Wednesday, May 25, 2022

LCD and wobbly surgical foundation…

Thomas Cutler

“I reject your reality and substitute my own.” Adam Savage, Mythbusters
I applaud the tireless efforts of AOPA, NAAOP, and others. My comments here are to support what they have been saying: Please seek our involvement in finding a solution. You will find that we have unique and valuable input.
I wrote a “Perspective” piece for the Edge and in it I claim that the only way to encourage collaboration in O&P research is to inquire about possible shortcomings found in prosthetic research when our offer for input is refused. Following a refusal, I simply offer this inquiry as lesson one:
The laws of physics work for me. If you own a boat, the laws of physics introduce the force couple relationship as you deal with navigating a trailer in reverse. Understanding this relationship makes you proficient when launching a boat.
Or when doing amputation surgery.
So, what are you saying, Tom? This is where authors state that the tensor fasciae latae is the abductor for the hip.Page 184: “The primary function of hip abduction would then be via the tensor fasciae latae muscle.” I like it because it makes sense and follows the laws of physics.
So… in the adductor myodesis procedure, the “gold standard” of transfemoral surgical techniques, why would some of those same authors take the IT band with the TFL insertion and move it to the posterior femur? (per POI 2001, Persson).
Great question, right?
Back to the TFL article:”the theoretical predictions of these models are not always borne out by the clinical findings.” pg 179 Our ability to help a vulnerable population is built on and contingent upon the accuracy of the physiological and anatomical foundation which is provided to us as prosthetists. Theoretical claims that “all the hip abductors are intact” don’t align with reality.
That is why, when you understand that the TFL as a hip abductor has been removed from patients (purportedly to assist in hip extension to prevent hip flexion contractures. Wrong, but another discussion.), the fog surrounding the following studies starts to clear…
But now you read our revered Atlas, the book responsible for the education and training of the surgeons providing the basis of our profession. What is the theme for AK surgery?
Answer: They fear the hip abductors, the very muscle group that supports and stabilizes the body in stance.
Where are you going Tom? Why, back to the TFL article for another quote, of course!
“review of these papers revealed the absence of a satisfactory anatomical and dynamic model to explain adequately the findings of these studies, and thus did not allow those authors to draw valid conclusions.” Yep. And the authors who wrote that got pretty close, too.Colleagues, our field provides a unique perspective that reveals the superior model of hip abduction that this paper was seeking.
But now we have CMS, MAC, and the LCD. Maybe we should just call them Curly, Moe, and Larry. The fact is that some random prosthetist in the middle of central California has found that they don’t even understand the biomechanical principles of how the hip supports our patients. We get treated like Shemp. So, I would suggest that the prosthetist get “input” in the process, perhaps even a “role”, and not just “comments” on the process as we do now.
I have just torn asunder the surgical misconceptions that have negatively impacted the lives and families of 84,000 transfemoral amputees annually. Does that get me a voice at this table? Dear bureaucrat responsible for the LCD, what have you done that qualifies you alone to determine what is best for my patients?
To the organizations advocating for me, my gratitude. To CMS, my offer of assistance. To certain researchers who dismiss and devalue the role of the prosthetist, class is dismissed.

Thomas J. Cutler, CPO, FAAOP, CPHMLimb.itless, LLC113 N. Church StreetSuite 312Visalia, CA 93291559-334-3741 phone559-553-8837 fax”I can hardly wait for tomorrow, it means a new life for me each and every day.” ¯ Stanley Kunitz


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