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Misnaming and Misunderstanding

Many terms develop to become derogatory, despite originating with a benign meaning.
Thus some terms transmogrify to become catagorised as “vile” or “despicable” and many other similar deprecating terms. This reflects the common human heuristic (a short cut), demonstrating the inability to quantify within a spectrum. Humans rely upon “binary” neurology. Therefore the instant (emotional) categorization (heuristic) is either “good” or “bad”, “desirable” or “undesirable”, “repulsive” or “attractive”.
Where a spectrum is presented, new and specific words are evolved to demarcate each position on the spectrum as a distinct entity: This is illustrated in the colour spectrum, where a multitude of words have been evolved to describe each component of that spectrum.
What if this wording goes wrong? What if the wrong word is accepted as valid?
In orthopaedic surgery, in relation to the descriptions of the commonest deformity suffered by humans, such a misnomer is universally accepted, which has allowed an incorrect concept to evolve. Subsequently a plethora of incorrect surgical procedures have been invoked and inflicted upon an un-suspecting public.
That word is “metatarsal” when it is (incorrectly) applied to the longest bone supporting the great toe. That bone is, correctly, a phalanx. Thus the (human) great toe has – like all the other toes and fingers – three phalanges. What determines the correct appellation? Many bones have characteristic sites of the “growth plates”, seen only in the growing bone. In the phalanges that growth plate is “proximal” that is towards the head. In the metatarsal it is “peripheral”, that is away from the head.

Therefore the great toe, correctly, has three phalanges. The true metatarsal is reduced to become the short “medial cuneiform”. Such changes might be related to the evolution of an “opposable” first ray in both the hand and the foot (as an atavistic expression in the foot). This is an important concept because the commonest deformity of the great toe exactly emulates the (similar) deformity in the second toe, which is named “clawing” in the lesser toes (if untreated that might become a “hammer toe”).
Thus the cause of this deformity of the great toe duplicates exactly the cause of a “clawed” second toe. Consequently the appropriate treatment of the great toe deformity should duplicate the treatment of a “clawed” lesser toe.
Hallux valgus (and “metatarsus primus varus”, another fallacious term) recurs, following “conventional” surgery. This has spawned a number of scientific papers addressing the question “Does excessive laxity of the ‘metatarso-cuneiform joint’ predispose to recurrence of the condition?”. This is fatuous, since the anatomy of that joint has no bearing on the cause of the pathology. That joint only has a bearing on the “Hallux Paradox” (see elsewhere)

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Hallux Valgus Paradox

Typical Hallux valgus does not cause a degenerative arthritis in the great “mt”p joint. Gross distortion, with subluxation of the phalanx, does produce degenerative changes, but of a different type.

However it is the “aligned” great toe which evolves into osteoarthritic damage (the “Hallux Rigidus”)

A problem which arise are that the symptoms of patients with pain at the “mt”p joint are not taken seriously at family practitioner level. There is a reason for that, which is the unsatisfactory and highly painful, surgery currently “conventional” for the great toe.

  1. Instead the patient is often advised to “wait until it gets worse”, before obtaining expert advice. The tragic outcome is that (otherwise preventable) destructive changes are allowed to evolve.
  2. Another problem is that “straightening” the great toe converts a hallux valgus (itself infrequently painful) into an incapacitating destruction of the great “mt”p joint. This is illustrated below.

The etiologies of these evolutions are clear, and easily comprehended.

 

How does the surgery I offer differ from “conventional” forefoot surgery?

How does the surgery I offer differ from “conventional” forefoot surgery?

This re-cap follows years of requests. Indeed this information-to-patients is obligatory in terms of Health Professional Council requirements.

Conventional surgery is based upon the belief that the age related deformities of the forefoot is caused by abnormalities of the bones, thus granting the domain to orthopaedic surgeons.

