Updates in Wound Wizardry

[Adam Smasher]

First I did search the forum, couldn't find a recent a thread on this topic, didn't feel like bumping threads from 2022.

In recent months I've been contacted by reps from different companies about the newest latest greatest amniotic/chorionic membrane grafts. The conversations have been light on science and heavy on finance. Apparently these new super-products are extra good, cost $$$ but reimburse $$$$, with profit margins to the tune of $400 per sq cm. I suspect this is a response to the new rules on cellular tissue products, if you can't apply 12 in a row, get the most profit you can applying 4. The graft grift continues on.

What we need is a product that is about the thickness and durometer of plastizote that can be applied to the insole of the shoe and not the wound, and still get reimbursed $$$$. Until then, I hope not to need these new products, but, as the song goes, there ain't no rest for the wicked

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[HardRoadPaved]

The conversations have been light on science and heavy on finance.

Literally have reps coming in the office and just talk money without even saying what the product does or how its better than competitors. I figured a dog fight would ensue with those that can offer cheaper acquisition that will win.

 

[Hybrocure]

I don’t know why anyone bothers with them anymore with how much trouble docs are getting into for using them

 

[heybrother]

I was offered a graft the other day for in the office. Comes in 2x3 and 3x4. Cost is $780 per cm^2. reimbursement is $1200 per cm^2.

They didn't tell me what my kickback would be 😉🤣

Hopefully I can share a cell with those NPs in Arizona who defrauded Medicare out of $900 million so I can learn a thing or 2.

 

[Weirdy]

Used a lot in residency when indicated.
Stagnant wound not healing even after proper vascular workup etc.
Grafts would get them healed in conjunction with offloading soft tissue procedures.

Rotating with group outpatient offices only saw about 25% or less of the wound care volume being done and even less with grafts.

Unsure how they impact bottom line in outpatient setting outside of residency.

 

[Podstar]

Never used much of these in residency. The only grafts I ever really used was Integra bilayer or Dermacell to help granulate over medullary bone/tendon for guillotine TMAs etc and these actually work well for this in combination with bolster dressing or wound vac. Otherwise it was tried and true good debridement/source control, surgically offloading, NWB to area, and STSG/wound vac if needed. Keep it simple stupid for wound care is the best way unless they need a flap or something then do the above and send them over to plastics.

 

[Hybrocure]

Used a lot in residency when indicated.
Stagnant wound not healing even after proper vascular workup etc.
Grafts would get them healed in conjunction with offloading soft tissue procedures.

Rotating with group outpatient offices only saw about 25% or less of the wound care volume being done and even less with grafts.

Unsure how they impact bottom line in outpatient setting outside of residency.

Outpatient has more to do with cost. It’s easier to place them in a hospital type setting

 

[Feli]

Refer wounds that are not straightforward to local wound center and/or hospital DPM.
It's not a skill thing... wounds are easy AF. It should simply be a preference and resources thing. Anything that is not reasonable to heal in a month goes bye-bye. Cite staffing or space or whatever. Just get the ulcers of Charcot, obese, poorly controlled DM, too many comorbid to heal well, etc referred out.

Now that is the way to handle wounds. ^^
Heavy wound care is for VAs, hospital WCC, residency, hospital DPMs with RVU and required call. Let them have it all.
I feel bad that most WCC wizards will just do bogus "graft$" and HBO and fancy dressing$, but those be the breaks. Can't save the world.

...For PP, unless you are doing it basically to scam the graft $ or you don't have any better appointment demand early on, wound care is just not a good thing. Fix or amp what basic wounds as you can with DME/debride/surg, but trying to do a lot of wound care or encourage wound refers can absolutely destroy an otherwise good PP office, staff, and schedule.

There are way too many podiatrists nearly anywhere... let others clog their schedule with wounds. There are exceptions, but in general, it'll be the bottom feeder PPs in any area that do a whole lot of wound and inpt stuff (and the hospital DPMs, who have no choice). One of the best things of PP (unless bottom of totem pole associate DPM) is that you can choose your refer strategies... so why encourage any high number of wounds? Yes, wounds are easy, but basically nobody thinks it's enjoyable (hence MDs/orthos happy to have DPMs do it). Seriously... life is short. Wound care is nearly as bad as nursing home podiatry. Build your patient and refer base how you want.

• Appointments that have MCA and take an hour = bad.
• MRSA, Escherichia, etc in the office on a regular basis = bad to da bone (sometimes literally).
• Exam chairs creaking under pt weight or lymphedema drainage on the chair = bad.
• Frequent outpt wounds turning into inpts and ER calls and early/late/weekend work or surgery = very bad.
• TCCs or greenish bandages overflowing the garbage cans = bad.
• Wide wheelchairs running over the sandal of athletes and working ppl in the wait room = mucho bad.
• Good staff (including the doc) starting to hate their job due to pus bus = quite bad.
• ...More appointments for people who will get better and have good payers for ingrown, bunion, verruca, ankle sprain, etc = goooood.

 

[Hybrocure]

Refer wounds that are not straightforward to local wound center and/or hospital DPM.
It's not a skill thing... wounds are easy AF. It should simply be a preference and resources thing. Anything that is not reasonable to heal in a month goes bye-bye. Cite staffing or space or whatever. Just get the ulcers of Charcot, obese, poorly controlled DM, too many comorbid to heal well, etc referred out.

