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Rethinking orthopaedic and forefoot surgery.

This post continues the page Stop! Wrong way! in relation to orthopaedic management

Deformities of the forefoot. These include “bunions”, Morton’s “neuroma”, clawed toes and “flat foot” (whatever that is intended to mean). It is unlikely that any group of elective procedures has been performed, in total ignorance of the causative factors, more often, by more people, in more ways, than various forms of surgery to the forefoot.

Fractures being “set” as soon as possible after the injury. This damaging policy produces significant, irreversible, complications. It will be addressed in a separate post on this site at a later date.

Finger-tip injuries. These common injuries produced a plethora of surgical treatments, from skin grafts and”rotational flaps” to “cross-finger flaps”. These required not-inconsequential surgery, sometimes under general anaesthetic, were expensive and incapacitating for various periods, and unnecessary. Harvest was taken from uninjured areas of the palm and other fingers, scarring those. The best results however have been shown to be obtained by doing nothing beyond usual wound care! The body’s capacity to heal itself at that site is not unexpected, being as easily and frequently injured as the fingers are.

“Traction” for so called “slipped discs” (mostly that diagnosis was incorrect, in the event). Tens of thousands of patient-days were lost by placing these unfortunates in hospital and attaching weights by cords to their legs, literally tethering them to their bed for days or weeks. This was entirely ineffective since the friction of the legs prevented transmission of any “traction” to the discs. The management was adversely effective, since most low back pain improves more rapidly with movement (ideally in water). Deep vein thrombosis would be expected to be increased by this form of immobility. I wonder how many died of resulting pulmonary embolisms.

 Osteomyelitis. Antibiotic usage and aggressive resection of bone is often counter productive and dangerous. The loss of the limb might result from some current management policies. This is addressed in a separate post on this site.

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Broken leg!

Breakages of the tibial shaft are often tragic injuries. Relatively common, they often occur in the young and active, often the bread-winner with a young family. The convalescence is long, often harrowing and at times results in the loss of a leg.
It is only the shaft breaks which are so distinctly different. Breaks of the tibia near the knee or ankle, although challenging to the surgeon, nevertheless follow the relatively predictable course of other breakages. Tibial shaft breakages are different from other long bone breaks and are notorious for the following triad of serious complications.:

1. The bone easily breaks through the skin because of the closeness to the skin.
2. These breaks are prone to develop infection (osteomyelitis).
3. These breaks are prone to delayed union, or fail to unite.
“Conventional wisdom” has traditionally sought to explain the behaviour of tibial breakages as follows:
1. The skin breaks easily, therefore the wounds become contaminated at the time of the accident
2. Contaminated wounds cause infections.
3. Infections cause the delayed union or non union.
This “wisdom” then dictates that the contamination requires immediate treatment, and it is claimed that if the infection is prevented or treated early enough, all will be well. Is this true? Why then is there such a problem, and why are limbs still lost?

The management is often less than optimal because this “authoritatively” held rationale is fallacious. This is demonstrated by the following:
1. Tibial breaks in which the skin is not damaged also become infected. This is contrary to the normal resistance of non-injured bone which, in the adult, is remarkably immune to infection.
2. Impaired union also occur without infection.
Therefore there must be another explanation, and an additional factor operative.

In fact there is, something that has been long known, but now not considered by some. This is the unique blood supply to the tibia. Because the cortex is so thick and dense, the major part of the bone of the distal tibial shaft is supplied by “endosteal” vessels. Usually only a single artery gains entry through one (occasionally more) “nutrient foramen” into the marrow cavity. This is a small hole in what is otherwise a solid and strong bone. When the tibia breaks it might do so through that perforating tunnel (not unexpectedly since it is a potential weakness in the bone) the site of the nutrient artery. The fragments displace, and this vulnerable vessel is easily torn. Once this happens a large part of the tibia is deprived of its blood supply and could die.
Well known analogies are breakages of the scaphoid and femoral neck, where the blood supply is often damaged with resulting impairment of union.
In addition to the endosteal supply tibia has a lesser blood supply from the surface (not the marrow) of the bone, via “periosteal” vessels. However these, also, can be damaged directly by trauma or indirectly by “compartment syndromes”, or (tragically) ill designed surgery. The analogy here is with injudicial surgical “stripping” (destruction) of the periosteum in the process of plating the bone. This also causes bone death, which is followed by loss of resistance to infection and loss of capacity to unite.

