Adult flat foot repair with implant

There are many ways to fix a flat foot.   This patient is an older patient and lives alone, a 12 wks nonweightbearing in a cast after a triple arthrodesis procedure is not a good option for this patient due to social conditions.   Discussed using the hyprocure implant as an option to allow for quicker recovery.   The results for this patient was amazing.   She is ready to do the opposite foot, the trick of this surgery is to make sure the ligaments in the subtalar joint are released properly and proper sizing of the implant itself. 

right foot after implant / stent notice the arch

Notice left foot flattening

Lump on back of the heel: Haglund's deformity, Achilles tendonitis, Tendonosis

Lump on back of the heel is the complaint most people put as the reason for their office visit. Diagnosis for this case is:  Haglund's deformity (aka pump bump), Achilles tendonitis / Tendonosis

Symptoms:

Burning in the achilles, unable to run, jump or wear shoes due to the rubbing of the achilles. 

Throbs

Tightness in the Achilles

Conservative treatments:

See 1) NSAIDS such as motrin, etc if tolerated

2) Physical therapy

3) Home stretching excercises

4) Ice

5) Avoid shoes that rub on that area. 

6) High Energy Shockwave therapy

7) Platelet Injections / Stem Cell therapy

Diagnostic tests:

• MRI will likely show degeneration, partial tears or chronic inflammation, value of such is questionable. 
• Xrays are great for seeing the bony deformity that is causing this condition and surgical planning. 

Surgical treatment:

• Removing of the Bump 
• Removing of any spurs as indicated. 
• Removing inflammed or damaged achilles tendon
• Repair of the Achilles back into the insertion.

Below is an actual FFLC patient preop Xrays and clinical photos. 

Notice the bump right above the achilles insertion

Another view of the swelling

Side view of the painful bump

What is looks like on Xray, Multiple issues to be addressed.
1) Haglund's Deformity (top Arrow)
2) Insertional spur growing into the achilles tendon (bottom arrow)
3) bone cyst / erosion from chronic inflammatory condition. 

Patient is an active runner, pain immediately subsided after surgery. 

"Bump" no longer visible or irritated. 

4 wks in a cast, then another 2 wks in a boot that he can remove to start range of motion excercises. 

Physical therapy and boot to be used for walking at 6 weeks. 

Tens unit can be used to help with the cast disease that develops from not using the limb for some time. 

Overall, this is a very simple surgery to correct the condition.  Technique chosen by your surgeon varies.    I personally prefers to keep the achilles attachment and remove the spurs from varying angles to avoid prolonged recovery.  This also allows for anatomical repair without a question as to where mother nature intended. 

FFLC taking new patients

239 430 3668 option 2 for scheduling or you can request online through our PATIENT PORTAL. 

Bump on bottom foot aka plantar fibroma

Plantar Fibroma treated with conservative care at first at our center without avail.   Initial treatment consists of topical gel of Verapamil 15% gel and other topical compounds to help relieve the pressure and pain in an attempt to reduce the size but was to no avail. Typical protocol is 3 x a day application up to  9 months even.   She was not able to continue conservative care due to pain with every step. 

How are they formed? 

No true answer to this. Theories have involved: microtrauma, genetic predisposition, that causes the body to form extra fibrous tissue. 

Where are the fibroma commonly located in the foot? 

Typically the medial to central band of the plantar fascia. 

Medial being the side towards your big toe and central being around the 2nd and 3rd to region.  The photos below is a classic example of the fibroma in the medial and central bands. 

What are the chance of regrowth and is surgery successful? 

Fibromas have a high recurrence rate, up to 80% in some papers.    

Recommendation is usually to only remove such only if symptomatic. 

Symptoms can occur with even very small fibromas, some patients with even huge fibromas do not hurt. From experience the patients that complain about pain are those that have the fibroma growing right over a nerve, often an inflammed nerve is found under this fibroma.   The best case scenario is no regrowth or recurrence but next best out come is that if the fibroma regrows it forms in a different area that does not compress on the nerve. 

What steps can my doctor take to improve success? 

Papers have stated up to a 1.5 cm margin of regular tissue to be taken out in addition to the fibroma itself to reduce the chances of recurrence. 

I have them on my hands and my feet is that normal? 

Some people do have it in both areas but not always.  A hand surgeon or plastic surgeon will help address the hand lesions.  You have the same band of tissue called the aponeurosis in the hand as well as the foot. 

If you or loved ones have this condition call us at 239 430 3668 option 2 to schedule an appt!

Preop from the side of the Fibroma

Bottom look at the fibroma, see the dark area
 due to rubbing of the fibroma in her shoes. 

z incision made for adequate exposure for removal

Note the lesion with viable margins also removed
 to help  prevent regrowth

What You Want to Know About Ankle Arthritis

According to the Mayo Clinic:
The two main types of arthritis — osteoarthritis and rheumatoid arthritis — damage joints in different ways.
Osteoarthritis
The most common type of arthritis, osteoarthritis involves wear-and-tear damage to your joint's cartilage — the hard, slick coating on the ends of bones. Enough damage can result in bone grinding directly on bone, which causes pain and restricted movement. This wear and tear can occur over many years, or it can be hastened by a joint injury or infection.
Rheumatoid arthritis
In rheumatoid arthritis, the body's immune system attacks the lining of the joint capsule, a tough membrane that encloses all the joint parts. This lining, known as the synovial membrane, becomes inflamed and swollen. The disease process can eventually destroy cartilage and bone within the joint.

