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From: Elliot Udell, DPM


Thank you, Dr. Peacock, for pointing out that a well-trained surgeon can decide whether a minimally incisional surgery or a completely open procedure is best for an individual patient. The days when podiatrists were divided into two classes, those who only did open procedures and those who only did minimal incisional procedures is thankfully coming to an end. A well-rounded surgeon could decide what is best for a particular patient and should not be guided by prejudice or lack of training.


Today, orthopedists are doing spinal and many other procedures using minimally invasive techniques. Podiatry was light years ahead of its time when minimally invasive procedures were invented but as with back surgery, foot surgeons have to know when to choose what procedure for a particular patient. 


Elliot Udell, DPM, Hicksville, NY

Other messages in this thread:



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: Irv Luftig, BSc, DPM


After 41+ years in practice, I've seen my share of colleagues, myself included, teaching podiatry students/residents/younger podiatrists the finer points of what makes our profession so specialized and necessary. Dr. Abe Plon took me under his wing and set me on a wonderful path back when I was a student in the 1970s and again after I started practicing in the early 1980s.


I've never had an orthopedic surgeon I work with show me how to do a hip, or a total knee or shoulder replacement. I've never had a nuclear cardiologist show me how to catheterize a heart. That would be a ludicrous expectation. Why are podiatrists like Dr. Overstreet teaching practitioners who never stepped inside a podiatry classroom to take our places. It makes no sense.


Irv Luftig, BSc, DPM, Hamilton, ON, Canada



From: Jeff Root


Dr. Rotwein asks if you would teach a non-podiatrist how to cast for orthotics. I suggest that the answer to that question depends on who and why you might want to teach others to cast for orthotics. If the podiatrist is skilled at casting and is capable of training a non-podiatrist such as an office assistant to properly cast, then the answer might be yes. In this scenario, the podiatrist can personally evaluate the cast or scan of the foot and can prescribe an appropriate orthosis for their patient.


However, in my opinion it would be inappropriate to train a non-podiatrist to cast if that person was not qualified or was not working under the supervision of someone who is qualified to prescribe, dispense, and provide any necessary post-orthotic follow-up. Successful foot orthotic therapy requires both a quality cast or scan of the foot and an appropriate prescription that is specific to the individual patient’s condition and needs.


Jeff Root, President, KevinRoot Medical



From: Don Peacock, DPM, MS


This post is of interest to me because I know both parties involved. I rotated through Dr. Kominsky’s program as a podiatry student. I was impressed by his surgical talent and his willingness to teach. Likewise, I know Thomas Bembynista, DPM and I met him at minimally invasive academy seminars. He is a superbly trained foot surgeon with stellar surgical skills. 


Like Dr. Kominsky, I shy away from claims of better when it comes to techniques. There are too many variables. One of these is who does the surgery. The post reminds me of one of the best foot surgeons I have ever known who practiced in NC for years. He did not have hospital privileges for most of his career. He performed large foot surgeries in the office under local with perfectly skilled outcomes. He often used K-wires for large rearfoot fusion cases performed under local anesthetic in his office. His name was Barry Johnson, DPM and his surgical skills were amazing. There was something almost magical with his abilities.


The truth is some surgeons are just good at what they do. Drs. Kominsky and Bembynista would fall in this category. Whatever technique they do, it's likely to have good results. It ain’t the car (technique), it’s the driver (surgeon).


Don Peacock, DPM, MS, Whiteville, NC



From: Don Peacock DPM, MS


The comparative studies between traditional and MIS HAV corrections have shown some slight differences in VAS scores in the early recovery period. However, the VAS scores even out fairly quickly at 3 weeks or so. Trying to answer the question as to which is best is not easy to conclude. Scientifically, there seems to be no difference between the disciplines with respect to HAV correction.


I do believe the increased popularity of MIS HAV correction will continue and will be patient driven. People like small scars, especially in the case of percutaneous procedures. There is psychology involved here as well; similar to the well-known placebo effect. It is likely that percutaneous scars are going to be well received by the patient and better results reported because the wounds appear smaller. If it looks like less trauma is done, then it will be perceived as such.


