A more developed companion website can be found as address below, recommended as a starting point:
JP Driver-Jowitt is a surgeon with wide experience across the entire field of orthopaedics. He spent much of his professional career in vertebral management, and now has a special interest in the foot and ankle.
He ha
s been registered in many countries, including the United Kingdom, Ireland, Malta and Zimbabwe with decades of experience in five continents. These include the National Health Services of United Kingdom, Canada, New Zealand and others. He has been a Professor of orthopaedic surgery and has held posts as a teaching hospital consultant as well as with the armed forces, and a dedicated private practice. He has worked extensively in underdeveloped countries, with wide experience of battlefield and other trauma.
Comments or enquiries are welcomed: large volumes of requests are received which means that questions which have earlier been addressed will not necessarily receive a response.
Dr J P Driver-Jowitt 
I have? hammer toes. 59 year old female.
Is it possible to have these operated on without a general anaesthetic?
How does one obtain a referral.
I routinely use regional anaesthesia for all the foot surgery which I do. I cannot understand why regional anaesthesia is not used universally for foot surgery.
My diabetic insulin dependant husband good blood sugars age 76 has a 12 month old foot ulcer he has it dressed 3times a week he doesn’t want to loose this leg as well any surgestions please Annalea1945@icloud.com thank u
Where is the foot ulcer? Is it in the sole skin? If so I will have some suggestions.
How would you know or what would i feel if the screw on my ankle where to be infected?
Pain is the commonest presentation. However intermittent temperatures and a general sense of malaise can also be expressions of infection.
I have broked elbow last year and now its exact one year for surgury.i had a humerous fracture totally broken and had a dislocation and a crack in ulna bone and all were fixed by two plates and appr.20 screws and one lag screw.now one of the plate have came out from the skin left side from left elbow.and i feels that my radius is liyyle bit moving when i work.now one of the doctor told me that all hardware will be removed.
So please can u give me an advice that what should i do and its very iritable.
And if u say i will send u the xrays.
Please send the x-rays (jpeg) to jpdriverjowitt@gmail.com
My husband (now 70 years old) had surgery to fix a broken hip in 2010. He broke his femur and now has a screw through his hip and a plate along the bone. Ever the since the operation he has been in pain which varies from a dull ache to very painful when he walks. He saw the local hip surgeon earlier this year, who said that from the x-rays there was no problem at all with the hip, it was one the best he had seen. He wrote in his report to our GP that he had explained to my husband that he can’t expect to be as good as he was before he broke it and that the pain wasn’t adversely affecting his lifestyle. This is not true as Jack can’t walk any distance at all without having to sit down because of the pain. Also he can’t get up steps without a handrail. Running or any activity apart from a short very slow walk is out the question. If he fell he would struggle to get himself off the floor. It can’t be right that he is expected to live with such pain for the rest of his life. Something must be causing this pain. When he first had the operation the surgeon who did the op told him that within 2 months the bones would heal and he would be pain free. What do you think? I would appreciate your advice on this and if it is normal for somebody to be in constant pain 5 years after an operation.
You are correct. There is no reason why your husband should not be free of pain and have function (if not perfect) which approaches his function before the accident.
From this (electronic) distance I cannot diagnose the cause of the pain – there are many potential causes. If nothing more specific can be found then it would be reasonable to remove the implanted metal. Then, and only then, should he is still incapacitated the possibility of a nip prosthesis must be considered.
Last year I broke my ankle when I lost my footing at the landing of the stairs. My injury/surgery/recovery was further complicated by the fact that I was 28 weeks pregnant at the time of my injury. I nada Right Bimalleolar ORIF ankle surgery several days after my injury. I currently have a plate and six screws on the Fibula and 2 large screws on the other side. Due to chronic pain, inability to regain full range of motion, discomfort when the area is touched, perturbing hardware (you can literally see my hardware on both sides with my ankle at rest, it is more obvious if I move my ankle from one side to the other), and pain/numbness of the upper portion of my foot; I sought a second opinion about hardware removal. He said he wasn’t quite sure why my previous surgeon used the size hardware that he did but it seem too large for my frame. Surgeon recommended removal of all hardware but one screw (in X-rays it appears to be floating near the fibula, which I know is not the case) and exploratory surgery to try to find why feeling has not returned to the top of my foot. I have 3 children (ages 4.5 yrs, 23 months, & 8 months), I’m a high school teacher (always on my feet), and a varsity cheer coach. I trust this doctor very much but I felt that I got some vague answers to my equations. I’m very active.
