MIS Bunion, no hardware

[pod squad]

Have been seeing an uptick in people performing 'hardware-less' MIS bunions. Typically in office-based surgery suites. The only fixation seems to be the bandaging. Does anyone have any experience with these techniques? Success stories? Horror stories?

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[Feli]

Talk to 1970s and 1980s, and you will see how that ends up

 

[GreenHousePub]

There's a guy on linkedin who brags about it, and his postops honestly look like dog ****.

I get great results with using fixation and doing MIS bunions. No sense in not.

 

[pod squad]

I get great results with using fixation and doing MIS bunions. No sense in not.

I assume the reason for not using hardware is it cuts into the profits for the PP in-office surgery

 

[HardRoadPaved]

I assume the reason for not using hardware is it cuts into the profits for the PP in-office surgery

But I thought it was to reduce need for hardware removal thus saving patient from a second surgery

 

[Hybrocure]

I don’t have the balls to do fixationless osteotomies even with full visualization let alone MIS.

If we are talking just shaving bumps though seems fine to me. I think silvers are underutilized for bump pain.

 

[NatCh]

I don’t have the balls to do fixationless osteotomies even with full visualization let alone MIS.

If we are talking just shaving bumps though seems fine to me. I think silvers are underutilized for bump pain.

Have you done many Silvers? Did you see increased valgus in those patients a few years later?

 

[Hybrocure]

Have you done many Silvers? Did you see increased valgus in those patients a few years later?

Haven’t been practicing long enough to see them come in for problems yet. I’ve only done them in older patients with sketchy bone stock

 

[Sweatshirt]

Talk to 1970s and 1980s, and you will see how that ends up

Feli and I agree on something. Everyone go buy a lottery ticket

IMO you should only be doing MPJ fusion and Lapidus, Austin in about 5% of patients. I understand doing Silver for focal bump pain only with minimal deformity but you need to educate them heavily on recurrence

 

[Hybrocure]

Feli and I agree on something. Everyone go buy a lottery ticket

IMO you should only be doing MPJ fusion and Lapidus, Austin in about 5% of patients. I understand doing Silver for focal bump pain only with minimal deformity but you need to educate them heavily on recurrence

Yeah the thing is with silvers I’ve found patients have been ok with reoccurrence if it means they can have a couple years of relief. They’re usually at an age where in 5 years they’ll have bigger health problems of concern rather than their foot

 

[DYK343]

Have you done many Silvers? Did you see increased valgus in those patients a few years later?

I did one 4-5 weeks ago for a small bump and her toe is way over already.
Never again. I told myself no. I tried to say no in my own mind. But I did it. Never again.

 

[heybrother]

(1) A few months ago I met a young man in his 30s. A podiatrist did a Silver in the office on him a year ago. Its now massively over, trackbound and terrible. Its going to have to be revised to a 1st MPJ fusion. He knew the moment he saw it that it didn't work. Still hurts. Still prominent. Silver don't work.

(2) I've shared some videos online from a podiatrist (who is deceased) who did MIS surgery in the office. In one of his videos I believe he indicated that 1st ray without fixation is where things get interesting and where your liability increases. Of course technically the original Austin cuts were designed to be stable. If you read some of the in office MIS literature / watch videos of the MIS procedures performed in the office what you will see is they definitely aren't the procedures people are performing in the operating room. There's a tendency towards procedures with medial closing wedges to relocate cartilage, heavier focus on Reverdin type stuff etc. Look-up Isham type procedures. People doing MIS in the OR probably just do straight Hohman or Austins, but I don't think that's what people are doing in their office. Open to being wrong.

(3) I was recently at a conference and met another podiatrist who mentioned MIS on their website. They've done some MIS in their office but they haven't pulled the trigger yet on 1st ray. They attended TJ Ahn's course and its apparently discussed extensively at the course. The person I spoke to was hesitant. They were sticking to hammertoes, ostectomies, and tailor's bunions.

(4) I've watched most of TJ Ahn's videos. There aren't a lot of post-op 1st ray x-rays. In the one that comes to mind there was a lot of callus which would be expected of an unfixated procedure.

