Offloading diabetic foot ulcers

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My ASC requires anyone over 50 to get EKG done which means I have to send them to PCP for full medical clearance. It’s dumb.
 
wakaflocka88 said:
My ASC requires anyone over 50 to get EKG done which means I have to send them to PCP for full medical clearance. It’s dumb.
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For patients I self clear, I send EKGs to the local imaging center. They subsequently contract a cardiologist to read it.
 
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DYK343 said:
Do you ever run into anesthesia that for whatever reason doesnt want to do MAC for diabetic cases? In residency tons of MAC. Where I am now its like pulling teeth to get a MAC even with discussion with anesthesia that there is no need for a popliteal block or deep anesthesia due to neuropathy. Its like they skipped the diabetic foot/neuropathy chapter in medical school. (generalizing - not all).
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I’m rural. Our staff is entirely CRNA. They function independently. They are salaried. They do MAC + local or MAC + regional on elective osseous cases in sensate patients if I book it that way. Really no questions asked. Occasionally they will convert or decide on general (LMA) even though I say I can get away with MAC, and that’s for airway reasons rather than them not believing I can adequately anesthetize the foot. I have never had anesthesia try to over-anesthetize a neuropathic patient. That doesn’t make any sense (other than the occasional obese/apneic patient where they’ve done general with an LMA). But even in those cases I will typically suggest just a little versed and let the patient chat it up with them on the other end of the bed. They are good in terms of erring on the side of lighter anesthesia as opposed to paralyzing and intubating these people.

You have a good gig but between clipboard nurses and anesthesia and no vacation because you’re responsible for every inpatient at all times, you work with *****s. No offense to said *****s or you.

wakaflocka88 said:
My ASC requires anyone over 50 to get EKG done which means I have to send them to PCP for full medical clearance. It’s dumb.
Click to expand...

You can’t just order an EKG?

We (podiatrists) don’t do any “high risk” or really even “intermediate risk” surgeries from a cardiac standpoint. I’ve heard of facilities requiring EKG on low risk patients without cardiac symptoms at a certain age (generally the cutoff is 50 or 60). Other than cardiac patients or patients with any recent cardiac symptoms, I get EKGs on diabetic patients, patients with renal disease, significant PAD or history of Stroke/TIA basically regardless of age. They usually happen to be older than 50 any ways. For low risk patients undergoing low risk surgery, I get an EKG if they are over the age of 60 and haven’t had one in a year (they usually haven’t unless they’ve had a recent surgery) mostly to make anesthesia happy. There are plenty of risk stratification flow charts that would suggest an EKG in a 61 year old with no known medical conditions undergoing low risk foot surgery (basically any foot surgery) does not need a pre-op EKG. But enough anesthesia departments make public recommendations regarding pre-op EKG on people over a certain age that I do it.
 
dtrack22 said:
I’m rural. Our staff is entirely CRNA. They function independently. They are salaried. They do MAC + local or MAC + regional on elective osseous cases in sensate patients if I book it that way. Really no questions asked. Occasionally they will convert or decide on general (LMA) even though I say I can get away with MAC, and that’s for airway reasons rather than them not believing I can adequately anesthetize the foot. I have never had anesthesia try to over-anesthetize a neuropathic patient. That doesn’t make any sense (other than the occasional obese/apneic patient where they’ve done general with an LMA). But even in those cases I will typically suggest just a little versed and let the patient chat it up with them on the other end of the bed. They are good in terms of erring on the side of lighter anesthesia as opposed to paralyzing and intubating these people.

You have a good gig but between clipboard nurses and anesthesia and no vacation because you’re responsible for every inpatient at all times, you work with *****s. No offense to said *****s or you.



You can’t just order an EKG?

We (podiatrists) don’t do any “high risk” or really even “intermediate risk” surgeries from a cardiac standpoint. I’ve heard of facilities requiring EKG on low risk patients without cardiac symptoms at a certain age (generally the cutoff is 50 or 60). Other than cardiac patients or patients with any recent cardiac symptoms, I get EKGs on diabetic patients, patients with renal disease, significant PAD or history of Stroke/TIA basically regardless of age. They usually happen to be older than 50 any ways. For low risk patients undergoing low risk surgery, I get an EKG if they are over the age of 60 and haven’t had one in a year (they usually haven’t unless they’ve had a recent surgery) mostly to make anesthesia happy. There are plenty of risk stratification flow charts that would suggest an EKG in a 61 year old with no known medical conditions undergoing low risk foot surgery (basically any foot surgery) does not need a pre-op EKG. But enough anesthesia departments make public recommendations regarding pre-op EKG on people over a certain age that I do it.
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Doing a chronic Achilles repair (2 hours prone) on a 47 BMI. No meds, A1c is 5.3. One of those healthy morbidly obese people. Yeah I am having someone else see her before surgery. 1 facility all CRNA said no, facility with anesthesiology say yes can do her.


