Outpatient Foot and Ankle Continues to Grow

CMS’ addition of a key surgery to its ASC-approved list provides the latest boost to a thriving same-day subspecialty.

Foot and ankle surgeries have long been performed same-day, but advances in technique and reimbursement have driven them increasingly to ASCs. For orthopedic and multispecialty surgery centers considering adding a foot and ankle line, some unique accommodations must be made for the subspecialty, but with proper planning and forethought, foot and ankle can be safe for patients and profitable for centers.

A changing specialty

Eric Bartel, MD, FAAOS, is a board-certified foot and ankle orthopedic surgeon with Fox Valley Orthopedics who operates at hospitals in Elgin and Geneva, Ill., and Fox Valley’s own Geneva ASC, of which he is a partner with other Fox Valley doctors. He has performed same-day foot and ankle surgeries all 27 years he has been in practice. What’s changed over that time is the number of procedures he can perform same-day.

“We started with very simple, basic things like bunions, hammertoes and other minor procedures that are short, quick cases where people can walk on them right away,” he says. “It’s evolved over the last decade to include most people with fairly straightforward broken bones, and more complex reconstruction-type surgeries where we’re treating things like tendinitis. Over the last 15 years, we’ve been doing more fusions of the ankle and hindfoot. More recently, we’ve been doing bigger procedures that would normally have been in the hospital and the patient would stay for a couple days — things like ankle fusions, pilon fractures or complex fractures of the tibia and the shin, and now that we have approval from CMS, we’re doing ankle replacement surgeries as well.”

Total ankle replacements have become much more common over the last decade. “The implants have become more refined, so the results are comparable to hips and knees as far as longevity,” says Dr. Bartel. “The alternative was doing ankle fusions. When I started practice, we were probably doing 90% ankle fusions, 10% replacements. It’s probably flipped at this point; now we’re doing 90% replacements and 10% fusions. We’re seeing a younger, more active population that needs ankle replacements to maintain their activity level, and those are prime people to do at an ASC.” He still performs some same-day procedures at HOPDs when it’s less expensive for HMO patients, for example, but prefers the surgery center setting.

Podiatric surgeon Eric Barp, DPM, FACFAS, is a Fellow Member and Immediate Past President of the American College of Foot and Ankle Surgeons and co-chair of the board of directors with The Iowa Clinic in West Des Moines. He focuses on total ankle replacement, hindfoot surgery and trauma, and has performed same-day surgeries for 21 years, gradually expanding his procedural arsenal. “Within the last 10 years, we’ve been able to push the envelope as far as what we can do in an outpatient setting,” he says. “For example, we now can do total ankles, or ankle or hindfoot reconstruction at the ASC. From a practice management standpoint, anything we can push to an ASC outpatient setting, we want to do.”

Total ankles are so much more expensive to do in a hospital setting than at an ASC.
Eric Barp, DPM, FACFAS

Dr. Barp calls CMS’ embrace of total ankle replacements in the ASC setting a big deal. “My charge as a surgeon is going to be the same whether I do inpatient or outpatient, but from our clinic’s business model standpoint, we like to do these outpatient because of cost control,” he says. “Total ankles are so much more expensive to do in a hospital setting than at an ASC.” Even though the ASC’s margins are smaller because it receives a lower reimbursement than a hospital would for the same procedure, he says total ankles are profitable for Iowa Clinic.

Equipment and instrumentation

The big-ticket capital expense for foot and ankle is intraoperative fluoroscopy using either a large C-arm or mini C-arm. Fox Valley’s ASC has both on-site. “The big C-arm is needed for visualization in total ankle replacements, but a lot of foot and ankle can be done under the mini C-arm,” says Dr. Bartel. The large C-arm is also used for spine cases and hips and knees at his ASC, while the mini C-arms are also used for upper extremity procedures and some shoulder and elbow cases.

Subspecialities at his ASC also share the same towers, controllers and video screens. “Since we’re a multispecialty orthopedic practice, we cross-use all those things, which is nice,” he says.

Dr. Barp reports similar fluoroscopy requirements. “For a lot of the ankle and hindfoot procedures we do, we use the large C-arm, but for most surgeries we use the mini C-arm,” he says. “Fluoroscopy allows us to do a couple things. One, if I’m doing a total ankle, for example, live X-ray enables me to look and make sure I have the foot and ankle aligned properly, and two, it helps me place the implant in an anatomic position for that patient.”

