TFP Thread

[air bud]

Are you managing it for a patient for 1 month? 3 months? Years?

Month. Follow-up 3 to 4 weeks after initial prescription. Titrate if necessary. PCP refills

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[Adam Smasher]

This is beyond the scope of TFP, but I am a proud diplomate of the board of podiatric MEDICINE so...

I start with Gabapentin 300 TID. Warn patients about drowsiness but most people can tolerate it. Rx lidoderm patches as well, wear them to bed. One or the other is usually enough.

If 300 TID is too much, scale down dose and/or frequency. If it's ineffective, up it to 600 TID. There are no guidelines for dosing Gabapentin and I've had patients with lumbar fusions being dosed with 1g QID, and they live to tell the tale, so I'm not shy about working my way up.

Need to be cautious with Gabapentin in the 70+ age range, since it has been shown to be an independent risk factor for falls, in addition to polypharmacy. To offset this risk, the TFP in me will rx balance braces (that is a joke, don't do that).

When Gabapentin doesn't work at all, Cymbalta 60 mg daily is another option, and it's on-label. It works quite well, too. However, I don't rx Cymbalta if the pt is taking other psychotropics because serotonin syndrome is a helluva lot scarier than anything you think you could do with Gabapentin.

I've tried qutenza, it did nothing for my pts and the logistics of getting it are obnoxious.

I had a rep approach me about referring pts for spinal cord stimulators. Problem is no sane pain medicine specialist will do it on a pt with hga1c over 8, which rules out 90% of my neuropathy pain pts.

I haven't tried B-vitamin complexes much. Anyone have luck with them?

 

[DYK343]

Are you managing it for a patient for 1 month? 3 months? Years?

I start 300mg (100 is BS it does nothing) nightly. I give them 3 month Rx.

I do see these patients back about 1ish month. Tell them its a slow process and not instant relief. If needed I increase dosage to 600mg. 1 morning 1 night.

Ultimately though I punt to PCP for chronic managment. But if they want to continue to see me for it ill collect that 99213 for no effort. But long term its a PCP issue.

 

[Adam Smasher]

Month. Follow-up 3 to 4 weeks after initial prescription. Titrate if necessary. PCP refills

Or, refill their rx during nailcare visits for the easy 99213-25. 🦞👑

 

[DYK343]

I haven't tried B-vitamin complexes much. Anyone have luck with them?

In alcoholic neuropathy yes
Diabetic neuropathy doesnt do much IME

 

[DYK343]

Or, refill their rx during nailcare visits for the easy 99213-25. 🦞👑

I used to hate nails. Still do. Its soul sucking work. I genuinely hate busting crumblies.

I decided to start doing nail care because a lot of my wound patients are medicaide and when I discharged them there was no preventive care available for them. So to tug on my heart strings I decided to do "charity" care 1 half day a week for 0.54 RVU a pop.

Until I realized they are not just 0.54 RVU.

They are 1.3 RVU + 0.54 RVU + callus. And 10 min/5 per hour. Because NO patient only wants to talk about only nails - at least not in my patient demographic.

OK maybe 10-20% are there only for nails.

But yeah they can make the lobster claws click. About to give up half my admin day to add on more nails because I dont wanna do this past 50.

 

[Hybrocure]

What do you guys do for patients who chief complaint is: peripheral neuropathy?

Assuming they bypass the “I don’t treat neuropathy” check when scheduling it’s a recommendation to follow up with their PCP.

Curious wtf the pods who manage neuropathy do when the patient calls you complaining about gabapentin side effects

 

[air bud]

Assuming they bypass the “I don’t treat neuropathy” check when scheduling it’s a recommendation to follow up with their PCP.

Curious wtf the pods who manage neuropathy do when the patient calls you complaining about gabapentin side effects

Don't take it then. It treats symptoms not the disease. We tried. Next.

 

[deleted1162946]

What do you guys think about one screw fixation for MIS? Such as the VOOM bunionplasty…

I’m trying to find the best way to learn MIS. I didn’t get really any training in residency on it besides watching one or two attendings do it. They offer a lab.