These questions are just as much answered by psychological effects imparted by a perception of less invasive techniques. These effects cannot be understated. If the patient thinks it is less invasive, it probably will be perceived as such. The placebo effect is well documented in medicine and patients can even get better with sham surgery. We have only scratched the surface on understanding how we heal and how our patients perceive healing.


Don Peacock DPM, MS, Whiteville, NC



From: Brian Kiel, DPM


Dr. Bregman, you are correct in your statement that it takes at least 20% alcohol to cause nerve destruction. The purpose of sclerosing, however, is to have an effect that is not destructive. I feel that there is a desensitization of the nerve rather than destruction. Of course I have no studies to prove it and I think that would be an excellent project. In the meantime, my patients respond and those who have developed neuroma pain in another area, several years later, return to my office as a result of successful treatment. 


Brian Kiel, DPM, Memphis, TN



From: Charles Morelli, DPM


What is not being mentioned, and has not been mentioned when deciding whether or not to excise the neuroma or address the deep transverse intermetatarsal ligament (DTML), is the actual size of the neuroma. All neuromas are not created equal. If the neuroma is quite large and fills the interspace, a DTML procedure is doomed to failure and you will eventually need to go back again and excise it. That has been my experience. Conversely, if the lesion is small and the patient's symptoms are mild to moderate you should realize success by only addressing the ligament. I can’t tell you where to draw the line, but that comes with experience. 


I also discuss both procedures with the patient and let them know that we may have to do a second procedure if the DTML is not successful. Some are okay with this and some are not. Some don’t mind rolling the dice, and some will say "just take it out doc" as they don’t want to go through a second procedure. I also will consider an invasive procedure after attempting sclerosing or steroid injections on small to moderate sized neuromas, and I have stopped injecting larger ones as for me, that has not been successful. Nor have pads or orthotics as patients do not wear them 24/7 and have pain barefoot. As always, evaluate your patient and do what is in their best interest. 


Charles Morelli, DPM, Mamaroneck, NY



From: Paul A. Galluzzo, DPM


Dr. Cox and Dr. Roth are right on track regarding neurectomy. I have been doing alcohol sclerosing injections since 2001. My father, Dr. M.A. Galluzzo, was doing these injections even before that. I haven't had to remove a neuroma in over 15+ years due to the high success rate of this treatment. I have done in-office DTL release only when the injections have failed which is less than 10 % of the time. I also have great success with neurolysis for stump neuromas. For those who say the success is anecdotal, I would like to know how many patients you have treated with alcohol injections. 


When those patients who have undergone this treatment come back for other services and/or refer friends and family, I call that a success. If anecdotal equals success, then I'll keep providing this excellent level of care. And for those of you who don't do neurolysis with alcohol and may be located close to my practice and are thinking of neuroma excision for your patient, you can refer them to me. If it doesn't work, I'll refer them back to you for the procedure. 


Paul A. Galluzzo, DPM, Rockford, IL



From: Peter J. Bregman, DPM, Brian Kiel, DPM


Dr. Cox, I am glad that you are doing the procedure although you’re not doing the open more definitive procedure. It also seems from your response that you were concerned about reimbursement. However, our goal is to give the patient the best result and while an endoscopic-type procedure is very good, I am a proponent of the open procedure using the appropriate microsurgical techniques. 


Peter J. Bregman, DPM, Las Vegas, NV


In-office release of DTL and osteotomies of 2 metatarsals with anecdotal success is a recipe for malpractice. Our obligation is to do the best for the patient, not what is best for us, whether it be our time or pocketbook. If surgical excision is the "best" treatment for a particular patient, then you are obligated to do that procedure or refer them to someone who will do it. I have maybe 3-4 neuroma surgeries per year as we perform sclerosing injections, a minimum of 6 every week or two weeks, with excellent results. We tell the patient that the usual course is 6-8 injections but occasionally there are 1 or 2 more. 


Brian Kiel, DPM, Memphis, TN



From: Bruce Pinker, DPM


When I saw this article quoting me, I immediately emailed Dr. Barry Block, the editor of PM News, asking for the source. I do not recall communicating with the writer. The writer has quoted me out-of-context from another article in which I was quoted.


