Wound Care Products/dressings you should have in your PP office or be using/prescribing/ordering

[heybrother]

Disclaimer. For the longest, longest time I was solidly and totally in the camp that all you really need is good debridement, good offloading, good blood flow and the wound would heal. Dressings and crap are for wound healing centers who perpetuate and drag out wound care until the definitive surgery can be done. Iodine is all you need, etc *So if you are posting to tell me that - I already believed it - and I'm looking for information about something new. I used to think everyone need a lapidus or a 1st MPJ fusion. I'm expanding my game.

However, having practice awhile - I find myself for example - performing a wonderful surgery. Getting a massive, deep, down to bone ulcer to heal on the bottom of the foot, and then getting stuck with a stagnant dorsal incision wound that the wound healing center graciously, rapidly heals with just a little bit of some random packing.

As I've previously explained elsewhere - WHCs receive about triple the reimbursement from Medicare that PP doctors receive so I cannot carry or give out for free expensive dressings because there's no real margin. Maximum reimbursement in my office for a 11042 is $205. Floor is probably $120 on 11042 and is a much higher mode.

What should we have in our office?
Are people still using Prisma?
Should I be pushing the AMERX collagen kits (and risking an audit?)
What can be applied in the office?
What can be dispensed?
Do you order supplies from somewhere/ie. a prescription and then have them bring the dressings with them?
If you recommend something I need to know the logistics of how you do it, charge their insurance etc.

Thank you for your time. I obviously do not have time to complete a wound care fellowship.

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[air bud]

Your original premise was correct. Also you are not using wound vacs enough. Also, while I understand at this point in your career a 2 year wound care fellowship may be unfeasible, consider just a 1 year.

 

[Adam Smasher]

When called by VNAs with inquiries about how the wound should be dressed, I tell them "There's more than one correct answer." Which is another way of saying it doesn't matter. Whether or not your patient gets an amputation does not hinge on whether you use a foam or an alginate.

In terms of products, I love santyl for wounds. Call me a ***** for smith and nephew, I don't care.

I used to love Total Contact Casting. I've had too many patients go nowhere with them recently so I'm gravitating away from it.

There is a company I use to rx dressings. I send a progress note and a demo sheet and they bill their insurance. I like this, I earn $0 for doing this and no one can accuse me of trying to milk the patient. PM me if you want to know who, they're good, but they don't pay me to promote them on SDN

Ultimately, the single best product to heal ulcers is cold steel. Whether that means debridement, surgical offloading, or amputating a little now so you don't need to amputate more later, this is what delivers lasting results* to the patient.

*results may vary

 

[Adam Smasher]

***** above is meant to be a vulgar term for a professional who exchanges intimate services for money

 

[Hybrocure]

Be very aggressive with flexor tenotomies that’s usually how most start in a PP/outpatient situation.

I keep it simple wound care wise. Generally no grafting. I am a big fan of prisma honestly. But I try to take care of most things surgically.

Not the biggest fan of TCCs. They get swampy, take up office time and generally those who need them are also the type of patients you don’t want to have a wound not looked at for a week. Great for a hospital or VA setting where you have people to handle the work with them. Not great for PP.

Vacs work amazingly. But also, absolute headache in PP. My experience with anything involving home care for patients in PP is always a struggle admin wise mostly on the nursing end with orders.

 

[Feli]

I concur your orig assumption was right...
Wound care needs revasc eval if it's PAD.
It needs abx and amp/debride if contaminated/trauma.
It needs compress +/- debride if venous.
It needs offload DME/surgery if it's pressure.

The more basic wound care surgery proc like amps, deformity recon, offload surgery, VAC application, STSG or flaps have their merits if used well.

Imaging and path/histo/biopsy is obviously needed sometimes.

In my office, I have gauze dressings, alcohol, betadine, silvadene, debride instruments, Rx pads (for DME and imaging and Vasc refers), and surgical boarding slips (for amp, recon). I doesn't change, and it's just not that difficult.

...The rest of "wound care" is basically a hocus pocus cash grab the people and facilities doing it to try to get more money, lunches/dinners, rVU bonus, imaging. They get that stuff by using endless silliness like "grafts," HBO, dressings billable, lotions and potions, whatever. I always get a kick out of the ESRD pt with 0.4 ABIs who thinks MediHoney is going to heal the wound after going to the WCC. Hilarious, and sad.

