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From: Keith L. Gurnick, DPM


It may be that Dr. Paul Greenberg was misquoted, because making generalized statements about the after-effects of toenail avulsions and toenail matrixectomies such as, “It doesn't require any bed rest, and patients can usually do whatever activity they want by the day after the procedure” is inappropriate and not honest for many of our patients. Each patient should have specific after surgery orders and instructions and necessary restrictions or modifications depending on their specific needs and requirements.


Our patients need to be informed in advance that there are potential risks and complications, and also that there is expected disability and recovery time after toenail avulsions and matrixectomies, just like all the other procedures and surgeries that we perform. Even simple and routine procedures can inflict short-term pain and require some time for healing. In some patients, the necessary post-operative recovery does include rest, activity, and shoe modification and could also require time off work or time away from participation in sports activities as well. It just depends on the individual needs and issues of each patient.


Understating the potential post-operative effects of toenail surgery will set you up for an unhappy patient and the possibility of delayed healing, infections, and further disability. We owe it to our patients to be honest with them, and the same should be true when participating in radio or magazine or media interviews and on our websites as well.


Keith L. Gurnick, DPM, Los Angeles, CA

Other messages in this thread:



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



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



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



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



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.



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.



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.



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.



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



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



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



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



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



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.



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



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



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



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



From: Dennis Shavelson, DPM, CPed


High arched foot types (the rigid rearfoot, rigid forefoot functional foot types) only put excess weight on the outside of the foot in the rearfoot (a low rearfoot SERM-PERM Interval). In the forefoot, the rigid FFT has a plantarflexed and stiff first ray that results in too much weight and function on the inside of the foot (a low forefoot SERM-PERM Interval). They have medial forefoot pain, osteoarthritis of the 1st MP joint, and callus and wounds under the 1st metatarsal head confirming excess weight-bearing on the inner, not outer, side of the foot. High arched feet reflect lateral heel and medial forefoot dysfunction and lack the ability to perform tasks. They are poor shock absorbers and do not handle inclines and obstacles well. Summarily, they lack the ability to pronate the rearfoot and supinate the forefoot (their forefoot is pronated, not supinated). Click here to read reference.


For years, podiatry has focused its education and practice on reconstructive foot surgery as it has morphed and matured into a sophisticated surgical specialty with new terminology, expanded applications, and predictable outcomes. It accomplished this over time with a foundation of a three-year surgical residency and a practice focused on being a great surgeon. There was no longer room to remain expert in other fields of podiatric medicine such as biomechanics and human movement that have similarly morphed and matured over time as its practitioners have sacrificed surgical prowess to become an expert in like me. Am I the only podiatrist who cares?


Dennis Shavelson, DPM, CPed, Tampa, FL



From: Ivar E. Roth, DPM, MPH


Todd Sommer, DO, DPM, congratulations on your position at the wound center. You make podiatry proud.


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



From: Jay Kerner, DPM


Suggesting an anti-inflammatory diet to patients with gout, inflammatory arthritis, diabetes, etc. is good medicine. Suggesting cherry juice, turmeric, bananas, watercress, and low fat milk products as gout preventatives is, however, in the realm of alternative medicine. Though there have been individual studies suggesting the effectiveness of cherry juice as a gout preventive, there are recent studies that show it has no effect. There are papers now questioning the role of purines in initiating gouty attacks.


There are no studies for these foods for any pathology with the strength of the vitamin D3 or anti-inflammatory diet studies. Advising patients to take them based on ‘recent studies’ is more a belief or exaggeration than evidence-based medicine...regardless of ‘epigenetic factors’. 


Jay Kerner, DPM, Rockville Centre, NY



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)



From: Robert Kornfeld, DPM


Kudos to Dr. Mitchell for discussing foods that not only can cause gout attacks (which we all know), but foods that can ward it off. The healing effects of food (and likewise the pathology inducing effects of poor diet) are not applied enough clinically in our profession. Epigenetic assessment is critical in so many conditions and simply treating symptoms alone does not improve the overall health of our patients.


Robert Kornfeld, DPM, NY, NY



From: Ivar E. Roth, DPM, MPH 


According to Dr. Glenn Davison, with early intervention, it is possible to avoid bunions. That means obtaining proper foot support with the best shoes for bunions.


I hope Dr. Davison was misquoted concerning that the wearing of shoes with proper foot support will possibly avoid bunions with early intervention. This statement is not true at all and just perpetuates a myth that should be eradicated from being reinforced in the media, especially by our profession.


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



From: Robert D Teitelbaum, DPM


I too, have a very low recurrence rate from P&A procedures because I saw the problem early on in my career. A side nail matrix to me brings up the following image: sticking an index finger into a cup of pudding, then quickly retracting it. What do you have? A hole with the matrix extending in all directions up from the floor of the indentation. With the thinned out cotton tipped applicator soaked in phenol, I apply firm pressure in a centripetal fashion to soak all sides, including the invisible dorsal side of the matrix.


Twenty seconds from the finish, I do this again. With this, I get minimal 'residual nail spurs' 6 months post-procedure. In addition, what is very important is to explore the evacuated space with a curette after using the anvil nail splitter. Many times, I have pulled out a small piece of matrix that would be left without this inspection.


Robert D Teitelbaum, DPM, Naples, FL  

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