The Best of the AOFAS Masterclass Series: Insertional Achilles Tendonitis

Summary

Podcast Summary: The Best of the AOFAS Masterclass Series: Insertional Achilles Tendonitis

Podcast Information:

• Title: The AOFAS Orthopod-Cast
• Host/Author: AOFAS Podcast Committee
• Episode: The Best of the AOFAS Masterclass Series: Insertional Achilles Tendonitis
• Release Date: January 29, 2025

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Introduction

In this comprehensive episode of The AOFAS Orthopod-Cast, the AOFAS Podcast Committee delves deep into the intricacies of managing insertional Achilles tendonitis. Hosted by Dr. Anish Kadakia, the discussion features insights from Dr. Jason O'Dell of McLeod Orthopaedics and Dr. Lauren Gainey, Program and Fellowship Director at UConn. The episode offers a blend of clinical experiences, surgical techniques, and postoperative management strategies, making it an invaluable resource for orthopedic specialists and practitioners dealing with foot and ankle pathologies.

Initial Nonoperative Management

The conversation begins with the foundational approach to treating patients presenting with insertional Achilles tendonitis. For instance, Dr. Kadakia poses a scenario involving a 40-year-old female runner experiencing six weeks of heel pain.

Dr. Lauren Gainey [02:07]:
"My first conversation with them typically involves sending them to physical therapy. I encourage physical therapy as a first step, emphasizing that while there might be an increased risk of rupture, it's still extremely unlikely."

Dr. Jason O'Dell concurs, highlighting the rarity of tendon ruptures in actively treated patients without prior steroid injections.

Dr. Jason O'Dell [02:44]:
"I think it's quite rare to see somebody who you're actively treating for that then proceed to rupture in the absence of having had a steroid injection."

Success Rates and Patient Counseling

The panel discusses the efficacy of physical therapy (PT) in treating insertional versus non-insertional Achilles tendonitis. Non-insertional cases often respond well to eccentric strengthening exercises, with success rates around 70-80%. However, insertional cases present a different challenge.

Dr. Lauren Gainey [04:14]:
"I typically tell them 50 to 60% improve with physical therapy. Recurrence of pain is common because the underlying bone spur and tendon abnormalities remain."

This candid discussion underscores the importance of setting realistic expectations with patients, acknowledging that while PT can alleviate symptoms, underlying structural issues may persist.

Transition to Operative Treatment

When nonoperative measures fail, the conversation shifts to surgical options. The panel explores indications for surgery, emphasizing the importance of thorough patient evaluation and imaging.

Dr. Anish Kadakia [05:40]:
"After six weeks of failed PT, what's the next step? Options include PRP, steroid injections, and ultimately surgery if conservative measures don't yield desired results."

Surgical Techniques: Open vs. Minimally Invasive Surgery (MIS)

A significant portion of the discussion centers around the debate between open surgery and minimally invasive techniques for treating insertional Achilles tendonitis.

Dr. Jason O'Dell [09:26]:
"For patients who don't respond to PT, I often recommend open surgical reconstruction. This involves a midline open approach with bone resection and tendon repair using four anchors."

Contrastingly, the concept of MIS is introduced, though Dr. Kadakia admits limited personal experience with it.

Dr. Anish Kadakia [21:51]:
"Minimally invasive techniques are being explored, but they present technical challenges and haven't gained widespread adoption compared to open methods."

Specific Surgical Approaches and Protocols

Dr. O'Dell elaborates on his surgical protocol, detailing the use of anchors, suture techniques, and the incorporation of amniotic allografts to enhance healing.

Dr. Jason O'Dell [10:20]:
"I use convergent anchors and a woven suture technique to ensure a robust repair. Additionally, I incorporate tissue paper-thin amniotic allografts to support tendon healing, allowing for earlier suture removal at two weeks."

The discussion also touches on adjunctive procedures like gastrocnemius recession, with differing opinions on its necessity.

Dr. Lauren Gainey [15:04]:
"I perform gastrocnemius recession only in cases with significant tendon calcium deposits and tightness, ensuring it contributes to relieving insertional tension."

Postoperative Rehabilitation

Effective rehabilitation is crucial for optimal recovery. The panel outlines varying postoperative protocols, emphasizing the balance between immobilization and early mobilization.

Dr. Lauren Gainey [27:38]:
"Post-surgery, patients are non-weight bearing in a plantar flexion splint for two weeks, followed by a boot with heel lifts. Weight-bearing is gradually introduced around eight weeks, transitioning to regular footwear by ten weeks."

Dr. Jason O'Dell [27:58]:
"My protocol involves two weeks of non-weight bearing in a cast post-splint removal, progressing to a boot with wedge supports and eventual transition to gym shoes by nine weeks."

Complications and Management

Wound healing complications are a significant concern, especially with open surgical approaches. The panel shares strategies for managing such complications, balancing nonoperative and surgical interventions.

Dr. Anish Kadakia [29:36]:
"I opt for black boots with foam backing for Achilles interventions to reduce pressure on surgical wounds, minimizing healing issues."

Dr. Jason O'Dell [31:52]:
"In cases of wound complications, I employ topical wound vacs and antibiotics, managing minor openings nonoperatively unless signs of chronic infection emerge."

Coding Considerations

Accurate surgical coding ensures proper reimbursement and documentation. The panel discusses best practices for coding insertional Achilles tendonitis surgeries, emphasizing the importance of distinct codes for concurrent procedures.

Dr. Lauren Gainey [39:40]:
"I code for secondary Achilles reconstruction and use CPT code 28118 for partial calcaneus excision associated with insertional spurs."

Dr. Anish Kadakia [40:38]:
"Proper coding involves detailing each procedure with unrelated diagnoses to avoid bundling, ensuring all aspects of the surgery are reimbursed appropriately."

The Role of Flexor Hallucis Longus (FHL)

Flexor Hallucis Longus tendon transfer is a technique employed in certain cases to enhance tendon repair integrity.

Dr. Lauren Gainey [35:07]:
"I perform FHL transfers in approximately 10-15% of cases, particularly in patients with extensive tendon degeneration visible on MRI."

Dr. Jason O'Dell [37:08]:
"I utilize FHL transfers in over 50% of cases involving Achilles avulsions and selective cases where significant tendon removal occurs."

Use of Platelet-Rich Plasma (PRP)

PRP therapy emerges as a topic of debate, with differing opinions on its efficacy and role in managing Achilles tendonitis.

Dr. Jason O'Dell [42:34]:
"PRP might offer long-term benefits, showing superior outcomes at one year compared to corticosteroids, though immediate effects are similar."

Dr. Lauren Gainey [44:57]:
"The placebo effect plays a role, especially when patients invest financially, enhancing their perception of improvement."

Conclusion and Takeaways

The panel converges on several key points:

1. Initial Nonoperative Management: Physical therapy remains the first-line treatment for insertional Achilles tendonitis, with a 50-60% success rate.

2. Surgical Intervention: When conservative measures fail, open surgical reconstruction is commonly preferred, with meticulous attention to surgical technique to minimize complications.