I will concentrate on the osteoarthritis particularly in the ankle.  Most common complaint from a patient coming into the office:   pain , stiffness in the morning and relieves slightly after walking as well as swelling in the ankle.    Most will have history of ankle sprains or even a severe ankle fracture in the past. 

Did you know that even "mild" ankle fractures or sprains can lead to arthritis?  Ankle injuries can lead to OCD or osteochondral defects in the talus bone.    Translated: Pothole in the talus, the bone that connects to the ankle joint.  Will leave this for another blog to discuss treatment. 

Ankle arthritis or synovitis is inflammation of the ankle cartilage, joint inflammation from a variety of causes.    

Treatments: 

• NSAIDS: Motrin, Aleve, etc
• Steroid injections
• Platelet Rich Plasma injections
• Amniotic stem cell injections
• Ankle arthroscopy (scope of the ankle to roto rooter out the ankle joint)
• Ankle arthrodiastasis (stretch out the ankle joint after an ankle scope to provide room for new cartilage growth and recovery)
• Denovo  Juvenile cartilage grafts
• End stage ankle fusion or ankle implants

FFLC surgeons and physicians are well versed in treatment of this condition. 

Top technology and experience for this condition. 

Call 230 430 3668 for appt

Check out our various youtube videos discussing this disease. 

Lump on the top of the foot aka Ganglion Cyst of foot

Often, patients come into my office with a complaint of having a lump on the top of the foot. Sometimes they are referred here promptly from their primary care physician with concerned about this lump for possibility of cancer. The reality is that most of these lesions on the top of the foot happens to be a benign ganglion cyst.   

What is a ganglion cyst?

A ganglion cyst is a fluid filled sac usually with synovial synovial fluid. The synovial fluid has a very high viscosity which is the same fluid as a joint or a tendon which are two of the most common sites of origin of this to cyst. However, there are situations , and conditions that mimic a ganglion cyst that can be cancerous they are synovial sarcoma, giant cell, tumors or even bone tumors,  an MRI scan with contrast can help to differentiate the lesion.    Your podiatric surgeon will assess your individual situation. Those that require excision are:  rapidly increasing in size,  discoloration or  limits your ability to walk. 

Family Foot & Leg Center, we keep you walking and treat these bumps with ease. 

239 430 3668  option #2. 

Additional information from the American College of Foot and Ankle Surgeon about ganglion cyst below.

Ganglion Cyst

What Is a Ganglion Cyst?A ganglion cyst is a sac filled with a jellylike fluid that originates from a tendon sheath or joint capsule. The word “ganglion” means “knot” and is used to describe the knot-like mass or lump that forms below the surface of the skin.

Ganglion cysts are among the most common benign soft-tissue masses. Although they most often occur on the wrist, they also frequently develop on the foot – usually on the top, but elsewhere as well. Ganglion cysts vary in size, may get smaller and larger, and may even disappear completely, only to return later.

CausesAlthough the exact cause of ganglion cysts is unknown, they may arise from trauma – whether a single event or repetitive micro-trauma.

SymptomsA ganglion cyst is associated with one or more of the following symptoms:

• A noticeable lump – often this is the only symptom experienced
• Tingling or burning, if the cyst is touching a nerve
• Dull pain or ache – which may indicate the cyst is pressing against a tendon or joint
• Difficulty wearing shoes due to irritation between the lump and the shoe

DiagnosisTo diagnose a ganglion cyst, the foot and ankle surgeon will perform a thorough examination of the foot. The lump will be visually apparent and, when pressed in a certain way, it should move freely underneath the skin. Sometimes the surgeon will shine a light through the cyst or remove a small amount of fluid from the cyst for evaluation. Your doctor may take an x-ray, and in some cases additional imaging studies may be ordered.

Non-Surgical TreatmentThere are various options for treating a ganglion cyst on the foot:

• Monitoring, but no treatment. If the cyst causes no pain and does not interfere with walking, the surgeon may decide it is best to carefully watch the cyst over a period of time.
• Shoe modifications. Wearing shoes that do not rub the cyst or cause irritation may be advised. In addition, placing a pad inside the shoe may help reduce pressure against the cyst.
• Aspiration and injection. This technique involves draining the fluid and then injecting a steroid medication into the mass. More than one session may be needed. Although this approach is successful in some cases, in many others the cyst returns.

When is Surgery Needed?When other treatment options fail or are not appropriate, the cyst may need to be surgically removed. While the recurrence rate associated with surgery is much lower than that experienced with aspiration and injection therapy, there are nevertheless cases in which the ganglion cyst returns.


FFLC treats these and other foot / ankle ailments with ease. Call: 239 430 3668 option 2. 

Passing on your foot problems to your kids

Did you know that if you have ingrown nails, there is a 50% chance that your child will get ingrown nails?

If you have flat feet that caused terrible hip and back pain, your child may be doomed to such without proper monitoring and preventative care, a simple orthotic can help your child develop properly.

Continuing education a way of Life

Medicine and surgery changes very fast nowadays with innovative products and techniques.    Glad that the minimally invasive bunionectomy via the Lam modification is gaining traction as other doctors and more FFLC patients see the benefits.  
Patients are able to walk the day of surgery in a boot, even had a plastic surgeon return back to work 3 days after surgery!  This surgeon definitely appreciated the 6 mm bunionectomy.

www.ScarlessBunion.com    to see more photos and actual patient pictures.

