Attendings! whats your favorite secret technique!

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cool_vkb

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Just wondering what the attendings/residents out here prefer when they treat:

(a) rigid hallux limitus

(b) HAV (low IM angle , mod IM angle, Severely abnormal IM angle)

(c) Tailors

(d) Capsilotomy styles (do u like the "z' or linear or whatever u like)

(e) Digital stuff (claw, hammer etc)

Now i know all the possible available options and when to choose which procedure based on the angles, patient, underlying factors,etc.

but i wanna know what you guys do out their in real world! Iam pretty sure everydoc must have his own style or fav procedure which they use over any other.

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Just wondering what the attendings/residents out here prefer when they treat:

(a) rigid hallux limitus

(b) HAV (low IM angle , mod IM angle, Severely abnormal IM angle)

(c) Tailors

(d) Capsilotomy styles (do u like the "z' or linear or whatever u like)

(e) Digital stuff (claw, hammer etc)

Now i know all the possible available options and when to choose which procedure based on the angles, patient, underlying factors,etc.

but i wanna know what you guys do out their in real world! Iam pretty sure everydoc must have his own style or fav procedure which they use over any other.

Ooooh, this is the first question in the two years I've been here that actually asks about patient care! About time!

Like you said there are lots of variables, but some of the stuff I enjoy doing is:

(a) rigid hallux limitus
Arthrosurface HemiCAP implant

(b) HAV

low IM angle: Austin because it's old reliable and has easy recovery for the patient.

mod IM angle: Austin because it's old reliable and has easy recovery for the patient

severely abnormal IM angle: Lapidus with an external fixator because patients can ambulate almost right away. Dr. Wang told me he is now walking the patients immediately but I still wait two weeks.

(c) Tailors: Mini-TightRope

(d) Capsilotomy styles (do u like the "z' or linear or whatever u like) Which joint?

(e) Digital stuff (claw, hammer etc) OrthoPro intramedullary hammertoe screw because it maintains alignment indefinitely yet you can stabilize the MTPJ with a k-wire for a few weeks unlike with the bioabsorbables or other toe implants.


What else?
- I'm starting to use Smith&Nephew Exogen bone stim on all osteotomies immediately.
- Cantharidin/Aldara for verruca

 
Ah, the question of the naive and inexperienced!!

Unfortunately, your questions are excellent but vague;

1) "rigid hallux limitus" There's no such thing. There's hallux limitus, and there's hallux rigidus, but I've never heard of rigid hallux limitus! Regardless, I have no one "favorite" procedure, because it all depends on the etiology of the condition. Each one of these conditions can be caused by different etioloties, including trauma, arthritis, metatarsus primus elevatus, an elongated first metatarsal, a long proximal phalanx, a previous surgery (iatrogenic), etc.

Therefore my procedure of choice is always dependent upon addressing the cause of the deformity. Each case is unique and has to be addressed accordingly. If the joint surface is not salvageable, I may perform a joint resurfacing such as NatCH. If the joint surface is salvageable, I may perform a decompression osteotomy.

Once again, it is always dependent on the etiology.

2) Low angle IM is usually an Austin type osteotomy, since I rarely perform "just a bumpectomy". Naturally, soft tissue structure releases are also performed. Medium angle IM deformities also include an Austin type procedure. For high IM angles I prefer a Lapidus. The type of fixation always depends upon the bone stock/density of the patient and the patient's "mental status", since not all patients can handle an external fixator on their foot. (You didn't ask about PASA so I didn't address that deformity).

3) Tailor's bunion. Once again this is dependent on the level of the deformity. Some are very mild and can be addressed with a simple "bumpectomy". Some can be treated with mini-tightrope as per NatCH and some with a mild increase in the IM angle can be treated with a mini Austin type procedure. However, some Tailor's bunions present with a "bowing" of the 5th metatarsal and must be treated with an oblique wedge osteotomy. So as previously stated, there unfortunately can not be one "favorite" procedure, since it is always dependent on the etiology.

4) Capsulotomy--that all depends upon what you are attempting to accomplish with your capsulotomy or if you are performing a capsule tightening procedure. Are you attempting to balance the area, de-rotate the area, etc?

5) Toe- Don't really have a favorite toe procedure, though I love a simple 5 minute arthroplasty.

6) I'm jealous of NatCH, because where I practice, there's NO WAY any insurance company would pay for an EXOGEN bone stim for every osteotomy procedure. They are only paid in my neck of the woods when there is a definite delayed or non union.
 