3. Rehabilitation Protocols: A structured postoperative regimen is essential, tailored to individual patient needs and surgical specifics.

4. Complication Management: Proactive strategies and patient counseling are vital in handling wound complications, emphasizing timely intervention to prevent chronic issues.

5. Coding Accuracy: Proper surgical coding is crucial for administrative efficiency and financial reimbursement, requiring detailed documentation of all procedures.

6. Adjunctive Therapies: Techniques like FHL transfers and PRP therapy are valuable tools, though their application depends on specific patient presentations and surgeon expertise.

Notable Quotes:

• Dr. Lauren Gainey [02:07]:
  "I encourage physical therapy as a first step, emphasizing that while there might be an increased risk of rupture, it's still extremely unlikely."

• Dr. Jason O'Dell [10:20]:
  "I use convergent anchors and a woven suture technique to ensure a robust repair."

• Dr. Anish Kadakia [21:51]:
  "Minimally invasive techniques are being explored, but they present technical challenges and haven't gained widespread adoption compared to open methods."

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This episode serves as a vital resource for orthopedic practitioners, offering nuanced perspectives on the management of insertional Achilles tendonitis. From initial conservative treatments to advanced surgical interventions and postoperative care, the insights provided by Drs. O'Dell and Gainey equip clinicians with the knowledge to enhance patient outcomes effectively.

Transcript

[Host 1]

Welcome to AOFAS Ortho Podcast where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the views of the AOFAS or its members.

[Host 2]

Welcome to this CME podcast from the American Orthopedic Foot and Ankle Society. The AofAs Ortho podcast CME episodes Feature interviews with thought leaders discussing challenges in foot and ankle surgery. Claiming CME credit is easy. Tap the link in the description and follow the instructions. Thank you and enjoy this episode.

[Dr. Anish Kadakia]

Support for this podcast is provided by an educational grant from Stryker. Welcome to the AOFAS Ortho Podcast. This is our CME edition and we'll be talking about Insertional Achilles issues. So I'd like to welcome our two guests. We have Dr. Jason O' Dell with McLeod Orthopaedics in Florence, South Carolina. So welcome Jason. The podcast in private practice as well.

[Dr. Jason O'Dell]

Yes, that's correct.

[Dr. Anish Kadakia]

Outstanding. We've got Dr. Lauren Gainey, who's the program director and fellowship director, I believe at UConn, and one of our Footnackle colleagues up there. So welcome Dr. Gainey to the podcast.

[Dr. Lauren Gainey]

Thank you. Thanks for having me.

[Dr. Anish Kadakia]

Outstanding. I've got my co host Anish Kadakia who's always exciting on the podcast. Looking forward to his color commentary. We like to say there. So first thing I wanted to talk about. So with insertional Achilles tendonitis there's been a lot of new things out there as far as open percutaneous techniques as well as at least in my hands, a lot of patients do fairly well non operatively. So see if a person come in with Achilles tendinitis, Dr. Gainey, what's the first thing that you do for them? It's been going on for let's say six weeks. This is a 40 year old female that comes in, I've had pain going on for six weeks. I like to run, I like to do yoga and it's been hurting in the back of my heel. What's your first conversation with them?

[Dr. Lauren Gainey]

My first conversation with them typically sending them to physical therapy. And I think that the discussion with these patients that want to get back to these activities, I think a lot of them are really concerned about rupturing and so that's always the question, can I get, can I still run? Can I do X, Y or Z? And I tell them, I let them essentially decide based on their pain level and I say yeah, sure, maybe there is an increased risk, but if it was one in a thousand now you're one in 500. It's still, it's twice the risk but still extremely unlikely. And as long as pain wise you can tolerate it, then you can really do whatever you feel comfortable doing. But I really encourage physical therapy as a first step.

[Dr. Anish Kadakia]

Jason, is it pretty similar conversation your client?

[Dr. Jason O'Dell]

It is. I think it's quite rare to see somebody who you're actively treating for that then proceed to rupture in the absence of having had a steroid injection, maybe at a outside provider. But that's the times I've seen it anyway.

[Dr. Anish Kadakia]

For me it's a non physician provider at times.

[Dr. Jason O'Dell]

Right, right.

[Dr. Unknown]

They can't be physicians. Let's be clear how we define so we get in trouble. They're physicians, they went to their own type of medical school.

[Dr. Jason O'Dell]

It is state dependent. But I would say I have the conversation of, you know, is this an every step, every day situation? And if it is, then I put them in a boot, let them cool off a little bit because to me those people don't seem to do as well with PT when they're really hot and aggravated. So it's usually boot topical, cool it off and then then therapy after that.

[Dr. Unknown]

What do you tell them? The success of pts for insertional versus non insertional. Because for non insertional therapy's fantastic. Right. We went with eccentric strengthening, et cetera. 70, 80% will do fine. But with insertional, my understanding is in my experience is totally different. So do you counsel them at your visit? Do you make them do six, eight weeks of PT even if they're having a lot of pain? Because there's a lot of. We get a lot of complaints if there are people are suffering. So what do you learn? What do you tell them? Like, hey, you got insertional disease, etc. You get the X ray. My protocol is you're going to do PT for six weeks. Then if that doesn't help you, then then what I guess is part two of the question. But how long do you make them go through PT? What do you tell them success rate is a PT for insertion?

[Dr. Lauren Gainey]

So I typically tell them 50 to 60%, I think is. And I think the recurrence of pain afterwards is common too. So you go to pt, it gets better or more tolerable enough that they can do the things that they want to do. But understanding that you still have a bone spur, you still have abnormal tendon and there is a chance that we do all this and in six months you're back here with the same pain and I Do think that it's one of these things that's hard for patients to understand too because they see the spur and then they say, well, physical therapy is not going to take my spur away. And then you argue, well, six weeks ago I bet you had the spur too and you didn't have the pain. So I do make them do it. A lot of them will. And then when I describe the surgery, they're like, oh yeah, no, I'll do like, sure, we can do the surgery, take the bone off, take the tendon off, reattach it, make you on crutches for five weeks and like, yeah, no, I'll try the PT first.

[Dr. Unknown]

So if somebody does pt well, assuming that their pain is not from a shoe, because all of us know PT doesn't do anything for that. It's not shoe. We're directly related, bacteria related. So you know, Jason Lawrence, center for pt, they come to you after six weeks. That didn't do anything for me. What am I doing now? Are you, are you offering? What's the next conversation? Is it prp? Is it a. We can go through all the options. I won't go through all the surgery, but is it, is it prp? Is it a steroid injection? Which I tell you I think is totally wrong. Is. I think all of us might agree. But what is your next step? Six weeks, you've done all the shake and baked.

[Dr. Anish Kadakia]

Yeah, I'm gonna actually go back for a second. So I think as far as the non operative rate, do you. Would you also say 50 to 60% or get better? Non operatively. Like what's your number if somebody pushes you to put your.

[Dr. Jason O'Dell]

Well, I think it's a little, I mean in my clinic it's a little skewed because if they're seeing me, they're not, they've not gotten better with. We have a pretty broad non operative clinic.

[Dr. Anish Kadakia]

Okay.

