Stege's Podiatric Topics


Immobility and Pain Can be Overcome

Surgery of any sort is an unpleasant idea for most people to contemplate, and foot surgery is no exception. Podiatric physicians also look upon surgery as a last resort, and like other medical practitioners today, they generally exhaust all avenues of conservative medical treatment before they recommend surgical intervention.

But when they do, they know that the correction of crippling disabilities -- even immobility -- and the relief of pain and discomfort overcome the mental anxiety that the thought of surgery produces.

Doctors of podiatric medicine are specialists who treat diseases, injuries, and other disorders of the foot and ankle. They are trained at four-year colleges of podiatric medicine in the United States, which grant the DPM degree, and many of them also receive up to three years of postgraduate residency training. All 50 states, the District of Columbia, and Puerto Rico license DPMs to correct foot problems by medical, surgical, and other means.

The Surgical Setting

Most foot surgery can be performed properly and safely in a podiatrist's office or clinic; if a procedure is more complex, it will be done in a hospital outpatient setting, or with a hospital stay that generally will not exceed three or four days. Sometimes, a patient's preference can be a factor in the selection of a setting.

When a surgical procedure is done in a podiatrist's office, clinic or surgical center, or on a hospital outpatient basis, a patient will be in and out on the same day. The doctor will provide cautions about eating before surgery, and it may be necessary to alter temporarily the dosage level of prescription medications the patient is taking. He or she will generally suggest that a friend or relative drive the patient home after the surgery. If a hospital stay is necessary, it generally will not exceed three or four days. The doctor may want additional laboratory tests, including X-rays, or other special attention, and the hospital staff is on hand for that.

The use of anesthesia: In the office or clinic, a local anesthetic that numbs an area of the foot probably will suffice, but the doctor may prescribe pre-operative medication to help the patient relax. In a surgical center, or as a hospital outpatient, an intravenous (IV) sedative may be administered before the local injection; it is intended to be relaxing, and most people will become drowsy, although they remain awake during the surgery. If there is to be a hospital stay, it is more likely that an anesthesiologist will also administer a general anesthetic to allow a patient to sleep through surgery.


Typical Surgery

The correction of bunions and hammertoes, surgical treatment of nail problems, removal of warts and soft-tissue benign tumors, and tendon operations comprise the bulk of surgical treatments recommended by podiatrists. There is a growing number of surgeons who specialize in less common and more complex rear foot and ankle procedures.

None of the procedures is truly "routine," since normal anatomical variations and acquired changes to the bone and soft tissue are involved.

Nail problems are perhaps the commonest reason for podiatric surgical intervention. The correction of ingrown nails, which can be partially or totally ingrown and are frequently associated with fungus infections or injuries, generally can be performed in an office or clinic. Nail deformities are also sometimes associated with small bone spurs under the nail, which also can be removed in office procedures. Spurs, which are an overgrowth or enlargement of bone, can occur elsewhere, and ordinarily can be removed in similar fashion. Generally, a patient is able to bear weight on the feet following such surgery, but the podiatrist will probably schedule a return visit in a few days to check bleeding and healing.

Bunions are deformities of the joint at the base of the big toe, in which a bony growth causes the big toe to turn inward toward the other toes. The joint bows out at a 'V' angle, and becomes irritated and swollen. Bunions have a strong hereditary basis, and seem to be more common among women than men. They can be aggravated by shoes that are too tight across the toe box. There are several different surgical procedures which can be used to correct a bunion, and depending on the degree of severity, a procedure might be performed in an office, a clinic, or a hospital outpatient facility. The same factors will determine the doctor's decision on postoperative management, which might range from splints and a walking shoe to a below-the-knee cast. As with all bone surgery, individuals may differ in the actual time necessary for healing, which could range from three weeks to six or eight.

Hammertoes often accompany a bunion, although they occur on their own, as well. Most frequently they involve the second toe, but the other smaller toes can also be afflicted. The bones of the toe buckle into a claw-like position. Hammertoes can be flexible (the joint can be straightened with the fingers) or rigid. The former can be corrected by soft tissue or tendon surgery, while the latter may require removal of a small segment of bone. These surgeries can be done in an office setting; in both situations, a splint and a surgical, or wooden, shoe probably will be needed, for as little as a week after the soft tissue/tendon surgery, but up to three or four weeks following the bone removal.

Plantar warts which are caused by a virus, can be removed in a doctor's office, using various relatively simple surgical procedures, and the patient probably will be able to walk immediately following the process. However, warts can occur in multiples and clusters, and may require that more than one visit be paid to a podiatrist. They can also recur, like other viral infections.

Neuromas are soft-tissue tumors, almost-always-benign growths on nerves, usually between the third and fourth toes. They can be removed in surgery in the office or clinic, and a patient is ordinarily able to walk immediately after the procedure, although the podiatrist will change the dressings and monitor recovery during return visits.

Ganglions are fluid-filled sacs that appear in various spots on the top or side of the foot. They can be removed in the doctor's office and the patient can usually bear weight right away; as with neuroma removal, return visits for dressing removal and monitoring will be required.

Heel spurs occur as a bony growth on the front part of the bottom surface of the weight-bearing part of the heel bone, where a long band of tissue called the plantar fascia, which runs to the forefoot, is attached. Spurs may be caused by injury or other foot stress. The band of tissue can be released, and the spur surgically removed, possibly in a well-equipped clinic or in a hospital outpatient setting, although a hospital stay will likely be necessary. Recovery will most likely require immobilization of the foot, and use of crutches or another ambulatory aid for about two weeks.

Insurance Coverage

Much foot surgery is frequently referred to as "elective surgery," although that certainly is a misnomer for a patient who has neglected a bunion to the point where it causes constant serious pain and deteriorating mobility. However, a growing number of insurance carriers require that a second opinion be obtained before such surgery is undertaken. Podiatrists are happy to make referrals for second opinions, whether they are required or are the preference of a patient.

The services of doctors of podiatric medicine are covered by most public and private insurance programs, and many podiatrists accept their assignments -- i.e., the insurance carrier's payment schedules.

Lasers in Foot Surgery

Patients frequently ask about the use of lasers for surgery. They may be used in surgical procedures that involve soft tissues, such as wart removal and treatment of ingrown nails. But they aren't recommended for use in treating bone conditions, meaning that surgery on bunions, hammertoes, and heel spurs would not utilize the laser.

There is no good reason for a patient to be overly concerned about surgical scars. The stitches (sutures) are sometimes visible while healing proceeds, but others are "buried" beneath the surface of the skin and, since they are made of absorbable material, do not have to be removed. Traditional stitches may stay in one or two weeks. The choice of suture material can vary from one procedure to another, from patient to patient, and even from one area of the foot to another, and all those things can also affect the degree of disappearance of the incision line.

Foot surgery, as all surgery, is an attempt to correct a pathological, or diseased, condition, and it ordinarily yields good results. However, instances of recurrence of a condition are not unknown.

(c) Copyright 1996 - David C. Stege, DPM - All rights reserved.