For the record, minimalist footwear and barefoot running, when utilized and performed properly and safely, can be very beneficial to the lower extremity. It is a well-known fact that many sneakers of the past few decades have been criticized for adding unnecessary features that can actually weaken the foot and prevent the usage of muscles and tendons. Many individuals, however, benefit greatly from modern running shoes, and need to wear them in order to exercise. Minimalist footwear is definitely not recommended for everyone, but many...


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



From: Howard E Friedman, DPM


I have been following the series of posts regarding the suggested benefit of "twistable running shoes" which I understand to refer to lightweight flexible shoes and their effect on foot strength. This is a topic I have been interested in and have followed for several years. I am glad that at this point in time most podiatrists will accept the proven fact that the size of foot intrinsic muscles will increase in response to less supportive footwear rather than more supportive or robust footwear or the use of foot orthotics. This fact has been proven multiple times and measured both with ultrasound and MRI studies.


Dr. Fellner requested in his post evidence that increasing foot intrinsic muscle size, which is associated with increased strength, is correlated with reduced injuries. His request is timely as a new report proving...


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



From: Kevin A. Kirby, DPM


It appears as if the “Barefoot Professor”, Daniel Lieberman, PhD, is at it again. As some of you may remember, Dr. Lieberman was at the forefront of the failed barefoot running and minimalist running shoe fads a decade ago when he and his co-authors suggested that midfoot and forefoot striking running would help prevent injuries in runners in his questionable study on barefoot running (Lieberman DE, Vankadesan M, Werbel WA, Daoud AI, D’Andrea S, Davis IS, Mang’Eni RO, Pitsiladis Y: Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature 463: 531-536, 2010).


Lieberman then became to be known as the “Barefoot Professor” in the barefoot-running-crazed media of the time. His lab at Harvard was funded for many years by Vibram FiveFinger, a company which later on agreed to a class-action settlement for $3.75 million due to...


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



From: Ira Baum,  DPM, John Mozena


I have been a proponent of the evolution of podiatry to allopathic or osteopathic medicine for many years. There are many who agree and many who disagree with the change. There were several reasons I thought that the profession was ready for the change. This was similar to that of chiropody to podiatry; the education, training, and scope of practice changed and our members moved from “chipping and clipping” to more sophisticated diagnostic and medical and surgical procedures. Our profession was recognized as “physicians” by the government, but not on par with MDs or DOs by third-party payors. Although long before most of today’s podiatrists remember, we were accepted by few hospitals, not by the majority and certainly not by successful and prestigious hospitals. Post-graduate training was scarce.


Podiatry is a different profession than it was in the past. The reason I rehash all of the above is because even though I applaud Dr. Sokoloff and Dr. Levy, I’m not sure I understand the objectives of a dual degree for our profession. I’m not clear how a dual degree changes anything for podiatry/podiatrists regarding the public's perception of podiatry or reimbursement for services; that is, of course, unless the podiatrist is billing as an MD or DO. We have many dual degree (DPM/MDs/DOs) out there. Speak up and tell us your positive and negative experiences the dual degree afforded you. 


Ira Baum, DPM, Naples, FL


I applaud the idea of a dual degree (DPM/DO). Many of the osteopathic students already sit side-by-side with the DPM students in their first two years of medical education. Hopefully, this will lead to podiatry as a sub-specialty within the DO community and true equality for our graduates!


John Mozena, DPM, Portland, OR



From: Allen Jacobs, DPM


In my opinion, we have made the treatment of retrocalcaneal pathology far too complicated. It appears as though the performance of such surgeries has been directed by corporate-driven theoretical arguments rather than practical considerations. Whether Haglund’s deformity or insertional tendinosis, many patients may be successfully managed without the need to detach a major portion of the Achilles tendon, the use of orthobiologic materials to “enhance healing”, suture bridges, or anchors. When retrocalcaneal surgery results in complications, the undesired outcomes are often major in nature, resulting in prolonged recovery and disability. 


Careful and thoughtful surgical technique frequently allows the surgical interventions to be performed without the utilization of foreign materials with their added risks. When conservative palliative/accommodative therapy fails, keep it simple. Advise the patient that prolonged recovery and persistent edema may occur. Retrocalcaneal surgery is on my list of “do only if you have to” surgeries. Based upon my observations as an expert witness in retrocalcaneal surgical cases, I believe such complications are likely more common than generally appreciated, and can be of great significance, at times devastating. "Tantum  dilgentissame praecavete" should rule the day in the back of the heel.