[Dr. Jason O'Dell]

So it's rare that I see a new patient to the practice with Achilles tendinopathy. A lot of those patients have already been seen by our family care sports medicine doctors who've done the appropriate workup. So most of those people. So I think 50% is reasonable and I think because it's that many people are willing to try it. I don't have a super athletic population, so they've got a little time they can spend in a boot and do pt And a lot of those people get better. I always have the conversation about the spurs you mentioned. I mean they, it's not causing the point of the X ray. What about. I Got that heel spur. What about the one on the bottom? Well, you're not hurting on the bottom, you're hurting the back. That's been there a lot longer than you had these symptoms. And that represents the degeneration of the tissue, but it's not causing it. So it's like a cause and effect. I point that out to them, but those patients after they fail PT get an MRI and then we kind of talk about it. And I would say that it's been very, very rare that I've ever, you know, a handful of people under 25 maybe I've given a little bursa injection too. Steroid when they truly have a cold MRI and just bursitis that's isolated. Those are the people I've done that to a few times. And some of those people that maybe have that truly isolated disease, I would consider more of a percutaneous resection of the Haglund. But that's been also a pretty limited case series of mine. At least I do have the discussion of people I feel like if their symptoms and MRI findings are, let's say not quite if I think they have severe symptoms, but maybe the MRI changes are mild to moderate. I might offer that patient PR in the office one time, try it, see how it does. And I've had that help a fair number of patients, even especially more elderly patients who didn't want surgery and got better. But the majority of people that are at the level of lingering symptoms, MRI with moderate to severe changes, we'll just fix them. But I try to give them a chance for three months or so.

[Dr. Anish Kadakia]

I've seen a couple patients and as you mentioned, the young athletic population that have had truly isolated retrocochineal bursitis probably do a Hackland's deformity. It just hasn't been going on for 20 years or 30 years or 40 years like the patients we see in their 40s, 50s, 60s, some of those I have again rarely done a retrocalcaneal bursa injection under ultrasound guidance, not in the tendon. And a couple of those I have gone and just shaved the hagglens off kind of percutaneously with a power rasp. Now a minimally invasive bur. And those have done well. But I think that is a pretty slight patient population different than the vast majority of people I see with that. Has that been yalls experience as well?

[Dr. Lauren Gainey]

I think you have to be careful of that, you know, and I think that the over diagnosed. I think if you can, if you can confirm and I think an MRI is Helpful that often there's a pocket of fluid in there. If you can confirm that that's really the source of their pain, then I think you're okay. But I think a lot of those are confused with posterior impingement or other things. I've had some come from my partners and you know, they're ready to take that non prominent hagglens off. I'm like, I'm just not convinced that that's the pathology. So I think it exists. But I think you have to be careful and make sure that's really the source of the pain.

[Dr. Anish Kadakia]

Agree. I think that's a rare patient that I see. It's mainly in the athletic population that I see that. And so you have somebody who's failed six weeks of therapy or eight weeks of therapy. What are you offering them, Jason?

[Dr. Jason O'Dell]

So most of those people were offering them, you know, surgical reconstruction.

[Dr. Anish Kadakia]

Are you open?

[Dr. Jason O'Dell]

Open? Yeah. Yeah. So I mean traditional reconstruction for me is a, you know, midline open approach. Resection, secondary repair, four anchors. And I think early on in my practice I was really aggressive doing a sort of a mid level posterior strayer vulpius technically. Now don't do it as often, but when I do it, I'll do the proximal medial gastroc release.

[Dr. Anish Kadakia]

How often do you generalize, what percent of patients would you say?

[Dr. Jason O'Dell]

I would say I do it about 25% of the time.

[Dr. Anish Kadakia]

Yeah. When you put your, you mentioned you use four anchors. I use four as well. Do you put two in perpendicular to that angular cut you take off the back of the calcaneus and then do you. Do you put your other two in like parallel to those or I put the other two in parallel to the plantar aspect of the calcaneus.

[Dr. Jason O'Dell]

So they're sort of convergent. Correct. Is that correct?

[Dr. Anish Kadakia]

Yes.

[Dr. Jason O'Dell]

Yeah, that's the way I do it. So we have the broad bony resection and I explain to the patient what I'm doing. Hey, this is a broad bony surface that has excellent bleeding that's going to give us the ingrowth that we want. So yeah, I put it in that way. One thing that I changed that I think does make a difference is most of those anchors, let's say you have two proximal tape type sutures. Those anchors will also have a cord type suture attached. And I'll retain the cord type suture and sort of run that back and forth as a like a woven suture. Not a Krakow with a locking, but just sort of a back and forth weave suture. Bury the Knot the midline. I think that gives them a little bit more robust repair. I do also close with one of the sort of tissue paper thin amniotic allografts. I started that several years ago and I found that I felt more comfortable removing the sutures at two weeks, whereas I traditionally removed them at four weeks when I first started my practice 15 years ago. So I think that makes a difference in healing. So I do use that for that procedure, but pretty much that procedure alone and then pretty standard rehab, you know, two weeks in a splint, two weeks in a cast. I let them weight bearing a boot at four weeks and begin therapy.

[Dr. Anish Kadakia]

Ear wedges and wean them down.

[Dr. Jason O'Dell]

So yeah, wedge wean progressed. Weight bearing and shoes at eight weeks is the goal.

[Dr. Anish Kadakia]

Lauren, how do you handle. So what type of surgery is your preferred technique at this point?

[Dr. Lauren Gainey]

Same.

[Dr. Anish Kadakia]

So open.

[Dr. Jason O'Dell]

Open?

[Dr. Lauren Gainey]

Yep, open.

[Dr. Anish Kadakia]

Four anchors. Do you do the similar where you did that? Whatever you want. Center stitch or that cord.

[Dr. Lauren Gainey]

I hold on to that retention stitch if I'm not happy with my tension afterwards. So sometimes you'll see one side is tighter than the other. And so I'll pass it through almost like a mattress just to try to cinch down one side or the other to equal the tension if I'm unhappy with it.

[Dr. Anish Kadakia]

One thing that I found, and I love your experience, Anisha, on this, was for a while I would try and pass that the rope of sutures, you know that double loaded suture. I try and pass that. So between the middle and medial third and the middle and lateral third. What I found was sometimes at the bottom I had escape of it. So I started passing that suture a little bit wider, like in the medial and lateral one sixth of the tendon. Sometimes I'll have my assistant grab the bottom of the tendon so we make sure we capture that tendon so it doesn't go out the side. I found that to be a little bit helpful. Spreading those proximal stitches a little bit wider has helped me do that. Have you guys seen that at all?

[Dr. Unknown]

I've had some issues with it technically on my fault. So what I do is I, you know, we always split that tendon all the way up when we do it open. I think one of the easiest, easiest fixes is to repair that central stitch with the pds, whatever you want to do, so that it's now one big fat tendon then. Now I just have a big fat tendon now.

[Dr. Anish Kadakia]

You do that before you put your distal.

