When You Have To Get Creative With Surgery

William Fishco DPM FACFAS

Every once in awhile, we get to be creative in surgery. Most of the time, our surgical procedural selection is straightforward using time-tested surgical techniques. Let’s face it. The Austin bunionectomy works.

I have a case to share with you that illustrates how one can be creative in surgery. A 75-year-old female presented to my office with left foot pain. She twisted her foot on a curb and initially saw a chiropractor who attempted to manipulate her foot. The treatment exacerbated her pain.

Clinically, her foot was swollen and ecchymotic in the dorsal midfoot. Her neurovascular status was intact. There was no break in the integument. Palpation of the foot revealed generalized tenderness along the medial column and dorsal foot.

Plain film radiographs revealed a diastasis between the first and second cuneiform bones. I noted proximal migration of the first cuneiform on the navicular bone. Some fragmentation of bone was also present on the first cuneiform bone. At this time, I diagnosed a Lisfranc-type injury and ordered a computed tomography (CT) scan for preoperative planning.

The CT scan revealed a vertical fracture line in the first cuneiform with fragmentation. There was an impressive diastasis between the first and second rays.

From a surgical standpoint, certainly you can argue for performing a medial column fusion as the injury involved ligamentous derangement, intra-articular fractures and instability.

For this older woman, who really could not easily be non-weightbearing for two months, I chose an anatomic/fracture repair instead. This is where the creativity comes into play. Since there was significant proximal migration of the first cuneiform on the navicular, I wanted to restore the length of the first ray to allow restoration of the naviculocuneiform joint. I also knew that there was a instability between the first and second cuneiforms with vertical fracturing of the first cuneiform.

I chose to keep it simple. I did the entire case percutaneously with application of an external fixator to regain length of the medial column. I also used a percutaneous screw between the first and second cuneiforms to reduce the diastasis and concomitantly fixate the fracture of the first cuneiform.

For this patient, I felt this approach was ideal due to her advanced age. She did not have a high demand for activity and was somewhat frail. Her surgery happened about 10 years ago and I recently treated the patient’s daughter, who told me she passed away two years ago. She told me the surgery I did for her mother kept her walking up until her death and she never complained of any foot pain.

In the case, the real genius of the surgery was keeping it simple. I knew that if she developed painful arthritis in the future, I could always do a fusion surgery.

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