Consequently the surgical “correction” is aimed at the bones of the forefoot. This takes the form of dividing and angling the “metatarsal” of the great toe, and fixing that “correction” with plates and screws. The clawed lesser toes have some or all the joints ablated. These damaged lesser toes are then held in a “corrected” position by pins or screws driven down the marrow cavity of those toes. Following this surgery to bone it is hoped that these divided bones will heal and join, as fractured bones (usually) heal. This requires immobilisation for many weeks using plaster-of-Paris or surgical “boots”. Crutches are often required and ambulation is severely impaired for many weeks. The lesser toes become permanently rigid, often looking “awkward” and un-natural.

Since the cause of the deformity is not addressed, this “conventional” surgery is effectively “cosmetic” surgery. Unfortunately, also, “conventional” surgery is also not a permanent solution, and deterioration of the joint at the base of the great toe (developing degenerative osteoarthritis) is common. The other (un-operated) toes progressively (but at an unpredictable rate) “claw” and become uncomfortable, with corns on the top and calluses on the sole.

Recurrence of the deformity is a common occurrence following “conventional” surgical treatment of hallux valgus.(Arch Orthop Trauma Surg. 2012 Apr;132(4):477-85. doi: 10.1007/s00402-011-1447-6. Epub 2011 Dec 29.)

This “surgery-to-bone” for “bunions” and the other deformities of the forefoot was developed over a hundred years ago and has been passed down unaltered through generations of orthopaedic surgeons. Over one hundred forms of treatment for “bunions” have been described. Clearly there is not one which is convincingly superior to the others, and the selection of one form of correction as opposed to another is simply a “stab in the dark”.

It has been reported that of those subject to conventional “bunion” surgery over 30% suffered pain for at least two years (Foot Ankle Int. 2016 Oct;37(10):1071-1075. Epub 2016 Jun 19.) A recent paper presented in Europe claimed that in more than 30% of cases of “bunion” surgery were ultimately regarded as a failure.

I have been able to demonstrate (as I do for all my patients) that the problem is not in the bones of the toes, and “conventional” surgery damages – usually  irreparably – perfectly normal bones and joints, which then are expected to heal (effectively a gamble)

I have been able to show convincingly that the problem lies in the muscles serving the forefoot, and appropriate surgery demands that these soft tissues need to be corrected. This is the foundation cause to be addressed.  [The cause of the muscle imbalance requires a paper in its own right, and is unlikely to do with footwear]

A justified surgical axiom is that “if the cause is unknown the appropriate treatment is impossible”. To that end I have lectured to the South African Orthopaedic Association and the Foot and Ankle Society of South Africa, (“What REALLY causes Bunions?” – available on request).  By and large the message has been ignored for over twenty years, in defiance of objectivity.

The majority of persons with deformities of the forefoot are elderly, often living alone and dependent upon themselves entirely. Often financial resources are limited. Thus when I designed the procedure it was intended that this should be performed under regional anaesthesia (with a rapid return to a safe sensate foot) allowing the patient to be discharged from hospital the same day, able to walk independently, securely and safely [not encumbered by a cast or “boot” or (God forbid) crutches.] The procedure should be economical (with day-case discharge mostly) and not incur the costs of screws, plates, casts or boots.

What does the procedure NOT do?

Correction of the “bunion” might be slow or incomplete.  This is because long delays before seeking treatment (usually the case) allow progressive deterioration and multiple other irreversible changes at the base of the great toe (the “bunion”) . However this is likely irrelevant because it is the PAIN which drives people to surgery. The “bunions” become painless following this surgical management. The lesser toes often, or usually, lose the ability to “curl” or “claw”. However this is irrelevant, since the very reason the surgery is performed is to reverse “clawing”. In any event “conventional” surgery causes the toes to be rigidly inflexible and ugly. This disability has been over-ridden or ignored by those who harvest FDL at the level of the ankle joint

What is preserved, and develops progressively more, is the ability to “arch” the forefoot, necessary to hold slippers and other loose shoes in place.

