Surgery advice.

[seekerofwisdom]

Bill,

A bit of brain picking and trying to get away from the eternal FHP debate.

Had a client last week who I will never see again who has been being treated for an IGN medial 5th nail.

The treatment has been over a number of years, basically hacking back the nail.

My diagnosis was a corn at the base of the nail.

Enucliated and a dig wedge made.

We discussed etiology and possible interventions.

Etiology was a burrowing 5th toe, she suggested 'cutting it off', I agreed but suggested just the distal phalange.

I know it is hard without seeing the patient, but if you accept no medical contras, is it a good idea and how much privately? Client approx 40.

Shy

[billliggins]

Hello Shy

Thanks for an interesting question.

It would really depend on what the Xray showed. Frequently, in such cases, there is a hypertrophic tuft at the base of the distal phalanx; interestingly, this is also true when there is an ankylosis of the intermediate and distal phalanges. In such a case it might be possible to carry out removal of the tuft or as an alternative a phalangectomy.

Amputation of a 5th toe is not often carried out today because of the loss of the butressing effect resulting in problems with the 4th, although in extreme circumstances it could be. A Symes partial could be carried out as you suggest.

I can't give you an accurate figure for costings because the major portion of the fee is charged by the hospital and I don't have those charges. However, I would think that she would be looking at somewhere in the region of £1500.00.

All the best

Bill

[seekerofwisdom]

Bill,

Thanks for the reply, hopefully I can think of more like that. Do you think 'we' (Podiatrists) sometimes avoid the surgical option?


It would really depend on what the Xray showed. Frequently, in such cases, there is a hypertrophic tuft at the base of the distal phalanx; interestingly, this is also true when there is an ankylosis of the intermediate and distal phalanges. In such a case it might be possible to carry out removal of the tuft or as an alternative a phalangectomy.

Interesting, do you think the schools should teach X ray stuff as routine?

Amputation of a 5th toe is not often carried out today because of the loss of the butressing effect resulting in problems with the 4th, although in extreme circumstances it could be.

Agreed seen some bad 5th amputations. Not as disastrous as all 5 though.B

A Symes partial could be carried out as you suggest.

Would the removal of the tuft be by MIS or is that never used?

I can't give you an accurate figure for costings because the major portion of the fee is charged by the hospital and I don't have those charges. However, I would think that she would be looking at somewhere in the region of £1500.00.

Now that is indeed 'silly money', what are we talking LA 10 mins maximum and a big bandage?

Shy.

[davidh]

Aug 4, 2009 8:10:23 GMT seekerofwisdom said:

Bill,




I can't give you an accurate figure for costings because the major portion of the fee is charged by the hospital and I don't have those charges. However, I would think that she would be looking at somewhere in the region of £1500.00.

Now that is indeed 'silly money', what are we talking LA 10 mins maximum and a big bandage?

Are you confusing simple nail or skin surgery with a far more complex procedure?

Put simply, in any kind of bone surgery there is a greater risk of adverse reactions, therefore the safety measures necessitate a team rather than a surgeon and one other. This is one of the reasons why we don't all carry out minimallly invasive surgery (MIS) in our offices.


Rent your Op Theatre, nursing staff, recovery room, disposables, add in the surgeon's fee (which will usually include anaesthetic) and imaging services, and see how much change you have left from £1500 .

[billliggins]

Hello Shy

I've always thought it a good idea for podiatry students to have an idea what other specialities do with regard to the foot - when all is said and done we are supposed to be the foot experts. Having some exposure (pun intended) to radiologists opinions concerning feet, including the uses of Xrays, ultrasound and MRI would be really useful. However, the IRMER (ionisating regulations in medical imaging) regulations would preclude podiatrists from using the modality in a clinical sense.

It seems that all practitioners tend to view presenting complaints from a slightly different perspective. So although I accept that surgery is the last, not the first option and always offer alternatives to my patients, I think it more likely that I will recommend a surgical solution than perhaps a colleague in pp. Having said that, the vast majority of my patients are covered by private insurance and by the time thay knock on my door, have already spoken to their GP or pp about surgery in any case.

David is right on the button with his comment on costings. Even using L.A., a theatre team consists of a scrub nurse (frequently a Sister), a runner, an anaesthetic nurse (needed to look after and monitor the patient) and an Operating Department Practitioner - some of whom scrub. Add to those theatre orderlies who bring the patient in and out and all the back up theatre staff, together with the use of a room and the nursing and admin staff required to look after the patient on the ward and book Outpatient follow up. Then there are the reservations staff who deal with the logistics and contact the patients with regard to attendance etc. The inevitable admin staff are needed to deal with accounts, insurance and so on, and there are of course management staff to keep everything on an even keel. Purchase/building of hospital premises are horrendously expensive, as is the upkeep. Theatres for bone surgery require the use of a Charnley tent or other filtered air system. Clinical investigation departments - pathology, radiology, haematology etc. are all required. When you take all this into account, the fees are not really silly but reflect costs, and these costs are very similar in the NHS. It's an interesting fact that Nuffield Hospitals are, and BUPA Hospitals were, when in business, not-for-profit organisations.

