Minimally Invasive Foot Surgery Egg Harbor Township, New Jersey 08234

In the past couple of years Minimally Invasive Surgery (MIS) has become popular in most surgical specialties. For example, within general surgery, laparoscopic surgery is now mainstay. In orthopedic surgery, arthroscopic knee and shoulder surgery is very common. In foot and ankle surgery, MIS is becoming very common and popular. In this blog I will discuss some indications for these type of surgeries and the pros and cons as well.

How is MIS applied to foot surgery?

There are a few types of foot and ankle surgeries that traditionally are performed with MIS techniques. For example, ankle arthroscopy is commonly used to clean out arthritis from the ankle joint. In addition, ankle arthroscopy can be used to remove a talar dome lesion (which is a when a flake of bone gets detached from the talar bone). Traditionally, these 2 types of surgeries were done with large incisions and extensive healing time. Due to arthroscopic ankle surgery, surgery requires a few small stab incisions with a short healing time.

Traditionally, surgery for plantar fasciitis was thru a large incision. More recently it has been replaced with endoscopic surgery. This type of instrument is used to perform the surgery and requires one or two incisions less than an inch long. By using an endoscopic camera and appropriate instrumentation, podiatrist are able to decrease the size of their incision. In addition, there is less damage to the surrounding tissue with this type of surgery.

What are the advantages to this type of surgery?

The most obvious advantage is that with a smaller incision there is a significant reduction in healing time. If bony work is performed that will take the same amount of time to heal, but the skin incisions will heal in a shorter period of time. In many instances these types of surgeries can be performed in a same day surgical suite due to the MIS aspect of the surgery. This type of surgery may have less pain in the post-operative period.

What are the downfalls to this type of surgery?

Due to the fact that these types of surgeries require small incisions, some argue that it can be hard to visualize the appropriate anatomic structures to properly perform the procedure. This can be true in MIS bunion and joint fusion types of surgery. In addition, many times in these types of surgery using x-rays during surgery is typically required. This exposes the patient to more radiation than may be necessary with a larger incision. Some argue that due to small incisions, the surgeon may not be able to see all the vital structures and therefore, there can be damage to important structures during the procedure.

In conclusion, each patient and their surgeon need to discuss what type of surgery is right for them. In addition, there is more data and evidence that certain type of surgeries work better with a large versus small incision and vice versa. Appropriate consultation with your surgery prior to surgery to discuss these matters will determine whether or not you qualify for MIS.

For more information, please visit our website at www.footnj.com

Joint Fusions- Part II

In last week’s blog I discussed the details of what is entailed in foot and ankle joint fusion surgery. I discussed the indications, actually surgery and recovery. In this week’s blog I will discuss the pros and cons; I will also discuss when to decide whether or not to have this type of surgery.

What are the pros to joint fusion surgery?

One of the main pros to having this type of surgery is to decrease and hopefully eliminate pain. Many people have severe arthritis or disability from a trauma and have been suffering with pain for years. If this is the case then many times joint fusion surgery will help to eliminate the pain and decreased disability. Joint fusion surgery can help return a patient to a pain free life especially while weight bearing. Another advantage to having this type of surgery would be that most times fusing joints lasts a lifetime and there isn’t a need for a “re do” surgery.

What are the cons to joint fusion surgery?

With joint fusion surgery there is usually close to zero motion at the joint that has been fused. Many patients that have these types of surgeries already have significant decrease in motion in those joints, but by permanently fusing the joints there will be NO motion in that joint. This can be difficult to comprehend until after the surgery is complete. For example, fusing an ankle joint will make it almost impossible to flex the ankle. Fusing the big toe joint will make it difficult to crouch, lunge or go up and down a ladder.

Another disadvantage is that years later there can be residual arthritis that forms in the joints around the joint that was fused. Since the fused joint has no motion the joints around it tend to have increased motion, which may lead to arthritis in those joints.

How does this relate to Lori P?

As I mentioned last week our biller, Lori P., was in a severe car accident in April 2013. She had an open fracture, which is when there is a fracture in addition to bone that is sticking out of the leg. At that time the surgeon was primarily concerned about her losing her leg. When she was medically stable and it was determined that her leg was able to be saved she was in extreme pain. She had severe bone loss and SEVERE arthritis. At that time the decision was made between her and her surgeon that an ankle fusion would be the best option for her long term ability to walk. She went through multiple surgeries, a long recovery, including non-healing wounds and severe pain, but today she is doing great. She walks with a slight limp and on rainy days she complains of arthritis pain in her surgical area. When I told her I was writing this blog about joint fusions she said “the ankle joint fusion saved my life and leg, because of it I am able to walk, live life, work and most importantly, enjoy my grandson”.

