Hallux Rigidus(stiff big toe)-Joint Replacement Surgery

Posted by on Monday, January 16th, 2012

Hallux Rigidus is a specific osteoarthritic condition of the great toe joint. It can result from severe injury to the big toe but is most likely an inherited problem. It is usually present in both great toes but usually one is worse than the other. The process usually starts as a bony bump on the large joint of the great toe. It starts on the part of the joint that faces the second toe. It then proceeds over the top of the joint and around the inside border of the joint facing the other foot. As the process progresses, the bony bump gets larger. Eventually,the bumps on the top of the toe joint hit one another and prevent the toe from bending up. This can become very painful when one is walking, running, jumping, or dancing. It will become increasingly painful to wear shoes with an elevated heel.We refer to this condition as an arthritic condition.Unique to hallux rigidus is that the center of the joint and the bottom portion of the joint are spared until the very end stages of this process. At the very end stages ,the joint becomes very stiff in all directions.When the first metatarsophalangeal joint becomes arthritic this way, it becomes enlarged due to the bony bumps around the top and sides of the joints. Therefore, the initial treatment for pain has to be a shoe with a wider and higher toe box. This will prevent the shoe from squeezing the enlarged joint. When the pain associated with hallux rigidus can no longer be relieved in an acceptable manner,surgery is an option.As with bunion surgery,the surgery should be done to relieve the pain and discomfortand to improve one’s quality of life. As with all surgeries, it is important to remember that there are potential complications as a result of the surgery. The desire or need for surgery should outweigh the potential risks and complications. The most common procedure done for hallux rigidus,when the center and bottom parts of the jointare moving decently, is to shave off the top part of the metarasal head with the abnormal bony bumps and corresponding enlarged portion of the base of the proximal phalanx. This procedure is called a Cheilectomy. We published a 10 year retrospective study on this procedure in the Journal of Foot Surgery. This procedure removes the arthritic spurs in the top part of the metatarsal head and proximal phalanx. The toe usually moves well at the end of the operation. Generally, exercises to start moving the toe up and down should be started within the first week after surgery. If the center and bottom parts are damaged and there is little to no movement in the joint,then either a joint replacement (implant) or fusion of the joint should be considered. The joint can be replaced on the toe joint side , the metatarsal side or both sides of the joint. The implant is either made of a nickel and titanium alloy or high molecular weight silastic. The doctors in our office have over 40 years of experience in successfully replacing painful arthritic joints. The doctors have found that  joint replacements provide  functional and pain free movement of the big toe joint. The doctors also perform fusions of the joint . A fusion means that the large bone in the toe is put against the metatarsal bone,and they grow together. They will heal like a broken bone but will heal to form a solid union. Generally, people with a fusion function well, although they are limited in their choice of shoes.

If you have a stiff, painful big toe joint and would like one of the doctors evaluate your foot condition call 212-996-1900 or if you live in Westchester 914-328-3400.

Bunions-Part 3 Treatment

Posted by on Monday, September 19th, 2011

Drs Geldwert,  Lai and Minara have over 60 years of combined experience successfully repairing bunion deformities.

