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Well at this point it's there to get the skin closed then it's surgery.
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- Thread starter EthylMethylMan
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What are your thoughts on doing an MIS metatarsal osteotomy on a patient who smokes? They previously had a 2nd digit amputation about 1 year ago and now have an ulcer sub 2nd metatarsal head. They healed the incision from the amputation surgery well.
Also planning to do a Keller for a chronic plantar hallux ulcer, do you all place a kwire on those? Any other tips?
Also planning to do a Keller for a chronic plantar hallux ulcer, do you all place a kwire on those? Any other tips?
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I mean if it's an ulcer then yeah. In theory we don't really care if the bone heals. It will eventually and they won't feel it. Even a smoker should be able to heal a single stab incision.
The Keller is a different issue, according to @Retrograde_Nail he doesn't recommend mis Keller so that may be more of a problem
I’m planning to do the Keller open, not MIS. And technically I would be doing the met osteotomy open but just through a very small incision and using a hammer toe saw blade.
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Just use a Arthrex or Stryker MIS cutting burr. One single stitch, done in 5 minutes max.
I do them in higher risk patients fairly frequently. Obviously try not to but an open wound is a ticking timebomb in a smoker with A1c 9.
IMO its best to heal the wound asap. I do Rx prophylactic antibiotics in these patients post surgically.
Any tips on using the MIS burr for met osteotomy? I tried doing this on a cadaver (without fluoro) and it seemed like the burr had trouble cutting the bone. Maybe the burr was dull from previous use since it was at a lab. The things that seemed to help was letting the burr do the cutting without forcing it and cleaning off the burr about half way.
Also, what CPT are you all billing for this?
Also, what CPT are you all billing for this?
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Don't try to cut through in one motion, because the torque will cause the burr to roll along the bony cortex/periosteum and it's harder to control.
Some advice I got from an 1st gen MIS dude: drill directly through the bone to create what he called a "pilot hole," which isn't even the correct use of the term but work with me here. Once you're in, you can then work in any direction, one swipe up and one swipe down.
Some advice I got from an 1st gen MIS dude: drill directly through the bone to create what he called a "pilot hole," which isn't even the correct use of the term but work with me here. Once you're in, you can then work in any direction, one swipe up and one swipe down.
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You enter the bone like stabbing it as described above....then cutting through cancellous bone with windshield wiper motion. You cut cortical bone from inside out. This is not a saw blade that you cut through cortex from outside in. User error. And rep should have been smart enough to know this.
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No tourniquet. Let everything drain and let the blood cool the burr. Flush thoroughly.
You don't want bone putty just sitting in there.
Swiping motion like everyone said or you're going to be riding cortex.
Burr middle. Find your hole. Swipe one side. Stop and find middle. Swipe the other side.
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Yeah, I've had actually problems with hammer toes not healing because I haven't used enough irrigation and then there's just slurry and other junk coming out continuously and the incision doesn't heal forever. User error
For lesser met osteotomies I make dorsal stab incision. Insert it from a dorsal approach plantar to the met coming in at about a 45 degree angle. Confirm location on C arm. And use some torque with the 45 degree angle to cut thru the bone. Takes about 5ish seconds and a nice clean cut. Works for me.
I do at least 1 a week. Sometimes more. All for wounds. Never had one fail to date.
I do at least 1 a week. Sometimes more. All for wounds. Never had one fail to date.
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"Dear Lord Baby Jeebuz, or as our brothers in the South call you: 'Hey-suz'. We thank you so much for this bountiful harvest of MIS... and we pray that the long term follow up turns out ok. In your name."
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MIS for diabetics is game changer ...you have always known they needed surgical offloading but afraid of incisions healing.
Keller is one of my most performed procedures. They work so well for hallux ulcers.
Taught in school to never do one. Fusion or nothing. Maybe a cheilectomy. "Never a Keller"
I never did one in residency.
Out of residency I avoided them because thats what was taught.
Literature is there. Had a non healing chronic hallux ulcer. Decided to give it a go.
Healed quickly.
Now I do them nearly weekly for the last 2ish years. Love them for non healing ulcers hallux with hallux limitus.
Ancef/clinda/or vanc prior to case. Prescrub the foot myself with chlorhexidine brush on OR table. Really scrub that wound. Debride callus if necessary. Debride non viable tissue if necessary. Rinse with alcohol. Then RN formally scrub/prep with betadine. I typically pack with vanco powder at closure and give 5 days oral antibiotics. This method has served me well with open wounds and surgical intervention. Fast easy effective case. Good results. Takes 20min. Pays same as a lapidus.
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Sorry, Feli says this is not respected and a 1st year resident could do it.
Well its true. But I embrace my lobster claws and go for it.
I put Vanco powder in when closing on all diabetics too. This guy was actually pretty well controlled with his DM so didn’t do oral Abx.
Glad to have some solutions for these patients with chronic wounds. This has been a game changer thread, none of the attendings in my residency did these types of cases.