I would say that if you go, go all out. Be the first 3 year wound fellowship trained?

 

[deleted285117]

You also got to know your "gen med" when it comes to wound care... meaning know when/what to biopsy, when to refer to rheum/derm, know how to properly treat pyoderma (hint: not w/ topical steroids or medrol dosepak), diagnose lymphedema, recognize CHF exacerbation, when to order specific testing for other issues (ex. palpable purpura + systemic stuff? biopsy lesion + autoimmune labs + chest XR + SPEP + etc...), proper indications for surgery, etc.

BTW I also use prisma quite a bit... it's a license to kill for a fully granulating wound. Otherwise, I love medihoney gel or iodosorb for infected/fibrotic wounds. VACs are magical 🙂

 

[air bud]

Be very aggressive with flexor tenotomies that’s usually how most start in a PP/outpatient situation.

I keep it simple wound care wise. Generally no grafting. I am a big fan of prisma honestly. But I try to take care of most things surgically.

Not the biggest fan of TCCs. They get swampy, take up office time and generally those who need them are also the type of patients you don’t want to have a wound not looked at for a week. Great for a hospital or VA setting where you have people to handle the work with them. Not great for PP.

Vacs work amazingly. But also, absolute headache in PP. My experience with anything involving home care for patients in PP is always a struggle admin wise mostly on the nursing end with orders.

Would love to know how many flexors are being done on rigid hammertoes....RVUS....not directed at you bro.

 

[air bud]

You also got to know your "gen med" when it comes to wound care... meaning know when/what to biopsy, when to refer to rheum/derm, know how to properly treat pyoderma (hint: not w/ topical steroids or medrol dosepak), diagnose lymphedema, recognize CHF exacerbation, when to order specific testing for other issues (ex. palpable purpura + systemic stuff? biopsy lesion + autoimmune labs + chest XR + SPEP + etc...), proper indications for surgery, etc.

BTW I also use prisma quite a bit... it's a license to kill for a fully granulating wound. Otherwise, I love medihoney gel or iodosorb for infected/fibrotic wounds. VACs are magical 🙂

You mentioned like 5 things that don't ever cross my mind when evaluating a wound....need to freshen up my brain, fortunately I only work 1 day a week now for the next 3 months so I have time.

 

[Hybrocure]

Would love to know how many flexors are being done on rigid hammertoes....RVUS....not directed at you bro.

What’s an RVU. I only poke the flexies

 

[diabeticfootdr]

Disclaimer. For the longest, longest time I was solidly and totally in the camp that all you really need is good debridement, good offloading, good blood flow and the wound would heal. Dressings and crap are for wound healing centers who perpetuate and drag out wound care until the definitive surgery can be done. Iodine is all you need, etc

I'm still in that camp, with the exception of the iodine.

But the caveat is having a protocol/pathway driven treatment, even in your private office - just make your own based on evidence and what you will have available. Here is the DFU Guideline we just wrote for the Wound Healing Society with what is supported by evidence and what is not.

Evidence-based infection diagnosis and management, ensuring adequate perfusion, then best practice offloading with good debridement is key to healing.

However, having practice awhile - I find myself for example - performing a wonderful surgery. Getting a massive, deep, down to bone ulcer to heal on the bottom of the foot, and then getting stuck with a stagnant dorsal incision wound that the wound healing center graciously, rapidly heals with just a little bit of some random packing.

Agreed. Surgical management of wounds and deformities leading to wounds should be a primary consideration.

What should we have in our office?

- Handheld vascular Doppler
- ABI machine
- Debridement tools (scalpel, curette, EZ-Debride)
- Irrigation (saline, or one of the antiseptic/antimicrobials)
- Offloading: TCC-EZ, DME (adhesive felt and foam, post-op shoes, knee-high CAM boots)
- Basic dressings (hydrogel, non-adherent, collagen, alginate, foam, gauze, ABD, Kerlix, ACE)
- 1 or 2 shelf-stable skin substitutes

Also I think everyone should have a FLIR attachment for your phone (~$300) for thermal imaging.

Are people still using Prisma?

I use Promogran or Prisma as a hemostatic after debridement

Should I be pushing the AMERX collagen kits (and risking an audit?)

I don't use this ... seems too salesy for me.

What can be applied in the office?

