Orthopedics: Foot and Ankle

Transcription:

Bill Klaproth: Everyday our feet and ankles bear the brunt of pressure that comes from supporting our full body weight. According to the American Academy of Orthopedic Surgeons, 75% of Americans will experience foot health problems of varying degrees of severity at one time or another in their lives. So, we’ve assembled a panel of foot and ankle specialists to talk with us about treating foot and ankle conditions such as bunions, neuropathy, ankle replacement surgery, and foot health as we welcome Dr. Julie Johnson, Dr. David Friscia, and Dr. Michael Seiberg. Doctors Johnson and Friscia are board certified orthopedic surgeons specializing in the foot and ankle. Dr. Seiberg is a pediatric all with Eisenhower Desert Orthopedic Center. Thank you all for joining me today. Dr. Seiberg, let’s start with you. I'm sure you treat and operate on people with bunions quite frequently. What do we know about the cause of bunions and how is a bunion different from arthritis in the foot?

Michael Seiberg, DPM:Well that’s a good question. Bunions are very common in the adult population. Between 18 and 65 years of age, 23% of adults will develop bunion deformities. Then adults over 65, up to 36%. A bunion is a crooked toe, and it’s not necessarily a growth of bone. The cause is probably multi=factorial. Hereditary is definitely the strongest culprit of bunion deformities. You see bunions running in families. Families may have abnormal gait disorders or abnormal biomechanics. Occasionally bunions can be caused from neurological disorders or an injury, but this is not as common. A lot of patients want to blame their shoes for causing bunions. This probably doesn’t cause bunion deformities, but rather aggravate a preexisting bunion deformity. 

Now that’s different than arthritis. Arthritis is a damaged joint where there’s loss of cartilage. That normally protects the joint and allows it to move smoothly without pain. When you lose that cartilage, its bone rubbing on bone. That’s what causes arthritic pain in the joint. So, it’s possible to have a bunion, or a crooked toe. You could have arthritis in the big toe, or you could have both, a crooked toe with arthritis in the joint. There’s different types of treatment, different types of surgery to address the two separate problems. That’s why we always take x-rays in the office and perform a thorough investigation of the deformity. 

Bill:  And speaking of surgery, let me turn to you Dr. Friscia. I know all three of you perform bunion surgery. At what point do you recommend surgery though? Is it the severity of the disfigurement or pain or a combination that determines if surgery is appropriate?

David Friscia, MD: It is well established that the primary indication for bunion surgery is to relieve pain. People have pain over the bump of a bunion or from the great toe rubbing on the second toe or causing a second hammer toe, or even causing dislocation of the second toe. Most surgeons do not recommend surgery on a symptomatic mild bunion as there is a risk of developing pain after surgery. The foot looks much better after bunion surgery, but the surgery should not be done for cosmetic reasons alone. The degree of pain together with the severity of the deformity helps to determine the need for surgery and they type of bunion surgery necessary. A mild to moderate deformity can be painful and requires a much different procedure than a severe deformity. Sometimes bunions do not become symptomatic until the great toe impinges on the second toe. These more severe cases may require a more complicated bunion procedure, cutting the bone in two places to correct the deformity. 

Bill: And Dr. Seiberg, if I could follow up with you quickly. What should patients know about the results of a bunion surgery? Can bunions reoccur or is there something you can do to reduce the chance of reoccurrence? 

Dr. Seiberg: Yeah, well reoccurrence is always a concern. That can happen up to 20% of patients that have bunion surgery. The way that we try to minimize reoccurrence is first to address the surgery, where the deformity is. So like Dr. Friscia mentioned, sometimes you may have to make a cut of the bone further back to correct the entire bone, which is crooked, rather than just trying to do something more simple and just take the bump off the side of the foot. Patients should expect swelling after the surgery as their foot is often times in a dependent position. So, it’s pretty normal to have several months of swelling after surgery. Post-operative splints can be used after surgery to maintain the toe while the soft tissue and bone continue to heal. Sometimes we recommend orthotic devices in the shoe to take the pressure off the side of the foot that had the surgery on it.

Bill: Dr. Johnson, let’s bring you in. We often hear that people with diabetes need to be careful because they may develop neuropathy in their feet and may also develop wounds that don’t heal well. How do you assist patients who have foot issues due to chronic conditions like diabetes?

Julie Johnson, MD: One of the most significant factors of diabetic footcare is education and surveillance. So just to incorporate paying attention to your feet and actually examining your feet, either you or a family member, on a daily basis. Because of neuropathy, there is decreased sensation to the skin, which can put a diabetic patient at risk for stepping on a rock or a piece of glass, and they don’t realize that there’s been a breach or a cut in the skin. They just keep going about their life until an infection develops or an ulceration, which is a wound, that doesn’t heal. Then it can become a very significant problem. They get wounds that develop into serious infections that effect the bones in the foot. It can lead to such significant consequences such as amputation or loss of part of the foot or the entire foot. 

So, it really is about seeking medical care regularly and also surveillance and looking at the feet. If there’s anything that happens to look different than your normal foot, you have to seek care and have a medical professional look at it. So early presentation to the physician is one of the keys to saving and protecting your feet.

