As chair of surgery at our hospital, I sit on peer review, credentials and medical executive committee.  I have to admit that it’s hard not to take a punitive stand at times.  Developing a work culture that is focused on patient safety is always in play at our hospital, especially following errors or bad outcomes.  But developing a work culture cannot be done effectively if it’s done retrospectively.  Developing a work culture is something that requires interaction between staff and administration on many levels.  Administration needs to be fair and consistent.  They need to be ever present.  They need to be more than engaged.  They need to lead.

This article is on my ‘need to read’ list for our hospital committees.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

On one hand, it’s about time that physicians stepped up to the plate to deliver cost effective care.  Not just care and lot of it, but cost effective care.  If not physicians, then who is to slow this freight train down.  Health care costs continue to grow at an unsustainable rate. 

But wait a minute.  Is there not just a little bit of a conflict of interest here.  Let’s say the ACP called me (I’m still waiting for the call) and asked me to determine how I could reduce health care costs associated with foot and ankle care.  What would I say?  As a surgeon, I’d eliminate most of the non-surgical care provided by podiatry.  But let’s say that I was a nonsurgical podiatrist….I’d be inclined to say that there’s too much surgery being done, right?

The ACP consists of mostly internists.  What might you think they may say about surgical specialties?

Still scratching my head.  Great to see the fox guarding the hen house and expecting us to believe that we’re not having chicken for dinner.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

The second and more commonly used procedure is a partial head resection and a metatarsal osteotomy with fixation.  The addition of the metatarsal osteotomy to the partial head resection really does improve the success rate for the correction of tailor’s bunions.  But the addition of the metatarsal osteotomy also increases the disability time and possibility of complications.  Think of a metatarsal osteotomy as a broken bone.  Broken bones are going to take 6-8 weeks to heal.  Possible complications include infection and delayed or non-union of the osteotomy.

Now let’s consider the patient with commodities that has a symptomatic tailor’s bunion.  Let’s say this patient is grossly obese and has diabetes.  Their social history includes a current history of smoking.  Also, this patient wants to return to a job on their feet.  Do we opt for the simply partial head resection or do we take a chance on this patient and perform an osteotomy? 

There is another option, that although is an ‘old school’ solution, may actually be a good choice for this patient.  The other alternative is a metatarsal head resection.  A metatarsal head resection is performed at the same level at the metatarsal osteotomy but includes an additional step of resecting, or removing the metatarsal head.  I’ve used this procedure on a number of cases where a diabetic patient has both lateral 5^th metatarsal head pain as previously described as a tailor’s bunion and plantar 5^th metatarsal head pain.  The upside to the head resection is that it will enable the patient to get back on their feet sooner.  There will be a much lower chance of complications such as a non-union of the osteotomy.

What’s the downside of a metatarsal head resection?  First and foremost is the fact that the 5^th toe is going to telescope or get shorter.  It’s not actually that the toe gets shorter, but in the absence of the metatarsal head the 5^th toe is going to be seated closer to the metatarsal and take up the space left by the metatarsal head resection.  The other downside is an alteration of the weight bearing surface of the plantar foot.  I’ve not seen this to be a problem in my practice but a head resection does tend to increase load to the adjacent 4^th metatarsal. 

Is a metatarsal head resection a good choice in the correction of tailor’s bunions?  It’s not for everyone, but in some cases, a metatarsal head resection can actually be the best choice.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

The patient is a 35 y/o female with a history of chronic lateral ankle instability.  She has a history of recurrent ankle sprains.  She also has a history of previous ankle surgery for repair of an osteochondral defect (OCD) of the talar dome.  This OCD was likely due to one of her previous lateral ankle sprains.  He vital signs include her weight of 390 lbs with a BMI of 66.  

Exam of the patient notes uncompensated rearfoot varus and lateral ankle ligamentous laxity.  Uncompensated rearfoot varus would be addressed with a calcaneal osteotomy and screw fixation.  Ligamentous laxity will be fixed with a Brostrom lateral ankle repair.  Both procedures necessitate a minimum 6 weeks non-weight bearing. 

It takes a very strong person to lift over 100 lbs.  So what about a 380 lbs patient?  How do they manage their ADL’s when they are non-weight bearing?  To be able to lift 380 lbs our of a chair to rise from a sitting position is quite a task and significantly raises the risk of falls. 

