Offloading diabetic foot ulcers

[Pronation]

Tendonotification?

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[Feli]

Tendonotification?

I shall hook a syringe full of air to the 18ga to bill a topaz type ablation.
Must make sure to get a prior auth for unlisted code 28899 foot.

Try plantar fasciotomy also for a few needle swipes after syringe removal. It may get denied... but worth a shot.

 

[dtrack22]

We are probably talking different things...

For FDL (and FDB) flexible lesser digit tuft ulcer, 18ga tendonotomy works fairly good... I agree. I probably bag an avg of 0.68 digital proper branches per proc, but yeah. Works well.
FHL with 18ga = sketchy at best. Not reliable. Not the right tool.
Plantar fascia meaningful 18ga release = not happening. Not effective.

It’s just not true. The cutting edge of the needle will cut through any soft tissue of the foot. It can take longer/more passes as the tendon gets larger, but FHL is no more dense than FDL. I did perc tenotomies of toes 1-5, 3-4 weeks ago. Patient had loss of plantarflexion consistent with FHL release during procedure and again 2 weeks after at first return visit. The 18ga will cut the FHL no problem.

I have an instep plantar fasciotomy in a couple weeks. I’ll go ahead and have a rep record the fasciotomy while I do it with an 18ga instead of a #15 blade. Then we’ll listen to Feli explain to us how it’s still impossible for an 18ga to resect a portion of the plantar fascia.

 

[Shiyuan]

“In my hands” (😉) it’s worked well. We’ll see with time how things go.

 

[Feli]

...I have an instep plantar fasciotomy in a couple weeks. I’ll go ahead and have a rep record the fasciotomy while I do it with an 18ga instead of a #15 blade. Then we’ll listen to Feli explain to us how it’s still impossible for an 18ga to resect a portion of the plantar fascia.

It's definitely not impossible... it's just not the right tool.
InStep is also not blind swiping in the clinic. But no matter.

The needles just get beat up FAST. We are talking after even one insert... definitely beat to heck after multiple swipes or inserts. Flaking off shards of metal, denting, blunting. It's very real. There are tons of the microscope pics of dulling/damage to inject needles after uses, mostly medical... some dent, vet, acupuncture, etc. Even vets and agriculture view it as inhumane to re-use needles. I found most of this out doing research on 'injectables' back during undergrad weightlifting, lol.

So yeah, I mean, we could maybe even use a 20ga to do an Achilles tendonotomy or TAL with 100 passes, or we might be able to do a Weil with a 15 scalpel and enough swipes... but can vs should. I don't think the 18ga is anywhere near effective or efficient for PF (Mayo scissor or Sistrunk or 15 blade or multiple is more on par). I only find it to work well for FDL lesser. Jmo though... gotta hit gym, last word is yours. Glad it works 4u.

 

[dtrack22]

FHL is still a decnt sized tendon and has irregular at best office results done perc (again, 18ga unreliable

Plantar fascia meaningful 18ga release = not happening.

….

The needles just get beat up FAST

 

[msuDPM]

Don't disagree that all of these things CAN be done with an 18 Ga needle, but personally have never understood why people have wanted to screw around with doing tenotomies with them.

Save yourself some time and buy a pack of #6200 beaver blades. Same, if not smaller incision.

Also, from a practice standpoint, the times I have done a FT with a needle I couldn't help but feel it looked quite silly and wondered what I would think as a patient being billed for a "surgical procedure" as this dude roots around in my toe with a inch and a half needle..

 

[dtrack22]

#6200 beaver blades

Nothing wrong with that. The point is simply to do a procedure which doesn’t require a stitch and essentially clots/closes within a day.

However, it doesn’t satisfy Feli’s main concern which converted to needle damage (his pictures are from a study in India using 30ga insulin needles…). If the needle is going to release shards of metal or break in the patients foot so will a 6200 beaver blade. Also, since it’s the size of an 18ga needle then I’m not even sure how it can reliably cut through the FHL if you were to use it for that…food for thought

 

[shadesofgrey]

I’ve done a few (maybe 12) of the distal plantar fasciotomies, with maybe 50% success rate. I think the failures I’ve seen were when I underestimated how rigid the deformity was or thought I had released it and didn’t fully.

