The Quest For Shorter Down Time by Jay Lieberman, DPM, FACFAS

Jay Lieberman, DPM, FACFAS, Director of Podiatric Medical Education, Northwest Medical Ctr.

In the New York Catskill Mountains, an enterprising gentleman named Morris Katz entertained the guests by creating “masterpieces” in ten minutes or less.  They called him the "Catskills Picaso". For fifty dollars, a guest would shout out a theme for a painting and the colors they wanted and “voila” …a work of art that matched the family’s living room couch.  At ten minutes a pop, this guy had carved out his niche.  He was no starving artist and never sought to be.  Art aficionados would call him gauche, but his customers got what they wanted.    

In medicine today, everyone is seeking to prove they can do “it” through a small incision, get the patient back on the tennis court within hours and have a better result.  If “it” is done with a laser or robot, so much the better.

The medical consumer has the challenge of having to sieve through the myriad of options that may or may not suit their individual needs.

For example, the “stent” has proven to be an incredible advancement in cardiovascular surgery.  If the indications are correct, the patient can avoid open coronary artery bypass surgery or femoral popliteal bypass surgery with better or similar results.

Lasers today are capable of opening narrowing channels in male urethras without the need to remove large components of the prostate and the dreaded catheter.

An ACL can be repaired with a scope.  It is no longer the career ender it used to be.

Microdiscectomies for radiculopathies associated with disc extrusions are very much in vogue today.  Through a 1/8” incision, the disc material can be removed, therefore eliminating pressure on the nerve as it passes through the foramen.  But what if the problem is not the disc, but a stenotic foramen or an arthritic joint? 

Will this procedure work?  Probably not. 

In South Florida, we have a tremendous population of retired people.  Almost everyone here has a masterpiece made for them by the Catskills Picasso.  In my practice, I come across many elderly people with painful foot and ankle conditions that no one will address, simply because of their advanced age.  As a result, their activity level is limited and their quality of life is compromised.

This 83-year-old woman sustained a fracture to her right ankle four years ago.  At the time, she underwent an open reduction.  Obviously, the result was suboptimal.

The patient lived in one of the larger retirement communities and wanted nothing more than to dance without pain.  The patient’s medical history was as follows: PMH-hypertension, osteoarthritis, and bronchitis.  Medications:  HCTZ.  Allergies:  NKA.  Social history:  Not a smoker.  Did not consume alcohol.  Drank two cups of coffee daily.  Lower extremity physical examination:  Dorsalis pedis and posterior tibial pulses were graded at +2/+4 bilateral.  Digital hair was present.  Capillary refill was less than five seconds bilateral. No rubor on dependency or pallor on elevation.  Proprioceptive sensoriums were intact.  Skin was supple and well hydrated. Nails were dystrophic and discolored consistent with tinea ungum. 

Initially, the patient was fitted with an AFO to limit sagittal and frontal plane motion in the ankle. She was injected with 10mg. of Depo Medrol.  Her relief was short lived and she ultimately resorted to a four leg walker and wheelchair to eliminate or limit weight bearing on the affected limb.

I have learned over the years that if the surgeon and patient can have realistic expectations of surgery, almost everyone can be helped. Initially, my plan for this patient was simply to insert a T2 ankle arthrodesis nail without exposing the ankle.

I felt that the compression and stability offered by the nail would be all that the patient needed.  Ultimately we decided to remove the plate and screws.  This afforded us exposure to the ankle.  A curette technique was used to remove the degenerated cartilage.  The nail was inserted in the manner described on the Stryker web site.

Click on the image below for full view.

Post Op AP View

Post Op Lateral View

I immobilized the patient for six weeks and then initiated physical therapy. Skeptics may say “but you also froze the subtalar joint.” One has to keep in mind that elderly patients who have severe degenerative joint changes in the ankle also have limited frontal plane motion.  The benefits of this minimally invasive approach outweigh the drawbacks.

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Stryker is one of the world's leading medical technology companies and is dedicated to helping healthcare professionals perform their jobs more efficiently while enhancing patient care. We provide innovative orthopaedic implants as well as state-of-the-art medical and surgical equipment to help people lead more active and more satisfying lives. See how Stryker is focused on what matters most. Stryker T2 Ankle Arthrodesis Nailing System Stryker Trauma has produced the T2 Ankle Arthrodesis Nail for tibiotalocalcaneal fusion with a retrograde intramedullary nail. Features & Benefits: The T2 Ankle Arthrodesis Nailing System is based on the established T2 instrument platform and locking screws and offers a unique locking configuration for tibiotalocalcaneal fixation.   • Limited soft-tissue damage in ankle area   • Locking hole provides axial stability   • Compression of subtalar and tibiotalar joints

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