One of my residency attendings once told me it takes five years of practice before you settle in to a “standard” set of procedures.  I imagine this would, in reality, vary based on the individual. I didn’t see myself taking five years to figure out which procedures I thought best for different situations. I’m pretty opinionated (if you haven’t already noticed after over 100 opinion pieces), so when I graduated from residency I felt pretty set as far as what treatment methods I’d employ for my surgical patients. However, over time I have noticed somewhat of an evolution in my methods. After 2 ½ years in practice, this evolution is obviously still ongoing.

To Do Surgery?

To start, my surgical prep time and consent process have increased significantly.  First, I will not schedule a patient for elective surgery on the first visit. I often, as a resident, met surgical patients who had seen the attending physician once as a new patient and was immediately scheduled for elective surgery such as bunionectomies and hammertoe repairs. In practice, my methods differ. I will discuss all options for treatment on the first visit, and if a patient requests surgery, I will schedule them for a preoperative 2nd visit, where we discuss the options in more detail. This gives my patient another opportunity to know me better and vice versa. The consent form itself is five pages long, including a diagram of the procedure, an information page containing various perioperative topics (such as smoking will prolong healing), two consent forms (mine and the hospital’s), and a checklist the patient signs to indicate they understand what we’ve discussed. I’ll present my consent form in a later issue for all to critique. I spend much more time now discussing their surgery than I ever did before.

What Surgery to Do?

Overall, I’m leading more toward comprehensive reconstruction rather than simply addressing that specific problem. For example, my plantar fascial surgeries are more successful when I address the equinus and sometimes an associated flatfoot. You have to balance, though, the desire to correct all deformities with your patient’s threshold and current standard of care. I had a patient with plantar fasciitis that I had treated for about 6 months when we started talking about surgery. She then went to a local orthopedist, who did a full flatfoot reconstruction (she didn’t have a flatfoot) with a subtalar and naviculocuneiform fusion. Six months later, I meet her again, limping with continued heel pain. Her initial problem was never addressed, and she continued to suffer from pain. How much quicker and effectively would she have healed if she’d had a simple plantar fasciotomy and calf lengthening?

Anesthesia Considerations

Let’s talk about surgery itself. First, anesthesia.  I’ve grown very fond of popliteal/saphenous blocks preoperatively. I remember perhaps one case as a resident where we chose this type of anesthesia. I strongly recommend it. My patients average 30 hours of postsurgical complete pain relief, breaking the pain cycle, and they require less overall pain medication. I’m not worried about local blocks and fluid obscuring my dissection. The patients uniformly tolerate the actual block well. My anesthesia staff is very easy to work with and are willing to take the time to do it right. I couple this anesthesia with sedation or general depending on the procedure. For example, when I use a thigh tourniquet, I go with general (or spinal anesthesia, as necessary). I would recommend adding a half-hour to your surgical time for the block itself.

Forefoot Surgery

Hallux Abducto Valgus

My most common choice for bunions is the modified Lapidus bunionectomy. When I first started, I performed more head procedures than anything (mostly Reverdin-Green-Laird). Patients did well with full weightbearing about one week postop. Screw fixation allows immediate weightbearing, but have fun dealing with the swelling. Patients were generally satisfied, but the correction was limited by the anatomy (ex. a thin metatarsal shaft allows only a small amount of translocation). Additionally, I’ve noticed MUCH LESS stiffness of the 1st MTP joint after a Lapidus. This is due most likely to the lack of distal osteotomy, less dissection, and improved overall metatarsal position (no more hypermobility). Rarely, I have to perform a head procedure in addition, to adjust PASA. I was once told there’s no such thing as PASA, but I inspect the cartilage position every time, and I have seen it. In general, I’ll release the 1st MTP joint, move to the 1st met-cuneiform area for the fusion, and then see what position the hallux is in. Most often, I’ll use canullated screw fixation. I once laughed at a rep who asked me about ex-fix for a Lapidus, but I actually have two cases scheduled where I’ll be using external fixation. I’ll present these cases in a future editorial for us to argue over.

Preop and postop bunionectomy with fusion.
Intraop fusion with crossed screws.

Hallux Limitus/Rigidus

In the more severe cases with significant joint degeneration, I tend toward fusions. They’re “functional,” pain relieving, and predictable. For the mild to moderate cases, I’ll do cheilectomies (especially for athletes) and Lapidus if there’s an elevatus.

Lesser Toes

I almost uniformly perform arthrodesis for my 2nd hammertoes (typically end to end fusion) sometimes with flexor tendon transfers. For some unknown reason, I tend to have very severe deformities walk into my office, so I perform the standard sequential release of the MTP joint with or without a bone procedure. I’m sure I’ll open myself up to much criticism with my next comments. I’ve found astounding success, not with the Weil osteotomy, but rather with a joint arthroplasty (removing a small portion of the head of the metatarsal). I learned this from my previous boss, who had fantastic results. When I first saw him do this, I said, “Are you crazy? That’s a joint destructive procedure on an otherwise healthy joint.” Well, I saw some of his patients, and then did a few of my own and the results were, in fact, excellent! They were slightly stiffer, but always pain free. I don’t do this on younger patients. However, the advanced deformities are most often on the elderly. This is the same set of procedures I do for pre-dislocation syndrome. I have performed plantar plate repairs, actually very successfully, but the recovery seems longer, and the procedure, in my hands, is somewhat more difficult.

Neuromas

I still do neuroma excisions, although I try alcohol sclerosing injections first (usually so successful they don’t need surgery).  I still approach the neuroma dorsally.  I offer decompression for those patients who want something less invasive.

What are your preferences for surgical planning and forefoot surgery?  We’d love to hear from those of you in practice for many years.  How has your practice style and surgery changed over the years? For those of you residents, how comfortable do you feel making surgical decisions?  Do you have a preference for certain procedures? Write in with your thoughts and joint the conversation.