[Dr. Unknown]

Before I do anything. First thing to do is make that split one, because sometimes then you miscalculate, it can tear through. So make it one. Then I'll fire my sutures through wider, like you said. And then I'm pretty aggressive about a gas truck. If I'm going to do it, I'll plant a flex was tight. I'll do a gas rock. Then I'll just stick it down just below the insertion point so I have a proper, you know, large surface area to do it. And I will take sometimes the center stitch. So you get the two stitches pull through, you cut them, and I'll tie them together to crush that tendon back down to the bone before I make my M construct. So you have the two coming out from the proximal row. But instead of just going straight down, one of my buddies taught me to suture it to each to itself, left and right to itself. And that'll actually make a crossbar stitch that will force the tendon down to the calcaneus. And then I make my M after that so that I don't just have it so it can't just rip all the way through that M construct.

[Dr. Anish Kadakia]

Interesting. I have not tried that. Have you guys tried that?

[Dr. Jason O'Dell]

No. Do you find that that's kind of a prominent knot stack or Because.

[Dr. Unknown]

No, because they just do one knot, two.

[Dr. Jason O'Dell]

Not because you have to use.

[Dr. Anish Kadakia]

But because the sutures are. Are. They're one suture that's through the end of that. So you do tie two suture strands. Two. Two suture strands.

[Dr. Jason O'Dell]

Do you pass. So the. The paired suture from the proximager. You split it and pass it in two separate places.

[Dr. Unknown]

So once you take that, double the needles on both sutures, right. You pop them through the proximal and you cut the needle, as we all do. And I have two sutures on each side. I just take one from each and just tie it to each other. Yes. It slides a little bit, but not really.

[Dr. Anish Kadakia]

Really. Okay.

[Dr. Unknown]

And then you just tie it to itself. One knot, two knots. Because you're just trying to. That knot has no real strength issue because the strength comes from the distal row.

[Dr. Anish Kadakia]

Sure.

[Dr. Unknown]

I don't need that 6, 7 knot, 4 knot that we typically do for these suture. We don't. I just do one or two, and that shoves the tendon back down. Then I dunk them down.

[Dr. Anish Kadakia]

Gotcha. It's interesting, I would say, you know, do you do gastrotom recession?

[Dr. Lauren Gainey]

I was gonna ask that, because to me, I've done it before when I have a lot of calcium in the Tendon, and I feel like I just can't get it to sit down. It's like, too short, but it's never. Cause, I mean, maybe you guys don't do it, but I splint them in plantar flexion. So if you do a gastroc release and they're splitting a plantar flexion, aren't they just gonna tighten up?

[Dr. Unknown]

So I would say no, because you're whaling on the fascia. And I get them moving at two weeks, they ain't gonna heal that fast. I always ask, I mean, I didn't practice doing a lot of gastrocs, but I asked myself, why do you have this problem? My buddy, one of my buddies, went out to dinner last night. He's a Seattle guy, and he thinks everybody has a gas contractor. Obviously, Seattle way. I didn't come from that training, but he has a point. So if pre op, they have a tight gastroc and I do all this work, I just ask myself, why do some people get insertion case stenosis? And the truth is, lord knows, I don't know. So if they are tight pre op, I'll do it. Because even though I know I can get the tendon down, I can splint them. That's not the issue, per se. Most of the time it's. I want to relieve the tension on the insertion so it doesn't come back in five, 10 years or in six months. Now, the rate of recurrence of insertion tendinosis surgery, I don't even know. Actually. I think the surgery overall works pretty well.

[Dr. Anish Kadakia]

I think it does. My experience has been, I had a while where I think I didn't realize on the very edges of my broad bony resection, I may have gotten. I didn't get all the way to the edge. And so I had a couple people I had to go back and revise because I didn't get that very side thing out. And so now I pay very much attention. My nurse practitioner also feels I feel all the way around the edge to make sure I got those sides. And since I've done that, I've had very few, like, recurrences of it. I mean, obviously no surgery is perfect, but overall, pretty good with that.

[Dr. Unknown]

Two controversial questions for you, because I want to make sure we move it along, is how much bone do you resect? I've seen people take out, like, huge angles of bone, so it looks like there's a massive cavity in there, which I disagree with on many levels.

[Dr. Anish Kadakia]

You're wrong. That's okay.

[Dr. Unknown]

It's all right, I'm never wrong. And then I make it look like a normal calcaneus, the way, quote unquote, God made, Right? God made a nice, normal, rounded calcaneus. You know, Ben thinks he's better than God, and that's fine, but I just make it look like a normal calcaneus. Why do we take out? I mean, I trained on that, and I'm like, I disagreed, so I just stopped doing it. Why do we take out such a huge chunk?

[Dr. Lauren Gainey]

I've taken less and less.

[Dr. Unknown]

So she thinks you're totally full of the two totally appropriate high five.

[Dr. Lauren Gainey]

All you need is a bony surf, like a bleeding surface to reattach, right? So. And I do think, you know your haglins, and it's ironic, right? Some of these are sharp, some of these are flat, and we know that. Does that really have a bearing on it? Right? So, I mean, I think you take down the prominence, and I think you need a bleeding bony surface, and I think you need to take down the osteophytes distally. But other than that, I don't know why you have to be aggressive.

[Dr. Unknown]

I think this podcast is over. Thank you very much for listening.

[Dr. Anish Kadakia]

So my issue is always, I think, you know, you run into the issue where at the bottom of your incision is right where you make your cut. And when you make your cut, it wants to hit the skin on the side. You get wound healing issues with that. So that's part of. Don't go more vertical, because that means I extend the incision even further. And I found the people, I make the incision even lower down, they tend to have more pain associated from what I think is just the inferior part of the incision. So that way, if I'm not quite as high, I can take a little bit more of an angle. I would say my ankle is 45 degrees. I take off roughly the posterior 1/5 or 1:6, the calcaneus. A big cut, but I've had an issue with it. The other thing I think is I have done zero gastrocnemius retentions with this ever. Most of the patients get 10 to maybe 20 degrees of dorsiflexion. I think part of it is because I take that huge bony cut, so there's less restriction. There's nothing for the tendon to bump into the bone.

[Dr. Unknown]

She almost detaching it, letting it fly and just giving them a flail leg is what you're describing.

[Dr. Anish Kadakia]

Except they do great.

[Dr. Unknown]

Oh, yeah. So, you know, it's funny. So on that, Jason, you Got to break the top.

[Dr. Anish Kadakia]

You got to break the tire. How do you handle this? Smart man.

[Dr. Unknown]

She's a program director and fellowship director.

[Dr. Anish Kadakia]

Yeah, he's a.

[Dr. Unknown]

He's got to listen to patience, not me.

[Dr. Anish Kadakia]

In the ivory tower, this guy's man trudging it out there. Blue collar. How are you handling it?

[Dr. Jason O'Dell]

So if I am lucky enough to get that piece out in one piece, laid it on the table, it might be a centimeter tall. So it's not too big.

[Dr. Unknown]

It's not too big.

[Dr. Anish Kadakia]

I'm comfortable with that. You're wrong.

