Learning To Pick Your Battles When Surgery Is Not The Answer
- William Fishco DPM FACFAS
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Pediatric flatfoot is a common condition that we see on a regular basis. I have case that I want to share with you. A 14-year-old male presented with his mother and grandmother for a second opinion regarding surgery. His parents were concerned because of the way he walks. His feet turn out, according to his mother. For years, his pediatrician told the family that he would eventually grow out of it. Now that he is a teenager and still walking with an out-toed attitude, his pediatrician decided to refer him to a specialist for evaluation.
The recommendation by the specialist was surgical correction for a severe flatfoot deformity and bunion correction. The doctor told him surgery was necessary because if they left his feet untreated, his knees and hips would eventually compensate for his foot condition, and lead to problems.
Evaluation of this young man revealed a 200 lb., mature looking 14-year-old. While he was sitting in the treatment chair, I noticed he had seemingly normal looking arches. I asked him about his pain level and difficulties that he had with running, sports, walking, etc. Surprisingly, he told me he has no pain and no difficulty with wearing shoes, and can run and play sports.
So even before I had examined him, I had an uneasy and somewhat paranoid feeling about this case. Why would another specialist recommend surgery on a child who has no pain or dysfunction? Am I missing something? Is it me?
His neurovascular exam was normal. The dermatologic exam failed to reveal any redness, swelling or signs of inflammation. The orthopedic exam revealed +5 degrees of ankle equinus bilaterally. He had ligamentous laxity as confirmed with the passive apposition of the thumb to the flexor aspect of the forearm test and recurvatum of the elbow and knee. No pain was present with range of motion of the ankle or foot. His feet were very flexible with no sign of rigidity that would be consistent with a tarsal coalition. No pain occurred on palpation into the sinus tarsi, the posterior tibial tendon course or the navicular tuberosity. His gait exam revealed a too many toes sign with moderate forefoot abduction on the rearfoot. On stance, his arches did not collapse.
After examining him, I really had to scratch my head as to wonder why the foot and ankle specialist recommended surgery. I asked if he ever wore orthotic devices or if that was an option for treatment. His response was that he has never worn them and his mother was told that orthotics would not fix anything.
As you can imagine, this case was really weighing on me. Personally, I tell my patients that you consider surgery when you have pain every day, you have difficulty wearing shoes and the condition interferes with the quality of your life. Even though I am a surgeon, elective surgery of the foot should always be the last resort.
In one of my earlier blogs, I told you the single most important mantra to be practicing at the highest standard is: “Do the right thing for every patient all of the time.” Clearly, the foot and ankle specialist did not maintain this standard with this particular patient.
After a thorough discussion of this case with the patient and family, we are going to try foot orthotics and monitor his condition. Certainly, if he should develop pain or dysfunction, then we can consider further treatment and/or surgery. After reviewing his X-rays and examining him, it is clearly a case of ligamentous laxity leading to overpronation. His underlying metatarsus adductus is the cause of his bunion deformity. Moreover, he does not have a “flatfoot” condition.
It is also important to educate patients that all flat feet are not painful. Just because a patient has flat feet, that doesn’t mean treatment is necessary. Just like one would do with any other medical condition, podiatrists should address pain and dysfunction associated with flat feet accordingly.
Aggressive calf/Achilles tendon stretching, wearing supportive shoes and orthotics still work. Not everything needs surgery. Luckily, very few conditions that we treat on a daily basis require immediate surgical intervention.
Remember, you have to pick your battles. What are the chances that you take a foot that does not hurt, do surgery on it and it is “anatomically corrected” and is still pain-free? On the flip side, what are your chances of taking a foot that has chronic pain and dysfunction, do surgery on it and the foot is better due to pain resolution or reduction?
These are rhetorical questions but you get the point. I always look at best case and worse case scenarios. If I did surgery on a 14-year-old that did not work out perfectly, he may have pain for the rest of his life, need more surgery or this may prevent him from exercising later in life. I don’t know about you but I have enough to worry about. This case is just not a good battle to pick. Start out with the KISS (keep it simple, stupid) principle and do more later if the simple things do not work.