(5) My surgical outcomes have been very good lately, but my patient compliance outcomes have been attrocious. People walking on everything in spite of counseling and discussion about the treatment plan. Haven't gotten burned but somewhat dumbfounding moments. If someone won't stop walking on a fusion I'm somewhat concerned what will go wrong with no fixation... or maybe the bone will just be strong enough and everything will be great.

(6) If you watch TJ Ahn's videos - going out of network and offering in office MIS surgery is theoretically the backbone of success. I've made this comment before - "there's no procedure you can do each day where you can just be done". Well... technically that's not true. Imagine if you just did 1 surgery a day but you billed $3K cash for it. How man patients a day would you need to see if you had a $3K surgery as the backbone of the day.

(7) I've spent some timing looking at the costs and reimbursement for doing these in the office. The math for purchasing fluoro and what not is just a lot more compelling if you are also adding 1st ray reimbursement. People who do this may be trying to spare the patient facility fees or anesthesia, but there's quite a bit of extra $ available if you have a Medicare based contract that multiplies by the non-facility rate.

 

[PTPuser]

(1) A few months ago I met a young man in his 30s. A podiatrist did a Silver in the office on him a year ago. Its now massively over, trackbound and terrible. Its going to have to be revised to a 1st MPJ fusion. He knew the moment he saw it that it didn't work. Still hurts. Still prominent. Silver don't work.

(2) I've shared some videos online from a podiatrist (who is deceased) who did MIS surgery in the office. In one of his videos I believe he indicated that 1st ray without fixation is where things get interesting and where your liability increases. Of course technically the original Austin cuts were designed to be stable. If you read some of the in office MIS literature / watch videos of the MIS procedures performed in the office what you will see is they definitely aren't the procedures people are performing in the operating room. There's a tendency towards procedures with medial closing wedges to relocate cartilage, heavier focus on Reverdin type stuff etc. Look-up Isham type procedures. People doing MIS in the OR probably just do straight Hohman or Austins, but I don't think that's what people are doing in their office. Open to being wrong.

(3) I was recently at a conference and met another podiatrist who mentioned MIS on their website. They've done some MIS in their office but they haven't pulled the trigger yet on 1st ray. They attended TJ Ahn's course and its apparently discussed extensively at the course. The person I spoke to was hesitant. They were sticking to hammertoes, ostectomies, and tailor's bunions.

(4) I've watched most of TJ Ahn's videos. There aren't a lot of post-op 1st ray x-rays. In the one that comes to mind there was a lot of callus which would be expected of an unfixated procedure.

(5) My surgical outcomes have been very good lately, but my patient compliance outcomes have been attrocious. People walking on everything in spite of counseling and discussion about the treatment plan. Haven't gotten burned but somewhat dumbfounding moments. If someone won't stop walking on a fusion I'm somewhat concerned what will go wrong with no fixation... or maybe the bone will just be strong enough and everything will be great.

(6) If you watch TJ Ahn's videos - going out of network and offering in office MIS surgery is theoretically the backbone of success. I've made this comment before - "there's no procedure you can do each day where you can just be done". Well... technically that's not true. Imagine if you just did 1 surgery a day but you billed $3K cash for it. How man patients a day would you need to see if you had a $3K surgery as the backbone of the day.

(7) I've spent some timing looking at the costs and reimbursement for doing these in the office. The math for purchasing fluoro and what not is just a lot more compelling if you are also adding 1st ray reimbursement. People who do this may be trying to spare the patient facility fees or anesthesia, but there's quite a bit of extra $ available if you have a Medicare based contract that multiplies by the non-facility rate.

You mentioned a while back that you wish we went back to the time of in-office surgery and I think about that all the time. It would be so much nicer.

 

[pod squad]

My concern would be that if you stake your practice's whole reputation on doing this stuff in-office...all it takes is one bad outcome and you become the town butcher. I'm sure it works great until it doesn't....

 

[heybrother]

You mentioned a while back that you wish we went back to the time of in-office surgery and I think about that all the time. It would be so much nicer.

