Residency Insight -- A PRESENT Podiatry eZine

Allow me to reintroduce PRESENT's New Surgical Editor, Harold Schoenhaus, DPM, FACFAS.

Dr. Schoenhaus is currently in private practice in Philadelphia, PA and a full professor at the Temple University School of Podiatric Medicine and also a member of the Board of Governors. He brings 39 years of experience and relationships to further enhance surgical education. He is an attending Podiatric Surgeon at Presbyterian Medical Center, which is part of the University of Pennsylvania Health System, and also has privileges at Chestnut Hill Hospital, Temple University and Cooper Hospital in New Jersey. Dr. Schoenhaus' career in Podiatric medicine and surgery began in 1971, following his studies at the Pa College of Podiatric Medicine and serving a Foot & Ankle surgical residency at Parkview Hospital in Philadelphia.

In this weeks' issue of Residency Insight, our new Surgical Editor, looks in at the differences in various disciplines performing foot and ankle surgery.

—John Steinberg, DPM, PRESENT Editor

Harold Schoenhaus,
DPM, FACFAS
PRESENT Surgical Editor

A Marriage Made in Heaven

When we critically look at the differences in various disciplines performing foot and ankle surgery, one fact clearly stands out in identifying the unique qualities of a Podiatric Surgeon.

Biomechanics has long been appreciated by exciting thinkers and innovators such as — Root, Wed, Orien, Sgarlato et al. I have long felt that to be a great surgeon, numerous skills sets are necessary. Certainly basic and advanced training, good hands, ability, dimensional appreciation, knowledge of instrumentation and technology and the ability to interpret diagnostic tests.

However, the key ingredient along with the above is that of a true understanding of biomechanics. Static and dynamic understanding of lower extremity function is critical for proper outcomes. Functional demands which are unique to each individual must be understood to determine appropriate procedures of given deformities.

A thorough biomechanical exam of the lower extremity may identify or uncover structural deformities of the leg/knee above which may have impact on our procedural goals. For example, genuvalgam will influence implant positioning in total ankle replacement, or may preclude its use completely.

Gait analysis - is imperative to observe for its influences and abnormalities influencing deformities. The phasic activity of muscle is critical to an understanding prior to lengthening or shortening of tendons or tendon transfer.

When complex reconstructive procedures are performed, outcomes and patient satisfaction will often depend on our thorough documented analysis pre-operatively.

Biomechanics sets us apart. Considered by some to be a basic science, it enables science and art to come together in a single application. Surgical outcomes, compensatory mechanics occur regularly to deal with structural abnormalities which are often tri-planar and multi-directional. Many tri-planar soft tissue deformities are reversible, such as forefoot supination, and yet we often proceed to correct such a deformity which may not be necessary if the original deformity force such as Equinus can be neutralized. Muscles and mechanics or the failure of joint integrity from trauma or Charcot arthropathy will lead to multidirectional abnormalities which are challenging to the experienced surgeon. Often poor outcomes are experienced secondary to poor planning, which should be comprehensively evaluated in advance.

X-rays are static and may be misleading in evaluating deformity. Gait analysis adds the dimension of compensation and structural effect to deformity.

In pediatrics, functional adaptation plays a continuous role in post-operative results understanding normal development. It may often alter selection of procedures, such as extra-anticular re-alignment procedures versus fusions of important joints.

Post-operative control with functional orthotics rounds out the total approach to the surgical candidate.

Orthotics are often used to support, re-align or neutralize deformity following correction. Considering the changing dynamics of the foot post-operatively, close control and monitoring is essential for more predictable outcomes. Proper casting techniques or computerized images will provide more accurate control of the dynamic foot. Orthotics may have to be altered as functional demands change or functional adaptation and re-positioning occurs. Patients should be aware - an orthotic is not made for life, but may have to be modified or changed as life goes on.

Biomechanics is functional orthopedics — use it to our advantage for better outcomes.