Other requirements include small-bone power tools and subspecialty-specific instrumentation. Dr. Bartel says much of this is shared with hand and upper extremity surgeons at his center, although some retractors, clamps and other instrumentation are unique to foot and ankle. “For example, for arthroscopy, we use small-joints scopes that are 2.7-millimeter, where knees and shoulders are 4.0 millimeter,” he says.

Going forward, Dr. Bartel is intrigued by the ability to perform more minimally invasive procedures. “There’s been a development in the equipment — burrs and other instrumentation — so that commonly-performed hindfoot procedures such as bone cuts, osteotomies, fusions of the foot and the toes, and bunion corrections can now be performed as minimally invasive procedures with just as good results,” he says. “There’s less swelling and smaller incisions, which tends to equate to faster returns to work and school.”

Implants

TOOLS OF THE TRADE Foot and ankle surgeons require small-bone power tools and some subspecialty-specific instrumentation.  |  Fox Valley Orthopedics

Dr. Barp says the implants he uses work well, although some patients’ specific anatomy falls between sizes. “Anything we can do to tailor that implant to that patient, we’re going to have better outcomes,” he says. “In total ankle, just like in total knees, you may be ‘in between’ implants. When you put the smaller one or the larger one in, the outcomes might not be as optimized as something that’s patient-specific.” As a result, he is enthusiastic about customized 3D-printed implants for total ankles and total talus based on preoperative CT scans of the patient’s anatomy, which he calls “a huge thing on the horizon for us.” Currently too cost-prohibitive at his ASC, he typically employs 3D-printed implants in the hospital setting. “As they become more mainline and mainstream, we’ll definitely push the envelope and do these in an ASC setting,” he says.

Dr. Bartel infrequently uses 3D-printed implants, which he deems more appropriate for high-level inpatient trauma cases. “I can do them, but they actually don’t provide an advantage over standard off-the-shelf implants, and the cost is quite exorbitant,” he says. “Given the equipment we use, size is usually not an issue. There are a large variety of sizes and shapes in two-millimeter increments. Trying to be more precise than that just is not necessary for the patient’s care.” However, he does use custom-made cutting jigs for total ankles when the patient has had a preoperative CT scan. “We map out the patient’s personal anatomy, and the cutting guides will then be made for the individual,” he says.

Anesthesia and analgesia

Dr. Bartel says anesthesia is tailored to the procedure. Patients frequently receive regional blocks with light sedation, along with an anesthetic to the extremity. “If it’s out near the toes, some fusions, bunions, hammertoes, we’ll do a local or block of that digit,” he says. “If it’s back in the ankle, the hindfoot or a bigger procedure like total ankle, we’ll have anesthesia do a block on the nerves at the level of the knee, so everything from the knee to the toes goes numb. That tends to last a bit longer; they’ll have surgical anesthesia for up to 24 hours after the surgery.” For postoperative pain management, Dr. Bartel focuses on icing and elevation, along with NSAIDs. “For most patients, we will have a backup narcotic for short-term use, but they may never use it or need it,” he says. “Some may need it for three days or so, but we really don’t ever see it going past two weeks, and even that is just nighttime use toward the end.”

Dr. Barp also relies on anesthetic techniques and NSAIDs such as ibuprofen. “We’ve really gotten away from using a ton of narcotics, and patients don’t ask for them,” he says. The first 24 hours postoperatively, he says, are the most painful for patients. “If it’s a procedure like a hindfoot ankle where we think there will be a lot of pain, we’ll have anesthesia do a peripheral block of the nerves up by the knee or sometimes in the groin, which will cause numbness anywhere from 24 to 36 hours on the extremity we’re working on.” He only will prescribe a small amount of a narcotic for subsequent breakthrough pain. “It’s really rare for them to take the entire script,” he says.

OR staff

Dr. Bartel’s typical team consists of a PA as first assist, a scrub nurse, a circulating nurse and an anesthesia provider. For cases that require the large C-arm, an X-ray tech is on hand. Dr. Barp says his typical OR staff consists of a scrub tech who helps with instrumentation, an anesthesiologist and a circulating nurse. Occasionally an extra nurse is in the room.

Operative times

The lengths of foot and ankle surgeries tend to be fairly predictable, especially for more experienced surgeons. However, because the subspecialty encompasses such a broad range of procedures, OR time varies. “It’s kind of all over the place, depending on the procedure,” says Dr. Bartel. “Some small surgeries such as forefoot, hammertoe or bunions take 30 minutes. Depending on the severity, fixing an ankle fracture can take 40 minutes to an hour-and-a-half. Ankle replacement could take an hour-and-a-half to two hours.” Even the most complicated surgeries last no longer than two hours, according to Dr. Bartel.