 

[Retrograde_Nail]

I used to hate nails. Still do. Its soul sucking work. I genuinely hate busting crumblies.

I decided to start doing nail care because a lot of my wound patients are medicaide and when I discharged them there was no preventive care available for them. So to tug on my heart strings I decided to do "charity" care 1 half day a week for 0.54 RVU a pop.

Until I realized they are not just 0.54 RVU.

They are 1.3 RVU + 0.54 RVU + callus. And 10 min/5 per hour. Because NO patient only wants to talk about only nails - at least not in my patient demographic.

OK maybe 10-20% are there only for nails.

But yeah they can make the lobster claws click. About to give up half my admin day to add on more nails because I dont wanna do this past 50.

This organic nail cycle is a nice idea.

I did the same thing when I was at small community hospital at my first job. The community hospital was in an area where podiatry was over saturated. So I needed to keep these patients in our system.

It does start to dominate your schedule over time. So you will have to make a choice at that time.

At my current job which is a trauma center we have a non surgical DPM that I send all my healed wound care patients to for routine foot care needs.

 

[Retrograde_Nail]

What do you guys think about one screw fixation for MIS? Such as the VOOM bunionplasty…

I’m trying to find the best way to learn MIS. I didn’t get really any training in residency on it besides watching one or two attendings do it. They offer a lab.

One screw is enough. Does not matter what company screw it is. As long as its exiting out of the first metatarsal cortex proximally and into the metatarsal head you will be fine. You need that cortical fixation to hold reduction of deformity.

 

[heybrother]

What do you guys think about one screw fixation for MIS? Such as the VOOM bunionplasty…

I’m trying to find the best way to learn MIS. I didn’t get really any training in residency on it besides watching one or two attendings do it. They offer a lab.

First metatarsal single-screw minimally invasive chevron-akin osteotomy: A cost effective and clinically reliable technique - PMC

The common disease hallux valgus results in foot discomfort and dysfunction. Less soft tissue damage and faster wound healing have made minimally invasive surgery (MIS) more popular. However, little research has compared the fixation results of ...

pmc.ncbi.nlm.nih.gov

 

[deleted1162946]

One screw is enough. Does not matter what company screw it is. As long as it’s exiting out of the first metatarsal cortex proximally and into the metatarsal head you will be fine. You need that cortical fixation to hold reduction of deformity.

Any pearls for these? I’ll have to learn more and do labs but proximal to sesamoids, transverse osteotomy, windshield wiper motion…

Have heard the bone cut is the most important/difficult. And then there’s a lot of different ways to hold the alignment when throwing the wire for fixation

 

[air bud]

Any pearls for these? I’ll have to learn more and do labs but proximal to sesamoids, transverse osteotomy, windshield wiper motion…

Have heard the bone cut is the most important/difficult. And then there’s a lot of different ways to hold the alignment when throwing the wire for fixation

Arrhrex is a transverse osteotomy and Stryker is Chevron....they both work

Edit - modified Chevron....make a real one and you will be sorry. Source: trust me bro.

 

[Retrograde_Nail]

Any pearls for these? I’ll have to learn more and do labs but proximal to sesamoids, transverse osteotomy, windshield wiper motion…

Have heard the bone cut is the most important/difficult. And then there’s a lot of different ways to hold the alignment when throwing the wire for fixation

You should do an arthrex or stryker lab before attempting MIS anything.

 

[Adam Smasher]

Schedule an open bunion/cheilectomy but do it with the MIS burr so you can see what you're doing in real time

 

[DYK343]

I have still yet to do a MIS bunionectomy.
Those post op films freak me out.
If that goes to a non union the options for a functional recovery are limited.
R/bunion has some prime examples of MIS gone wrong.

I lapidus everyone still (or MPJ fusion).

 

[heybrother]

Schedule an open bunion/cheilectomy but do it with the MIS burr so you can see what you're doing in real time

My reps kept flaking on the lab, but they let me use the equipment. I had some other cases and I'd add an MIS Akin. Most bunions benefit from it, the impact/injury is low, and it helped build experience for me so that when I did bigger cases I already had more reps.