VAC, TCC, skin substitutes

Do you order supplies from somewhere/ie. a prescription and then have them bring the dressings with them?

I don't think you're "allowed" to do that ...

If you recommend something I need to know the logistics of how you do it, charge their insurance etc.

- Know your referral specialists for vascular, ID, plastics, HBOT, O&P, and whoever will do your BKs
- Know the prior auth process for Nuzyra (omadacycline) ... it's one of my favorite antibiotics now. Oral, once-daily, broad-spectrum and anti-MRSA. (Doesn't cover pseudomonas). It has helped me avoid hospitalizations. In moderate DFI (without an abscess), I will start Nuzyra and see them back in 1-2 days. If not better, then admission.
- Process to order Wound VAC and start from the clinic.
- Process to order Topical O2 (if you believe in that)

Another new thing, that we're doing, is remote patient monitoring (service billable to Medicare) with either Podimetrics or Orpyx. Pros and cons of each (message me). Cheaper alternatives coming to the market soon.

 

[Homo sapien]

When called by VNAs with inquiries about how the wound should be dressed, I tell them "There's more than one correct answer." Which is another way of saying it doesn't matter. Whether or not your patient gets an amputation does not hinge on whether you use a foam or an alginate.

In terms of products, I love santyl for wounds. Call me a ***** for smith and nephew, I don't care.

I used to love Total Contact Casting. I've had too many patients go nowhere with them recently so I'm gravitating away from it.

There is a company I use to rx dressings. I send a progress note and a demo sheet and they bill their insurance. I like this, I earn $0 for doing this and no one can accuse me of trying to milk the patient. PM me if you want to know who, they're good, but they don't pay me to promote them on SDN

Ultimately, the single best product to heal ulcers is cold steel. Whether that means debridement, surgical offloading, or amputating a little now so you don't need to amputate more later, this is what delivers lasting results* to the patient.

*results may vary

Is this rx dressing company headquartered in NC? IF so, I've used them too. Fairly beneficial

 

[Adam Smasher]

Is this rx dressing company headquartered in NC? IF so, I've used them too. Fairly beneficial

Mine happens to be based in NYC. I don't care. I've had patients show up with wounds dressed in tissue and scotch tape. It's 2 min of extra paperwork to ensure my patient gets gauze squares and rolls for the month.

 

[air bud]

I'm still in that camp, with the exception of the iodine.

But the caveat is having a protocol/pathway driven treatment, even in your private office - just make your own based on evidence and what you will have available. Here is the DFU Guideline we just wrote for the Wound Healing Society with what is supported by evidence and what is not.

Evidence-based infection diagnosis and management, ensuring adequate perfusion, then best practice offloading with good debridement is key to healing.

Agreed. Surgical management of wounds and deformities leading to wounds should be a primary consideration.


- Handheld vascular Doppler
- ABI machine
- Debridement tools (scalpel, curette, EZ-Debride)
- Irrigation (saline, or one of the antiseptic/antimicrobials)
- Offloading: TCC-EZ, DME (adhesive felt and foam, post-op shoes, knee-high CAM boots)
- Basic dressings (hydrogel, non-adherent, collagen, alginate, foam, gauze, ABD, Kerlix, ACE)
- 1 or 2 shelf-stable skin substitutes

Also I think everyone should have a FLIR attachment for your phone (~$300) for thermal imaging.


I use Promogran or Prisma as a hemostatic after debridement

I don't use this ... seems too salesy for me.

VAC, TCC, skin substitutes

I don't think you're "allowed" to do that ...

- Know your referral specialists for vascular, ID, plastics, HBOT, O&P, and whoever will do your BKs
- Know the prior auth process for Nuzyra (omadacycline) ... it's one of my favorite antibiotics now. Oral, once-daily, broad-spectrum and anti-MRSA. (Doesn't cover pseudomonas). It has helped me avoid hospitalizations. In moderate DFI (without an abscess), I will start Nuzyra and see them back in 1-2 days. If not better, then admission.
- Process to order Wound VAC and start from the clinic.
- Process to order Topical O2 (if you believe in that)

Another new thing, that we're doing, is remote patient monitoring (service billable to Medicare) with either Podimetrics or Orpyx. Pros and cons of each (message me). Cheaper alternatives coming to the market soon.

I have wondered about Nuzyra....is there much out of pocket for it? Any major drug interactions with it? (Ssri)

 

[Adam Smasher]

is there much out of pocket for it?

