IF YOU HAD TO HAVE SURGERY – Part 3

IF YOU HAD TO HAVE SURGERY – Part 3

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

In the last two articles 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.

 

IN PART II OF THIS ARTICLE, WE DISCUSSED BUNIONS

The first major article on bunions done through small incisions was done in 1991 by someone with whom I had the pleasure of studying.

The concept was picked up and developed throughout Europe, and then made its way back to the U.S.

It has become one of my favorite types of bunionectomies.

 

THEN I DEVELOPED AN INGROWN TOENAIL

As Gilda would have said, one thing led to another.

I needed to have an ingrown nail removed permanently. (If not permanently, it would have recurred.)

Unfortunately, although the incision was small, it split open, which delayed healing and caused additional discomfort.

 

IS THERE A BETTER SOLUTION?

What if the procedure could be done without any incision through the skin’s outer layer? How good would that be?
As it turns out, it would be very good.

A podiatrist from Ohio by the name of Dr. Ray Suppan developed a nail procedure in which the blade is inserted under the cuticle region after removing the toenail.

Thus, there is no incision through the outer layer of skin, which is fine because that layer does not contain any nail root (matrix) cells.

Then the blade is used to excise the deeper layer containing the cells (nail matrix) that cause the nail to grow.

Some podiatrists then use sutures. I believe it is better to omit the sutures.

The fact that the outer layer of skin is not incised means that one does not need for this layer to heal (albeit the deeper area that contained the matrix does require time to heal), the nerves and blood vessels in the outer layer are not disrupted, and there is no scar.

 

In the picture on the left (before treatment) , the patient was in pain because the nail was very incurvated.  The edges were digging into the tissue, causing swelling, redness, and drainage along both edges, which were infected.  Therefore, both edges were removed.  The patient was seen again a few days later (picture on the right), by which time the swelling, redness, and drainage were almost completely resolved and the patient had almost no remaining pain.

 

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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