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From: James Nuzzo, DPM, Elliot Udell, DPM


Gouty tophi consuming a digit like the one depicted in the photo often actually replace the bone. The best course of action (providing the patient is a candidate) would be a distal amputation, especially if the tophi are emanating from the wound.


James Nuzzo, DPM, Fox River Grove, IL


Pegloticase is a possible option. It lowers serum urate levels more than any of the oral medications. The problem as Dr. Lenz pointed out is finding a rheumatologist who is trained and comfortable with administering this drug via infusion. The drug has a lot of potential system side-effects and the administering doctor has to be very knowledgeable and prepared to manage any of these potential problems. The rheumatologist must also be willing to examine the patient in order to make sure she has no other medical risk factors that would disqualify the patient from having this treatment.


Elliot Udell, DPM, Hicksville, NY

Other messages in this thread:



From: Don Peacock, DPM


Dr. Sullivan, my experience has been good with the percutaneous metatarsal osteotomy compared to the the Weil which I did for years. Recently, Henry, et al. published a study that compared the classic fixated Weil osteotomy with a non-fixated percutaneous distal percutaneous metatarsal osteotomy (DMMO). The percutaneous DMMO procedure is an extra-articular osteotomy without internal fixation. Thomas Bauer also published findings on the non-fixated DMMO with more than 150 patients. All but a few patients had complete resolve in their symptoms and no non-union.


What has been documented is post-op pain and swelling up to 3 months after DMMO. The surgical recovery is longer after DMMO than...


Editor's note: Dr. Peacock's extended-length letter can be read here.



From: Sheldon Nadal, DPM


When minimally invasive surgery is performed by a properly trained surgeon, using appropriate technique and instrumentation on an appropriate, compliant patient, there is no reason to expect a non-union. I used the words "chances are" because no guarantees can be made regarding outcomes prior to performing foot surgery and PM News is not a court of law. Perhaps Dr. Sullivan uses different words to indicate the same. 


By performing a non-fixated lesser metatarsal osteotomy, I would not be leaving the lateral movement of the metatarsal head up to chance. I would be leaving it up to Wollf's Law, which states that "bone in a healthy person or animal will adapt to the loads under which it is placed.It seems pretty obvious from this particular case that fixating an osteotomy does not guarantee a good outcome, and, in this situation, may have contributed to a bad one.


Sheldon Nadal, DPM, Toronto, Canada



From: Tip Sullivan, DPM


I felt compelled to respond to Dr. Nadal's post suggesting non-fixated osteotomy of the second metatarsal as a salvage surgery. I quote: "Had he or she left it unfixated, chances are that the metatarsal head would have shifted slightly laterally." 


The key here is "chances are". If he believes that the met head should be moved, why leave it up to "chance". I think it would not look good if there were a complication (i.e.-non-union) and one had to defend themselves with "chances are"!


Tip Sullivan, DPM, Jackson, MS



From:  Sheldon Nadal, DPM


If you look at the original x-rays, it appears that metatarsals two and three are adducted. Not surprisingly, the second and third toes are abducted since the toes tend to move in the opposite direction of the metatarsals. I think the post-operative problem is due to the fact that the surgeon decided to fixate the second metatarsal osteotomy. Had he or she left it unfixated, chances are that the metatarsal head would have shifted slightly laterally. This would have caused the second toe proximal phalanx to shift slightly medially and give a more congruent joint.


Personally, I would now simply perform an unfixated transverse...


Editor's note: Dr. Nadal's extended-length letter can be read here.



From: Martin Girling, DPM


Consider a plantar plate repair before resection of the base of the proximal phalanx. Wright Medical has a great system or try Smith&Nephew's HAT-TRICK.


Martin Girling, DPM, St. Pete Beach, FL



From: Harold Koehler, DPM 


If you remove the base, you may have some instability but the pain should resolve. It is equivalent to doing a Keller which generally yields a good result also. One thing you may consider is to add GraftJacket as a spacer in the joint and/or wrapped around the met head.


