Key Considerations When Recommending Elective Foot Surgery

The decision to recommend foot and ankle surgery is not always straightforward. Unless the clinical condition is a serious fracture, abscess or dislocation, we have to rely on other criteria. Unfortunately, the criteria that we rely on are mostly anecdotal.

For example, we all learn somewhere in our training that we should consider surgery for plantar fasciitis after six months of active treatment, which usually includes a series of cortisone injections, physical therapy, orthotics and possibly an immobilization period. Do you always adhere to this treatment protocol dogma?

In this blog, I want to share some of my opinions and observations regarding the factors that influence us to recommend elective foot and ankle surgery for our patients. When it comes to treatment protocols, most of us cannot remember how we learned our protocols. Maybe it was just trial and error, talking to other colleagues, learning from an experienced associate or from residency.

I had to do an ingrown toenail surgery my first day in private practice. I confidently did a partial nail avulsion with a matrixectomy, wrapped the toe up and walked out of the room feeling like I was "the man." My medical assistant asked me, "When do you want to see your patient again?" I looked at her dumbfounded because I did not know what to say.

In residency, we did not have a clinic. We only performed hospital-based surgeries and we did not do any follow up with these patients. Therefore, my only basis for reference was big cases like a triple arthrodesis. In such cases, the patient would be admitted to the hospital floor after surgery and we would do a dressing change/cast application at three days postoperative. So getting back to my story, my response to my medical assistant was: "Have her come back in three days."

Certainly, we all have our own protocols for office-based care. I am sure we all have similar regimens and we use our personal experiences to guide us in our treatment recommendations. Ultimately, the goals when treating our patients, regardless of their condition, is to improve their quality of life, resolve pain and resolve dysfunction.

Key Factors To Mull Over Before Performing Elective Surgery

I am going to give you a list of the common factors that we typically have to consider when contemplating elective surgery.

Severity and duration of symptoms. This is probably the most convincing element to consider. When a new patient presents to your office with longstanding, serious pain and dysfunction (or a longtime patient presents after receiving treatment from you), it is hard not to offer surgery as a means for treatment.

X-ray and magnetic resonance imaging (MRI) findings. We all know the expression, "We don't treat X-rays." I tell my patients that almost every day. We have all seen horrible arthritis on an X-ray that may not be clinically relevant. What about the MRI report that has tendinitis/tendinosis/partial tears in multiple tendons along with rupture of lateral ankle ligaments? You can throw in an osteochondal lesion of the talus as well.

So what does all that mean? Do you fix every problem noted on MRI? Probably not. This is where your experience and clinical acumen play the most important roles in decision making. Your history taking, physical exam and diagnostic injections are paramount in unraveling the accurate diagnosis when advanced imaging studies show a lower extremity that is riddled with pathology.

One scenario to consider is a complete rupture of the lateral ankle ligaments. Does this require surgery? I have personally found that aggressive physical therapy can rehabilitate a severe ankle sprain. It does not always work but it is worth trying. Another example includes Achilles tendon pathology with partial tears with tendinosis. I have also found that physical therapy with eccentric loading and stretching, and ASTYM® treatments (Performance Dynamics) can resolve the pain with tendinosis although the thickened tendon usually persists.

So the diagnosis of torn ligaments or partial tendon tears does not necessarily mean surgery. Remember, we are talking about elective surgery, which can always occur at a later time. The worst thing that can happen is that your treatments do not resolve patients’ symptoms and then they ultimately have surgery.

Patient expectations. What do you do when a patient is demanding surgery? You know the story: "I had plantar fasciitis on my left foot about five years ago and had to have surgery after going through months of painful shots, expensive orthotics and costly co-pays. Now my right foot has the same problem and I do not want to go through those treatments again. I want surgery." How about this scenario? "My insurance will be terming at the end of the month. I cannot afford to go on COBRA. I need to have the surgery done right away."

Moreover, I am sure you have been pressured into performing bilateral foot surgery because your patient could not afford to miss work twice. These scenarios are all too common. You can be sympathetic to patient concerns but you need to know where to draw the line.

The condition/diagnosis. Certain pathologies rarely get better with conservative treatments. Although I do not usually recommend surgery on the initial office visit, shoes can really only accommodate advanced bone and joint deformities. For example, I am more likely to recommend surgery for a young woman who presents with a large, painful bunion deformity than I am to recommend wearing wider shoes and pads.

However, we discuss all treatment options for the sake of completeness so the patient can make an informed decision. In the case of advanced arthritis of the great toe joint, your treatment options are limited. You can recommend stiff soled shoes and arthritis medication. That certainly is not going to fix the problem. This may be appropriate for the geriatric patient but less desirable in a younger, more active patient.

Exhaustion of conservative treatments. There comes a time when you are sitting on your stool, your patient is reclining in the podiatry chair and is shaking her head and stating that she is no better. You have nothing left to offer her other than surgery. Some things just require surgery to get better. You cannot always explain it. Why does one patient get better with non-surgery treatments and another does not? If every patient responded the same way, then treatment protocols would be absolute.

In Summary

There is a lot of information to synthesize to arrive at the decision to perform elective podiatric surgery. My advice to you is to reflect on your past experiences with other patients with similar scenarios. Avoid getting pressured into doing something that is not in the best interest for your patient, such as rushing into surgery due to work-related or insurance constraints. We are all guilty of falling into that trap and we have all regretted it from time to time.

Listen to your gut instincts and do what you do best. Use all the techniques at hand (that only a podiatrist knows) to heal your patient's foot conditions.



Anonymoussays: September 13, 2010 at 3:54 pm

Excellent articles.

You bring up some very valid points, the first of which is that they just don't teach you how to run an office in most residencies. Where are you supposed to learn what the global for a P&A Matrixectomy is? They should really incorporate more practice management into residency these days. Its a shame they don't.

What a fine line we have to work on. Even if you KNOW the patient's problem will become a surgical one, you still feel compelled to try the conservative treatments and you should. Some insurance won't "let" you perform surgery unless something conservative is attempted and failed.

Please don't let a patient convince you to do something you are not comfortable with. If it means turfing to someone else who has more experience/skill, then let that be the case. Your ego should not dictate what you do and who you do it on. Please.

The real issue for me is what do to and how far to go to help your patients. Do you not do a very needed surgery on a high risk patient, with HIV, Hep B, history of drug abuse, with pain management issues because of their PMH and SH? Only you can answer that question. My hope is that you stay within your comfort zone and learn to be smart in residency as, if you're the cowboy, invariably you will get shot, so to speak.

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Anonymoussays: September 13, 2010 at 11:52 pm

I personally do not turn down care (surgery if needed) for patients with hepatitis or HIV+. I have done and still do reconstruction work on these patients. I personally feel that we are all human beings and they deserve care too. Moreover, I have the training to help them with compound deformities, and as a result, they are usually referred to me whether the referring DPM can help them or not. Unfortunately, if I don't help them, then nobody will. I personally feel obligated to do my best for all of my patients regardless of their past history (drugs, ETOH, communicable diseases, employment status, etc.)

William D. Fishco

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Anonymoussays: September 21, 2010 at 10:49 am

I'm with you 100% Doc.

I do the same but some don't. I feel as you do that if I can help I do regardless of PMH or SH. I also feel I can address many compound issues and don't let patients' histories taint my treatment of them.

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