I had a guy pay a $3k copay

 

[Feli]

I have wondered about Nuzyra....is there much out of pocket for it? Any major drug interactions with it? (Ssri)

Reps bringing WCC and hospital lunches say it'll catch on just like tygacil did (source = trust me bro) 😆

 

[heybrother]

Thank you to those who replied - one in great detail. At some point I will write an article describing trying to incorporate dressings in a very limited fashion into a private practice, but for now I'm concerned about the regulatory burden. Simply ordering in the limited number of cases that I need assistance from a vendor seems a lot more reasonable.

https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/909475surgicaldressings_2_24_2018.pdf

Article - Surgical Dressings - Policy Article (A54563)

Use this page to view details for the Local Coverage Article for Surgical Dressings - Policy Article.

www.cms.gov

 

[DYK343]

adhesive felt and foam

I gave this up. I feel like it creates more pressure at the wound margin where we are trying to gain basement membrane migration/epithelialization. IMO it creates more pressure on the wound edge. Too many times I see window edema and stalled wounds with adhesive felt.

I still do felt occasionally. But almost never now. My results improved once I got rid of it.

TCC, surgical offloading, crutches, knee scooter, sometimes CAM boot.

Tried the football dressing and it didn't work for me.

Non compliance ends in amputation and I am firm when I tell them that.

Preaching to the choir here but if deformity it must be corrected. No wound care is going to fix long term 75% of these foot ulcers. Keller, minimally invasive elevating osteotomies, flexor tenotomy, P longus tenotomy, Split tibialis anterior tendon transfer, TAL/Baumann, FHL transfer to calc. Along with a good vascular surgeon/interventionalist these should be in every wound care providers armory.

I do multiple of these procedures a week (5ish) and is a major part of my RVU production. Fast. Easy. Effective. Results are great.

Whenever I see a wound I try to determine the best wound care approach - but I also ask myself why is there a wound there. There is a biomechanical reason and this can be addressed.

Im beginning to wonder if my wound center is starting to dislike me seeing foot consults. I heal and discharge too many of them. They have been sending me nothing but venous ulcers for the last 2 months.... I peeked at the non surgical wound care providers schedules and they are full of foot wounds.

 

[heybrother]

Will have to look into this thermal camera approach.

https://www.zgt.nl/media/19026/validation-of-low-cost-smartphone-based-thermal-camera-for-diabetic-foot-assessment.pdf

Benefits of thermal imaging in the diagnosis of osteomyelitis and Charcot foot - Thermidas

Acute Charcot foot has symptoms similar to osteomyelitis, and making the correct diagnosis can be challenging. Blood tests, X-rays or an MRI scan can help

thermidas.fi

Infrared Thermal Imaging for Automated Detection of Diabetic Foot Complications - PMC

Although thermal imaging can be a valuable technology in the prevention and management of diabetic foot disease, it is not yet widely used in clinical practice. Technological advancement in infrared imaging increases its application range. The aim ...

www.ncbi.nlm.nih.gov

Clinical Utility of Mobile Phone-Based Thermography and... : Indian Journal of Vascular and Endovascular Surgery

and a stand-alone handheld device (Nubee, Duarte California, USA) to provide simple, quantifiable images to assist in rapid clinical visualization. Therefore, the purpose of this manuscript was to highlight the potential day-to-day application of these tools....

journals.lww.com

 

[DYK343]

Will have to look into this thermal camera approach.

https://www.zgt.nl/media/19026/validation-of-low-cost-smartphone-based-thermal-camera-for-diabetic-foot-assessment.pdf

Benefits of thermal imaging in the diagnosis of osteomyelitis and Charcot foot - Thermidas

Acute Charcot foot has symptoms similar to osteomyelitis, and making the correct diagnosis can be challenging. Blood tests, X-rays or an MRI scan can help

thermidas.fi

Infrared Thermal Imaging for Automated Detection of Diabetic Foot Complications - PMC

Although thermal imaging can be a valuable technology in the prevention and management of diabetic foot disease, it is not yet widely used in clinical practice. Technological advancement in infrared imaging increases its application range. The aim ...

www.ncbi.nlm.nih.gov

Clinical Utility of Mobile Phone-Based Thermography and... : Indian Journal of Vascular and Endovascular Surgery

and a stand-alone handheld device (Nubee, Duarte California, USA) to provide simple, quantifiable images to assist in rapid clinical visualization. Therefore, the purpose of this manuscript was to highlight the potential day-to-day application of these tools....

journals.lww.com

Yeah im into this thermal camera thing. Thanks diabeticfootdr. Way cheaper than a luna (not as good - but still)

 

[Retrograde_Nail]

Im beginning to wonder if my wound center is starting to dislike me seeing foot consults. I heal and discharge too many of them. They have been sending me nothing but venous ulcers for the last 2 months.... I peeked at the non surgical wound care providers schedules and they are full of foot wounds.