 

[Retrograde_Nail]

I have still yet to do a MIS bunionectomy.
Those post op films freak me out.
If that goes to a non union the options for a functional recovery are limited.

R/bunion has some prime examples of MIS gone wrong.

I lapidus everyone still (or MPJ fusion).

I disagree with this. I've had a couple early MIS bunions be very slow to fill in. I got them a bone stimulator after 3 months and they went on to heal fine.

If the osteotomy does not heal there are plenty of options to revise such as bone block from the calcaneus and plate.

I've done about 50 MIS bunions in practice so far since I started over a year ago. None have gone to non unions. A few needed a bone stim after 3 months but ultimately healed.

 

[DYK343]

I disagree with this. I've had a couple early MIS bunions be very slow to fill in. I got them a bone stimulator after 3 months and they went on to heal fine.

If the osteotomy does not heal there are plenty of options to revise such as bone block from the calcaneus and plate.

I've done about 50 MIS bunions in practice so far since I started over a year ago. None have gone to non unions. A few needed a bone stim after 3 months but ultimately healed.

Im not saying theyre not good procedures.
They just freak me out.
I edited/posted a link to the above comment from R/bunion.
One example shouldnt stear me away from them. But they still freak me out.

Are you able to frontal plane correct the 1st met head during the procedure? Thats the biggest game changer for bunions and it seems to be going out of favor for these MIS bunions. I did the stryker MIS lab and like airbud says they want a modified austin osteotomy. So couldnt rotate head - not that you couldnt just do a straight transverse cut and try to rotate.

 

[air bud]

I have still yet to do a MIS bunionectomy.
Those post op films freak me out.
If that goes to a non union the options for a functional recovery are limited.
R/bunion has some prime examples of MIS gone wrong.

I lapidus everyone still (or MPJ fusion).

But it works. Trust the process. Enough people are doing it. It's just like lapidus and early WB. We were all trained 6 weeks NWB. Immediate Heel WB or 2 weeks holy crap that's crazy I would never ....then more and more people do it and have good outcomes ...so just trust that it works.

 

[heybrother]

I have still yet to do a MIS bunionectomy.
Those post op films freak me out.
If that goes to a non union the options for a functional recovery are limited.
R/bunion has some prime examples of MIS gone wrong.

I lapidus everyone still (or MPJ fusion).

You could write a bunion pathology disasters textbook out of what's going on over at reddit bunions. Even lapidus looks like a disaster over there.

 

[air bud]

I have still yet to do a MIS bunionectomy.
Those post op films freak me out.
If that goes to a non union the options for a functional recovery are limited.
R/bunion has some prime examples of MIS gone wrong.

I lapidus everyone still (or MPJ fusion).

This was literally the most extreme deformity have ever seen...this post doesn't show preops, another post does. And no fixation. Even a lapidus alone probably didn't fix that. Surgeon error. Bad example.

 

[air bud]

You could write a bunion pathology disasters textbook out of what's going on over at reddit bunions. Even lapidus looks like a disaster over there.

Yes. Lot of terrible surgeons out there. Ortho and Podiatry. But remember, every patient thinks their surgeon is the best. Use that to your advantage when things go wrong.

 

[josebiwasabi]

in my region, no one does the modified chevron cut. everyone just does a straight transverse cut, whether it's with arthrex or stryker. i also do an MIS akin 90+% of the time. haven't regretted doing it on a patient yet.

 

[DYK343]

Also something I always questioned - at about 40 seconds into the stryker animated technique guide there is considerable torque on the1st tarsal metatarsal joint. I know this is an animation and real life wont be quite that much. But curious if this will lead to degenerative changes of this joint in years to come.

 

[DYK343]

This was literally the most extreme deformity have ever seen...this post doesn't show preops, another post does. And no fixation. Even a lapidus alone probably didn't fix that. Surgeon error. Bad example.

Yeah it is extreme preop films. I agree. But lapidus would have been the choice. Especially with the 2nd/3rd stress fractures that are either chronic or new since post op. Regardless that ray needs more stability that MIS cant offer.