Harold Koehler, DPM, Auburn Hills, MI



From: Todd Lamster, DPM


With all due respect to my colleague who posted this query, a resection of the base of the proximal phalanx will make your patient much worse, as it will only serve to destabilize the joint further and allow the toe to dislocate, probably leading to an eventual loss of the toe. The joint is subluxed because of a plantar plate disruption; a result of overload. Look at the length of the lesser metatarsals in comparison to the 1st metatarsal. The x-rays show considerable swelling, so I would first apply a stabilizing splint around the toe with a soft cast, and have the patient take a short course of an oral steroid (if appropriate). Assuming a reduction in the swelling and inflammation of the area, an arthrodesis of the 1st MTPJ with a flexor tendon transfer of the 2nd MTPJ and toe would be your best option. (I wouldn't cut through the 2nd met again to repair the plantar plate.)


If you don't address the 1st MTPJ, whatever you do on the 2nd MTPJ is doomed to failure. Also, I wouldn't worry too much about arthritis of the joint, as going back into that joint and performing a flexor tendon transfer will create significant scarring and stiffness, obviating the need for an implant.


Todd Lamster, DPM, Scottsdale, AZ



From:  Don Peacock, DPM, MS


This patient's poor outcome could be alleviated through minimally invasive procedures. The second metatarsal can be shortened with an oblique percutaneous osteotomy proximal to the screw implant. This would decompress the second metatarsal joint. After the osteotomy, the 2nd metatarsal head could be translated laterally, which would tighten the medial structures and loosen the lateral structures of the 2nd MPJ and help pull the 2nd toe medial.


Also, a percutaneous osteotomy could be made with a lateral wedge in the base of the proximal phalanx without removing hardware. This would place the toe in a more rectus position. Finally, a percutaneous incision to release the tight lateral structures of the second MPJ could be performed. These maneuvers would place the toe in a rectus position and decompress the joint.


It is likely this would resolve the patient's pain and would be easier on both the patient and surgeon as opposed to removing the hardware and risk worsening the patient's pain. Removing the implant will elicit significant trauma, which the MIS work-around surgery would not. These procedures could also be done with a small incision and a bone saw if the surgeon is not comfortable with surgical correction via burr.


 Don Peacock, DPM, MS, Whiteville, NC



From: Jay Kaufman, DPM


1. Regarding the symptomatic 2nd MTPJ, I have had good success with tendon allograft interposition when few options remain. You only need a small section of tendon (about 5 cm long and 3-4 mm in diameter) and I usually use the gracilus or semitendinosus muscles. 


2. You would remove the screw from the metatarsal head and then use a small rotary burr to fashion contiguous joint margins in a concave manner to accept the tendon graft. The tendon is sutured on the back table until you have a good sized graft (like marble). Once you place the graft in the joint, you would cross the joint with a percutaneous driven K-wire to place the toe in correct alignment (typically, only a slight over-correction in specific planes) and also to maintain the tendon graft from migration. The pin is removed in 3 weeks. The tendon adheres to the bone and the toe will typically remains in a better position due to fibrosis, and it will allow some motion. 


3. The above is predicated on when the joint is opened, the amount of arthrosis is negligible, and the plantar plate cannot be repaired either primarily or through a flexor tendon transfer. 


Jay Kaufman, DPM, Allentown, PA



From: Bryan C. Markinson, DPM


Dr. Levy posted an alert regarding the utility of the ABCDE rule for ensuring a high index of suspicion for lesions that may be melanoma. The ABCDE mnemonic was developed in the early '80s as an aid for PATIENTS to self-evaluate lesions and bring them to the attention of the clinician. It proved to be so reliable that it was then taught at the medical school level and residency level for use by clinicians. The validity of the ABCDE rule is still strong, but it is not the whole story. There is one well referenced and important study published in December 2006 out of Australia by Wendy Liu, et al., Rate of Growth in Melanomas, Arch Dermatol/Vol 142. In this study, there were some very important findings regarding rapidly growing invasive melanoma, highlighted with the fact that in these cases, ABCDE may not apply. Specifically, rapidly growing invasive melanomas often demonstrate symmetry, regular borders, and amelanosis. 


