn the Lapidus technique, but in NO WAY do patients heals faster and return to shoes and activities faster with this technique vs. the more traditional Lapidus procedure.
Steve Kominsky, DPM, Washington, DC
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
11/09/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Bob Hatcher, DPM
Years ago, I changed my approach on going barefoot at home after having to remove a bucket full of foreign bodies. Toothpicks, needles, thumb tacks, nails, a small knitting needle, and even (in a diabetic) a Matchbox car!
I'll bet Dr. Kuizinas might do the same one day. All the best to her.
Bob Hatcher, DPM (retired), Raleigh, NC
10/05/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Bradley J. Makimaa, DPM
The official statement should be "See your sports podiatrist to evaluate if your running shoes can last you more than 200 miles." As podiatrists we are the experts in shoes. The 300/500 miles for shoes is outdated info. A study showing 40% collapse in the heel cushion at 200 miles is more indicative of what we should look for. I change my running shoes every 200 miles. My race shoes, I take a hard look at just over 100 miles.
The lighter, faster, and more high tech the shoe, the faster it usually will break down. This is usually related to the ability to create a lightweight, energy return-type foam. This new material cannot hold up as long and should not be compared to the heavy materials of the past. Of course, weight, stride, wear pattern, run surface, and general biomechanics all need to be considered.
Bradley J. Makimaa, DPM, Key West, FL
09/05/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Dennis Shavelson, DPM
I must debate Dr. Splichal on her recent highlight on PM News. Her posts continue to reflect personal bias regarding biomechanics and human movement. Dr. Splichal is a consultant to Nike and Apex shoes and Barefoot Science Orthotics and has her own vibration devices, mats and inserts that are not natural. She calls herself a "natural" podiatrist, but for me, natural should read “uncivilized”. She shows pictures of us on grass, dirt paths, and beach sand, and denies the 15,000 years of adaptation to paved roads, clustered homes, and a civilized lifestyle that have been so necessary, including shoes.
She suggests that we are better off allowing our forefoot to spread; that our toes are major balancers of our feet (not) and that if we are barefooted while active some part of the day, many of our woes and ills would be cured. Hopefully, she can give us references to back up her "natural" claims here.
Dennis Shavelson, DPM, Tampa, FL
06/29/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Al Musella, DPM
Insulin costs are just the tip of the iceberg. Drug prices are out of control. I got involved in brain cancer research and run a brain cancer foundation. For these patients, the co-pay for the first month of chemotherapy if they have Medicare alone is about $1,000. About half of these patients cannot afford it and go without it. This leads to an earlier death and a much smaller chance at long-term survival.
When my dad was diagnosed with a malignant brain tumor and he was told his cost for the chemo was going to be about $5,000 a month (this is before Medicare started paying for it), he refused it. When I found out he refused it, I bought it for him but it was too late. He died just 3 months later. Statistically, the average glioblastoma patient in the USA lives 8-9 months. However, if you only count patients who get access to treatments, the average is...
Editor's note: Dr. Musella's extended-length letter can be read here
06/28/2022
RESPONSES/COMMENTS (NEWS STORIES)
RE: Insulin Costs Outpacing Financial Resources for 4 in 5 Patients
From: Steven Kravitz, DPM
80% of diabetics or caretakers for someone with DM face credit card debt averaging $9,000 due solely to the cost of insulin. More than 60% have decreased the usage of insulin because of the cost, increasing multiple risk factors. The results are from the survey by CharityRx. The insurance industry, drug industry, and insurance regulators must look at this looming problem carefully. The risk involved with these patients is significant, potentially increasing morbidity tremendously. Secondarily, the resultant medical consequences can increase costs to the healthcare system.
This is just one of many aspects facing the elderly and anyone on a fixed income with any medical condition. The current rate of inflation, increased cost for food products, and decrease in the efficiency of the supply chain continue to make it more difficult for geriatric patients. Physicians are not given enough credit for the vast majority who care about their patients and independent of reimbursement concerns, put a hand out to help someone get the medical attention they need. More information can be found in: Forbes Healthcare, Deb Gordon. June 20, 2022.
