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RE: Intractable Plantar Keratoma Sub 2nd Metatarsal  (Gary Gugliada, DPM)

From: Multiple Respondents

In all likelihood, given the presence of an HAV deformity, the patient has a degree of metatarsus primus elevatus. This is an important consideration and needs to be addressed along with your 2nd metatarsal/digit repair. The patient won't be interested in the fact that they have "a normal metatarsal parabola" if the IPK does not resolve because you didn't address the 2nd metatarsal. The parabola may appear to be normal on a  AP radiograph, but functionally the 2nd ray is bearing most of the weight-bearing load. I would repair the hallux valgus deformity to remove the influence of the great toe on the 2nd toe, and address the elevatus with first metatarsal osteotomy, perform a osteotomy of the 2nd metatarsal to shorten it slightly (not so much that you end up with a transfer lesion) and an interphalangeal arthrodesis of the 2nd toe.


Thomas A. Graziano, DPM, MD, Clifton, NJ,

Consider a hammertoe repair with sequential reduction to the second toe. If it is semi-rigid, perform a PIPJ arthrodesis. Consider a Weil osteotomy of the second metatarsal as well. Sometimes, if the Weil osteotomy becomes unnecessary, you can often just plane down a hypertrophic condyle to the plantar surface of the metatarsal with a saw to help get rid of  the IPK. Do an axial sesamoid x-ray with that same lesion marker to see if a hypertrophic condyle or plantarflexed metatarsal can be seen.  This view is very useful in planning for these type cases. Fixing the toe will decrease the retrograde bucking forces on the joint and allow the plantarflexed metatarsal to come up as well.


Chris Browning, DPM, Nederland, TX,

If the toe & MPJ are flexible, and if the circulation is adequate, and you think the lesion is due to retrograde pressure, then percutaneous tenotomies and capsulotomies of the extensor and flexor longus would seem like a good option. I think that will reduce the pressure and still leave you the option of more open arthroplasty / arthrodesis work, if need be.

Using a wire marker around the point of interest on an x-ray still lets you identify where you want to focus attention, but it does not block out possibly important structures.

Andrew I. Levy, DPM, Jupiter, FL,

Editor’s Note: An extended-length letter by Dr. Mullen can be read at:

Other messages in this thread:



RE: Uric Acid Crystals, Post-op

From: Paul T Slowik, DPM

I have dealt with uric acid ulcers twice before. They are impossible to distinguish from osteo-based ulcers on any test or scan; neg cultures are a good sign. My approach was instilling a small amount, 1/10th cc. of Decadron, around the periphery of the ulcer. These patients were both  poorly controlled diabetics on dialysis, and the nephrologist had tried a plethora of meds. It took two or three injections spread over a couple of months. The injections hurt like the devil, so I recommend a digital block beforehand.

Paul T Slowik, DPM, Oceanside, CA,



RE: Exogen Bone Healing System (Tip Sullivan, DPM)

From: Narmo L. Ortiz, Jr., DPM

With all due respect to Dr. Sullivan, with the way health insurance is reimbursing for procedures, let alone for a bone healing stimulator without a pathological fracture and/or more than nine months of a confirmed non-union, why would you want to further burden the system and your patient's pockets? A properly made and fixated osteotomy should heal in due time without the addition of a bone stimulator. In addition, distal metatarsal osteotomies can be weight-bearing immediately post-op, while proximal ones can heal well with two weeks non-weight-bearing, followed by four to six weeks in a CAM walker boot.

Narmo L. Ortiz, Jr., DPM, Cape Coral, FL,

The Smith-Nephew Exogen bone system has an FDA indication for "fresh" fractures. In my experience, patients have quicker osseous healing times and also have quicker pain relief of the soft tissues while using it. I believe that Smith-Nephew is currently seeking indications for tendonopathies and other soft tissue afflictions. Despite its approved indication for fresh fractures, getting a health plan to pay for its use on a fracture that is not a delayed/non-union (fracture of greater than 3 month duration) is another issue that is often fruitless.

Russell F. Trahan, DPM, NY, NY,



RE: Mosaic Wart Treatment (Stephen Merena, DPM)

From: James Ricketti, DPM

I would pre-treat the lesion with Lazerformalyde Solution [Pedinol] daily for two weeks; then have the patient return in two weeks for debridement and application of Monocyte [Pedinol] with a dispersion pad. The next day, apply Lazerformaldye solution and Salactic Film [Pedinol] to the lesion daily. The patient returns every two weeks for the Monocyte application. It usually takes 2-4 treatments for full resolution.