I can confirm you can cut the fascia with an 18 g needle, as the last time I did it I checked it with our ultrasound machine because of my fear of not fully releasing it. To Felis point though, at times it took more than one needle and my hand felt like it was going to cramp.

I hate, hate, hate sub IPJ ulcers and don’t seem to have much luck offloading the bastards.

 

[DYK343]

I’ve done a few (maybe 12) of the distal plantar fasciotomies, with maybe 50% success rate. I think the failures I’ve seen were when I underestimated how rigid the deformity was or thought I had released it and didn’t fully.

I can confirm you can cut the fascia with an 18 g needle, as the last time I did it I checked it with our ultrasound machine because of my fear of not fully releasing it. To Felis point though, at times it took more than one needle and my hand felt like it was going to cramp.

I hate, hate, hate sub IPJ ulcers and don’t seem to have much luck offloading the bastards.

Ive failed so many times with these little tiny ulcers. They just seem impossible to cure and im not a fan of kellers.

Not gonna lie I have been TFP'in with the football dressing for these and getting them to heal up quicker than anything else ive tried. Usually 2 weeks when they almost always go on for months.

Im doing an akin tomorrow for one that just wont heal. Maybe I should do a p fascia release too!

 

[dtrack22]

I’ve done a few (maybe 12) of the distal plantar fasciotomies, with probably 50% success rate. I think the failures I’ve seen were when I underestimated how rigid the deformity was or thought I had released it and didn’t fully.

I can confirm you can cut the fascia with an 18 g needle, as the last time I did it I checked it with our ultrasound machine. To Felis point though, at times it took more than one needle and my hand felt like it was going to cramp.

I hate, hate, hate sub IPJ ulcers and don’t seem to have much luck offloading the bastards.

Yeah I had one recently recur. But they did heal around 3 weeks after the procedure even though they had been receiving wound care and had felt offloading on every day for the previous 3 months. Remained healed for 3-4 months. Recurred. Went to a Keller. Healed again. Good thing I did the Keller instead because we know those have zero complications…

I’ve had some that were very rigid and I don’t discuss the procedure with the patient. Same with rigid hammertoes, don’t even go in to option of perc tenotomy.

Even if you had a 50% success rate. It can be done on the spot in 5-20 minutes (depending on if you have DYK’s old clipboard nurses or not). If it doesn’t work you can still go to OR for your procedure of choice. I’m still waiting to find that I do more harm than good with the fasciotomy procedure.

 

[josebiwasabi]

I'm not really understanding Feli's posts regarding this procedure.

These are all patients who have failed at least 3 months of traditional offloading methods with regular local wound care. In the right patient, it's a great, relatively low risk office procedure that saves the patient a trip to the OR. It is also significantly less aggressive than a keller or IPJ arthroplasty so less bridges are burned.

I've had probably a 70% success rate with the medial band plantar fasciotomy with an 18G needle. My personal series is around 10 patients. The medial band of the plantar fascia at the level of the base of the 1st metatarsal is nowhere near as thick as the plantar fascia at the instep/heel region of a traditional plantar fasciotomy. It is quite easy to cut it with the 18G needle and there is a palpable dell immediately postoperatively after successful completion of the fasciotomy. Postoperative my bandage involves a 1/2" steristrip and a bandaid. They go into a CAM boot for 4 weeks without any special offloading or other accommodation.

On average, I find that these heal within 4-6 weeks after the procedure. The average ulcer duration of these patients (who are usually referred to my clinic) is >6 months.

Apart from the clear contraindicated1st MTPJ arthritis/rigidus, the patients who have failed are those are have a severe pes planus component (even without arthritis), so I don't do it on those patients any more.

 

[DYK343]

I just read the first page of this thread and have zero recollection that we already had much of this convo back in june...