Allen Jacobs, DPM, St. Louis, MO



From: Robert Scott Steinberg, DPM, Elliot Udell, DPM


I wonder, did Dr. Feinberg ask the woman how the podiatrist and the chiropractor obtained the impressions?


Robert Scott Steinberg, DPM, Schaumburg, IL 


I would wager to say, having seen a fair share of chiropractor dispensed orthotics, that the chiro devices seemed more comfortable to the patient because they weren't doing much to control the pathomechanics.


Paul Betschart, DPM, Danbury, CT



From: Paul Busman DPM, RN


"With a CRN wife and a DPM/RN degree for himself, I wonder if Dr. Busman would advise his children to pursue a DPM degree. It seems a CRN degree is a shorter career pathway with a wider scope of practice and a generous median income."


To tell the truth, in the current medical practice climate, I would be very hesitant to recommend anyone to go for a DPM, MD, or DO career. When I worked in a hospital OR, ALL of the surgeons and anesthesiologists complained regularly about practicing medicine these days. Now I work part time in an endoscopy clinic and it's the same thing there. 


Since I left podiatry in 2007, I've kept a bit of an eye on the profession here on PM News and seen that situation get worse and worse. I truly loved my podiatry practice until the practice climate changed out from under me, but to tell more of the truth if I'd known in 1977 what I know now, I might well have considered a "mid-level practitioner" career myself. That's just me and I'm really happy for all of you DPMs who continue to do well and enjoy your practices. It just stopped working for me. 


Paul Busman DPM, RN, Frederick MD



From: W. David Herbert DPM


Dr. Jacobs, individual states determine the standard of care for individual medical practitioners. For example, a podiatrist can testify concerning the standard of care for procedures performed on the foot by an orthopedic surgeon in California. That was not always the case, but it was changed by a court decision a few years ago. You will find that in some cases, nurses can testify against a physician as an expert as to the standard of care in some states. Of course it is up to the trial court judge in most cases to allow this. 


An attorney practicing in the malpractice area must know the law about who can testify against whom when it comes to any malpractice case. Also, pre-trial discovery procedures vary greatly state by state. I am familiar with malpractice laws in detail in only a couple of states. It is not possible to make general statements of what licensed professionals are allowed to do in every state. I understand that at least in one state, dental hygienists can fill cavities without dental supervision.


By the way, I have actually acted as a malpractice defense attorney in a few cases. 


W. David Herbert DPM, JD, Billings, MT



From: Todd Rotwein, DPM, Bill Beaton, DPM 


While I can certainly appreciate Dr. Chaskin's concern for NPs, my sympathies lie more with the 15 doctors. Nothing better underscores the need for physicians to unionize.


Todd Rotwein, DPM, Hempstead, NY


Don’t all states have podiatry practice acts that license podiatrists and protect the public from unlicensed practitioners? I wonder what the dental profession would do if NPs or PAs began to provide dental services. They should not be any better protected than podiatrists. We have already lost general foot care to pedicurists because of inaction by our profession to prevent practicing podiatry without a license. In addition most orthotic care is now being provided by those advertising custom-fitted arch supports to relieve foot, knee, and low back pain. Sadly, the public is being advertised into inferior foot care.


Bill Beaton, DPM, Saint Petersburg, FL



From: Stephen Musser, DPM


I disagree with my colleague Dr. Chaskin. Let’s compare apples to apples, and this is by no means a put down on CNPs. Podiatrists complete a minimum of 3 years (most complete 4 years and earn a degree) of undergraduate education, then go on and earn a DPM degree (another 4 years), and further their training with a 3-year residency. Unless I am mistaken, an RN is 4-year undergraduate degree, and to become a CNP requires an additional 2 years. 


We are the experts of the foot and ankle just as a cardiologist is the expert in cardiac disease. So I do feel bad for the physicians who were let go and replaced by CNPs. I feel this is a 'slap in the face' for both the highly trained physicians and a compromise on patient care for the sake of helping the bottom line. 


