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.

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