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02/08/2018    

RESPONSES/COMMENTS (CLINICAL)


RE: Treatment for Metastatic Cancer Spread to Feet


From: Roody Samimi, DPM


 


First of all, a biopsy is indicated. Any suspicions for metastatic cancer should be sent to  an orthopedic oncologist. Surgery by us is only indicated in benign cases.


 


Roodabeh Samimi, DPM Stockton, CA

Other messages in this thread:


03/07/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1B


RE: IM Angle Correction from Austin Bunionectomy 


From: Greg Caringi, DPM


 


I greatly appreciate the overwhelming response to my original question. In my 30+ years, I have seen many trends in our profession. I no longer do PMO or floating-V lesser metatarsal osteotomies. I think I have removed about half of the Silastic implants I put-in years ago. I hope that the modern Lapidus procedure stands the test of time. During my training, we were taught that there is no free ride when you fuse a joint. Sooner or later the adjacent joints will show the signs of increased wear and pressure. Mid-tarsal joint arthritis is a difficult problem to treat.


 


Distal 1st metatarsal osteotomies, especially the one described by Dr. Dale Austin, have stood the test of time. I have seen my work 20+ years later and the patients remain happy with their cosmetic and functional result. "We don't treat x-rays" is something I was told early in my career by two renowned foot surgeons, Dr. Abe Plon, a pioneer of minimally invasive surgery, and Dr. James Ganley, a personal friend and founding father of our profession. Dr. Ganley extended that thought further by advising us to "Do the procedure that best benefits the patient. Don't do more than is necessary simply to gratify your own ego."  


 


Greg Caringi, DPM, Lansdale, PA


 


Editor's note: This topic is now closed

03/07/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Allen Jacobs, DPM


 


Dr. Graziano, with reference to distal metaphysical osteotomy, suggests that we are deforming a normal bone to correct a deformity. Do we not do the same when we perform a calcaneal osteotomy for correction of a pronation deformity? Or resect bone in performing a digital arthroplasty? Or a “cheater Akin“? There are many theoretical benefits to the Lapidus procedure. But the theoretical is not always practical. 


 


Recently, I followed a local 3 year residency-trained “foot and ankle” surgeon in the OR. The pre-op and post-op films were still up on the screen. Literally, the only difference was...


 


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

03/06/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Ty Hussain, DPM


 


“Surgery is an art” as my colleague Dr. Lowell Weil Sr. explained in our academic books. I'm one to agree that the surgery we perform on our patients, albeit the need to meet book guidelines, is to meet the quality of aesthetics and functionality. After performing surgeries over 25 years, I have seen angles that are very high that were corrected with distal osteotomies, and because there was improvement over what the patient had prior, clinical improvement in most cases was the important factor over radiographic concerns.


 


Ty Hussain, DPM, Evanston, IL

03/06/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Thomas Graziano, DPM, MD


 


With all due respect to Dr. Rettig, I would challenge him and others performing bunionectomy procedures to critically look at the long-term outcomes of their work. As I said in my post on the subject, I agree that patient satisfaction is acceptable in “most” cases after distal osteotomy. It doesn’t change the fact that we take a straight bone and make it crooked with a distal osteotomy. Yes, it’s technically much easier, and yes it’s easier on the patient post-operatively. I was simply stating that long-term, it doesn’t hold up to a 1st metatarsal cuneiform arthrodesis. 


 


It doesn’t mean I don’t perform distal osteotomies. I just don’t push them to their limit because it’s an “easier” procedure. With regard to Dr. Rettig’s comment on counseling his patients, I don’t agree in “trade-offs” and “allowing my patients to choose” which procedure to use on them. They come to you as a specialist to make that decision. Otherwise, thank you Dr. Rettig for commenting on my post.


 


Thomas Graziano, DPM, MD, Clifton, NJ

03/05/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Richard Rettig, DPM


 


Dr. Graziano said regarding a Lapidus: "From a "corrective" and more "functional" standpoint, it provides superior outcomes when compared to any distal osteotomy. The stability of the first metatarsal cuneiform joint through arthrodesis and the correction obtained cannot be surpassed by any distal osteotomy, no matter what the configuration."


 


I do not disagree with his opinion that the correction from an arthrodesis cannot be surpassed, but I challenge it nonetheless. I have a totally different philosophy than him. I do the great majority of my bunionectomies by long plantar arm head procedures. I choose this in agreement with my patients after counseling on both procedures because in my hands, the head procedure gives almost the same quality of correction as a base wedge or a Lapidus combined with a much easier post-operative course for the patient, and with lower chances of morbidity. There is a trade-off, and my patients and I make a different choice than Dr. Graziano. I believe there is more than one "best" choice. 


 


Richard Rettig, DPM, Philadelphia, PA

03/05/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Don Peacock, DPM, MS


 


I agree with most of what the posters have said in this thread. I strongly disagree with the premise that the Lapidus bunion surgery correction is better than the Austin bunion correction. It depends on what the deformity is and what the goals are for both the surgeon and the patient. If you use only one bunion surgical procedure for every HAV deformity, you will experience unwanted failures and this is proven in the literature. 


 


We know that the head osteotomy is a good procedure in HAV correction with IM deformities up to...


