Jarrod Shapiro, DPM
Practice Perfect Editor
Mountain View
Medical &
Surgical Associates,
Madras, Oregon
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Surgery In the Real World
Most doctors will agree that the technical component of medicine is the less complicated part. What truly makes medicine and surgery challenging is the patient. It’s relatively easy to figure out the appropriate bunionectomy or flatfoot reconstruction. If the intermetatarsal angle is 20 degrees, you might choose a base wedge procedure or Lapidus. If there’s significant hindfoot degeneration or rigidity with that flatfoot, you might choose a triple arthrodesis. This part is pretty straightforward – in a perfect world. Now enter the real world, outside of the classroom and the theoretical, where our patient’s needs and limitations smack hard into “the textbook” version. The procedure we want to perform is not always the procedure we can safely perform. Two of the most troublesome issues as I see that impact my choice of procedures are weightbearing and age.
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In my opinion weightbearing — or more precisely the need to nonweightbear after surgery — is the single most challenging issue postoperatively. It’s no wonder that podiatric researchers have spent so much time creating procedures and modifications that allow early postop weightbearing. One reason the Austin bunionectomy is so popular is the ability to allow early protected full weightbearing. Recent research on the Lapidus arthrodesis has focused on early weightbearing. Proponents of external fixation technology tout the ability to partially or fully weightbear patients postoperatively. If this weren’t an issue, I don’t think there’d be much research into or consideration of early postop weightbearing.
Recently, I repaired a Lisfranc fracture-dislocation on a 6 foot 4 inch 280 pound man. Trying to keep him nonweightbearing postop has been a real challenge. He is unsteady on crutches, so has been relegated to a wheelchair while he awaits insurance approval for a roll-a-bout. Trying to transfer from wheelchair to exam chair is such a hassle that I’ve been doing his dressing changes in the hallway. It’s remarkable how small my exam rooms become when I’m seeing him! I cringe at the idea of his getting around at home. It was for this very reason that I used locking plates on his first and second met-cuneiform joints during the surgery.
Age presents another problem. When I speak of age, it would be more appropriate to say “physiologic age.” We’ve all seen that spry 90 year-old who doesn’t look a day over 60 and that 60 year-old who looks 90. The issues that come with age include not only potential delayed healing and overall health, but also osteopenia, level of activity, responsibilities caring for an unhealthy spouse, balance, overall strength, and the politically incorrect “years of life ahead.” This last is an important consideration. Do you really need to do a major reconstruction on a patient with only a few quality years left? Of course, who decides how many years are left and what constitutes quality? For example, about a year ago I repaired a bimalleolar fracture in a 55 year-old lady who did just fine intra- and postoperatively, healed her surgery, and was discharged from my office. About 6 months later, I found out from her daughter she went into renal failure (alcohol induced) and died. If I had known she had such a short life ahead, would I have done her surgery? Hindsight is 20/20.
Here’s a contemporary dilemma. Yesterday I was called to the ER to see an 87 year-old lady (HTN, no diabetes, visibly older than her stated age) who fell getting out of bed with her walker, sustaining a bimalleolar fracture. The radiographs below show her closed partially displaced medial malleolar fracture and nondisplaced fibular fracture (which, incidentally, the radiologist missed – always read your own radiographs!). Note the osteopenia (also not commented on by the radiologist). Under normal circumstances she’d go to surgery, but in this case, I splinted her in a partial Quigley position and Jones compression splint. I’ll likely handle this as conservatively as possible. If I was going to consider surgery, I might try a percutaneus reduction and fixation of the medial malleolar fracture. Not the best situation. What would you do with this patient?
Clearly these issues of weightbearing and advanced physiologic age make our jobs that much more challenging as physicians and surgeons. Unfortunately, there’s no good answer. Some simple considerations may decrease our risk of complications. Minimally invasive techniques, heavier fixation, alternate forms of offweighting, and eliciting the help of our general medicine colleagues may improve our odds of success. What methods have you found successful in dealing with the human aspect of medicine and surgery? Good luck with your next elderly, nonweightbearing patient.
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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