An oblique radiograph of the forefoot showing an acute sesamoid fracture. Reproduced from Coetzee JC, Ebelin P: Lisfranc, forefoot, sesamoid, and turf toe injuries, in Pinzur MS (ed): OKU Foot and Ankle 4, Rosemont, IL, Amer­ican Academy of Orthopaedic Surgeons, 2008, p 102.

AAOS Now

Published 5/1/2009
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Jennie McKee

Pearls and pitfalls in foot and ankle treatment

AOFAS “masters” discuss clinical topics, establishing patients’ trust

With more than 100 combined years of practice, Angus McBryde, MD; William G. Hamilton, MD; and John S. Gould, MD, have plenty of pearls of wisdom to share—and warnings of pitfalls to avoid. During their American Orthopaedic Foot & Ankle Society’s (AOFAS) 2009 Specialty Day “Notes from the Masters” session, moderated by Richard D. Ferkel, MD, they offered clinical advice, emphasized the importance of maintaining good rapport with patients, and discussed general strategies for obtaining successful outcomes.

Use caution with cortisone
“A steroid injection is used in orthopaedic offices every day,” said Dr. McBryde. Studies suggest, however, that cortisone can have serious side effects, such as tissue and fat atrophy, depigmentation, capsuloligamentous laxity, and joint damage or dislocation.

“Small joints are easily ruined by injections,” he said. “If you inject the same dosage you would use in the knee into a lesser toe metatarsophalangeal joint, you’re injecting many times the amount that’s needed. The joint is going to dislocate, later if not sooner.”

That’s what happened to one patient, an amateur tennis player. “He received one injection,” said Dr. McBryde, “and within a month he had a totally subluxed, dislocated third toe. He never returned to playing tennis.”

Patients like motion
“A colleague and I performed bilateral forefoot resection arthroplasty on a patient with rheumatoid arthritis,” said Dr. Gould. “I did the usual fusion of the great toe and resected the metatarsal heads of the other toes on the left foot, and he did the same on the right foot.

“My colleague struggled with the fusion and ended up with a painless nonunion,” continued Dr. Gould. The patient was much happier with the right foot and great toe because it had more motion.

Since then, he said, “I prefer to just resect all the metatarsal heads. I used to do it on low-demand patients, but now I do it on all rheumatoid patients who require a forefoot resection. I also perform more interpositional arthroplasties than fusions in the great toe in women with advanced hallux rigidus.

“Patients like to have moving parts and don’t like to have stiff hands or feet if they can avoid it,” he added.

Preserve the sesamoid, when possible
“The sesamoid—which is the smallest bone we deal with—is very important to everyone from recreational walkers to runners,” said Dr. McBryde. “But diagnosing a fracture of the sesamoid is sometimes difficult.”

Noting that the sesamoid can develop osteonecrosis and osteoporosis, Dr. McBryde emphasized the need to save it, if possible.

“You can excise part of it,” he said, “but a total sesamoidectomy might have a negative effect on the patient’s biomechanics, resulting in an angulation overload deformity.”

Always remember the Achilles tendon
“The Achilles tendon can be a problem depending on what you do or don’t do with it,” said Dr. McBryde, who shared his sis­ter’s experience undergoing surgery to correct a flatfoot deformity.

“It didn’t work because the surgeon didn’t lengthen the Achilles tendon,” he explained. “She had to undergo revision surgery, which was performed by William M. Roberts, MD, and Oscar L. Miller, MD, the former AAOS president who developed the procedure.

“My sister is doing fine now—she’s even climbing mountains—but only because she had her Achilles tendon lengthened the second time around,” he said. “So, always think of the Achilles.”

Start with “Plan B”—but cautiously
Dr. Gould said his philosophy is to “start with ‘Plan B.”

“Do the last operation first,” he said. “Instead of using one screw for something, use two because that’s what you’re going to do when the one screw fails.”

An oblique radiograph of the forefoot showing an acute sesamoid fracture. Reproduced from Coetzee JC, Ebelin P: Lisfranc, forefoot, sesamoid, and turf toe injuries, in Pinzur MS (ed): OKU Foot and Ankle 4, Rosemont, IL, Amer­ican Academy of Orthopaedic Surgeons, 2008, p 102.
A healed lateral sesamoid fracture that was treated with ORIF. Reproduced from Coetzee JC, Ebelin P: Lisfranc, forefoot, sesamoid, and turf toe injuries, in Pinzur MS (ed): OKU Foot and Ankle 4, Rosemont, IL, Amer­ican Academy of Orthopaedic Surgeons, 2008, p 103.

Dr. Gould also emphasized the importance of obtaining good fixation for the calcaneal cuboid joint and using both an interfragmentary screw and a plate for great toe fusion. He also advised removing all diseased tendon when dealing with insertional Achilles tendinosis.

“Also, instead of just cutting back recurrent neuromas, look for other ways to salvage them, such as by using vein conduits or various types of other conduits that are available commercially,” he suggested.

Dr. McBryde asserted that aggressive treatments, such as major foot reconstruction procedures, must be performed with caution.

“Even if the patient is very healthy, you could run into problems. In one situation, a midfoot and hindfoot reconstruction on a 70-year-old, nonsmoking, nondiabetic patient resulted in a artery shutdown and amputation. So, the time doesn’t arrive when you’re immune to getting into trouble.”

Dr. Hamilton agreed.

“No problem exists in the foot that you can’t make worse with surgery,” he said.

Think of the entire body
Think beyond the specific surgical site during a procedure, cautioned Dr. McBryde. He used the example of a patient with what he described as a “questionably subluxed shoulder” who underwent ankle surgery.

“The surgery—a lateral ankle reconstruction—was successful, but the orthopaedic surgeon didn’t examine the shoulder while the patient was under anesthesia. Six months later, the patient went scuba diving in the Bahamas and dislocated her shoulder.”

Although the patient’s lawsuit was unsuccessful, he said, “the fact is that there was something to be found under anesthesia that wasn’t found. So, it’s important not to just think of the ankle and foot—think of the whole body.”

Always treat patients with respect
Dr. Hamilton stressed that even though you may be pressed for time, you need to treat patients with respect.

“If you keep a patient waiting, apologize,” he said. “Patients will go from being irritated at you to understanding your situation. It’s a simple thing to do, but it’s very important.”

Dr. Gould agreed and recommended introducing yourself and shaking hands with patients to establish physical contact.

“It develops a sense of rapport and makes you more approachable,” he said. He also advocates explaining concepts to patients using simple terms and drawings.

“I draw on the exam table paper,” he said. “I’ve seen patients tear off the paper and put it in their pockets as I leave the room.”

Another recommendation was to never miss rounds. Seeing patients every day during their hospitalization, he said, helps to allay fears and provide comfort.

“Follow your patients throughout convalescence so that you know what happens to them. Let them know what to expect at various intervals and what their outcome will really be,” he said. “Quoting from journals is one thing, but to be fair and honest, you should know how your patients do and share that information with your future patients.”

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org