Why has “conventional” surgery persisted? Partly because some of my colleagues know no better. I sympathise with them: this is what they were taught, their teachers have been taught this and have been taught so for generations.

However, some of my colleagues are content doing this surgery. It allows a high income, not only for the first procedure but for the subsequent removal of implanted metal. Further the “metal implant” industry is large, powerful and persuasive. Many of my colleagues have been “sponsored”  by the metal implant industry, at times with journeys paid to overseas congresses.

Then there is the widespread rigidity of medical science – a contented arrogant rigidity. Look at the history of discovery of Helicobacter for an example!

Many of my colleagues have been deprecating and defamatory towards me.  Some have prompted the idea of malpractice. In reality it is the “conventional” forefoot surgeons who are guilty of malpractice, by doing the wrong procedure for the wrong reasons.

Does Homeopathy Work?

Conventional medicine is not good at allowing “natural healing” the latitude which it deserves. This is an hard nut to crack in the present mechanistic world. It could probably be done via the mass media in the guise of entertainment. Dr. Marcus Welby was one such program, fostered by the American Medical Association. Dr. Finlay’s Casebook another. All the other ER and Grey’s Anatomy types of progam have a contrary (and so undesirable) message. That message emphasise an immediate, “scientific” solution to all illness, provided by “physicians”.

But homeopathy does give the latitude, by legerdemain, for natural healing to have its chance

http://gu.com/p/46g99/sbl

Piriformis Syndrome again

Originally published in Orthopaediciq, April 2013

The following  letter which demonstrates the difficulty some have in obtaining help from obdurate therapists.

 

Dear Doctor,

This is rather random, but I came across your contact details while trying
to find out where I could get the surgery to treat piriformis syndrome. I am
having great difficulty persuading my GP and spinal specialist that my
problem is piriformis syndrome as apparently it’s not seen as a legitimate
diagnosis in the UK. I am absolutely miserable with the daily pain and lack
of movement in my leg. I can’t enjoy life anymore and nobody will give me an
answer. I am supposed to be having an epidural in the spine which I know
will not work. I gave had the pain for nearly 2 years and its getting worse
as the range if movement decreases. I believe it is a result of falling on a
step wearing high heels on to me right buttock as that us when the sciatic
pain started and now I am in almost constant pain with ache and stiffness. I
guess I am just hoping you have an answer or more information. I just want
someone to release this muscle and give me my life back. I am only 26 and
feel like my life is over. I would be so grateful if you could reply. I
understand you are probably very busy.

 

Dear V,

I am sorry that you have received this rebuffing approach.
Further, could you tell me more about and where is your pain – does it extend down your leg? Is it aggravated by cough, sneeze and straining on the toilet? Do you have any difficulty in controlling your bladder or any sensation loss around the anus?

I find it curious that many qualified people “oppose” the diagnosis of the piriformis syndrome. What I find difficult to understand is that there is nothing “unconventional” about it. The anatomy is undeniable, and there are many ways of demonstrating its existence.

It might be that every sciatica is not attributable to the piriformis syndrome, but that is not invalidation.

The good news is that it can be conclusively diagnosed and equally conclusively treated. As is always the case diagnosis is the sine qua non. Therefore my current approach in establishing the diagnosis – if the clinical features support it – is to inject the muscle, under ultra-sound guidance, with local anaesthetic. This temporarily paralysis the muscle, reduces the spasm and as a sequel takes the constricting pressure off the underlying (and compressed) sciatic nerve. Some radiological skills are required and selection of a capable and interested radiologist (or orthopaedic surgeon) is advised

In your case there might be an accumulation of blood from the injury in the muscle which you sustained and CT scanning (or MRI) could be warranted. Once the local anaesthetic wears off, at the expected time, the pain would be expected to return. This is therefore a DIAGNOSTIC procedure. At times the benefit lasts, which is a great plus. But if it does not there are many other approaches to its management, sometimes by non-surgical methods.

