Download 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
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Conditions that predictably respond to CC
Non emergent conditions
Conditions with substantial recovery
High risk/difficult patients
Why Conservative Care?
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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
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Injections
NSAID’s
OTC/custom inserts
Night splints
PT (home and Rx)
Plantar Fasciitis Escalated CC
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PRP
Stem cell treatment
Laser therapy
ESWT
Cryo
Nerve ablation
Financial Considerations
• Conservative Care
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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
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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
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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
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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
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Medications
Orthotics
Bracing
Immobilization* (dual role)
PT
?Injections?
Procedures
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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
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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
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Conservative care is often succesful
Risk factor near “0”
Time=>Rapport
Trust
Rewarding
Decreases stress