Surgery-Does it pay anymore?

[DYK343]

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It should never be a stand alone procedure. You don't get enough correction on it. PL to PB deep tendon transfer is needed too. If they have severe equinus then a gastroc is indicated as well. Eliminate all sources of forefoot overloading.

What I don't buy is floating metatarsal osteotomies for the first ray in a neuropathic patient and saying that if you make the bone cut a certain way the first ray won't completely dislocate. You can get away with it on lesser mets but to do it on the first met is beyond reckless.

I uaually just cut the longus and let it fly. Ive done the transfer too but didnt see difference compared to recession. Always wondered if I transfer the longus to brevis if that would result in increased rearfoot valgus and ultimately more forefoot/sub 1st met pressure. Especially in a semirigid FF valgus patient/cavus patient

Im with you on floating 1st met osteotomies. Biomechanically it doesnt seem right. I did do one 6ish months ago on a disaster patient with horrible stasis dermatitis with rigid FF valgus (rigid FF valgus being the only patient I would even consider this procedure) because i had no other option. He healed. Ill take it.

order MRI if it shows first met involvement amp it

I rely less and less on MRI for limb salvage. Its often not reliable in my practice. If bone bleeds it can heal. If tissue bleeds it can heal. Too many amps for MRIs that are not true osteomyelitis or acute osteo that will heal with abx/debridement. Ill die on this hill.

Once you amp a ray its over for the patient. You just commited them to a life of further wounds and amputations. This is what costs medicare/insurance big bucks which is associated with negative stigma associated with limb salvage. We should always try to preserve the 1st-5th ray and IMO its worth spending big bucks to salvage the mets. If we dont its a slow widling process until they get the great whack.

Sometimes we dont have an option. But once its done its done - bka or a life of wounds incoming once you amp a ray. Diabetic shoes dont cut it. Save the rays.

 

[air bud]

Also as long as we are talking about rays....4th and 5th ray PARTIAL amps need a PT/TA (usually TA) tendon transfer often.....you lose the extensors and just lots of instability....think of it like dropping the reins for a horse...this is why I believe that good limb salvage has a basis in hindfoot reconstructive prinicples....ie this isn't basic stuff for 1st years and students that @Feli likes to harp on....yes anyone can amp a toe...it's about having a strong Reconstructive background to anticipate, prevent or correct the biomechanical instability that follows after an amp. Also I promise you understanding and articulating this is the key to getting jobs...

 

[air bud]

I uaually just cut the longus and let it fly. Ive done the transfer too but didnt see difference compared to recession. Always wondered if I transfer the longus to brevis if that would result in increased rearfoot valgus and ultimately more forefoot/sub 1st met pressure. Especially in a semirigid FF valgus patient/cavus patient

Im with you on floating 1st met osteotomies. Biomechanically it doesnt seem right. I did do one 6ish months ago on a disaster patient with horrible stasis dermatitis with rigid FF valgus (rigid FF valgus being the only patient I would even consider this procedure) because i had no other option. He healed. Ill take it.


I rely less and less on MRI for limb salvage. Its often not reliable in my practice. If bone bleeds it can heal. If tissue bleeds it can heal. Too many amps for MRIs that are not true osteomyelitis or acute osteo that will heal with abx/debridement. Ill die on this hill.

Once you amp a ray its over for the patient. You just commited them to a life of further wounds and amputations. This is what costs medicare/insurance big bucks which is associated with negative stigma associated with limb salvage. We should always try to preserve the 1st-5th ray and IMO its worth spending big bucks to salvage the mets. If we dont its a slow widling process until they get the great whack.

Sometimes we dont have an option. But once its done its done - bka or a life of wounds incoming once you amp a ray. Diabetic shoes dont cut it. Save the rays.

Agree, MRI is often times unnecessary.

I do wonder sometimes if should be doing more open stravix/Integra covered amps to maintain full met length. Often times bone not involving the metatarsal but requires removal of bone to get primary closure...should we preserve length and then use wound vac to get tissue coverage?

 

[DYK343]

Agree, MRI is often times unnecessary.

I do wonder sometimes if should be doing more open stravix/Integra covered amps to maintain full met length. Often times bone not involving the metatarsal but requires removal of bone to get primary closure...should we preserve length and then use wound vac to get tissue coverage?

