July 2013

How Effective Is Percutaneous Plantar Fasciotomy?

By Brian McCurdy, Senior Editor

The percutaneous plantar fasciotomy has the advantage of being less invasive than other fasciotomy techniques but how does it compare in its ability to get patients back on their feet quicker with less pain?

   The authors of a new study in the Journal of Foot and Ankle Surgery (JFAS) retrospectively reviewed the charts of patients with plantar fasciitis who had either open fasciotomy with heel spur resection (32 feet) or percutaneous medial fascial release (23 feet). The study notes the percutaneous group showed a mean pain reduction of 5.69 points at the first postoperative visit while the open fasciotomy group exhibited a mean pain reduction of 3.53 points on the Visual Analogue Scale.

   Researchers concluded that percutaneous medial fascial release was as effective at resolving recalcitrant plantar fasciitis pain as the open procedure and that patients who had the percutaneous technique experienced less postoperative pain and returned to full activity faster.

   In his experience, Allen Jacobs, DPM, FACFAS, has found all techniques of plantar fasciotomy are effective in properly selected patients, including in-step, endoscopic, percutaneous and open techniques. He says all those techniques are associated with equal incidence of long-term sequelae, namely lateral column pain, decreased arch height with associated stress induced pathology and nerve injury.

   “The key to success for all fasciotomy approaches lies in proper performance of technique, as well as the recognition and management of etiologic factors such as obesity, pronation syndromes or equinus,” notes Dr. Jacobs, who is in private practice in St. Louis.

   Similarly, Martin Pressman, DPM, FACFAS, finds that both the open and percutaneous plantar fasciotomy techniques yield long-term favorable results, noting that he uses ultrasound guidance when performing percutaneous releases. Dr. Pressman recently finished an as yet unpublished study of 175 percutaneous releases and found an 86 percent good to excellent result with a two-year follow-up.

   The advantage to percutaneous release is that it does not require expensive endoscopic equipment and is less invasive than open procedures, according to Dr. Pressman. He performs percutaneous release with a 16 gauge needle or a fasciotome, noting this seems to allow a quicker recovery similar to the JFAS study. He notes that his study did not compare open versus percutaneous.

   Dr. Pressman says percutaneous fasciotomy is effective for most of recalcitrant fasciitis cases. He advises that for patients with persistent heel pain after percutaneous release, in the absence of neurologic complaints, one should follow initial treatment with a formal partial fasciectomy.

   Dr. Jacobs generally prefers to use open fasciotomy, saying it allows limited decompression of the first branch of the lateral plantar nerve and, when necessary, permits spur reduction or partial fasciectomy. He will consider performing percutaneous fasciotomy in the patient with a clinically prominent, palpable and isolated painful band of the plantar fascia. On the other hand, Dr. Jacobs avoids percutaneous fasciotomy in those with diffuse or laterally expressed heel pain, or in patients with signs or symptoms that suggest possible nerve compression syndromes.

   Dr. Pressman, an Assistant Professor of Orthopaedics and Rehabilitation at the Yale School of Medicine, would avoid the percutaneous release in patients with mixed symptoms of neuritic pain and enthesopathy, or those who have had other procedures such as Topaz or radiofrequency ablation, opting instead for open partial fasciectomy.

Study Assesses Use Of STSGs In Patients With Diabetes

By Danielle Chicano, Editorial Associate

A recent study published in the Journal of the American Podiatric Medical Association concluded that podiatric surgeons should consider split-thickness skin grafting (STSG) as a wound closure option for patients with diabetes who do not have exclusionary comorbidities.

   The retrospective study looked at 203 patients, including patients without diabetes and patients with diabetes, both with and without preexisting comorbidities. All patients received STSGs to help facilitate wound closure. The study concluded that STSG patients with diabetes and preexisting comorbidities experienced the highest risk of delayed healing, post-op infection and a higher need for revisional surgery in comparison to the other two groups. Study authors did not find any significant differences in outcomes between patients with diabetes who had no comorbidities and patients without diabetes. Comorbidities included cardiovascular disease, neuropathy, retinopathy and nephropathy.

   David G. Armstrong, DPM, MD, PhD, is a strong proponent of split-thickness skin grafts, which he and his operating staff apply up to four times a week.

   “(Split-thickness skin grafts are) an integral part of our ‘vertical’ and ‘horizontal’ strategy. We advocate using STSGs to resolve epithelialization horizontally once we have resolved depth vertically with negative pressure wound therapy (NPWT),” explains Dr. Armstrong, a Professor of Surgery at the University of Arizona College of Medicine in Tucson, Ariz.

   Dr. Armstrong offers the following surgical pearls when utilizing STSGs on patients with diabetes.
• Use thicker STSGs in this population, especially on plantar wounds where one would normally see “glabrous skin.” He will go to 20/1000ths of an inch or even higher in high use areas.
• If the wounds are small and especially on the bottom of the foot, “pie crust” the STSGs rather than using 1.5:1 mesh.
• Apply NPWT to bolster the STSG. However, only use NPWT for three to four days. Then apply a simple compressive/bolster dressing.

   According to Dr. Armstrong, he and his staff use NPWT most frequently as a “vertical strategy” to fill the wound.

   “We use STSG most frequently as part of our ‘horizontal’ strategy to facilitate epithelialization. We have absolutely no problem repeating a STSG if it takes less than 100 percent,” adds Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance.

Could EMR Open The Door To Upcoding?

By Brian McCurdy, Senior Editor

With the Centers for Medicare and Medicaid Services (CMS) looking into the possibility that electronic medical records (EMR) could lead to physicians coding for higher level services, does a real danger of upcoding exist?

   As Barbara Aung, DPM, notes, most physicians “are quite aware” of the dangers of upcoding. She says the use of EMR does present some risks in instances in which the physician may “copy or push forward” the history and physical information from the previous visit’s exam.

   “When there is more documentation found in the note or the note looks more complete, oftentimes we can think and/or feel that we are justified in billing a higher level of service so this can lead to the danger of billing a higher level evaluation and management (E/M) code,” says Dr. Aung, a Certified Professional Medical Auditor, a Certified Surgical Foot and Ankle Coder and member of the American Association of Professional Coders. “What we all should keep in the forefront is that the documentation should support what we did for the patient on the particular encounter. It should stand alone to give us a picture of the particular event, answering all of the questions of who, what, where, when, how and why.”

   In Dr. Aung’s opinion, the most effective techniques to ensure accurate billing are to be knowledgeable of coding guidelines and documenting accurately to reflect the specific encounter. She suggests that vendors turn off the E/M “wizard” along with the ability to clone information and/or pushing forward information from one note to the next.

   Furthermore, Dr. Aung says a well-designed template can help a clinician be more thorough and document more accurately, which reflects the encounter and treatment as well as the decision making process. However, she warns that templates with pre-filled information can be dangerous as the note may appear the same from one visit to the next and/or does not support medical necessity for that particular encounter.

   “These are the ‘canned’ notes that will not stand up to an audit,” she explains.

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