There are 3 basic approaches to caring for bunion deformities.First is benign neglect. This involves wearing the most comfortable shoe that can possibly be tolerated with any degree of comfort. It also involves limiting one’s activity to those which are reasonably tolerated without pain.This is a perfectly acceptable way  of dealing with a bunion deformity as long as the individual is willing to live within the constraints that are applied.The second step involves active participation of the individual in caring for the sequelae of the bunion deformity.The most important thing is to get properly fitting shoes that accommodate the foot of the foot adequately. Invariably the heel will be loose and this needs to be adjusted or fixed by a shoemaker. Secondly, a pumice stone should be used on the calluses every day or every other day before getting out of the bath or shower to keep them under control so that the normal skin around them does not become painful when it is squeezed against the calluses. An over the counter insole or custom made orthotic may be appropriate at this stage. The orthotic would be used to help substitute ,in part,for the function of the plantar fascia.The third alternative is surgical correction of the deformity. Although there are well over one hundred procedures described to treat bunion deformities, there are certain basic guidelines that must be followed no matter which procedure is used. In treating any joint and bone deformity, the joint surfaces must be re-aligned. The bones must be re-aligned to do this.This means that the bones will need to be cut and re-aligned.The normal capsular balance must be fixed which means that the loose ligaments on the inside of the toe  joint will need to be tightened and the tight ligaments on the outside loosened. Also, the tendons must be re-aligned. If any one of these steps is not done, an incomplete repair may very well result. This can lead to a quick recurrence of the deformity.The decision as to whether to have surgery or not is a difficult one for any individual to make. There are several guidelines that are important. First,one should have tried conservative means for relieving the pain associated with the deformity.The decision to have surgery should be made only after the individual feels that his or her daily activities are being limited. This means that the individual can no longer wear the shoes that he or she wants to wear without pain and is not able to participate in activities that he or she wants to because of the discomfort associated with the deformity. It is important to remember that the deformity gets progressively worse with age. There is no advantage to delaying surgery once the deformity has progressed to the point where it interferes with the activities of daily living. As the deformity progresses, the surgery becomes more and more difficult. The potential complications increasesas the deformities get worse. The decision as to whether to have surgery is a personal decision that should be made by the individual and not by a doctor,family member, or friend.Unfortunately many non-medical people who know nothing about this type of surgery become authorities and give the perspective surgical candidate very poor and inaccurate advice.Remember the best advice one can get is from a qualified podiatric( foot) surgeon. If you have doubts about the procedure being done, get a second opinion.The operation should correct all of the components of the deformity. A procedure that is done to shave the bump only, is doomed to failure because it does not re-align the deformity. If you are going to have an operation, the proper procedure should be done and not a lesser procedure which may have an easier recovery but will  not give the same quality result. You should be sure to ask the surgeon about the risks of the procedure and how they can be handled if they occur. It is important to ask about the approximate time of recovery and about what will be expected of you in terms of range of motion exercises of the toe and how to use the toe in walking to get your foot back in shape.Also remember, bunion surgery is almost never an emergency or urgent.  Since bunion surgery is usually not done on an emergency basis, do your due diligence to feel comfortable about your decision.

We have performed approximately 10,ooo bunion procedures in our careers. Call us for an evaluation or second opinion at 212-996-1900 or 914-328-3400.

Bunions-Part 2 What Happens

Posted by on Thursday, September 15th, 2011

Drs Geldwert,Lai and Minara have 60 years of combined experience of successfully  repairing bunion deformities.

We don’t know exactly what the first step is in bunion formation,but we do know that there is medial or inward rolling or pronation of the first metatarsal along with its associated joint-the first metatarsophalangeal joint and the great toe. The skin, nerves,fat and the arteries are squeezed over the bony prominence. When a shoe squeezes the skin and associated soft tissue under the skin over the medial bump,pain will result. There is no dire correlation between the size of the bunion deformity and the amount of discomfor noted. Some people have tremendous deformity and no pain and some people have small deformities and significant pain. In individuals who have significant deformities and minimal pain, there is usually a smooth rounding to the bump which forms the bunion. In those people who have significant pain,there is usually a more angular deformity to the metatarsal head which may account for the increase in pain. As the 1st metatarsal moves toward the other foot,a small muscle on the inside of the foot pulls the end of the toe over so that it leans toward the middle of the foot.This is referred to as hallux ( great toe) valgus( an orthopedic term which means moving toward the midline of the foot).As the first metatarsal moves toward the midline of the body,(that is ,towards the other foot), it is referred to as metatarsus(metatarsal) primus(first) varus(which means it moves away from the midline of the foot). As a result of the bony migration, the outside portion of the capsule which holds the joints together becomes very contracted and the inside portion becomes very stretched out or attenuated. The tendons which connect the muscle with the bone run through tunnels in the capsule.As the joint capsule contracts laterally and expands medially,the tendons change position so that they no longer have their normal functions and positions.As the big toe moved away from the midline of the body,it can lift up the second and eventually third and fourth toes, causing them to hammer and to even dislocate where they conect to the metatarsals.As the deformity progresses, the individual has increasing problems using the great toe for roll-off. We start to roll off of the metatarsal head and therefore callouses begin to develop in the skin over the bottom aspect of the metatarsal head.These can become very painful.With the increase in size of the medial prominence(bump),shoe fittings becomes more and more difficult.