Additionally, they tended to be in patients with less nevi and freckles. These are all contrary to the accepted ABCDE features and may deflect the clinicians away from suspicion and cause them to inappropriately re-assure the patient. The authors point out that this in no way invalidates the ABCDE rule, but indeed these findings reinforce the skin biopsy as the gold standard in diagnosis, and should remind all clinicians, especially non-dermatologists that any initiation of therapy that does not provide rapid resolution should prompt a biopsy or a consultation.


Bryan C. Markinson, DPM, NY, NY



From: Ira Baum, DPM


As podiatrists, we see many skin lesions on the foot. In a busy practice, it’s difficult to study a lesion when it’s not the primary complaint. I want to share with the comminity a personal experience that doesn’t exactly fit the above scenario, but one that profoundly affected my professional life. A respectable, intelligent, health conscious 40-something individual presented to my office with a wound on the plantar aspect of the toe. The lesion was diagnosed, by a dermatologist as a wart and treated multiple times. The lesion appeared like a typical non-healing wound that initially responded as expected with a granular base, although a bit exuberant. Lack of migration of the wound edges led to a biopsy with a wide excision of healthy tissue. Pathological diagnosis identified a Clark level IV.  


Long story short, after multiple surgeries and experimental drug treatments, he died. What I am trying to teach here is the importance of having a clear plan of treatment that includes timelines with identifiable benchmarks that may help you quickly recognize when there is a problem that needs to be addressed. Treatment plan methodology is not only for potential melanoma, but for post-op course, diabetic foot ulcers, and every treatment we provide.


Ira Baum, DPM, Naples, FL



RE: Melanoma on the Extremities

From: Leonard A. Levy, DPM, MPH


Dermatology Daily reports on a 20-year-old African-American student at the University of Kentucky, diagnosed with melanoma on the sole of his foot. He eventually “underwent three surgeries to remove the cancer from his foot.” The article adds that “melanoma on the extremities – nails, hands, and feet – is the rarest subtype of the skin cancer,” but people should still follow the American Academy of Dermatology’s ABCDEs  (Asymmetry, Border irregularity, Color not uniform, Diameter greater than 6 mm, Evolving size, shape, or color) of melanoma to check those parts of their bodies as well. (Dermatology Daily, February, 4, 2019).


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL



From: Elliot Udell, DPM


Drs. Albritton and Jones show that there are multiple ways to skin a cat. In this case, the cat is the treatment of Raynaud's phenomenon. As Dr. Jones indicated, some people are hesitant to take an oral medication that is off-label for Raynaud's but FDA-approved for the management of hypertension. In our practice, we have done well with recommending disposable shoe warmers that are sold in sporting goods stores. Patients buy a box of them in December and it lasts until the spring. For others, we have successfully prescribed long-acting nifedipine. These patients take one pill a day starting in December and discontinue the drug when spring arrives. We check blood pressures on these patients before starting the drug to make sure they do not have hypotension and when they start, they are advised not to get up from a sitting position too quickly.


Two important points to consider are: 1) If the patient is taking other medications for hypertension, adding on nifedipine or the meds recommended by  Dr. Albritton could cause an abnormal drop in the patient’s blood pressure. In those cases, it is wise to coordinate treatment with the patient's primary care physician. 2) Order an ANA on patients presenting with symptoms for the first time to rule out the possibility of scleroderma or lupus.


Elliot Udell, DPM, Hicksville, NY



From: Howard Zlotoff, DPM


I shared the query with my son who is a pediatric dermatologist and this was his reply. I hope this gives some insight and a differential diagnosis. Congenital lymphedemas can present with up-slanting nails and sometimes takes a while for the lymphedema to be apparent. The toes here look a little edematous too. Stemmer's sign can be associate later. Milroy's disease is one of these syndromes but there are others. Here is an article mentioning the up-slanting toenails. Milroy's disease and the VEGFR-3 mutation phenotype.


Howard Zlotoff, DPM, Mechanicsburg, PA 



From: Allen Jacobs. DPM


The observation of Dr. Jones that activated folic acid may be helpful for the management of Reynaud's disease or phenomenon is not without a potential, although unproven, scientific basis. The utilization of l-methylfolate, B6, and methylcobalamin, increases nitric oxide levels. Nitric oxide is of course a well-established powerful vasodilator. It is also helpful in the reduction of homocysteine which is a non-essential amino acid inhibiting the coupling of nitrogen and oxygen to produce nitric oxide. It is now available in a generic form through EBM Phramacy. 