The most important thing ultimately is that we do the right thing for people, but its something interesting to think about. What if you didn't grind and see 40 people. What if you performed a mixture of valuable and well received, effective procedures in your own office. Under that mentality the forefoot is a gift. For today though I will just have to settle for having done a crapload of sinus tarsi and plantar fascial injections. It was ridiculous.

 

[heybrother]

My concern would be that if you stake your practice's whole reputation on doing this stuff in-office...all it takes is one bad outcome and you become the town butcher. I'm sure it works great until it doesn't....

I know what you are saying, but bad outcomes don't seem to be sinking people. I see so many botched and butchered bunions - obvious cases that deserved 1st MPJ fusion or lapidus that were done as tiny Austin pushes or less. Patients complaining they knew the bunion wasn't fixed at the 1st visit but the doctor kept telling them they just needed a splint to hold it over. Botching a bunion doesn't seem to keep people out of the operating room.

 

[pod squad]

Botching a bunion doesn't seem to keep people out of the operating room.

Agree, but maybe it would keep them out of the Magical Mustache office surgery suite?

 

[Hybrocure]

Bunions even are becoming not worth the headache with reimbursement to be honest especially factoring in global from an associate perspective for private practice.

Unless you’re lining up multiple bunions on an OR day and pumping them out in a timely manner like a factory line I find it more so just something you put up with for a net money loss compared to clinic work. And I know very few new grads with that ability or surgical load.

 

[heybrother]

Agree, but maybe it would keep them out of the Magical Mustache office surgery suite?

Botch enough cases and that's the only place you can operate. Calling it a surgery suite makes it sound fancy. Its hopefully a slightly larger room with an office chair, a mayo, maybe fluoro, and an Osada drill with some drapes thrown up.

 

[heybrother]

Bunions even are becoming not worth the headache with reimbursement to be honest especially factoring in global from an associate perspective.

Being an owner doesn't make it much better. Medicare pays $500-600 for 28296, 28299, 28297. Whether you multiply it by 30, 40, or 50% the deal is still pretty raw. And then you dispense them a boot and -that-, seriously, ridiculously, increases your reimbursement by 50%.

That said - for me the below has been life changing. We talk about surgery not being wortwhile, but effective well performed cases under this arrangement are I think very reasonable.

 

[NatCh]

I did one 4-5 weeks ago for a small bump and her toe is way over already.
Never again. I told myself no. I tried to say no in my own mind. But I did it. Never again.

Yeah, as a rule I don't do Silvers because of exactly what you had happen (although I'd maybe make an exception for someone who had a compelling reason like Hybrocure mentioned). That patient would have to be pretty convincing though.

 

[FootGuy]

Talk to 1970s and 1980s, and you will see how that ends up

Feli and I agree on something. Everyone go buy a lottery ticket

IMO you should only be doing MPJ fusion and Lapidus, Austin in about 5% of patients. I understand doing Silver for focal bump pain only with minimal deformity but you need to educate them heavily on recurrence

1. YES!

- Doc Brown from Back to the Future called..... he says he can fix your bunion like no one else in "modern medicine."

2. ABSOLUTELY YES!!!

- The "On-line Experts" from TFP University showing minimally invasive, non-fixated bunion correction and claiming to be the "World's Best Bunion Surgeons" ...... well ...... they just ARE NOT!

 

[DYK343]

Yeah, as a rule I don't do Silvers because of exactly what you had happen (although I'd maybe make an exception for someone who had a compelling reason like Hybrocure mentioned). That patient would have to be pretty convincing though.

The patient talked me into it.
I should have held firm on my training/instincts. It really was more of a bump than a bunion. Sesamoids were acceptable. She had really skinny feet and a prominent 1st met head medially. But now its leaning towards a real bunion lol.
Never again. I cant think of any other time I did one outside of residency/as a student. My one and only.

Bunions even are becoming not worth the headache with reimbursement to be honest especially factoring in global from an associate perspective for private practice.

Unless you’re lining up multiple bunions on an OR day and pumping them out in a timely manner like a factory line I find it more so just something you put up with for a net money loss compared to clinic work. And I know very few new grads with that ability or surgical load.

Im with you. Honestly they dont pay that well.

