Harold Schoenhaus, DPM reviews various types of complications that may occur post operatively. Dr Schoenhaus stresses the importance of informed consent and truthful expectations to be given to all patients.
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Harold Schoenhaus, DPM
Surgical Editor for PRESENT e-Learning
Penn-Presbyterian Medical Center
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TAPE STARTS – [00:00]
Dr Schoenhaus: Alright. Next speaker hails from Philadelphia, ex-football player, quarterback for the Eagles, play professional hockey and now is presenting in front of you today. That’s me. Aspirations. I'm getting old, I start dreaming of the things that I would have loved to have done through my career. Complications of foot and ankle surgery. Forty five years ago when I finished my training, I thought that I could do anything and everything possible to the foot and ankle. And I would do it well. And that complications were something that happened, but would never happen to me as I had all the answers. Well, 45 years later, I can tell you I didn't have all the answers. And if you don't have complications, you're not doing enough surgery. And the point of fact, I usually blame the patient for complications. As Dr. Turano [phonetics] showed some dorsiflexion capabilities of the great toe with his Lapidus procedure. And that’s on the operating table. And that’s the place and the time that your range of motion in any bunion procedure is the best that it will ever be. Postoperatively, things start to tighten. We get complications of stiffness. Maybe the great to sticks up in the air a little bit. The patient can't plantar flex the great toe the way they used to. They can't pick up a towel with their big toe which in Philadelphia is a problem because majority of the people are little overweight and to try to get down and pick that towel up is going to be a major problem. So the big toe helps in that respect. But the point of fact over time, range of motion diminishes. So we usually tell the patient that look what happened on the operating table. I did such a great job and yet what did you do to my surgery to cause it to have less motion. Were you wearing inappropriate shoes? Did you get back to activity faster than I told you could? Are you doing your exercises to bring the big toe up and down and do everything that I told you should do? Obviously patients don't do that. And I don't care what type of surgery you do, compliance is a major factor. The foot is one of the most difficult structures to operate on. I have said this for years. We have more joints and bones in anywhere in the body. And then we tried to correct deformity and then allow somebody to go out and run, jump, play, wearing shoes of different heel heights. The trauma that’s created postoperatively is going to do everything it can to give us a bad result. We may complicate that thought process somewhat or contribute to it by our method of fixation which we now tell patients don't worry I got enough hardware in there and you can walk on this right away. Makes no sense. Put less hardware in. As Mike pointed out the bone has to heal, the bone has to become a rigid structure if you have broken it. If you have repositioned it. The hardware is just holding and maintaining the position for stability and compression or angular change if that’s what you're expecting the hardware to do. If you put a frame on the patient, you can increase tension or compression over time through the external fixation capabilities because things change. Osteonecrosis occurs. It occurs, I don't care if you use iced saline in the OR. I like iced saline. Actually, I like the ice for my martini in the OR, why waste it on the incision site. I mean the fact is certain amount of burning is going to take place and certain amount of osteonecrosis occurs. That’s why the body is going to remodel. Osteoclastic activity get rid of the detritic bone and then eventually lay down new bone in the process of healing.
But in that interim, when that osteoclastic activity is taking place, what's happening to the stability across your osteotomy site or your Lapidus fusion site. Maybe not as tight and as compressed as you would like it to be. So I've always been a proponent of not considering early weightbearing unless I'm doing something rather simple that will allow a patient to do it. So the older I get and more experienced I have, I become not much more tolerant of, I guess, what I expect the patient to do, not so much tolerant of what they're going to do because I'm not tolerant what they're doing. They're out there to screw my surgery. Alright. Complications. I mean you could list complication. You just sit here and just think about it. Wound dehiscence, hardware implant failure, painful scars, epidermal inclusion cyst, keloid, suture reaction, over or under correction, recurrence, development of Charcot that you could create, nonunion, delayed union, malunion, continued worsen pain, nerve damage, RSD, CRPS, chronic swelling, DVT, compartment syndrome, minor or major amputations that might occur. Are you crazy doing the surgery? Look at the potential complications that are going to occur. When we explain surgery to patients, our obligation is to be sure they understand that what is happening in the OR can lead to problems postoperatively. It's not anybody's fault necessarily. Now, there are times when we do things that somebody may look at and think that your act was somewhat egregious, but the fact is majority of the time you're in there doing surgery, you're careful, you're concerned, you're realigning, you’re repositioning. You're using all of the important principles in surgical dissection and fixation and everything else you're doing, but that doesn't mean that complications won't happen. Infection, swelling, scarring all of these things we talk about. Inevitably, the patient denies ever being told that that’s going to happen. He never told me