Practical Keys To Improving Fluency In Foot And Ankle Surgery

Learning and performing effective surgery is akin to studying and speaking a foreign language. Not every one does so with the same fluency. The patient often does not speak a single word. Anatomy is the vocabulary, surgical procedure selection is the syntax and some aspects like verb conjugation and internal fixation sequences simply have to be committed to memory.
   There are levels of competence or dominion in both language and surgery. The most basic is phraseology. The second level of competency is conversational. Finally, there is complete fluency that includes the ability to lecture in the language at any time, be fully understood by all audiences and use nuances and idioms of the native speakers’ tongue effortlessly.
   Surgical fluency follows a similar course from theoretical coursework in medical school to residency program practical training to the continual learning and refinement of private practice.
   Accordingly, the following are shared lessons, experiences and exercises with the hope that they help colleagues communicate more effectively and speak the language of surgery more fluently.
   Lesson one: Do not forget your sharp surgical nail procedures. Chemical matrixectomies work great and some doctors have not done a surgical nail in 15 years. However, a certain number of patients with various medical complications, diminished circulatory status or suspect soft tissue integrity will do better with a sharp surgical nail procedure and heal in seven to 10 days.
   Practical experience: All it takes is one or two phenols that continue to drain for eight to 10 weeks to convert you to the occasional surgical matrixectomy such as Frost, Winograd or Zadik. Patients keep requesting antibiotics and consulting doctors start saying they “cannot exclude osteomyelitis” and order Tc-99 bone scans. In reality, it is simply a slow to heal phenol and nothing more. When performing surgical nail procedures, be absolutely certain there is no dense white matrix tissue left on the undersurface of the medial and lateral nail folds. If you are not looking at subcutaneous tissue, you have left matrix and will have a regrowth of a least a spicule.
   Translation to patient: We are surgically removing your nail root. Your nail may grow crooked if we only fix one edge. We can accept that possibility or fix both edges. It is your choice.

Key Considerations In Digital And First Ray Surgery

Lesson two: There is nothing worse than a perfectly straight fused lesser toe. Perfectly fused interphalangeal joints look great on X-rays but can be problematic for patients with shoegear.
   Practical experience: Perform flexed toe fusions for hammertoe or clawtoe correction. The result is more cosmetic and more functional. Normal flexion in a digit at the proximal interphalangeal joint is about 20 degrees. Strive to achieve that in your post-op results. I prefer fixation using an absorbable pin that allows adjustment of the final position of the toe in all planes prior to applying the dressing.
   Translation to patient: Yes, your toe will be stiff after surgery. Stiff in a functional position and slightly bent is better than stiff in a bad position that rubs in your shoes.
   Lesson three: Never commit to your proposed bunion procedure until you have performed the soft tissue releases. The key to bunion surgery is the flexibility or lack thereof in the first ray. Researchers have described over 130 procedures and they likely all have worked at some time for someone. Lasting correction comes from a congruent first MPJ and the metatarsal head well positioned over the sesamoids.
   How one achieves this is secondary. First consider whether an osteotomy is required at all. There are repositional options of the first and second metatarsals via screws, sutures or tape that work well in many cases. This of course depends on the flexibility of the first ray.
   Practical exercise: Always consider PASA correction and decompression via a distal osteotomy with rotational corrections of the intermetatarsal angle. A relative lengthening occurs. The difference between a good bunion correction and a great bunion correction is attention to PASA and more frequent use of the Akin.
   Learn to do a Scarf bunionectomy correctly and well. It is the most versatile and secure osteotomy available that still allows immediate weightbearing, secure fixation and multiplanar correction including PASA. It also resists shortening. Do not forger the Keller. An 88-year-old grandma will do just fine and heal in 10 days with a well-done Keller bunionectomy. Tag the flexors to the remaining proximal phalanx to improve toe purchase.
   Translation to patient: No, we cannot guarantee your bunion will never come back nor that your toe will be perfectly straight. Mild residual abduction of the great toe is preferable to hallux varus and fits in shoes better.

Addressing Severe Forefoot Deformity

Lesson four: Utilize Barouk’s approach to forefoot longitudinal and mediolateral decompression. By the time all the toes are pointed in 12 different directions and the hallux underlaps the third toe, the soft tissues are trying to tell us something. They have adaptively contracted beyond the length permitted by the osseous structures. In a sense, the bones have become too long for the foot.
   Practical exercise: One needs to decompress the forefoot bones in order to relax the soft tissues. Lengthening extrinsic tendons and pinning MPJ joints often do not last. The intrinsics are shortened as well. One needs to ensure the central metatarsals are harmonized with the first ray and that the whole forefoot is “relaxed.” Shortening Scarf and Weil osteotomies are the most effective options to achieve these results. Panmetatarsal head resection with digital fusions remains a very viable option for severe forefoot deformity as well.
   Translation to patient: Some toes may not fully touch the ground post-op. That is okay. They did not start off touching the ground either. We are looking for relief of painful metatarsalagia and toes less likely to ulcerate dorsally.

A Few Thoughts About Midfoot Surgery

Lesson five: Use more compression staples and locking plates. Compression staples make your life easier. For short, squarish, closely packed joints in the midfoot, region staples are ideal internal fixation.
   Practical exercise: Screws invite stress risers and compromised fixation due to the necessity of oblique presentation of the drills and screws. Staples also allow maximal bone-to-bone contact rather than traversing small joints with small surface areas with pins and/or screws, thereby impeding bony union. Locking plates similarly traverse joints and are incredibly stable. When one modifies and cuts up calcaneal locking plates, they can work wonderfully as fixation devices for complicated revisional midfoot and Lisfranc fusions.
   Translation to patient: Yes, the middle of your foot will be stiff after surgery. It already is now but it hurts. You have wear and tear arthritis, and we are trying to get rid of your pain. Unfortunately, no implants exist for these joints.