It is ironic that you have been lined up for an epidural injection (of what?). Epidural injections for back and leg pain are “random walks”. A loosely empirical “therapeutic trial” with little basis regarding the mode of action, an absence of any diagnostic accuracy, no established certainty of its benefit and not inconsequential risks. Therefore your clinicians, in denying the concept of the piriformis syndrome are proposing a form of treatment which is, itself, totally lacking in “legitimacy”

A “lost” comment

I apologise for having lost a comment from a podiatrist. If he could repost I would be appreciate.

My comment was as follows:

Thank you for your interest, I admire your assiduous pursuit of the best for you patients.

Risk needs be assessed in terms of frequency, and one function of the surgeon is to know that and make his own.

I think that I have posted a comment on the paper “Foot Ankle Surg. 2011 Sep;17(3):150-7. Epub 2010 Jul 9. Weil osteotomy: assessment of medium term results and predictive factors in recurrent metatarsalgia”

You use the analogy with the hip. In fact most hips survive until death even in nonagenarians. Only a fraction of human hips need replacement. Further, a hip arthritis might be unilateral and one must then ask why one went wrong and the other did not. The answer is unknown, but as illustrate it is clearly cannot be “age, wear and tear”.

If I extend that argument to a “long” metatarsal, it is not abstract to appreciate that such a metatarsal has worked well for the greater part of the patients life,  probably on both feet. Therefore there must be some other factor which has intervened and caused that ray to become painful, particularly if  one ray on only one foot is symptomatic. What is “abstract” is for surgeon to pick a long metatarsal, blame the pain on its length and shorten it. Indeed probable more often than not the deformed and painful ray could be one of the shorter metatarsals. The metatarsal shortening enthusiasts will then go ahead and shorten that “short” metatarsal.

Hallus rigidus and hallux valgus are very different pathologies, and the reason for the difference has been well assessed.

Weil osteotomy was born out of the failure of all other approaches. Remember that that before the Weil surgeons were convinced that they were doing the “right things”, and justified their conviction by a “rationale”. The rational currently used to justify the Weil is equally unconvincing to me.

The explanation and descriptions of the pathologic evolution of forefoot deformities (and flowing from that the treatment) has taken me some time, given that I have set myself a minimum (and large) number of patient in the study with a minimum follow up of 25 years. Hence the delay.

Best Wishes

Leatt-Brace and Similar Devices

 

The Leatt-Brace is promoted to protect the motorcyclist’s cervical vertebral column. However, this device may produce “dangers” of its own. Of course, a device cannot be considered “dangerous”: it is motorcycling which is dangerous. However this device could convert relatively innocuous or survivable injuries into injuries with greater morbidity and death.

Although claims are made that injuries to the vertebral column will be reduced if the Leatt-Brace is used, there is no possible way of substantiating this claim. Controlled trials are simply not possible. The tumult of a motorcycle accident and the multiple variables cannot be replicated.  It is certainly not possible to re- visit those injuries and introduce categories as controlled trials.

Motorcycle accidents on the road are difficult to reconstruct.  Race-track injuries are well documented, but these are usually slither-tumble injuries. On modern race tracks the impact against stationary objects is relatively infrequent. Rarely do these become projection or impact injuries and only occasionally “ride-over” injuries.

Motorcycle accidents on the road, however, are more likely to be collisions resulting in impact and projection injuries. Even in a slither event, the rider on the road often hits stationary or moving objects.

Therefore this claim by Leatt remains supposition,  based on a primitive, linear reasoning which is:

The neck is potentially vulnerable in that it is not protected by a strongly mechanical sheath, unlike the way that the lumbar, thoracic, and intra-cerebral spinal cord is protected. Let us then put a  brace about it, and so “protect” it.

Wish it were that easy.