Now that is the way to handle wounds. ^^
Heavy wound care is for VAs, hospital WCC, residency, hospital DPMs with required call. Let them have it all.
I feel bad that most WCC wizards will just do bogus "graft$" and HBO and fancy dressing$, but those be the breaks. Can't save the world.

...For PP, unless you are doing it basically to scam the graft $ or you don't have any better appointment demand early on, wound care is just not a good thing. Fix or amp what basic wounds as you can with DME/debride/surg, but trying to do a lot of wound care or encourage wound refers can absolutely destroy an otherwise good PP office, staff, and schedule.

There are way too many podiatrists nearly anywhere... let others clog their schedule with wounds. There are exceptions, but in general, it'll be the bottom feeder PPs in any area that do a whole lot of wound and inpt stuff (and the hospital DPMs, who have no choice). One of the best things of PP (unless bottom of totem pole associate DPM) is that you can choose your refer strategies... so why encourage any high number of wounds? Yes, wounds are easy, but basically nobody thinks it's enjoyable (hence MDs/orthos happy to have DPMs do it). Seriously... life is short. Wound care is nearly as bad as nursing home podiatry. Build your patient and refer base how you want.

Appointments that have MCA and take an hour = bad.
MRSA, Escherichia, etc in the office on a regular basis = bad to da bone (sometimes literally).
Exam chairs creaking under pt weight or and lymphedema drainage on the chair = bad.
Frequent outpt wounds turning into inpts and ER calls and early/late/weekend work or surgery = very bad.
TCCs or greenish bandages overflowing the garbage cans = bad.
Wide wheelchairs running over the sandal of athletes and working ppl in the wait room = mucho bad.
Good staff (including the doc) starting to hate their job due to pus bus = quite bad.
...More appointments for people who will get better and have good payers for ingrown, bunion, verruca, ankle sprain, etc = goooood.

Ingrowns, verrucas and ankle sprains pay well. This post absolutely rules and is true.

But bunions in private practice (ethically)? It has to be one of the least paying biggest headaches for a 90 day global

 

[Feli]

Ingrowns, verrucas and ankle sprains pay well. This post absolutely rules and is true.

But bunions in private practice (ethically)? It has to be one of the least paying biggest headaches for a 90 day global



View attachment 388825

I dunno... think big picture:

99203 + bunion pad
99213+ insoles
99214 (decision for surg) + L4361
2829x bunion + Weil + lessers + Akin or whatever is indic (not gonna get into coding Lapidus or etc)
[1wk, 2wk sutures, 1mo, 2mo... by 3.5mo or 4mo, you're getting paid again]
***PCP happy, maybe PT happy if you sent for ROM/adhesions, hospital OR/admins happy, pt happy... talks you up to fam/friend/neighbors/etc, get more refers from all of them, pt may return for HWR or other foot sx or orthotic or other F&A issues***

Bunions might not be as bad as one thinks... but it does take customer service and efficienty.
I would say wounds actually make docs lazy (easy, outcomes don't matter much, pt are mostly on govt insurances, many unemployed).
Bunions make you sharper (pt expectations, often private insurance pts working age, pt has many other options for surgeon).
...I'll trade ya all your bunions for all my wounds? 🙂

 

[Hybrocure]

I dunno... think big picture:

99203 + bunion pad
99213+ insoles
99214 (decision for surg) + L4361
2829x bunion + Weil + lessers + Akin or whatever is indic (not gonna get into coding Lapidus or etc)
[1wk, 2wk sutures, 1mo, 2mo... by 3.5mo or 4mo, you're getting paid again]
***PCP happy, maybe PT happy if you sent for ROM/adhesions, hospital OR/admins happy, pt happy... talks you up to fam/friend/neighbors/etc, get more refers from all of them, pt may return for HWR or other foot sx or orthotic or other F&A issues***

Bunions might not be as bad as one thinks... I'll trade ya all your bunions for all my wounds? 🙂

I will trade you my bunions for your wounds

As long as they’re distal to the mtpj 😜

 

[heybrother]

I've recently had a bunch of old, fat, diabetic, neuropathic, fibromyalgia patients with substantial metatarsus adductus come in. Like not a cm of correction of 1-2 IM space available. If anyone wants to do adductoplasty on them - please reach out and I will refer to you. Thank you.

 

[Hybrocure]

I've recently had a bunch of old, fat, diabetic, neuropathic, fibromyalgia patients with substantial metatarsus adductus come in. Like not a cm of correction of 1-2 IM space available. If anyone wants to do adductoplasty on them - please reach out and I will refer to you. Thank you.

Plenty of new grads looking for those ABFAS numbers I’m sure…

 

[Forcewielder]

I've recently had a bunch of old, fat, diabetic, neuropathic, fibromyalgia patients with substantial metatarsus adductus come in. Like not a cm of correction of 1-2 IM space available. If anyone wants to do adductoplasty on them - please reach out and I will refer to you. Thank you.

Haha I went to a Treace workshop and Mindi Dayton was presenting. She showed an xray of a bad MA + HAV patient and asked what we typically do with that in our clinics now and I shouted "Refer". She happily replied she'd take them haha they can have them. I have no desire to get into that.