They do dislike you. When I joined my 2nd hospital job the wound care center was only staffed by nurse practitioners. There were two podiatrists on staff that hated wounds. So it was the perfect storm of crap. When I started seeing patients in the wound care center I must have healed 20 patients in a matter of weeks who had been there for over a year from chronic great toe ulcers. They all needed kellers.

We had a meeting a couple months ago where admin of wound care said "we used to see 60 patients a day". Nobody realized we are not because I am healing them so quickly.

Nobody offered total contact casts until I got there.

Nobody was using skin subs other than epifix before I got there.

This is not a jab at nurse practitioners only. I've come across plenty of MD/DO internal med, general surgeon, retired ERs docs in the wound care center who also have no idea how to manage lower extremity wounds due to complete failure of understanding the biomechanics.

Wound care centers are run by the wrong people, staffed by the wrong people. That's why they get a bad reputation. Nobody has a clue what they are doing from the knee down.

 

[Weirdy]

They do dislike you. When I joined my 2nd hospital job the wound care center was only staffed by nurse practitioners. There were two podiatrists on staff that hated wounds. So it was the perfect storm of crap. When I started seeing patients in the wound care center I must have healed 20 patients in a matter of weeks who had been there for over a year from chronic great toe ulcers. They all needed kellers.

We had a meeting a couple months ago where admin of wound care said "we used to see 60 patients a day". Nobody realized we are not because I am healing them so quickly.

Wound care centers are run by the wrong people, staffed by the wrong people. That's why they get a bad reputation. Nobody has a clue what they are doing from the knee down.

Second this experience.

Wound care center was run by pretty incompetent people pushing HBO on wounds that really needed amps, floating met osteotomies, surgical procedures to offload.

They'd push HBO and misinform hopeful patients until there was proven osteo and nothing else could be done.

 

[deleted285117]

Second this experience.

Wound care center was run by pretty incompetent people pushing HBO on wounds that really needed amps, floating met osteotomies, surgical procedures to offload.

They'd push HBO and misinform hopeful patients until there was proven osteo and nothing else could be done.

Third.

Doing a floating met on a guy next week who's wound has been open for ">2 years". I mean WTF...

Another guy had a wound come and go ~4 times in the past year (it just kept on coming back!!?? I wonder why...). Just did a TAL on him and he healed in <2 weeks.

People just don't get preventative maintenance.

 

[air bud]

An ulcer is biomechanical problem with open skin complicated by infection, blood flow and other comorbidity.

As I get ready to move to my new job where there is a very busy wound care center, I do think about better ways to thread the needle of not coming in like a bull in a china shop, healing patients, making friends/enemies.

If everything was in the best interest of patients and someone like myself could see every single lower extremity wound (DFU), I bet greater than 50 percent are healed in 3 months.

 

[Feli]

...my new job where there is a very busy wound care center ...

 

[air bud]

Bro, we talked about this I'm going to unbusy it by doing the surgery.

 

[MicroPod]

Bro, we talked about this I'm going to unbusy it by doing the surgery.

This guy keeps moving around shutting down wound care centers and working himself out of a job.

 

[Feli]

Bro, we talked about this I'm going to unbusy it by doing the surgery.

Ya, but them wounds, man... they're like rats... for every one you see, there's 100 more you don't.

Forget dem ulcers.
Sub-specialize in SEC conf women's track and cheerleader ankle sprains? Jmo.

...in all seriousness tho, yeah, a decent surgeon should offload and amp and recon and buzz through any WCC volume fairly quick. There are some that are just plain med/vasc turds that you just hope the CAD or ESRD kills them before the wound... but those are minority.