I worked in a CRNA only facility for 3 years. Was told they wouldn't do 2 cases and one of the I asked them to say no so I had a good excuse why I changed my mind and didn't want to operate on her. Granted I was doing 40. Cases a year so not a huge sample size....
 
dtrack22 said:
I’m rural. Our staff is entirely CRNA. They function independently. They are salaried. They do MAC + local or MAC + regional on elective osseous cases in sensate patients if I book it that way. Really no questions asked. Occasionally they will convert or decide on general (LMA) even though I say I can get away with MAC, and that’s for airway reasons rather than them not believing I can adequately anesthetize the foot. I have never had anesthesia try to over-anesthetize a neuropathic patient. That doesn’t make any sense (other than the occasional obese/apneic patient where they’ve done general with an LMA). But even in those cases I will typically suggest just a little versed and let the patient chat it up with them on the other end of the bed. They are good in terms of erring on the side of lighter anesthesia as opposed to paralyzing and intubating these people.

You have a good gig but between clipboard nurses and anesthesia and no vacation because you’re responsible for every inpatient at all times, you work with *****s. No offense to said *****s or you.



You can’t just order an EKG?

We (podiatrists) don’t do any “high risk” or really even “intermediate risk” surgeries from a cardiac standpoint. I’ve heard of facilities requiring EKG on low risk patients without cardiac symptoms at a certain age (generally the cutoff is 50 or 60). Other than cardiac patients or patients with any recent cardiac symptoms, I get EKGs on diabetic patients, patients with renal disease, significant PAD or history of Stroke/TIA basically regardless of age. They usually happen to be older than 50 any ways. For low risk patients undergoing low risk surgery, I get an EKG if they are over the age of 60 and haven’t had one in a year (they usually haven’t unless they’ve had a recent surgery) mostly to make anesthesia happy. There are plenty of risk stratification flow charts that would suggest an EKG in a 61 year old with no known medical conditions undergoing low risk foot surgery (basically any foot surgery) does not need a pre-op EKG. But enough anesthesia departments make public recommendations regarding pre-op EKG on people over a certain age that I do it.
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I think a lot of it is anesthesia can increase billing for deeper level anesthesia. Obviously thats wrong but clearly whats happeneing. Why would they demand a popliteal block when there is a large gaping wound on the plantar foot and no pain? There are a couple in my area that refuse to proceed with case without pop block. (and so im told popliteal blocks dont really pay very much).

About EKGs as you said above its more for anesthesia comfort. If you show up and they demand a preop EKG and gotta wait for cards to read it it just slows the day down. I get a lot of EKGs to keep things moving.
 
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DYK343 said:
I think a lot of it is anesthesia can increase billing for deeper level anesthesia. Obviously thats wrong but clearly whats happeneing. Why would they demand a popliteal block when there is a large gaping wound on the plantar foot and no pain? There are a couple in my area that refuse to proceed with case without pop block. (and so im told popliteal blocks dont really pay very much).

About EKGs as you said above its more for anesthesia comfort. If you show up and they demand a preop EKG and gotta wait for cards to read it it just slows the day down. I get a lot of EKGs to keep things moving.
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Bingo. Always follow the money.
It will be completely and totally bipolar based on how the CRNA locum or group or hospital or entrepreneur company pays them...

The per hour CRNA and anesthesiologists - usually hospital employee or some anesth locum companies - will want as few cases as possible, healthy pts, straight local if up to them (but will do mostly MACs, more spinals than most if it avoids generals). They avoid sick pts, try to avoid generals, pretend not to know what a pop block even is. They will do long cases but just don't want problems... no incentive for them to take risks. These are usually the cases where you end up trying to do a Lapidus or a TMA on a "dancing" patient... and they tell you to just try more local. They get paid for on-call, but they don't get much/any bonus for coming in, so they will talk their way out of cases and just add them on the next day if at all possible. They will reject "risky" cases and make you transfer those pts... again, no incentive whatsoever.