The next blog will cover what can be done to help treat your bunions. I f you would like one of the doctors to evaluate your bunions call either 212-996-1900 or 914-328-3400 for an appointment.

Bunions-Part 1

Posted by on Friday, September 9th, 2011

Drs. Geldwert,Lai and Minara have over 60 years combined experience in successfully correcting bunions. The following is an explanation of what bunions are. Future blogs will explain what happens to you when you have a bunion and the different approaches to caring for bunion deformities.

The term bunion comes from the word turnip. In this case,it refers to the large bump that forms on the head of the 1st metatarsal.The term bunion is a simple term that denotes a complex of deformities. One can see a bunion forming in a newborn baby’s foot,or it can develop in someone who is in their eighties or nineties. Bunions are genetically determined and are not caused by shoe-wear or abnormal mechanics. They may be severely aggravated by improperly fitting shoes and poor mechanics,but they are caused by one’s genetic background. Commonly associated with bunion deformities is ligamentous laxity. Ligaments hold joints together. Some people have loose or hyper-elastic ligaments. We often say these individuals are ” double jointed” because they have the ability to hyper- extend their fingers,elbows or knees. Many people with scoliosis,which is a lateral “s” curve in the spine,also have bunion deformities.There have been studies which document that barefoot tribes get bunions as well as people who wear shoes.

If you would like to have your bunions evaluated by the doctors call 212-996-1900 or 914-328-3400 for an appointment.

Solutions for Diabetic Foot Problems

Posted by on Wednesday, July 27th, 2011

I am delighted to introduce myself as the newest member of the Center for Podiatric Care and Sports Medicine. I hope to add to the excellent work done by Dr. Geldwert and Dr. Lai. I’d like to take some time to talk about a subject that has a very personal significance for me; Diabetic foot pathology, specifically Charcot Deformity.
I have been a Type 1 insulin dependent diabetic since age 10. I share the same daily concerns and struggles as all diabetics. I consider myself very fortunate to be involved in a profession where I can make a real impact on the lives of those sharing my disease. Diabetes can affect many body systems. One area of the body affected most commonly is the foot. Diabetics often face problems that arise from poor circulation and nerve function. A major issue I’d like to focus on is Neuropathy and the problems it can cause and Charcot Neuroathropathy, often referred to simply as Charcot Foot.

Neuropathy is a condition affecting the nerves, which leads to a gradual loss of protective sensation. While many people develop numbness, the condition may also cause strange feelings known as paresthesias, which can also be very painful. Over time, the body loses the proper feedback from normal foot function and biomechanics. Eventually joints can undergo a degenerative problem known as Charcot neuroarthropathy. This condition dramatically changes the structure of the bone and joints of the foot. The foot breaks down and severe foot deformity follows. Most commonly the process affects the midfoot, and leads to a “rocker-bottom” deformity. However, the process can occur in any joint, and lead to other types of bony deformities. Often, this abnormal bone position leads to increased forces on the skin and soft tissue, which eventually break down and ulcerate.

These ulcerations account for a large majority of diabetic hospital admissions, as they often get infected. These infections can often reach the bone (a condition known as osteomyelitis).
Untreated or improper treatment can lead to serious life or limb threatening infections.

If you suffer from these conditions, a foot care specialist must be an integral part of your health care. Treatment plans run from the simple to complex depending on the details of your condition. Proper wound care is vital, including regular monitoring and debridement of any non viable tissue. There are also several devices which can offload the high pressure areas causing ulcerations.

There are also several surgical options which I have training in including soft tissue and skin procedures to cover the wound, as well as skin substitute grafts. Also, depending on the deformity and one’s overall health, surgical reconstruction may be an option. This is designed to either remove the bony prominence, or correct the bony deformity. This can be accomplished with internal hardware fixation, external hardware fixation, or a combination of both.