I could get an infection. Are you kidding me? They just don't remember it. The point of fact is there have been studies to show that patients have been interviewed after being told by a doctor of all of the potential complications. They're brought into another room and someone would sit down them and state did the doctor tell you this? No. It was amazing what percent patients forget or didn't listen or hear right after you told them. And when you do that same questionnaire six to eight months later, maybe 10% retention of what they were told. Not that they're lying. God knows what people think. When you talk to somebody, you think they're listening to you, but they're thinking about whatever happened the night before the fight that they had with their wife, the fact that the stock market is crashing. How do you know they're listening to what you're telling? But you do your best. Wound complications, there is plenty to be talked about with wound and I'm not going to bore you with any of my scenarios. But certainly, areas of incisional planning are critically important. Anterior incision of the ankle. We do ankle joint replacements. Anterior incision is the disaster. It's an accident waiting to happen because of angiosomes over the anterior aspect of the ankle. The dissection we perform, the retraction we do. All of these things leading to the complication of wound healing which can be a disaster. I have introduced the concept and used amniotic membrane over areas where incisions have tendencies to dehisce or have difficulty in healing. I'm throwing everything I can at that patient to be sure I avoid this type of complication because if it happens over an implant and you dehisced down to the level of implant, you have a major problem on your hands. Just take a look at few things that I have experienced through the years. Anybody been here in practice long enough to know that silicon is the material that has been used for implantation. I used many silicon implants in my earlier day.
Total implants, [Indecipherable] [00:09:59] with silicon mesh, hemi implants with silicon. The body doesn't like silicon in bone, doesn't like it in soft tissue. You get detritic synovitis. You look at the walling off of the stem of the implants, the engulfment of the implant. There is another type of procedure, great range of motion on the table. Six months later the daunt things don't move. They don't move because of in-growth, because of capsule that grows into the area, the synovium that fills that little groove that was created. Some people do well with that implant, but many have to have them removed and changed. Here is an example. This implant obviously did not allow for motion. It was painful. You see the bony changes on both sides of the joint. Here we are taking out the implant. Had to clean out the cavities. The implant silicon is walled off. You could take a curette and remove fibrotic tissue out of the canal of the proximal phalanx and distal metatarsal. I need to get that out because this is going to lead to effusion of great toe joint unless you want a little stub of the hallux by the time you are done. So here I used iliac crest from the patient, autograft, carved it to the side and placed it in the joint. I like hemi implants for hallux limitus rigidus where I'm not going to do effusion. It is an example of hemi implant. This was one of my patients. They came back about 8 to 10 years later. Said I'm having problems beneath my other metatarsals. Submet 2, 3. The range of motion of great toe joint, the position of the hemi implant perfect except we see there is a little shortening of that hallux. The first metatarsals are little short and now we got transfer lesion submet 2, 3. So observing metatarsal length pattern is important in your decision process of doing surgery as well. So here we went in and did wild osteotomies to shorten mets 2 and 3. Hallux varus, what a miserable complication. Here the patient wishes they had the original bunion deformity because the big toe is sticking out medially and up in the air and I have yet to see a shoe developed by any manufacturer that accommodates hallux varus, just not happening. And there is a number of etiologic factors. You can over correct an IM angle. You could put an implant in with angulation that could be problematic. You can remove a fibular sesamoid. And I'll tell you I rarely if ever remove a fibular sesamoid in bunion correction deformities. Here was an example of correction of hallux varus with an osteotomy of the head and we actually repositioned the re-angle D implant for the great toe. Here is another interesting case. It's amazing what goes through the minds of some people. What the hell somebody was thinking. This is a shish kebab of the hallux. [Laughing] Looks real good. You can park your car in there. You can put your chewing gum. I mean we got these implants for the lesser toes and they're breaking. Somebody had the thought process say, I'm doing something good for this patient as who knows martinis in the OR get you. Here is another patient, nice stable osteotomy, doing Austin bunionectomy or you do a head procedure. I think everything is great, early weightbearing. I got to tell you most of my Austin procedures, I encourage some weightbearing. I usually put two screws in the metatarsals. The location and the direction of the cuts is kind of basic and simple. It can't get any easier. It is the most stable osteotomy I have ever done on the metatarsal. I knew Dale Austin [phonetics] the gentleman who came up with this procedure personally. And when he first started doing, he said Harold, no fixation. You want to put a pin and go ahead. I'm impacting the metatarsal head on the shaft. It's cancellous bone in that head impacted. It's stable. It stays in position. You want to what? put a wire in there. Good. goodbye. No, we as podiatric surgeons realize that screws were invented for a reason. So why don't we screw the first metatarsal.