Being award Amongst Top Podiatrists in America

Grateful to be recognized for my hard work and dedication to the foot and ankle surgery world.   That path was not always easy.   As a college student I was accepted to start podiatric medical school right after my toughest year as a junior.  As with all college students the senior year was to be a year to unwind, look for jobs, find ourselves and our future path.     On the fast track to the Doctor of Podiatric Medicine degree at the Temple University School of Podiatric Medicine, managed to still engage in NCAA Tae Kwon Do competition circuit and get graduation honors.     The dean of the school, Dr. Mattacci took me under his wing for my internship year after graduation from Podiatric Medicine, of which I am very grateful for.   The opportunity at Mt Sinai Medical Center in Miami Beach and Jackson Trauma Center in Miami was a great experience to learn all phases of podiatry from foot care to trauma and restorative / reconstructive surgery.    

Running an office, mentoring young doctors and student doctors has always been my way of giving back to the profession.     Treating patients and getting them better is my passion.  

Whether I'm at a conference learning or teaching new techniques, to being a consultant with various orthopedic companies and groups, the field of Podiatric Medicine / Surgery, excites my sense of community service and curiosity.

Thank you for the honor. 

Dr. Kevin Lam 

Snow Bird Season in #SWFL starts October

It is that time again where our northern friends return to enjoy our beautiful weather.   A few tips, when you are driving down, please make several stops and walk around to prevent deep venous thrombosis or clotting of the veins that can be deadly if progresses to the lungs.
Symptoms are redness, swelling, warmth of usually one let.  Present to the nearest emergency room immediately to get checked.  Any medical treatments and surgeries done up north, please bring a copy with you to your doctors here in SWFL.
Make sure that if you have had any address , insurance company changes, you let your doctor's offices here know about such.

Welcome back, enjoy our weather and hospitality.  If any of our patients requires a referral to a generalist or another specialist, please feel free to contact your FFLC doctor as we have a wide network  and have the inside information for your safety.

We have 3 offices to service your needs:
661 Goodlette Road, Suite 103
Naples, FL  34102

12250 Tamiami Trail East, Suite 101
Napes, FL 34113

1661 Medical BLVD, Suite 302
Naples, FL 34110

Central Scheduling:
Call: 239 430 3668
Fax: 239 692 9436

Jon Bon Jovi has heel pain relieved with endoscopic release

For the past three decades, Jon Bon Jovi has been performing concerts all over the world in front of millions of loyal fans. What those fans did not realize was that he was pushing through intense foot pain for many of those concerts. “The pain was so severe during my 2013 Because We Can Tour that I would want to jump through the ceiling whenever it was touched,” Jon says. “I got to the point where I was given injection therapy, orthotics, shockwave therapy, and platelet rich plasma (PRP) therapy, but they did not alleviate the chronic condition.” After the tour concluded, Jon revisited John Connors, DPM, a sports podiatrist at Riverview Medical Center.


Jon Bon Jovi and Dr. John Connors


At Riverview, under the care of Dr. Connors, Jon underwent endoscopic plantar fasciotomy (EPF), which is a minimally invasive and minimally traumatic surgical treatment for chronic plantar fasciitis. Six weeks is the typical recovery time for this surgery. “Exactly six weeks later, Jon was again walking and jogging on the treadmill,” Dr. Connors added. “He is now 100 percent for the first time in years.”

Source: Robert Cavanaugh, Meridian Health Views [September/October 2014]

From Dr. Kevin Lam:
EPF is a procedure using small stab incisions and a 4mm camera used to visualize the plantar fascia then a blade is inserted from the opposite side to cut the fascia to relieve the pain. FFLC has this and newer technology for those nagging heel pains.

Back Pack Tips for Back to School

September 17th is National School Backpack Awareness Day

The kids are back in school and toting around those ever–present backpacks crammed with books, notebooks, electronics and lunch. But all too often a backpack can weigh 12–15 pounds, which can be too heavy for a child’s frame to carry.

A too–heavy backpack can lead to poor posture and back pain and injuries, such as:

Stress fractures Inflammation of growth cartilage Back and neck strain Nerve damage in neck and shoulders Low back pain

Look at it this way – carrying a 12–pound backpack to and from school and lifting it ten times a day for a school year puts a cumulative load on a child’s body of 21,600 pounds – the weight of 6 mid–sized cars!

Carrying a backpack that is too big or heavy also changes the way kids walk, putting them off balance. This increases the risk of falling, especially on stairs, and can cause foot and ankle injuries like torn ligaments and sprains.

Visit the American Occupational Therapy Association (AOTA) website for information on this year’s National School Backpack Awareness Day on September 17th. You’ll find helpful information on injury risk factors and strategies for choosing and loading a backpack properly. Here are a few examples:

A child’s backpack should weigh no more than 10% of his or her weight. Choose a pack that ends above the waist and that has padded, adjustable straps; always wear both straps. Carry only what is necessary. Consider a backpack that has rolling wheels if permitted in your child’s school.

Joan Rivers and outpatient surgery environment, shouldn't be done?

The death of a comedic icon, Joan Rivers is unfortunate and has shed a spotlight on the topic surgical settings. 

Reality is that mortality, death, can happen even in the most minor of procedures either in the hospital , office based surgery or the ambulatory surgery outpatient setting.    The regulations in place for all outpatient surgery requiring anesthetics of any kind that is more than local anesthesia (commonly referred to as novacaine)  is very strict by various state laws.  