Charcot Deformity can be a troubling, frustrating problem. If you suffer from this condition, or other diabetic foot issues, I can help. Call the office, 212-996-1900 or 914-328-3400 for an appointment.

Triathlon Injury-Plantar Fasciitis

Posted by on Wednesday, July 20th, 2011

In March I was invited to speak to TRIARQ,a community of physicians,patients and physical therapists, on Plantar Facsiitis. I would like to share some of the salient points of the lecture. Plantar Fasciitis is a condition whose cause is primarily biomechanical in nature.The pain associated with plantar fasciitis is usually located to one of three areas on the foot. The attachment of the fascia to the heel,under the center of the heel or along the arch.The pain of plantar fasciitis is usually delayed. What I mean is that in the early stages of plantar fasciitis you can run without pain but the pain occurs about 1-2 hours after your run.The pain is usually worse the next morning ,especially the first steps out of bed and is bad after periods of inactivity.When the condition becomes more chronic the pain can occur during a run as well as afterwards.
In 1998,Dr. Lai and I presented a paper at the annual meeting of the American College of Foot and Ankle Surgeons entitled Conservative treatment of Plantar Fasciitis and Intermetatarsal Neuroma with Orthotic Devices.The purpose of the paper was to present a retrospective review of 53 consectutive neuroma and 107 consecutive plantar fascial patients who were prescibed orthotic devices for treatment.We concluded that orthotic devices are an effective treatment for neuroma and plantar fasciitis. The significance of our paper was that neuromas and plantar fasciitis are common foot problems which should be treated conservatively first with orthotic devices before considering surgery.The results of our paper concluded that most cases of plantar fasciitis and intermetatarsal neuromas improved or resolved with conservative treatment. The corrections on the orthotic must be very specific for the patients biomechanical problems and condition in order to be successful and that 92% of patients did not require surgery.
Since 1998 we have found that with the advent  of newer technologies including Extracorporeal Shockwave Therapy,Platelet Rich Plasma Therapy injections and biopuncture with plant based injectables we have increased our success rate even more.We now operative on less than 3% of patients with plantar fasciitis.In those patients who require surgery we either will do a coblation(Topaz) procedure or an Endoscopic Plantar Fascial release through a minimal incisional approach.

Barefoot Running/Minimalist Shoes

Posted by on Sunday, May 15th, 2011

With nice weather finally arriving in the New York area the talk has turned to getting outside for walking, running or cycling.  A few weeks ago I participated in a panel discussion at the Jack Rabbit NYC Running show on barefoot running and minimalist shoes. Joining me on the panel was Johanna Bjorken, John Durant, Nikhil Jain and Katherine Petrecca. Johanna Bjorken Johanna Bjorken has been the head “shoe geek” at JackRabbit since 2004. In that time, she has become one of the most influential shoe buyers in the specialty running industry. Johanna decides which shoes JackRabbit carries and develops all of the staff training for JackRabbit’s shoe fitting process. Johanna is a marathoner, a triathlete and a mom. John Durant John is a longtime barefoot runner living in New York City. He is the organizer of the annual barefoot race on Governor’s Island and of the Barefoot Runners NYC Meetup group. He has appeared in numerous articles and TV shows including “The Colbert Report”. Nikhil Jain Nikhil is the technical running product manager at Saucony and is responsible for the design and development of Saucony’s new Hattori, the company’s minimalist shoe.  He is a longtime runner and champion hurdler. Katherine Petrecca An 11-year veteran at New Balance, Katherine is the Business Unit Manager for Running and Outdoor Specialty with a focus on technical product launches and new innovation projects. Over the last two years, she has led the development and launch of the Minimus footwear collection. My Opinion I discussed some of my concerns with barefoot running including a discussion of some of the injuries that I have seen. The injuries have ranged from Achilles tendon/calf strains, plantar fasciitis to stress fractures of the metatarsals and tibia. I also discussed the fact that there are no definitive studies that prove that running in shoes causes injuries and that running without shoes or running in minimalist shoes prevent injuries. However, we do know that running in worn shoes with broken down mid soles and outer soles can cause injury, as can running in too soft a shoe or too stiff a shoe. But is it the shoe or running form that makes the difference? I am a strong believer that improper running technique  is a major contributor to running injuries. We know that approxiamately 60% of running injuries are due to overuse with training errors associated with most of them.  Listening to your body and training in a responsible manner will eliminate the majority of running injuries. Approximately 40% of running injuries are due to some fault in biomechanics with subsequent abnormal impact overload, abnormal loading rate and increased joint torque (twisting). Therefore, it becomes important to get a proper biomechanical examination and evaluation of running form like what we offer at the Center for Podiatric Care & Sports Medicine. (See section on Gait Analylsis and Orthotics) The question then becomes: Can, or should, a particular runner changeover to barefoot running or running with minimalist shoes? If you are healthy and running well there is no need to do anything differently. As the saying goes, “Don’t try to fix the wheel if it ain’t broke.” If you have a history of injuries, then a change to barefoot running or to a minimalist shoe may be worth trying. To properly make this change, you will need to: retrain your running mechanics; go slowly and gradually to allow for physiological adaptation for your bones, muscles and tendons; try more forgiving running surfaces, such as dirt or grass; and strengthen calf and foot muscles. If you have a history of repetitive  injuries it would be wise to make an appointment to have your running form and biomechanics  analyzed to determine whether your running mechanics are contributing to your injures. Call (212) 996-1900 or (914) 328-3400.