What You Should Know About Hindfoot Surgery

Lesson six: Position, position, position. “Thou shalt not varus” has been beat into our heads. We get it. One can even correct this, if necessary, with revisional wedging laterally or through the midfoot. Hindfoot and ankle fusions in excessive valgus are even worse. Bracing is difficult due to medial malleolar irritation. Shoeing the foot is difficult due to forefoot to rearfoot malalignment. Revisional surgery is complicated as the axis of correction is medial and underlies the neurovascular bundle.
   Practical exercise: It is better never to get there. Always prep above the knee with hindfoot and ankle fusions to have a proximal reference for alignment for the foot to the leg. Use the position of the lateral process of the talus in relation to the floor of the sinus tarsi as your reference for inversion to eversion within the foot.
   If necessary, use a calcaneal displacement osteotomy in addition to fusion. The heel must contact the ground in a sound and stable positon in gait. The calcaneal displacement osteotomy is essentially a tendon transfer of the Achilles and a tip of the rearfoot axis. Use it to ensure correct alignment intraoperatively if necessary. The deformity of excessive valgus will not forgive you postoperatively.
   Translation to patient: You will have functional limitations after surgery. Other joints will accept more stress. We cannot reverse the average American weight gain of two pounds per year between the ages of 20 to 40 with foot surgery. We want to stop further collapse.

Should You Suspect Peroneal Tendon Tears With Lateral Ankle Instability?

   Lesson seven: Always suspect longitudinal tears of the peroneal tendons and subtalar joint instability with unresolved lateral foot and ankle pain. Peroneal tendon pathology and the adult-acquired cavus foot are the first cousins of the more frequently discussed posterior tibial tendon pathology and adult-acquired flatfoot. Magnetic resonance imaging (MRI) scans can be unreliable. One must suspect the diagnosis clinically. Longitudinal tears in the insertional zone of peroneus brevis and retromalleolar flattening of the brevis with low-lying muscle belly are the most frequent yet undersuspected pathologies.
   Practical exercise: Primary repairs and tubularizations work well but do not address deforming forces. Consider the calcaneal osteotomy as well with lateral displacement or in combination with the Dwyer correction.    Subtalar joint instability is a translational fore and aft instability of the talus above a weightbearing calcaneus. The modified Brostrom-Gould technique works well as the repair crosses the subtalar joint. When tendon transfer are necessary, use free graft or the peroneus longus. The brevis is our main evertor.
   Translation to patient: You will likely still need a lateral ankle brace for high demand activity. We can support a pronating foot more readily than we can control a supinating structure.

What About Retrocalcaneal And Achilles Surgery?

Lesson eight: Stay off the back of the heel. Use medial or lateral incisions when possible for Achilles and retrocalcaneal surgery. Direct midline incisions contract more and are more susceptible to wound complications and shoewear irritation.
   Practical exercise: The medial and lateral supporting arterial vessels do not quite join in the direct midline heel. Although the vast majority of incisions heal without difficulty, the occasional posterior heel breakdown will drag on for one to two years, take five years off your life and require reconstructive plastic surgery with possible free flap transfer. You will also get sued. With substantial Achilles insertional calcific pathology or weakening, use of the FHL tendon to reinforce the insertion can provide functional strength gain. Consider proximal gastrocnemius release in conjunction with posterior heel surgery.
   Translation to patient: Achieving 75 percent improvement in preoperative symptoms a year after surgery is an excellent result. See lesson six.

When Regular Follow-Up Is Not Possible For Patients With Clubfoot

Lesson nine: Ponseti is the gold standard but is not always the best or the most practical option. A complete series of Ponseti casting is ideal for clubfoot correction. There is no argument. However, globally, one stage surgical release is as necessary as ever. If you only do one Ponseti casting of the series and never see the child for follow-up, it is worse than a surgical release. You may only get one chance with a patient living in a remote area.
   Practical exercise: Use zigzag incisions to reduce scar contracture both medially and laterally. Partial recurrence or residual metatarsus adductus is not unusual. Do not beat yourself up. Postoperative splinting is mandatory and still must be insisted upon in developing regions of the world with limited resources. One may even use the bivalved cast.
   Translation to patient: No surgery has ever converted a clubfoot to a normal foot. The goal is a plantigrade, pain-free, shoeable foot.

Final Notes

Lesson 10: Be humble. We all periodically slip into thinking we are wonderful and have it all figured out. We are not and we do not. We will have complications and make some mistakes. We are all prone to human error. You can be chief of your section at the community hospital and not be allowed in the main OR at the university teaching hospital unless you have an acute abdomen and are the patient.
   Practical exercise: Keep your pride under wraps and check the ego at the door. Absolutely maximize your own potential but never take yourself too seriously. We are all replaceable. Michelangelo died in February 1564 in Italy. Shakespeare was born two months later in England.
   Translation to doctor: “There is no package smaller than a man wrapped up in himself.” We are all just passing through.

Dr. Cicchinelli is a faculty member of the Podiatry Institute. He is teaching and lecturing in Vigo, Spain to help develop Spanish surgeons. He will join East Valley Foot and Ankle Specialists in Mesa, Ariz. this fall.

Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified in foot and ankle surgery. He is in private practice in Little Rock, Ark.