I really want to know if this surgery will help me regain my range of motion? Will I be able to sit criss-cross again (currently if I sit criss crossed on the floor with my kids the pain is unbearable)? Will the area stop hurting from the slightest touch? Is the possibility of permanent nerve damage real (I cannot feel part of my foot but it feels superficial, as if only the top layer of skin is effected)? Could exploratory nerve surgery potentially cause more harm than good? And what can expect post operatively? I know these are quite a few questions and understand if you cannot answer them all. Either way, thank you for your insight and your words on this site.
My interpretation of your letter is that at least some of your pain arises from prominent screws which are palpable through the skin. If so that part of your pain / tenderness is likely to be improved by removal of the metal (perhaps under local anaesthetic).
“Exploring” nerves is often not wise, and can worsen matters. An accurate assessment of nerve damage can be made clinically (by a knowledge of the area of skin supplied by particular nerves, and other techniques such as blocking individual nerves with accurately placed local anaesthetic.) Electronic nerve conduction tests are also useful.
These tests are usually the realm of a neurologist.
At this stage I cannot help you more, but I would like you to send me photographs of the position of the scars, which will give me a far better idea as to which nerves are damaged. Could you also draw on your foot (for a second set of photographs) the numb and painful areas (for example use dots for the numb areas, stripes for the painful areas)
Also, I’m curious if the heat on my ankles is normal. The “Binet”
Part of my ankle gets very hot from time to time. Thank you again for your help and quick response Dr. Driver.
The warmth of your ankle to the touch is of concern, and if that warmth has coincided with increased pain, infection must be excluded. Please demonstrate the warm area to your surgeon.
our comment is awaiting moderation.
May 18, 2015 at 7:40 pm
Dear Dr Driver. I have had 2 ” problems ongoing with left hip. Firstly I had a CT scan for some other reason back in September which showed up the operation I had when I was 8 for perthes and the bone graft. The drs thought it was a tumour so I was sent to see Orthopaedic surgeon who checked my Xray records did blood tests and MRI scan finally back in December. This showed tumour very unlikely and was repeated last month same result I am repeating Xrays and blood tests in 12 months. This was the MRI scan which reported the “T b/g e” finding which I was not told about until 2 weeks ago. In the meantime I had been getting very stiff and painful in the left buttock/hip area and my hip kept feeling like it was giving way occasionally when weightbearing – I didnt fall just felt a painful snapping. As I had previously had a piri formis following running I thought it was the same and was doing stretches for that. When I found out what MRI said I was v worried that been doing wrong exercises. I am 59 and (usually) walk a lot(dogs) up until recently also running and falling over (3 knee arthroscopies) I do yoga and zumba.The op when I was 8 was a huge incision and left that leg very slightly shorter (not noticeable in everyday life) The aching I am now getting in hip particularly at night is very tiring and I feel very down about it. My GP told me I could get an injection for it and I asked to be referred to have an image guided injection. Have not seen the radiologist yet. Meanwhile I am getting treatment from osteopath with advice on exercises (very mild) and sleeping with pillow between knees etc taking NSAIDS and Turmeric. If you have any advice for me I would be very grateful for any help with this.
Matters are now getting more complicated.
Perthes “disease” is unusual in females, and (by today’s standards) early bone grafting for that condition is unusual. I therefore wonder if you had an acetabuloplasty. Or perhaps you had an attempted “re-vascularising” bone graft of the femoral neck?
I say all this to emphasise that you do not seem to have had a precise diagnosis yet.
I also emphasise that good “diagnosis” is the product of a good diagnostician. Scans, X-rays and “blood tests” seldom give a diagnosis. Instead these tests (at best) contribute to the assessment of the diagnostician.
Your pain might not be arising from the trochanteric region, despite the apparent MRI findings.