[Dr. Lauren Gainey]

No, but to your point, of the pain on the sides, though, and I think I've learned to bevel it because people, when they have pain, at least in my hands afterwards, it's always either medial or lateral. It's not the tendon. And I think that if you take less, the edges just have the more natural contour of the bone that was there before. And, you know, as I started to take less, I think those. Maybe I'm just paying more attention to it, but those symptoms for me were decreasing.

[Dr. Anish Kadakia]

All right, so we're talking less. Let's go.

[Dr. Unknown]

Let's just. So I think it's all good. No, no. So I think so when we do less, you probably do more gas rocks. So if you're doing this crazy resection that you're doing, which I see all the time, do you think that's like a Zadic osteotomy equivalent so we'll get into Zadac. Because I don't know if anybody here does that. I've never done one.

[Dr. Anish Kadakia]

I have done them.

[Dr. Unknown]

You have?

[Dr. Anish Kadakia]

Yeah.

[Dr. Unknown]

Oh, good. This is like, take the whole calcaneus off guy, and then do a zadic. I don't even understand what you're doing over there.

[Dr. Anish Kadakia]

Two separate operations.

[Dr. Unknown]

So the question is, and you're the only one with experience I read about it, obviously, is, do you think when you take out all of that bone, is that effectively creating what happens when you do a Zadigra?

[Dr. Anish Kadakia]

Probably.

[Dr. Unknown]

And that's why that's a good. That's why they do so. So all my, you know, comments aside, I think that's why a larger section actually works really well.

[Dr. Anish Kadakia]

I think. Two reasons. I think one is that I'm able to get rid. So I start my cut below the most inferior aspect of the Achilles tendon insertion. So I start it low and aim up. So I think I remove all the invisopathy. I remove all the Achilles tendon insertion posteriorly. I think I'd give a good Blood bed of bleeding bone. I think also resect out if there's, you know, that crab meat Achilles, that tendinopathic Achilles, I resect that out sharply. So basically get new Achilles tendon to heal down a new bone. And also I think I change the angle of pull, which is probably part of it, which is why some people do. I say gastroint recessions for insertion Achilles tendinopathy or tendonitis or enthesopathy. I think those are pretty much all the same thing. They'll do isogastric sessions. And some of those people do. Okay. I mean, I don't know what the numbers are. 60% maybe or something. So, yes, I do think so. In my opinion, I'm doing all of it in one.

[Dr. Unknown]

That makes sense. So then to make it more controversial. So everybody here does open. I obviously I started doing MIS recently for obvious reasons, but the idea behind an MIS resection, which has been out there for years now, there's now some products that make it easier. But do you think there's any value in doing this mis? The wound complication rate. Zadic or not zadic mis. We should probably talk about Zadig again because this is a CME podcast. It's really important. But an MIS insertion Achilles debridement.

[Dr. Anish Kadakia]

I don't even know what that is. I'm being serious.

[Dr. Unknown]

Okay. Nobody else does it. So.

[Dr. Anish Kadakia]

So define what you're talking about. So everybody is on the same basis.

[Dr. Jason O'Dell]

What's. What's the technique? If that's the thing.

[Dr. Unknown]

So it's out there's been published by other people. But what. What it is, is instead of doing it, everything that we're talking about open, you make two small incisions and fairly at the. Where you would put your anchors. Basically, wherever you put the anchors in open, those are incisions that you would do for the mis. Sorry, good point. That's what those are incisions for the mis. So you make the. You make the incision, then you just make a sub. You make a plane anterior to the Achilles tendon between the Achilles and the calcaneus. You take your MIS bur that you do for MIS bunions, whatever. You take the appropriate bur and you destroy the insertional intesified and you do the resection. Kind of like you do probably. Ben, as much I did it, I do it much less than that. It's hard to get the contoured version that Lauren and I seem to like because it's hard to make a rounded surface. But it doesn't really matter. I don't think you take out all of that bone, take out the hag lungs and you do it through all four incisions. Take it all out. Then you put the anchors in, suck it back down. It's a little bit more headache but it's the same idea. You're putting the tendon right back down in the bone. But all the resection is done with the MIS burn. Gotcha.

[Dr. Anish Kadakia]

So I have not done that. I've done the zeta can either be as in the family invasive thing.

[Dr. Lauren Gainey]

So I've done even before the MAS stuff coming out. I'll take down haglins endoscopically or MAS if I'm just doing that. I haven't.

[Dr. Anish Kadakia]

That's what I've done.

[Dr. Lauren Gainey]

I have not taken down. So I haven't taken down the thesa fight. And I just don't really understand how they lift. How do you lift it off?

[Dr. Unknown]

It's not. It's. It's goofy on theory and when you do it it's not that hard. So the bird destroys it. Right. So you take it And I'm not here to sell anything but it's something that I know people are talking about. I've done it. I've booked a bunch more. But the idea is to avoid the wound complication. Right. So I guess the point of the comment is not to. I'm not here to sell anything to anyone because I know that will be thought that way. Is that MIS techniques are now coming to do what we do open. It's technically difficult. Slightly more expensive. Do you think the wound complication rate from this operation open is a big deal or do you think it has no value whatsoever? I will tell you if you do it mis they walk right away in a boot. There's. There's weight bearing accelerated post op in a boot. That's my protocol. It's worked really well. Versus open. I don't let them walk for two, three weeks. The wounds healed so there's a slight difference. But do you think it's a big deal or not?

[Dr. Lauren Gainey]

So you don't. So in your open ones you don't wait bear them because of the wound not because of the bone to healing.

[Dr. Unknown]

The fixation is ridiculous. They'll be fine.

[Dr. Anish Kadakia]

Yeah. I would say yeah. I don't know. I really want to do a study because I think there are a lot of products out there. No matter what is. We can talk about bunion. We talk about a lot of things. Or Achilles. The people that I let them weight bear right away. I don't believe Any of those people weight bear right away. I want to put a pressure sensor in people's boot and see how much weight people are bearing when they can bear weight, quote right out of the operating room. Because I don't believe many people do that. I think they're self limited by pain. So I don't know. I have not done that operation. I've done the zadig. I've had one pretty serious wound healing complication with the zadig in a very young, completely healthy like 29 year old woman. And I think it's because the heat from the burr that I generated because you got to burn a lot of bone out of that calcaneus. It's a lot of burring. It's from that burr site. It probably took her two months to heal that thing in like I think she got necrosis. I basically gave her again you had a paraphrase, a second degree burn because of that thing. But the tissue necrosed around there and it took forever to heal that thing in.

[Dr. Unknown]

Did you use a regular bur or the mis bur with the water irrigation?

[Dr. Anish Kadakia]

The mis bur. So we're doing some studies, hopefully be publishing in cadavers where we've looked at the heat. The heat in general is not all that much. So actually for my mis surgeries, for my bunions, I don't use any water at all.

[Dr. Unknown]

No water?

[Dr. Anish Kadakia]

No water.

[Dr. Unknown]

Use a tourniquet or tourniquet or no.