 

[PMG03470]

Refer wounds that are not straightforward to local wound center and/or hospital DPM.
It's not a skill thing... wounds are easy AF. It should simply be a preference and resources thing. Anything that is not reasonable to heal in a month goes bye-bye. Cite staffing or space or whatever. Just get the ulcers of Charcot, obese, poorly controlled DM, too many comorbid to heal well, etc referred out.

Now that is the way to handle wounds. ^^
Heavy wound care is for VAs, hospital WCC, residency, hospital DPMs with RVU and required call. Let them have it all.
I feel bad that most WCC wizards will just do bogus "graft$" and HBO and fancy dressing$, but those be the breaks. Can't save the world.

...For PP, unless you are doing it basically to scam the graft $ or you don't have any better appointment demand early on, wound care is just not a good thing. Fix or amp what basic wounds as you can with DME/debride/surg, but trying to do a lot of wound care or encourage wound refers can absolutely destroy an otherwise good PP office, staff, and schedule.

There are way too many podiatrists nearly anywhere... let others clog their schedule with wounds. There are exceptions, but in general, it'll be the bottom feeder PPs in any area that do a whole lot of wound and inpt stuff (and the hospital DPMs, who have no choice). One of the best things of PP (unless bottom of totem pole associate DPM) is that you can choose your refer strategies... so why encourage any high number of wounds? Yes, wounds are easy, but basically nobody thinks it's enjoyable (hence MDs/orthos happy to have DPMs do it). Seriously... life is short. Wound care is nearly as bad as nursing home podiatry. Build your patient and refer base how you want.

Appointments that have MCA and take an hour = bad.
MRSA, Escherichia, etc in the office on a regular basis = bad to da bone (sometimes literally).
Exam chairs creaking under pt weight or lymphedema drainage on the chair = bad.
Frequent outpt wounds turning into inpts and ER calls and early/late/weekend work or surgery = very bad.
TCCs or greenish bandages overflowing the garbage cans = bad.
Wide wheelchairs running over the sandal of athletes and working ppl in the wait room = mucho bad.
Good staff (including the doc) starting to hate their job due to pus bus = quite bad.
...More appointments for people who will get better and have good payers for ingrown, bunion, verruca, ankle sprain, etc = goooood.

I somewhat disagree with this. In my area at least wound debridements pay pretty well. I don’t do any shady grafting stuff. I can get every wound patient in and out in 15mins or less. I will do serial debridements for 3 months every 1-2 weeks. If not healed by then or not improving will take to OR for exostectomy/tendon lengthening or transfer etc. The only patients I refer to wound care center are those with the knee to ankle venous stasis wounds. I make good money with wound care and I do not feel that it bogs down my schedule. All the docs in my practice rotate call, so of course some end up inpatient, but the burden is even spread. Once you heal the wound you have a patient for life and they tend to refer a lot of other patients (not just obese diabetics etc). Plus it impresses PCPs if you do good wound care and they now refer me everything. Idk I just disagree with this take on wound care.

 

[Feli]

I somewhat disagree with this. In my area at least wound debridements pay pretty well. I don’t do any shady grafting stuff. I can get every wound patient in and out in 15mins or less. ...

Wound care is fine... it pays the bills.

Early after residency, you are still used to wounds and hospital work and don't realize the costs. Once you are a bit further out of training, you typically wont want as much of it (all DPMs will inevitably have to do some wounds). It takes fairly significant staff and supplies and autoclave resources. The wound patients will typically get your schedule derailed with new issues, add-on appointments, infection or needing hospitalization, positioning and body habitus needs, etc.

If you get every wound patient in n out 15mins, you're light years ahead of any setup I've ever worked.

... Once you heal the wound you have a patient for life ...

Yes, but that's not a good thing.
Re-ulcer rates are high, even with good DME and care.

At this stage in the game, I'd rather have RFC patients than wounds... because RFC won't get infected or need surgery that'll ruin a weekend. Truthfully, though, you don't want to encourage referrals for either wounds or RFC (the main reasons podiatry exists). There is good reason MD/DO happily give that stuff up to DPMs or nurses.

For pod PP (income and just job quality), the top choice imo is always new patients for sports or derm or ortho stuff... things you can do some proc, maybe DME, possibly elective surgery, get healed, and get more new patient slots again. And, of course, those will get you more of same... "like refers like."

 

[PMG03470]

Wound care is fine... it pays the bills.

Early after residency, you are still used to wounds and hospital work and don't realize the costs. Once you are a bit further out of training, you typically wont want as much of it (all DPMs will inevitably have to do some wounds). It takes fairly significant staff and supplies and autoclave resources. The wound patients will typically get your schedule derailed with new issues, add-on appointments, infection or needing hospitalization, positioning and body habitus needs, etc.

If you get every wound patient in n out 15mins, you're light years ahead of any setup I've ever worked.


Yes, but that's not a good thing.
Re-ulcer rates are high, even with good DME and care.

At this stage in the game, I'd rather have RFC patients than wounds... because RFC won't get infected or need surgery that'll ruin a weekend. Truthfully, though, you don't want to encourage referrals for either wounds or RFC (the main reasons podiatry exists). There is good reason MD/DO happily give that stuff up to DPMs or nurses.

