Most complicated surgery performed by podiatrists?

[DrYES]

???

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[CaliforniaKid]

???

bunion surgery

 

[jonwill]

???

My opinion:

trauma surgery - pilon fractures
elective surgery - cavus foot reconstruction (I think the biomechanics are more complicated than the flatfoot recons).

But honestly, whether it's a bunion, ankle fracture, or hammertoe, when a case doesn't go well, EVERYTHING becomes complicated!

Anybody else?

 

[Skippygonenuts]

I imagine it would be brain surgery!!

 

[RATM2010]

???

I would ask this question is a section with actual attending podiatrists to get a better answer. This site is full of pre-pods that don't no much besides undergrad science facts and mcat memorization tricks.We have not attainted that level of knowledge quite yet.

 

[g squared 23]

Charcot foot reconstruction. Some of those cases are insane.

 

[jonwill]

Charcot foot reconstruction. Some of those cases are insane.

Absolutely, some of those can be tough.

 

[PADPM]

You think THAT'S complicated...have you ever tried cutting a lady's toenails when she hasn't had the courtesy to remove her toenail polish?

 

[jonwill]

You think THAT'S complicated...have you ever tried cutting a lady's toenails when she hasn't had the courtesy to remove her toenail polish?

That makes it even MORE difficult to diagnosis onychomycosis!

 

[PADPM]

And when the polish is red, they always accuse you of making them bleed!

 

[347932]

Charcot foot reconstruction. Some of those cases are insane.

This times a million. I do them and they are always more complicated then they seem peri and post operatively.

 

[Feli]

My opinion:

trauma surgery - pilon fractures
elective surgery - cavus foot reconstruction (I think the biomechanics are more complicated than the flatfoot recons).

But honestly, whether it's a bunion, ankle fracture, or hammertoe, when a case doesn't go well, EVERYTHING becomes complicated!

Anybody else?

I would tend to generally agree here.

Pilons and calcs - esp if there's no good keystone fragment - are long, greuling surgeries sometimes. The worst part is that, even if you get a good joint reduction/alignment, there's still a very high chance of arthritis 😛. The nice thing about trauma is that expectaitons are generally low, and you can always blame the injury. Before surgery, they couldn't walk. After surgery, if they can even walk at all, it's an improvement. Any residual arthritis, deformity, etc is from "the very bad fracture"... and not a crummy ORIF (unless a lawyer - or another gutless competing surgeon - throws the orig treating doc under a bus).

For elective, I'd agree with anything neuromuscular being the most complicated of elective recon... cavus foot definitely, and I'd include flatfoot as a neuromuscular imbalance on a very basic level also. Charcot recon can also be hard, but like trauma, expectations are rock bottom if you prep the patients well pre-op. They can't walk without a CROW, so any smaller brace/shoe is a big success. The Charcot recons are tough due to bad bone and bloodflow... but the neuropathy and "well, the severe diabeties caused the amp" are always your easy (and often true) bailout for failure.

I would really be careful to underestimate any elective procedure, especially in (surgical) virgin feet. There is just nowhere to hide from complications. A Lapidus/Akin or even a hammertoe with plantar plate tear isn't viewed as very hard, but if it's a Chanel purse toting doctor or lawyer's wife from the suburbs, you had better bring your "A" game. Unlike trauma surgery, Charcot, etc, the elective is a game where the stakes are raised: everything from the scar to the neuritis to bleeding through the bandage to a minor cast complication to the slight malrotation of the toe post-op is a potential land mine.

...in terms of "wow" value, I guess Ilizarov, ankle implants, and IM nails have the most "oomph" of any F&A surgery. I don't really think either IM nails or static frames are all that hard (dynamic ring frames are, though), and I just don't agree with ankle implants based on principle. Nonetheless, those 3 - and probably heavy trauma like pilons or bi and trimall ankles have the most "cool case" value for pod students, 3rd party XR lookers from other med or non-med specialties, etc.

 

[347932]

I would tend to generally agree here.

Pilons and calcs - esp if there's no good keystone fragment - are long, greuling surgeries sometimes. The worst part is that, even if you get a good joint reduction/alignment, there's still a very high chance of arthritis 😛. The nice thing about trauma is that expectaitons are generally low, and you can always blame the injury. Before surgery, they couldn't walk. After surgery, if they can even walk at all, it's an improvement. Any residual arthritis, deformity, etc is from "the very bad fracture"... and not a crummy ORIF (unless a lawyer - or another gutless competing surgeon - throws the orig treating doc under a bus).

