docHelping Your Practice and Helping Your Patients While
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Helping Your Practice and Helping Your Patients While
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 Xrays Injection(2) OTC inserts Night splint Follow up (2) $109.15 $29.07 $59.42 $40 $161.53 $73.09 Total $531.68 Risk 0 ESWT $1250/231.17 Ultrasound $25.03 • Surgical care – EPF – Instep etc – Boot $441.08 $302.01 $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 – Xrays – Heel Lifts – Boot – Follow up (2) Total $109.15 $29.07 $20 $263.29 $73.09 $567.64 Risk 0 ESWT $1250/231.17 $36.52 Ultrasound 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 • 28740 Subtalar fusion Isoltated midtarsal $98,625 $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
