Posts for category: Surgical Information
I would like to invite you to peruse with me on a short hiatus from the informative reports on classic foot and ankle pathology and dip your feet in the ocean of medical ethics. As I filtered through some blogs that I occasionally find myself reading, I happened to come across a short article entitled “The Bioethics of Podiatry,” by Michael Cook. It was posted in late April of this year in The BioEdge, a weekly newsletter discussing frequently encountered bioethical issues. Obviously, as a foot and ankle specialist, the report was intriguing.
The article by Cook was a short, few paragraphs highlighting the “burgeoning field of aesthetic podiatry.” Cook mentions that Podiatrist, particularly in the Manhattan and Beverly Hills areas, are delving more and more into this realm and points out that an ever growing interest in foot and ankle surgery exists for the sole purpose of accommodating fashionable shoe gear. Now, I had to finish the article and investigate further as I found this troubling. Cook continues, and quotes a podiatrist in the Beverly Hills area who stated, “On the surface, it looked shallow. But I came to see she needs these shoes to project confidence, they are part of her outside skin. That’s the real world.” Herein rests our question and why I titled the blog the way I did. First of all, is there an ethical concern with placing an individual under the knife for fashion’s sake, especially if the patient requests such actions? Lastly, what does this say about our culture that one’s confidence hinges on their outward appearance or fashion?
Now, I am not seeking to answer these questions in this blog per se, but perhaps provoke a form of mental dialogue. The podiatrist quoted above has a full marketing video highlighting procedures that he has renamed such as the High Heel Foot, Perfect 10 (toe shortening), and Foot Tuck (fat augmentation). All these procedures are designed to surgically modify ones foot to accommodate fashionable shoe gear. In my opinion, the Hippocratic Oath of “Do no harm,” screams out in this scenario. Any surgical procedure no matter how big or small carries significant risks of potential complications. Even if patients urgently request surgery for dreams of a fashion statement, one needs to consider the potential ethical ramifications; unless of course, you deem ethics as relative, which is yet another discussion all together. Regardless, what is more troubling, a surgeon willing to operate on otherwise healthy feet for improperly designed shoes or the fact that people are willing to take such risks in attempts to be fashionable? Or, is either troubling at all?
As foot and ankle surgeons our group is committed to improving quality of life, restoring functionality, and saving limbs and lives with our surgical and medical expertise. There comes a time when one must realize or understand that certain things or fashions are of the utmost importance. It is unfortunate that people feel they need inhumanly designed fashion to project confidence. It is certainly, in my opinion, a sad commentary on our culture and society.
Fifteen years ago while I was visiting my parents in Wales, my mother slipped and fell down a few stairs twisting her foot. She was in a terrific amount of pain so we took her to Casualty (ER). They x-rayed her foot and diagnosed her with a Jones fracture. This rather well known fracture was first described Sir Robert Jones (a fellow Welshman) who sustained this injury himself while dancing in 1902. He wrote a paper in the Annals of Surgery that same year describing the fracture in himself and 5 other individuals. Initially he thought he may have torn his Peroneus Longus tendon (a tendon on the outside of the foot) but he felt the tendon and found it to be intact. Although x-rays were relatively new at that time he suspected bone involvement and asked his colleague Dr. David Morgan to take radiographs of his foot. Examination of the radiographs revealed a fracture, 3/4 of an inch distal to the fifth metatarsal base (at the metaphyseal-diaphyseal junction). He was surprised that this fracture did not occur due to direct trauma but rather a cross-strain applied to the bone. The mechanism of injury was forced inversion (twisting in) of the foot when the ankle is tilted down (plantar flexed) and the weight is on the outside ball of the foot. These fractures are known to be relatively poor healers due to diminished blood supply at the metaphyseal-diaphyseal junction of the fifth metatarsal.
Conservative care for a non-displaced acute Jones fracture usually involves non-weightbearing in a cast for 6-8 weeks; however, many doctors recommend surgical repair of this fracture in more active individuals, athletes, or in cases where the fracture is chronic in nature. Surgical repair will often increase the healing rate and decrease the risk of re-injury. Surgical techniques vary. Often a small incision is used to place a guide wire in the bone followed by a cannulated screw down the intramedullary canal of the fifth metatarsal bone.