Allen Jacobs. DPM, St. Louis, MO



RE: Recommendations for Raynaud's Disease (Chris Albritton, DPM)

From: Paul Clint Jones, DPM


I would like to extend kudos to Dr. Albritton. That was very well outlined and clear as to the standard of care of treatment for Raynaud’s. Raynaud’s is undoubtedly difficult to get consistent results. I commend you. I would like to point out that this outline clarifies that these drugs are off-label use and have the common side-effect of orthostatic hypotension. In my experience, it’s also difficult to convince an otherwise healthy patient of any age to begin taking an anti-hypertensive drug. 


That being said, I would like to share a trick I stumbled upon in...


Editor's note: Dr. Jones' extended-length letter can be read here



RE: Recommendations for Raynaud's Disease

From: Chris Albritton, DPM


Recently, a podiatry colleague diagnosed an 18-year-old female with Raynaud’s disease and asked for my recommendations for treatment. I sent the following as a summary of my experience in treating Raynaud’s disease over the past 38 years and thought PM News readers might be interested.


First of all, nothing works great in Raynaud's. Since Raynaud's is a vasospastic problem, I've had fair success in using alpha-blockers to counteract vasospasms.


FIRST is prazosin, aka Minipress, starting with...


Editor's note: Dr. Albritton's extended-length letter can be read here.



From: Bryan C. Markinson, DPM


Dr. Borreggine's advice regarding consideration of risk for use of off label use of drugs is prudent but somewhat overstated. If one reads the Oxford Textbook of Hepatology, you would never write a prescription for anything. There are many reasons that specific indications for drugs are not FDA-approved, and that usually has more to do with the drug not being studied for those indications and NOT safety. For example, Marcaine is not FDA-approved in kids but is used every day off-label in pediatric tonsillectomies for extended post-op pain relief. Ketoconazole has been used off-label in urology for prostate issues, taking advantage of its effect on pertinent hormones.


As far as cimetidine for warts goes, although not FDA-approved, it has been studied (not FDA studies) quite well for this indication in both children and adults. JAPMA 95(3): 229-234, 2005, Arch Dermatol 1996 Jun;132(6):680-2, J Am Acad Dermatol. 1999 Jul;41(1):123-7. None of the studies saw any increased risk with high dosing of cimetidine, and all indicated some benefit for its use. My personal experience, especially in children, has been quite amazing.


Lastly, the statement by Dr. Borreggine that "off-label uses of medication have a risk," is not always true. The best example of this is the "off-label" pulse dosing format of terbinafine for onychomycosis, which calls for 70% less total drug than the FDA-approved 90-day continuous use with virtually the same efficacy. In this case, off-label use is decidedly SAFER, although the FDA-approved dosing is universally regarded as safe.


Bryan C. Markinson, DPM, NY, NY



From: Joseph Borreggine, DPM


Regarding the recent posts on the “off label” use of certain oral medications to treat plantar verruca - Even after seeing the result of the lawsuit caused by the ignorance of the treating DPM, there are still suggestions on what other “off label” oral medications can be used.


“Off label” means that this medication is not approved to be used by the FDA for treating a condition for which the medication was formulated and tested prior to going to market. Yes, I understand that doctors can do whatever they think is “best” for their patients to treat a medical problem. But, remember the Hippocratic oath: “Do no harm.” 


“Off label” uses of medications have a risk, and one must be able to face the consequences if something goes horribly wrong. Why take the risk? Has anyone heard of using sal acid 40% and Aquaphor (compounded) which is applied qhs under occlusion x 3 weeks to treat warts? It has worked for me for these past 30 years and was initially suggested to me by a SCPM professor and Chicago dermatologist Ronald Wise, MD. Interestingly, I have not had one liver failure using this medication during my many years of using this Rx compound for plantar verrucae treatment. Give it try. 


Joseph Borreggine, DPM, Charleston, IL



From: Connie Lee Bills, DPM


What dosage of famitodine do you use off-label to treat verruca? 