The RVU-based locums (rarely to have that setup as FTE hospital employ) want many cases, fast cases, everything is "general," happy to do a pop or ankle block for a 5th digit plasty, etc. They get paid for coming in on-call, they are happy to do late or Saturday cases... make it a general with a pop block tho!

The private practice anesth ones (CRNA or MD... usually doc-owned or mega PP groups like TeamHealth) want everything general, everything fast. They try to dump the long cases and slow surgeons on hospital hourly anesth. They love ASC days with 5 foot cases in a morning. They are basically same as RVU locums, but they cater to certain payers also. They do have more ability as they are not on an island without anesthesiologist backup. Again, you will tend to notice "want and ultrasound ankle block" and "make sure you dictate that it was general anesthesia" even for a hallux amp or ganglion.

...I never clear my own pts, ever. It all depends on your practice situ. In PP, it's good to get your name out and keep being a "team player" with PCPs or Peds anyway. I wouldn't even consider it unless it's a ASA 1 or 2 and bona fide time-sensitive emergency like open fx on weekend or something. I would never do it for 3 or higher, which all DM with a foot surgery need are. I don't care if I "could" or I have H&P privileges there is no reason to. I'm not in IHS with basically no liability anymore, where I would sometimes have to clear even the higher ASA people who needed amp or I&D quick right from the ER (admits already had H&P obviously).
But in PP, why do it at all? It happens every year that there's a plastics or ENT or two who has a teen or young person die (anesth complication), makes national news, and you're done if that happens to you with no H&P or a H&P you did yourself.
 
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Feli said:
makes national news, and you're done if that happens to you.
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If that happened to a DPM they would probably just tank the whole profession!
 
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DYK343 said:
If that happened to a DPM they would probably just tank the whole profession!
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In residency, almost every surgical patient we had needed clearance by admitting doc (internal med lol) and if they had any cardiac issues at all, would also request cardiac clearance. I think moving forward, I will keep that olive branch open so they can send me more total nail replacement patients ;)
 
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DYK343 said:
I think a lot of it is anesthesia can increase billing for deeper level anesthesia. Obviously thats wrong but clearly whats happeneing.
Click to expand...

I would agree with you and Feli. That was my first thought. It’s also why I mentioned our CRNAs are salaried. They get paid regardless of level of anesthesia…

Follow the money. Almost always.
 
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dtrack22 said:
I would agree with you and Feli. That was my first thought. It’s also why I mentioned our CRNAs are salaried. They get paid regardless of level of anesthesia…

Follow the money. Almost always.
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1256cf.jpg
 
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Love this thread, agree that a lot of foot ulcers need a surgical solution. Since the pandemic a lot of systematic reviews came out to support floating osteotomies and flexor tenotomies, I’m surprised that a lot of podiatrists still don’t think about these surgical options for diabetic problems
 
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AttackNME said:
Love this thread, agree that a lot of foot ulcers need a surgical solution. Since the pandemic a lot of systematic reviews came out to support floating osteotomies and flexor tenotomies, I’m surprised that a lot of podiatrists still don’t think about these surgical options for diabetic problems
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Too busy with jams and jellies and EpiFix and stringing the patient along for as long as possible. It’s tragic and sad when a surgical option can save a limb much quicker.
 
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AttackNME said:
Love this thread, agree that a lot of foot ulcers need a surgical solution. Since the pandemic a lot of systematic reviews came out to support floating osteotomies and flexor tenotomies, I’m surprised that a lot of podiatrists still don’t think about these surgical options for diabetic problems
Click to expand...
Can you point us in the direction of those?
 
I've had 2 semi-recent cases of patients with ulcerations of the hallux and a rigid to semi-rigid contracted hallux IPJ. One was dorsal over the IPJ due to contracture. The other was a distal tip ulceration. Neither were dorsally subluxated at the MPJ. I told both of them they'd like require some variation of IPJ fusion/arthroplasty. That said, I tried both of them with an aggressive flexor tenotomy + capsulotomy and joint release. Was able to enter the joint in both from the plantar aspect and achieve a substantial release through a minimalist incision. Good clinical correction led to rapid resolution of the ulcerations. Doesn't burn any bridges. Both were questionable surgical candidates from a patient behavior / health approach so I was glad to avoid putting in hardware. I do love this procedure.

In my area though if you are PP and submit a claim to Novitas for multiple 28232s they will ask for the operative note like every single time and an explanation line for why you billed it.
 