For pod PP (income and just job quality), the top choice imo is always new patients for sports or derm or ortho stuff... things you can do some proc, maybe DME, possibly elective surgery, get healed, and get more new patient slots again. And, of course, those will get you more of same... "like refers like."

What costs though? In our office costs include instruments (which are used 1000s of times before replaced), scalpel blades, gauze, Neosporin. Everything else the patient needs for wound care at home I order for them at no cost to myself. Yes I am only 3 years out of residency, however I pay extremely close attention to costs etc, secondary to me planning on opening my own practice in the next year or two.

Maybe once a month is there an issue that delays my schedule, all other wounds in and out in 15 mins or less. I have been referred bunion surgery by my wound patients and I have been referred many things (warts, Achilles tendinitis etc. by pcps that got to know me through my wound care patients and result).

But we shall agree to disagree.

 

[Feli]

What costs though? In our office costs include instruments (which are used 1000s of times before replaced), scalpel blades, gauze, Neosporin. Everything else the patient needs for wound care at home I order for them at no cost to myself. Yes I am only 3 years out of residency, however I pay extremely close attention to costs etc, secondary to me planning on opening my own practice in the next year or two.

Maybe once a month is there an issue that delays my schedule, all other wounds in and out in 15 mins or less. I have been referred bunion surgery by my wound patients and I have been referred many things (warts, Achilles tendinitis etc. by pcps that got to know me through my wound care patients and result).

But we shall agree to disagree.

Staff.
Staff is by FAR your biggest cost and training/retention/reliability issue.

If staff has to clean instruments, pack them, autoclave, put away... takes time. Thats also more red bag and sharps disposal costs.

If staff has to wheelchair/obese wound patients to room, transfer help, take their shoes off as they can't reach feet, take off bandages, take them to xray, put shoes back on, heavier room cleaning, garbage fills much faster, staff help them to bathroom, clean bathrooms, etc.... takes much time. That's not to mention possible nightmare of employee back injury or sharps stick or whatever.

...now contrast that with simple PP heel pain or warts or bunion patients who walk in, walk to room or xray, shoes on/off themselves. They probably just get an injection or cash OTC stuff with very minimal staff and supplies. Ingrown nail or flat foot teens don't call to ask office staff to help them in from the parking lot... but wound patients will.

I can virtually guarantee your staff would much prefer fitting a CAM boot or handing you ice spray and kenalog injection... versus taking off unna boot from tree trunk wound leg or lifting obese ppl into wheelchair and helping with comp socks and shoes. They don't love ulcer aroma or pts with poor hygiene any more than you do.

Hospital pod clinics and WCC (should) have a lot of staff for good reasons.. they accordingly charge a ton. Most hospital or wound RNs or Dpm dont like the wound work either, but hey... thats why it pays good. However, you'll have a pretty tough time keeping $20-25/hr office MAs if you make them do appreciabe amounts of crap work. 🙂

 

[Adam Smasher]

I too can handle a diabetic foot ulcer in a 15 min slot. Also putting someone's shoes and compression socks back on isn't hard. I learned how to do it quick from a triathlete who had to put on compression stockings right after swimming. Obviously I don't want to do it but it expedites patient care and takes 30 sec. And it's not like everyone has them.

Venous leg ulcers are a refer out. Unna boots are too much work and pay bad. No matter how good are your unna boots, they'll never be healed once and for all.

I amputate toes occasionally but never at 2am

 

[Retrograde_Nail]

I think the certifications in wound care are completely pointless as limb salvage is a staple in any podiatry residency. I do not understand podiatrists who end up getting some certification and only then consider themselves wound care experts.

Majority of these podiatrists who get wound care certifications can not even put on an ex fix, delta frame, mini rail or do a muscle flap to save their lives. They can't do a charcot recontruction. So if you can't do anything surgical from limb salvage standpoint what the heck are you actually doing????

I think its a dangerous thing this profession continues to do which is sub specialize in an area of the body that is already small to begin with. Sub specialization in wound care does not even need to happen.

The only people who should be getting wound care certs are nurses who never did any kind of residency training program.

Very rarely have I come across an MD general surgeon, internal medicine provider or even old school ER docs who works in these wound care centers that have actually gotten any kind of certification in wound care. Make zero sense. It's just common sense.

 

[Homo sapien]

I think the certifications in wound care are completely pointless as limb salvage is a staple in any podiatry residency. I do not understand podiatrists who end up getting some certification and only then consider themselves wound care experts.

Majority of these podiatrists who get wound care certifications can not even put on an ex fix, delta frame, mini rail or do a muscle flap to save their lives. They can't do a charcot recontruction. So if you can't do anything surgical from limb salvage standpoint what the heck are you actually doing????

I think its a dangerous thing this profession continues to do which is sub specialize in an area of the body that is already small to begin with. Sub specialization in wound care does not even need to happen.

The only people who should be getting wound care certs are nurses who never did any kind of residency training program.