 

[air bud]

I’ve done a few (maybe 12) of the distal plantar fasciotomies, with maybe 50% success rate. I think the failures I’ve seen were when I underestimated how rigid the deformity was or thought I had released it and didn’t fully.

I can confirm you can cut the fascia with an 18 g needle, as the last time I did it I checked it with our ultrasound machine because of my fear of not fully releasing it. To Felis point though, at times it took more than one needle and my hand felt like it was going to cramp.

I hate, hate, hate sub IPJ ulcers and don’t seem to have much luck offloading the bastards.

That is because a IPJ ulcer is a surgical case.

Also haven't been doing Keller's, instead IPJ arthroplasty. Offsetting incision and leaving tendon alone. Makes a little hard to get bone out. Probably will try some MIS burrs next and just liquify that bone.

And as continually gets noted with hospital vs PP.. completely understand why PP doesn't want this stuff. It's 10 minute case. I walk 50 yards down the hallway to the OR, finish and then walk another 25 yards to the physician lounge for lunch then back in my office and did this all during lunch break. That is a 2 hour waste of time with driving and other stuff in PP.

 

[air bud]

I’ve done maybe a dozen of these and far more flexor tenotomies with 18ga needles. The statements above are rather ignorant. You actually believe you are going to break an 18ga needle in the foot while swiping across the plantar fascia?

Thinking that a prefab is healing these people in my clinic (procedure is only done when they have already failed custom accommodative inserts and or daily felt offloading) is also pretty ignorant.

Feli is slowly morphing into bitter old TFP man around here 🙄

Watch out next thing you know he will be telling you that you can do a lapidus with 2 screws and 1st mpj fusion with stainless steel plate and crossing screw .

 

[HardRoadPaved]

Watch out next thing you know he will be telling you that you can do a lapidus with 2 screws and 1st mpj fusion with stainless steel plate and crossing screw .

Or next level up... Treace Medical's Lapiplasty sets

 

[Feeter]

I'm not really understanding Feli's posts regarding this procedure.

These are all patients who have failed at least 3 months of traditional offloading methods with regular local wound care. In the right patient, it's a great, relatively low risk office procedure that saves the patient a trip to the OR. It is also significantly less aggressive than a keller or IPJ arthroplasty so less bridges are burned.

I've had probably a 70% success rate with the medial band plantar fasciotomy with an 18G needle. My personal series is around 10 patients. The medial band of the plantar fascia at the level of the base of the 1st metatarsal is nowhere near as thick as the plantar fascia at the instep/heel region of a traditional plantar fasciotomy. It is quite easy to cut it with the 18G needle and there is a palpable dell immediately postoperatively after successful completion of the fasciotomy. Postoperative my bandage involves a 1/2" steristrip and a bandaid. They go into a CAM boot for 4 weeks without any special offloading or other accommodation.

On average, I find that these heal within 4-6 weeks after the procedure. The average ulcer duration of these patients (who are usually referred to my clinic) is >6 months.

Apart from the clear contraindicated1st MTPJ arthritis/rigidus, the patients who have failed are those are have a severe pes planus component (even without arthritis), so I don't do it on those patients any more.

There are couple articles that support this. I think the pts that did well were the ones who had increased ROM of the first MTPJ after the plantar fascia release. Successful healing was in the 60% range which isn't great but better than Keller imo. Keller has had poor success in my hands.

First plantar IPJ ulcers I do TAL, medial PF release and shave down phalanx. Walk in boot until ulcer heals and then diabetic shoes and inserts. Works alright.

 

[Feeter]

Don't disagree that all of these things CAN be done with an 18 Ga needle, but personally have never understood why people have wanted to screw around with doing tenotomies with them.

Save yourself some time and buy a pack of #6200 beaver blades. Same, if not smaller incision.

Also, from a practice standpoint, the times I have done a FT with a needle I couldn't help but feel it looked quite silly and wondered what I would think as a patient being billed for a "surgical procedure" as this dude roots around in my toe with a inch and a half needle..

I just use a 15 blade and put one stitch in it. Local if pt has sensation. Nothing wrong with 18 gauge needle if it works in your hands.

