Helping Your Practice and Helping Your Patients While Limiting Risks. Michael C. McGlamry DPM, FACFAS

Transcription

1 Helping Your Practice and Helping Your Patients While Limiting Risks 2015 Michael C. McGlamry DPM, FACFAS

2 Conservative Care When Why Who

3 When to Apply Conservative Care Conditions that predictably respond to CC Non emergent conditions Conditions with substantial recovery High risk/difficult patients

4 Why Conservative Care? It works Minimal risks Allows you to get to know the pt. Medical/legal implications

5 Who? All Non emergent conditions High risk pt s Medical Social

6 Conditions

7 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

8 Plantar Fasciitis CC Treatments Injections NSAID s OTC/custom inserts Night splints PT (home and Rx)

9 Plantar Fasciitis Escalated CC PRP Stem cell treatment Laser therapy ESWT Cryo Nerve ablation

10 Financial Considerations Conservative Care IOV $ Xrays $29.07 Injection(2) $59.42 OTC inserts $40 Night splint $ Follow up (2) $73.09 Total $ Risk 0 ESWT $1250/ Ultrasound $25.03 Surgical care EPF $ Instep etc $ Boot $ Total $ day global Risk $53,737

11 Claims Instep or other open Complete Steindler stripping EPF

12 InsertionalAchilles Tendonitis/ RetrocalcanealExostosis 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**

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14 InsertionalAchilles Tendonitis/ RetrocalcanealExostosis Complications Weakness Persistent pain Achilles tendon rupture Other injuries from falls while NWB (High BMI pt s DVT/PE

15 InsertionalAchilles Tendonitis/ RetrocalcanealExostosisCC Immobilization Oral steroids NSAID s (oral and topical) Alteration shoe gear Heel lifts Bracing (Achillotrain, AFO etc.) PT (treatment and evalution for NWB ability)

16 InsertionalAchilles Tendonitis/ RetrocalcanealExostosis Escalated Conservative Care PRP injections Stem cell Topaz ESWT NO STEROID INJECTIONS!!!!!!

17 Financial Considerations Conservative Care IOV $ Xrays $29.07 Heel Lifts $20 Boot $ Follow up (2) $73.09 Total $ Risk 0 ESWT $1250/ Ultrasound $36.52 Casting $150 Surgical care Resection exostosis $ Repair Achilles $ Boot $ Total $ 90 day global Risk $62,118

18 Posterior TibialTendon 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

19 Posterior TibialTendon Dysfunction Complications Delayed or nonunion swelling DVT

20 Posterior TibialTendon Dysfunction Conservative Care Medications Orthotics Bracing Immobilization* (dual role) PT?Injections?

21 Procedures Kidner Calcaneal osteotomy Triple arthrodesis 18 claims Average payout $101,389

22 Other Procedures Subtalar fusion $98, Isoltated midtarsal $225,000

23 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

24 Charcot Neuroarthropathy Surgical Complications Wound dehiscence Nonunion Infection (+/- 30%) Ampution Death

25 Charcot Neuroarthropathy Conservative Care EARLY DX!! Offloading Ulcer care when present Bracing TCC Bone stimulation Bisphophonate therapy

26 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

27 Consent Detailed discussion about procedure as well as normal expected recovery Alternative conservative treatment options Risks Common Catastrophic

28 Summary Conservative care is often succesful Risk factor near 0 Time=>Rapport Trust Rewarding Decreases stress

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