Due to insurance and government's efforts to control costs more procedures are going outpatient to the latter two of the facilities.   Cost savings are enormous for the government, insurance carriers and to patients.   

Hospitals usually charge and receive up to 3 times the reimbursement for the same procedures done at outpatient facilities while doctors are paid similar regardless of facilities chosen. 

The question that was brought up recently was safety, is it safe? 

Yes, the outpatient facilities are just as safe as hospitals and are under tighter scrutiny, just ask the administrators of those outpatient facilities.   If sedation or general anesthetics are used the surgeon as well as the anesthesiologist are both required to be certified by American Heart Association in Advanced Cardiac Life Support.     The same doctors responsible for life saving actions in the hospitals are present during outpatient surgeries as well as same drugs. 

The media seems to spin things out of proportion for ratings.    The outpatient facilities tend to deal with cleaner cases which also tends to lower infection rates vs hospital setting.  This is a big plus for patients.    Hospital acquired infections are less common in the outpatient setting as there are no long term patients undergoing dirty procedures such as a perforated bowel, MRSA wound washouts, etc.

The other topic being brought up is should an 81 year old have elective surgery?    Some 40 year olds I've seen are in worse shape health wise then my 85 year olds that walk 5 miles a day etc.    Age is nothing but a number is correct,  the health age is more important.   Just because a person is over 65 does not mean they are over the hill for elective surgeries.  For myself as a podiatrist, most of what I do is elective such as bunions, hammertoes, fusions, ankle arthroscopies, as long as the patient is healthy enough and active risk of anesthesia death is relatively low.

Foot Fractures more common during "ankle sprains."

"Doc I sprained my ankle and it has been hurting for the last month,the ER says my ankle is not broken," the patient.  

Heard this a million times. What we have always trained our staff at FFLC is to take the Ankle and Foot films in these cases. The reason is that most ankle sprains are just that, sprains of ankle ligaments.   BUT foot fractures due to twisting of the ankle is more common than ankle fractures.

• Fifth metatarsal base fractures

• 

  5th metatarsal base fracture

  

  Surgical fix with screw. 

• Anterior process calcaneal fractures 
  
• Jones' Fractures.
• Lis Franc's fracture / dislocations

I know the last one personally. I twisted my foot during Brazilian Jujitsu practice and immediately my foot and ankle swelled up.   Being a foot / ankle doctor, the treatment that night consisted of ICE, rest and ace wrap, the next morning Xrays were taken.  Luckily, no fractures but I did have a lis franc's sprain which has taken up to 6 months to get me back to 90 % of my physical activity.    

So when you think of ankle sprains now, think, check the foot!

Worker's compensation and Motor Vehicle Accidents of the Foot / Ankle

Often the difficulty comes from a patient waiting too long to seek medical attention or they do not tell all their complaints to their treating doctor.   They can be concentrating only on one area of the body, eg: shoulder / back pain but forget about the ankle injury and thinks that it is only a sprain.  There are times when clinicians can get tunnel visioned in treating one area of significant injury but inadvertently do not address another area. Being trained in trauma surgery and reconstructive surgery, I have seen the neglected ankle sprain being a tendon rupture / ligament rupture, nerve damage, etc.     MRI's and through physical exam by a specialist physician are very useful around the time of the injury to see active swelling, injury to the tissues in question.   This can help to answer the age old question of if this a new injury from this accident or a preexisting injury or even an aggravation of a preexisting condition.    

If you need a second opinion after any accident about your foot / ankle concerns seek a board certified expert with experience in trauma care and reconstruction. Independent medical examinations (I.M.E.) can be done to help also.

Life altering ankle sprain why you should see a doctor.

Hint: NOT AN ANKLE SPRAIN but ligaments and tendon ruptures

Active tennis coach who took a wrong step and twisted his ankle on the court while teaching about 4 months ago, ankle never felt better and in fact worsened and also feels unstable on this ankle.   Pain, burning sensation noted about the outside ankle bone.   MRI notes tears in both tendons on the outside as well as 2 ligament tears.  There are 3 ligaments on the outside of the ankle the Anterior TaloFibular Ligament (ATFL), Calcaneal Fibular Ligament (CFL) and the Posterior TaloFibular Ligament (PTFL) as well as 2 tendons the Peroneus Brevis and the Peroneus Longus tendon. 

Most people will shrug off an ankle twist and think that if they can still put weight on the foot, they are fine, just a sprain.   This is just one of the complications of a neglected "ankle sprain."      In fact, often ankle fracture are less painful than a ligament tear.    There are also discussions with new imaging technology that even those injuries classified as sprains are actually mini ruptures of the ankle ligaments.   Repeated injury can cause lengthening of the ligaments and predispose a person to more injury in the future if significant injury has not already been done. 

Back to this case:  This person injured tore two of the 3 lateral ankle ligaments, then the two tendons were injured in the same accident.  Bracing and therapy would not help in this situation though was suggested by the insurance company and the independant far from caring reviewing orthopedic surgeon hired by the insurance company to deny MRI's and surgeries.   Orthopedic surgeon or podiatrists are hired to do reviews of these cases to first deny MRI's and then to deny surgeries.   Acting as a patient advocate in this case and many calls made, finally an MRI and surgery was done, the orthopedic surgeon's callus opinion was overturned by a case manager. 