It's no small wonder the SFe WCC near me has one non-op pod and a few NPs and that's it. They have dozens in the weekly debride and graft and HBO loop. I feel bad for my pts who I recommend BKA and they instead go there to putz and putz and HBO awhile.

 

[DYK343]

Ya, but them wounds, man... they're like rats... for every one you see, there's 100 more you don't.

Forget dem ulcers.
Sub-specialize in SEC conf women's track and cheerleader ankle sprains? Jmo.

...in all seriousness tho, yeah, a decent surgeon should offload and amp and recon and buzz through any WCC volume fairly quick. There are some that are just plain med/vasc turds that you just hope the CAD or ESRD kills them before the wound... but those are minority.

It's no small wonder the SFe WCC near me has one non-op pod and a few NPs and that's it. They have dozens in the weekly debride and graft and HBO loop. I feel bad for my pts who I recommend BKA and thy go there to putz and putz and HBO awhile.

Wounds are insanely profitable on a RVU system.
I dont feel like Im taking patients for a "RVU ride" either.
If they need the great whack I tell them.
I can salvage a lot as long as not severe PAD or they wait too long where the whack is the only treatment option.

 

[MicroPod]

I know there are a few states out there that allow DPMs to treat wounds anywhere on the body. Anyone doing this or not really?

Edit: ok, looked it up and it’s not anywhere but includes the torso and extremities

 

[air bud]

This guy keeps moving around shutting down wound care centers and working himself out of a job.

Oh there is a reason I keep moving jobs that's for sure....but I keep on getting them...when you got it you got it...

 

[Homo sapien]

Wounds are insanely profitable on a RVU system.
I dont feel like Im taking patients for a "RVU ride" either.
If they need the great whack I tell them.
I can salvage a lot as long as not severe PAD or they wait too long where the whack is the only treatment option.

The whack lol

I call it the big chop

 

[deleted285117]

I have a recalcitrant sub styloid process ulcer. Thoughts on surgical correction? AT open z-lengthening? SPLATT? Any magical percutaneous approach I don't know about?

Thnx y'all.

 

[DYK343]

I have a recalcitrant sub styloid process ulcer. Thoughts on surgical correction? AT open z-lengthening? SPLATT? Any magical percutaneous approach I don't know about?

Thnx y'all.

Hard to say without an exam. I assume cavus foot?
1st met driven cavus? Elevate 1st met
Flexible? Try STATT or anterior tibial tendon lengthening if contracted. Lateral calc slide if varus rearfoot (TCC/heal first for this)
PT tendon tends to favor rearfoot but if contracted might want to lengthen PT tendon.
Non flexible? TCC until healed then do a lateral slide with adjunct cavus procedures
Poor eversion strength/loss of brevis? Transfer FHL to brevis or anchor to 5th met base/cuboid. Or rearfoot fusion procedures.
Excising the 5th met base and transferring brevis to cuboid w a biotenodesis anchor works well for community ambulators.
Charcot? forget it recons dont work.

 

[Feli]

I have a recalcitrant sub styloid process ulcer. Thoughts on surgical correction? AT open z-lengthening? SPLATT? Any magical percutaneous approach I don't know about?

Thnx y'all.

Dwyer + gastroc... if abpm ppl know of that stuff? 🙂

As said, cavus is pretty complicated... lot of moving parts and variables.
Wound surg - or DME - also depends if osteomyelitis and level of activity and ambu demands, obviously.

 

[Homo sapien]

Dwyer + gastroc... if abpm ppl know of that stuff? 🙂

As said, cavus is pretty complicated... lot of moving parts and variables.
Wound surg - or DME - also depends if osteo and ambu demands, obviously.

We do lol

Gastrocs are a really versatile procedure. I honestly see a lot of people who'd benefit from one

 

[deleted285117]

Forgot to mention he's in his 80s with few comorbidities.... i'll prob stick to some soft tissue procedure like TA lengthening or SPLATT. Thanks fellas!

 

[DYK343]

Gastrocs and cavus make me fearful of worsening the deformity.

 

[PMG03470]

Forgot to mention he's in his 80s with few comorbidities.... i'll prob stick to some soft tissue procedure like TA lengthening or SPLATT. Thanks fellas!

I did one a year ago where I did a z lengthening of AT and planed the plantar surface of the 5th met base, healed right up. Just make sure you expose enough tendon to do an aggressive lengthening. If you don’t that proximal stump will retract and you will be screwed.