Very rarely have I come across an MD general surgeon, internal medicine provider or even old school ER docs who works in these wound care centers that have actually gotten any kind of certification in wound care. Make zero sense. It's just common sense.

this. we need to just have good residencies that give us all, even the ass end students, quality training in all aspects of foot/ankle care. not this hodgepodge of buggery we have now

 

[Feli]

I think the certifications in wound care are completely pointless as limb salvage is a staple in any podiatry residency. I do not understand podiatrists who end up getting some certification and only then consider themselves wound care experts.

Majority of these podiatrists who get wound care certifications can not even put on an ex fix, delta frame, mini rail or do a muscle flap to save their lives. They can't do a charcot recontruction. So if you can't do anything surgical from limb salvage standpoint what the heck are you actually doing????

I think its a dangerous thing this profession continues to do which is sub specialize in an area of the body that is already small to begin with. Sub specialization in wound care does not even need to happen.

The only people who should be getting wound care certs are nurses who never did any kind of residency training program.

Very rarely have I come across an MD general surgeon, internal medicine provider or even old school ER docs who works in these wound care centers that have actually gotten any kind of certification in wound care. Make zero sense. It's just common sense.

This is 100% correct.
Wound care is easy, but biomech and surgery is needed to do it well. Any podiatrist has plenty of residency exp.

Far too many "wound care" protocols by podiatrists, midlevels, and RNs - even semi-retired MDs - just do debridement q1w and try to push their big ticket items... HBO, grafts, fancy bandages, or topicals that they get incentive or rep lunches for doing. The patients get the wounds bandaged... but typically no real healing. My local wound center (hospital-based) currently employs a couple NPs and a podiatrist who does not even do surgery. It's sad.

 

[AttackNME]

personally I’m glad the skin sub lcds are changing, hopefully they get rid of reimbursing in-office skin subs altogether. Better to spend that insurance premium monies on other things

 

[Adam Smasher]

Majority of these podiatrists who get wound care certifications can not even put on an ex fix, delta frame, mini rail or do a muscle flap to save their lives. They can't do a charcot recontruction. So if you can't do anything surgical from limb salvage standpoint what the heck are you actually doing????

For the benefit of pods like me who graduated from middling residencies, kindly elaborate.

Years ago, when I had loftier hopes for my career, I did an ACFAS course on exfix with Bill Grant. First thing he said was, "take a deep breath, yes you're only a podiatrist but you can still do this." And he was right. The execution was easy. And I know courses on cadavers aren't the real world. But because I don't have residents or PAs to babysit the inevitable complications over the months to follow, I choose not to use external fixators. However, if terrorists from Hamas ever kidnap me and say "apply this ex fix or else," I'd give it a go. So I could probably do it to save my life at the very least, but the terrorists can have the final say on that.

I still treat charcot. A cuboid bumpectomy + custom inserts + plastizote + glue works great. No implants, ambulate after a week if not sooner. Not saying there's not a place for external fixators, but I've been able to accomplish plenty without them.

Which brings me to my second point of inquiry. What kind of myocutaneous flaps are you using? I'm legitimately curious. I learned random flaps (bilobe, rhomboid, v-y) from an integra course. They're great. I always fashion a myocutaneous flap during TMAs, not that I bill it that way. I've read about obscure flaps for calcaneal wounds or 5th met base wounds, never tried em. Anyone who needs anything that complicated is generally so far past the point of no return (double digit hga1c, bad PAD) that bka is the endpoint, if their life expectancy will allow it. But that's just my experience. We want to hear yours.

personally I’m glad the skin sub lcds are changing, hopefully they get rid of reimbursing in-office skin subs altogether. Better to spend that insurance premium monies on other things

The Adam Smasher of 10 years ago would agree with you. But the logical conclusion to your argument is "PP should not be profitable." As a PP guy, I get pennies on the dollar for basic e&m services compared with other providers. Reimbursement for common procedures never keeps up with inflation. While I don't support abusive practices, it's nice to not be shafted on at least on service.

 

[Hybrocure]

I think “low talent” salvage (forefoot amps, wound care, etc) is extremely important.

We do actually do it better than NPs, PAs, and near-retired or nonsurg Gen surgeons who don’t give a care. And we do it broadly as a profession pretty well. We know how to offload and know the biomechanics behind it. And generally, follow the patients closer and care about it more.

I’ve seen my fair share of ex fixes in residency. A lot of the time it was headaches as inpatient, clinic follow ups with pin infections, all the while the patient does not give a **** still and has already mentally accepted a BKA.

There are those few patients who actually can make it work but it’s few and far between. It’s important to have docs who want to do that work but I think it’s absolutely fair for podiatrists to choose not to do it.

I agree the additional cert to do wound care is pointless. We already have the ability to do it without that. And really, the only thing people want from a wound certified podiatrist is whether you’ll take hospital call for wounds

 

[Weirdy]

Which brings me to my second point of inquiry. What kind of myocutaneous flaps are you using? I'm legitimately curious. I learned random flaps (bilobe, rhomboid, v-y) from an integra course. They're great. I always fashion a myocutaneous flap during TMAs, not that I bill it that way. I've read about obscure flaps for calcaneal wounds or 5th met base wounds, never tried em. Anyone who needs anything that complicated is generally so far past the point of no return (double digit hga1c, bad PAD) that bka is the endpoint, if their life expectancy will allow it. But that's just my experience. We want to hear yours.