 

[Pronation]

There are couple articles that support this. I think the pts that did well were the ones who had increased ROM of the first MTPJ after the plantar fascia release. Successful healing was in the 60% range which isn't great but better than Keller imo. Keller has had poor success in my hands.

First plantar IPJ ulcers I do TAL, medial PF release and shave down phalanx. Walk in boot until ulcer heals and then diabetic shoes and inserts. Works alright.

Surprising to hear that you’re not having great results with a Keller. Literature shows good results and I’ve had the same. I love Kellers.

 

[air bud]

Surprising to hear that you’re not having great results with a Keller. Literature shows good results and I’ve had the same. I love Kellers.

I have stayed away from colors mainly just because the ipj arthroplasty seems to be working. Need to do more gastrocs but right foot, compliance, balance etc...easier to not do and wear a surgical shoe vs boot

 

[dtrack22]

I have stayed away from colors

 

[air bud]

Lol. Nice voice text autocorrect. That would be Keller's

 

[HardRoadPaved]

So yeah, I mean, we could maybe even use a 20ga to do an Achilles tendonotomy or TAL with 100 passes

View attachment 370035

 

[DYK343]

Don't disagree that all of these things CAN be done with an 18 Ga needle, but personally have never understood why people have wanted to screw around with doing tenotomies with them.

Save yourself some time and buy a pack of #6200 beaver blades. Same, if not smaller incision.

Also, from a practice standpoint, the times I have done a FT with a needle I couldn't help but feel it looked quite silly and wondered what I would think as a patient being billed for a "surgical procedure" as this dude roots around in my toe with a inch and a half needle..

I like the beaver blade method. I dont know the # but one has a curved edge and would probably be better.
That said I think a Beaver blade could actually come loose in a foot. Ive had them pop off mid ingrown nail before.

I might try this at the wound center next week. Ill find a sacrifical lamb.

@diabeticfootdr What do you do for plantar medial hallux ulcers being a wound care guru?

 

[heybrother]

#64 is the ideal flexor tenotomy blade.

-The tip is rounded so you can either cut across or cut with pressing the tip
-The blade main cutting surface is 1 sided instead of 2 sided like a beaver blade
-With a #64 you can insert the blade with the blunt side again the flap, turn and cut. If you try to do that with a beaver you'll cut the flap and get a cross-shaped cut.

 

[AttackNME]

Who cares how you cut the thing, I think you’re all winning here because you actually know there is a surgical option. I’ve had patients with toe tip ulcers see me and say that their podiatrist hasn’t been able to heal it for months and is trying to get the patient to do hyperbaric oxygen. 🙄

I laughed, did a ftt and healed it in 2 weeks, patient was dumbfounded

 

[p100]

This might be a bit controversial but hear me out.

The first few visits of wound care do your best. Give them education and offloading etc. If they are non-compliant and do not seem to care at all then use the most expensive products and make bank. This kind of patient may be encouraged to be compliant when they get big bills so in a way you are treating them. If they still don't care then don't worry about taking their money because if you don't the hospital will when they die.

 

[msion]

This thread reminded me something that happened at Kaiser SF.
One nonsurgical wound care doc dropped dead one day. So bunch of the chronic ulcer patients flooded into other DPMs' schedules. And of course over there some of the big boys of ACFAS were/are working at the time. There was no way Schuberth would debride ulcers in clinic. No freaking way.

So here was what happened: the DPMs there basically worked nights and weekends and amp'd everyone. TMAs at a minimum, BKAs went to Ortho/Vascular.

The results were actually good that this essentially eliminated the demand for a replacement nonsurgical wound care DPM.
Not sure how it is now over there but I always reflect back on this. Demand for wound care can be artificially created or eliminated.

 

[Adam Smasher]

This thread reminded me something that happened at Kaiser SF.
One nonsurgical wound care doc dropped dead one day. So bunch of the chronic ulcer patients flooded into other DPMs' schedules. And of course over there some of the big boys of ACFAS were/are working at the time. There was no way Schuberth would debride ulcers in clinic. No freaking way.