[Dr. Anish Kadakia]

Yeah, no tourniquet, no water without going too much down the rabbit hole. So because of that I typically do not use much water even for the zadig and I may be wrong about that, at least in her case. We did a cadaveric study looking at that. Results are pending on that. We've done all the data. We just. We have to get a micro CT of the cadaver because I think the bone density of the patient matters a lot and probably done mis can feel that difference of somebody that's really old and really young and how hard that bone is. There's a young healthy black woman and I think she had really hard bone and so I think it took longer to burn through that and generated more heat. That's probably why she had the necrosis and I didn't use a bunch of water on it admittedly. So I think that that's what the risk is, that's what people's concern is. But I think the Zadigs have done well. I just had two conversations in the last week with patients about this. I haven't decided which one I like more, I totally tell them. I think it's up to you. I think the, the open approach. I can tell you I'm going to take care of all of your bone spurs and remove all of your bone spurs. The zeta osteotomy. I'm not going to remove any of your bone spurs, but it doesn't seem to matter. And probably the weanling complications are lower with that. That's what I tell patients and I say it's up to you and they can't want to make it up to me. And I keep telling it's up to you because I don't know which one's better. We're looking at it from patient board outcomes and stuff like that, but I don't know.

[Dr. Jason O'Dell]

Your protocol is the same for both.

[Dr. Anish Kadakia]

For me it's no weight bearing for two weeks. And as long as your incision's healed at two weeks, I get you in a boot with four lifts. Wear four lifts to week six. We take one lift out in the office at week six and then you're down to week nine. Week nine and week ten, you're flat in the boot. Ten, you're out of the boot into a lace up brace. You wear that decreasingly for six weeks and obviously that's Achilles tendon rupture. That's insertion Achilles, that's zadig. It's all the same repair for me.

[Dr. Unknown]

So I disagree with that post op rehab protocol. So I'm curious and there's no right answer here, obviously. What do both of you do? So that's about 12 weeks in a boot, give or take 10.

[Dr. Lauren Gainey]

10 for the Open insertional.

[Dr. Unknown]

Open. Let's talk about open zatic since Ben's the only one doing it. Yeah, I think they but open insertion debridement. What is your post op portal? Because everybody does wants to know.

[Dr. Lauren Gainey]

I do two weeks non weight bearing planar flex splint, stitches out at two weeks, then into a boot with two heel lifts, still non weight bearing. And at week five, I let them walk every week. One lift comes out and then they're in a shoe by eight weeks.

[Dr. Unknown]

Perfect. Jason.

[Dr. Jason O'Dell]

So similar. I just use a cast for about a two week period after the splint comes off.

[Dr. Anish Kadakia]

Okay, so you're four weeks. So we're two weeks of non weight bearing.

[Dr. Lauren Gainey]

So they're in a boot. Okay, but still non weight bearing.

[Dr. Anish Kadakia]

So you're no weight bearing for five weeks, you're nobody for four weeks. I'm no weight bearing for two weeks.

[Dr. Jason O'Dell]

You're no Weight bearing for two weeks.

[Dr. Anish Kadakia]

Two weeks and then they're in a boot.

[Dr. Unknown]

Boot with two wedges. Just my Achilles rupture protocol, my insertion protocol are all the same. So two weeks non weight bearing if it's open, if it's not open, if it's perk, I just let them go. But let's talk open. I do two weeks non weight bearing in a boot, two wedges. Then they're walking in the boot with two wedges. Six weeks they should be flat heel, wedge, weight bearing and flat weight bearing in the boot. Gym shoes at six weeks with a wedge and then by nine weeks they're just in regular gym shoes.

[Dr. Anish Kadakia]

What kind of wedge are you putting in a regular shoe?

[Dr. Unknown]

It's one fatty. We call them fatties or skinnies. So probably not PC, but it's about a 3 quarter inch lift. Is a single lift in their shoe.

[Dr. Anish Kadakia]

And is it made of like a gel or is it the same wedge that's in your boot?

[Dr. Unknown]

It's the boot wedge. That fat, the foam, the felt, felt one, the felt pad. And then if they're, they hate if it doesn't fit in their shoe. I just tomagulate a silicone one from Amazon or something like that and shove it in there. I don't think it matters, to be honest. I gotta admit, I don't think any of this stuff matters. I think it matters. The first six weeks in the boot for sure. I think after that none of this matters.

[Dr. Anish Kadakia]

The other thing I would mention, I had some complications because I, I prefer the, the gray type boot. That's three straps at the top over the black boot. I had problems specifically with Achilles tendon issues in that gray boot because it curves in. So we have four lifts in there. We had wound healing complications because the boot was pushing directly on their wound. So it's only for Achilles tendon issues, whether rupture or insertional. I put them in a black boot because it's got the foam backing to it. Just as a. Have you guys seen that at all?

[Dr. Jason O'Dell]

I have seen that. Yeah, I've seen that. Yeah, I've seen. You know, so maybe my patients who might tend more towards neuropathy. If I'm using a boot, I usually do that less restrictive boot.

[Dr. Anish Kadakia]

Okay. Are you using it like a same one?

[Dr. Lauren Gainey]

The one that's like three quarters of the way around? We used to have hinged boot and I don't know why they got rid of it, but it was those knobs on the hinged ones were putting pressure on the malleol isop even though it's nice because you can kind of dial in how much you want. Number one, they're impossible to change the settings on. And two, where the dials are, you know, we're causing people symptoms.

[Dr. Unknown]

So you got a wound infection. Let's suppose you do this open. It occurs. I, I hate the open incision because every single one that I don't want to get a wound infection on, I'm like, you're gonna, you know, this is gonna be bad. And they all get them either high profile or whatever their issue is, what do you do? So they come back at two weeks, say four weeks. At two weeks, they all look okay. We take the stitches out. Sometimes we just leave the stitches in because we're scared. Four weeks you take stitches out because they ain't doing anything. And now you got a hole. And, you know, there's skin, tendon and bone and a bunch of stuff you just put in there. So what do you do? Are you antibiotic person? Are you watching? Wait and see. Are you go back to the operating room right away because there's some foreign material in there.

[Dr. Lauren Gainey]

I mean, if it's.

[Dr. Unknown]

It's just like popped open 2, 3 millimeters.

[Dr. Lauren Gainey]

If it's acute and I know it's down to the tendon, I'll take it back, wash it out.

[Dr. Anish Kadakia]

What do you do when you take it back?

[Dr. Lauren Gainey]

Oh, at that point, I try to maintain the. What's in there? Right. Because, I mean, you presume you didn't see them that long ago.

[Dr. Unknown]

Sure.

[Dr. Lauren Gainey]

So it hasn't been open for that long. So initial debridement. I'll debride, wash, scrape, and then keep in there. What's in there? And pray.

[Dr. Anish Kadakia]

Do you still suture back together? Do you do a wind vac or insertion vac, anything like that? Okay, fair.

[Dr. Unknown]

We'll take that as a no. Do you put any other adjunct in there before we go to Jason? So you've washed it. Close it. You put vancomycin powder, and you're taking cultures and stuff, I'm assuming, but no, no powder. Fair enough.

[Dr. Anish Kadakia]

Prayer.

[Dr. Jason O'Dell]

Yeah, I agree that, you know, in the bad cases, you have to treat that as an implant and take everything out at some point. I have disposable topical wound vaccine. The office, we use this pretty aggressively. I think that helps. I've had also good success with a saline.