A 5 minute toe amp on a hospital floor pays the same. 1-2 preop visits, toe amp itself, and post op visits add up. Granted my office is in the hospital. If i had to drive to consult/amp/post op round that would be way different.

Toe amps are the most unstressful cases in the world. I'm leaning more and more away from elective bony cases. I am good at them (minus my Silver..) but the expectations are high and they take a lot more mental energy.

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Back to MIS without hardware cases. Absolutley not. I know some people doing them. They claim good results. Back to normal activity in 1-2 weeks. The feet look OK but when I see the xrays it’s non union city. Granted an asymptomatic non union doesnt necessarily need treated but it also shouldnt be the goal. The xrays are atrocious. Yes, yes I know treat patients not xrays. But I suspect all those patients with the 1st met head non unions will develop sub 2nd met head pain. I’ll pass on the screwless MIS stuff.

Why is everyone so afraid of an incision? An Austin could technically be back to normal activity in 2 weeks once stitches are out. With the new plates/constructs the lapidus could be back to normal activity in 2 weeks once stitches are out. I walk all my 1st MPJ fusions day 1. They do great (minus swelling).

Also why the hate on an Austin? I would 100% more trust an Austin than a MIS met osteotomy with or without screw fixation. I have been known to push the limits with my Austin. Really crank it over. That said 7/10 times I lapidus. But I still do Austins every now and then. They always get a bad wrap but if done properly/in the right patient you can get a good correction. Weve all had patients who come in with recurrent bunions post Austin in the 80s or whenever. But we also all have patients that come in for something else and their 80s Austin still looks good. Right patient/done properly is key.

I dont fuse many bunions unless there is 1st MPJ arthritis. Fusion is an effective procedure but its not always the best bunion procedure. Yes I know that is a very provacative statement to the fusion people.

I think we can all agree - never implant.

 

[Sweatshirt]

The patient talked me into it.
I should have held firm on my training/instincts. It really was more of a bump than a bunion. Sesamoids were acceptable. She had really skinny feet and a prominent 1st met head medially. But now its leaning towards a real bunion lol.
Never again. I cant think of any other time I did one outside of residency/as a student. My one and only.

Im with you. Honestly they dont pay that well.

A 5 minute toe amp on a hospital floor pays the same. 1-2 preop visits, toe amp itself, and post op visits add up. Granted my office is in the hospital. If i had to drive to consult/amp/post op round that would be way different.

Toe amps are the most unstressful cases in the world. I'm leaning more and more away from elective bony cases. I am good at them (minus my Silver..) but the expectations are high and they take a lot more mental energy.

------------------

Back to MIS hardware cases. Absolutley not. I know some people doing them. They claim good results. Back to normal activity in 1-2 weeks. The feet look OK but when I see the xrays its non union city. Granted an asymptomatic non union doesnt necessarily need treated but it also shouldnt be the goal. The xrays are atrocious. Yes, yes I know treat patients not xrays. But I suspect all those patients with the 1st met head non unions will develop sub 2nd met head pain. Ill pass on the screwless MIS stuff.

Why is everyone so afraid of an incision? An Austin could technically be back to normal activity in 2 weeks once stitches are out. With the new plates/constructs the lapidus could be back to normal activity in 2 weeks once stitches are out. I walk all my 1st MPJ fusions day 1. They do great (minus swelling).

Also why the hate on an Austin? I would 100% more trust an Austin than a MIS met osteotomy with or without screw fixation. I have been known to push the limits with my Austin. Really crank it over. That said 7/10 times I lapidus. But I still do Austins every now and then. They always get a bad wrap but if done properly/in the right patient you can get a good correction. Weve all had patients who come in with recurrent bunions post Austin in the 80s or whenever. But we also all have patients that come in for something else and their 80s Austin still looks good. Right patient/done properly is key.

I dont fuse many bunions unless there is 1st MPJ arthritis. Fusion is an effective procedure but its not always the best bunion procedure. Yes I know that is a very provacative statement to the fusion people.

I think we can all agree - never implant.