Glad to have some solutions for these patients with chronic wounds. This has been a game changer thread, none of the attendings in my residency did these types of cases.
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Just today. 1 pack a day smoker, poorly controlled but not terrible diabetes. Huge callus 4cm diameter sub 2/3. Medicaid. Take callus down, minimal ulcer. But we all know one day it's going to blow up. Some equinus for sure. Of course would prefer gastroc. But instead go to OR, hell if I have my way local only. 1 stab incision in 2/3 interspace. Bluntly dissect and do Floating osteotomy 2 and 3. 28308 x 2. 1 stitch what 5 mins? Takes longer to put dressing on and close stitch than procedure.. Ulcer gone in 2 weeks. I see him what 2 times post op? Easy money and most importantly solves this dudes problem.
Hell at this point when do we start doing floating osteotomy in office? Just need setup. It's a matter of time. Zero reason for OR if intact skin. Anyone doing TAL in office? Obviously gastroc usually enough and walk in boot right away for a few weeks. How aggressive are people with perc TAL?
We continue to repeat. Wound care is surgery
desertpod8
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There’s newer studies on distal plantar fasciotomies for sub HIPJ ulcers. My success rate is 100% (only have done 1 in office😄)
Clinical outcomes of selective plantar fascia release for hallux interphalangeal joint ulcers - PubMed
The authors believe that SPFR can be utilized in the treatment of hallux IPJ ulcers if both surgeons and patients are aware of the potential complications and limitations of this procedure. Further research is warranted to evaluate the efficacy and reproducibility of these results.
pubmed.ncbi.nlm.nih.gov
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In PP-land where I Iive, I've had pushback from payers unless I diagnose the pt with hallux valgus.
I put a skin sub on the ulcer after Keller is done and at the preoperative visit bil 15004.
I prefer using a pituitary rongeur to nibble out the bits of bone through the portal, as it does in fact resemble a lobster claw under fluoro. 🦞
Way ahead of you...OR block time? Where I'm going we don't need OR block time...
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I've done 2, and my rate of lacerating the FHL tendon is 100%. Healed the wound though
I havent had any problem using hallux limitus and getting them approved by insurance
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I guess in these types of patients it’s not super important, but if you want to use a newer low speed/high torque power unit, the answer is “when they stop charging $300-400 for a bur.”
Yes. WBAT in a boot for 6 weeks. Only done a few but it was easy.
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How do you do TAL in office?
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Lift leg up and perc it bro
Never done a TAL in office. Dont think I would. Would be catastrophic if the tendon ruptured.
Ive done a lot of toe amps in office. Especially PIPJ amps.
Had an uninsured guy I did a hallux amp at MPJ in office. Dude took it like a champ.
Ive done a lot of toe amps in office. Especially PIPJ amps.
Had an uninsured guy I did a hallux amp at MPJ in office. Dude took it like a champ.
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Do you just look up CPT and charge cash accordingly for this?
Have a small ankle cyst case I may do in office but unsure how to go about.
Humana stopped taking on providers.
Billing department takes care of it.
But yes I dropped a 28820.
Way cheaper than OR management.
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Well I work in an ortho clinic (when not covering the wound clinic) so I have access to rooms with exam tables. They lay on their belly, I inject local, I do a triple hemisection, and I suture. I guess I did one in wound care, but again there are rooms with gurneys/stretchers/hospital beds up there so same idea.
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Plenty but never acutely ruptured one in my office
You’ve never treated an Achilles rupture conservatively before?
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The perc TALs don't rupture in the office... they'll rupture a few days, maybe a week, later.
Some realize right away, a few don't.
There are few associates in my area who do them.
It's pretty rare, but extremely lame, when they rupture... like often BKA lame. These aren't compliant or healthy patients to begin with.
Luckily for them, it's an associate mill that hires and has DPMs leave every year, so I doubt they usually still work there or even know what happened to the pts.
yeah.... no. I've ruptured them on the table. It's obvious when it doesnt go as planned. For surgeon and a conscious patient.
It doesnt hapen often. But it happens. Anyone who claims different is a super surgeon who we should all bow down to. Or doesnt actually do them regularly.
I do about 2-3 a month. Haven't had one rupture on table in awhile but I wouldn't want the patient awake for that.
Personally I wouldn't do one in office. Not saying it can't be done. But I wouldn't. Everyone do what they're comfortable with. But i'm not doing that.
I cant think of anyone I would do a TAL in isolation in the last year or two. It's always with another procedure. Mostly TMAs.
Also, being an avascular structure in almost certainly a diabetic (im not doing clubfoot casting...) it's a high risk patient. IV antibiotics, surgical prep, MAC, or general anesthesia.
Was texting airbud earlier about Baumann. We all have strong opinions. But IME the soleus release does not give much correction. If I need correction its TAL unless obviously 100% gastroc mediated ankle equinus. Cutting the gastroc and soleus just leads to adhesions and chronic pain. At least thats my experience. And yes I stagger the soleus/gastroc cuts.