[Dr. Unknown]

Hold on. So they'll come back at four weeks, and you're at that point, you just put the topical wound back on in the office, not back to the operating room.

[Dr. Jason O'Dell]

Well if it, if they didn't have a cellulitic appearance, it was localized.

[Dr. Unknown]

There's a hole in the skin, right.

[Dr. Jason O'Dell]

We see that they're still swelling, they're still draining. That's probably part of why it's staying open. I want to manage that drainage. So you know, I may go with the Keflex and do, do the topical disposable wound vac which lasts a week. I'm going to bring him back in a week anyway, which is the bad part of clinic because there's already 70 people that day and you're going to come back next week to be number 71. But that's, that's the way that I would do it typically.

[Dr. Anish Kadakia]

Yeah, I do antibiotics and either I put them in a cast or I do an una boot if there's a lot of swelling. So I do that compressive like coban uniboot thing. Like let's see, I see them on a Wednesday, they'll come back for change on Friday, uniboo change on Monday, I'll see them back the following Wednesday. I've had pretty good success with managing those small open wounds non operatively. Two things I counsel patients on. One, if it opens, it's going to be two months before it heals. I mean it's going to be a long time before those 3 millimeters heal. And also I tell them you're going to have pain for twice as long as what we thought. Because of that wound healing issue. I found those patients just hurt for a lot longer. Their long term outcome I found to generally be the same, but it takes a lot longer before they get there. Has that been your experience?

[Dr. Unknown]

Oh yeah. I agree with you. Everybody asked, why does it hurt? Wiser, I'm like, cut your finger, figure out how long that hurts you. Wounds hurt for a long time and tell them it takes three, four months. I'm sorry, it's not going to. I'm with Orlando. I hyper, go back, wash it out, close it. I use some of their proprietary device that helps take tension off the skin. I got no skin in the game, but I do everything I can to wash out because the problem is, and maybe just my practice, that when things go wrong, they show up to my clinic from all over the place. I've had a couple osteo and chronic infection and those people are impossible to deal with. Like it's a disaster. And so I just figured, you know what, I took you to the operating room once. I thought you weren't going to die on the table. Then I'M going to do it again. We hesitate. I'm going to take you back to the operating room. I made the decision the first time. I'm going back in. I ain't scared about taking the operating room again. And they may be upset. And I tell everybody pre op, I said, look, if there's anything wrong with the wound at two weeks, three weeks, you're going to go back. I don't mess around. If you're okay with that, that's fine. I don't cry about it. We're not putting our head in the sand going back to wash it out. Because a chronic infection that is so unlikely to occur, all the protocols that we said is fine, the problem occurs. What happens when it's a chronic infection. You managed it non op for three months and now it's like edema. It's a problem. Now you're kicking yourself in the healing. You know, why did I do this? Why did I do this? And patients for sure in my world in Chicago already lighten you up. So much more aggressive dishes from practice. But I don't know what the right answer is. Before we quit this podcast, we didn't talk about it, but what's your fa? Nobody talked about doing an fhl. How come I didn't hear that from anybody?

[Dr. Lauren Gainey]

So here's my theory on FHLs. So do you. I think that I do an FHL and almost all my non insertional and I think because the majority of them respond to PT and if they don't, they're really, really bad.

[Dr. Anish Kadakia]

You're not insertional tendinopathy, not insertional rupture.

[Dr. Lauren Gainey]

Correct Nonopathy. I think the majority of my patients when it's insertional is you just don't have. I think you can debride it back and I think you still have enough tendon.

[Dr. Unknown]

Now before you finish sentence, how much do you debride it back? Because everybody asked me that question, how much do I take off? I'm like, I don't know, but don't take off More than half. That's my answer.

[Dr. Anish Kadakia]

And I think you mean half of the insertion part of the Achilles, so.

[Dr. Unknown]

Half the width of it. So if you're going to debride it. I debride universally less than half. I treat anything that's calcified. Obviously. Then you have that tissue that ain't calcified but doesn't look normal.

[Dr. Jason O'Dell]

It's yellow.

[Dr. Unknown]

Yellow. Now how far back do you go? When I was young, I would take it all out and I'd have most of my Achilles would be disappeared. I'm like, well, this doesn't make any sense. So five years I did FHLs on everyone because I had no Achilles left. I'm like, I'm an outlier here. And so now, with our new rigidity, I take out anything that's hard. It's not about my. I'm supposed to answer the question, but I take out anything that's hard to basically about half. If it's kind of okay at that point, I leave and then reinsert, and they seem to do fine. And I do gastroc as well. But how much do you do? Like, when do you stop?

[Dr. Lauren Gainey]

So that's where I find the MRI helpful, honestly, because typically your diagnosis is already made, right? Your prognosis, your decision to operate is based on their symptoms and their response. So I get an MRI ahead of time to understand how bad the tendon is, so I know where to look for the bad stuff. And then if I look at it and it looks super thick and there are these huge calcifications in there, then I expect to do an fhl. I'll also do an FHL on, you know, I have a guy who is kind of quitting a, you know, overseas professional basketball career. You know, he's in his 30s, and it's killing him, and he's huge. So I did an FHL on him because I just. I mean, number one, tendinopathy is awful, but I think that he. Somebody like that is going to do better with a tendon transfer in addition. But I say 15%, 10% maybe.

[Dr. Unknown]

So not common at all. That makes sense. Jason? Yeah.

[Dr. Jason O'Dell]

You know, I think similar to what I was saying about the Strayer, I used to do it a lot more frequently. I still will certainly talk about the patient and consent them as a possible BMI. 40, 45. Probably going to just go ahead and do it on those patients. And I think a lot of those patients understand it because you say, look, I'm going to take healthy, normal tissue because really, I'm repairing disease tissue however you do it. You're repairing disease tissue or doing an osteotomy and hoping that it heals. Let me bring healthy tissue to the party. I do an FHL on 100% of, you know, avulsions. So Achilles avulsion, insertional avulsion, different topic. But I will do it all the time on those patients. I do think if I debride and I critically feel like there's more than 50% gone, and I would say the same thing. I've taken Less over time. Certainly take out the hard stuff, certainly take out the calcifications. I would still do an FHL if they were real heavy patients. And I've also had a few people, perhaps you've had the same. They just kind of linger. They just don't get better. They maybe get a follow up MRI at some point. They have bone edema, which I've come to understand. Everybody has vitamin D deficiency. I had vitamin D deficiency. So everybody gets vitamin D In my clinic. We're super aggressive about that. But even with that, there's still some people that have this lingering insertional change. And I've gone back and done an FHL on those patients. They've done fine. And a lot of those were bigger patients. So I try to be predictive of that.

[Dr. Anish Kadakia]

One of the things I want to get to is actually the coding of this. So at first, about eight years of my practice, I didn't actually code the surgery properly. So I would say for the patients that have a loose piece of bone in their Achilles tendon, I code A28120 which is partial incision calcaneus. Then I code for a secondary Achilles reconstruction. Because I use the four anchors in the suture tape. I didn't know you should do that. So for eight years I coded up just a primary Achilles repair. And then if they have those masses in the Achilles that are not touched calcaneus, I code that for excision. Benign bone mass. So is that how you guys code it or do you code it differently than that?