For more information please visit our website at www.footnj.com

Fused Joints of the Foot and Ankle- Part I in Egg Harbor Township, NJ

Joint fusion surgery is not very well known about, so I figured I would use this week’s blog to discuss exactly what this produce entails. I was inspired to write this week’s blog because of our office biller, Lori P., who had an extensive ankle injury, and was healed via an ankle fusion.

What exactly is joint fusion surgery and when is it performed?

Joint fusion surgery is a surgical procedure where any joint in the body is fused together as one unit, typically using internal or external hardware. In my profession, fusing joints in the foot and ankle can be done via one, two or even three joints being fused at the same time.  Joint Fusions are usually a last resort treatment option for degenerative arthritis. Many patients suffer from painful arthritis (I have discussed at length in the arthritis blogs) and use many different medical treatments to help with their pain. When all conservative treatments fail and the patient is still in pain, many times the patient and their surgeon opt to fuse joints. Another reason why someone may need a joint fusion is due to trauma, rheumatoid arthritis, infection or other failed ankle surgeries.

What are common foot and ankle joints that get fused?

In the foot, the most common joint to get fused is the great toe joint. Many patients suffer with arthritis in the great toe joint and have significant pain with each step they take. After all conservative treatment has failed many patients opt for a joint fusion.

The ankle is another joint that can be commonly fused; usually ankle arthritis is due to a trauma years prior that did heal well. In the rearfoot (the back of the foot) the subtalar joint, which is the joint beneath the ankle, is commonly fused, to help with severe flatfoot/arthritis.

Keep in mind, whichever joint gets fused, a patient will have zero motion in that particular joint.

What is the recovery like after these types of surgeries?

These types of surgeries require a cast post operatively for approximately 6-12 weeks. During this time being non weight bearing is imperative. At the 12 week mark you will slowly be allowed to weight bear with a below knee removable walker. At this time you will begin physical therapy. Patients should understand that when they get a joint fusion there is zero motion in that particular joint, therefore the joints around that joint will take the brunt of the movement. This fusion will take time for the body to adapt to and physical therapy can help with this transition. Pain is common post operatively but your surgeon will make sure you are prescribed the appropriate medications. Preventing an infection is controlled with antibiotics. Good patient compliance is important to allow for these fusions to heal. Since this is a complex procedure preventing complications is important.

Next week I will discuss the pros and cons of joint fusions and relate them to our biller Lori P.’s ankle fusion.

For more information, please visit our website at www.footnj.com

Plantar Warts

What exactly is a plantar wart and how is it caused?

A plantar wart, also known as a verruca, is a form of the Human Papilloma Virus (HPV) that presents itself on the soles, or the bottom, of the foot. Plantar warts are caused by contact with the virus and they enter the skin through tiny cuts or scraps. Due to the fact that many of these viruses are microscopic they are usually present for a few weeks or months before they are noticeable. Many times warts get “pushed into the skin” and a new layer of tissue forms over the wart. This can cause pain with weight bearing, walking and exercise.  On the other hand, some patients have no pain whatsoever but notice a lesion on their feet.

How can a plantar wart be diagnosed?

A plantar wart is diagnosed via clinical exam.  Differentiating a wart from a corn is critical in treatment. Unlike a corn a wart will have small black dots in the center, which are capillaries or the blood supply to the wart. In addition the wart will have pain with direct pressure. Lastly, the skin lines that run on the bottom of the foot will wrap around the wart versus run through the corn.  

How can a plantar wart be treated?

There are many different treatment methods for plantar warts. Different physicians may have different techniques and protocols to treat warts. There are many different topical medications that can be used. Salicylic Acid is a common medication that can be purchased over the counter or prescribed by a physician. Canthrone, which is a beetle juice extract, can be used, which causes a blistering affect, and subsequent removal of the wart. There are different injectables that can be injected to the wart to eradicate the virus.

The warts can be removed via cryosurgery, or the freezing of the warts. Surgical excision, or removal of the warts, can be performed. Laser surgery, which has become more common lately, is another way to treat hard to cure warts.

In general, treating and curing warts is difficult due to the perseverance of the virus. Many of the options listed above take many weeks of treatment. Many physicians have a step wise approach to treating warts. I personally will use Cryotherapy on a younger patient, canthrone on an older patient. I will have the patient apply a medical strength Salicylic Acid during the 2 weeks between appointments. I will typically do 3-4 treatments. For the difficult to treat warts I reserve Laser therapy. Surgical removal of the wart has fallen out of favor due to the many different treatment options available. In addition, surgical removal would require an incision on the bottom of the foot, which is painful and takes a while to heal.

In conclusion, warts are very contagious, easy to contract but difficult to eradicate. Local care by a physician will close follow up and compliance is a great recipe to recovery. If you have a painful or non-painful suspicious lesion on your foot see a physician right away.

For more information, please visit our website at footnj.com

Charcot Arthropathy

When someone is first diagnosed with this disease their first response is “charcot, like a shark”. Charcot Arthropathy, is pronounced “shark-O” and has a French/German derivative.