I think with a little extra work, this patient has come to understand that they are not a good surgical candidate for this surgery.  The patient is a mom and wife.  Although she’s not employed outside the home, she supports most of the family needs.  We decided to use a brace and limit activities that might contribute to lateral ankle sprains. 

Will we be able to complete the surgery at some point in the future?  You bet.  Our goal is to wait till the patient looses 200 lbs and the kids are out of the house.  Honestly, I think with some support at home, we’ll get it done at some stage.  It’ll take some work, but we’ll get it done.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

Under normal circumstances for a 37 y/o, I’d tend to think about resection of the osteomyelitis with a staged fusion of the ankle.  But this case is very different.  The patient has severe, advanced PAD for his age.  Two attempts at revascularization by endovascular atherectomy have proved unsuccessful to improve ABI’s.  Also, in terms of surgical risk, the patient’s cardiomyopathy makes him an ASA category 4.  Category 4 means that there is a significant and likely chance of death with anesthesia. 

This case has been reviewed by cardiology, orthopedics and podiatry and the consensus is that amputation of the limb would be in the best interest of the patient.  His osteomyelitis has stabilized with IV antibiotics for the time being.  No one involved in this case wants to see the leg go, but in the best long term interest of the patient, that seems to be the only viable choice.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

Conservative care for partial ruptures of the Achilles tendon consists of ice to the injury site several times a day.  Most important though is the need to use a heel lift or walker with a heel lift.  Elevating the heel will weaken the pull on the Achilles tendon.  Decreased tension in the Achilles tendon is at the core of getting a partial rupture to heal with conservative care.  I’ve found in my practice that partial ruptures of the Achilles can mend but there are two constants to healing.  First, the tear has to be a small tear, less than a cm.  And second, be prepared for a long period of healing.  Healing can take 4-6 months.  During this time, it’s important to continue to elevate the heel and ice the injury site.

For most partial ruptures, debridement of the tendon with a small slide lengthening is my procedure of choice.  There will certainly be an argument regarding whether the tendon needs to be lengthened of not.  I’ve tried debulking the injury site and allowing patients to walk on the surgery.  My success has no been the best with this procedure.  I prefer to perform a small Z-plasty lengthening and integrate the debulking in the center of the Z-plasty.  The down side of this procedure is that it is a non-ambulatory procedure and requires a cast for 6 weeks. 

What’s the best procedure to treat partial ruptures of the Achilles tendon?  Actually, I think that question would garner a number of different responses and would depend to a great degree on the skill set of the providers, where s/he trained and what has worked well in their hands over the years.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

The past medical and surgical history of this patient was somewhat difficult to obtain due to the patient being a poor historian.  He was born with spina bifida that resulted in congenital lower extremity peripheral neuropathy.  He had developed a sore of the left heel in 1989 that resulted in osteomyelitis and a left BK amputation.  So not only did the patient have multiple commodities that would make him prone to loss of protective sensation, he was also very non-compliant.

The onset of right leg problems had begun years ago.  The patient has had a recurrent ulceration of the right forefoot.  The right leg presented with +4 pitting edema with stasis dermatitis.  Pulses in the foot were non-palpable but hair growth was present.  Sharp sensation was absent from the plantar foot.  Vibratory sensation was absent to the knee.  X-rays showed a flat topped talus and evidence of a triple arthrodesis performed as a child.  The flat topped talus could have been congenital or could have been secondary to AVN post triple arthrodesis.  No evidence of osteomyelitis was found on plain films.  No indication of neuropathic arthropathy of the midfoot or ankle were seen with plan film.

The best history came from the patient’s most recent visit with his nurse practitioner.  The most striking finding was that his uric acid was 12.7 mg/dl (normal range 4-8). 

So how do you sort out this data to come to a conclusive diagnosis and establish a treatment plan?  Notes from the university visit confirmed the absence of infection with both a CBC and Indium scan.  The patient is non-weight bearing and wheel chair bound.  It may be a stretch to make this call, but I don’t think that the activity level that the patient describes would speak to a load bearing phenomenon such as neuropathic arthropathy.  So that leaves gout as our primary working diagnoses.