 

[Retrograde_Nail]

Also something I always questioned - at about 40 seconds into the stryker animated technique guide there is considerable torque on the1st tarsal metatarsal joint. I know this is an animation and real life wont be quite that much. But curious if this will lead to degenerative changes of this joint in years to come.

I always do a straight cut for my osteotomy.

Sometimes the 1st TMT joint will sublux but in my opinion this locks the first ray and decreases hypermobility. Time will tell if this leads to early arthritis of the 1st TMT joint.

 

[air bud]

in my region, no one does the modified chevron cut. everyone just does a straight transverse cut, whether it's with arthrex or stryker. i also do an MIS akin 90+% of the time. haven't regretted doing it on a patient yet.

I hate akins. Because I suck at them. Do less than 5 percent of time. Seriously. Agree with the saying nobody regrets doing an akin, but you regret not doing one. That being said....when that code goes away eventually....will people still do them? Or is just an easy couple RVUs?

Haven't had any problems with modified Chevron. It rotates and reduces. And really doesn't require holding and preventing sagittal subluxation. One less thing to worry about

Also when Treace comes out with there jig this summer it's going to be awesome. Anyone done the Paragon jig? Going to be switching to pretty much all Paragon/Zimmer when that goes through.

 

[DYK343]

I hate akins. Because I suck at them. Do less than 5 percent of time. Seriously. Agree with the saying nobody regrets doing an akin, but you regret not doing one. That being said....when that code goes away eventually....will people still do them? Or is just an easy couple RVUs?

Haven't had any problems with modified Chevron. It rotates and reduces. And really doesn't require holding and preventing sagittal subluxation. One less thing to worry about

Also when Treace comes out with there jig this summer it's going to be awesome. Anyone done the Paragon jig? Going to be switching to pretty much all Paragon/Zimmer when that goes through.

Wait I though at the billing/coding course they said Akin wasnt being reimbursed with 1st TMT fusion anymore?
Maybe I misunderstood them.

 

[deleted1162946]

But it works. Trust the process. Enough people are doing it. It's just like lapidus and early WB. We were all trained 6 weeks NWB. Immediate Heel WB or 2 weeks holy crap that's crazy I would never ....then more and more people do it and have good outcomes ...so just trust that it works.

This is the main reason I want to switch to doing more MIS. Keeping my lapidus NWB for 5-6 weeks makes so many people just not surgical candidates

 

[shadesofgrey]

Have pretty much made the switch to all MIS bunions. The learning curve was steeper than I expected but I'm not happy with them. My main struggle wasn't the osteotomy, but guide wire placement, as it tended to skive distally down the shaft or be to plantar/dorsal. I also found it somewhat challenging to be aggressive enough with the burr when removing the shelf at the distal met osteotomy site or medial eminence. Kept worrying what I was doing to the soft tissue with the burr.

I do think in some ways MIS has been more forgiving in complications for me. Most people bounce back pretty quick. The joint motion is maintained. They are back to ambulating faster. Less worry about incisions. In my experience, it always heals (knock on wood). I've done a number on smokers, and I brought them back for xrays like 6-12 months later just to make sure the osteotomy healed. Yes, it takes a long time to not look at the xrays and grimace.

If you are gonna do them without any residency training, I would do a few labs and then be prepared for your first several cases to suck and take way longer than you expected.

 

[josebiwasabi]

My first few MIS bunions I only booked 2 other cases and had my bunion scheduled last. This way I had from noon until however long it took me to do it. Thankfully they went smoothly but if you talk to people it can take up to 3 hours trying to troubleshoot etc. You don't want the stress of having another patient waiting or dealing with intraop complications at 4pm as the surgery center is trying to close down for the day.

 

[Retrograde_Nail]

Have pretty much made the switch to all MIS bunions. The learning curve was steeper than I expected but I'm not happy with them. My main struggle wasn't the osteotomy, but guide wire placement, as it tended to skive distally down the shaft or be to plantar/dorsal. I also found it somewhat challenging to be aggressive enough with the burr when removing the shelf at the distal met osteotomy site or medial eminence. Kept worrying what I was doing to the soft tissue with the burr.

