What A Rorschach Test Reveals About Patient Pathology, Brand Reliance And Plantar Plate Injuries

Stephen Barrett DPM FACFAS

Sitting in the Rorschach Café, tucked deep in the dark narrow streets of the Music Capital of the World (you should be thinking Vienna and not Nashville), Dr. Hermann asked me what I wanted for the entrée. Looking down at the stained and torn café menu, one offering jumped out at me like a mugger in a dark alleyway. It was written in German, of course, but without really needing confirmation of my translation, I asked my schizophrenic colleague anyway for the literal English translation for “Fuß Platte.”

Some cosmic destiny told me this was what I really needed to order as I had retained enough Deutsch from a high school summer in Klagenfurt to know that Fuß Platte meant “foot plate.” As a foot surgeon, this “foot plate” piqued my curiosity big time.

By that time, I had enough Grüner Veltliner and any culinary reservations I may have had prior to imbibing with Dr. Hermann and his white ambrosia were completely gone. I knew that if “foot plate” is listed under the “Rindfleisch” (“red meat” for those of you with no German background) section, then it must be had.

“Vat have you decided?” Hermann inquired in pseudo English with a heavy German accent, accentuated with spittle aerating across the close space over the table, only filtered by his unkempt bristly mustache. Each time I tried to look him directly in the eyes, I was distracted by the clinging residue circling his mouth. “I must have the Fuß Platte,” I acquiesced. “What else should a foot surgeon order?” Sometimes we all just have to throw caution to the wind and go with the whim.

Hermann seem captivated by the simple fact that I would order something off the menu without fully understanding his language just because it had something to do with the foot. “Americans love brands and make purchases all the time simply based on emotion,” I explained apologetically.

He snapped back, “Do you base your surgical decisions on emotion as well?”

Shaking my head back and forth attempting to affirm the negative, I knew that he was right. We do buy on emotion. We also select surgery and different types of intervention based on emotion. Remember the surgeon heuristic that a surgeon can do 100 operations exactly the same and if the last five turn out badly, the procedure or technique is suddenly no good and things must change now.

A Closer Look At The ‘Ink Blot’

Casually, he reached into the satchel by his side and pulled out two radiographs. “I am going to give you a test. Tell me what it is you first think of when you see them.” This dinner was getting good. We hadn’t even ordered the entrée and the conversation relegated whatever food would come to something far less important than a culinary experience. “Okay, I’m ready,” I said while swirling the white ambrosia.

“Here it is. Quickly — what is it?” Hermann barked intentionally to give me less than milliseconds to think cognitively and proffer my answer from deep in my surgeon subconscious like a cranial burp (see photo at left).

“Intraoperative paintball,” I blurted out.

“Vat is paintball, doctor?” Hermann asked.

“Oh, it’s a game we play where we run around different courses and shoot each other with these little paint balls that explode with paint upon impact with your body. By the way, it hurts like hell with a pretty good sting.”

Dr. Hermann could not understand until I explained it a little further. “Ja, ja, I know,” he said. “No, this is not paintball. This is an arthrogram.”

I didn’t know arthrogram sounded the same in German as in English. “Of the MPJ,” I sputtered.

“Ja. Better than MRI for diagnosis of plantar plate injuries. Very cheap. Squirt, squirt into the joint and plain film radiograph, and you have answer.” Nodding affirmatively, there was no doubt. Now that I had a few more minutes for contemplation to review the image, I could see easily that dye was leaking from the metatarsophalangeal joint (MPJ) like the oil staining my driveway from my cousin Ernie’s ‘65 Ford Falcon every time he visited (uninvited of course).

I had not seen an arthrogram for years. We had magnetic resonance imaging (MRI), diagnostic ultrasound and the sophisticated modern gadgets of course. Now my curiosity was getting the best of me. “Show me the next one,” I implored.

He pulled out the next one and there was … just a little crescent sitting in the joint space (see photo at right). “Same foot?” I asked. “Certainly,” he responded indignantly.

“Wow, how did you fix that?” Before I could start explaining about how we would go about our surgical techniques for the repair of plantar plate injuries, his explanation interrupted me.

“I make an 8 mm transverse incision at the level of the MPJ. I separate the soft tissues off the extensor tendons, release the tendon sheath, retract it medial or lateral, whichever is easiest. Then I perform a Weil osteotomy without disturbing the capsule or periosteum.”

Stroking the spittle impregnated mustache nervously, he finished. “Little schnitzel slides back a few millimeters, and we close. Maybe there is five minutes total surgical time.”

Now this was unbelievable. Here was a highly respected foot surgeon telling me that all he did was make a small opening, pull the tendons to the side, perform a Weil osteotomy and close the skin. “When do you let them walk?” I asked, still internally castigating him.

“When they wake up usually, with a surgical shoe, of course.”

“So you’re telling me that first ‘ink blot’ of a disaster of a plantar plate rupture you just showed me can be fixed with just cutting the bone and letting it slide back into position?”

Smiling wide, he said, “Ja, look at the second ink blot, Mr. Highfalutin American Doctor.”

“No dye leaking like cousin Ernie’s car!” These ink blots spoke for themselves, I had to admit.

By the way, the “Fuß Platte” finally arrived at our table and turned out to be a giant braised bratwurst that was a foot long sitting on a pile of red pickled cabbage. As bad as it looked, it inversely tasted damn good. But what Hermann had demonstrated to me was astounding.

“How fast do these patients recover?” I asked. Now I was beyond the spittle and into making my patients better.

“As soon as the osteotomy heals — four to six weeks. They get full weightbearing immediately in the surgical shoe.”

I knew I now had him. “You don’t fixate these, though. How many nonunions do you get?”

Dr. Hermann smiled. “It’s you that is fixated! Virtually none of the soft tissues are disrupted so the osteotomy doesn’t go anyplace. The osteotomy almost always heals.” He coughed and then added, “I’ve seen as many screwed that have displaced that I have done with this method.”

There was one more question I had to ask. “How does the plantar plate heal?”

My German colleague shook his head in disbelief of my naïveté. “It bleeds, it is decompressed and it heals. Look at the ‘ink blots.’”

So the next time you stare at an “ink blot,” don’t think about the ‘65 Falcon. Think about what is going on physiologically and how beautifully Mother Nature can do our work for us if we set it up properly.

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