Posts for tag: Foot Surgery
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.
I certainly believe, if you are able to read this blog, you likely can espouse numerous detrimental effects smoking can have on your overall health. After all, in 1997, the tobacco industry agreed to pay 360 billion dollars over a 25 year period to fund antismoking campaigns and public health efforts. The well documented and supported relationship between cigarette smoking and cardiovascular disease, lung cancer, and pulmonary disease are, for the most part, well understood, or at least has been well engrained into much of our society. However, despite these well-known effects, nearly 20.8% of Americans smoke tobacco cigarettes. In fact, according to a 2005 report by the Centers for Disease Control and Prevention, smoking remains the leading preventable cause of death, accounting for approximately 1 of every 5 deaths. These are interesting facts and I understand a family physician emphasizing the need to quit, but what does this have to do with foot & ankle surgery?
There are numerous reasons your tobacco use matters to us as foot & ankle surgeons, one of which is we are physicians and your overall well-being and health matter to us, not just the state of your feet. However, three specific and crucial effects of cigarette smoking on the lower extremity, that are worth briefly highlighting are peripheral arterial disease (PAD), wound healing, and bone healing.
Cigarette smoking has been shown to be the most important variable risk factor causing peripheral arterial disease. A 2008 animal study, showed that nicotine exposure can increase vessel density, which results in decreased blood flow. PAD is a significant risk factor for lower extremity amputation, and the risk of PAD for smokers is 4 times that of nonsmokers. It has been proven that smoking cessation slows the progression of PAD, and decreases the risk of amputation.
Cigarette smoking has been implicated in poor wound healing and bone healing as well. Consider the following information gleaned from a 2002 study conducted by a group of plastic surgeons. “Smoking a single cigarette may cause cutaneous vasoconstriction for up to 90 minutes; hence, a pack-a-day smoker remains tissue hypoxic for most of each day.” In other words, the skin lacks the blood flow and oxygen levels needed to heal when exposed to cigarette smoke. Nicotine, carbon monoxide, and hydrogen cyanide are three components of cigarette smoke, in addition to the 43 cancer-causing substances, that are particularly detrimental to the healing process. These substances decrease tissue perfusion, inhibit oxygen from getting to the tissue, alter the cells responsible for laying down the necessary materials for wound healing, and delay bone formation across bone cuts and fusion sites.
Numerous studies have been conducted indicating the effects smoking tobacco can have on the human body. Foot & ankle surgeons have noted, specifically in foot & ankle surgery, that smokers take nearly twice as long to heal and are at risk for significantly greater complications following surgery, than nonsmokers. In fact, it is not rare to find surgeons who will simply refuse to do surgery if a patient admits to tobacco use. Research has ranges all over the spectrum as to how far out from surgery and for how long after surgery one should limit their exposure to tobacco. It is best to simply begin the road of complete cessation, and never waiver from the path as your body will thank you and your foot & ankle surgeon will thank you.
Photo Credit: (1) Harrisburgfootandankle.com (2) blog.sfgate.com