Surgery involved arthroscopy of the ankle joint to assess the cartilage and remove any inflammed tissue in the ankle, patient did have an anterior lateral impingement syndrome that was cleared with arthroscopic tools through a 4mm portal.  Both tendons repaired, bone removed from the outside of the heel bone, the peroneal tubercle is a natural occurring structure but in this case worsened his situation.   New ankle ligaments were made for this patient with his native tissue, yes, we can make new ankle ligaments. 

Updates to follow: 

Silver retractor points at the Peroneus Longus tendon that is scarred to wall of heel bone. Brass colored retractor on the Peroneus Brevis tendon, notice the bulbus tear just to the right of the retractor.  

Notice the tear of the Peroneus Brevis tendon with a bone (peroneal tubercle wedged between the tendon)

Same issue as above with instrument pointing at the peroneus brevis tear.

Saltwater Catfish Barb injuries

While fishing Naples Pier, there are days when it seems that the only fish around are the catfish eating your precious baits.  Or in the backwater.   Few injuries have come into the office when people tried to kick the catfish off the pier or dock while wearing sandals, crocs, etc only to get a catfish barb in the toe or foot.  They are very painful injuries, not only because of a puncture wound but also because of a protein toxin in the spines.     While you can get most of the barbs out, it breaks off easily and stays under the skin.   This will be very painful.   What to do in the situation?

1) Soak in warm / hot water without scolding your skin
2) Seek medical attention for xrays and possible extraction under local or general anesthesia
3) Retrieval of barb by a medical professional
4) Antibiotics as a precaution.


Best way to treat this?   Do not get close to the barbs with your hands or your feet. FFLC treats these injuries on an emergent basis with in office xrays, and ability to clean the wound and retrieve the barb from your foot or lower leg.   At times admission to hospital to get general anesthesia may be required.

Buy Shoes For Back to School, how to avoid foot pain for your child.

1. 75 % of american buy shoes too small for themselves imagine their children?
2. Need at least 1/2 inch or a thumb's width between the longest toe to the end of the shoe while the child is standing
3. Running shoes are not recommended for everyday usage for walking and activities.  Running shoes are meant to be light for competition, not deal with the punishment of everyday walking and grueling activities.  
4. Wrong shoes are the major reason for pediatric heel / achilles and knee pain. 
5. Get you child's feet measured at least once a year professionally by a podiatrist , pedorthist, or qualified shoe salesman
6. The shoe measuring instrument, brannock device,  is meant to be used while standing, not sitting.   
7. Width of the shoe is as important as the length of the shoe. 
8. Painful flat feet? Need to see a podiatrist ASAP before other symptoms start. 

Posterior Tibial Tendon Dysfunction Grade II

Our very own Dr. Ramy Fahim discusses treatment for Grade II of this disease.
There are various ways to treat this deformity from stents such as the hypocure to bone fusions, bone slides, reconstructions, etc.

Below are videos of a single arthrodesis to the triple arthrodesis.   Arthrodesis or fusion is the mending or bringing together two or more bones.    Set it and forget it as Ronco used to say.  Fusions are typically for more advanced disease such as grade III or IV or if the patient is overweight with grade II disease.  

Grade I :  Tendonitis
Grade II: Tendonitis / Tearing
Grade III:  Flexible adult flat foot
Grade IV: Rigid adult acquired flat foot

Popping Peroneal Syndrome, Ankle Popping / instability by Dr. Kevin Lam

Peroneal Subluxation Syndrome.

1. Does your ankle pop on the "outside" during certain movements?
2. Pain on the outside of the ankle? 
3. Unstable ankle, feeling of about to fall off the ankle
4. Burning pain outside the ankle. 
5. Audible popping sound when you are rolling your ankle around. 
6. Visually see your tendon on the outside rolling and popping? 

Achilles tendon ruptures fixed with PRP and casting

Not all achilles ruptures require surgery.    
Some patients do well with casting and Platelet Rich Plasma injections.  See the difference in this video.
One important fact about this process is that it works best when we get the patient early in the rupture, when the tendon has not retracted up the leg.    

Malignant Melanoma on the Leg PART 2

Followup from my earlier blog about Malignant Melanoma 5 years in duration. Lucky for this patient his was a superficial spreading kind and has not grown deep enough to spread beyond the local skin.  A 1 cm margin of safety excision will be done in accordance to NIH guidelines.    Cure rate is in the high 90 % mark.  Patient will need followup with Dermatology and now living in FL will need a whole new look at sunscreen and sun clothing such as those from coolibar, etc.
When in doubt biopsy it out, it can save a life.

Another leg and life saved at the Family Foot & Leg Center, PA.

American Idol Michael Johns dies of Blood clot from Ankle. What you need to know now!

According to Entertainment Weekly, the Australian born singer, who was on the Fox program in 2008, died Friday at age of 35.   He apparently died of a blood clot in the ankle?   How can you die from a blood clot in the ankle one may ask.     Without knowing the official reports, based on the news that out there  about his death a blood clot in the ankle is noted as the cause of death.  I am assuming that he died from a clot that started in the ankle / calf and travelled to his lungs.    This is called a pulmonary embolism, AKA P.E. as noted in the medical text and jargon.

How do you get a blood clot in the ankle /calf.  One way is sitting still on a flight or any situation for along time with blood pooling in the legs, the blood then clots in deep leg veins causing swelling due to the blood not being able to return to the heart.   When a clot breaks off and does return, it is lodged in a pulmonary vessel causing difficulty in oxygen exchange in the lung tissues.  Depending on the location and size of the clot this could cause some serious damage leading to death.

