IF YOU HAD TO HAVE SURGERY – Part 2

IF YOU HAD TO HAVE SURGERY – Part 2

 

 

IF YOU HAD TO HAVE SURGERY,
WOULD YOU PREFER A BIGGER OR A SMALLER INCISION?
Part II

by Dr. Jay C. Goldstein

 

 

WOULD YOU PREFER A BIGGER OR A SMALLER INCISION?

PODIATRY COMES FULL CIRCLE (ALMOST) AND WHY YOU SHOULD CARE

In the last article we discussed that many years ago, some podiatrists did surgery through small incisions, often in their office using local anesthetic.

They were often derided for not making big “man-sized” incisions, and using screws and plates and pins to “fix” the bones in position.

As time went on, surgeons decided maybe it was not so wonderful to make big incisions (which have the benefit of being able to better visualize structures) that require more dissection and therefore the potential of causing more tissue damage.

In many cases the small incision procedures could be performed faster, with less operating room time and less anesthesia time required, all of which are positive, but only if the results are at least as good as the more “open” procedures.

In some cases the smaller incision procedures lead to faster healing. This philosophy is being adopted by all types of surgeons, often aided by technological advances.

The key concept in the above paragraph is that the best aspect of some of the small incision procedures is that they can lead to faster recovery, sometimes with results as good or even better than more “open” procedures, but are only appropriate if the results are at least as good.

What that means is that in today’s world, some procedures are best done through small incisions, but others still require larger incisions in order to visualize and deal with more bone and tissue, or perhaps because those screws and plates are needed for that particular procedure.

In other words, smaller or bigger depends upon what needs to be accomplished, and that is something to be discussed with your surgeon.

Hopefully, this means that your surgeon is adept at performing both types of procedures, and therefore can help choose the procedure that is best for your problem.

 

IN PART I OF THIS ARTICLE, WE DISCUSSED NEUROMAS

A colleague developed a “small incision” procedure for a relatively common foot problem known as a Morton’s Neuroma.

The premise of his procedure was that instead of cutting out the nerve mass, it was as good or better to only decompress the nerve.

He then created some instrumentation to decompress the nerve through a one-half inch incision.

It requires much less dissection. Healing is faster.

The results are similar to the more open procedure that requires more dissection and takes longer to heal.

 

WHAT IS A BUNION AND DO YOU HAVE ONE?

 

Bunions are malalignments of the great toe joint that can be recognized by the great toe drifting toward the second toe and a bump developing at the inside portion of the big toe joint.

Since the bones are not in alignment, it is not surprising that the cartilage begins to erode, resulting in osteoarthritis. This can be painful, and usually gets worse over time.

Conservative treatment for bunions may consist of better fitting shoes and custom biomechanical foot orthoses (orthotic devices). Sometimes patients have waited too long, and it is too late for conservative treatment to help.   Depending upon age and symptoms, surgery may be indicated lest the cartilage erode more and the symptoms increase.

There are many different procedures to correct a bunion, depending upon the age and health of the patient and the degree of malalignment. The vast majority of procedures, in order to properly correct the problem, require a surgical fracture (osteotomy).

In 1991, a podiatrist with whom I had studied as a resident, published what may be the earliest major paper on performing a bunionectomy through a small incision. Since then, this subject has been studied extensively, primarily in Europe.

Recently, a colleague from whose expertise I have benefited over the years presented the results of about 250 such procedures. The results were quite favorable, but not just because of the smaller incision.

In my opinion, the degree of correction, faster healing, and superior postoperative range of motion are even more beneficial than the smaller incision. It has become my favorite bunionectomy, of about seventeen different types that I do or have done.

 

NO SURGERY IS PERFECT!

I am quick to tell my patients that the only procedure that I perform with a certain “success” rate are amputations (only performed for problems such as gangrene when there is no other option).

Thus, you, the intelligent reader, should always inquire about conservative (non surgical) options, along with the pro/con of each. Sometimes surgery is best, and sometimes it is not.

If surgery is the best option, perhaps a small incision procedure has been developed for that particular problem. If so, it is worth discussing with your surgeon.

 

Dr. Goldstein is a podiatrist who is Board certified by the American College of Foot and Ankle Surgeons, the American Board of Podiatric Medicine, and a Fellow of the American Society of Podiatric Surgeons. He is a member of the American Podiatric Medical Association and the American Society of Podiatric Sports Medicine. He has run about 34 marathons; if his brain had not bounced up and down so much he could probably remember exactly how many, a problem not likely to be helped by any size incision.

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