This linear reasoning appears not to have fully comprehended the functional anatomy of the mechanisms of the cervical vertebral column, which makes it invalid.

If my head is fully protected by a helmet, is it not logical to extend that protection to my neck?

Firstly one must ask what protection the helmet offers.

There can be no debate that the crash-helmet reduces head injury and death in motorcyclists, a worthwhile but not universal protection.

The helmet prevents many penetrating, abrasive and direct contact facial injuries But it offers little protection against rotational injuries (which produced diffuse axonal and brainstem lesions) and these injuries might be increased  by the helmet’s inertia if body rotation decreases rapidly.

The helmet reduces deceleration injuries to some extent but concussive and contra-coup injuries will be reduced only by a margin when deceleration is from speeds of excess of 50 km an hour.

Direct blows on the top of the head (axial compression injuries) are a common cause of spinal injuries. These might be increased in some circumstances by the weight of the helmet

The Leatt-Brace will not prevent axial compression injuries: But it could promote or worsen that injury, because it interferes with evasive actions

There is some evidence that helmets reduce injuries to the cervical vertebral column, but this is poorly documented and the types of spinal injury which are reduced by the use of a protective headgear are not well analysed.

 

How do we protect ourselves from external forces?

Humans, like most other mammals, have exceedingly good “energy dissipating devices”. What this means is that there are highly sophisticated neuromuscular circuits designed to protect the individual from that universal enemy, the force of gravity. It is therefore possible for the human to fall, sometimes heavily, and sustain little or no damage. This is well illustrated in contact sports, notably rugby and professional wrestling.  The sophistication of the martial arts has allowed specific techniques of energy dissipation to be trained into participants early in their martial arts career.

In American and rugby football, energy dissipation or “break fall” is not usually trained: Instead the players rely on intuitive and inherent capacities to protect themselves from injury when their balance is perturbed. Some fondly imaginings this is a “conscious” mechanism: it is not. It is not possible in the time available to rationalise which strategies should be employed. With very few exceptions, there is no time to anticipate the vectors of destructive forces. Humans survive by the blessings of ”hardwired” and intuitive mechanisms [1]

That these mechanisms of energy dissipation exist is easily demonstrated. Most individuals could jump from a table to the floor and suffer no injury. There would be no outward expression of the kinetic forces, such as loud sounds, generation of heat or light or damage. On the other hand, if a 75 kg facsimile of that individual in granite was pushed from the table the forces of falling would convert to  sound, heat, light and damage. Another example: Robots can do much, even mimic running. But robots do not have the energy dissipating mechanisms of humans. A robot on a rugby field would not survive the first tackle or even, perhaps, the first nudge, without damage. Watch a cat fall.

 

How is this done?

The human frame, in its vertical axis is designed as a complex zigzag from the toes to the skull. Each of the angles of these zigzags is controlled by muscle allowing these zigzags to be compressed, concertina-like. During this compression, muscles response near instantly by tensioning, and by using their inherent energy allow the external energy to be slowly and safely dissipated.

Rotational movements are also used to dissipate energy, and allow the limbs to flex, reducing their lever-arm length, or tucking the limbs beside or behind the trunk.

There seem to be priorities in the methods of protecting the body. The head brain and eyes seem to have a priority re. protection. The hands and mouth are next in this triage and the feet follow.

Why a high head and a thin neck?

It is no coincidence that the head is placed high on the body. Better surveillance is an obvious benefit. Perhaps more important, by its height the brain is maximally protected from injury. Whilst accepting that the phrasing which I use is teleological, the “purpose” of the mobile and relatively thin neck is that it allows the head a great freedom of movement and consequently the maximum capacity to protect the brain from jarring or other forces (including rotation) which could damage the enclosed brain. It is well-recognised that, when people fall, the head is rapidly moved away from a potential point of contact.

