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Degenerative joint disease of the Great Toe Joint

Discussion in 'Foot Surgery' started by richardkoenig, Oct 5, 2008.

  1. richardkoenig

    richardkoenig Member

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    Hello, I am Richard Koenig, a board certified foot and ankle surgeon. I researched and developed the Total Toe System for 4 years, then began performing the surgery for my patients in 1988. My goal is reconstruction, using implants, of the severely diseased great toe joint in a manner similar to total hip and total knee implant reconstruction. My aim is elimination of pain with restoration of function. My invention has two implants to replace both sides of the diseased great toe joint and dedicated instruments that make the surgery accurate and results reproducible.

    Degenerative Joint Disease (DJD) of the Great Toe Joint of the foot is a very painful and activity-compromising disease. We know that sufferers from degenerative joint disease of the great toe joint of the foot have symptoms of painful loss of motion, a noticeable enlargement of the joint which causes undo pressure from shoe wear, restriction of activity due to great toe joint pain and a change in their walk, which may include a limp, due to loss of motion. The causes of degenerative joint disease in the Great Toe Joint are attributed to osteoarthritis, rheumatoid, gouty, traumatic arthritis, and undetected mal-alignment of the joint probably from birth and exacerbated with time and wear. According to the 2005 study of Frost and Sullivan*, commissioned by HCUP (Healthcare Cost and Utilization Project) of NIH, there may be as many as 17 million Americans who suffer from DJD of the great toe joint. **

    After performing this surgery for 20 years and influencing the development of competitive designs, my colleague’s and my surgeries are now being termed experimental and being denied access and reimbursement by major insurance companies.
    Some of these companies are administrators of the Medicare program. This restriction prevents the insurance subscriber from alternative, modern medical care. It is our position that insurance companies should not be dictating advanced medical/surgical care, especially when that care is well established and in the best interest of the patient. Insurance companies insist that the “gold standard” is a 100 year old surgery.

    This action by a few insurance companies establishes a very bad precedent and should not be tolerated. Their unwillingness to compromise demonstrates bad faith. We need any and all help you can offer. This is what you can do: go to greattoe.com and learn about the Great Toe joint replacement procedure, then notify your insurance company’s Chief Executive. Tell them that you disagree with their position and you want the opportunity to choose your treatments. Contact your state representatives and make them aware of your opinions. Thank you for your time and consideration.
  2. Heather J Bassett

    Heather J Bassett Well-Known Member

    :welcome: Richard, your welcome goes into quite some depth.
    Perhaps you could repost under the foot surgery forum as not all pods may read the introductions.
    You may also get some replies here though.
    Good Luck with your quest.

  3. drsarbes

    drsarbes Well-Known Member

    Hi Richard:
    I also have been performing total joint replacements for many years (30) but have not had any problems with insurance companies.
    What part of the country are you in and what companies are you having trouble with?

  4. richardkoenig

    richardkoenig Member

    Hi Steve:

    I practice in South Florida and Tennesse. I am glad to hear that you are not having problems. Up until recently, I was not experiencing difficulty either. Dr. King and Tritto of the APMA have been in discussions with Aetna, United Healthcare and the progenitor Cigna. They got silastic implants and hemis back, but not Total Joints. I, of course am most interested in Total Joints. Do you have any secrets? Also, can you provide any documentation to help the cause. It seems the failure to report the long term results is what bothers the companies most (or so they say.) If you have something prepared, my address is on my website: greattoe.com


    Last edited by a moderator: Oct 6, 2008
  5. admin

    admin Administrator Staff Member

    Richard :welcome:

    Sorry, but you would have got an error message when you posted the above message. We have a big spam problem here and have software that automatically sends for moderation any message with a link in it for any member with less than a certain number of posts (spammers always post links to there product; eg viagra) ....
  6. drsarbes

    drsarbes Well-Known Member

    Hi Richard:

    South Florida and Tennesse. OK. What's your gas bill?