For elective, I'd agree with anything neuromuscular being the most complicated of elective recon... cavus foot definitely, and I'd include flatfoot as a neuromuscular imbalance on a very basic level also. Charcot recon can also be hard, but like trauma, expectations are rock bottom if you prep the patients well pre-op. They can't walk without a CROW, so any smaller brace/shoe is a big success. The Charcot recons are tough due to bad bone and bloodflow... but the neuropathy and "well, the severe diabeties caused the amp" are always your easy (and often true) bailout for failure.

I would really be careful to underestimate any elective procedure, especially in (surgical) virgin feet. There is just nowhere to hide from complications. A Lapidus/Akin or even a hammertoe with plantar plate tear isn't viewed as very hard, but if it's a Chanel purse toting doctor or lawyer's wife from the suburbs, you had better bring your "A" game. Unlike trauma surgery, Charcot, etc, the elective is a game where the stakes are raised: everything from the scar to the neuritis to bleeding through the bandage to a minor cast complication to the slight malrotation of the toe post-op is a potential land mine.

...in terms of "wow" value, I guess Ilizarov, ankle implants, and IM nails have the most "oomph" of any F&A surgery. I don't really think either IM nails or static frames are all that hard (dynamic ring frames are, though), and I just don't agree with ankle implants based on principle. Nonetheless, those 3 - and probably heavy trauma like pilons or bi and trimall ankles have the most "cool case" value for pod students, 3rd party XR lookers from other med or non-med specialties, etc.

I generally agree with this Feli. Excellent post.

I lose more sleep from my Charcot recon than anything. I practice in the state of VA, and I'm very cautious since we are able to do ankle surgery, but tibial fixation can cause complications that we, as podiatrists, can't take care of. I've heard/seen IM nails fracture tibias and that's a whole situation I just don't want to get into.

Ilizarov is probably my most favorite. But I do mini rail stuff which is intricate but is very rewarding and interesting intra-operatively. Evans, Brachymet and Met fracture repair are really my cup of tea. All with mini rails.

I also love doing Ankle Scopes. I haven't done a primary ATFL repair in a very long time, since I do thermocapsular shrinkage and have had incredibly positive results with this procedure. Doesn't take long, but requires a good bit of technical skill to be done well and quickly. All that Playstation growing up really helps lol!

 

[jonwill]

My partner and I did a STJ/Ankle fusion with an IM nail followed by ex-fix application on a charcot patient yesterday. The patient's rearfoot/ankle was pretty much blown out so we'll see.

 

[PADPM]

Jonwill,

Just curious, what was your total time in the O.R. to perform that case? And prior to joining the practice, was your partner able to perform these procedures or did he refer them to another practice?

The reason I'm asking these questions, is because our practice is facing a dilemma. Although every doctor in our practice is ABPS certified, a few are no longer performing surgery, some are limiting the types of procedures they are performing and a few of us are still performing the full spectrum of cases.

However, our practice is fortunately extremely busy, but unfortunately there is a significant amount of managed care involved. The simple answer is to say "drop out of the managed care plans".

But if you drop out of these plans, the large number of PCP's that refer to our offices will no longer refer to our practice. The reality is that they like to keep it "simple". They don't want to send only the "good paying" patients to practice A, and the managed care to practice B. They want to tell the staff at their front desk, to send ALL patients to a particular practice.

Our practice has always maintained the philosophy that we treat all patients the same, no matter what insurance they have. We treat patients, not insurance companies.

This is where our dilemma arises. Most of the managed care plans in our area include surgical services in the "capitation", meaning we don't receive any additional money for performing surgery on these patients. Spending several hours each week in the O.R. performing complicated surgical procedures on these patients, with the added liability is an economic nightmare.

We can't "ethically" set an office policy to only perform complicated surgical procedures on non managed care patients and send our managed care patients with complicated surgical procedures out for referral. Therefore, some of our partners have proposed that we simply limit our practice to foot surgery and basic rearfoot surgery and stop performing the major reconstructive surgical procedures on ALL patients, and that when these patients need surgical care we send them to one of the young guys in the area that "needs" the work and can get paid fee for service.

