Track 3: Surgical Blitz
Friday, July 28
A series of short presentations will explain surgical tips and techniques developed by podiatric surgeons. Among the topics addressed will be deformity corrections, a tendon transfer for the second toe, treatment of bone marrow lesions, whether to fix the knee or the hindfoot first, and the management of infected hardware.
A complex debate with no correct answer is whether to fix a deformity quickly or to use a gradual process. Cassandra Tomczak, DPM, of Summit Orthopaedics, Portland, OR, will present key concepts to consider when performing deformity correction.
Does the patient have a history of previous infection or traumatic scarring? What is the extent of the deformity? Is there a bony and/or soft-tissue component? Is the deformity on multiple levels? They are all factors to consider, she said.
“What are the pros and cons for the patient? Some people cannot stay off their feet during their recovery time. Maybe somebody will do better with external fixation versus internal fixation. Also, what can their body tolerate?” Dr. Tomczak asked.
“As our technology evolves, so do the methods for how we address these complex deformities. There is no one right way to do it, and you must think through all of the potential complications when you are addressing it,” she said.
An extensor digitorum brevis (EDB) tendon transfer to correct transverse deformity of the digits has proven to be successful with a decrease in recurrence of the deformity when compared to other procedures, said Kimberlee Hobizal, DPM, MSA, of ASP Orthopedics and Sports Medicine, Beaver, PA.
The procedure is typically used on patients with a second crossover digit or an elevated toe who have continued pain and swelling.
“We isolate the tendon, secure it with a whip stitch, and transfer it through the metatarsal and the proximal phalanx to recreate the ligament that has been attenuated or the ligament that is no longer supporting the digit,” Dr. Hobizal said. “We secure it with a Bio-Tenodesis Screw.
“Follow-up of three to four years shows a decrease in recurrence of deformity, a decrease in pain, and a 90-percent patient satisfaction rate.”
Bone marrow lesions are essentially chronic insuffciency fractures that never heal, said Robert J. Toomey III, DPM, of Potomac Podiatric, Haymarket, VA. Complicating the issue is that open reduction and internal fixation is the preferred treatment method of a fracture but often is not performed. Also, patients often are not kept in a non-weight-bearing position long enough.
These patients have chronic pain because the bone marrow lesions have increased edema, which increases pressure and pushes on nerves in the area. A novel idea is to fixate these bone marrow lesions with a calcium phosphate substitute that is injected into the lesion. This procedure works well in the knee or hip, but there is a lack of literature for it in the foot or ankle, Dr. Toomey said.
“Foot and ankle surgeons, particularly those affiliated with teaching institutions, should investigate the use of calcium phosphate in foot and ankle applications so there is more literature, as well as to see how proven it is versus the knee or hip,” he said. “There are only case studies and no long-term studies.”
For physicians, the question of whether to repair the knee or the hindfoot first in patients with problems in both areas is akin to, “What came first, the chicken or the egg?” Jacob Wynes, DPM, MS, assistant professor of orthopedics at the University of Maryland School of Medicine, treated a patient who presented a unique perspective in developing an answer.
The patient lost much of his foot when he stepped on a land mine during the Korean war. The patient had a rigid contracture that led to a need for a knee replacement—several times.
“Despite perfect anatomic alignment, it became a puzzle about why this gentleman continued to break down and be in pain,” Dr. Wynes said. “It turned out the foot was driving his knee deformity. Because the foot could not be fixed, the segment above the knee had to be fixed.
“That begged the question of what influences what? The short answer is, it depends. If the subtalar joint is supple, then the knee will influence the hindfoot position. However, if it is a rigid deformity that is so bad that it does not allow for adequate compensation of the subtalar joint, that will influence the knee. If the foot is flexible, it is likely the knee will have an influence on the foot to one-half the magnitude. If the foot is rigid, it will have an influence on the knee.”
One of the most complicated situations for a podiatric physician to deal with is infected hardware or nonunions, said Michael L. Sganga, DPM, of Orthopedics New England, Natick, MA. A lack of literature about these infections in the foot and ankle makes treatment difficult.
Dr. Sganga studied medical literature about infections in the hip and long bone trauma to develop treatment theories for the foot and ankle. Important factors are whether the surgery type is trauma or elective, the timing of the infection, the type of implant used, and whether the implant can be salvaged.
A key is to follow the foundations of treatment, including proper debridement, identifying the organism, gaining and maintaining stability, controlling the infection, and managing dead space, Dr. Sganga said.
“You can get profound wound and fracture healing in the setting of infection when you properly manage the infection based on those principles,” he said. “Oftentimes, you can keep the hardware or completely heal the patient without significant loss as long as you act quickly.”