Risk factors:
Being overweight and inactive, being on birth control pills, being immobilized after an injury  in cast, being immobile while on a long flight or drive, genetic clotting disorder, smoking, family history of blood clots etc.   Any combination of the above can be a recipe for disaster.   If you are having surgery of the lower extremity and have any of the risk factors above or combination of such, notify your surgeon ahead of time where proper tests can be done as well as proper post operative protocols can be done to help prevent most blood clotting situations, nothing is 100% in medicine.  I have seen people with bunion surgery go onto having these clots.


Symptoms include: swelling of legs, coughing, radiating pain to the arm / chest, deep pain in one or both legs with swelling, severe varicose veins, redness of the leg (s), difficulty breathing, feeling tired / light headedness,  looking pale / clammy or discolored skin, rapid / irregular beating heart etc.

Mayo clinic information
NIH Source on pulmonary embolism.

Disclaimer: as of this writing, I do not have the official report of his death,  only information out there at this time is death due to blood clot in his ankle.    This is the most common way you can die from a blood clot originating in the ankle, him being a star from American Idol probably travels a great deal on airplanes and sitting still for long periods of time between performances. 

Malignant Melanoma on the Leg at www.NaplesPodiatrist.com

Patient of the Family Foot & Leg Center, PA in Naples FL was seen for a trauma of the other foot, trauma taken care of in surgery, but he had a dark spot on the other leg.   Started about 5 years ago after he had scrapped his leg on an object and started bleeding.  No history of cancers, etc in the family.  He was not even sure he should have even brought this small problem up to me. Given the pattern of this and that he was not born with this lesion a 3 mm punch biopsy was done.   Behold the report came back malignant melanoma.  Instant referral to a dermatologist and general surgeon was made for more definitive care and diagnostics.   Malignant Melanoma on the foot is the 2nd deadliest cancer a man can have, this is in the leg not much better.

Possible treatments can involve a below knee or above knee amputation depending on spread of this disease.

Update:Patient's melanoma is the superficial spreading kind which is very much on the surface.  Dermatologist removed a majority of it and then an oncological surgeon removed the rest along with a lymph node biopsy. 

Patient's leg  and life saved. 

President Barack Obama has Right Heel Pain

#Heelpain

Heel Pain is the most common problem seen by #podiatrist, not even the president is immune.
NaplesPodiatrist.com   this is one of the most common none surgical  problem that we see.


 A few reasons why:

1) We are poorly educated about shoes by the media and pop culture. What is cool is not the best for you.

2) Lack of flexibility and stretching of achilles. Even in martial arts schools, running teams, they neglect this area of the body. Achilles is the biggest tendon in the body!

3) Weight, though not President Obama's issue, this does weigh heavily in why we are seeing so many heel pain patients. Want to know more about heel pain or stretching visit:
Naples Heel Pain Page

Pediatric Flat Foot & Pain, what you should know

I still hear from some patients that they have no idea where to turn for pediatric flat foot / flatfeet advice.   The video above is a great resource as well as the videos below highlighting the problems kids go through with their feet.      Not all pediatric flat foot deformities are surgical cases.  In fact, most are treated conservatively.     But true surgical cases must be managed by those with extensive experience and training for such.  Here is link to a flow chart as recommend treatment protocols by the American College of Foot & Ankle Surgeons.

Dilemma on talking to patients about weight issues contributing to foot / ankle pain

Funny, as a physician we are supposed to make sure our patients stay healthy and free of aches and pains. Obesity is a big issue in some areas and when it is the cause of our patient's problem, most will not listen or even criticize the doctor via email for, "How dare you tell me to lose weight when all I had was pain all over my body and feet, which is why I came to see you in the first place. I did not pay for you tell me to lose weight." This email caused me to reflect on my role as doctor or learned friend. In my years of practice, I have had the most pleasure not correcting a clubfoot or reconstructing an unusable limb due to trauma to one where the patient can walk on it, no. The one case that brought me the most pleasure was a 350 pound man with collapsing ankles and flattening feet / arches in a disease known as posterior tibial tendon dysfunction. I have known this wonderful gentleman for 2 years, every time he comes in is the same complaint, doc my ankle hurt I'm having problems walking on it, can you please do surgery on me. For 2 years I refused to do surgery on this fellow and the main reason I gave him is that if I did surgery on him, it would fail due to his weight. The goal for him was to lose 100 lbs or I would not operate on him. Don't get me wrong, I did treat the fellow with medications, braces and physical therapy orders as a temporary solution. The final straw for him was when his pain returned this year, I referred him to a weight loss physician as well as getting him a custom Ankle Foot Orthosis commonly known as AFO. He lost 40 lbs with the doctor and discovered that he was eating for pleasure and living to eat instead of eating to live. Suddenly his foot / ankle pain is gone and he is happily wearing his brace. With all this talk about the ACA, obamacare, ACO's, how about a good dose of self responsibility. Most physicians are too busy these days to help monitor weight loss, etc. They would just say lose weight, see you at your next checkup. Or write a pill for your type II diabetes is  much faster and easily accepted by patients nowadays vs a good prescription of diet change and workout regimen with a trainer. If I had to do it again would I tell this obese female who sent me an email degrading my doctoring skills to lose weight? Of course I would, she will go from doctor to doctor who will bandaid her problem if at all possible. Or seek gastric surgery only to fail without proper mental / psychological preparation. Having trained at a center where they did a lot of bariatric surgery, I can tell you that counselling is essential as the mentality towards foods have to changed and reprogrammed. Food is an addiction and must be treated as such in order to succeed.

