This patient is one I saw just this morning in the hospital. Let’s call him Mr. Jones. I first met Mr. Jones at his bedside in one of my local hospitals several months ago. He had a severe lateral foot infection that involved his 5th toe and metatarsal. I did an incision and drainage, which became a partial 5th ray amputation. He resolved his infection and was discharged uneventfully. Later, the incision dehisced and I wound up taking out the 4th metatarsal head in an attempt to salvage his forefoot. In both cases I took a somewhat conservative approach, trying to maintain as much tissue as I could. Infection again ensued, and I eventually did a transmetatarsal amputation and percutaneous tendoachilles lengthening, an arguably more aggressive approach. After this, he healed uneventfully.

During the recovery period after the final amputation, Mr. Jones was building an ulceration on his contralateral plantar great toe due to Hallux limitus and excessive plantar pressures. Due to a health insurance limitation (I was not on his health plan and was seeing him in the 90-day global period after his amputation). I was only able to treat this wound “conservatively,” which meant moist wound care, debridement, and offweighting with a boot. When the other foot healed, the patient was sent to a new provider. Fast forward a few months to this morning, and Mr. Jones is now re-admitted to the hospital, needing a great toe amputation.

Consider this: if I had done a surgical procedure to eliminate Mr. Jones’ great toe ulcer while he was in the hospital the last time, would he have needed the amputation?

I would argue a very strong “no.” For a large variety of reasons, the longer I’ve been in practice the more aggressive I have become in treating certain disorders, especially trauma and diabetes. When it comes to the diabetic foot, the surgical approach is often the one that leads to improved outcomes. In many of these situations, “surgery” is appropriate and “conservative measures,” being more likely to fail, are the inappropriate treatment. For example, Armstrong and associates found that performing a 5th metatarsal head resection for neuropathic ulceration had greater healing success and in a shorter period of time than standard local wound care.¹

In traumatic situations time may be of the essence, requiring a decisive and aggressive approach. About a year ago, one of my residents was on an ER rotation at one of our local hospitals when she came across a 12-year-old boy with a displaced triplane ankle fracture. Concerned for the patient, my resident advocated to have the patient admitted (when the ER physician wanted to send him home), and we performed an immediate open reduction internal fixation. This patient had Medicaid, and if he were discharged, he would have been required to follow-up with a primary care physician, receive a referral to a specialist, obtain an appointment, and then be scheduled for the surgery. This delay in care would have been detrimental to his overall outcome, which I’m happy to say was excellent due to my resident’s “aggressive” approach.

I don’t like the implication that “surgical,” as the opposite of “conservative,” is somehow less valid or more risky. In the well-chosen patient, the surgical option is often the better one, as these examples show. This is, of course, not always true, but vocabulary has the power to guide our thoughts, and we have to maintain a flexible mindset. I offer as an alternative, simply changing this dichotomy to nonsurgical and surgical. These are simply two options in the toolbox, and it is each of our responsibilities to diligently consider when one is the more appropriate option. Deciding what treatment will give the patient the best outcome is the hardest part of being a medial provider.

This ezine was made possible through the support of our sponsors:

Grand Sponsor

Major Sponsor