Practice Perfect - A PRESENT Podiatry eZine
Practice Perfect - PRESENT Podatry

Jarrod Shapiro, DPM
Jarrod Shapiro, DPM
Practice Perfect Editor
Mountain View Medical &
Surgical Associates,
Madras, Oregon

 

Am I Too Aggressive?

Agressive
Throughout my career thus far, I, like all of us, have spoken with colleagues around the country about methods of treating various conditions. I’ve always found it interesting that, no matter whom I speak to — whether at a conference, dinner meeting, or on PRESENT’s eTalk forum — there’s a large variety of aggressiveness in how we podiatrists treat our patients. Our treatment plans can range anywhere from pedorthic types of treatment with shoe modifications, to orthotics, to various surgical procedures (whether common or exotic) — all for the same indication. During these discussions, I reflexively categorize myself in relation to those with which I speak, and I often seem to fall in the center-aggressive area (on a center, conservative, aggressive scale). When I look back on this, though, I have to wonder if I’m appropriate. Am I too aggressive or not aggressive enough?



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Here’s my question: How does one know the correct level of aggressiveness in treating our patients?

I’ll provide a few examples to illustrate my point.

  1. Last week, I saw a new patient referred from my ED.  A 38 year-old overweight female patient sustained a mildly displaced SER 2 ankle fracture (a spiral oblique lateral malleolar fracture displaced 4 mm with no other apparent injury).  The only significant medical history was a DVT 6 years ago after a hysterectomy, treated with 6 months of Coumadin with subsequent mild chronic venous insufficiency.  I recommended waiting one week to do her surgery (an open ORIF), placed her in a compression dressing with splinting, elevation, nonweightbearing, and Fragmin (just in case).  I wanted to be sure her edema was well controlled prior to her surgery.  Over the subsequent week she obtained a second opinion from someone else who recommended a more conservative regimen ,with 6 weeks casting and then surgery if she had any problems later.  The patient agreed with this and cancelled her surgery with me.  I would argue my treatment option is the LESS aggressive of the two options.  An otherwise healthy 38 year old (minus the DVT risk and obesity) should in my opinion be treated surgically.  She’s going to have to live for many more years on that ankle.  Perhaps I’ll see her a few years from now for the fusion.  What’s aggressive in this case?

  2. Here’s another common one most of us deal with: hallux valgus.  In almost all of these patients, other associated deformities are present – flatfoot, equinus, etc.  For the majority of patients, I’ll focus on the hallux valgus, the local pathology, and omit other procedures that focus on the cause– unless a clearly major deforming force is present.  I’ll place the patient in an orthotic postop to control the pronation.  But I wonder, should I be more aggressive?  What if I did a “full” reconstruction for a patient complaining of 1st MTP joint pain, but no other issues?  What if I had a complication from one of the other procedures?  How happy would the patient be with me?  I can hear it now: “Dr Shapiro, I had bunion pain and now the rest of my foot hurts.  Why didn’t you just fix my bunion?”

  3. I had an interesting patient that brings up an anecdotal counterargument.  I performed bilateral Lapidus bunionectomies on a female patient of mine (at two different times).  I did the exact same Lapidus procedure on both feet (except for the fixation – crossed screws in the first and one screw and locking plate in the second).  I also altered another parameter: in the first procedure, I also did a subtalar implant and endoscopic gastrocnemius recession and omitted these two ancillary procedures in the second.  Now here’s the issue: about 4 months after completion of the second Lapidus, she had a mild recurrence.  I looked back at the radiographs and found almost identical immediate postop IM angles but a slight increased IM angle of a few degrees on the second one 4 months later.  None of her other pedal angles were different between feet.  I’m not sure why the difference.  Was it something particular to the patient, my postop care, or the fixation?  What about the other procedures?  Could it have been that I improved her hindfoot and midfoot pronation and equinus, decreasing the forces that caused the hallux valgus?  I think it just might be.  My point, here, is that perhaps a more aggressive and comprehenisve treatment plan would have lead my patient to a better result the second time around.  I think this is an area that needs more research to help us answer these questions.

    This brings up an inconsistency in my own practice.  I treat “elective” reconstructions much more conservatively than I do my diabetic limb salvage patients.  A simple comparison to illustrate my point.
     
  4. My stage 2 PTTD patient is more likely to receive an AFO, shoegear instructions, stretches, and physical therapy long before I do the reconstructive surgery.  On the contrary, my diabetic patient with a plantar forefoot ulcer will see my OR very quickly.  I’m thinking TAL or gastrocnemius recession much sooner in the course of their therapy, for instance.  Similarly when I do amputations or reconstructions on diabetics, I’m much more likely to add tendon balancing procedures, for instance, than I am to add the gastroc recession with an Austin bunionectomy. 

Why am I varying my concepts like this?  Why am I so inconsistent?  The obvious answer is that in the diabetics, we’re talking limb salvage, the operative word being SALVAGE.  It’s easier to make the decision when the stakes are higher.  It’s easier for me to tell my patient, “If we don’t do this amputation, your abscess and bone infection will become worse and you’ll either lose your leg or die from sepsis.”  I think that’s a lot easier than dealing with an elective bunion reconstruction.  How easy would it be if bunions were somehow deadly?  “Mr. Smith, we’re going to have to fix your bunion tonight or you’ll be dead by the morning.” 

I’m not sure what the right answer is here.  I don’t have any pithy comment or list of “to do’s.”  Perhaps this judgment is something that comes with time in practice.  Perhaps more research would help with some of these decisions.  Perhaps I’ll never truly know.  For now I’ll evaluate each patient separately and do what I feel is best for them.  This is the art of medicine.  Hopefully, I’m a good artist.

I'm very interested to hear your opinions.  The art of medicine is made up of the thousands of judgement calls we need to make.  In the 4 cases above, would YOU opt for the more conservative or the more aggressive treatment plan, and why ?

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Agressive

Keep writing in with your thoughts and comments or visit eTalk on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!


Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]


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