Innovations in Outpatient Foot Surgery More foot cases are migrating into the ASC setting BY ROBERT KURTZ


evelopments over the past few years have made this a particu-

larly exciting time for outpatient foot surgery, says Scott VanValkenburg, MD, foot and ankle surgeon at Upstate Orthopedics Ambulatory Surgery Cen- ter in East Syracuse, New York. “Almost every foot and ankle pro- cedure we can do is listed by Medicare as an outpatient case,” VanValkenburg says. “If you have a strong anesthesia team that can provide a great periph- eral nerve block, you can now do many foot and ankle procedures in the ASC. I try to do all of my cases on an out- patient basis that are not major ankle reconstructions or fusions.” Over the past few years, several procedures have migrated from the inpatient to the outpatient setting, says foot and ankle surgeon Raymond Sul- livan, MD, medical director of the Hartford Surgery Center at the Bone and Joint Institute in Hartford, Con- necticut, and partner at Orthopedic Associate Surgery Center in Rocky Hill, Connecticut. “Complex ankle

fractures in the

elderly are being performed more com- monly in the outpatient

setting,” he

says. “There is also a push to perform selected total ankle replacements on an outpatient basis. At the moment, this is for select patients who receive adequate pre-operative education and post-oper- ative rehabilitation. While these proce- dures are not yet being performed con- sistently on an outpatient basis, I foresee a growing trend toward doing more total ankles in ASCs in the near future.” VanValkenburg says the cost of the total ankle replacement implant is preventing more ASCs from per- forming these procedures. When the cost comes down, he expects that to change. “Total ankle replacements are improving all of the time, not neces-

sarily the implants themselves but the data in terms of implant survivorship. We are growing more and more com- fortable with performing these proce- dures in younger patients, relatively speaking, as evidence on longevity is increasingly optimistic.” Two approvals by the US Food and

Drug Administration (FDA) over the past few years also are likely to ben- efit ASCs soon, VanValkenburg says. In 2016, FDA approved the Cartiva synthetic cartilage implant. “It is an alternative to first metatarsophalan- geal fusion, which has been the gold standard for treating arthritis of the big toe. Implanting Cartiva is just the type of procedure that would be considered bread and butter for outpatient surgery. Somewhat of a hurdle at the moment is that it is an expensive implant. As more time passes from when Cartiva received FDA approval, hopefully, the price will be coming down.” In 2015, the FDA approved Wright Medical’s Augment bone graft. “It


is the first FDA-approved bone mar- row substitute for just the foot,” Van- Valkenburg says. “Such bone grafting substitutes have the power to change an inpatient case to an outpatient case. Like most new technology, the Aug- ment system is cost-prohibitive at the moment. We look forward to the price dropping so we can bring more of those cases into the ASC.” Sullivan says what he finds most

exciting is that there is essentially no longer a distinction between foot sur- gery innovation in the inpatient and outpatient setting. “It used to be that everything new would be done mostly at a hospital setting. Now it is just as common to perform the more innova- tive procedures in an outpatient facility. “More and more cases are going to be done in an outpatient setting with fewer complications and improved costs,” he says. “As someone who is a partial owner in ASCs and believes we perform procedures better and for less, it is a good trend for patients.”

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