I recently returned from the Windy City Podiatry Conference in Chicago, which was co-hosted by the Podiatry Institute and the Illinois Podiatric Medical Association. Marking the first collaborative effort between these two organizations, the meeting had an exceptional turnout and was among the best I have attended in many years. I was honored to be part of an exceptional faculty who taught me so much in just two short days.
To me, the conference illustrated that many new surgical technologies being marketed in the podiatric profession show little advantage over longstanding techniques. The astounding costs of these new technologies should make any podiatric surgeon step back and evaluate the cost to benefit ratio for the patient. Three esteemed clinicians opened my eyes and made me reconsider my own current use of “new” technologies.
Jeffrey Boberg, DPM, is a well-respected faculty member of the Podiatry Institute. At the conference, he presented a compelling argument against using fancy fixation compression screws for distal osteotomies of the first metatarsal. Dr. Boberg witnessed numerous malunions and nonunions from cannulated screws and compression plates in comparison to standard K-wire fixation. Therefore, he and his colleagues set out to compare surgical outcomes with popular fixation techniques for distal first metatarsal osteotomies.
Dr. Boberg presented the results of this prospective study at the conference. According to his results, there is no advantage of using compression screws in comparison to threaded K-wire fixation for distal first metatarsal osteotomies. The cost comparison, however, was less than $5 for the K-wire versus up to $300 for a cannulated screw.
Thomas Smith, DPM, another respected Podiatry Institute faculty member, presented a beautiful overview of the history of staple fixation for foot and ankle surgery. He demonstrated that simple staples can act in the same method as locking plates, fixation screws or standard compression plates. Dr. Smith presented a multitude of applications for simple staples. When properly applied, staples can provide reliable fixation for hindfoot fusion, fracture fixation and first metatarsal osteotomies. Again, the cost comparison of staples versus locking plates shows a significant difference in favor of simple staples.
Finally, Jack Schuberth, DPM, presented a very pointed criticism of new bone graft substitutes for foot and ankle surgery. Dr. Schuberth is a widely recognized expert in ankle trauma as well as reconstructive surgery of the foot and ankle, and is never hesitant to voice a strong opinion. He presented compelling evidence that we have little reason to use exorbitant bioengineered bone graft technologies. Podiatrists can easily obtain a simple autograft from patients while working within the podiatric scope of practice. Dr. Schuberth showed a simple step-by-step approach to obtain either a calcaneal autograft or a distal tibial autograft, which will solve the needs of 90 percent of podiatric surgeries with minimal patient disability.
I have been an avid consumer of many new surgical technologies over the past 10 years. Following this conference, I have begun to pause and reflect on my previous surgical experience using simpler yet more cost effective hardware or techniques. I realize there is nothing wrong with using a threaded K-wire on a standard chevron osteotomy for bunion correction. In certain applications, a simple staple can achieve the same type of fixation as a locking plate. If I need bone to fill a defect or repair a nonunion, the best option is an autograft, which I can easily obtain with minimal cost and disability for the patient.
When I attend surgical lectures at our major scientific meetings, new technologies often inspire me. Many times, I fail to step back and re-examine if any of these gadgets or bioengineered materials are in fact superior to traditional solutions. Instead, there is a curiosity and sense of adventure, which leads me to try out new things and often forget previous techniques that were working fine.
The podiatric community has made great advances in foot and ankle surgery in the past two decades. This is due in part to the willingness of investigators and companies taking a chance in developing new technologies that make a difference. Our challenge is proceeding with caution as we embrace these technologies. We must remember that many of the things we did in the past remain useful. We need to constantly evaluate whether any new technology can justify its cost. Most importantly, we must assess whether it truly improves surgical outcomes and quality of life for our patients.