Yes! Save the ray at all cost. Even if it takes a long time and money its better for the patient and I would argue cheaper in the long run for the healthcare system.

Debride the cartilage off the met head. Integra. Vac. Split thickness skin Graft later.

 

[Feli]

... I rely less and less on MRI for limb salvage. Its often not reliable in my practice. If bone bleeds it can heal. If tissue bleeds it can heal. Too many amps for MRIs that are not true osteomyelitis or acute osteo that will heal with abx/debridement. Ill die on this hill.

Once you amp a ray its over for the patient. You just commited them to a life of further wounds and amputations. This is what costs medicare/insurance big bucks which is associated with negative stigma associated with limb salvage. We should always try to preserve the 1st-5th ray and IMO its worth spending big bucks to salvage the mets. ....

Eh, it's more the endless debride + HBO + graft "wound care" that goes nowhere and still ends up gas/abscess and BKA that gives "limb salvage" a bad name and high cost. Sadly, this is what 90% of hospital wound centers do (DPMs, midlevels, or occasionally MDs too).

The other big issue is the hospitals (often DPM residency ones) that do crazy ex fix for everything, "offloading frame," dumb amps like Chopart and stuff that don't last long, Charcot recons that have about 3% chance of success, expensive plastics stuff with virtually no chance, Dakins-vacs, and other stuff that is just a giant waste of OR, meds, imaging, biologics, implants, nursing, and inpatient days. They seem to get away with it saying "blah blah... the patient didn't want amputation... wanted to do everything." (duh)

...for most of us, in typical practices and hospitals, a balanced TMA (+/- equinus correct) is a very good operation for confirmed forefoot osteomyelitis of met head(s) based on MRI or biopsy or just gas/infection. With proper toe filler +/- carbon plate AND proper pt edu and f/u q2-3mo lifetime even once healed, that's a big win. That's the standard of care and will always be. It is a limb salvage. It is sad to see those pts who haven't had a toe filler in years or didn't understand the importance of ongoing care when they moved or their doc retired, though. I totally agree that single ray resects and amps have their issues (and are harder to make good fillers for than full TMA).

Most important, it's also just practical. TMA amp and closure gets them OUT of the weekly wound debride and bulky DME and the antibiotics and the endless loop (which is why most wound center$$$ fight so hard against TMA/BKA/etc). A lot of these folks have many DM comorbid issues and are big or CAD or ESRD and just don't have a ton of time left, so 3-10+ less hours weekly of foot wound care and maybe PICC or HBO and etc etc with related travel is significant.

Perfusion aside, it's risky to go against MRI osteomyelitis (in the marrow)... in terms of both results and med-mal risk. Mainly, you stand to lose your flap for the durable TMA if the pt ends up with gas or nec fasc in the ER after a missed appointment or two (or just random travel or bad luck or illness where their immune system dips and the foot infection snowballs). I also echo what @air bud said that amps are often as much for closure as for osteo. Closure with no/low tension asap is always the end game. I suppose it's situational if the patient is on board with a long complicated closure try or medical osteomyelitis attempt and the doc is fairly shielded for malpractice (govt, univ, etc hospital). It is pretty impractical in most DPMs' setups, though. MRI osteo with no amp or an infection near hardware with no HWR done is just such ultra-low hanging fruit for attorneys and pt/family when the result ends bad (BKA, sepsis, death, etc) - and rightly so.

 

[Hybrocure]

Eh, it's more the endless debride + HBO + graft "wound care" that goes nowhere and still ends up gas/abscess and BKA that gives "limb salvage" a bad name and high cost. Sadly, this is what 90% of hospital wound centers do (DPMs, midlevels, or occasionally MDs too).

The other big issue is the hospitals (often DPM residency ones) that do crazy ex fix for everything, "offloading frame," dumb amps like Chopart and stuff that don't last long, Charcot recons that have about 3% chance of success, expensive plastics stuff with virtually no chance, Dakins-vacs, and other stuff that is just a giant waste of OR, meds, imaging, biologics, implants, nursing, and inpatient days. They seem to get away with it saying "blah blah... the patient didn't want amputation... wanted to do everything." (duh)

...for most of us, in typical practices and hospitals, a balanced TMA (+/- equinus correct) is a very good operation for confirmed forefoot osteomyelitis of met head(s) based on MRI or biopsy or just gas/infection. With proper toe filler +/- carbon plate AND proper pt edu and f/u q2-3mo lifetime even once healed, that's a big win. That's the standard of care and will always be. It is a limb salvage. It is sad to see those pts who haven't had a toe filler in years or didn't understand the importance of ongoing care when they moved or their doc retired, though. I totally agree that single ray resects and amps have their issues (and are harder to make good fillers for than full TMA).