Eat your veggies, keep a healthy weight, lifestyle, don't smoke, drink in moderation all the stuff your grandmother would tell you.

What you need to know about Spurs in the Achilles Tendon

Most common complaint for this problem is a pain in the back of the heel and stiffness.  Or even a bump on the back of the heel.    The xray below shows an unfortunate patient with two types of spurs in the back of the heel that can cause a problem with the achilles.  Not to mention a large spur on the bottom that is currently not symptomatic.    


Red: is the Haglund's deformity AKA pump bump, common in old fashion days when pumps were popular and the back the pump rubs against the back of the heel bone.  

Orange arrow: points to the spur within the achilles tendon.  As you can see there is a shadow of the achilles noted in the back of the heel bone.  It is also very inflammed in nature as noted with the thickness noted in this xray.   MRI's are more telling of the actual tendon inflammation, injury and likely partial tears of the achilles.   By the time a patient presents to me with these xray findings they have been having pain for some time already.  


Not all patients with these xray findings will require surgery. Conservative care with anti inflammatories, physical therapy, shockwave therapy, massage therapy can help the condition, but if the pain persists beyond conservative care, surgical care will be required.

Below shows an xray of the same patient 2 weeks post operatively.
Notice the two noted spurs have been removed and staples in place for skin closure.
No pain at the 2 weeks mark and able to stand on the foot, not walk yet, but can stand.  Will allow range of motion at 4 weeks, then therapy and a boot to be used at 6 wks.   7/22/2014, stay tuned /subscribe for updates as the patient heals from her successful surgery.

Office Based Surgery Suite as cost savings to patients, insurers, government

Did you know that the most expensive part of your surgery is not your surgeon?
It is the facility such as the hospital or surgery center, that cost can be as high as 10 times your surgeon's fees.    With all this talk about cost savings and need for medicare and patients to save money the trend is towards office based surgery suites.  They are based out of the surgeon's office and is certified by the state department of health.   This significantly brings down the cost of surgery procedures by eliminating the highest cost in the equation for surgical procedures.  This allows the surgeon /physician to control the cost of the extraneous expenses and the patient gets the best value.   You still get the same care, anesthesia, etc, but at a fraction of the cost.    The one big barrier to this model of care is that when implants are being used, such as screws, wires, joints, insurance companies are not paying the office suites for these thus possibly passing the cost to the patient.   In most cases even if the cost of implants are forwarded to the patient, office based suites still is a great value vs other facilities.    As our healthcare system goes through these changes we should see more OBS sites.

Lateral ankle ligament surgery what you want to know

Tore some ankle ligament?    This is a story of an active male that had lateral ankle ligament reconstruction elsewhere and is here for a 3rd opinion.

Problem:  wound would not close and drains as well as continued unstable ankle.



How solved: removed all prior internal stitches (fiberwire) none absorbable that were used for the ligament repair.    Flushed / power washed the site with 300 liters of pressurized saline to clean any bacteria out.  Sent patient to infectious disease for powerful intravenous antibiotics for 6 weeks.   Repair with none braided smooth and absorbable antibacterial suture with amniotic tissue graft used for reinforcement due infected tissue that had to be removed.



Discussion:  Infections happen even in the most skilled hands and seemingly sterile environments.   Microbes are all over the place. I have steered away from certain braided none absorbable sutures now due to increase incidence of bacterial colonization.    Braids can hide bacteria better & also presents a barrier for antibiotics to get through.     Lateral ankle ligament reconstruction is not very difficult to do, most patients have enough of their own tissue nearby that can be rotated to reconstruct ligaments.

Secrets to Buying Shoes For Back to School

Can not believe it is back to school shopping again for SouthWest Florida Schools.

Let us look at the proper way to assess and buy shoes for your child to avoid foot , heel, or ankle pain.

Many of the problems we see in kids can be avoided with the proper fitting shoes and proper length.

Having a child that is in his growth spurt, I know it can be challenging in keeping up the size of shoes in kids.

Timeline for replacement can be anywhere from 3 months to 6 months depending on activity of the child, weight, etc.

Arthroscopic Ankle Fusion by Dr. Kevin Lam

Frank discussion about ankle fusion and this technique to achieve such.

Fusion of the ankle can be complicated and difficult to heal from with up to 50% nonunion rates (failed fusion) depending on technique.     Arthroscopic fusion is greater than 90% fusion rate according to studies mostly from lack of dissection, keeping nerves and blood supplied intact and mostly the anatomy also is intact during this type of fusion.    

With the advent of percutaneous intermedullary rods and external fixation techniques most ankle fusions do not need to be opened.

Rainy Season & Fungi growth on ur feet 5 things you need to know

1. Air out your shoes / socks, do not keep them on too long if you happen to step on a puddle
2. Dry / scaling feet or cracks between the toes, smelly, time to see your podiatrist
3. Diabetics with redness or cracks in the feet must see a doctor or risk infections and amputations
4. Rotate your shoes have at least 2 pairs to alternate daily humidity and wet weather is a great breeding ground for fungi
5. As a preventative, you can use baby powder or foot powder between your toes every day to keep the sweat from becoming a problem. 

If you ignore your fungal infection, you can colonize bacteria and cause a bacterial cellulitis that can be life threatening and difficult to treat, even requiring IV antibiotics at times. 

