Offloading diabetic foot ulcers

[DYK343]

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so you're doing it with a 18 gauge 1-2cm proximal to the sesamoids? I assume we're talking about this article:

https://www.fastracjournal.org/article/S2667-3967(23)00029-0/fulltext

have you seen transfer ulcers in these?

Yes that article is the technique I use. No transfer ulcers to date. Takes me about 30 sec to a minute to release the medial band of the fascia with an 18g needle. Again, has to be funtional hallux limitus. Any bony component/true limitus and its straight to Keller arthroplasty for me.

I wouldnt mind trying an MIS cheilectomy in one of these patients. I have had dehiscence and osteo issues with keller. Still low compared to the amount I do. But ive had some problems.

 

[BeaverBlade]

Yes that article is the technique I use. No transfer ulcers to date.

How many have you done? Have you ever accidentally cut the FHL?

 

[DYK343]

How many have you done? Have you ever accidentally cut the FHL?

Probably 1 a week for at least a year. Maybe longer.

...Not that im aware of.

 

[BeaverBlade]

Probably 1 a week for at least a year. Maybe longer.

...Not that im aware of.

Thanks. Good info. Well I’m probably going to start trying this. I’m not sure why I’m so skeptical of it. Do you do it right away or only after failing wound care/offloading for a certain time?

 

[DYK343]

Thanks. Good info. Well I’m probably going to start trying this. I’m not sure why I’m so skeptical of it. Do you do it right away or only after failing wound care/offloading for a certain time?

I certainly offer it right away/first visit.

IMO 95% of diabetic/neuropathic foot ulcers will recur (I think literature says something like 60% but lets be real - these ulcers keep coming back).

Shoes only benefit if they wear them 24/7. Which no one actually does.

DFUs are a pressure point/biomechanical defect. Gotta address the biomechanics to heal the wound long term.

- - -

Make sure private insurance patients know their cost upfront if you do in office procedures.

 

[air bud]

Refer to the wound care center and when they want surgery do that. Then send them back to the wound care center.

 

[footpainhealer]

Thanks. Good info. Well I’m probably going to start trying this. I’m not sure why I’m so skeptical of it. Do you do it right away or only after failing wound care/offloading for a certain time?

I have been hesitant as well because I feel like all I can feel in the FHL only and I can't differentiate the medial band PF and FHL as distinct as I would like before doing this

 

[Sybly]

Yes that article is the technique I use. No transfer ulcers to date. Takes me about 30 sec to a minute to release the medial band of the fascia with an 18g needle. Again, has to be funtional hallux limitus. Any bony component/true limitus and its straight to Keller arthroplasty for me.

I wouldnt mind trying an MIS cheilectomy in one of these patients. I have had dehiscence and osteo issues with keller. Still low compared to the amount I do. But ive had some problems.

Somewhat related. All part b contractors to end Florescence wound imaging..Probably hurt Larger supergroup - billing practices

 

[BeaverBlade]

I have been hesitant as well because I feel like all I can feel in the FHL only and I can't differentiate the medial band PF and FHL as distinct as I would like before doing this

you just have to be very superficial. (Not speaking from experience, still haven't done it)

there's a video of a dude on youtube doing it and he's for sure just tearing up the FHL lol

 

[Boba Foot]

Medial band plantar fasciotomy works great. The only people I've done it on that hasn't worked had really bad deformity and/or hallux rigidus to begin with. If you do the fasciotomy closer to the met-cuneiform joint like Chiu says, you're not that close to the FHL.

 

[Sendin_Toes_2market]

you just have to be very superficial. (Not speaking from experience, still haven't done it)

there's a video of a dude on youtube doing it and he's for sure just tearing up the FHL lol

Do it in the OR with a .5-1cm incision. Isolate with a mosquito and cut it like a Tenotomy. Also protects the nerve. The PF is literally right against the skin. Stay parallel and DF the hallux. If you have tension you are on the FHL. If you only really have tension when simulated weight on the plantar met 1, you are on the medial band of plantar fascia.

 

[BeaverBlade]

Medial band plantar fasciotomy works great. The only people I've done it on that hasn't worked had really bad deformity and/or hallux rigidus to begin with. If you do the fasciotomy closer to the met-cuneiform joint like Chiu says, you're not that close to the FHL.

I thought his technique was just proximal to the sesamoids

 

[Boba Foot]

I thought his technique was just proximal to the sesamoids

He has a video on Foot and Ankle Surgery Academy that shows how he does it and he specifies just distal to the met-cuneiform joint because the FHL is not as close in that area.

 

[Stormblest]

If you have an ultrasound you could do it ultrasound guided to make sure you have the PF.