Look into local intrinsic muscle flaps.
For medial, plantar, lateral, dorsum foot can use abducto hallucis, FDB, Abd Dig Mini, EDB
Proper debride/washout of the deficit. Flap it, primary closure over your flap and donor site, skin substitute over whatever's still showing muscle belly.
Throw ex fix on after to offload site.
Proper vascular work up, mindful of angiosomes, good dissection - easier than you think because all the muscle you need is right there after skin and subcue dissection.

All of the above is a bit different with Charcot changes. Have to fix the inherent structure first.
Kind of hard to do sometimes- patient not healthy enough, uncontrolled a1c, CKD, patient doesn't want to do it or have resources for after care etc. They can't heal the wound, but they're too sick or have socioeconomic stuff going on to have surgery to heal the wound.

Ankle gets a little trickier. PB is useful for lateral deficits. Havn't seen a lot of medial ankle flaps.

Heel is tricky. Have seen plenty of failures once it reaches calc even with aggressive calcanectomy and ex fix to clear infection before skin sub application and local wound care, even flaps can fail those.
Have primary scrubbed reverse sural but it takes a lot of planning, prep, and experience with complications and how to fix them.
Lots of general medicine optimization and even then, those patients are already sick in general.
Also the whole "BKA is possible" at every point of the discussion with patient.

 

[deleted285117]

Wound Center NP/PA when reading the posts about surgical options for wounds:

 

[Feli]

Wound Center NP/PA when reading the posts about surgical options for wounds:

They just want to keep the Medi-Honey and Santyl and Prisma train a blowin... talk of surgery to offload or doing amp to clear the osteomyelitis is witchcraft to most wound APRNs.

 

[air bud]

Feli got hurt by a wound care nurse at some point in his career. Also insoles and bunion pads and whatever else for bunions are a joke just like these grafts. Wound care is surgery. Arthroplasty floating osteotomy gastroc. Again leaning stronger into the idea of amputation prevention. Proactive intervention especially with MIS. Wound care is a reactionary method. First time ulcer in this location? Sure I'll give it 4 to 6 weeks of appropriate immobilization. Surgical shoes are junk everything is a camboot minimum, maybe TCC. Recurrent ulcer? Surgery booked first visit. I do very few isolated toe amps anymore. If I'm amping a toe and there's another toe that is crooked that's getting an arthroplasty. Amputation prevention. We know how this stuff turns out they're going to break down someplace else it's a matter of time reduce 4-ft pressure reduce hammer toes.

Also earlier vascular referral and aggressive use of wound vacs are how you heal these wounds. I haven't needed a graft in the last year and a half. If it needs a graft it needs more aggressive full thickness excision in the OR and then application of Integra bilayer or stravix. Quit trying to turn crappy tissue into good tissue. Cut it all out and start over. Wound vacs are amaZing. Set it and forget it. It gets changed once a week maybe a few times a week once you have good granulation tissue and you can start putting some collagen underneath the black foam.

Like everything in life show me the incentive and I will show you the outcome. That's why these grafts get put on. Because they pay. Not because they work and not because they are the best option. I repeat cut out all the bad stuff and start over again.

 

[deleted1162946]

Feli got hurt by a wound care nurse at some point in his career. Also insoles and bunion pads and whatever else for bunions are a joke just like these grafts. Wound care is surgery. Arthroplasty floating osteotomy gastroc. Again leaning stronger into the idea of amputation prevention. Proactive intervention especially with MIS. Wound care is a reactionary method. First time ulcer in this location? Sure I'll give it 4 to 6 weeks of appropriate immobilization. Surgical shoes are junk everything is a camboot minimum, maybe TCC. Recurrent ulcer? Surgery booked first visit. I do very few isolated toe amps anymore. If I'm amping a toe and there's another toe that is crooked that's getting an arthroplasty. Amputation prevention. We know how this stuff turns out they're going to break down someplace else it's a matter of time reduce 4-ft pressure reduce hammer toes.

Also earlier vascular referral and aggressive use of wound vacs are how you heal these wounds. I haven't needed a graft in the last year and a half. If it needs a graft it needs more aggressive full thickness excision in the OR and then application of Integra bilayer or stravix. Quit trying to turn crappy tissue into good tissue. Cut it all out and start over. Wound vacs are amaZing. Set it and forget it. It gets changed once a week maybe a few times a week once you have good granulation tissue and you can start putting some collagen underneath the black foam.

Like everything in life show me the incentive and I will show you the outcome. That's why these grafts get put on. Because they pay. Not because they work and not because they are the best option. I repeat cut out all the bad stuff and start over again.

Changing a vac once a week?

 

[air bud]

Changing a vac once a week?

Yeah. If no infection and just developing granulation tissue once a week is just fine. MAYBe 2x a week if someone is helping

 

[Feli]

Yeah. If no infection and just developing granulation tissue once a week is just fine. MAYBe 2x a week if someone is helping

I remember those VAC thingeys from residency. 1-2-blue.

 

[deleted1162946]

I remember those VAC thingeys from residency. 1-2-blue.