Most important, it's also just practical. TMA amp and closure gets them OUT of the weekly wound debride and bulky DME and the antibiotics and the endless loop (which is why most wound center$$$ fight so hard against TMA/BKA/etc). A lot of these folks have many DM comorbid issues and are big or CAD or ESRD and just don't have a ton of time left, so 3-10+ less hours weekly of foot wound care and maybe PICC or HBO and etc etc with related travel is significant.

Perfusion aside, it's risky to go against MRI osteomyelitis (in the marrow)... in terms of both results and med-mal risk. Mainly, you stand to lose your flap for the durable TMA if the pt ends up with gas or nec fasc in the ER after a missed appointment or two (or just random travel or bad luck or illness where their immune system dips and the foot infection snowballs). I also echo what @air bud said that amps are often as much for closure as for osteo. Closure with no/low tension asap is always the end game. I suppose it's situational if the patient is on board with a long complicated closure try or medical osteomyelitis attempt and the doc is fairly shielded for malpractice (govt, univ, etc hospital). It is pretty impractical in most DPMs' setups, though. MRI osteo with no amp or an infection near hardware with no HWR done is just such ultra-low hanging fruit for attorneys and pt/family when the result ends bad (BKA, sepsis, death, etc) - and rightly so.

Agreed. Add in the fact that most patients coming in needing ray amps likely have horrible A1C and noncompliance for success for things like tendon transfers or grafting. The moment that 350lb foot stomps on the ground for a nighttime trip to the bathroom even though they’re supposed to be NWB those sutures are going bye bye.

That’s not to say it can’t still work often, I know where DYK is coming from and I feel that way just as often as I feel the way you do. Just gotta weigh the pros and cons depending on the patient. We all know the patient that comes in for their New Patient visit that we look at immediately and know “this will be a BKA”.

 

[AttackNME]

Agreed. Add in the fact that most patients coming in needing ray amps likely have horrible A1C and noncompliance for success for things like tendon transfers or grafting. The moment that 350lb foot stomps on the ground for a nighttime trip to the bathroom even though they’re supposed to be NWB those sutures are going bye bye.

That’s not to say it can’t still work often, I know where DYK is coming from and I feel that way just as often as I feel the way you do. Just gotta weigh the pros and cons depending on the patient. We all know the patient that comes in for their New Patient visit that we look at immediately and know “this will be a BKA”.

Well we can’t cure the diabetes (yet) nor the noncompliance, so if we have a low threshold to recommend BKA, what about the the other foot? It too is at risk and a low threshold for BKA will trend towards increasing prevalence of bilateral amputees. Do you feel that life is worth living? Are you going to recommend hospice or euthanasia then? Not picking a fight, it’s just this doesn’t end well for a lot of people whether we as providers have a high or low threshold for BKA

 

[Hybrocure]

Well we can’t cure the diabetes (yet) nor the noncompliance, so if we have a low threshold to recommend BKA, what about the the other foot? It too is at risk and a low threshold for BKA will trend towards increasing prevalence of bilateral amputees. Do you feel that life is worth living? Are you going to recommend hospice or euthanasia then? Not picking a fight, it’s just this doesn’t end well for a lot of people whether we as providers have a high or low threshold for BKA

The question isn’t whether we feel that their life is worth living but whether they feel that way.

There’s definitely a portion of high risk limb salvage patients we see as a profession who have checked out. You cannot help someone who doesn’t want to help themself, and this applies across all aspects of medicine.

The best we can do is give our recommendations and do the best we can to help save their limb. I’ve learned from experience the toll it can take on yourself trying to be the hero and get super involved despite the patient sabotaging everything along that path though, and it is not a healthy way to live your life as a practitioner.