Disclosure: I am the Inventor of the Monocyte Swab

James Ricketti, DPM, Hamilton Sq, NJ,



RE: Hallux Limitus/Rigidus Implants (Craig Aaronson, DPM)

From: Multiple Respondents

It appears that you are getting a jamming of the 1st MPJ during gait. To avoid this, I remove slightly more of the proximal phalanx base than the company suggests. I remove slightly more than ½ the thickness of the implant. In this case, I would remove the implant, remove more from the base of the phalanx and re-insert the implant. It appears on the x-rays that the implant may be slightly too large for the joint (I always go smaller), but the motion is coming from the fact that not enough bone was removed.

If you choose to re-do the procedure, get the patient to an outside physical therapist for early range of motion exercises.

David M Davidson, DPM, Buffalo, NY,

It appears that the implant is well-seated, however, it appears to be angled relative to the 1st MPJ and a little tight. The few Arthrex hemis I have done have all been a little stiff, but not painful. You may want to consider either re-doing the hemi and taking a little more bone and angling your cut to decompress the joint, and make it more congruent or use a total implant. Say what they will about totals......the motion is good and pain-free.

William Sachs, DPM, Toms River, NJ,

It looks as if the implant was put in perfectly from a technical standpoint. It appears that there is no space between the implant and the head of the first metatarsal, with most of the proximal phalanx remaining. I suggest removal of the implant and resecting more of the base of the proximal phalanx, then reinserting the implant to see if you get better range of motion. I would also drill some holes with a K-wire where the cartilage was damaged. One would want to start ROM exercises immediately after surgery. I am sure you will get many different ideas, however, I personally do not like to fuse a first MPJ in a 58y/o female.


Steven H. Goldstein, DPM, Royal Palm Beach, FL,

Editor’s Note: Dr. Peter Bregman's extended-length letter can be read here. Dr. Barry Mullens' extended-length letter can be read here.



RE: Custom Orthoses vs OTC Study (Dan Preece, DPM)

From: Allen Mark Jacobs, DPM

The Cochrane database of systematic reviews had examined studies on the utilization and efficacy of othotics. This is available at the Cochrane database of systematic reviews, Hawke, et al.;(online) (3) pp CD006801. There is evidence from appropriate studies that orthotics are useful for the management of pes cavus, plantar fasciitis, hallux valgus, and foot pain.


In addition, the use of orthotics for the management for plantar fasciitis (as well as other modalities) has been reviewed by Crawford and Thompson, Cochrane database of systematic reviews (online) (3) CD000416.


Allen Mark Jacobs, DPM, St. Louis, MO,



RE: Swimmer with Cramps in Arches (Alan Mauser, DPM)

From: Amol Saxena, DPM

I treat a lot of tri-athletes that come from a running &/or cycling background. It is common to get foot (& even hand) cramps when beginning swimming. Some of it may indeed be due to electrolyte imbalance, but I believe more often than not, it is due to the new foot position that is needed to be a swimmer. The 18 muscles on the bottom of the foot will always beat the one dorsal one; this results in arch cramps when not enough ankle plantarflexion is available.


This gradually goes away with time. If not, then electrolyte testing may be warranted.


Amol Saxena, DPM, Palo Alto, CA,



RE: Neuropathy From Chemotherapy (Jim Benedict, DPM)

From: Jack Ressler, DPM, Steven H. Goldstein, DPM

I have been prescribing Metanx for about three years and have had some good results. If you prescribe it to a patient and they feel it isn't working (minimum of one month), have them discontinue taking them. In several circumstances, the patients will call the office and will want to be put back on it. What they realize is that they were getting some relief and when they stopped the Rx, the symptoms returned. I find the renewal rate for these patients is high. The beauty of Metanx is that it can be taken with most medication, with the exception of people taking medication for Parkinson's disease.


Jack Ressler, DPM, Lauderhill, FL,

This is a subject that is near and dear to my heart as my own mother has severe neuropathy from undergoing chemotherapy for colon cancer. She was given oxoleplaten which has a high incidence of producing neuropathy. Although her oncologist told her it would dissipate with time, it has actually gotten much worse over the past 4 years to the point of becoming disabling. The symptoms were confirmed by EMG and NCV studies. That being said, we have tried everything possible, from drugs to different therapies, without much success. The point to take away here is that one should use whatever is offered to try to reduce the symptoms as quickly as possible. She had many side-effects from Cymbalta, Neurontin, and Lyrica. We tried Metanx, High potency B complex vitamins, alphalipoic acid, all with very little help. I am puzzled as to why her neuropathy has gotten progressively worse. I always tell her not to give up as we will find something to help.