I do think in some ways MIS has been more forgiving in complications for me. Most people bounce back pretty quick. The joint motion is maintained. They are back to ambulating faster. Less worry about incisions. In my experience, it always heals (knock on wood). I've done a number on smokers, and I brought them back for xrays like 6-12 months later just to make sure the osteotomy healed. Yes, it takes a long time to not look at the xrays and grimace.

If you are gonna do them without any residency training, I would do a few labs and then be prepared for your first several cases to suck and take way longer than you expected.

Use threaded wires instead of smooth to decrease skiving.

For the shelf throw a wire through it, drill it, then use the burr to finish it off. Pull the shelf out from one of your previously made stab incisions.

 

[Feli]

I have no problem with the MIS bunions from a simplicity standpoint, but it's just a base wedge once it's healed... that's all it is.
(a base wedge that did major devascularization to the first met medullary canal).
The short term results, recover, low complications in skill hands, etc are fine... but long term may or may not be such.

We've been through timespans when pods did a lot of met osteotomies (base wedge, Austins, Scarf and other randomness).
We know how that story ends. We know met osteotomies have their issues. The indications are more narrow now.
I do tons of revision bunionectomy surgery, and most of us do... for Austin recur, proximal osteotomy recur, McBride recur, Austin OA, whatever.

The revision/salvage mostly end up needing fusions later (MPJ usually - or Lapidus if severely under-corrected). Not fun when they're older.
The MIS bunionectomy will almost all have recurrence, and they'll need MPJ fusion.. and the MIS really destroyed the medullarry canal of the first met. The hardware is also absolutely in the way for revision/salvage. So, the revision of MIS stuff people do today is going to be fairly ugly and complicated. That is my main concern. Time will tell.

Where I'm at, and where I have been at, is that probably half my bunions are Lapidus (any reasonably young/active/flexible person),
about a third are MPJ fusion (revision/salvage, DJD first MPJ, etc)...
and that remaining 1/6 or so of bunions are other type (Austin or other met osteotomy, McBride, Valente, etc)
The MPJ fusions and other type are usually salvages of recur bunions and fail implants and etc for very old and minimally active ppl. Lapidus aren't hard once trained/exp, and they don't have a long recovery with lock plates. Lapidus do have their issues (mostly just HWR), but the met osteotomies just don't hold up well in time. We know this.

 

[air bud]

This is the main reason I want to switch to doing more MIS. Keeping my lapidus NWB for 5-6 weeks makes so many people just not surgical candidates

Right but what I'm saying is now everybody walks them in 1 to 3 weeks. Fixation is better obviously if you use a jig it compresses better. My wife started walking on her lapiduals.about week after surgery and had a great outcome. And that was just a plate and screw construct. Young healthy people the days of 5 to 6 weeks non-weight bearing is over. And again that's what I'm saying that's what you were taught but once you get out and you start talking to other people and you realize how many people are walking early and having good outcomes it's fine to do. Just trust the process.

Edit - if you want to use a two screw construct and save the hospital money and be an old school, old man like Feli... Then stick to five or six weeks non-weight bearing. If you want to be one of the cool kids and do a lapiplasty.... Pretty much immediate weight-bearing.

 

[air bud]

I have no problem with the MIS bunions from a simplicity standpoint, but it's just a base wedge once it's healed... that's all it is.
(a base wedge that did major devascularization to the first met medullary canal).
The short term results, recover, low complications in skill hands, etc are fine... but long term may or may not be such.

We've been through timespans when pods did a lot of met osteotomies (base wedge, Austins, Scarf and other randomness).
We know how that story ends. We know met osteotomies have their issues. The indications are more narrow now.
I do tons of revision bunionectomy surgery, and most of us do... for Austin recur, proximal osteotomy recur, McBride recur, Austin OA, whatever.

The revision/salvage mostly end up needing fusions later (MPJ or Lapidus if severely undercorrected). Not fun when they're older.
The MIS bunionectomy will almost all have recurrence, and they'll need MPJ fusion.. and the MIS really destroyed the medullarry canal of the first met. The hardware is also absolutely in the way for revision/salvage. So, the revision of MIS stuff people do today is going to be fairly ugly and complicated. That is my main concern. Time will tell.