Stephen Musser, DPM, Cleveland, OH



From: Edward Cohen, DPM


Surgery has definitely improved over the years with both traditional and MIS surgery. A lot of the foot surgeries that were done forty years ago no longer require a cast or a hospital stay for several days. This trend to getting the patient out of the hospital and walking around as soon as possible can be seen in almost all surgery from gall bladder, heart, vascular, orthopedic, and most general surgery.


The trend in surgery seems toward smaller incisions using non-invasive techniques and equipment that allow...


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



From: Bryan C. Markinson, DPM


This ongoing discussion presents an interesting set of opinions centering on the themes of medical necessity, complications, and litigation. We should all adhere to the same accepted ethical standards regarding full informed consent (as Dr. Jacobs has stated) no matter what the reason for the patient wanting the surgery. Even without any threat of litigation, all of us can appreciate the attendant frustrations and anxiety that accompanies a less than optimum result, and the wide divergence of patient opinion on what is optimum and what is not. We all know how one unhappy patient can make us forget the many happy ones.


Based on my review of cases alleging failure to adhere to accepted standards of care, once litigation comes into the picture, any establishment by plaintiff or defense that the procedure was for cosmetic purposes, or to fit in fashionable shoes, etc. NO MATTER HOW WELL INFORMED (also subject to wide interpretation about how well informed is well informed enough), puts the defense at a not insurmountable but definite disadvantage.


Bryan C. Markinson, DPM, NY, NY



From: Scott L. Schulman, DPM


An 82 year old unhealthy patient presented with a horribly painful bunion, with an infected ulcer, and asked me to fix the bunion and end his pain.  I found him not to be a surgical candidate and could offer little help other than standard ulcer care and off-loading. He responded, "Why the heck didn't that other guy tell me this could happen and why didn't he fix it 10 years ago?


Bunions are hereditary, PROGRESSIVE deformities that WILL in most cases get worse. I do not think it is "Just cosmetic." Doctors don't just treat pain, they treat conditions and potential problems. High blood pressure does not hurt. Neither does melanoma or even dental cavities, but we treat these conditions to PREVENT bigger problems down the road. How many bunions end up causing bigger problems later?  I think we owe it to our patients to at least educate them on the progression and likelihood of bigger issues, increased pain, and more extensive surgery down the road if left untreated. 


Scott L. Schulman, DPM, Indianapolis, IN



From: Allen Jacobs, DPM


You can view a podiatry friendly fall risk evaluation at the Center for Podiatric Education. It reviews the CDC guidelines for fall prevention. Or go directly to the CDC fall risk prevention site for appropriate guidance. The CDC guidelines (the STEADI guidelines) may be easily incorporated into your practice. 


Allen Jacobs, DPM, St. Louis, MO



From: Ira Baum, DPM, Donald R Blum, DPM, JD


Dr. Levy’s recommendations to reduce the risk of seniors falling and risking severe injury is a responsibility that all podiatrists should honor.  I add the importance of gait aides to mitigate falls, when necessary, for the aged and not so aged, with neurological impairment to the lower extremities. Our concern for the whole person is what makes us physicians.


Ira Baum, DPM, Naples, FL


Thank you, Dr. Levy, for comments about "Falls" related to "Seniors". One more item that needs to be considered, for all ages, is injuries resulting from walking the dog. People are out walking the dog or walking for exercise and paying more attention to a telephone conversation, a text, or a social media post than the squirrel or rabbit that your dog wants to run after; or they are just not paying attention to the curb or the debris on the sidewalk.


Donald R Blum, DPM, JD, Dallas, TX



From: Steven Selby Blanken, DPM


No one can look at a picture of a foot and make a statement that an MIS procedure can make a bunion straighter. Remember the words "Standards of Care." You are evaluated by your peers' performances around you too. In my region, no one can truly justify that a MIS bunion is an all-around better procedure than a traditional open osteotomy with correct, rigid, compressive fixation techniques. MIS, from what I know, is not taught in the schools and most residencies, and I believe it is not required by the CPME. I am sure there are few examples of good MIS procedures, such as ostectomies. The Royal's bunionectomy and outcome cannot be evaluated by the picture alone. The biggest question nowadays is Juvara vs. the new methods for Lapidus procedures.


Steven Selby Blanken, DPM, Silver Spring, MD

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