Bill: Well that makes sense. Education and surveillance. Great information Dr. Johnson. Dr. Friscia lets turn to you. We hear a lot about joint replacement for hips and knees, but ankle replacements are becoming more common now. Can you give us an idea of who an ideal candidate is for an ankle replacement and why it might be preferable to a fusion?

Dr. Friscia:Yes. One of the most exciting developments over the years in my career is to see the development of reliable ankle replacements. In the early years of joint replacement surgery for arthritis, hips and knees did very well, but ankles had a high failure rate due to the higher forces over smaller bone and the thin soft tissue in them. However, over the last 10 years, new techniques and designs have made the procedure reliable with a good success rate and high patient satisfaction. Results now approach reliability and satisfaction or hip and knee replacement with studies with the newer implants showing excelling long-term results. 

Although an ankle fusion provides good pain relief, people miss having motion. A stiff ankle can put extra stress on other joints and may lead to arthritis in other parts of the foot. I have found a satisfaction pain relief from ankle replacement with early motion in my patients to be excellent and usually occurs fairly soon after surgery. I believe the key has been improved instrumentation, technologically innovate implants, and 3D printed custom cutting guides custom made for each patient through pre-operative CT scans.

As for the ideal candidate, this is someone who has ankle arthritis, usually over the age of 50 with good circulation. If the patient has a significant foot deformity, other procedures might first be indicated to align the foot mechanics properly and allow for proper alignment of the ankle replacement. In orthopedics, it is said that life is motion and motion is life. With the latest innovations, total ankle replacement is now the preferred procedure for patients with ankle arthritis in my practice. At the Desert Orthopedic Center, we use the latest devices and are participating in multi-center clinical research studies on ankle replacement.

Bill:That is just amazing. Ankle replacement. I can't even fathom that. Like you said, so fascinating. Dr. Johnson, turning back to you, the foot is the lowest extremity of the body and obviously carries our weight. What kind of recovery can people expect when they have a serious foot injury or a surgery?

Dr. Johnson:So, I think the most important factor when you're talking about recovering from foot surgery is that there are 28 bones in the foot and ankle and they all work together to achieve the complex and important goal of walking. However, when you have an injury or when you have foot surgery, it is very rare for you to address the entire foot. So that’s a very important concept that I use as an education tool for my patients. That yes part of your pain is going to be resolved depending on the target of the reconstruction surgery or the fracture that needs to be fixed, but you're not fixing the entire foot at once. So, it is not uncommon for patients to experience some degree of foot pain after a large reconstructive surgery. Maybe not necessarily in the area that was operated on, but in other areas of the foot.

The foot is sort of the master of compensation in that when one area of the foot is affected by arthritis or a fracture or disease, the foot still achieves the goal of walking, but it will out abnormal pressure points on other areas of the foot. That’s a very important concept for understanding is that the recovery is long for large reconstruction surgeries such as ankle arthroplasty or significant fractures. It takes one year for the patient to achieve their best as far as swelling and as far as motions.

Yes, gravity is always the enemy of foot and ankle surgery because the foot is down and when it’s down it swells. It’s more difficult for the body to pump the fluid up from the foot back to the heart. So, swelling is one of the most annoying sequelae of foot and ankle surgery for patients. Unfortunately, it’s something that just takes time, compression, and elevation. To have a good result from a really painful arthritic or deformed or fractured foot, patients are satisfied but you just have to be very careful about managing their expectations.

Bill:So, a lot to think about and remember. Dr. Seiberg, if you could wrap it up for us. What do you recommend for general foot health to keep people feeling good and mobile?

Dr. Seiberg:Yeah, well we usually recommend patients to wear a tennis style lace up shoe. Those are generally going to have the most cushioning in the insole, a reasonable height of the heel to minimize pressure on the fore foot and to minimize developing Achilles tendon problems. Patients should buy shoes at the end of the day. That’s when your feet are the most swollen and it’s better for your feet to be a little bit too big than too tight. There’s also sports specific shoes. So, a walker may require a different type of shoe than a runner. There are different materials that are used in the shoes to fabricate the different sport shoes.

We recommend replacing shoes about every 8 to 10 months if you're active. It’s a good idea to use a small amount of absorbing powder in shoes over night to have the shoes dry out and minimize developing fungal infections. Don’t use medicated corn removers which have an acid in them that eat the skin and can lead to problems such as ulceration. Non-medicated pads are okay to use. Patients shouldn’t walk around the house barefoot, especially when there are tile floors because that can lead to plantar fasciitis and heel pain. Patients should see a specialist if there's any open sores, drainage, or signs of infection. We always also are concerned about the diabetic patients. They require special attention with special accommodative insoles and diabetic shoes. Also, more periodic foot exams.

Bill:Well those are great tips. Thank you so much for sharing those with us. Dr. Johnson, Dr. Friscia, and Dr. Seiberg, thank you for much for your time today. To learn more about Eisenhower Desert Orthopedic Center and their foot and ankle specialists, call 760-773-4545 or visit eisenhowerhealth.org/edoc. That’s eisenhowerhealth.org/edoc. This is living well with Eisenhower Health. I’m Bill Klaproth. Thanks for listening.