So we put two screws in the Austin bunionectomy which I happened to agree with by the way and it provides tremendous stability. Here is an example of one that actually cracked and broke with one screw fixation. It is early weightbearing. Of course you blame the patient. Told you not to walk on the front of your of your foot. You are supposed to walk on the back. It's tough to walk on the back of your heel. So you have to go in and repair. I had one case that I unfortunately don't have the picture to show you that. We impacted the head of the first metatarsal. And I watched the entire head crack and it was like a hinge. The cartilage at the first metatarsal was the only thing holding the two ends together. That’s when you go change your shorts and come back in and think about what the hell you did wrong. Now, you got to create major form of fixation and hope to heck the daunt thing comes together. But you are in cancellous bone. Cancellous bone is very forgiving. And this was what was done on that case but now you turn to simple screw procedure into something with a plate with multiple screws and hope that the patient understands what happened. I'm not going to do Charcot. Here is an interesting case. We have become experts in total ankle reconstruction, haven't we? I have always been a proponent that motion is life and that if I can maintain range of motion in particular joint, I want to be able to do that. That’s why I use as many implants as I use in the great toe joint. The ankle is a different animal. It's very complex joint. It's triplanar. It’s a joint that functions between the leg and the foot. The torquing kick conversion capability of the subtalar and midtarsal complex must function normally in order for an ankle joint to work. If you have degenerative arthritis of the ankle, do you think you have degenerative arthritis of any of the joint? You better believe the subtalar and possibly midtarsal are involved. [Indecipherable] [00:17:27] not the subtalar. So you torque conversion with every step that you take of internal and external rotation cannot occur. There is no torque capability in the foot. So where does it transfer to? the ankle joint. So when you look at the total ankle reconstruction and replacement, the confines and construct of that joint doesn't allow for transverse plane motion to take place. Now, we have a mobile bearing total ankle joint, no question. And that’s supposedly helps to alleviate some of that transverse plane motion from taking place. I have done a good number of ankle joint replacement and I'll tell you, you live with these patients for the rest of your life. Some do very well but many of them develop the typical ancillary complication as time goes on. My thought process has almost been now, do an ankle joint fusion because the patients do very well with the fusion. You could fuse an ankle, they still have possible some subtalar joint motion and the talonavicular bone socket joint now becomes the joint that gives you the dorsiflexion in the foot that you lose by doing the ankle fusion. So the complication rate is far less doing fusion. So let's take a look at the couple of these crazy cases. Here is one. It looks pretty good. When you look at this AP view, you see a little bit of clear space medially which I'm not too happy about over here. It looks like the edge of this implant is pretty close to the fibula. This carries doesn't look bad, but we are right up against the fibula and right there which I don't think you can see well is a fracture. There are two stirrup bones, the fibular malleolus and medial malleolus are frequently fractured intraoperatively. And precautions have to be taken even before you start a procedure to deal with that. I used to put pins right up the medial malleolus before I did any of the ankle works so I would not with the instrumentation knock off one of that medial malleolus because you're not going to get it back on very easily intraoperatively, so prepare for it. When we did lateral work, we often put a plate on the lateral aspect of the fibula especially with old Agility ankle to fuse the syndesmosis and provide a stability of the plate. Now, this young lady unfortunately, this looks good except when she walks she is external rotated and has marked varus. She has a subtalar fusion and mid tarsal fusion, so she's had triple and a fixed position of the foot and one unhappy camper. So what we did with this woman was I took off the fibular plate. We put a rod up the fibula so that we're going to have stability of this lateral component. We actually did an osteotomy, Dwyer calcaneal osteotomy to get the calcaneus out of varus which it was in an attempt to deal with the abnormal position. What we are eventually going to have to do is deal with this. This portion of the implant the talar component is too posteriorly placed. This patient has virtually no dorsiflexion. With the foot that’s higher arched in position, can't dorsiflex. You can't dorsiflex, you have to walk externally positioned. So this becomes somewhat of a nightmare for this particular patient. This was the osteotomy we did on the calcaneus to get it into a more vertical position at heel strikes so this patient doesn't walk to the outside. Nonunion, diabetes, smokers, noncompliance. I don't know if anybody smokes as much as they do in this country. It's amazing how after the industry got smacked for billions and billions of dollars because of cancer being produced by smoking, did that affect anybody? People smoke like crazy. Unfortunately, half of those people are in our office. And then we're going to do creative things. I wonder why the bone doesn't want to heal so quickly. Nicotine is horrible for bone healing. So nonunion can occur. There is no question. Here is a nonunion back here at this second met cuneiform articulation