Source: Report from the Academy of Physicians in Wound Healing Newsletter, June 23, 2022
Steven Kravitz, DPM, Winston-Salem, NC
06/24/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Janet McCormick, MS
As much as I admire Dr. Brenner, I must comment on the statement that DPMs and estheticians are performing "medical pedicures." Know this: Estheticians are not licensed to touch the feet or perform pedicures in any of the tri-states and are not trained to do so. Reality is that they are not licensed to touch the feet in any state, though in a few, they can "add moisture." They cannot wield instruments, files, polish, etc.
Pedicures are a regulated skill in every state in the U.S. and estheticians are not allowed to perform them. And when performed by a podiatrist, they are called "routine foot care" for that reason. Additionally, training estheticians to do "medical pedicures" by shadowing a podiatrist is not adequate for performing this service, nor is it legal or safe. One infected nick or cut by an esthetician performing a "medical pedicure" will not be supported by your insurance company in the case of a lawsuit. Check it out. An esthetician's legal standard operating procedure (SOP) involves the face and ends at the decollette except for the "adding moisture" thing in some states. BTW, I am an internationally certified and licensed esthetician and have trained estheticians for 20+ years. I know their SOP.
Janet McCormick, MS, Frost Proof, FL
06/20/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Andrew Levy, DPM
Today’s PM News hads very mixed messages for our 1987 PCPM class. Congratulations to Dr. Patrick Dwyer of joining a new group and seeing his success. In a few paragraphs, we found sad news of Maureen Brennan-Weavers’s passing. A quiet passing in her sleep, but a loss of one of the leaders of our class. My condolences to her family and loved ones.
Andrew Levy, DPM (Retired), Jupiter, FL
05/26/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Bryan C. Markinson, DPM
Oftentimes, common parlance used to describe procedures does not align with the exact definition or even intent of the procedure. It is in that vein that I feel compelled to make a statement regarding what my colleagues routinely call a “nail biopsy.” The procurement of a sample of nail plate and subungual tissue by a clinician for analysis under a microscope is NOT A BIOPSY. On the laboratory end, although they may call it a biopsy or mention the word biopsy in the report, the pathology billing is under the domain of the laboratory procedures and is in no way connected to the procedure done in the podiatry office.
There has been discussion (and passionate disagreement) about this for a few years now, with many a word to the wise about calling the submission of nail tissue samples a biopsy. It is not. Even though the CPT descriptor of the nail biopsy, CPT 11755, would seem to indicate that...
Editor's note: Dr. Markinson's extended-length can be read here.
05/11/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: David E. Samuel, DPM
Thanks, Dr. Jacobs, for those stats. This is so classic in that therapies that could have some benefits in very specific circumstances are destroyed and become not payable for over- utilization purely based on the mighty dollar. This will happen to graft codes soon enough, putting thousands of dollars of quality products on ulcers that are not properly off-loaded, compressed, debrided, etc., and would never heal until a met head is excised or vascular status maximized, or compression therapy initiated, to allow for healing.
Wonder why they want to limit applications now? Keep using them 8 times on your patients who walk in the door in their normal shoes, carrying their knee scooter, or holding their crutches/walker, swearing they ‘hardly’ walk on it. Why is PRP or amniotic injections considered experimental and...
Editor's note: Dr. Samuel's extended-length letter can be read here.
05/10/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Steven Kravitz, DPM
Dr. Udell points to an interesting but realistic question and the economic drivers that are unfortunately involved in medical decision-making. By economic drivers, I also reference the political relationship between physicians in the hospital setting. That includes the need for continued referral for business.
However, you still can stand on your two feet and explain and present the articles that support your position. There are many articles on HBO. Unfortunately, the vast majority (according to the major research articles) are poorly constructed and do not provide valid evidence to support...
Editor's note: Dr. Kravitz's extended-length letter can be read here.
05/09/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Allen Jacobs. DPM
With reference to hyperbaric oxygen therapy, over a decade ago, the OIG reported the following compliance issues:
1. Billing Medicare for the use of HBO for non-covered services;
2. Inadequate documentation to support the medical necessity for HBO;
3. Giving patients more HBO treatments than necessary;
4. Failing to perform the appropriate testing or treatment prior to HBO;
5. Not having a physician present during the HBO treatment;
6. 32% of all HBO payments were inappropriately billed;
7. 11% of payments were for excessive treatments;
8. 37% lack of sufficient progress to justify continuing treatment with HBO.