Extracorporeal Pulse Activation Therapy ( EPAT) for Heel Pain

Posted by on Wednesday, February 16th, 2011

Heel pain is very common among  competative and weekend athletes. The pain is localized to the bottom of the heel and along the arch.The pain can be quite persistent,lasting for months or even years. Plantar Fasciitis( heel pain that is mechanical in origin) is characterized by pain and stiffness upon arising in the morning. The pain has a tendency to decrease after a few minutes only to recur at the end of the day. In the early stages of plantar fasciitis the pain is more inflammatory in nature .The more chronic and longer lasting the pain the more the problem becomes one of  Plantar Fasciosis or degeneration of the fascia.

The treatments are quite different depending on how long you have had heel pain.

Treatment options for the inflammatory type of fasciitis can consist of the following: padding and strapping,therapeutic orthotic insoles,oral anti inflammatory medication,cortisone injections,achilles and plantar fascial stretching.

As the heel pain becomes more chronic, the following can be effective treatment options: Prefabricated and custom made orthotic devices, night splint, repeat cortisone injections or our preference bio puncture with homeopathic agents( to be discussed in a later blog) , physical therapy, cast or boot immobilization.

If there has been no improvement with the previous recommendations then EPAT( Extracorporeal Pulse Activation Therapy) is a very advanced and highly effective non-invasive treatment approved by the FDA. The technology is based on a unique set of pressure waves that stimulate the metabolism,enhance blood circulation and accelerate the healing process. Damaged tissue gradually regenerates and eventually heals.

The non-invasive EPAT has virtually no risks or side effects. In some cases, patients may experience some minor discomfort which may continue for a few days. It is normal to have some residual pain after intense exercise or a full day of work.

The beneficial effects of EPAT are often experienced after only 3 treatments. Some patients report immediate pain relief after the treatment,although it can take up to 4 weeks for pain relief to begin. The procedure eliminates pain and restores full mobility. Over 80% of patients treated report to be pain free and/or have significant pain reduction.

If  EPAT is not successful: PRP (to be discussed in a later blog), bipolar radio frequency, endoscopic plantar fasciotomy are further viable treatment options.

Dr. Geldwert and Dr. Lai presented a study on the conservative treatment of Plantar Fasciits at the American College of Foot and Ankle Surgeons annual meeting and they found that 87% of their patients responded to Custom made orthotic devices and a stretching program. Subsequent to that study, Dr. Geldwert  found that with the use of EPAT the success rate incresed to close to 95%.

EPAT is an emerging technology in the US and, unfortunately, insurance companies do not yet cover the EPAT treatment. The EPAT treatment fee is reasonable by most patient standards and is a significant savings compared to paying deductibles,multiple co-pays and other non-insurance covered expenses as you attempt several months of conservative treatments,surgery and rehabilitation.