where Lisfranc fusion was attempted across here. This looks good, but now we got a mesh right in this region. Here is a good example, one of my patients. I did an Evans calcaneal osteotomy on this patient. I had done a translocation ostetotomy [Indecipherable] [00:22:58] with one of these Biofoam blocks, titanium. Everything was looking good until this damn started to push up. I had to go in and grind it down. I called the company. I said, listen I've got displacement of this piece, I don't want to take it out. What do you recommend we do to cut this to implant. No idea. I said, what do you mean, no idea. We never encountered this before. I said what would you normally use. They could not give me an answer. So I actually went in and just took a burr and burr down this whole thing. Now the other component of problem, take a look at this bottom because all the subsidence and radiolucency around the implants somewhat incorporated here. Now, this whole area is kind of irregular. So the best laid plans of mice and men went astray with me on that one, I tell you that. Here is another malunion nonunion -- sorry, medial malleolus. Got two screws, long enough. We got supposed compression, not doing what they should, here is another part of fracture on this side. Here is another nonunion. Just because we put plates and screws across joints that doesn't mean they fuse. Mike pointed out something critically important. The preparation at a joint in order to get a fusion, you got to get past the subchondral plate. You got to get to that bleeding bone and I like to see cancellous bone on both sides. That’s good bone. That has a chance to heal. Here is a goal they talked about just taking the cartilage off the joint so that you have good anatomic apposition and leave the subchondral plate. And then you're going to drill a few holes in there and that’s going to allow for all this in-growth, you got to be kidding me.
That’s the violation of basic principle of fixation and preparation prior to fixation. It has to fail. So when you do go into have these failures, you better be prepared to go in and clean as much bone out as you have to. You have to resect a nonunion site, get down to bleeding bone and if you have to put it into positional bone graft in there, you do it. Here is another example of one of -- this patient was referred to me from South Jersey. An Agility ankle six months postop. This patient had a number of things done by a surgeon, triple arthrodesis, got a plenty of hardware over there. There is no hardware deprivation down here. This is in place. This doesn't look terrible, but we got a problem with this fibular portion abutting up against here. Look at the lateral part of this implant abutting up against the fibula. So you got this plate on here. Do you think that’s going to hold the position. Here is what it looked like. Look what's happening. Tilting within the plate. The syndesmosis here looks good, but look at that, cracked right at the level of this implant. Pretty much a disaster with tilting in here. How is that going to ever function. [Indecipherable] [00:26:25] is going to break down completely. Eight months post medial malleolus stress fracture is what the patient develops. So this patient is not doing too good with this Agility ankle. We have angulation. We had a fractured medial. We have a fractured fibular malleolus, but the syndesmosis looks pretty good. And now, the foot is going into valgus, not good. And what do you see over here. Hardware is not going to prevent transformation of force. Here is the screws are backing out, the plate is broken. So we went in and did tension band on that lateral side, did an osteotomy of the calcaneus because she was in valgum with an external fix [Indecipherable] [00:27:17]. This was a high 5 in the OR, looking good, plates off, everything is back in position. I'm happy, it's looking good. Six months postop, not terrible. We are done. Talar dome collapse now. Now the talar component is driving right down into the talus still angulation, still see a little over here, medial malleolus ultimately healed. Now, what am I going to do? So we're not done. We went in and just revised the talar component. This is always something more we can do. This poor patient at the other end of the table. They have gone through all of this surgery and at this point you got to wonder is an amputation the ultimate answer for that patient. So when we talk about complications, we can go on forever doing it. And these are patients that are in our practice. I know you guys don't see anything like that. You don't have complications like that. But avoiding complications, compliance, pick your patients properly. If you suspect anything -- you have a patient that comes in and tell you I got fibromyalgia, I have had RSD, I am on Lyrica, been on gabapentin, but I'm hurting over here and I would love you to operate on me. Are you crazy, not today. Smoking. I have heard a lot of podiatric surgeon say they test their patients for nicotine and unless they're clear, they're not operating on them. Probably a good thing to do but I doubt whether most of us do that. PT adherence. Physical therapy. Are they going? Are they complaint? Do they go two three times a week, once a week? Don't worry I could do it at home. You're not doing anything at home other than eating and walking to the bathroom. It's not going to happen. Patients do not do PT at home. It's not happening. Comorbidity management. Make realistic goals, patient selection and never make promises. Never promise a patient. Believe me, I'm going to fix this for you. You're going to love it. Or I'm going to give you a new joint. No, the only joint you give him is if you live in Nevada or California. Now you can give him a joint. Thank you very much for your time.
TAPE ENDS - [29:57]