Pretty standard in my residency training to have home health care change twice a week and then once in office or 3x a week somehow. So I could’ve just left them on longer? damn

 

[air bud]

Pretty standard in my residency training to have home health care change twice a week and then once in office or 3x a week somehow. So I could’ve just left them on longer? damn

Oh yeah. You literally take it off for 5 mins and debride and put back on. If you have appropriately debrided in OR then all it is doing is filling in so once a week. It's not like you are giving the skin under the plastic draping a breather or time to de macerate. Set it and forget it.

 

[air bud]

They just want to keep the Medi-Honey and Santyl and Prisma train a blowin... talk of surgery to offload or doing amp to clear the osteomyelitis is witchcraft to most wound APRNs.

Yeah I have a "conversation" coming up with a wound care team and while I am sure admin likes me talking about all the surgery that could be added, the WC staff may not like the idea of losing these patients and it might backfire on me...

 

[air bud]

Look into local intrinsic muscle flaps.
For medial, plantar, lateral, dorsum foot can use abducto hallucis, FDB, Abd Dig Mini, EDB
Proper debride/washout of the deficit. Flap it, primary closure over your flap and donor site, skin substitute over whatever's still showing muscle belly.
Throw ex fix on after to offload site.
Proper vascular work up, mindful of angiosomes, good dissection - easier than you think because all the muscle you need is right there after skin and subcue dissection.

All of the above is a bit different with Charcot changes. Have to fix the inherent structure first.
Kind of hard to do sometimes- patient not healthy enough, uncontrolled a1c, CKD, patient doesn't want to do it or have resources for after care etc. They can't heal the wound, but they're too sick or have socioeconomic stuff going on to have surgery to heal the wound.

Ankle gets a little trickier. PB is useful for lateral deficits. Havn't seen a lot of medial ankle flaps.

Heel is tricky. Have seen plenty of failures once it reaches calc even with aggressive calcanectomy and ex fix to clear infection before skin sub application and local wound care, even flaps can fail those.
Have primary scrubbed reverse sural but it takes a lot of planning, prep, and experience with complications and how to fix them.
Lots of general medicine optimization and even then, those patients are already sick in general.
Also the whole "BKA is possible" at every point of the discussion with patient.

Sounds like you are an Orthoplastic Foot and ankle surgeon. I didn't so those in my residency, can you please recommend a fellowship I could do to learn those?

 

[Weirdy]

Sounds like you are an Orthoplastic Foot and ankle surgeon. I didn't so those in my residency, can you please recommend a fellowship I could do to learn those?

One year Fellowship in GSKTR techniques (GyattSKibbidiToiletRizz).
Also learned how to SDN powertrip and be as pretentious as possible.

Heard Zgonis is starting a fellowship focused on this stuff in North San Antonio.
Maybe reach out to him.

 

[Adam Smasher]

Good, we need more fellowships.

 

[Retrograde_Nail]

Yeah I have a "conversation" coming up with a wound care team and while I am sure admin likes me talking about all the surgery that could be added, the WC staff may not like the idea of losing these patients and it might backfire on me...

You will take all their patients because you will be doing biomechanical procedures to prevent ulcers from recurring and skin grafting all their non healing wounds.

 

[Retrograde_Nail]

For the benefit of pods like me who graduated from middling residencies, kindly elaborate.

Years ago, when I had loftier hopes for my career, I did an ACFAS course on exfix with Bill Grant. First thing he said was, "take a deep breath, yes you're only a podiatrist but you can still do this." And he was right. The execution was easy. And I know courses on cadavers aren't the real world. But because I don't have residents or PAs to babysit the inevitable complications over the months to follow, I choose not to use external fixators. However, if terrorists from Hamas ever kidnap me and say "apply this ex fix or else," I'd give it a go. So I could probably do it to save my life at the very least, but the terrorists can have the final say on that.

I still treat charcot. A cuboid bumpectomy + custom inserts + plastizote + glue works great. No implants, ambulate after a week if not sooner. Not saying there's not a place for external fixators, but I've been able to accomplish plenty without them.

Which brings me to my second point of inquiry. What kind of myocutaneous flaps are you using? I'm legitimately curious. I learned random flaps (bilobe, rhomboid, v-y) from an integra course. They're great. I always fashion a myocutaneous flap during TMAs, not that I bill it that way. I've read about obscure flaps for calcaneal wounds or 5th met base wounds, never tried em. Anyone who needs anything that complicated is generally so far past the point of no return (double digit hga1c, bad PAD) that bka is the endpoint, if their life expectancy will allow it. But that's just my experience. We want to hear yours.


The Adam Smasher of 10 years ago would agree with you. But the logical conclusion to your argument is "PP should not be profitable." As a PP guy, I get pennies on the dollar for basic e&m services compared with other providers. Reimbursement for common procedures never keeps up with inflation. While I don't support abusive practices, it's nice to not be shafted on at least on service.

If you are doing a bumpectomy on charcot then the deformity was never that severe. You can't get away with that in severe deformities. If there is subtle deformity then I will do MIS exostectomy to see if that helps otherwise its full recon.

External fixation is not hard. Management of it is if you don't have residents doing you dirty work and pin site changes. I don't. I make the nurses who work the wound care center do it. I have inpatient wound care nurses who do the dressings for me. I am usually using ex-fix for any revisional work in the ankle for extra-stabilization.