Where I'm at, and where I have been at, is that probably half my bunions are Lapidus (any reasonably young/active/flexible person),
about a third are MPJ fusion (revision/salvage, DJD first MPJ, etc)...
and that remaining 1/6 or so of bunions are other type (Austin or other met osteotomy, McBride, Valente, etc)
The MPJ fusions and other type are usually salvages of recur bunions and fail implants and etc for very old and minimally active ppl. Lapidus aren't hard once trained/exp, and they don't have a long recovery with lock plates. Lapidus do have their issues (mostly just HWR), but the met osteotomies just don't hold up well in time. We know this.

Agree on some. This is why right now I say wife gets a lapidus....mom gets an MIS. I do MIS for 60 plus. 50 to 60 depends on activity level....younger gets lapidus always

 

[Flip-flop-flerpity]

I have done 100+ MIS bunions with maybe 3 or 4 delayed unions. I've noticed that the arthrex system is really gaining popularity in my region, but for some reason doesn't seem to develop the robust lateral regenerate that other systems do? I've never used it. I had a patient come in last week for second opinion, they had the arthrex mis procedure 4 years ago, thought that the screws were irritating so went back to original dpm and had screws removed. Came to see me for 2nd opinion for post op pain amd swelling. Wafter thin regenerate bone from a greater than 100% shift. Turns out the screws were the only thing keeping it stable, fractured right through it with normal walking. Anyways..

 

[air bud]

I have done 100+ MIS bunions with maybe 3 or 4 delayed unions. I've noticed that the arthrex system is really gaining popularity in my region, but for some reason doesn't seem to develop the robust lateral regenerate that other systems do? I've never used it. I had a patient come in last week for second opinion, they had the arthrex mis procedure 4 years ago, thought that the screws were irritating so went back to original dpm and had screws removed. Came to see me for 2nd opinion for post op pain amd swelling. Wafter thin regenerate bone from a greater than 100% shift. Turns out the screws were the only thing keeping it stable, fractured right through it with normal walking. Anyways..

Oh the complications and long term consequences are coming....but this is not Cartiva. Nobody is going to get sued for doing an MIS bunion. If in doubt, lapidus. I disagree with everyone specifically young people getting MIS. Also, if you need good solid bone healing (any osteotomy/arthrodesis) other than hammer toes, EVERY patient should be on 6 weeks 50k units VD3. Ideally for 3-4 weeks prior to surgery but no evidence to support that. If any concerns, just add lab to pre-op workup. NEVER assume a patient has good bone and will heal. As far as I am concerned, vitamin D is just as important as not smoking. Yeah don't operate on smokers electively .

 

[air bud]

I have done 100+ MIS bunions with maybe 3 or 4 delayed unions. I've noticed that the arthrex system is really gaining popularity in my region, but for some reason doesn't seem to develop the robust lateral regenerate that other systems do? I've never used it. I had a patient come in last week for second opinion, they had the arthrex mis procedure 4 years ago, thought that the screws were irritating so went back to original dpm and had screws removed. Came to see me for 2nd opinion for post op pain amd swelling. Wafter thin regenerate bone from a greater than 100% shift. Turns out the screws were the only thing keeping it stable, fractured right through it with normal walking. Anyways..

What have you used? Stryker? Novastep? Anything you like dislike.

 

[Weirdy]

Agree with 2 weeks soaking too much.
1 week enough

what if nail fungus? Check for 90 day course? Or no ?

From what ive read (last 5ish years) ask if known liver problems. If none Rx without checking.

I still check once. But thats because of JDs in this world and the standard of care in my area with PCPs (actually they still checking at about 30 days in).

If mildly high I do pulse dose. 1 tab a day for 7 days. Stop for 21. Repeat for 6 monts (42 tabs). Results are the same as a traditional 90 day course.

Practice management I should see them back at a month to check LFT/advise but thats lame and I dont like to keep people out of work for my pocket book.

Derm guy I know did the same with pulse dosing.