Steven H. Goldstein, DPM, Royal Palm Beach, FL,



RE: Neuropathy From Chemotherapy (Jim Benedict, DPM)

From: Multiple Respondents

Neuropathy from chemotherapy can sometimes be so intense that it becomes the most debilitating side-effect. Besides intense tingling, burning, and numbness, it can interrupt sleep and create anxiety far beyond other side-effects. I've had patients come in crying that they can't sleep, can't walk, can't eat and are mentally exhausted. High dose Neurontin (up to 3000 mg daily), might calm it down slightly, but it comes with many side-effects. 

A change to Lyrica might be an alternative choice, but it usually isn't enough. I would stay away for Cymbalta. Studies show that it could bring on suicidal intentions, and that's the last thing you want to do in this situation. 

I know that there has been some controversy over the use of B-12 (cyanocobalamin) lately, so this is a good test for the effectiveness of the treatment. I usually mix 1cc of cyanocobalamin with 0.5 cc of triamcinolone (20mg), and 1.5 cc of 2% lidocaine plain. I would give a therapeutic nerve block to the posterior tibial nerve with this 3cc combination in both feet. Keep them on the Neurontin and the Zoloft, and have them come back in a week. I usually give a series of three in one or two week intervals. If it works, you're a hero, and if it doesn't, the patient is happy that you tried something. It has been my experience that it ALWAYS WORKS. 

Randy Bernstein, DPM,  Dearborn Heights, MI,

The most important aspect of this clinical history to determine appropriate therapy which was not mentioned, is does the patient have pain? If the answer is no, then none of the medications should be used. Neurontin, Lyrica (which are in the same drug class and should not be used together) in addition to Cymbalta are all for painful neuropathic symptoms. Zoloft is not an effective drug for painful neuropathy. Painless neuropathy, especially one caused by a toxin (chemotherapy), is unlikely to resolve. Since the patient can not feel the Semmes-Weinstein monofilament, she is at risk for foot ulceration. Supportive therapy by preventing ulceration with education, footwear, and perhaps home thermometry should be recommended.

Lee C. Rogers, DPM, Des Moines, IA,

I have had success treating all forms of neuropathy utilizing nutritional medicine and MicroVas therapy. When used properly in the protocol, MicroVas makes a big difference in outcome.

I have no financial relationship with the company, but have given lectures on its benefits.

Bob Kornfeld, DPM, Manhasset, NY,



RE: Drop Foot (Richard Hofacker, DPM)

From: Multiple Respondents

For you youngsters out there, Saturday night palsy is when a drunk would fall asleep on the park bench with one arm over the back upright of the bench and wake up in the morning with a compression palsy. This can happen, and is called crutch palsy when a patient leans incorrectly on a pair of crutches in the axillary area.


I  suggest this has happened to your alcoholic patient.  Although you or he may never know what position he “fell down drunk into”, it appears pretty obvious this could be a cause, especially with the rapid onset of symptoms. Possibly, the common peroneal nerve was damaged but that is just my hypothesis.


I strongly suggest a referral to a neurologist, not to mention AA. Insurance or not, improper treatment of this patient by refusing a referral based on financial considerations could be construed as negligent. If the patient declines, document this refusal. It is also within your purview to suggest AA or a similar program.


David E. Gurvis, DPM,  Avon, IN

This sounds like it may be an acute compartment syndrome. The patient probably passed out and had pressure on his lower, and possibly upper leg, affecting the peroneal nerve. If the swelling has gone down, he may not need a release of the lateral compartment. He might benefit from an injection to the peroneal nerve near the fibular head, if you can do that in your state. Something needs to be done ASAP for him so that he can potentially improve from this or he may be debilitated for the rest of his life.

Bruce Williams, DPM, Merrillville, IN,

This sounds like the patient has a common peroneal nerve palsy, common in alcoholics who pass out with their legs crossed, causing prolonged pressure on the common peroneal nerve where it emerges superficially just below the lateral knee. It’s self-limiting, most of the time. If a brace and improved nutrition is not effective, surgical exploration of the fibular tunnel is indicated.