So here was what happened: the DPMs there basically worked nights and weekends and amp'd everyone. TMAs at a minimum, BKAs went to Ortho/Vascular.

The results were actually good that this essentially eliminated the demand for a replacement nonsurgical wound care DPM.
Not sure how it is now over there but I always reflect back on this. Demand for wound care can be artificially created or eliminated.

I wanted to react with an emoji but I can't pick which one. Instead, here's a youtube clip that comes to mind:

 

[DYK343]

This thread reminded me something that happened at Kaiser SF.
One nonsurgical wound care doc dropped dead one day. So bunch of the chronic ulcer patients flooded into other DPMs' schedules. And of course over there some of the big boys of ACFAS were/are working at the time. There was no way Schuberth would debride ulcers in clinic. No freaking way.

So here was what happened: the DPMs there basically worked nights and weekends and amp'd everyone. TMAs at a minimum, BKAs went to Ortho/Vascular.

The results were actually good that this essentially eliminated the demand for a replacement nonsurgical wound care DPM.
Not sure how it is now over there but I always reflect back on this. Demand for wound care can be artificially created or eliminated.

Brutal

I wanted to react with an emoji but I can't pick which one. Instead, here's a youtube clip that comes to mind:

extra brutal

 

[DYK343]

I considered a perc plantar fasciotomy today in the wound clinic. Patient declined.

 

[ExperiencedDPM]

Feli is correct. Could is different than should.

A circumcision could be done with an 18 gauge needle……but …..,,

 

[Shiyuan]

Feli is correct. Could is different than should.

A circumcision could be done with an 18 gauge needle……but …..,,

But, “in my hands”....😉

 

[PeaJay]

So what CPT is being used for the first mpj plantar fascia release? The same as for medial band at central heel?

 

[Feli]

So what CPT is being used for the first mpj plantar fascia release? The same as for medial band at central heel?

Yeah... it's the normal PF code that I listed on the previous page. That's the whole idea of build EBM for it, doing it, saying it works well, etc: to get paid (then probably get paid again for Keller and/or open PF later also).

Whenever something surgical - or clinic or DME - comes out or starts getting popular that doesn't make a ton of sense, you can usually just figure out the differences in total RVUs or global and figure out why...
STJ + TN instead of classic triple
Akins on everything everywhere all at once
billing TMAs or rays as toe amp + deep/open bone biopsies to avoid global
"spot weld" fusions
bogus wound grafts (whichever happens to get paid by MCR or pay well shockingly "works best" also)

 

[Pronation]

STJ + TN instead of classic triple

wat

 

[dtrack22]

wat

Yeah Feli didn’t take his meds again. Some of those examples (ie spot weld, deep bone biopsies) are billing/coding shenanigans but others have legitimate EBM or sound biomechanical theory behind them.

 

[Feli]

Yeah Feli didn’t take his meds again. Some of those examples (ie spot weld, deep bone biopsies) are billing/coding shenanigans but others have legitimate EBM or sound biomechanical theory behind them.

I'm not saying medial approach double - or triple - arthrodesis doesn't work (esp for valgus hindfoot), but the 28715 (triple) pays 28.2 rvu and the TN + STJ (28740 + 28725) pays 24.7 + 23.3... so so 36.4 rvu with the smaller code 50%. That's a difference of 8rvu aka approx $400. With work rvu, I think the % increase is even higher.

The reduction in what the CPT code for triple pays played into the change in popularity. It's not as if triple suddenly stopped working, but people coincidentally got interested in and started lecturing and publishing on something similar that pays significantly more. It's definitely not unrelated.

That's how the game is played.

 

[dtrack22]

It's not as if triple suddenly stopped working, but people coincidentally got interested in and started lecturing and publishing on something similar that pays significantly more.

Never mind the unnecessary nature of the CC fusion in a vast majority of flatfoot correction. It must be billing driven and not the fact that it’s a pointless procedure that doesn’t change outcomes and increases complication rates in most cases 🙄