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the 6-month surgical guideline

Posted by elliott on 9/20/02 at 09:37 (095829)

Many of the ESWT studies say something like the following:

'All patients had failed at least six months of physician supervised conventional conservative methods and would have been considered surgical candidates by guidelines set forth by the AOFAS.'

This is verbatim from the FDA study with the number of patients removed, but I've seen similar language elsewhere. (BTW, is that six month thing for any surgery or just PF?) My question is, why is six months the criterion for PF surgery? There seems to be compelling and mounting evidence that one should wait much longer--not just because of the risks specific to PF surgery, but because many cases will resolve, even more so with doctor supervision. I personally know four runners who fought serious cases of PF for 2 or 3 years before recovering (and all still run). There are casual acquaintances I know who had it more than 6 months and recovered. It just doesn't seem so rare to recover after this length of time.

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Re: the 6-month surgical guideline

Pauline on 9/20/02 at 09:54 (095831)

Elliot,
You pose an interesting question. I've always been told 6-8 months before I'd even begin to see any improvement, however, my cases went far beyond that.

The problem is most people can put their lives on hold, stay off their feet for such extended lengths of time. Their employers don't understand this condition at all unless they had or have it.

It's vicious, but on the surface it shows nothing. People don't understand how we can be in so much pain. They accept cancer pain even if they don't see the tumor, but they don't accept P.F. pain period.

No one has ever mentioned looking at prevention. I wonder if we should be looking in that direction as well as into cures. If we could prevent the condition all together we could eliminate the cure.

Re: the 6-month surgical guideline

Ed Davis, DPM on 9/21/02 at 09:49 (095895)

Elliott:

The 6 month figure is really arbitrary. It is based on an attempt to come up with some criterion that establishes PF as 'intractable.' Third parties, understandably, need some basleline criteria to work with.

The time to surgery has been suggested to be as long as 12 after initiation of conservative treatment. Again, somewhat arbitrary but we are looking for some way to provide guidelines that prevent some hotshots from rushing patients to surgery. My approach is to look at the patients' progress as opposed to just 'time.' A patient who is improved with conservative therapy, albeit slowly, is given a significant amount of time before considering surgery as long as there are gradual signs of progress. That amount of time will be less with ESWT. A patient, on the other hand, who has had conservative treatment but is making no or little progress need be considered for ESWT or surgical treatment a lot sooner.
For example, I have had an occasional patient who has had virtually no response to conservative treatment after 3 months and remains in significant debilitating pain. It is unfair to ask that person to wait another 3 to 9 months for surgery or ESWT.
Ed

Re: the 6-month surgical guideline

Ed Davis, DPM on 9/21/02 at 09:55 (095896)

Pauline:

I have patients om worker's compensation who are disabled by PF. We determine the amount of permanent partial disability by a book entitled, 'Guides to the Evaluation of Permanent Impairment, 5th ed.' which is published by the AMA. This book has no reasonable means to provide accurate impairment ratings for an individual with PF, yet it is the national standard. Unfortunately politics rears in ugly head in medicine at times.
Ed

Re: the 6-month surgical guideline

Dr. Z on 9/21/02 at 10:04 (095897)

I agree with Ed. The progresive improvement or lack of is what determines the direction of treatment. Time is a factor but just one . That why flow sheet, triad are helpful but should never replace the judgement of the physician or the choice of the patient.

Re: the 6-month surgical guideline

john h on 9/23/02 at 14:04 (096021)

Dr. Ed: My Ortho Foot and Ankle Surgeon has a protocol of at least one year of conservative treatment before he will consider surgery. Another will not do it under any circumstance. I would guess each doctor sets his/her own standards in this area as I have never read anywhere that there is a 'medical standard' for this in any speciality.

Re: the 6-month surgical guideline

elliott on 9/23/02 at 16:33 (096029)

But aren't there many PF cases that seem to show no progress at all for some time and then all of a sudden start getting better?

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Re: the 6-month surgical guideline

Pauline on 9/20/02 at 09:54 (095831)

Elliot,
You pose an interesting question. I've always been told 6-8 months before I'd even begin to see any improvement, however, my cases went far beyond that.

The problem is most people can put their lives on hold, stay off their feet for such extended lengths of time. Their employers don't understand this condition at all unless they had or have it.

It's vicious, but on the surface it shows nothing. People don't understand how we can be in so much pain. They accept cancer pain even if they don't see the tumor, but they don't accept P.F. pain period.

No one has ever mentioned looking at prevention. I wonder if we should be looking in that direction as well as into cures. If we could prevent the condition all together we could eliminate the cure.

Re: the 6-month surgical guideline

Ed Davis, DPM on 9/21/02 at 09:49 (095895)

Elliott:

The 6 month figure is really arbitrary. It is based on an attempt to come up with some criterion that establishes PF as 'intractable.' Third parties, understandably, need some basleline criteria to work with.

The time to surgery has been suggested to be as long as 12 after initiation of conservative treatment. Again, somewhat arbitrary but we are looking for some way to provide guidelines that prevent some hotshots from rushing patients to surgery. My approach is to look at the patients' progress as opposed to just 'time.' A patient who is improved with conservative therapy, albeit slowly, is given a significant amount of time before considering surgery as long as there are gradual signs of progress. That amount of time will be less with ESWT. A patient, on the other hand, who has had conservative treatment but is making no or little progress need be considered for ESWT or surgical treatment a lot sooner.
For example, I have had an occasional patient who has had virtually no response to conservative treatment after 3 months and remains in significant debilitating pain. It is unfair to ask that person to wait another 3 to 9 months for surgery or ESWT.
Ed

Re: the 6-month surgical guideline

Ed Davis, DPM on 9/21/02 at 09:55 (095896)

Pauline:

I have patients om worker's compensation who are disabled by PF. We determine the amount of permanent partial disability by a book entitled, 'Guides to the Evaluation of Permanent Impairment, 5th ed.' which is published by the AMA. This book has no reasonable means to provide accurate impairment ratings for an individual with PF, yet it is the national standard. Unfortunately politics rears in ugly head in medicine at times.
Ed

Re: the 6-month surgical guideline

Dr. Z on 9/21/02 at 10:04 (095897)

I agree with Ed. The progresive improvement or lack of is what determines the direction of treatment. Time is a factor but just one . That why flow sheet, triad are helpful but should never replace the judgement of the physician or the choice of the patient.

Re: the 6-month surgical guideline

john h on 9/23/02 at 14:04 (096021)

Dr. Ed: My Ortho Foot and Ankle Surgeon has a protocol of at least one year of conservative treatment before he will consider surgery. Another will not do it under any circumstance. I would guess each doctor sets his/her own standards in this area as I have never read anywhere that there is a 'medical standard' for this in any speciality.

Re: the 6-month surgical guideline

elliott on 9/23/02 at 16:33 (096029)

But aren't there many PF cases that seem to show no progress at all for some time and then all of a sudden start getting better?

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