It is this dead bone, like all dead organic matter, is then becomes vulnerable to becoming infected by organisms which are in or on the body, and which might be transported by the blood stream. Certainly some infections are introduced by breaks in the skin, but it is the death of the bone which allows the infection to become established, and resistant to treatment. That will explain why the infections in broken tibias can occur after a delay, sometimes a considerable delay. It also explains why non union occurs, which is because dead bone does not have the vitality to unite. Natural healing tendencies do cause new blood vessels and new bone to try to grow into the dead skeleton and so re-vitalised it. Therefore, at times, even when the tibia is dead, and perhaps infected, union might eventually occur.

However the absence of early radiological evidence is not surprising; unless there is a blood supply the calcium and other minerals cannot “wash-out” and become radiologically identifiable. But once bone regeneration occurs (usually via the periosteum provided this has not been destroyed surgically) new bone becomes apparent radiologically and the well recognized “involucrum” can be seen. As newer blood vessels invade the dead bone, then the mineral is resorbed, fragmentation becomes possible and this dead bone separates as a “sequestrii”. At some stage after a tibial break spicules of bone (caused by the break or perhaps surgical reaming) can, not unexpectedly, be expelled, as reparative secretions tend to wash out inert debris.

What is the evidence for this hypothesis?
1. The vulnerability of the blood vessels is supported by long established anatomy.
2. The portions of the tibia near the knee and ankle have a different, less vulnerable blood supply, and do not have these complications.
3. Dead bone is demonstrable at surgery.
4. In order to produce osteitis experimentally in animals it is usually necessary to introduce a “sclerosant” to kill the bone at the time of inoculation with the bacterial infection. Living bone effectively resists infection.
5. Radioisotope labels do not label dead bone, and this has been shown to be the case with infected and non-uniting tibial shafts
6. Radio isotope labeled white cells can be shown to attach to infected or non-uniting tibial shafts, reaching the bone, not through the blood supply, but by migration.
7. Intravenous antibiotics are less effective in the management of tibial infections (because of poor blood supply) than antibiotics administered by lavageing fluids, an alternate route.
8. Compartment syndromes, common in tibial injuries, are known to interfere with the periosteal blood supply, which could otherwise supplement insufficient endosteal supply.
9. Surgical “reaming” for fixating intermedullary nails has been shown to cause a higher infection rate. This is because the endosteal vessels are further damaged, and aggressive reaming can burn the tibia with further death of bone.
10. The analogies with other bones.

Recognizing that the primary cause of the complications of tibial shaft fractures is a failure of the blood supply has important relevance to the treatment of tibial shaft fractures, particularly where infection and delayed union develop

Noxious placebos

Placebo, originally meaning “to please”, has come to mean applications which are believed not to have a known biological effect. Since these applications (“placebos”) are assumed to be “inert”, and specifically not harmful, they have been used as a standard against which planned biological manipulations (“treatments”) can be measured objectively. In this way placebos are perceived to satisfyingly demonstrate a cause and effect chain from treatment to benefit

 

However, although having no rationale, placebos themselves can produce a subjective sense of benefit. The reasons are not understood, but could include the effect of having been a centre of attention, or a mystical belief that some type of interference or intrusion into the soma must have a potential benefit. Intermediary pathways have been demonstrated with changes in dopamine and the endorphins and activation of brain areas demonstrated by imaging.

 

Although these intermediary phenomena are interesting as correlated observations, they do not advance any comprehensive explanation of the linkage between cause (application/placebo) and benefit.

 

Subjective reporting by the patient is often used to measure the benefit of treatments. In some of these cases it may not be possible to distinguish between the benefits of placebo versus planned biologically manipulation (’treatment”).

 

Let us now consider applications (“placebos”) which have no comprehensible therapeutic value but are neither inert nor benign. There are many historical examples ranging from trephination and blood-letting to purging and emeticism. Many of these “non-benign” applications persist contemporarily, such as excoriation by witch doctors, bee-sting therapy, piercings and many more. While it will have been clear to all that these treatments were harmful, with obvious damage or perturbation to the body, they must also –in the long run- have been perceived to have been beneficial to have been continues. These forms of irrational treatment must be assumed to have placebo mediated (“placebo effect”) benefit, either objectively or (more likely) subjectively.