I offload the entire patient to the DPM down the hall. Ulcers... pffffft
 
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air bud said:
Can you point us in the direction of those?
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pubmed.ncbi.nlm.nih.gov

Metatarsal Osteotomies for Treating Neuropathic Diabetic Foot Ulcers: A Meta-analysis - PubMed

Diabetic foot ulcers (DFUs) are usually treated with conservative management based on debridement, topical agents, and nonsurgical off-loading; however, the recurrence rate following such standard care is reported to be high. In the case of recalcitrant or recurrent ulcers, a surgical...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

This is the most relevant one. Honestly just lookup all articles by that author since 2019, it’s all super relevant to this thread
 
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Can’t believe all of you missed the boat. Just put him in magnetic insoles and it’ll cure those pesky ulcers and cure his ED.

And if all else fails….a HyProCure should do the trick.
 
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ExperiencedDPM said:
...and cure his ED.

And if all else fails….a HyProCure should do the trick.
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Do you put the insoles in his shoes or in his underpants?

I don't even want to know where to pop in the HyProCure...
 
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CutsWithFury said:
Speaking of fraud…

Please tell us how many times you catch podiatrists billing ORIF of STJ dislocation when all they do is implant an arthroereisis?
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Please please please
 
CutsWithFury said:
Speaking of fraud…

Please tell us how many times you catch podiatrists billing ORIF of STJ dislocation when all they do is implant an arthroereisis?
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ALL the time. And some actually bill it as a subtalar arthrodesis.

But when those cases hit my desk I just smile knowing they aren’t getting away with it THIS time AND I’m getting paid to make sure these thieves don’t get the fraud approved.
 
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heybrother said:
View attachment 356870
For your amusement.
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S2117
0335T

Those are the ONLY two acceptable codes. No insurers pay for these codes, but these are correct. And of course you have to choose one or the other, not both.

NCCI policy states that a code must be billed to the highest specificity. So despite all these *****s trying to rationalize, any code other than the two I provided is simply fraud.

But we already know that fact.
 
AttackNME said:
pubmed.ncbi.nlm.nih.gov

Metatarsal Osteotomies for Treating Neuropathic Diabetic Foot Ulcers: A Meta-analysis - PubMed

Diabetic foot ulcers (DFUs) are usually treated with conservative management based on debridement, topical agents, and nonsurgical off-loading; however, the recurrence rate following such standard care is reported to be high. In the case of recalcitrant or recurrent ulcers, a surgical...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

This is the most relevant one. Honestly just lookup all articles by that author since 2019, it’s all super relevant to this thread
Click to expand...
This is promising, but we are basically just viewing them as akin to doing met head resections from biomech result, right? I don't see how they won't have all of the same issues (transfer lesions, drifting crazy toe, eventual TMA even with best custom insoles afterwards). There is no reason to call 1.5yr avg f/u on diabetics "long term" when those DFU amputee pts will have quarterly - or more freq - pod exams lifelong.

A lot of things just get rinsed and repeated in podiatry...
The "let the met head find its own level" float central met osteotomy was popular awhile ago, before DPMs realized it crashed and burned... and Weil became standard.
The rope-a-dope for HAV got reinvented as tightrope for HAV and failed even faster that time.
MPJ 1 implants from silicone to hemi to totals are on their ump-teenth generation... still suck and no real benefit (except that cpt pays better than fusion).
Scarf and other midshaft stuff gets played around with , but they're fairly disastrous in practice and with long term re-op and recur f/u.
MIS had its brief heyday and now has its rebirth moment in the sun right now.

A lot of things didn't work then and are unlikely to now (small exception to Lapidus with tight flannel bandage vs Lapidus with internal fixation).
 
Feli said:
I don't see how they won't have all of the same issues (transfer lesions, drifting crazy toe, eventual TMA even with best custom insoles afterwards).
Click to expand...

You don’t violate the MPJ capsule and you don’t shorten the digit or the “joint.” Would you really expect to have the same rate soft tissue related complications as a met head resection? As far as transfer lesions, it makes sense to me that dorsal translation of a met head and maintaining length/functional status of the toe at the level of the MPJ and distal to it, should lessen the amount of force that is transferred to adjacent rays when compared to a met head resection. It’s also nice that it can be done percutaneously, but that’s not a huge deal.

I’ve done a handful, no transfer lesions yet and no toe complications. I’m sure the transfer lesions are coming, I would be surprised to see toe issues though.
 
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ExperiencedDPM said:
Beyond belief. How did you know that was the word I used? Did you read it prior to them censoring the word?
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I didn’t. It’s the word I used that got censored in the post right above the one you quoted. The censoring is put into the message board code, so that it auto censors a predetermined list of words. Anything that’s censored is coming out that way as soon as you hit the “post reply” button.

