What are your go-to offloading strategies in a patient like this? I’d appreciate any recommendations or pearls that have worked well for you.
Ok so a lot of this is going through the motions so it looks on paper like I've done all the conservative treatments that any plaintiff's expert would testify that should have been tried before doing the thing that will actually heal the patient. You start with a surgical shoe or a diabetic shoe. Next, you get some white plastizote from you preferred vendor, I use
JMS Plastics. No idea what it's actually called, all I know is it's plastizote and it's white. For met head offloading, you cutout a metatarsal pad with a cutout around the are of ulceration. For pts with a severe forefoot varus, you can get something higher durometer like nickelplast, glue it to the forefoot, and mill it so it's a wedge-shaped forefoot post and glue it to the insole or the surgical shoe to achieve some forefoot offloading. If you don't have a orthotics mill, you're not a TFP and you don't belong in this thread.
For a fixative, TFPs have traditionally used
Barge Rubber Cement. This product is a pain in the 🍑. My now retired partner would apply it to a piece of plastizote and cook it for 2 min in a convection oven so it binds to the plastizote and the plastizote becomes more malleable to the shape of the insole before fixating. As a board-certified foot and ankle surgeon, I do not have time for this nonsense, so I use instead
3M Industrial Strength Spray Adhesive to affix my plastizote. I then clamp it to the insert/surgical shoe using a
vice grip. Let it sit for 10 min, see another pt or do some FMLA forms, then come back and check on your work. It's faster and the fumes from the spray adhesive help you forget the life choices you have made that lead up to your use of this therapeutic intervention. Also 3M is a solid company to invest in, they make real products, there's little volatility and they pay nice dividends.
Finally, @dtrack22 commented that Medicare should stop paying for shoes altogether and focus on custom molded insoles. To that, I wanted to respond with some reimbursement info. I randomly selected a patient from earlier this year and here's the EOB info. Not Medicare but the fee schedule is close.
For a diabetic shoe (not custom molded) A5500, I get $80 per shoe, so $160 total. Anodyne charged us $66 for the shoes
For the custom molded insoles A5513, I got $48 per insole or $145 total for 3 of them. Anodyne charged us $48. Normally we would bill for 6 inserts since it's 3 pair per foot, but this pt was s/p TMA so instead we got...
an amputation filler L5000 which reimbursed $542.58. Anodyne charged us $159 for that.
So it's $575 profit and we rinse and repeat annually for this patient. If we billed only the inserts and not the shoes, the profit margin actually improves. But let's be real, patients don't give a damn about the inserts, they just want the free shoes. So if you ban the shoes then patients lose all interest in this therapeutic modality. I don't know/care what the solution is. As I've written before, the powers that be want pts to be in these shoes, the patients want to have em, the government wants to pay for em, and I get a payout for basically facilitating a retail transaction. I'm adhering to the standard of care and making money in the process so idgaf what else.
Lastly, if you actually want to offload your patients and heal their ulcers, consider MIS floating metatarsal osteotomies. Because this is the TFP thread, I am not qualified to elaborate further.