I had an accident when i was 16 years old and as a consequence i had plates inserted to my tibia and fibula. I am now 25 soon 26 years old and I would like to know if these plates can be removed. I do not necessarily feel them coming out or any major problems with them but if I find myself being a little restricted as I don’t really run/ walk too fast. This thing is foreign to me and as I become older i am more concerned about removing them. However, I was told not to remove them if its not giving me problems. I want them out if it is possible.
I regard the distaste for “foreign material” implants as valid as (and a variant of) body image. Thus the aversion is as valid as aesthetic aversions.
Because of that I regard requests for removal of implanted materials as valid reasons for removal – assuming the risk / benefit ratio has been understood by all involved.
I suggest that you put this premise to any “reluctant” surgeon.
I just received an e-mail from a new post and remembered my son’s injury. I want to thank Dr. J P Driver Jowitt!!! You gave me such peace in a very difficult time!
My son had a second surgery in which the doctor took out all the metal – rod, screws, etc…. He is doing SO MUCH BETTER having these removed! Thanks so much for answering all my questions during that time! Very much appreciated!
I just re-read all the answers which took a considerable amount of time to answer! So amazing that you would answer and care about someone you don’t know! 🙂
I want to publicly thank Dr. Driver-Jowitt for the information he provides. It is remarkable that a doctor of his stature presents expert information without selling products. I am grateful for his efforts and all the time he must spend doing this. Thank you, Doctor.
I looked up compartment syndrome on the internet. Would this be an easy detection for the doctor yesterday? or is this something that continues to progress? Example the more numbness and tingling he is experiencing in his toes? I’m very concerned. I saw where they can do blood, urine tests and pressure tests. What should we do? On the internet I saw where the problem was more in the leg not the foot. Jared’s swelling is on the ankle of the foot.
His fractured fibula was five inches above the ankle, with likely much impact on the soft tissues. At that level it is possible to have a compartment syndrome. The tingling / numbness of a compartment syndrome are most likely in the first day or two, but can persist.
I hope your not tired of hearing from me! We decided to change doctors to one with much more experience and specialty of the foot and ankle. We feel better about our decision. Waiting the extra week gave us time to research. We meet with him on Monday and hopefully surgery next week. However, the last couple of days JP, my son, has had night sweats and a low grade fever. Is this normal? The first hospital visit in the emergency room put a support cast on his leg no cleaning of the leg. Then when we visited the doctor on the following Monday there was a small scrape that they cleaned and put something on it and re-supported his leg with a partial cast. He doesn’t move much and keeps his leg elevated with ice. Not sure why he’s not feeling well? He did stop taking the pain medication on regular 4 hour intervals. His pain was not that great – it aches. I told him the medicine was as needed, but he thought the doctor wanted him to take if every 4 hours. Now he’s taking the pain medication once a day to help sleep. Could stopping the medication quickly have effects? I’ll be so glad when we can move on with this! It has been a very stressful week!
A temperature after trauma does not necessarily imply infection. Collections of blood (“bruises”) can raise body temperature, as can thromboses in the veins.
Thank you for your quick response! I wonder about the ligaments that were torn in his ankle. The doctor said they do not repair those anymore that letting them scar has the same outcome as repair of the ligaments have had in the past. Is this accurate? You also, mentioned delayed management, as one of your philosophies, but I’m having trouble finding information on what kind of delays? Such as when is it best to have a fracture surgery after the injury? One more question: My son is taking pain medicine every four hours. Should I be concerned about the type of pain medication and the length of time he is taking this? He is on Norco 325 mg. It has been 5 days since his football injury. I wished you would do my son’s surgery! I would feel much better! It is not easy trying to find someone that has the same type of experience and who really cares enough to dig deeper into what is best practice based on the “uniqueness” of the patient. Thanks again!
“Repairing” ligaments was always a fatuous ritual.