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When the S&N reps told me they're getting insurance coverage for the Exogen from all but one company, even without needing prior auth, my initial reaction was, "GTFOH!" but so far so good. S&N also will write off the charges on anyone who can't pay, or so they claim. That situation hasn't presented itself yet.

I'm pretty pleased with the insurance situation here. Years ago the local docs formed an independent practice association that represents and negotiates with insurance companies on behalf of all practices. That way we're not undercutting one another and getting picked apart by the insurance companies.
 
6) I'm jealous of NatCH, because where I practice, there's NO WAY any insurance company would pay for an EXOGEN bone stim for every osteotomy procedure. They are only paid in my neck of the woods when there is a definite delayed or non union.

S&N is the only bone stim that has been approved by the FDA for FRESH FRACTURES. So you can use it for osteotomies. It also will be approved if you have a smoker (which I will not perform surgery on) or past smoker (since those are risk factors for non-unions). I've used Exogen for over 5 years and love the results with it. It is also only a 20 minute proceudre for the patient, which they love compared to the old 8 hour application time. You should have your local S&N to send you to one of the sympsiums regarding the bone stim unit.
 
S&N is the only bone stim that has been approved by the FDA for FRESH FRACTURES. So you can use it for osteotomies. It also will be approved if you have a smoker (which I will not perform surgery on) or past smoker (since those are risk factors for non-unions). I've used Exogen for over 5 years and love the results with it. It is also only a 20 minute proceudre for the patient, which they love compared to the old 8 hour application time. You should have your local S&N to send you to one of the sympsiums regarding the bone stim unit.

I was going thru the S & N website regarding exogen. It looks pretty small and kewl.is this something you guys keep in your office and considered an inoffice procedure (aka daily visits) or the patient can buy the whole unit and self expose himself for that given amount of time?

How much does it costs per visit? or the whole thing?
 
I was going thru the S & N website regarding exogen. It looks pretty small and kewl.is this something you guys keep in your office and considered an inoffice procedure (aka daily visits) or the patient can buy the whole unit and self expose himself for that given amount of time?

How much does it costs per visit? or the whole thing?

This is something that is done between S&N and the patient. I have no idea about the cost of this and NO you cannot bill for this in your office for daily visits.
 
I was going thru the S & N website regarding exogen. It looks pretty small and kewl.is this something you guys keep in your office and considered an inoffice procedure (aka daily visits) or the patient can buy the whole unit and self expose himself for that given amount of time?

How much does it costs per visit? or the whole thing?

The young, 6'0", blonde, very attractive S & N Rep with the mellifluous voice dispenses the unit to the patient at a follow-up visit, after which the patient takes it home for self-treatment. The patient can then "expose himself" as much as he wants...in private.

Cost gets billed to insurance and any balance is on a sliding scale based on patient ability to pay. They never like to give a concrete number when you ask how much it costs.
 
The young, 6'0", blonde, very attractive S & N Rep with the mellifluous voice dispenses the unit to the patient at a follow-up visit, after which the patient takes it home for self-treatment. The patient can then "expose himself" as much as he wants...in private.

Cost gets billed to insurance and any balance is on a sliding scale based on patient ability to pay. They never like to give a concrete number when you ask how much it costs.

now you are tempting me to break my bone and call the 1-800 S&N number.:)

PS: are all doctors very good narrators? i mean describing things 100% accurately? after spending time in clinic presenting cases and describing the foot to attendings. i can now describe pretty much anything with full detail. lol.

Cant you give an estimate cost?
 
3) Tailor's bunion. Once again this is dependent on the level of the deformity. Some are very mild and can be addressed with a simple "bumpectomy". Some can be treated with mini-tightrope as per NatCH and some with a mild increase in the IM angle can be treated with a mini Austin type procedure. However, some Tailor's bunions present with a "bowing" of the 5th metatarsal and must be treated with an oblique wedge osteotomy. So as previously stated, there unfortunately can not be one "favorite" procedure, since it is always dependent on the etiology.

.

What is this procedure called as? can you give me more info on this please. i read mcglamry and never found this procedure. i saw the head (chevron,hollman),shaft (Z), base (gerbert closing wedge) etc. but didnt find anything about mini tight rope.
 
When the S&N reps told me they're getting insurance coverage for the Exogen from all but one company, even without needing prior auth, my initial reaction was, "GTFOH!" but so far so good. S&N also will write off the charges on anyone who can't pay, or so they claim. That situation hasn't presented itself yet.

I'm pretty pleased with the insurance situation here. Years ago the local docs formed an independent practice association that represents and negotiates with insurance companies on behalf of all practices. That way we're not undercutting one another and getting picked apart by the insurance companies.