Deep heel ulcers I do FDB muscle flaps. Fibular ulcers I do peroneus brevis flaps. Anterior distal leg wounds with exposed tibia I will do split anterior tibialis muscle flap. Plantar foot ulcers that are not complicated will get a schrudde flap.

I have gotten really aggressive with other salvage procedures. If a patient has a fibular ulcer but doe not have perfusion for a flap then its excision of fibula and retrograde nail fusion of AJ/STJ. If a patient has chronic heel ulcer due to calcaneal gait I am taking them to the OR for retrograde nail fusion of AJ/STJ and shrudde flap to close the heel ulcer. If someone needs an aggressive calcanectomy and you have enough of the STJ...once you have cleared the bone infection you can always go back and do MIS prep of the STJ and AJ and put a nail in allowing the patient to walk again in the future rather than relying on an AFO which may or may not work.

Calcaneal gait causing chronic recurrent heel ulcers is the bane of my existence. Of course I will do debridements and offloading in total contact casts and it will heal but it always comes back even with diabetic shoes and inserts. After the third or fourth recurrence I will push for surgical correction of the deformity. I've tried taking these patients and doing achilles tendon shortening and FHL tendon transfers. Putting the foot in max plantaflexion....it does not work. Retrograde nailing solves a lot of problems. If the patient has high hemoglobin A1c or skin quality is an issue this where mastering MIS bone debridement comes into play. Being able to prepare the STJ and AJ with an MIS burr has made doing these cases safer and even easier to do. It has made doing these cases feasible.

 

[Hybrocure]

If you are doing a bumpectomy on charcot then the deformity was never that severe. You can't get away with that in severe deformities. If there is subtle deformity then I will do MIS exostectomy to see if that helps otherwise its full recon.

External fixation is not hard. Management of it is if you don't have residents doing you dirty work and pin site changes. I don't. I make the nurses who work the wound care center do it. I have inpatient wound care nurses who do the dressings for me. I am usually using ex-fix for any revisional work in the ankle for extra-stabilization.

Deep heel ulcers I do FDB muscle flaps. Fibular ulcers I do peroneus brevis flaps. Anterior distal leg wounds with exposed tibia I will do split anterior tibialis muscle flap. Plantar foot ulcers that are not complicated will get a schrudde flap.

I have gotten really aggressive with other salvage procedures. If a patient has a fibular ulcer but doe not have perfusion for a flap then its excision of fibula and retrograde nail fusion of AJ/STJ. If a patient has chronic heel ulcer due to calcaneal gait I am taking them to the OR for retrograde nail fusion of AJ/STJ and shrudde flap to close the heel ulcer. If someone needs an aggressive calcanectomy and you have enough of the STJ...once you have cleared the bone infection you can always go back and do MIS prep of the STJ and AJ and put a nail in allowing the patient to walk again in the future rather than relying on an AFO which may or may not work.

Calcaneal gait causing chronic recurrent heel ulcers is the bane of my existence. Of course I will do debridements and offloading in total contact casts and it will heal but it always comes back even with diabetic shoes and inserts. After the third or fourth recurrence I will push for surgical correction of the deformity. I've tried taking these patients and doing achilles tendon shortening and FHL tendon transfers. Putting the foot in max plantaflexion....it does not work. Retrograde nailing solves a lot of problems. If the patient has high hemoglobin A1c or skin quality is an issue this where mastering MIS bone debridement comes into play. Being able to prepare the STJ and AJ with an MIS burr has made doing these cases safer and even easier to do. It has made doing these cases feasible.

What’s your opinion on the validity of probe to bone tests with these patients with exposed bone you do flaps on?

I’ve personally noticed the stats on the research we were all taught don’t really correlate to how it is in practice especially once I get bone biopsies back. But too many times people think bone hits air = osteo

 

[air bud]

What’s your opinion on the validity of probe to bone tests with these patients with exposed bone you do flaps on?

I’ve personally noticed the stats on the research we were all taught don’t really correlate to how it is in practice especially once I get bone biopsies back. But too many times people think bone hits air = osteo

Who cares? Its still getting IV antibiotics and it's still getting covered once perfusion confirmed/optimized and clinical infection is gone. Data is for nerds. We need more Ricky Bobby's and less David Armstrongs.

 

[Hybrocure]

Who cares? Its still getting IV antibiotics and it's still getting covered once perfusion confirmed/optimized and clinical infection is gone. Data is for nerds. We need more Ricky Bobby's and less David Armstrongs.

Does IV abx kill osteo

 

[air bud]

Does IV abx kill osteo

Don't know. Don't care. Doing everything reasonable to cut infected bone out.

 

[Retrograde_Nail]

What’s your opinion on the validity of probe to bone tests with these patients with exposed bone you do flaps on?

I’ve personally noticed the stats on the research we were all taught don’t really correlate to how it is in practice especially once I get bone biopsies back. But too many times people think bone hits air = osteo

There is contamination of bone most likely. A little bone debridement and some bone biopsies after debridement before flap is common practice. If it happens to be osteomyelitis then let the bone cultures guide long term ABx therapy turning it from an acute process to a chronic process. People live and function find with chronic osteomyelitis with no active infection just fine.