5 Things you want to know about MRSA in Jujitsu, karate, gyms, etc.

5 Things you want to know about Methicillin Resistant Staph Aureus.

1) Staph Aureus is all around us, on our skin, desktops, phones, etc.   MRSA is just a variant of this bacteria that is resistant to methicillin a form of beta-lactam antibiotic aka penicillin family.

2) MRSA starts out as a bump on the skin / boil, blister, etc.

3) Can go deeper through the skin to the fat, muscles and blood where it can be deadly

4) Only way to identify is through cultures taken at the doctor's office or hospital.  In fact, most patients in the high risk category such as immunocompromised or diabetics, that are admitted to hospitals nowadays are assumed MRSA infection until otherwise noted

5) There are newer oral antibiotics that are effectively treating MRSA, IV antibiotics is still the quickest way to get the antibiotics into your system for limb or life threatening situations.

5 ways to avoid or pre diagnose MRSA

1) Nasal Nares cultures:   taking a culture of the nasal passages can determine if the person is a carrier and if so a regimen if antibiotic application and bathing in selective solutions can help

2) Wash your hands frequently, and use hand sanitizers.

3) Make sure you wipe down and pre-wipe all equipment at the gyms

4) Jujitsu or karate uniforms must be clean at all times, jujitsu more so then karate. No badge of honor for sticky yellow uniform that is supposed to be white.  Use long rashguards to avoid skin abrasions.

5) Mats or other contact surfaces must be cleaned and disinfected with anti MRSA solutions.


When you have a skin rash, infection, make sure a culture is taken and empiric (broad spectrum)  antibiotics are started immediately, can be a matter of limb and life loss.

Remember Kevin Randleman's Staph infection? Vinny Magalhaes had to step out of Metamoris 3 lineup due to this infection.

Not to say, do not practice contact sports for I love Brazilian Jujitsu and Karate, you and the gym should take precautions against MRSA.   As a medical student and even as a resident back in late 1990's, MRSA was not as common.   How does this happen, where and when did this happen that MRSA is so common?

One big blame is the overuse of common antibiotics like penicillins, bacteria generations are way shorter then humans and through true Darwinian concepts, one bacteria forms resistance and thrives while others are killed.    The overuse of antibiotics is one major cause.    We actually need bacteria on our skin to keep a balance as well as bacteria in our gut for proper food digestion, not all bacterias are bad.    

Hospitals , nursing homes and jails are big source of community acquired MRSA due to both population density and antibiotic usage.

Dr. Kevin Lam
www.NaplesPodiatrist.com

Unstable ankle, pain / burning lateral ankle: Os peroneum

10-15 year old with foot pain

Typically the parents bring in the patient with foot pain that they have tried to treat at home with motrin, etc and the patient's pain is the same or worse.     At about the ages of 10-15 the child will undergo massive growth spurts and the growth plate can become inflammed from the counter pulling of muscles / tendons, etc. Added to the fact that this is also the age where most kids become active and serious into sports, karate, etc. Two common diagnosis for kids of this age group is:

• Severs Disease  inflammation of the heel growth plate.  I see this in basketball players and karate students.     Best way to treat this at home is to do achilles stretching, wear proper shoes and heel cups.   If these fail, then a visit to your local podiatrist would be in order.  Below is a film about stretching, for more resources, visit www.Naplesheelpain.com
• Os Vesalium Syndrome: Swelling and pain the base or back of the #5 metatarsal base (bone on the outside of the foot.    Stretching, rest, Ice.
• OsGood Schlatter disease:   Pain in front of the knee where the patellar tendon inserts into the tibia.  Patients will complain about knee pain typically in the 10-15 year old age group. Stretching the hamstrings and quads will help this condition as well as Rest, Ice, and topical anti inflammatories. 

Lesson in all this is that with increased activity and growth the child needs a consistent stretching program to avoid these problems as well as bone spurs when they are adults. 

Tight muscles , tendons, ligaments are the reason why heel spurs, bone spurs are formed in the lower extremity.   Proper training programs requires proper stretching programs to coincide. 

Stretching instructions

Below talks about Pediatric Heel Pain

Below talks about how to buy shoes for your child.

• Second most common foot pain in a child of this group is Os Vesalium syndrome.  

Hope you find this informative and ask questions. What do you want to know? 

Dr. Kevin Lam,DPM, FACFAS

www.NaplesPodiatrist.com

239 430 3668

Tips to control foot odor / fungus

Summertime is here and if you live in SWFL you will notice the humidity.   We are seeing more cases of athlete's feet , aka tinea pedis, aka fungal infection of the feet / toe/ nails.
Steps you can take to control, avoid such

• spray your shoes / sandals with lysol and allow to air for 24 hours, also alternate shoes, sandals
• if you sweat a lot, use antifungal foot powder spray to keep odor and fungus at bay
• wash socks in color safe bleach
• do not wear wet shoes! Dry them out completely before wearing
• pay attention to between your toes,   toe jam = dead tissue that can be a breeding ground for fungus

Fungus is a tiny organism that lives off your skin cells.   Infections starts with mild itching, scaling of the feet.   Worsening infections can lead to bleeding, pain and severe odor.  Once there is a crack in your skin, the skin is open for bacteria to enter and cause bacterial  infection called cellulitis.    

Diabetics, people with peripheral neuropathy or PAD (peripheral arterial disease) should not try to treat this themselves.   

When all else fails see your podiatrist as soon as possible to prevent further complications.