...Tenotomies, arthroplasty for toes, even simple cheilectomies can be done under local (albeit a very very good block). I don’t thin u necessarily need a full converted “surgery center room” in the office but you would need sterile drapes, instruments etc. I’ve heard a lot of talk on this from other docs ...
Yep, you can do that stuff under local. Or you can care about patient safety, infections, your license and career, etc.
This is one of those "can be done" vs "should be done" situations.
It is no longer the standard of care to do any bone/joint surgery in the regular office. Most of the DPMs still doing that stuff are the bottom of the barrel and not getting very many patients/referrals, so they are usually also the ones trying to operate on old/sick/obese people that others in the area are too smart to (even in a real OR). They will have no legal ground to stand on, and any expert saying they were choosing to do sub-standard care and take unnecessary risk when they get a cardiac complication from local, axniety attack, infection that needs an amp or PICC, etc from doing office bone surgery. If you read the meeting minutes for state pod boards, they all have to deal with these in-office disaster complications every year.
As said, the accredited surgery center in/near a DPM office where you have real equipment (proper insurance, ASC corp setup, scrub sink, real lights, power saw and drill and driver, tourniquet set, anesthesia machine, IV poles and fluids, crash cart/kit, full sterile instruments set and backup, basic screw set and pins set for backup, bovie setup, suction, nitro and O2 tanks, maybe flouro, etc) is significantly different. The costs are tens of thousands, usually well into six figures before even hiring the staff. That can be very profitable to get that accreditation in the long term, and you can do basically any basic forefoot or soft tissue case if you are skilled - or even a bit more like gastroc and Lapidus and basic rearfoot if you have good skills and flouro. You can do MIS if you believe in that voodoo and that the 2nd coming will catch on better than the first (just like MPJ implants?). The limiting factor for the tiny ASC when it comes to podiatry cases, beyond surgeon skill, is usually any case requires thigh cuff will require general due to pain (and longer op time)... so, most CRNAs will balk at that due to risk, longer recovery time, slight risk of needing hospital xfer for admit. They (wisely) don't want that in that setting, and the docs shouldn't want that in that one-room "surgery center" either. Those are cases for more of a real surgery center, or a hospital.
...However, it is a risk. It's not cheap buy all that "accredited surgery center" stuff and definitely not cheap to pay a CRNA, circ nurse, pre/post op nurse, tech, receptionist or service, etc that can all coordinate for a few days per month. Beyond just the equipment and logistics of staffing, if a patient cancels or weather is terrible or even one staff member calls in sick last minute, you are up a creek and out a ton of money. Even assuming you have all the moving parts in place, you're still a fool if you take anything more than ASA II patients to a place like that. Those small accredited ASC setups can usually work if you have the volume or incentivi$e other area surgeons to do cases at your center - and the centers do work for many plastics, ENT, pod, etc. I have seen a few DPMs make it work fairly well, but it is becoming more rare (I think most young DPMs would just invest in a surgery center, get into one through ortho/MSG, etc). The mini "accredited surgery center" is infinitely different and more costly than trying to do straight local bone surgery in a basic podiatry office, though.
In the normal pod office, a lesser toe amp, perc tendonotomy or fasciotomy, wound care, removal of a pin, skin lesions, and similar soft tissue stuff is about as far as you want to go. I agree with what's said above regarding what is reasonable and within standards for the office setting. Those goofballs you see taking out ankle lipomas or doing digit arthroplasty under local in regular office on YouTube are nuts and probably doing it because they don't have privileges. It is not a "let your conscience be your guide thing," it is about knowing what is normal in your profession and safe for patients. If you are ever in your exam room and looking at a bone or joint that wasn't already exposed from a wound when the patient came in, you screwed up royally. Some plastics or ENTs do quite a bit in office under local since it's within standard of care for them and/or the patient insurance won't cover ASC/hospital since it's cosmetic... but that's not the case for podaitry. It is all about the standard of care, patient safety, and not crashing off the guard rails on that.
...In the end, regardless of your practice situation,
you'd be surprised how much bringing cases to various local ASCs and hospitals at least semi-frequently helps get your name out there as the competent and friendly F&A doc. I agree you don't do ingrowns or warts or stuff in OR unless you really need to (peds, developmental disability), but even something borderline like a plantar fasciotomy is something I'd much rather do at the ASC or hospital since they'll be glad to have the case, you will have at least a dozen people see your name that way, I can do a better job, and it's safer and less anxiety for the patient. That is well worth getting $500 instead of $800 or whatever it'd be to do that CPT in the office under local. Don't step over dollars to save dimes in that regard. Of course, the best case is that you have shares/own a center or your MSG/ortho owns one and you bring most of your cases there, but it works out regardless. The ASCs basically want quick cases, and hospitals tend to respect that more too. They think you're a star if you can bang out 5 easy/medium cases like Austin, neuroma, Lapidus, plantar fasciotomy, hammertoes in a morning... but the hospitals tend to dislike if some other doc takes that 3-4hrs to do one Charcot case or one flat foot case. It is just the way things are... the staff don't understand the complexity levels, so
they will almost invariably think fast and friendly surgeon = good surgeon.