Sometimes for chronic fracture non-unions (where a fracture has failed to heal over a period greater than 6 months) a metallic plate may be used with or without a bone graft.
You may have read Dr. Coker’s blog in October regarding post-traumatic arthritis and noticed she mentioned the idea that joints can be fused or sometimes replaced. You may even have had a knee or hip replacement already and were wondering if your ankle may need something too, as it no longer works like it used to.
Yes, we do replace ankles, just like knees and hips are replaced. However, not everyone walking through the door with arthritis in their ankle is a good candidate for an ankle replacement. First of all, an ankle replacement needs to be done by an experienced and certified foot and ankle surgeon, as the procedure is technically demanding. One must be qualified, capable, and willing to deal with any and all potential complications. Secondly, all patients considering an ankle replacement must be thoroughly educated on the risks and benefits of the procedure as well as the post-operative recovery. They must also understand the alternatives as well in order to make a well informed decision. Lastly, it never hurts to obtain a second opinion if you do not feel adequately informed about the procedure.
With that said, what makes a patient a good candidate for an ankle replacement? There are numerous criteria, some of which are more important than others. When considering a total ankle replacement, the assumption is that you have attempted conservative measures such as bracing, nonsteroidal anti-inflammatory medication, injections and shoe gear modifications. The criteria for an ankle replacement is obviously not a systematic checklist of indications as every case and patient must be considered individually in light of their physical and social situation. However, with that said there are some basic indications that are considered with each patient.
An ideal candidate for a total ankle replacement (TAR) is an individual who is less than 250 pounds, over 50 years old, has no hindfoot deformity, has a lower physical demand, and has severe pain secondary to ankle arthritis. Relative contraindications to a TAR is a high activity level (determined between you and your surgeon), weight greater than 250 pounds, bone loss, osteoporosis, and a history of infection. A patient with diabetes and a history of Charcot Neuroarthropathy, or with an ongoing infection or ulceration should never be considered for an ankle replacement.
A careful look at the literature comparing ankle arthrodesis, or fusion, to a total ankle replacement, shows that the early and intermediate-term outcomes of the two procedures are comparable. Individuals with a fusion tend to have a worse functional outcome due to the restricted motion, whereas, those with a replacement have a higher rate of complications. One study in 2001, noted that 67% of patients with an ankle fusion were happy with their results after 20 years. In comparison, a study in 2007 reviewed 531 total ankle replacements and found a 76% 10-year survival rate. This was confirmed in a 2009 study that found a 75% 10-year survival rate of total ankle replacements.
Both an ankle fusion and ankle replacement has its risks and benefits and it is important, that if determined to be a candidate for either procedure, that you understand the potential risks and the long term effects. Ankle replacements have come a long way and can be a very gratifying and beneficial procedure but it certainly is not for everyone. However, if you are suffering from ankle arthritis it is a procedure to discuss with your foot and ankle specialist to determine if it is a procedure for you.
My heel pain will not go away and I have tried it all …Now What?
Generally speaking there needs to be 6 months of non-operative measures that have failed before surgery is suggested. There are multiple surgical procedures to combat heel pain. There is open release of the plantar fascia that one will look for nerve entrapment. There are also minimally invasive procedures that try to stimulate healing. Our physicians perform a range of these procedures, including but not limited to use of TOPAZ which is radiocoblation therapy. There is also a newer procedure that will help regain your active lifestyle via the FAST technique.
What is the FAST Technique and Is It Right For Me?
The FAST technique is a fasciotomy and surgical tenotomy that can address your foot and ankle pain in an innovative and minimally invasive way. Eventually scar tissue in the tendon or fascia will limit your ability to move and perform the activities you may like or need to do. The damage may be due to trauma or repetitive motion- damage to the tendon from overuse in work, exercise or activity. It can cause the tendon tissue to break down and form scarring and pain. The FAST technique is advanced technology that was developed in collaboration with the Mayo Clinic. FAST is a minimal invasive treatment designed to remove tendon scar tissue, allowing you to return to your active lifestyle. It is performed with the guidance of ultrasound to identify the scar tissue and with the aid of a small instrument that delivers ultrasonic energy specifically designed to break up and remove damaged tissue safely and quickly, without disturbing the surrounding health tendon tissue. With such a wide array of options in techniques, it is best to schedule a consultation with one of our physicians and discuss the best option for you.