[Dr. Unknown]

I don't code that last one. I always say the Haglins is unrelated to the Achilles disease. I'll code, you know, was opened up as mechanical impingement with the spur on the dorsal aspect of the calcaneus. Unrelated to. During my dictation, unrelated to the Achilles tendon. Parts of the decision calcaneus to remove that. And then I do the secondary reconstruction of the Achilles and then that's. And the gastroc is separate. But I don't ever record that loose body one. That's a new one. I should.

[Dr. Anish Kadakia]

I mean it is a benign bone mass. It's not a fracture. It's a benign bone mass. You're removing it. As long as you put the measurement in there, you know, and it, you know, it's an intra tendinous. So it's not subcutaneous. It's an intramuscular intra tendinous one. I would just throw that out there. How do you guys code it?

[Dr. Lauren Gainey]

I do secondary repair and then I do a 28118 for removal of the partial calcinectomy, I guess for the insertional spur.

[Dr. Anish Kadakia]

So you do the ostectomy instead of partial excision code. Yeah. So there's a little bit of a difference in the pain in that. I say in mine because I do a big cut. I like your word. Broad bony resection. That's great. So I say that I resect the posterior 1/5 to 1/6 the calcaneus, which, I mean, I take a big cut of it, so. Because otherwise if you don't. I think the proper code is the ostectomy code.

[Dr. Jason O'Dell]

I could also code as a subtalar arthrotomy, right?

[Dr. Unknown]

Yeah.

[Dr. Lauren Gainey]

What about Dobreedman 27680? Like, did you ever code. Somebody told me to code debridement. I never have.

[Dr. Anish Kadakia]

Of the Achilles tendon.

[Dr. Unknown]

Yeah, I think that's bundled with secondary reconstruction. You can't do. Because I've talked about coders too. I don't think you can. You'll get that. But if you do my learning for coding and Andy Xu gave a nice lecture. He's a master coder. But I don't have the patience for all of that. Is the key thing is just make sure the codes have unrelated diagnoses so that you can't be like, I just did a resection with Achilles, you know, reconstruction, and I used the bur to take out the calcaneus. Well, the. The coders are going to go to the least risky thing, which is it's all one thing. But if you say they're unrelated, which in many ways the headlines is not related to insertion Achilles, we know that we're not being unethical about it. Separate pathology. So there's two diagnoses. The diagnoses have to be as many codes as you have in general. That's what I try to do. And the coders told me that makes it way easier for them. So the pre op diagnosis is exostosis calcaneus. Number two is insertion Achille generation number three. If you're going to code the way he does, which is, I think genius. Benign pathophony pathology. And Achilles post op diagnosis is the same and you have three codes that each match up with the diagnosis. The coders have a much easier time separating those out and getting that paid for. You can't just have insertion Achilles tendonosis and three surgeries. They're like, they're just going to have to. They're going to bundle it as one. And that's a good way to Minimize the risk of not getting paid for the work that we do.

[Dr. Anish Kadakia]

Yeah, that's great.

[Dr. Unknown]

I think it was great. So, you know, I think it's a great discussion. We have, you know, two different viewpoints, private versus academic, but in the end it's the same conclusion. Try some non op. You can offer prp. I got into an argument with somebody at the winter meeting last year about it and the fight was what? PRP is total, has no data, so everyone should get surgery after six weeks. And I said I disagree. And I still fully, respectfully or disrespectfully disagree with that comment. PRP is not harmful. Offer it if the patient denies it, be honest about it, that's fine. I've done a lot of prp. A lot of people get better. Whether it's mental or physical, who cares?

[Dr. Anish Kadakia]

Placebo effects real.

[Dr. Jason O'Dell]

21% placebo effects real. I think that, and I'm not an academic person, but I think that if you look at the studies that talk about prp, they don't, they're not looking at, okay, you know, you really have kind of mild to moderate changes. I don't know that they are grading it for the severity of the, of the changes. Everybody that has this problem got the prp. We couldn't show a difference. I mean, is that right or do they look at the severity?

[Dr. Anish Kadakia]

I haven't seen a ton for pathology. I've seen, I've seen PRP is equal to corticosteroids for plantar fasciitis, but I haven't seen it for this particular pathology.

[Dr. Unknown]

This I've seen it and they show no significant difference for plantar fasciitis. What I've seen is that at one year and I don't, I don't have any skin to game for prp. I could care less. But PRP has superior outfit effect. At one year where three months they were the same at one year was a better long term effect with prp, whatever the reason is. And I sure, like all of us don't know the science of prp, because it's not, what we do is I think you should offer patients what is out there in the community and just be honest with them. But don't pooh pooh it and tell them, well, you have to have surgery. Surgery is not benign. Surgery is expensive. When you get a complication, it's devastating. And if PRP is a benign procedure, I'm not telling them. I don't even get the money for the prp. I'm at an academic institution I haven't make any money off this thing, so it doesn't matter that much.

[Dr. Jason O'Dell]

What do they charge people?

[Dr. Unknown]

They charge 850. I get the same code you get for any injection. So for me it's like a hundred bucks is what, 120 bucks? It's not like it's a money making operation. It takes a long time to do.

[Dr. Jason O'Dell]

Yeah.

[Dr. Unknown]

So I don't do this to make any money, but I think the idea is that you should offer them a benign something to help them. Besides, say surgery is the only other solution and that's not a good practice model in this 20, 23 age. People don't trust you. I'm not saying do amniotic injections. We know that has zero value. You can offer that, but you just got to be telling, I don't know if it's going to help you or not. And I don't think anyone should use this term stem cells. This is a CME podcast. I think we should all be better about how we talk. You argue bma, that's maybe slightly different, but any of these injections are not stem cells. Even BMA is mesenchymal stromal cells. I say stem cells and I quote my fingers. And I said, look, I just. They're not exactly stem cells. We need to get away from that word. That is probably a misleading description of what we do. But you should offer them growth factors and see if it helps. It may not. The truth is the pain is money and some pain. But I personally think PRP is phenomenal for it. But that's just personal bias.

[Dr. Lauren Gainey]

The more you pay for it, the higher the placebo effect.

[Dr. Unknown]

Oh yeah. If you look at placebo effects, it's.

[Dr. Lauren Gainey]

Been shown, which makes sense, right? The more you pay for something, the more you really want to work.

[Dr. Anish Kadakia]

But I think also the fact that, that it's kind of like people asking about glucosamine for arthritis. This is only going to hurt you in the pocketbook. It may or may not help you, but it's only going to hurt you in the pocketbook. So I think there's something like that.

[Dr. Unknown]

Perfect. Thank you very much.

[Dr. Anish Kadakia]

I appreciate it.

[Dr. Jason O'Dell]

Yep, it's great.

[Host 2]

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[Host 1]

Thank you for listening to the AOFAS Ortho podcast, a Conveymed production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.