I have no experience of MIS but I understand that all operating theatres now have to be registered by the CQC, so the costs would be much the same whatever technique was used.

Personally, if I ever have to go under the knife, I want the surgery carried out under the very best of conditions and subject to stringent checks!

Bill

[seekerofwisdom]

Bill,

It's always a pleasure to discuss with you as you always go that extra mile to elaborate.

I do not mean to cause any offense with this reply, I find I learn best by asking questions.

If we return to the original query, do you consider a dis articulation of a distal phalanx 'bone surgery'?

I was always under the impression it was more akin to a tooth extraction with stitches.

Basically a V shaped incision on the dorsum of the phalanx, dis articulation of the joint and removal of the bone, imposition of some soft tissue over the head of the intermediate phalanx trim excess tissue, stich it up. Anaesthesia achieved by a ring block at the base of the proximal phalanx, aka nail surgery. Walk in walk out zero recovery time 14 days to tissue healing.

After all this is a common self treatment when mowing the lawn in flip flops and using a flymo? ;D

You can get a Hysterectomy for £6500 including 8 days in patient , si £1500 still seems a bit expensive to me?

As you point out probably what the insurance boys are prepared to pay, would there be a discount for uninsured patients?

Shy

[billliggins]

Absolutely no offence taken.

The powers-that-be consider any surgery involving bone as requiring a registered operating theatre. Quite how this sits viz a viz peridontal work I do not know. I think flymo self treatment comes under a different heading, involving as it does A & E!

I find that the private hospitals usually charge more for self-payers than for the insured.

Bill

[10feet]

So although I accept that surgery is the last, not the first option and always offer alternatives to my patients, I think it more likely that I will recommend a surgical solution than perhaps a colleague in pp.

Interesting point, Bill

With the invent of CPD and an increased willingness of pod surgeons, radiologists , orthpods to share knowledge with the humble podiatrist in the private sector, I have found, when appropriate, I am much more likely to offer a surgical option as a first line treatment.

I am mortified at how few of my colleagues carry out an assessment on the patient's first attendance and include a treatment plan. In the treatment planning that is where I always discuss treatment options - conservative, surgical, palliative, radical - whatever my skills as a podiatrist deem appropriate. Patients are given an option then of what treatment they wish to receive based on my guidance.

I find more often than not the patient will initially choose conservative rather than surgical based on risk of surgery rather than "cure". A review of the treatment plan at regular intervals may bring about a change in thinking.

I must admit it sometimes catches me out when a patient does choose surgery as their 1st option but then
I am aware that my fee structure is not the cheapest in the district and often I am way down the list of service provider for the patient who bases choice on cost. In other words patients most often make their way to my door from recommendation and not the " how much does it cost to get me feet done" phone call. Once they have done the rounds with that hammer toe resplendent with corn on top and "nobody has got it out", surgery suddenly becomes very attractive.

So I do believe from our 1st point of contact with patients it is our duty to explain a foot condition to a patient, with consideration to that persons medical history and offer treatment solutions, including surgery.

Sadly only a small percentage of private practitioners are willing and able to offer a service to this standard. Some are just not trained to achieve this but too many do not have a fee structure to enable a high turnover of patients from 1st point of contact to cure and discharge. So its not just education that changes our way of engaging with the patient, it is business skills also.

Pete

[billliggins]

Hi Pete

I agree. Certainly, when I did my diploma training - obviously a few years ago - the business education was a big fat zero. Without wishing to be in any way controversial, I understand that the various non-registerable courses at that time were immeasurably better in this regard.

Co-incidentally, I am working on a day course, dealing with assessment, clincal clerking and communication with GPs and other medics. I plan to have a couple of colleagues with the appropriate knowledge joining me to deal with management, public relations and 'selling oneself'. Hopefully, this will convince pp's that they are not humble but are to this profession what GPs are to medicine. I read yesterday of a GP earning £380,000 per annum and I look forward to the first pod getting there!

I find that what goes around comes around and the profession has a perception that unless you actually do something practical, you can't charge a reasonable fee. So more power to your elbow in carrying out a proper initial assessment/diagnosis/advice and charging for it. Personally, I have never believed that everybody can be an expert at everything. So I refer patients to colleagues, particularly for functional t/t but also routine etc. where appropriate.

Bill

[dawnbacon]

Aug 4, 2009 17:35:15 GMT billliggins said:

Hello Shy

Having some exposure (pun intended) to radiologists opinions concerning feet, including the uses of Xrays, ultrasound and MRI would be really useful. However, the IRMER (ionisating regulations in medical imaging) regulations would preclude podiatrists from using the modality in a clinical sense.


I can report good progress on this front in our trust at least.

We recently had 15 pods attending an "Imaging interpretation for podiatrists" CPD course. Four of us have undertaken the Ionising Radiation (Medical Exposure) Regulations [IR(ME)R] course. We routinely order x-ray, MRI, CT and Ultrasound investigation as part of our role. This activity is also being "built in" to the job descriptions of the clinical specialist podiatrists.

I think that this is really positive news for service users and podiatrists.

BW
Dawn