Legally speaking, I believe it is. Medically speaking, I don't believe it is. The default is always to perform conservative care in elective surgical cases. In the case of bunion deformity, conservative care and surgical planning can go hand in hand and not result in a delay in pain relief for your patients.
I routinely provide patients with pre-fabricated orthotics and a post-operative bunion splint or bunion protector depending upon the surgery. This is given to to the patient as his or her conservative care attempt and then is used post-operatively. One can always preliminarily set up the surgery and then cancel should the conservative care not work. On the return visit, the patient can then give his or her report on the success or most likely failure of conservative care, and no time will have been lost working the patient into the surgical schedule.
Jon Purdy, DPM
I do not know of any legal obligation to tx a signficiant deformity with palliative care if the patient does not want to do this.
Everything is relative. A minor deformity can be managed conservatively. A major deformity cannot be corrected palliatively and the joint will continue to degrade.
I think not offering surgery for a major bunion deformity is required, not the other way around.
Of course, all options should be offered to the patient so they can decide.
How about just using our heads and good podiatric care? There is no one answer to anything.
There are so many factors to consider on a case to case basis with the general tone being to offer legitimate conservative care prior to surgery so a patient can make an informed decision. Here are five factors to consider.
1. the stage of deformity. The higher the IM and clinical sequelae, the less conservative care will offer.
2. the health and nutrition of the patient. Bad circulation, diabetes risk, severe arthritis, poor nutrition all would lead to an emphasis on conservative care deferring or reserving surgery.
3. the conservative or surgical skill of the practitioner. Surgeons deliver poor conservative care, non-surgeons deliver poor surgical care and this would be reflected in treatment bias.
4. the greater the underlying biomechanical, postural and metabolic health of the patient, the less bunion surgery has to offer. Severe arthrtitis, severe low back disease, severe PTTD or let's say navicular sag, the remaining problems that the patient would suffer post bunionectomy, the less the patient gains from the surgery.
5. the shoe style requirements, job and career image of the patient, and the influence of vanity and cosmetics also play a part in the decision making process. A young female patient with a career in the entertainment industry would be an example of someone who I would lean toward surgical correction if nothing contraindicates a procedure.
In summary, there are always exceptions to the rule posed by this question which begs the understanding that in an interpersonal EBP basis, DPMs need both accumens in their medical bag. If a patient wants surgery, then a great surgeon needs to be in front of him/her. If a patient doesn't want to test the risks of a procedure, then great conservative care must be practiced.
I would rephrase the question as follows: In your environment, are you capable of delivering both non-operative and operative bunion care to your patients? I would then ask each of us to fill in the blanks with education, mentoring and an expansion of their practice into the direction of weakness or making sure that complimentary care is available to your patients using consultation or referral..
There is no conservative care for a bunion. Any so called conservative therapy will relieve the pain and temporize the condition, but not correct the deformity. The patient will sooner or later have to deal with the problem from a cosmetic point of view or functional and structural point of view. The deformity is progressive and will get worse. Every patient who has had a fusion or joint implant from a bunion with arthritic joint at some point in the progression of the deformity could have had a reconstructive procedure instead of a joint destroying procedure.
No orthotic, shoe, injection or manipulation therapy will correct the deformity. Orthotics may ameliorate the forces causing the deformity but not correct it. That is why they are, in most cases, necessary postoperatively. Conservative therapy amounts to a dentist telling you we need to numb your tooth for a bad cavity or an orthopedist telling you your young daughter can wear a brace for a while for a severely dislocated hip.
Then the question arises is treatment medically necessary. That decision can only be made by the doctor and his or her patient after they understand the prognosis of the bunion deformity and the risk involved in correcting or not correcting the deformity. No insurance company should or could determine that for you and your patient. The question whether it is medically or legally necessary to institute conservative therapy is irrelevant.
I am not sure about United States legislation but the question really should be
"Should Conservative Care Be Mandatory Prior To Bunion Surgery?" This will be a test of knowledge as well as intent!
In many cases, the law is not well known.
When the pathology is obvious and the patient tried to accomodate the problem with different shoes "conservative care was administered"
Would conservative care work for a chronic cryptotic toenail?
Conservative care = marginal $
Surgery = $$$ BANK!
You should be ashamed for even thinking that way ... !
Dr. Ozinga's statement is absurd. If a patient comes in with a stage IV bunion and wants it corrected, 100% of the time they have tried wider shoes. Orthotics don't do jack for this. Surgical correction: GAME ON!
"Conservative" care would be proactive surgical treatment. It is up to the patient, not us. We all know this tends to be a progressive deformity. This relatively simple condition has itself a prognosis of increased risks and complications, compounded by other related compensation and accomodation deformities and problems.
I regard conservative care as dispensing orthotic devices after "bunion" corrective procedure(s). Since orthotic devices control RF, that tends to be a a cause to merely help control pre-disposing abnormal motion. Controlling this problem helps to avoid later recurrrence or other conditions.
We know that an Austin is relatively conservative in comparison to a base wedge. My practice seldom had a "bunion" surgery since the average age was about 29.1in Alaska. However, I often saw early signs (and symptoms) from RF to FF and FF to RF compensatory biomechanics and/or subjective accommodation from other conditions. I would likely take a similiar surgical approach.
Lastly, well documented records of patient education of other options, alternatives, risks, complications, fees and benefits of surgical corrections as well as a patient's past conservative care that they have tried as well as any other heath care provider's treatment. We must all remember the right of self autotomy and self determination. It is the patient's ultimate decision to do with his or her body what he or she wants. It is not really our decision as physicians and surgeons. Is it?
A well informed patient. Pay for it now or pay for it later. What would my best friend, Dr. Harold Vogler, or Kieth Kasuck do? Depends upon a focus of your practice as well as community care or standard of care practices. Vogler invented the offest "V", not Stanley Kalish, DPM. Just ask him.
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