The Healogics HBO 22.51 million dollar false claims act liability for improper billing of...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
05/06/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Elliot Udell. DPM
Kudos to Drs. Kravitz and Jacobs for informing us that research shows that hyperbaric oxygen is not the be all and end all of wound care management. Be that as it may, in our geographic area and I suspect most geographic areas, hyperbaric oxygen centers are closely affiliated with, if not owned and operated by, the major hospitals. Many respected physicians and surgeons have affiliations with these centers. The problem is that there is political pressure and even implications of negligence brought against practitioners who might choose not to send their patients to these centers for hyperbaric treatment.
Very recently, I was treating a patient with a "diabetic" wound and his cardiologist told him that he “must" go for hyperbaric oxygen. I referred him and the patient went and there was no difference in outcome. The patient feels that he wasted his time. My concern was if I had not sent him for this treatment, could I have been sued for negligence for not having put the patient though this treatment and would I be facing his cardiologist and some major players from multiple hospitals in the courtroom?
Elliot Udell, DPM, Hicksville, NY
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
05/04/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Steven Finer, DPM
Once again, the public gets the idea that one "clips" the diseased fungal toenail as if snipping a hair. During 40 years in practice, I and thousands of practitioners will remember those patients spending a half hour with them. We would use multiple instruments relieving them of disfigurement.
A Medicare payment would barely cover the overhead. I have watched cavity preparation videos which technically do seem the equivalent of fungal nail debridement. Try to find a dentist who charges $45 dollars.
Steven Finer, DPM, Philadelphia, PA
03/25/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Clifford Wolf, DPM
Today's lower extremity surgeon is well aware of the principles of biomechanics, as taught in the Compendium of Podiatric Biomechanics (Root, Weed, Sgarlato, and Orien). This has evolved into an understanding of limb alignment. This, combined with imaging and clinical exams, means that so much has changed and continues to change. Get on board.
Clifford Wolf, DPM, Oceanside, CA
03/24/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Kevin Kirby, DPM
I have been following with interest this topic on “supination” here on PM News over the past week. Since I have been writing and lecturing on foot and lower extremity biomechanics and custom foot orthosis topics now for the past 37 years, I wanted to make a few important points. First of all, just because a number of podiatrists do not immediately respond to a post on PM News regarding the subject of foot and lower extremity biomechanics and foot orthosis therapy does not also mean that many other podiatrists don’t “care” about the subject.
Many of us who are truly interested in biomechanics and foot orthosis therapy do not feel the immediate need to use their valuable time to comment on every PM News posting. That being said, I am quite happy to ...
Editor's note: Dr. Kirby's extended-length letter can be read here.
03/23/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Robert Scott Steinberg, DPM
I agree one hundred percent with Dr. Stess. Almost every week, I see a new patient whose orthotics, produced from a scan, fail to address the complaint. These devices have many of the same things in common: Below 10mm heel cup; no external rearfoot post; arch height one half of what it should be. The plate is too flexible.
When I see these devices, I am embarrassed for our profession.
Robert Scott Steinberg, DPM, Schaumburg, IL
03/17/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Paul Betschart, DPM
I agree completely; I perform artheroresis when indicated. A corrective custom foot orthotic will certainly improve if not eliminate symptoms and prevent further mechanical stress for the vast majority of patients. I could never abandon this effective, non-invasive treatment for the supposed better reimbursement of a surgical intervention.
Paul Betschart, DPM, Danbury, CT
03/16/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Ivar E. Roth, DPM, MPH
Dennis, you’re not the only one. The company that pushes the subtalar artheroresis implant is so wrong when they say that orthotics will not help. Since using a specialized orthotic, my surgical load with treating pediatric flatfoot has dropped 98%.
While it is less financial remuneration for my practice, I know that my patients are being better served. More of our podiatric brethren need to re-examine the current world of orthotics.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
03/15/2022
RESPONSES/COMMENTS (NEWS STORIES)
From: Arnold Ross, DPM
No, I’m going to see that you're not the only one who cares about biomechanics. I care as well!
Arnold Ross, DPM, Los Angeles, CA
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