Doing Bunion Surgery: Is It Worth The Hassle?
This communication is in response to the Forum column by John McCord, DPM (see “Dispensing Orthotics: Is It Worth The Hassle?,” November 2001, pg. 75). I had a very similar frustrating experience with my bunion surgery and solved the problem almost the same way Dr. McCord did. Here’s what used to happen. I would see a patient with severe bunions. I would do a thorough work-up and X-rays. I would present my patient with, granted, the more expensive option of surgery. Classically, I like to do Silver Bunionectomies on all my patients regardless of their type or severity of their deformity. I would get prior approval for the surgery, then collect the deposit and perform the surgery. Two weeks later, the patient would come in for a follow-up visit. I hated these visits. I would hear moaning and groaning and whining as I approached the room. I walk into the room with a concerned look and find an angry looking patient staring at his feet. “My feet look and feel the same,” the patient would say. I would review my X-rays and examination. I would confirm my suspicion that I knew absolutely nothing about the patient’s foot function before doing my surgery. I would explain to my patient that I did my best and it must be the fault of the suture company, Surgery Center, the person who handed me the instruments or Dr. Silver himself. “Do I get my money back since your surgery is worthless?” “No sir, you read and signed a disclaimer that explained that the surgery is not guaranteed.” A few months before I turned 50, a nice guy named Ralph came to my office and handed me his card. He is an orthopedic surgeon. He seemed very knowledgeable and had a nice business philosophy called kickback. I have been sending my bunion patients to Ralph for almost five years now. His success rate is not any better than mine. Instead of sitting in my exam room complaining of their failed bunionectomy, the patients now sit in his waiting room. I no longer have post-op dressing mess or a pile of depositions. My revenue from surgery is zero but so is my stress level from doing bunionectomies. I gave Ralph my supply of Tums. I have been thinking of going into refrigeration repair next but I hear that also requires me to learn a lot about how it works to be able to do it right. -Paul R. Scherer, DPM San Francisco Was There An Omission On Penlac? The article entitled, “Can We Reduce the Debate Over Onychomycosis?” (see “News And Trends,” October 2001, pg. 11), reports a treatment algorithm for treating onychomycosis. I feel there was an omission regarding treatment options. When conditions exist that contraindicate oral therapy, ciclopirox nail lacquer 8 percent Penlac is a safe alternative for treating onychomycosis (not involving the nail lanula) and should be included in this algorithm. Patient conditions that would contraindicate oral therapy include elevated liver enzymes upon baseline lab testing or a pre-existing cardiac condition, especially CHF (in the case of itraconazole). In either situation, ciclopirox nail lacquer provides an additional option that can and should be used along with preventative nail care by the podiatrist in the management of a patient’s onychomycosis. -Benjamin D. Overley, DPM Philadelphia Lee Sanders, DPM, responds: At the time that the VA onychomycosis treatment algorithm was developed for selection of an oral antifungal drug (the gold standard), ciclopirox nail lacquer was not available. Certainly, Penlac Nail Lacquer provides an additional treatment option that can be used along with preventative nail care for motivated patients that are not candidates for oral therapy. Patients should be advised, however, of the limited efficacy of topical therapy for the treatment of onychomycosis. Raising Questions About The Safety Of Pletal I am writing in response to “Inside Insights For Treating Frostbite” by Gerald V. Yu, DPM, et. al., in the November, 2001 issue. I am sure the authors are aware that a published article is read by many people and that it is usually considered to be accurate and worthy of using the information when treating their own patients. With this in mind, on page 55, the square labeled “What you should know about Pletal” might lead a practitioner toward using this so-called “very safe drug.” The authors state, “No serious adverse reactions reported” and nothing could be more erroneous or misleading. The PDR states that in greater than 2 percent of patients taking the drug; aside from the less serious side effects, they list: heart palpitations (10 percent), tachycardia (4 percent), peripheral edema (9 percent), dizziness (10 percent) and pharyngitis (10 percent). They further list in less than 2 percent of patients: Edema, hemorrhage, CHF, atrial fibrillation and flutter, infarct, myocardial ischemia, supraventicular tachycardia, ventricular extrasystole, anorexia, cholylithiasis, gastroenteritis, stomach ulcer, diabetes, anemia, polycythemia and purpura to name but a few. Perhaps the 2 percent figure may be low but try to explain that to a patient you are treating for claudication that winds up with a myocardial infarct from the medication you prescribe. To minimize the side effects or dangers of using a particular drug without listing the possible serious complications is tantamount to causing them. I hope this information proves helpful. — Richard M. Schiller, DPM Point Reyes Station, Calif. Gerard V. Yu, DPM and Andrew Vincent, DPM respond: We acknowledge and appreciate the response by Dr. Schiller regarding the adverse effects of Pletal®. As with any drug, we encourage consulting the PDR prior to its administration. The most common adverse reactions reported for Pletal during the placebo-controlled clinical trials are reported in the text along with contraindications to the use of Pletal. The manufacturer of Pletal characterizes these side effects as “generally mild to moderate in severity.” With this in mind, the PDR does indicate that during the clinical trials, some 83 adverse reactions affecting many different organ systems were reported in patients taking Pletal, less than 2 percent of the time. The PDR states that the only adverse effect resulting in discontinuation of the drug in greater than 3 percent of cases was headache. If one were to review the PDR with respect to some of the most frequently prescribed NSAIDs, you would find striking similarities in the listing of rare adverse reactions occurring less than 2 percent of the time. In fact, the PDR identifies more than 130 adverse reactions that occurred less than 2 percent of the time in patients receiving Celebrex. The intent of this article was not to “minimize the side effects or dangers” of using Pletal, but to introduce that Pletal is a safe drug as adjunctive treatment in the management of frostbite. It is the responsibility of the physician to be knowledgeable of the adverse reactions that might occur as a result of prescribing any medication and to assess the benefits and risks of any drug before it is prescribed. Physicians are not expected nor required to know all the possible adverse reactions or untoward side effects of medications they prescribe.