Equinus

Let’s talk about equinus first.  I agree with those who state equinus is the most significant pathological factor of most foot disorders.  I focus much of my attention on equinus – in my physical exam, nonsurgical treatment, and surgery.  I do the Silferskoild test on all patients and see a greater number of gastrocnemius equinus than mixed gastrocsoleus equinus.  I have moved away from open gastrocnemius recessions to endoscopic gastrocnemius recession(EGR).  Patients love the small incision, the results are excellent, with a significant increase in dorsiflexion, and minimal pain and recovery time are seen.  I don’t cut the plantaris tendon, and I don’t see any limitation of postoperative dorsiflexion with it intact.  I still do percutaneous TALs on diabetic neuropathic wound patients, although I see significant advantages to the EGR in these cases (less risk of tendon rupture, immediate postop weightbearing, and less risk of overlengthening).  I haven’t found much research on the EGR for diabetic forefoot wounds, so there’s little literature to back this up instead of the TAL.  However, I did do an EGR on a diabetic patient with a preulcerative forefoot callus with resolution of the callus over a couple months postop.  I usually perform an EGR with any plantar fascial or Achilles tendonopathy or exostosis surgery.  If equinus exists, I want to eliminate it.

Flatfoot

My PTTD reconstructions in adults have moved from joint sparing procedures (Cotton and Evans, for instance) to fusions. For example, I find midfoot fusions like a naviculocuneiform arthrodesis to be more predictable with a better postop appearance and function. I'll still do an EGR, medical calcaneal displacement osteotomy, and primary PT tendon repair (sometimes with a flexor tendon transfer) along with the "arch" procedure. I'll also occasionally use a subtalar implant. All this is, of course, based on a full history and examination of the patient. I'll consider planal dominance, but after hearing some of our national speakers, I don't think it's the most important consideration. I'll use it as a guide while considering other factors like flexibility and weight. One thing I have found very interesting is the lack of pain these patients have postoperatively. Since residency, I've admitted all my flatfoot reconstructions for pain control, expecting that with four or five procedures they'd have a lot of pain. In practice, though, that has uniformly not been the case. Even without a popliteal block, they're not as painful as I'd expect. Perhaps my blocks improved over time!

Click on the images below for a full screen view.
Postoperative flatfoot reconstruction for PTTD.

The Ankle

When it comes to ankle surgery, I don’t do all that much, unfortunately.  I receive very little ankle trauma that requires surgery, with most of my work on lateral ankle instability and tendonosis.  I tend towards the modified Brostrum for ankle instability, but I’ve also performed secondary stabilizations with very positive results.  I see the occasional arthroscopic ankle case.  In my experience, patients are much less likely to elect to have ankle surgery than the foot, but that’s just one doc’s experience.

Intraoperative peroneus brevis repair.

Wound Care Surgery

Let’s move on to wound care surgery.  I spent much of my first 2 years in practice doing wound care.  In residency, I didn’t enjoy this aspect of podiatry, but in practice I came to appreciate it and now find wound care the most rewarding part of podiatry.  If I had the opportunity, I would subspecialize in limb salvage as a niche practice.  However, in the rural environment in which I work, that’s not possible.  Over time, I’ve become increasingly aggressive with my limb salvage management.  I offer reconstruction much sooner than I did earlier in my career, often recommending procedures such as TALs, joint resections, and osteotomies after a lower threshold of nonsurgical care.  I would go so far as to argue that the TAL should be a first line treatment for diabetic neuropathic ulcers without osteomyelitis. 

On a related subject, I performed relatively few transmetatarsal amputations as a resident, but in practice found it a highly successful procedure for limb salvage.  I did increasing numbers of TMAs as my early practice progressed, and the TMA became somewhat the workhorse for those severe forefoot salvage cases.  In all cases but one, I added a TAL, and in the one case that I didn’t, the patient ulcerated at the distal plantar stump.  This patient had just undergone a fem-pop bypass and I was concerned about the TAL incisions healing.  This was a freshman mistake.  If they can heal the TMA, why wouldn’t they heal the more proximal stab incisions of the TAL? 

postoperative transmetatarsal amputation

One of the things I love about podiatry is the large number of surgical options available to us to treat various pathologies.  How many bunionectomies are there?  Over 150?  How about flatfoot reconstructions or limb salvage?  Compare this with appendicitis.  If you have an infected appendix, you get an appendectomy.  That’s pretty much it.  Two options (open or laparascopic) – how boring!  What are your favorite procedures?  How do you like to handle reconstruction of the foot and ankle?  What do you like to do for Charcot reconstruction?  What tips and pearls make your surgical life easier and more exciting?

Write in – let’s start a conversation.  Best wishes on your next case.