Before the BKA is even done though, keep in mind there’s an MD or DO actually doing it who agrees “Yeah, this guy needs a BKA”. And sometimes it’s actually an AKA. The general surgeon/ortho/vasc surgeon doesn’t really want to do it but they know it needs to be done and have seen this situation for years.

 

[Feli]

Well we can’t cure the diabetes (yet) nor the noncompliance, so if we have a low threshold to recommend BKA, what about the the other foot? It too is at risk and a low threshold for BKA will trend towards increasing prevalence of bilateral amputees. Do you feel that life is worth living? Are you going to recommend hospice or euthanasia then? Not picking a fight, it’s just this doesn’t end well for a lot of people whether we as providers have a high or low threshold for BKA

Yeah, it's probably the toughest pt education we do. These are 100% not easy issues.
The false hope of antibiotics, debride, fancy bandages eventually loses its luster... or the wounds blow up, though.
It's always a race of stable closure vs deep/serious infection.
They gain weight being in a chair or bumbling around in a CAM boot/CROW/shoe on and off for years, antibiotics grind on gut/kidneys.
So, delaying/refusing amps is not benign either. Definitely no easy answers.

Some of them want to do "limb salvage" and WCC stuff forever, others don't. Particularly for working people, the endless on/off work, in/out of boot, antibiotics/picc/hospital, bandages and open/closed wound circus is very destructive. I try to underscore that (even though I'm undermining my own "cash register"). They are usually better served to get their biomech salvage surgery or toe amp or TMA or BKA and get on with it... surgery, shoes+fill or prosthetic+rehab, back to work (maybe modified job if need). With the infinite wound care, they just run out of leave and get laid off anyways. Where I work, I have a good number of security guards, chemists, drivers, retired ppl going around with BKA or TMA. All kinds of jobs or activity. They took FMLA or changed jobs, but they're back to baseline - or better. Most acutally lost weight after their amp because they walk better and/or it's a wakeup call for their DM/health.

It's a personal call for them, though. Our counseling is key for whichever path they choose.
I have some choose amp, some choose wound care (I do suggest they put a reasonable timeline on it).
I have had people with terrible Charcot and multiple wounds/osteo spots that flat out refuse amp. That's fine. They can go to a xfer hospital or do WCC, which will promise them the moon and that osteo heals with Prisma and Santyl. It's their leg. 🙂

 

[dtrack22]

You cannot help someone who doesn’t want to help themself,

But we get paid to try, so…

 

[air bud]

Yes! Save the ray at all cost. Even if it takes a long time and money its better for the patient and I would argue cheaper in the long run for the healthcare system.

Debride the cartilage off the met head. Integra. Vac. Split thickness skin Graft later.

Saving the system money by generation of more RVUs.....I like it

 

[DYK343]

A lot of good comments.

Its important to take note there is no one single path for every patient.

A balanced TMA is a good, stable, procedure but it is also a huge wound to heal. And commonly has problems especially in the chronically ill patients that are getting them. I do 1-2 TMAs a week. They can be problematic.

We all know the outcomes of BKA.

A toe amp w integra bilayer (or pick your bone approved graft of choice) over a 1st met head that has a negative bone biopsy is perfectly fine in my book. I do it a lot and I haven't had much issues.

But do I also resect a healthy 1st met head for closure sometimes? Yes. But I really try not to.

And it is a risk to go against the horrible radiology foot reads that I see every day. A good radiologist read is valuable. But the fellowship trained neuro guy reading foot MRIs is not valuable. I dont think our local radiology group, despite a population of about 600k, has a true MSK radiologist. The foot/ankle reads are not reliable.

A bone biopsy for culture is and always has been the gold standard for osteomyelitis and that will hold in any court.

 

[DYK343]

The best we can do is give our recommendations and do the best we can to help save their limb. I’ve learned from experience the toll it can take on yourself trying to be the hero and get super involved despite the patient sabotaging everything along that path though, and it is not a healthy way to live your life as a practitioner.

I have a very experienced wound nurse in the wound center. Great nurse. We work well together. Shes close to retirement. Genuinely cares. But she constantly gets worked up about non compliance while i just move onto the next. It doesn't look healthy.

I provide advice and try to explain their situation and what can/will happen. What they do with that information is up to them. I cant fix everyone. Its the only way to practice limb salvage. I guess I'm cold hearted. I am thorough in my explanations though. They have been warned. So I sleep at night.