We're also using it post op for fusions, osteotomies, etc. We dispense it at the first post op visit (Exogen) and the insurance has covered it. If you want to use a different stimulator, like PEMF (Biomet), then you dispense it in the OR before the patient leaves the table and it gets covered as an OR implant/device.

We also use the implantable DC (Biomet) stimulator in our Charcot fusions.
 
I have a S&N rep and was aware of the "fresh fracture" application, but was not aware of the fact that also applied to a surgical osteotomy that included rigid fixation.

I thought that the use of rigid fixation precluded the necessity of the Exogen until the osteotomy showed evidence of delayed union, where a "fresh" traumatic fracture qualified since it did not have primary rigid fixation.

However, I am obviously incorrect and will contact my rep for a better explanation.
 
What is this procedure called as? can you give me more info on this please. i read mcglamry and never found this procedure. i saw the head (chevron,hollman),shaft (Z), base (gerbert closing wedge) etc. but didnt find anything about mini tight rope.

The Mini-TightRope is a product, not a procedure.

It's a pulley system that people can use in various applications, such as LisFrancs dislocations, bunionectomies, tailor's bunionectomies, hallux varus correction, or whatever applications you can come up with.

Here's a pdf:
 

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now you are tempting me to break my bone and call the 1-800 S&N number.:)

PS: are all doctors very good narrators? i mean describing things 100% accurately? after spending time in clinic presenting cases and describing the foot to attendings. i can now describe pretty much anything with full detail. lol.

Cant you give an estimate cost?

I am guessing the billed charge for the Exogen is around $3000-$4000. That's just a guess. The next time I have a patient in who has one, I'll ask what number was on their EOB (explanation of benefits) sheet.
 
The Mini-TightRope is a product, not a procedure.

It's a pulley system that people can use in various applications, such as LisFrancs dislocations, bunionectomies, tailor's bunionectomies, hallux varus correction, or whatever applications you can come up with.

Here's a pdf:

thanks! i just read it. wow thats pretty cool.
 
I see that they are hiring the same type of reps across the nation. Here I thought it was just my territory due to the amount I use the product. :D
Mine offered to sponsor me on a trip to Scottsdale later this month for whatever scientific conference is going on down there. Can you just picture how well that would go over? Sheeeeeeeeit.
 
thanks! i just read it. wow thats pretty cool.

It's a clever idea and good in theory but is tricky in application. In a bunion repair so much tension gets directed through the 2nd met that they are prone to 2nd met fractures. The 2.7mm drill hole through the 2nd met takes up such a large percentage of the 2nd met height that it's difficult to center. There have been several modifications such as using two smaller drill holes, using a plate on the lateral 2nd met (my idea), and anchoring the TR in the base of the 2nd met.

Patient selection is critical because anyone outside of the range is more likely to have a failure. Having to fix a comminuted 2nd met fracture when one of these pops through sucks (almost as much as explaining to the patient what happened). Ask me how I know...
 
PS: are all doctors very good narrators? i mean describing things 100% accurately? after spending time in clinic presenting cases and describing the foot to attendings. i can now describe pretty much anything with full detail. lol.

Here I go, off on a tangent again:

Sometimes I wonder if the descriptive method of documentation isn't antiquated. We learn to describe with words in detail a pathology or procedure, but nowadays it's dead-easy to snap a pic or shoot a vid. If I were to say, "maculopapular rash in a moccasin distribution" you guys then have to translate those words into your own mental image. Instead, a pic would let you see for yourself. Already many docs take pics and load them into their EMR. I do that with gross pre-op and post-op appearance (when I remember to bring my camera). I've done it with skin lesions too.

When I get a call from a patient post-op concerned that their foot "might look weird; is it okay?" then I ask them to email a pic. It is especially beneficial for my rural patients who can't easily just pop into the office.

We narrate the sequence of events in a surgery and anyone who reads the Op Report then has to take at face value that the events were accurate as described, but a video would show without embellishment or inaccuracy. I'm sure you guys have looked up foot surgery videos on YouTube, right? Wasn't that more illustrative than reading about it? I can see how this could work against us, so I'm sure many in the medical professions would resist such a change. I'm not pushing for this change myself; I'm just wondering out loud.

Right now data storage would be an issue but you know how quickly technology changes. You know the old saying, "a picture is worth a thousand words."

In some ways pictures will not replace words though. How do you take a picture of malodor or muscle tightness?
 