 

[DYK343]

Do it in the OR with a .5-1cm incision. Isolate with a mosquito and cut it like a Tenotomy. Also protects the nerve. The PF is literally right against the skin. Stay parallel and DF the hallux. If you have tension you are on the FHL. If you only really have tension when simulated weight on the plantar met 1, you are on the medial band of plantar fascia.

Its not wrong to do it in the OR. Its just a lot for such a simple procedure that can be done in clinic in <5minutes.
Especially since they have no pain due to neuropathy.

Hour turnovers make this unfeasible (at least in my practice).

 

[Boba Foot]

Its not wrong to do it in the OR. Its just a lot for such a simple procedure that can be done in clinic in <5minutes.
Especially since they have no pain due to neuropathy.

Hour turnovers make this unfeasible (at least in my practice).

You’re also giving up almost double the reimbursement you get for doing it in the office when you take it to the OR.

It’s really not rocket science. Beveled 18-gauge. Stay near the skin. Sweeping motion until you hear the crunchiness of the fascia being cut stop. Not much different than a flexor tenotomy. Windlass it a few times to make sure you got it all. 4x4 and paper tape. Send em home.

 

[air bud]

You’re also giving up almost double the reimbursement you get for doing it in the office when you take it to the OR.

It’s really not rocket science. Beveled 18-gauge. Stay near the skin. Sweeping motion until you hear the crunchiness of the fascia being cut stop. Not much different than a flexor tenotomy. Windlass it a few times to make sure you got it all. 4x4 and paper tape. Send em home.

That part doesn't matter for hospital employed....paper tape?? Wtf?

 

[Boba Foot]

That part doesn't matter for hospital employed....paper tape?? Wtf?

You can just replace "I am a dog and play basketball. Coming back in 26" with "I am hospital employed" so you don't have to repeat it on a weekly basis. We know dude.

Paper tape, Mepore, whatever you wanna call it.

 

[air bud]

You can just replace "I am a dog and play basketball. Coming back in 26" with "I am hospital employed" so you don't have to repeat it on a weekly basis. We know dude.

Paper tape, Mepore, whatever you wanna call it.

Who hurt you?

I bet you are fun at parties

 

[DYK343]

You’re also giving up almost double the reimbursement you get for doing it in the office when you take it to the OR.

It’s really not rocket science. Beveled 18-gauge. Stay near the skin. Sweeping motion until you hear the crunchiness of the fascia being cut stop. Not much different than a flexor tenotomy. Windlass it a few times to make sure you got it all. 4x4 and paper tape. Send em home.

PP gets reimbursed less for in office procedures over OR?

Somewhere stored in my brain I have they actually pay more as it saves the insurance money. No idea where I heard that.

 

[heybrother]

PP gets reimbursed less for in office procedures over OR?

Somewhere stored in my brain I have they actually pay more as it saves the insurance money. No idea where I heard that.

As a general rule in PP - office procedures usually reimburse more. Medicare reimburses 28060 at about 50% more if the procedure is done in the office.

Bizarrely - the reimbursement for that code is better in an ASC with BCBS than in an office (Less than $100 difference). I think its an unforseen consequence of their ASC reimbursement model.
EDIT: added remark about BCBS ASC reimbursement.

 

[Boba Foot]

PP gets reimbursed less for in office procedures over OR?

Somewhere stored in my brain I have they actually pay more as it saves the insurance money. No idea where I heard that.

Paid more if done in office. Varies from CPT to CPT but a lot of times 50% higher if done in office. This is why you’re seeing some docs doing MIS in office in a surgical suite.

 

[dtrack22]

PP gets reimbursed less for in office procedures over OR?

You read that backwards. You get less money in PP to go to the OR because when doing it in office you do get some reimbursement above and beyond the professional fees that may or may not actually cover the supplies/instruments/hardware you used.

 

[Sendin_Toes_2market]

Paid more if done in office. Varies from CPT to CPT but a lot of times 50% higher if done in office. This is why you’re seeing some docs doing MIS in office in a surgical suite.

As a hospital employed podiatrist I have a procedure room in the OR for these cases,
so It doesn’t slow down my Clinic. I wasnt a hospital employed podiatrist, I would just do them in my office. Did I mention hospital employed? lol.

I got paid 25% more for tenotomies in office than hospital when I was private practice. I was waiting around my procedure room today for 25 minutes for a time out because the nurse had the taco bell ****s. So there are pluses and minuses.

 

[DYK343]

You read that backwards. You get less money in PP to go to the OR because when doing it in office you do get some reimbursement above and beyond the professional fees that may or may not actually cover the supplies/instruments/hardware you used.

I did read it backwards. I was confused as to why anyone would want to do it in OR from a financial (and honestly patient care..) standpoint.