Ligaments cannot be repaired, they can only heal. Does operating help the healing? There is no evidence of that. What happens, instead, is that the surgery interferes with the regional blood supply by cutting (i.e. damaging) even more tissues, and so adding even more swelling and inflammatory response. The ligaments are usually shredded, and any form of secure mechanical reconstruction is impossible. Those surgeons who did operate could have seen, and should have known, this to be the case. Instead they performed a perfunctory idealization of what the patient wanted to believe – that they were being repaired, in a fantasy parody of a mechanical repair to machinery. Then the incised skin needed to be opposed, with more puncture wounds and (usually) tight sutures. As the swelling followed, these sutures became even tighter, with more tissue damage, more risk of infection and more pain.
Even the idea that the tissues were being “put back into the right place” is wrong. The volume underneath the skin cannot do more than accommodate the tissues in their anatomical sites. Providing skin, bone and joint are intact, these tissues cannot move more than millimeters, which is inconsequential, and a very acceptable trade-off against open surgery.
The ligament sutures, tied tightly around living tissues, strangled the blood supply within the ligament, causing more dead tissue, introducing foreign material, more to become rancidly infected, more pain and, and less living material to partake in the healing mechanisms.
What would worry me more than the dose of analgesics your son is receiving is why he still has such sever, extended pain.
[ligament “replacement”, “substitution”, “re-routing”, “augmentation”, “creation”, are a different domain, usually elective surgery, but which also demand critical appraisal]
I asked my son about his pain. He said it aches a lot after the medicine wears off and he can’t sleep. He can’t sleep with the medicine until he becomes exhausted, which usually isn’t until morning when he finally falls asleep. He doesn’t move much right now. He only uses his crutches to the bathroom. He is tall and lean: 6’5, 215 lbs. He is waiting on surgery, but most likely not until next Thursday because of the blisters on his ankle. The doctor said there would only be a 20% chance of having to open the ligament area up; which would only happen if the ligaments were under the bone and he couldn’t line the fibula properly. But, he wasn’t comfortable operating until that area healed more just incase of infection and the cut site not healing well knowing the soft tissue is severely damaged in the ligament ankle area. However, after reading your response, that doesn’t sound like that could happen? His skin, bone and joint are intact.
Another concern I have is knowing in the past my son gets keloid scarring. Will this effect his healing and mobility?
Thanks again for answering my questions!
An injury to a limb is usually described in terms of which bone is broken, “I had a fractured tibia” and similar. This is because the most graphic X-ray display is of the bones. However, it is never a broken tibia: it is always a broken LIMB.
At times the soft tissue damages (seldom shown on X-ray) are the most important injuries. This is because the functional, dynamic, machinery of the limb is the soft tissue. The bone is a relatively inert, passive accomplice of the soft tissues. At times the most important long term complications are in the damaged soft tissue, such as fibrous shortening of soft tissue following a “compartment syndrome”. If pain persists it is imperative to constantly re-visit and reconsider the reasons for this.
Keloids exist primarily in particular parts of the skin : It is unlikely that this tendency will interfere with the recovery of the limb injuries.
My son recently had a football injury, blew his deltoid ligaments and broke the fibula about 5 inches from the ankle. We talked with his orthopedic surgeon about removing the screws connecting the fibula with the tibia. He said it wasn’t necessary, but he could take them out in 12 weeks. I said I had been reading and thought 6 weeks would be better to avoid them breaking off in his leg. He said that would be too soon that the ligaments would not have had time to heal. I also asked about removing the plates and screws. He said he would not do that that it opens him up for infection and the nerve could get damaged which were unnecessary risks. He said if the plate was closer to the ankle that might be different because the plate is closer to the surface of the skin. I respect your experience as I have been reading on your site. What would your response be to this doctor? My son’s surgery was postponed a week because of blood blisters from the injury in the ligament area.
All surgical decisions depend on variables of context which include (at least) the uniqueness of the patient, type of injury, parallel illnesses, surgical know-how, available medical resources, and finance. Because of this I cannot reconstruct any idealized approach from a distance. All I can usefully contribute is what I regard, in my context, as “basic principles” (which comes to mean science based learning) into which I try and meld empirical experience. Surgery can never be an arena of “absolutes” and (heaven forbid) a rigid algorithm of tick boxes. Much of my philosophy, such as delayed management of fractures, and the removal of metal implants if good reason exists, you will already know from other comments. Regard a surgeon of rigid dictums with caution.