helping your practice and helping your patients while ... · while limiting risks 2015 michael c....

Helping Your Practice and

Helping Your Patients

While Limiting Risks

2015

Michael C. McGlamry DPM, FACFAS

Conservative Care• When

• Why

• Who

When to Apply Conservative Care

• Conditions that predictably respond to CC

• Non emergent conditions

• Conditions with substantial recovery

• High risk/difficult patients

Why Conservative Care?

• It works

• Minimal risks

• Allows you to get to know the pt.

• Medical/legal implications

Who?

• All

• Non emergent conditions

• High risk pt’s

– Medical

– Social

Conditions

Plantar Fasciitis

• Statistically responds well to CC

• Google search 3.7M

• Complications of surgical treatment

– CC syndrome

– Nerve entrapment

– Other nerve injuries

– Persistent heel pain

Plantar Fasciitis CC Treatments

• Injections

• NSAID’s

• OTC/custom inserts

• Night splints

• PT (home and Rx)

Plantar Fasciitis Escalated CC

• PRP

• Stem cell treatment

• Laser therapy

• ESWT

• Cryo

• Nerve ablation

Financial Considerations

• Conservative Care

– IOV $109.15

– Xrays $29.07

– Injection(2) $59.42

– OTC inserts $40

– Night splint $161.53

– Follow up (2) $73.09

Total $531.68

Risk 0

ESWT $1250/231.17

Ultrasound $25.03

• Surgical care

– EPF $441.08

– Instep etc $302.01

– Boot $263.29

Total $629.95-704.37

90 day global

Risk $53,737

Claims

• 28060 Instep or other open

• 28062 Complete

• 28250 Steindler stripping

• 29893 EPF

Insertional Achilles Tendonitis/

Retrocalcaneal Exostosis

• Responds fairly well to CC

• Google => 759,000 results

• Postop

– 1 month NWB cast

– 1 month fracture boot

– Gradual return to activities

– Lengthy rehab for “typical pt”

• Total recovery 1 year

– **Informed Consent**

Insertional Achilles Tendonitis/

Retrocalcaneal Exostosis

• Complications

– Weakness

– Persistent pain

– Achilles tendon rupture

– Other injuries from falls while NWB (High BMI

pt’s

– DVT/PE

Insertional Achilles Tendonitis/

Retrocalcaneal Exostosis CC

• Immobilization

• Oral steroids

• NSAID’s (oral and topical)

• Alteration shoe gear

• Heel lifts

• Bracing (Achillotrain, AFO etc.)

• PT (treatment and evalution for NWB ability)

Insertional Achilles Tendonitis/

Retrocalcaneal Exostosis

Escalated Conservative Care

• PRP injections

• Stem cell

• Topaz

• ESWT

•NO STEROID

INJECTIONS!!!!!!

Financial Considerations

• Conservative Care

– IOV $109.15

– Xrays $29.07

– Heel Lifts $20

– Boot $263.29

– Follow up (2) $73.09

Total $567.64

Risk 0ESWT $1250/231.17

Ultrasound $36.52

Casting $150

• Surgical care

– Resection exostosis

$424.71

– Repair Achilles $675.65

– Boot $263.29

Total $

90 day global

Risk $62,118

Posterior Tibial Tendon Dysfunction

• Moderate response to CC dependent on stage

and underlying structure

• Google => 239,00

• Postop

– 6-8 weeks NWB in cast

– 4 weeks PPWB in boot

– 3-6 months swelling/soreness

– 12 month full recovery

Posterior Tibial Tendon Dysfunction

• Complications

– Delayed or nonunion

– swelling

– DVT

Posterior Tibial Tendon Dysfunction

Conservative Care

• Medications

• Orthotics

• Bracing

• Immobilization* (dual role)

• PT

• ?Injections?

Procedures

• 28238 Kidner

• 28300 Calcaneal osteotomy

• 28715 Triple arthrodesis

• 18 claims

• Average payout $101,389

Other Procedures

• 28725 Subtalar fusion $98,625

• 28740 Isoltated midtarsal $225,000

Charcot Neuroarthopathy

• Conservative care success based on severity of

deformity

– Midfoot vs ankle

– Stable vs instable

– Ulcer vs closed

• Google => 264,000

• Postop

– 10-16weeks NWB Cast (Ex Fix)

– CROW 12 mo – life

Charcot Neuroarthropathy

• Surgical Complications

– Wound dehiscence

– Nonunion

– Infection (+/- 30%)

– Ampution

– Death

Charcot Neuroarthropathy

Conservative Care

• EARLY DX!!

• Offloading

• Ulcer care when present

• Bracing

• TCC

• Bone stimulation

• Bisphophonate therapy

When is Surgery Indicated?

• Failure/lack of response of conservative care

• Imaging/other findings to support that CC will

likely be unsuccessful

• Patient has already had extensive conservative

care elsewhere

– Caution!

– Obtain records

Consent

• Detailed discussion about procedure as well as

normal expected recovery

• Alternative conservative treatment options

• Risks

– Common

– Catastrophic

Summary

• Conservative care is often succesful

• Risk factor near “0”

• Time=>Rapport

• Trust

• Rewarding

• Decreases stress