Having a very busy office is great, but there comes a point when leaving the office for hours at a time is no longer cost effective. It's really a very tough situation, and I'm not in favor of the proposal, but in essence, according to the financial break down, the "big cases" are actually costing our practice money.

My partners do not believe there are any ethical or moral concerns, since ALL the patients will be treated equally, and no patient is being denied care. Any patient that requires complex surgical intervention will be referred to a skilled surgeon(s). All other surgical procedures will continue to be performed by our group.

It hasn't happened and I'm not sure it's going to happen, and if it does it would be the first time in my career that I referred a surgery to another doctor (with the exception of patients I smply refused to take to the O.R. due to the "bad" feeling).

 

[347932]

I would certainly say that f you've crunched the numbers and these cases are truly costing your practice money, you've made a good case to turf them.

That being said, some of your young colleagues may not appreciate these cases as much as you think, and may come to resent the fact that you aren't doing these complicated, time consuming cases and are sending all the "hard" stuff to them. Young practitioners need to be in their offices generating income even more so, rather than taking on these complex, difficult cases, bunches at a time. They will quickly become wise to the fact they you are turfing these cases for financial reasons and may not take them on that basis alone. We have practitioners locally who refuse complicated diabetic patients for just that reason, and as you know, these cases can become very involved both financially and time wise. The ones that turf a lot quickly get put on our "list" as it were.

Is there any way for you to negotiate the terms of your "capitation" with these insurances? Perhaps there is a way you can sit down with them and discuss these complex situations and develop an algorithm for payment when these cases demand more time/care/expense. I've dealt with this before and it is a very sticky situation so I certainly understand your position.

Good luck.

 

[PADPM]

You've made some excellent points, but we have really considered those issues.

We are by far the largest practice in the region, and have attempted to negotiate with the insurance companies based on our size and numbers. However, unfortuantely, there are scores of DPM's waiting in line with their hands out willing to accept the fees we are trying to negotiate higher.

The younger docs in are are certainly do not feel that we are dumping on them or turfing to them. We have spoken with a few of them and since there is plenty of competition, all the docs we spoke with were MORE than appreciative of the thought of us sending them the work. Each doc was interested in actually joining our group, but once again, it's not that we aren't capable of providing these surgical services, it's simply that at the present time it's not always economically feasible, especially with the managed care patients.

The simple thing to do would be to "turf" the managed care patients, but our office is not going to treat patients differently based on their insurance. So IF we decide to refer out our complex surgical cases, it will be ALL, not select insurace carriers.

 

[347932]

You've made some excellent points, but we have really considered those issues.

We are by far the largest practice in the region, and have attempted to negotiate with the insurance companies based on our size and numbers. However, unfortuantely, there are scores of DPM's waiting in line with their hands out willing to accept the fees we are trying to negotiate higher.

The younger docs in are are certainly do not feel that we are dumping on them or turfing to them. We have spoken with a few of them and since there is plenty of competition, all the docs we spoke with were MORE than appreciative of the thought of us sending them the work. Each doc was interested in actually joining our group, but once again, it's not that we aren't capable of providing these surgical services, it's simply that at the present time it's not always economically feasible, especially with the managed care patients.

The simple thing to do would be to "turf" the managed care patients, but our office is not going to treat patients differently based on their insurance. So IF we decide to refer out our complex surgical cases, it will be ALL, not select insurace carriers.

Sounds like a win/win situation for all then😀.

 

[Feli]

...unfortuantely, there are scores of DPM's waiting in line with their hands out willing to accept the fees we are trying to negotiate higher...

This will only get worse as time goes on. I think a lot of pod students (and residents) think they will practice similar to an ortho F&A and be doing basically nothing but surgery. That's just not reality when you consider the numbers, and as you hint at, the reimbursements will only be as about as high as the lowest bidders for those cases.

http://forums.studentdoctor.net/showthread.php?p=8398963#post8398963

It will be interesting to see how it all plays out with ObamaCare and a relative surplus of F&A bone/joint surgeons, but you can bet your bottom dollar that I'm going to try to provide as many different services for patients as possible. Sure, there will be types of cases I'll try to recruit more or fewer referrals/consults of based on personal pref and reimbursement rates vs time spent, but you have to do it all IMO. I want PCPs to know they can refer/consult me for basically anything below the knee.