There are a lot of *****s in this world so makes sense that we both ended up calling people *****s. Surprised there aren’t more posts about *****s to be honest.
 
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Feli said:
This is promising, but we are basically just viewing them as akin to doing met head resections from biomech result, right? I don't see how they won't have all of the same issues (transfer lesions, drifting crazy toe, eventual TMA even with best custom insoles afterwards). There is no reason to call 1.5yr avg f/u on diabetics "long term" when those DFU amputee pts will have quarterly - or more freq - pod exams lifelong.

A lot of things just get rinsed and repeated in podiatry...
The "let the met head find its own level" float central met osteotomy was popular awhile ago, before DPMs realized it crashed and burned... and Weil became standard.
The rope-a-dope for HAV got reinvented as tightrope for HAV and failed even faster that time.
MPJ 1 implants from silicone to hemi to totals are on their ump-teenth generation... still suck and no real benefit (except that cpt pays better than fusion).
Scarf and other midshaft stuff gets played around with , but they're fairly disastrous in practice and with long term re-op and recur f/u.
MIS had its brief heyday and now has its rebirth moment in the sun right now.

A lot of things didn't work then and are unlikely to now (small exception to Lapidus with tight flannel bandage vs Lapidus with internal fixation).
Click to expand...

Floating met heads are completely different than resecting met heads, you leave the DTML and that helps stabilize it. Much less incidence of transfer lesions than resections.
 
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AttackNME said:
Floating met heads are completely different than resecting met heads, you leave the DTML and that helps stabilize it. Much less incidence of transfer lesions than resections.
Click to expand...
I would hope so too, but here is no appreciable long term f/u...

The MIS float osteotomies for elective that were all the rage, taught in schools, promoted at CME, etc in 1980s and 90s (either pin them with driving back hammertoe k-wire for a month until removed... or just float the met cuts from the getgo) had very bad results with f/u. Weil obviously became the norm. Everything looks great for short and maybe medium term f/u... look at implants, base wedge, etc. The float met cuts fell out of favor quick back then 20-30+ years ago... doubt they are even given lip service in McGlamry or major texts anymore. 'Follow-up is the enemy of good surgery.'

Granted, the DM ulcer ppl might not be as active, but most are bigger folk. We shall see. I hope it ends better.

...I just saw a new pt lady in 40s today who had that done (unfixated distal met osteotomies bilateral... along with 1st met/MPJ under-correction) by "the best foot surgeon in Chile" just a year ago, now with dorsal dislocated central MPJs and recurring hammertoes less than 2yr post... not pretty. Her calluses are sub 4th MPJ and 2nd and 3rd dorsal PIPJs, medial 1st met head. It will be a pretty complicated save - and less than 2yrs after the "correction"... MPJ1 desis with Weils to try to correct parabola etc that the met osteotomies messed up? Not fun.

ap view.jpg
 
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Feli said:
I would hope so too, but here is no appreciable long term f/u...

The MIS float osteotomies for elective that were all the rage, taught in schools, promoted at CME, etc in 1980s and 90s (either pin them with driving back hammertoe k-wire for a month until removed... or just float the met cuts from the getgo) had very bad results with f/u. Weil obviously became the norm. Everything looks great for short and maybe medium term f/u... look at implants, base wedge, etc. The float met cuts fell out of favor quick back then 20-30+ years ago... doubt they are even given lip service in McGlamry or major texts anymore. 'Follow-up is the enemy of good surgery.'

Granted, the DM ulcer ppl might not be as active, but most are bigger folk. We shall see. I hope it ends better.

...I just saw a new pt lady in 40s today who had that done (unfixated distal met osteotomies bilateral... along with 1st met/MPJ under-correction) by "the best foot surgeon in Chile" just a year ago, now with dorsal dislocated central MPJs and recurring hammertoes less than 2yr post... not pretty. Her calluses are sub 4th MPJ and 2nd and 3rd dorsal PIPJs, medial 1st met head. It will be a pretty complicated save - and less than 2yrs after the "correction"... MPJ1 desis with Weils to try to correct parabola etc that the met osteotomies messed up? Not fun.

View attachment 356984
Click to expand...

Floating met osteotomies are fine for neuropathic diabetics to offload ulcers.

Not fine for elective surgery in a sensate patient looking for deformity correction.
 