 

Some, no doubt, have their benefit more at a societal level than at the level of the patient. By this I mean that the beneficiary is a group, rather than an individual. Procedures such as trephining could have appealed to the bystanders (as a group) as a “Don’t just stand there, do something” action, or alternatively as a protection to society by ridding one of its members of evil. (The evil will have been in the form of “spirits”, since the expectation was that the spirit was imperceptible, and therefore the release was not expected to be perceptible). Human sacrifice, judicial hanging and suicide bombing may well have been the extreme expression of a placebo producing a societal benefit.

 

Where physical damage occurs, a biological response (and perhaps a psychological response, if a distinction exists) is to be expected. Pain will produce a humeral and neurological reaction, as also would loss of body fluids or extreme temperature changes.

 

I will call these noxious placebos.

 

If one progresses to formal surgical assaults, it seems likely that such placebo effects should also exist in that domain. This would be expected to be particularly so where the motivation for surgery is more subjective than objective, and where the measurement of “success” is a subjective evaluation. In these circumstances the objective measurement of the surgical benefit might be highly distorted. [See page “Is conventional forefoot surgery proven as beneficial”]. If this is the case it will invalidate most self (patient) reporting scales of benefit.

 

I am concerned that many areas of surgery of the foot might fall into the category of noxious placebos. This is because the rationale for many surgical procedures on the forefoot is obscure. Further, a single surgical procedure might be claimed to have a benefit for a number of anatomically distinct problems [see page “Weir 2”].

I am concerned to read about the high number of complications which occur, and yet the patient (and by extension surgeon) rating of the outcome is “success”.

 

Finally, the web has many diaries of people who have undergone surgery, and suffered extreme and prolonged discomfort, sometimes multiple surgeries, and although yet to recover are already “pleased with the outcome”. One example, amongst many, is man who is “Happy with the results…so far” below…

 

Junior Member

(male)

 

Join Date: Jun 2007

Location: New York, NY, USA

Posts: 31

Re: Flat Foot Reconstruction Surgery–Share your advice & experiences please!

Just a quick update from me: I saw my surgeon yesterday, the foot looks good and he’s cleared me to start physical therapy! Any advice on what I should be expecting? I’ve been pain-free for a while but I know that’s going to change as I start to put weight on it again. Basically he said that the next 2 weeks I go to therapy but don’t do anything differently at home; every week after that, I put 25% of my body weight down, so that after 4 more weeks I should be fully weight bearing. At that point I should get out of the boot and into some sneakers!

Hope everyone’s doing well.

lori, has your son had his consultation with the orthopaedic surgeon yet? I know it’s scarely to contemplate surgery for a child, but based on what you say about how’s it is impacting his life it does sound necessary. I am happy with the results of the surgery so far, and while many of us complain here, it does seem that most of us are really, truly glad to have had the surgery in the long run. Best wishes to your son.

The spine is not so simple

Back pain, often associated with leg pain, is common. Rapid conclusions as to the cause are often made, and the unfortunate victim is told with authority by friends that “this is obviously a ‘disc'”. Even the profession was beguiled at one stage into believing in the “dynasty of the disc” for nearly half a centuary. However back pain originating is the disc is relatively rare.

The compendium of potential caused of back pain is large, and often originates from causes external to the vertebral column such as inequality of leg length and restricted (but unrecognised) limitations of hip movement. Even changes in the feet, by disturbing the fine and specific axis of balance of the vertebral colum can produce back pain. [This will be the subject of a dedicated page in the future].

Events near the vertebral column can produce back pain, such as gynaecological or bowel disease. Others include disease of the min arteries or ulceration of stomach or duodenum.

The ligaments, particularly the ilio lumbar ligament and fascia can produce intractable back pain. [Entrapment of the sciatic nerve by the piriformis muscle will be considered in a later post].