The local PCPs looked at me like I was insane when I said LFT + 90 days straight if cleared.
They do 30 days straight max, recheck LFTs monthly.
This was the answer for both new grad and 15+ year doc.

Made me question things but had never had issues doing LFT + 90 day script + back in 3mo during residency.

 

[heybrother]

Agree with 2 weeks soaking too much.
1 week enough

Derm guy I know did the same with pulse dosing.

The local PCPs looked at me like I was insane when I said LFT + 90 days straight if cleared.
They do 30 days straight max, recheck LFTs monthly.
This was the answer for both new grad and 15+ year doc.

Made me question things but had never had issues doing LFT + 90 day script + back in 3mo during residency.

https://jamanetwork.com/journals/jamadermatology/fullarticle/2707781#google_vignette

 

[Flip-flop-flerpity]

What have you used? Stryker? Novastep? Anything you like dislike.

Both Novastep and Synthes. I like the intramedulary stems, super stable, they just feel rock solid when you put them in. Always weight bear same day, nice robust lateral regerate bone if you leave lateral periosteum intact.

 

[Hybrocure]

Please keep MIS surgery out of the TFP thread. Thank you. Only Austin’s here.

 

[Hybrocure]

Agree on some. This is why right now I say wife gets a lapidus....mom gets an MIS. I do MIS for 60 plus. 50 to 60 depends on activity level....younger gets lapidus always

I will never recommend foot surgery to my family

 

[Feli]

https://jamanetwork.com/journals/jamadermatology/fullarticle/2707781#google_vignette

Yes.
I had to repeatedly print that for pharmacists at IHS (they'd try to refuse to give the 2nd and 3rd 30d supply of PO terb without more labs).
I'd highlight the "...Routine interval laboratory test result monitoring appears to be unnecessary in healthy adults and children taking oral terbinafine or griseofulvin for dermatophyte infections..." and the "...Abandoning frequent laboratory monitoring can decrease unnecessary health care spending, decrease patient psychological angst associated with blood draws, and allow for expanded use of these effective oral medications..."

It's crazy how many ppl cling onto the old ways.
I have had a ton of ppl whose terbinafine 90d course was truncated in the middle by PCPs due to repeated LFTs that never should've been ordered.

...Ask the right questions.
Give them topical onycho tx as foundation and to continue after (I just do generic crm).
For people with p450 meds or just a lot of meds, ppl with liver hx, drinkers, simply tell them PO is not for them.
Run the LFTs on anyone before the 90d PO course. (if high for no apparent reason, they can hydrate and try again if desired)
Only run more LFTs (and d/c the PO therapy) if there is a side effect. (this will be about 0.00x% assuming proper screening)

 

[Adam Smasher]

Please keep MIS surgery out of the TFP thread. Thank you. Only Austin’s here.

On a different TFP issue, Bako's Kera-42 is absolutely legit and sells easy

 

[Feli]

Oh the complications and long term consequences are coming....

Probably the best place to predict all of the MIS long term complications would be Chicago? (tons of Scarf proc with long term f/u now)

Both procedures effectively make the first met from straight to a boomerang.
Both fail to address the 1MC instability that causes the HAV deformity.
Both have cut and scarred up the first met bone marrow canal (but MIS much moreso).

I see failed Austins (recur, OA at first MPJ, or both... sometimes sub 2nd pain) the most often where I'm at now - and where I've been prior since residency.

What do ppl in/near Chicago do for the fail Scarf? What are the main issues?
Mostly recur and DJD first MPJ? Most salvages are hwr and first MPJ fusion?
...maybe lesser Weil(s) if the first ray was shortened? (they probably already got those if it's Chicago? 🙂 )

 

[air bud]

On a different TFP issue, Bako's Kera-42 is absolutely legit and sells easy

What is that? I am an orthoplastic reconstructive foot and ankle surgeon. The skin is just for covering bones which I must operate on. I don't know all these skin products you talk about.

 

[air bud]

Back to TFPs and nail fungus ...anyone have any literature for kids. Have a 3 year old. Yes 3 with fungus. Is there a peds dose of lamisil?