Connie Lee Bills, DPM, Mount Pleasant, MI 


Response: I use famitodine (Pepcid) 40mg h.s. (at night) up to 8 weeks, then 20 mg daily.


Richard Rettig, DPM, Philadelphia, PA



From: Elliot Udell, DPM


Many years ago, we had a patient who presented with an allegy to an OTC orthotic. After wearing them, he developed pruritic hives ascending from his toes up to his legs. Because of the severity of his condition, he was immediately given an IM injection of Kenalog and I placed him on oral Benedryl as well as oral steroids. It stopped the attack, but we both wanted to know if this was indeed an allergy to material in the orthotic or to something in his shoes or to something he ate that day. 


I  cut two pieces of hypoallergenic paper tape. I took a punch biopsy of the orthotic and placed the material on one piece of tape and then placed both pieces of hypoallergenic tape on two different areas of his back. 48 hours later, he returned and sure enough there was a large welt beneath the tape containing the punch biopsy and none beneath the plain piece of tape. This method can be done with the orthotic you are describing; however, you could do several punches of different materials in the orthotic and then determine what part of the orthotic caused the allergy. It is, however, best to do this test 48 hours after he is no longer taking antihistamines or steroids for the allergy. 


Elliot Udell, DPM, Hicksville, NY



From: Chuck Langman, DPM, Keith L. Gurnick, DPM


Try a Plastizote top cover. It has worked well for me in the past. 


Chuck Langman, DPM. Bryn Mawr, PA


You might try removing the entire top cover and instead of Naugahyde, you might try a genuine leather top cover. This might prove to be more acceptable to your patient's feet. 


PS -Your current top cover material is likely not genuine branded and trademarked "Naugahyde" which is a specific vinyl coated material manufactured by Uniroyal Global, originally created in Naugatuck, CT. It was given the name Naugahyde because the material looked like a hyde and was made in Naugatuck. Most coated vinyl materials  (often referred to as "simulated leather" top covers) used for orthotics by professional orthotics laboratories in the USA come from other manufacturers.


 Keith L. Gurnick, DPM, Los Angeles, CA



From: S. Jeffrey Siegel, DPM


Pediatric puncture wounds are always problematic. The posterior heel is certainly a very unusual location, and it's a very high risk site for puncture wound osteo. The fact that it has been 3-4 weeks and the wound is closed w/o edema or erythema is excellent. No metallic/lead-based foreign body on plain films again excellent. However, a 2 cm diameter area of significant pain is certainly an enigma.


I, personally, would have not started Keflex... there is no clinical infection to justify antibiotics, but it does pacify family and that makes them "happy". Out of curiosity, did you...


Editor's note: Dr. Siegel's extended-length letter can be read here.



From: Amol Saxena, DPM


As Dr. Busman related, a lot of information is missing. Some considerations:

1. Don't base treatment on the MRI. These exams can be misleading as many athletes have "normal abnormals". Acute Achilles ruptures in most cases are not preceded by symptomatology.

2. A clinical evaluation is needed. In the UK, orthopedic surgeons are not permitted to render advice based on imaging reports. Good rule to follow. Assess the patient for over-lengthening and weakness, including the core.

3. Achilles ruptures can be career-ending to NBA and NFL athletes as 30+% cannot fully return to their sport.

4. Never do something unproven on a professional athlete.

5. Now that you are aware of a "known" potential pathology, you need to involve the healthcare team in the athlete's care and assess risks of continuing to not say, "let pain be your guide." Pro athletes can and will play through a lot of pain, sometimes to their detriment.


Amol Saxena, DPM, Palo Alto, CA



From: Paul Busman, DPM, RN


While this post provides a lot of information, a lot is missing. What type of injury did the player have? How long ago? Was he symptomatic anywhere before the injury? Is it still symptomatic? There's lots more to learn. I never treated athletes at the professional level so I'm not the best expert on this but I think it's highly likely that the defects and inflammation in the Achilles plus other tendons and ligaments are related to his sports profession. Right off the bat, I can't imagine giving him the okay to return to professional level competition without a lot more work-up. Orthotics alone aren't going to do the trick for this fellow.


Paul Busman, DPM, RN, Frederick, MD