The problem is that the vertebral colum is an exceedingly complex anatomy of fine dimension, and is hidden deeply within the body. It is frequently assumed that one or other type of “scan” will be all-revelatory. Unfortunately even the most sophisticated investigatory equipment is too crude to give precise answers. Instead this equipment might show an abnormality which is no more than a “red herring”, with the regrettable outcome that  patient and therapist  alike begin to pursue this misleading cue even to the extent of attacking it surgically. Another problem is the cavalier surgeon who is determined to “explore”. Pain, however, is never found with a knife.

Are conventional explanations about “bunions” valid?

Hello Dr Driver-Jowitt. 

Thank you for suggesting I read your brochure about finding out more about foot problems on the internet. The first hit I found on Google just gave a quick overview of the different types of bunion surgery. The first they listed was for correcting the ligaments: Repair of the Tendons and Ligaments Around the Big Toe These tissues may be too tight on one side and too loose on the other, creating an imbalance that causes the big toe to drift toward the others. Often combined with an osteotomy, this procedure shortens the loose tissues and lengthens the tight ones. http://orthoinfo.org/booklet/view_report.cfm?Thread_ID=7&topcategory=Knee

(Name withheld by request)

Thank you for the enquiry. I am familiar with this paper, issued by the American Academy of Orthopaedic Surgery and co-developed by the American Orthopaedic Foot and Ankle Society. The Academy is a prestigious organization and it is disappointing that unsupported and irrational information is projected in this document. I am not aware that there is any evidence supporting the above suppositions. The comment about “tissues being too tight and too loose” is more an effect than a cause. Much of the paper discusses tight footwear as the causative factor, and the site says:” By far the most common cause of bunions is the prolonged wearing of poorly fitting shoes”.

As demonstrated in your case, the primary deformity is not the inward veer of the toe but the protrusion of the metatarsal away from the little toe. It is not possible for a tight shoe to cause the metatarsal to protrude outwards against the shoe.

The reality is that the deformity is zigzag, with the toe veering inward (towards the little toe) and the metatarsal veering outward (away from the little toe) and towards the shoe wall.

It is also improbable that your shoes were “too tight” when your deformity developed as a school-girl. Any shoe tight enough to produce a deformity, like any deforming force anywhere in the body, would be intolerably painful long before a permanent deformity could develop.

Many “Explanations” are not more than wild unsupported conjecture, without any validity or possibility of substantiation. Consider this suggestion by a surgeon discussing his “pain free” surgery in the online edition of a national newspaper.”Female hormones also soften this tissue, which is why women are prone to bunions”. http://www.dailymail.co.uk/health/article-1051558/Pain-free-surgery-cured-bunions-just-minutes.html

If this is the case why is a “bunion” often only on one side? Why do men and pre-adolescent girls get “bunions”? They don’t have “softening hormones”. This idea is simply fantasy.

More valid than the above “explanations” is the following statement by Drs Coughlin and Jones:” The…etiology of hallux valgus deformities…is a topic of great interest for all of us, but…is no closer to being defined now than in Morton’s era.” [Thomas George Morton 1835 -1903] http://www.ejbjs.org/cgi/eletters/89/9/1887#5193

I notice that one of the corrections suggested is aimed at dividing the bone of the metatarsal (an “osteotomy“). If the deforming forces were caused by pressure from the shoe acting on the toe, what is the rationale for a surgically attack the metatarsal?

The “exostectomy” described is nonsensical to me. There is no “exostosis” (i.e. no abnormal outgrowth of bone). The prominence is the normal bone, which is made prominent by the angular deformity, as I demonstrated to you. To remove the structures as in the diagram is quite wrong: The very ligaments which prevent the angular veer, and prevent the deformity from increasing, are having their attachments to the shaft of the bones  removed, and are therefore rendered ineffective.

I am sceptical about the claim that: “Many studies have found that 85 to 90 percent of patients who undergo bunion surgery are satisfied with the results.” Notice also the contrary comment “In fact, you will have some shoe restrictions for the rest of your life.”

A more realistic and objective assessment of the outcome of “conventional” surgery for deformities of the forefoot is the following meta-analysis in the Cochrane Database Intervention for treating hallux valgus (abductovalgus) and bunions. Ferrarid, HigginsJP, Williams RL. This paper is not optimistic about the outcomes of conventional surgery as it is at present

I would like to discuss your management further when you x-rays are available.