Howard R. Fox, DPM, Staten Island, NY,



RE: Platelet-Rich Plasma Injections (Neil B. Levin, DPM)

From: Nate Schwartz, DPM

I have been using APC therapy for about 3 years. I have had some incredible results.  It does not work every time, but the successes way outnumber the failures. I have never caused any problems with the administration of APC. In some instances, I have created a cure with APC, where no other treatment would have been considered a possibility for success.

Nate Schwartz, DPM, Smyrna, GA,



RE: Chronic Pain, Edema, and Neuropathy (Steve Wolfington, DPM)

From: Multiple Respondents

Considering the history, that it is progressive, and that you have increased redness with dependency, I would look into the vasculature very closely first. I would send this patient for venous ultrasound to ensure you are not missing a DVT. I would also send her to a local vascular surgeon to have a CT angio of the arterial tree. Next, without any further history on how this started, activity level of the patient or possible previous trauma, I would look into either anterior or anterolateral compartment syndrome, then into CRPS.

Todd Lamster, DPM, Phoenix, AZ,

After recently also having a patient with chronic pain, swelling  and neuropathy, my wisdom to impart to you is rule out the worst case scenerios first. In this case, rule out a DVT, and rule out RSD. Once you have ruled those out, you at least have time on your side.


Jeffrey Kass, DPM, Forest Hills, NY,

Venous Dopplers can be used to rule out DVT. Also consider x-rays or other imaging for sarcoma. If all are negative, consider CRPS/RSD -- see if a PT block provides any relief. The patient can also be referred to a PCP for possible fibromyalgia.

Roody Samimi, DPM, San Diego, CA,



RE: Custom Foot Orthoses Alter Rearfoot Dynamics More Than Running Shoes (Kevin Kirby, DPM)

From: Dennis Shavelson, DPM

No one wants research scientists to reduce their efforts in the biomechanics arena but I think the research Dr. Kirby alerts us to helps prove my point that until better and more powerful research exists regarding orthotics, EBM for biomechanics remains clinical and


12 runners represent an early study at best. What about the type of cast, the type of custom orthotic, the amount of RF posting? What about an angled varus wedge and no orthotic as a component of this study. Maybe it was just the post?

Kevin’s important statement here is that “this research clearly supports the fact that many of us who have been successfully treating injured runners with foot orthoses for years already know” and then goes on to claim that this small, full of questions paper is “important research.” My opinion is that when orthotic research forces all insurance companies to cover our custom orthotics when indicated, I will consider that important.

Dennis Shavelson, DPM, NYC, NY



RE: Best Procedure for Shortening Toes (Robert S. Adelman, DPM)

From: Nat Chotechuang, DPM

Another possible procedure that you might consider to shorten toes is to resect the desired length of the proximal phalanx at the distal metaphysis, then install an intra-medullary screw down the length of the toe to provide stability and compression until the osteotomy heals. Once the osteotomy heals, you could remove the hardware and the toe joints would still be intact and functional. 

OrthoPro markets their cannulated hammertoe screw, which is what I would likely use in this application. One could thereby avoid a joint destructive procedure such as an arthroplasty. I have not used it specifically for a toe shortening myself (I haven't had the opportunity), but I have used it for proximal inter-phalangeal joint arthrodeses successfully. It seems as if it would be a fitting application if you want to shorten toes.

Disclaimer: I have no affiliation with OrthoPro.

Nat Chotechuang, DPM, Bend, OR



RE: Mixed Fungal Infections (Greg Caringi, DPM)
From: Steven J. Berlin, DPM, Simon Young, DPM

Mixed fungal infections of toenails are very common and particularly more common in patients over 45 years of age. Aspergillus Niger is the most common non-dermatic fungal infection on the foot and is best treated with Sporanox. Lamisil is primarily a dermatophytic drug and has not been shown to be effective.

Steven J. Berlin, DPM, Baltimore, MD,

The literature is quite clear that 90% of pathogens are dermatophytes. On the other hand, I find clinically, a shift to non-dermatophytic molds as patients are older (in my experience with fungal cultures). I feel that younger patients are more likely infected with dermatophytes and older have a higher percentage of non-dermatophytic molds.

I am sure I’ll be chastised for poor specimen harvesting, but I’m sure I did it as prescribed. I don't know if there are studies showing age-related nail cultures of the feet e.g., 30-40 year olds, 40-50 year olds, etc.

Simon Young, DPM, New York, NY