Thinking About Biomechanics in a Reconstructive Foot and Ankle Practice

I'm Dr. Jayson Atves. I am a board certified foot and ankle surgeon. I practice out of Georgetown University Hospital in Washington DC.

A very loaded question, to be honest with you. Biomechanics, much as we learn in school and start to practice during residency, is a major focus for me. I think it's something that tends to not get as much play or as much attention because especially in a comorbid or complex patient population, it's much more difficult to put names to some of the deformities that we see or to identify them for various reasons. But hands down, and this is something that I'm extremely passionate about, is frankly that biomechanics plays a very, very primary role in all of our considerations. I think the only exception to that is when we find ourselves in patients who are now non-ambulatory. But even then, there's still biomechanical considerations. So absolutely it's something that's at the forefront of my mind and in all honesty, I think should be at the forefront of everybody's mind when they're considering reconstruction, regardless of the patient population.

Phenomenal question and really, the nidus for a lot of this is the nature of my practice, which is riddled with basically just complex and comorbid patients. I think the difficulty with naming and identifying and evaluating and planning with biomechanics for patient populations is that in a complex patient population or comorbid population, oftentimes, they don't have sensation. They don't necessarily have access to resources to help them to identify when they have an issue to get in front of someone like myself or my partners. So I would say, even though it is a primary type of consideration for everybody, it's really the complex patient population, especially the wound population that it's especially important for.

Gait exam is a fantastic way to evaluate people and really bring together your physical exam, perhaps your imaging exam as well. But to be quite honest with you, with a comorbid or complex patient population, it's almost unethical to perform a gait exam with someone who has a large or chronic wound. So in that way, it can become difficult, and that's why we really have to pay attention, I think, to the telltale signs of the location of a wound, its chronicity, determining its actual aetiology, which is helpful to make assumptions and make conclusions about how the gait has perpetuated in kind of an abnormal way.

So in all honesty, it's extremely important and I find myself doing a gait exam on just about everybody who doesn't have a wound, who doesn't have some type of disabling or debilitating deformity. So if it's something that is logistically feasible, absolutely, everybody gets some form of a gait exam. But if it's something where we just can't perform a gait exam for various reasons, and again, we have to just dig deeper and again, make assumptions based off of physical exam, the subjective information we're getting from the patient as well as the imaging, which is very, very important.