 


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

03/04/2019    

RESPONSES/COMMENTS (CLINICAL)



From: Thomas Graziano, DPM, MD


 


Dr. Caringi's inquiry as to whether or not a longer dorsal arm produces a more "functional and cosmetic result" in a bunionectomy procedure opens up an interesting discussion. Time has a way of enlightening a clinician and providing insight as to what "works" and what doesn't work. My perspective in this discussion comes from over 35 years of experience performing corrective surgery for hallux valgus deformity. I can say that my satisfaction with distal osteotomies of the 1st metatarsal whether short or long has decreased steadily over the years. 


 


I say this because while patient satisfaction is for the most part acceptable, I personally have been disappointed in long-term outcomes. For that reason, I have been routinely performing the Lapidus procedure. From a "corrective" and more "functional" standpoint, it provides superior outcomes when compared to any distal osteotomy. The stability of the first metatarsal cuneiform joint through arthrodesis and the correction obtained cannot be surpassed by any distal osteotomy, no matter what the configuration.  


 


Thomas Graziano, DPM, MD, Clifton, NJ

03/01/2019    

RESPONSES/COMMENTS (CLINICAL)



From: Allen Jacobs, DPM


 


Pure transposition is transposition, regardless of the length of the dorsal arm. Extending the dorsal arm, as originally described in German literature (the offset "V" osteotomy) and elucidated by Vogler, does not increase the amount of transposition available inherently. Geometry is geometry. Extending the dorsal arm does allow for the provision of more fixation, such that one might transpose the 1st metatarsal to a greater degree with the security of additional fixation to compensate for decreased “bone to bone“ surface area contact. Additionally, elongation of the dorsal arm provides a greater opportunity to rotate an otherwise purely transpositional osteotomy, thus further reducing the intermetatarsal angle at the expense of decreased bone area contact.


 


Every osteotomy affords a maximal correction (lineal, transpositional, angulational, rotational as examples). When such osteotomies are "modified", there is frequently some reduction in the benefits for which the original osteotomy was described. Of course, the entire question of distal osteotomy is silly. Perhaps the good doctor is unaware that to do anything but a Lapidus procedure is inappropriate and in this particular, associated with an 87% failure rate.


 


Allen Jacobs, DPM, St. Louis, MO

02/26/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1


RE: Pediatric Ingrown Nails


From: Barry Wertheimer, DPM


 


While in practice, I was privileged to examine many pediatric ingrown nail problems. I concluded that a high percentage of ingrown nails were a secondary result of wearing "footie" jammies. If the child tosses and turns a lot, they often roll the end of their footies to be tight against their toes. Also, when the footie is outgrown, it also puts pressure on the toes. I recommend that parents cut out the foot portion of the jamies and put on good fitting socks. Try it. it works.


 


Barry Wertheimer, DPM, Souhern Pines, NC

02/26/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 2



From: Burton J. Katzen, DPM


 


Those of us who perform non-fixated distal percutaneous metatarsal osteotomies can attest to excellent results that are obtained when performed by a well-trained MIS surgeon. One technique to prevent lateral or medial deviation is that instead of simply performing the osteotomy straight across, drilling a fail-safe hole and performing a "V" osteotomy. This technique allows for better stability and less soft tissue interaction since you are only cutting within bone. There also are several other factors that might be considered:


1. The angle of the cut which can be proportional to the amount of correction desired.


2. The relative metatarsal length pattern.


3. The Leventen formula to decide whether multiple metatarsals need correction.


4. The relative plantar protrusion of the adjacent metatarsals, which can be tested by dorsiflexing the toes and palpating the metatarsal heads (Peacock press).


5. The amount of equinus, especially with diffuse metatarsal calluses or pain.


 


I have been performing percutaneous non-fixated metatarsal surgery since 1980 and have never had a non-union, even in elderly patients where traditional surgery with fixation would be much more risky. It is our hope that these and other MIS procedures will soon become part of the academic curriculum in the schools and podiatric surgical residencies.


 


Burton J. Katzen, DPM, President, The Academy of Minimally Invasive Foot and Ankle Surgery


 


Editor's note: This topic is now closed.

02/25/2019    

RESPONSES/COMMENTS (CLINICAL)



From: Edward Cohen, DPM


 


I would approach this problem of the second ray the same way I would treat a first ray HAV deformity. You could do an Isham-Reverdin osteotomy (an oblique medial wedge osteotomy just proximal to the metatarsal hardware. Using a fluoroscan, the screw can be bypassed and the osteotomy made just proximal to the screw. You can mark it off before you start the surgery with the fluoroscan. 


 


You could also do an osteotomy proximal to the toe implant to bring the second toe in a more medial direction. These two procedures should give you a straight toe, correcting the adducted second metatarsal and lateral deviated second toe. An alternative correction to the Isham-Reverdin osteotomy would be the Katzen-Wilson osteotomy to correct the adducted second metatarsal. 


 


Edward Cohen, DPM, Gulfport, MS

02/22/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



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.

02/22/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



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


02/21/2019    

RESPONSES/COMMENTS (CLINICAL)



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

02/20/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



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.


02/20/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



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

02/19/2019    

RESPONSES/COMMENTS (CLINICAL)



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

02/18/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A




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


02/18/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



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


02/15/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



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

02/14/2019    

RESPONSES/COMMENTS (CLINICAL)



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

02/13/2019    

RESPONSES/COMMENTS (CLINICAL)



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

02/12/2019    

RESPONSES/COMMENTS (CLINICAL)


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

02/08/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 2A



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

02/08/2019    

RESPONSES/COMMENTS (CLINICAL) - PART 1



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 
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