I don't think there is so much "hate" for Austin's... there are just better and more reliable procedures nowadays. If you are a good doc with a conscious you'll likely pick Lapidus/MPJ fusion over Austin the majority of the time. No real hate to the Austin, technology and research has just advanced nowadays

MPJ fusion/Lapidus > Austin >>>>>>>>>>>>>>>>>>>>>> MIS >>>>>>>>>>>>>>>>>>>>>>>>>>>> implant

 

[dtrack22]

MIS bunions with fixation are just Austin’s done percutaneously with increased lateral translation and significantly less post-op stiffness at the MPJ. The non union rate is lower than 1st TMT fusion. Conflating in office hardware-less 1st ray procedures and current MIS “systems” is disingenuous. I do MIS, MPJ fusion and Lapidus. Newer MIS systems have simply allowed me to expand the number of folks I can offer distal osteoeomty procedures to, compared to open distal met procedures. But it doesn’t drastically change the formula/decision making process.

Currently doing malpractice work on a lapiplasty case…

 

[pod squad]

Looking more into Reverdin Ishams, I guess they would do OK without hardware since you are allegedly not violating the lateral cortex. But I have doubts about it actually fixing the deformity

 

[Feli]

I assume the reason for not using hardware is it cuts into the profits for the PP in-office surgery

They used to do the "surgery" under straight local, so you can't do fixation or full OR. They were just injecting the lido, scrubbing the foot, putting in the Shannon burr, and shaving bumps, making osteotomies, wrapping up nerves and arteries, all that fun stuff right in the office exam room "surgical suite."

Not using fixation is a way to save $ on fixation and all of the associated instruments, power, etc.

When you think MIS (burr w/o fixation), you are not thinking what's good for the pt. It's about profits.
The "new MIS" is debatable... I'm not onboard. Some ppl like it.

...again, basically everything we do (surgical or otherwise) is about profit. All of the trends come down to dollars. De/reattach is popular because it pays well as much as because it works. Ditto for TN + STJ fusion codes vs triple codes. Again for FHL transfer when doing Achilles (FHL xfer is better code). Obviously same reasoning on "spot weld" and other bunion unbundle gimmicks. In-office plantar fasciotomy or 3 stab TAL are suboptimal, but ppl do them because they pays better since you don't have to go to OR (well, you might to revise them). Same logic for "new MIS" versus open met ostetomies... faster for same pay.

Whenever a new procedure comes out, just follow the money and look up the CPT codes compared to what was done prior... it'll never be less RVU/$ value. Bank on that. Sure, they might work well also, but they become popular and interest starts mainly due to reimburse and almost always surgeons who were paid to develop and research the new stuff.

 

[podiatryresident]

MIS bunions with fixation are just Austin’s done percutaneously with increased lateral translation and significantly less post-op stiffness at the MPJ. The non union rate is lower than 1st TMT fusion. Conflating in office hardware-less 1st ray procedures and current MIS “systems” is disingenuous. I do MIS, MPJ fusion and Lapidus. Newer MIS systems have simply allowed me to expand the number of folks I can offer distal osteoeomty procedures to, compared to open distal met procedures. But it doesn’t drastically change the formula/decision making process.

Currently doing malpractice work on a lapiplasty case…

What do you think about lateral release and sesamoids reduction that MIS can't do ? I think Austin with longer dorsal arm is much better than MIS.

 

[pod squad]

What do you think about lateral release and sesamoids reduction that MIS can't do ? I think Austin with longer dorsal arm is much better than MIS.

Most of the good MIS outcomes I've seen have excellent sesamoid positioning, that's probably the one thing that looks good on x-ray. Can also do a perc lateral release MIS.

 

[dtrack22]

What do you think about lateral release and sesamoids reduction that MIS can't do ? I think Austin with longer dorsal arm is much better than MIS.

 

[air bud]

What do you think about lateral release and sesamoids reduction that MIS can't do ? I think Austin with longer dorsal arm is much better than MIS.

What is an Austin?

 

[NatCh]

What is an Austin?

It's like a Kalish but without a long dorsal arm.

 

[air bud]

It's like a Kalish but without a long dorsal arm.

Oh so a youngswick without the extra piece removed to rotate dorsally. Gotcha