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So when you rupture them in the OR you open these patients up on the spot and repair it? If not, I’m failing to see the difference between patient being awake or asleep if it were to happen.
Achilles ruptures aren’t really acutely painful injuries, especially not in neuropathic diabetics. And they heal really well on their own without surgery even with significant gapping.
I don’t routinely do gastrocs or TALs with TMAs. I don’t find that a majority of folks get plantar ulcers within years of the amp. They will continue to contract over time no matter what you do so I don’t do any type of lengthening until they actually develop a wound.
Side note.
When I was fresh out of residency I did an Austin bunionectomy under local only anesthesia - per patient request. Red flags everywhere. Should have known not to cut but young and eager.
After i made the osteotomy the patient had a panic attack and jumped off the table contaminating everything.
She eventually came to her senses and jumped back on the table afte about 30 seconds rampaging about the OR. Flushed the $hit out of that surgery site. Used a perc K-wire for fixation. Long term she actually did fine.
....I like anesthesia. Lesson learned.
When I was fresh out of residency I did an Austin bunionectomy under local only anesthesia - per patient request. Red flags everywhere. Should have known not to cut but young and eager.
After i made the osteotomy the patient had a panic attack and jumped off the table contaminating everything.
She eventually came to her senses and jumped back on the table afte about 30 seconds rampaging about the OR. Flushed the $hit out of that surgery site. Used a perc K-wire for fixation. Long term she actually did fine.
....I like anesthesia. Lesson learned.
No I dont. I tell patients it can happen. Still dont want that happening with a patient awake in my office. See my comment above.
You do you. But thats not for me.
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Simply trying to understand what would be “catastrophic” about a perc TAL rupturing when done under local vs general anesthesia. That’s all.
Patient experience is the answer.
Also efficiency. We all jump room to room on our clinic day. Last thing I want is a TAL turned ruptured achilles at 1015 time slot.
All around thats pretty catastrophic.
Anesthesia all day for TAL
Did not do TAL at all in residency, all attendings did gastroc. I do remember on a certain clerkship after doing one the residents would aggressively dorsiflex the ankle to treat it and one time it obviously ruptured, profuse swearing followed.
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We primarily did TAL's in residency over gastrocs. Never heard about any issues, they were probably happening but we didn't follow with them. I came out of training fairly gung-ho on TAL's, but after I became an attending I inherited 3 patients, in a short amount of time, that had calcaneal ulcers from someone performing overly aggressive TAL's on. I hate those wounds with a passion and it really made me step back from the TAL a bit.
When I was doing a lot (relative) of TAL's I didn't seem to have many ruptures. Someone mentioned they didn't feel they get the desired correction doing just a gastroc, definitely have also struggled with this. However, still have tended to reserve TALs for those with TMAs or proximal amps.
When I was doing a lot (relative) of TAL's I didn't seem to have many ruptures. Someone mentioned they didn't feel they get the desired correction doing just a gastroc, definitely have also struggled with this. However, still have tended to reserve TALs for those with TMAs or proximal amps.
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It sounds like a single patient encounter in residency (who underwent a totally different procedure) is the sole reason for your decision making, at least in this case. You’ve never actually had a perc TAL rupture when doing it under local have you?
Or… and I know this sounds crazy… you could not schedule the panic attack inducing in office procedure at 1015
we just have different definitions of catastrophic I guess
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This is pretty much what I do. I actually take the avoidance of TAL further.
I don't care if the DM pts have combo equinus on exam... the gastrocs just aren't going to have the epic fails that TALs can.
The test/Silfverskiöld answer might be TAL for combo equinus, but gastroc recession is just little/no chance of major issues (rupture... and more often, the incision site for mini open gastroc is also safer than TAL open procedure).
I do those gastrocs with some TMAs or first ray amps (if ankle dorsiflex <5deg... maybe 10%?), and they work fine enough (if the pt gets custom filler soon after). I have seen the ruptured perc/office TALs and calc gait pts from nearby DPMs at almost every job I've ever had (some of that is probably bad technique, but it's a risk). Either way, those are 95% chance of BKA soon after.
The only time I do full blown TAL (open, prone) is some wicked cavus recons. But those cases are rough no matter what.
Perc or open TALs are fine for peds flat foot if it's combo equinus on pre-op eval... but gastroc for 90% of adult flat foot recons in my hands.
Charcot recons do need TAL often also, but I'm sure not dumb enough to do those. 🙂
Calcaneal gait ulcers can happen but 95% amputation rate after a ruptured Achilles seems extreme. Like Dtrack said above they usually do pretty well. At least in my experience. I have had some ruptured achilles go onto calcaneal gait/ulcers. To be honest though I cant think of any from a TAL.
Sounds like we have different risk tolerance. Some people like Feli wont even do them. You do them in your office under local. Different people have different opinions. Like I said above.. you do you.
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Why do you hate RVUs bro?