    I started on silastic hemis way back when during my residency. In '83 I switched to Sutter Totals and progressed through LaPorta and now Lawrence designs (Futura).
    I must say I love them. Most everyone in my area fuses the 1st MTPJ so I look pretty magical when I get patients back in their own shoes in two weeks! I haven't fused a 1st MTPJ since residency.

    Of course, after this long of a period I have had the opportunity to replace a few replacements. Nothing to it.

    I asked my office manager about our charges. We use the normal code for total joint replacement 1st MTPJ. Of course we don't get as much as I'm worth!

  7. richardkoenig

    richardkoenig Member


    We are speaking about 2 different things. I am speaking of durable, 2 component total joint replacement.

  8. drsarbes

    drsarbes Well-Known Member

    "We are speaking about 2 different things. I am speaking of durable, 2 component total joint replacement. "

    The surgical fee is the same whether you put a two piece, once piece, hemi, Ti, silastic, ceramic.....doesn't matter as far as the surgeon's fee.

    Now, if you own a surgicenter or out patient facility and you need to charge for the implant, well, that's a different matter. I assumed from your original post that you were discussing the surgeon's fee.

    I don't use the two piece merely because the one piece has more intrinsic stability and, in my hands at least, has better outcomes.

  9. richardkoenig

    richardkoenig Member

    I don't wish to lecture you, but you are not correct on all issues. There is a big difference between billing for a silastic implant and a total joint replacement. Additionally, one should not be requiring a soft material implant to create stability. That is exactly how they begin to fail, by stressing a soft material. And fail, they do. The literature is full of radiographic examples of severe and dangerous failure. See: Esway and Conti, Foot and ankle Clinics 10 (2005) for only one of many papers.
  10. drsarbes

    drsarbes Well-Known Member

    Hi Mark:

    If the billing is different then I stand corrected. I don't do the billing, I just assumed an implant is an implant.

    We could argue how a one piece "soft material" can possibly be less stable than a two piece implant, but that's not our discussion here.

    And yes, please don't lecture me - I'm one of the last surgeons who needs a lecture concerning total joint replacements. I've have done literally hundreds, if not a thousand, and stand by MY results. You may often find certain procedures that various studies may find less successful than others, but YOU get predictably good results. It's the "in my hands" intangible that is important. Any replacement not put in correctly will get poor results.

    If a two piece works for you, by all means put them in. I certainly don't have a problem with successful surgery.

    Getting back to the original question - why is there a different procedure code for 1st MTPJ TOTAL replacement dependent on the implant type? Again, I'm assuming here, that if you do a total knee replacement; whether you use a Zimmer total or Biomet total, the surgeons charge is the same.

    Am I wrong?

  11. richardkoenig

    richardkoenig Member

    It's not the brand that matters, its the design. Using your example: a total knee replacement with or without the patellar component, or a uni compartmental knee will change the equation. Same for the great toe joint. Its based on degree of difficulty, number of components, bone prep, etc.

    Everyone has something to learn. Ego's aside. In my hands is an old and worn out excuse. Try to refrain from using it.

  12. drsarbes

    drsarbes Well-Known Member

    " In my hands is an old and worn out excuse. Try to refrain from using it."
    ooooooooo that hurts.

    Old and worn out? REFRAIN from using it? Wow, we are presumptuous.
    I really don't need any advice from you as to what I should or should not say.

    When it's true it's neither old nor worn out.

    Ego's aside. Great. I'm not seeing any ego problems here.
    I merely stated the truth.
    I've done HUNDREDS of total joints. I love the procedure. I get great results.
    I was informing you of my experience with the procedure.

    Now, if you can find fault with that then perhaps we need to end the conversation.
    If you can (put your ego aside) accept the fact that there actually ARE differences in surgical techniques and surgeons choices based on what works for him (or her), then we can go on.

    Perhaps you read something into my post that I did not intend. You have absolutely no reason to get defensive. I could care less what type of implant you use, as long as you are getting good results. If you feel it's technically more difficult and want to charge extra, please feel free to, and good luck.


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