What exactly is Charcot and who does it affect?

Charcot is a degenerative process of joints in the foot and ankle and can present in many different ways. It is a slow progressive process and usually presents itself with bones in the foot appearing to have fractures and dislocations. Charcot is a disease process where the joints of the foot and ankle have bony destruction. Charcot is caused by neuropathy, or a lack of sensation, which is primarily caused by Diabetes Mellitus. Other causes can be caused by Alcoholism, syphilis and other causes of neuropathy.

Charcot begins slowly but as the disease progresses it can appear similar to an infection. The joints of the foot that can are affected appear to be red, hot, swollen, deformed and perhaps have an ulceration. There are 4 different stages of Charcot. The first being Stage 0, this is a pre Charcot stage with minimal symptoms. Stage 1 is an acute stage, when a patient will present with the above mentioned symptoms including a red, hot, swollen foot. Stage 2 is the step down from Stage 1 and there is less redness, swelling during this stage. Stage 3 is a dormant stage and happens in between attacks/ Stage 1.

How is this diagnosed?

Diagnosis can be difficult because Stage 1 can represent other pathologies such as infection, gout or septic arthritis. Having neuropathy with Diabetes puts a patient with symptoms at high suspicion for Charcot. Diagnosis can be difficult because when someone presents to their physician with these symptoms the disease has usually been going on for a while. Diagnosis is usually by clinical exam but x-rays, MRIs and CT scans can be taken to aid in the diagnosis.

How is it treated?

Treatment is broken down into surgical or non-surgical options. During the Acute Phase/Stage 1 non-surgical options are the way to proceed. This includes a total contact cast, which is a non-weight bearing cast and doesn’t allow the foot to touch the ground. By using an offloading device it allows the joints to heal.  This phase of the disease can take many months and even up to a year to heal. Surgical treatment is recommended for Stage 3, which includes foot and ankle fusions and reconstruction. Not all patients are candidates for surgical treatment, since there are a lot of complications and a long recovery time from these surgeries.

What are the long term complications from this disease?

Even with early treatment and compliance this disease has flare ups. Flare ups cannot be predicted and as the disease goes on there can be increase bony destruction. As the disease progresses there can be a collapse of the foot with prominent bones that appear to be “sticking out of the bottom of the foot”.  This type of foot is known as a rocker bottom foot. At this stage certain shoes and orthotics can be custom made to help with support of this foot.

In conclusion, Diabetic neuropathy with Charcot can have devastating consequences for a patient. If you are a diabetic it is recommended to see a Podiatrist every few weeks to do a diabetic foot exam. Seeing a Podiatrist regularly can prevent some of these complications.

For more information, please visit our website at www.foonj.com

We are now on ZockDoc

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Arthritis Take 3

In this blog I will discuss a less commonly known type of arthritis. Psoriatic arthritis (PA), which affects 15-30% percent of people with psoriasis, can affect the foot and ankle. The skin disorder known as psoriasis is more common than the arthritis associated with it.

What are the symptoms?

PA is more common between the ages of 30-50 and it affects men and women equally. Like some of the other arthritic diseases we discussed in the past few blogs, people with PA can present with an array of symptoms. Systemically, patients can present to the physician being fatigue and lethargic.  Common symptoms are red, hot, painful and swollen joints. PA tends to affect the feet and ankles more than most other joints in the body. Patients can presents with large red toes, also known as sausage toes. Pain in the Achilles tendon and/or plantar fascia is a common symptom in this disease. Other common symptoms would be discoloration and separation of the toenails. In addition to have these symptoms a patient would have to be diagnosed with the psoriatic skin disorder in order to be diagnosed with PA. There is a genetic component to the disease, but there is little that is known about the exact cause.

Below are two pictures depicting the “sausage toe” and the separation and splitting of the toenail.

How do I get diagnosed with PA?

Just like some of the other rheumatologic disease, a Rheumatologist should be consulted to confirm or deny the diagnosis. There are no specific tests to diagnose a patient with RA, but other diseases can be ruled out.  A telltale sign to differentiate this disease from RA would be it affects the distal knuckles in the toes and fingers.  X-rays, MRI, CT scan or Ultrasounds can be performed to assess which joints are affected and the severity of the disease.  

How do I get treated for PA?
Just like the other rheumatic diseases, anti-inflammatory medications and the disease modifying antirheumatic agents are the common ways to treat it. Locally, corticosteroid injections into the affect joints can be performed as well. Exercise is important so that joints do not get stiff and cause long term disability.

This concludes the series of arthritis and the lower extremity. In conclusion, there is a lot of overlap with the symptoms and diagnosis of arthritis in the lower extremity. You should not ignore symptoms and should see a physician as soon as possible.

For more information, please see our website at www.footnj.com