Consider the tumult such as occurs in motorcycle accidents. This freedom to move the head will likely be the critical component to the broader “energy dissipating mechanisms” and its contribution to protecting the head from impact.

Where the body is thrown towards an impacting surface, even a few centimeters of intuitive movement of the head away from the potential point of impact (perhaps transferring impact to the shoulder or the upper limbs) could prevent severe injury to the head. If this flexibility is lost and the ability to move the head is prevented (as it would be with the Leatt-Brace) that latitude is lost.  . Even distances of one or 2 cm might be critical in preventing severe brain damage. Immobilisation by a neck brace might therefore result in severe injury

Whilst the Leatt-Brace could protect the neck from flexion injuries, by imposing immobility it is equally likely to make damage to the brain more common and more serious than any neck injury would have been.

Other functions of the head.

Inasmuch as movement of the head plays an important role in protecting the brain, the head also plays a vital role in the overall posture of movement, particularly movement during falling. The head weighs the equivalent of two bricks and functions as a counterbalance. The capacity to move the head rapidly and induce “coupling” dynamics in the physics of equilibrium is immensely important. If the head is restrained, for example by the Leatt- Brace, it becomes impossible to posture the body in space. This use of the head as a counter balance is well illustrated by springboard divers  to control backwards and forward somersaults. Without a free range of neck movement it would be impossible for the diver to obtain a posture safe for entry into water, or the gymnast to land. Try jumping from a step wearing a Leatt-Brace! Make sure that it is not more than a step, since jumping from a height of even half a meter, wearing the Leatt-Brace, could produce a severe injury including a fracture of the base of the skull.

I am not aware that this concept is discussed in standard textbooks of medicine, and for most medically and biologically trained people this is not considered.

Is the neck especially vulnerable?

The cervical vertebral column could be mistakenly considered a “vulnerable” area region. This might be because spinal cord injuries invoke highly emotive responses because they are potentially so incapacitating and incurable. However, taken overall injuries to the cervical vertebral column are less common than injuries to the brain. There are also specific situations where the vertebral column is at higher risk One is the diving into shallow water which has produced this devastating injury many thousands of times. The reason is that the diver does not expect to strike the head, and none of the “head / neck protection” mechanisms are recruited. Injuries to this vital part of the vertebral column also occur in road traffic accidents generally. These are far less specific and the victims range from pedestrians through to individuals who have survived motor vehicle accidents, and finding themselves inverted and held by seatbelts, then suffers catastrophic injury when a “helpful” individual releases the seatbelt: the victim then falls onto the (inverted) roof of the vehicle, and suffers cervical spinal cord injury.

How can we find out more?

Because it is so difficult to get sufficient information from road traffic accidents a possible model could be rodeo injuries, which are well documented. A number of rodeo injuries are caused by falls from height, such as would happen to a projected motorcyclist after hitting a stationary object.

In order to illustrate the effects on the neck of these types of falls, illustrations of Gauchos can be used to analyse the mechanics of the injury. Even more important is the analysis of the fail safe mechanisms which are spontaneously recruited by the rider. It is improbable that any rodeo rider would allow himself to be restricted by a Leatt-Brace – and it would be highly unethical to even suggest this.

 

illustration. It is apparent that this rider is already laterally flexing his head and rotated the left, whilst rotating the trunk to the right to allow his right hand to block the possible point of head impact. The probabilities are that he will strike his shoulder or shoulders and it is likely that he might escape injury free. However, had he been wearing a restrictive neck brace, he would not be able to posture his head in this protective way and the chances of him having a head injury would be considerably increased if not inevitable.

Is there a way to protect this vulnerability of the cervical vertebral column, and perhaps the brain as well? This seems possible and the author has researched this, including the compounded locus of movement of the neck and the neck-on-head, in much detail. That research has included a detailed investigation into the (complex) locus of movement and angular velocities of the cervical vertebral column. A later paper will consider an appropriate design for a protective neck brace.