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In the author’s experience, it was difficult to feel the subtle increase in hallux dorsiflexion, so confirmation of the release was done by remov-
ing the needle and palpating for the defect. Another confirmation wasd one by re-inserting the needle and gently swiping the needle again in
the coronal plane to feel for any snags of residual fibers


Is this just a fancy way of just jamming it in there and hacking away?
 
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HardRoadPaved said:
In the author’s experience, it was difficult to feel the subtle increase in hallux dorsiflexion, so confirmation of the release was done by remov-
ing the needle and palpating for the defect. Another confirmation wasd one by re-inserting the needle and gently swiping the needle again in
the coronal plane to feel for any snags of residual fibers


Is this just a fancy way of just jamming it in there and hacking away?
Click to expand...
Concur. ^

Case study = nonsense. That's not research. That group is generally one of the better ones in NMex and better results than the average bear, but showing an ulcer you could heal with a prefab insole and then calling a procedure effective and justifying billing a 28008 is the bottom line, not any real logic.

18ga vs plantar fascia = elephant hunting with a BB gun. It's a good way to break a needle off inside the foot or certainly to fail to accomplish what you set for.

If anything, do the FHL tendonotomy (IPJ level) if you can't heal the wound with DM shoes + insoles (probably have wrong shoes and/or poor compliance) and don't want to do the Keller. Even such, FHL is still a decnt sized tendon and has irregular at best office results done perc (again, 18ga unreliable at best... anything bigger, might as well take to OR and do it right). I have done fusion or Keller (or amp due to osteo) on many failed hallux ulcer office tendonotomies by other DPMs. With wounds, do good conservative or the best surgery possible; a half-measure office procedure is what it is: a billing trick.

MusicManMike said:
I [bill] p. fasciotomy.
Click to expand...
Yes, that's the whole reason for this "innovation." :)
 
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I have a ton of these wounds in the wound center right now. Same spot/location. They can be difficult to heal.
I know of others doing this same procedure and stating good results.
Ive yet to try but I am intrigued as I find them difficult to heal.

Just read the article. Only 4 patients completed. 2 of which developed a transfer ulcer.
 
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DYK343 said:
I have a ton of these wounds in the wound center right now. Same spot/location. They can be difficult to heal.
I know of others doing this same procedure and stating good results.
Ive yet to try but I am intrigued as I find them difficult to heal.

6 patients is not enough to make me dive in tho
Click to expand...
Yeah, that and the fact that maybe 3% of such patients have a fully reducible deformity with minimal/no rigidus component :)

This is just basically a scam to bill a PF that takes 3mins imo... then, the wound heals anyways with insoles/shoes/pad... or you can do the OR tendonotomy or Keller (after the 90d global).
 
Feli said:
18ga vs plantar fascia = elephant hunting with a BB gun. It's a good way to break a needle off inside the foot or certainly to fail to accomplish what you set for.
Click to expand...

Feli said:
again, 18ga unreliable at best
Click to expand...

I’ve done maybe a dozen of these and far more flexor tenotomies with 18ga needles. The statements above are rather ignorant. You actually believe you are going to break an 18ga needle in the foot while swiping across the plantar fascia?

Thinking that a prefab is healing these people in my clinic (procedure is only done when they have already failed custom accommodative inserts and or daily felt offloading) is also pretty ignorant.

Feli is slowly morphing into bitter old TFP man around here 🙄

excuse-me.gif
 
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Feli said:
Yeah, that and the fact that maybe 3% of such patients have a fully reducible deformity with minimal/no rigidus component :)
Click to expand...

Yup. I’ll keep this in mind for the next 35 yo a1c 13 with an HIPJ ulcer
 
dtrack22 said:
I’ve done maybe a dozen of these and far more flexor tenotomies with 18ga needles. The statements above are rather ignorant. You actually believe you are going to break an 18ga needle in the foot while swiping across the plantar fascia?

Thinking that a prefab is healing these people in my clinic (procedure is only done when they have already failed custom accommodative inserts and or daily felt offloading) is also pretty ignorant.

Feli is slowly morphing into bitter old TFP man around here 🙄

excuse-me.gif
Click to expand...
We are probably talking different things...

For FDL (and FDB) flexible lesser digit tuft ulcer, 18ga tendonotomy works fairly good... I agree. I probably bag an avg of 0.68 digital proper branches per proc, but yeah. Works well.
FHL with 18ga = sketchy at best. Not reliable. Not the right tool.
Plantar fascia meaningful 18ga release = not happening. Not effective.
 
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