The patient was placed on Allopurinal and we’ll monitor his uric acid over the next few weeks.  He was also referred to O&P for measurement and construction of a patellar weight bearing brace.  My hope is to get him to a point where he can bear weight on his right foot but not load the ankle an foot to more than 50% of full weight bearing by using the patellar weight bearing brace.  If we get him to that stage, then we’ll talk about a new prosthesis for the left BK amp. 

It’d be great to get this patient back to full weight bearing and active ambulation.  So much of it depends upon his compliance.  Fingers crossed.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

Supination can be caused by a number of biomechanical issues.  I personally am a classic example of a person who supinates.  I was born with clubfeet.  I have a fixed varus position of my heels (when viewed from behind it’d look like \ /).  I also have metatarsus adductus.  The combination of these two structural deformities rolls me to the outside of the foot.  I’ll occasionally have peroneal tendonitis, but my major problem is midfoot arthritis on the lateral aspect of the foot.  I’ve been trying a lateral sole wedge to control the supination in my foot and it seems to work quite well.

Lateral sole wedges are usually a modification that needs to be placed on the outer sole by a shoe repair shop or O&P shop.  We’ve been trying a new type of lateral sole wedge that slips into the shoe thereby making it simple to use.

What can a lateral sole wedge do for peroneal tendonitis?  A lateral sole wedge can have a significant impact on peroneal tendonitis.  The subtle lateral wedge will inhibit supination.  If supination is limited with each step throughout the day, the net effect can be pretty powerful.  Lateral sole wedges are only going to be effective for tendonitis and won’t work for peroneal tendon tears. 

Will lateral sole wedges help control other problems like lateral ankle instability?  I think the jury is sill out on that but we’re starting to try them in the office for lateral ankle instability.  I’ll give you an update on that as time goes by.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

Today, peroneal tendon tears are easy to diagnose with MRI.  Knowing that few if any of these longitudinal tears of the peroneal tendons heal on their own, we still need to surgically repair the tendons in active patients.  The repair involves the use of nylon suture material to sew the tendon back together.  Here’s some technique tips….

I try to make all of my correction done from within the tendon.  This means that the suture begins on the inside of the tear and ends with a knot on the inside of the tendon.  If you’re running the suture, be sure that the locking suture is also on the inside of the tear.  The reason that this is important is to decrease suture drag in the healed tendon.  Suture drag is where the suture may rub on the peroneal groove of the fibula or on the adjacent peroneus longus tendon once the patient is active.  Suture drag can result in chronic post-operative pain at the site of the surgery.

The other tip is to be sure to over suture the tear.  Even after successful repair of a longitudinal tear of the brevis tendon, I have seen propagation of the tear beyond the original injury.  Moral of the story?  Be sure to over suture the injury to insure long term correction.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.

A study run a number of years ago in American journal, The Journal of Bone and Joint Surgery, looked at patient recall 6 months following surgery.  In the study, patients were interviewed prior to their surgery and a specific list of points specific to their surgery were discussed.  Six months following their surgery, the patients were interviewed again.  The recall of each of these specific topics was less that 25%.  The fact that this recall rate was so low means that we really need to focus pre-operatively on patient counseling and building realistic surgical expectations.

When it comes to realistic surgical expectations, we take this part of our job very seriously.  Prior to surgery, we spend additional time with our patients, counseling them regarding each of the steps of the surgery.  And more importantly, we spend time making sure that the patient understands how the proposed surgery will affect their job and family life over the coming weeks and months.  We find that these simple steps are critical.  Also, spending a little time counseling patients and documenting that time is a significant step in prevention of law suits.  Not every case turns out the way we’d like it to.  Sometimes things just go wrong.  When communication is good, and patients understand why things may go wrong, it’s rare to end up in court.

But occasionally, we still find that as we close in on a surgery date, some patients fail to grasp the steps that are required to achieve a successful outcome with their surgery.  Even after counseling patients, sometimes their expectations are inconsistent with what we can provide.  The most common issue we see is where a patient feels they are going to be able to get back to a particular job where they stand for long periods.  This is particularly true in retail or in the restaurant business.  Standing and being active are inherent in those jobs.  Subsequently, getting back on their feet is going to be one of the greatest challenges in their care.

The most important part of defining surgical expectations is communication.  Sit and talk a bit with your doctor and their staff when you’re considering surgery.  Be sure to have all of your questions answered and be sure you understand your obligations to insure a good outcome of your surgery.

Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.