Just because the cases are short, however, doesn’t mean it’s easy to integrate foot and ankle into an ASC’s surgical schedule. “There are so many different procedures that foot and ankle does, similar to hand, that it can be hard when you’re starting a service line de novo at an ASC to wrap your mind around it,” says Dr. Barp.

Patient selection

Both surgeons are reluctant to operate on medically unstable patients with uncontrolled conditions at their ASCs.

“Current atrial fibrillation, recent heart attacks, anything where they are at higher risk of having a complication that might require them to stay and be monitored overnight, we’ll tend to do them at the hospital,” says Dr. Bartel. “But for people with medical issues like diabetes, high blood pressure or cardiac issues that are well-controlled, we’ll do those at the surgery center if we get them cleared by their cardiologist or primary care physician.”

Dr. Barp similarly cites patients with uncontrolled diabetes, obesity or cardiac issues as potential disqualifiers at his ASC. “But as long as we get cardiac clearance and the patient is stable, if their blood glucose and diabetes are well-managed, if their BMI is below 50, we can do that in the ASC,” he says.

Post-op safety

Dr. Bartel’s concerns include deep or superficial infections that lead to increased pain, redness, fevers or chills. He says wound healing is low-risk for most foot and ankle procedures — “less than 1%.” Dr. Barp concurs. “It’s rare for us to have a postoperative infection,” he says.

Dr. Barp is conscientious about wound healing. “If I’m keeping somebody non-weight bearing, I’ll typically put them in a posterior splint, which they keep dry until I see them back in two weeks,” he says. “To shower, they can use trash sacks or put specific sleeves over the splint to keep it dry. If it’s a forefoot procedure where they’re able to ambulate or a partial weight-bearer, I’ll usually see them back in post-op week one to change the bandage, and then they can shower or get it wet at that point. They don’t really have to do anything with the wound until we take the stitches out and then we’ll use some sort of scar cream with an amount of vitamin E.”

Facility leaders should be on guard against postoperative falls at home. “We worry about that especially with our more advanced-age patients,” says Dr. Barp. “We find out: What’s their care team at home? Do they live by themselves? Do they have somebody around who can help them do basic daily activities? The last thing we want is to do a reconstructive surgery and the patient goes home, falls and breaks their wrist, hip or face.”

He also focuses on preventing postoperative deep vein thrombosis (DVT). “We want that patient up and moving as quickly as possible,” says Dr. Barp. “One reason for that is DVT prophylaxis to ensure they don’t get blood clots. We put any patient who we are keeping non-weight bearing or who is high risk for DVT on some sort of DVT prophylaxis.” He usually prescribes baby aspirin twice a day for this, while he says other colleagues employ drugs such as Xarelto or Eliquis.

Physical therapy

Dr. Barp prescribes physical therapy as soon as the patient ambulates not only to prevent DVT, but also to address range of motion and gait change. He says physical therapy is crucial to success with outpatient foot and ankle. “Part of the reason we can do more foot and ankle procedures at the ASC is due to physical therapy,” he says. “We used to do stuff inpatient because patients would need physical therapy for pain control. But now anesthesia can do peripheral blocks for us, which helps with pain control, along with physical therapy.”

Fox Valley Orthopedics offers physical therapy at multiple locations. “Even if the patient is coming from 45 minutes or an hour away to our surgery center, when they go back home we’ll usually have physical therapy locations nearby,” says Dr. Bartel. “We can arrange for their therapy to start at the appropriate time when we schedule the surgery if we anticipate they’ll need it. We’ve made really good gains in pre- and post-op workups and preparation, and getting post-op therapy arranged so patients don’t need to stay in the hospital.”

With total ankle replacements and older patients who won’t be weight-bearing immediately postoperatively, Dr. Bartel often also prescribes preoperative physical therapy. “We’ll send them for one or two visits with therapy before they have their surgery so they can practice and work on those skills so they’re not surprised after their surgery,” he says.

Short cases, powerful results

Done right, outpatient foot and ankle can be a high-volume and profitable addition for an ASC. “Most cases are pretty short, so the volumes that can be done at an ASC usually are pretty powerful,” says Dr. Barp. “I can do 10 to 12 foot and ankle cases in a day.” OSM