If you would like more information about EPAT , other treatments for Plantar Fasciitis or need an appointment for evaluation and treatment call 212-996-1900 or 914-328-3400.

High Tech Laser Option for Fungus Toenails

Posted by on Monday, January 3rd, 2011

Laser treatment for  toenail fungus has recently been approved by the FDA. Prior to Lasers, the treatments for fungal nails were  limited to oral anti-fungal medications which have the potential for liver toxicity and topicals which deliver marginal benefits.The laser works by penetrating the fungal nail plate and destroying the fungus by the heat it generates. This clearing of the nails of the fungus can occur after only one treatment. Sometimes it is necessary to touch up one or two nails that haven’t responded to the laser.

Unfortunately laser treatment for fungal nails is not covered by insurance plans but is a covered benefit for those that have flexible spending health accounts.
So how would you pay for the treatment?

We have broken down the laser program into two components. The first is the examination and nail treatment which may be covered by your insurance carrier. The second part is the laser treatment which is not covered by insurance. The one-time charge for three office visits and nail care is $500. There is an additional one time laser fee of $70.00 per toe,which is charged at the first visit. For example,treating one toe only would be $570.00. However,  if you need all ten toenails treated,the charge would be $1200.00. We are able to provide laser treatment less expensively than other practices  because we own our laser and do not lease the laser like other practices who are required to pay a fee each time to turn the laser on.

We will bill your PPO insurance policy and request any benefit payment be mailed to you. The laser portion is not a covered service and,therefore, will not be billed to your insurance company. In an effort to make sure that you maintain the best results possible,we even offer additional visits within the first year of treatment for a nominal charge,which we will bill your PPO for your coverage.

Bunion treatment( New Advances)-Mini TightRope

Posted by on Monday, December 6th, 2010

A Bunion is a deformity of the 1st metatarsal that is characterized by the big toe pointing towards the 2nd toe and is often associated with what appears to be a bump on the side of the big toe joint. Bunions are predominately genetic( familial) in origin and progressive by  nature . Sometimes there is pain in the joint or over the metatarsal and frequently the bunion will cause other problems in the foot; such as pain in the ball of the foot or contractures and hammering (curling) of the small toes. Not all bunions require surgical management but many do. There are over a hundred different procedures to correct bunions.Most of the procedures require a cutting into the bone (osteotomy) to realign the big toe joint. The osteotomies are used in conjunction with soft tissue(tendon) balancing procedures and the location of the osteotomy distal (towards the tip of the toe) or proximal (towards the heel) are dependent on the degree and location of the bunion deformity. Each of the osteotomy procedures has potential complications  including malunion( poor alignment),shortening,elevation of the 1st metatarsal and angulation of the joint cartilage.

The Mini-TightRope ( Osteotomy sparing) procedure for Bunions was developed because of the determination that many bunions are a result essentially of  an acquired soft tissue angular deformity and malalignment( poor position). The TightRope has been very effective in correcting the angular deformity associated with Bunions while  eliminating the problems associated with osteotomies(cutting of the bone). See animation of the procedure   Mini-TightRope Bunion Procedure and   Mini TightRope FT .

Dr. Geldwert and Dr. Lai have been performing the Mini TightRope for 2 1/2 years with promising results. As with any procedure there are some inherent complications. The most frequent complications that we have experienced are stress fractures of the 2nd metatarsal,knot/fiberware failure  or prominence of the button.Sometimes we will combine the mini TightRope procedure with other procedures depending on the type of bunion deformity. We have found that the complications associated with the mini TightRope are less profound than the potential complications of shortening,dorsiflexion,malunion,transfer metatarsalgia (pressure on an adjacent bone) and avascular necrosis that can be seen with Bunion Correction utilizing osteotomies. The typical Mini- TightRope Bunion recovery allows for immediate weight bearing in a stiff soled shoe.
Our overall success rate for bunion surgery via osteotomy is over 95%; however we are looking toward the minitightrope procedure to lessen the profound complications that can  occur with osteotomies.
If you would like to know more about the Mini TightRope procedure or other bunion corrective procedures call The Center For Podiatric Care and Sports Medicine at 212-996-1900 or 914 328-3400.