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Mine offered to sponsor me on a trip to Scottsdale later this month for whatever scientific conference is going on down there. Can you just picture how well that would go over? Sheeeeeeeeit.

My partner is lecturing at that conference (next weekend). I lectured at their last one a few weeks ago in Orlando. We're not Exogen speakers, but they have an hour lecture to introduce the audience to Versajet.
 
...Digital stuff (claw, hammer etc) OrthoPro intramedullary hammertoe screw because it maintains alignment indefinitely yet you can stabilize the MTPJ with a k-wire for a few weeks unlike with the bioabsorbables or other toe implants....
That's pretty cool. I will get to do a fair amount of SmartToe implants at my program, but I hadn't seen that OrthoPro. I've also seen IM screws used, but never thought of the cannulation to cross the MPJ. Interesting.
 
That's pretty cool. I will get to do a fair amount of SmartToe implants at my program, but I hadn't seen that OrthoPro. I've also seen IM screws used, but never thought of the cannulation to cross the MPJ. Interesting.
I've been quite happy with the end result thus far. It does make me wonder if the joint destruction (arthrodesis) is even necessary any more. Why remodel and try to fuse the PIP joint when there will be an unbendable metal screw through it indefinitely?

If you wanted to shorten the hammertoe would it make more sense to remove a section of the proximal phalanx and fuse the shaft rather than remove a joint?

The SmartToe is a cool implant but you lose the ability to run a K-wire across the MTPJ for stability.

Speaking of percutaneous pins, you know how we fear pin tract infections? I find it difficult to apply gauze and Kling dressing at the tip of a toe. I therefore apply some Tegaderm at the distal tip of the toe after the pin is set (the pin penetrates the membrane). The Tegaderm should provide a waterproof/breathable membrane around the pin egress, which hopefully will help deny a portal for infection.

Nat
 
The use of any bonestimulator in patients who do not have predisposing factors for a non-union is IMO an example of decisions made without science. Based upon the low reported delayed/non-unions in a healthy patient the use of bone stimulators is a waste of healthcare dollars. I would ask do you give all patients VTE prophylaxis, insist on cast immoblization/NWB, give antiobiotics throughout the entire PO period? Of course not there is no scientific reason to.
 
Stick with me my brother. I will always tell the truth. This profession has been extremely good to me but will tell it's warts. The MDs,DOs,DDS,S ODs, and DCs all have benefits and risks. It's want you want.
 
While we are on this topic, I wanted to ask those of you who have had experience with this product, if you had run into complications like infection, and how you handled this complication?

My personal experience with this product was strictly in a workshop setting but I noticed that removing this implant is extremely difficult - so I was wondering if you would typically amputate in cases of infection or attempt to trephine through the IM canal (long shot). Thanks!
 
I've been quite happy with the end result thus far. It does make me wonder if the joint destruction (arthrodesis) is even necessary any more. Why remodel and try to fuse the PIP joint when there will be an unbendable metal screw through it indefinitely?

If you wanted to shorten the hammertoe would it make more sense to remove a section of the proximal phalanx and fuse the shaft rather than remove a joint?

The SmartToe is a cool implant but you lose the ability to run a K-wire across the MTPJ for stability.

Speaking of percutaneous pins, you know how we fear pin tract infections? I find it difficult to apply gauze and Kling dressing at the tip of a toe. I therefore apply some Tegaderm at the distal tip of the toe after the pin is set (the pin penetrates the membrane). The Tegaderm should provide a waterproof/breathable membrane around the pin egress, which hopefully will help deny a portal for infection.

Nat

You could also use dermabond or indermil (skin glue). I saw someone recently use this technique for an on-Q pain pump to keep the catheter in place and decrease risk of infx.
 
You could also use dermabond or indermil (skin glue). I saw someone recently use this technique for an on-Q pain pump to keep the catheter in place and decrease risk of infx.
That's a clever idea. I wonder how much force it takes to break the bond (i.e., how much does it hurt the patient when you pull the pin out in the office and have to first break the bond)?
 
That's a clever idea. I wonder how much force it takes to break the bond (i.e., how much does it hurt the patient when you pull the pin out in the office and have to first break the bond)?

good lord that sounds horribly painful!:scared:
 
That's a clever idea. I wonder how much force it takes to break the bond (i.e., how much does it hurt the patient when you pull the pin out in the office and have to first break the bond)?

In all honesty I have no idea, however in theory it is similar to superglue and recall if you glue your fingers together (I've done this before, I'm sure that most people have too) if you wait long enough (days) as your skin exfoliates the superglue "lets go". SO I assume that the same would happen with the catheter/pins.
 
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