February 2011

Out on a limb: Kinder cuts

By Jordana Bieze Foster, Editor

I was having dinner with a group of women, and, as often happens in such situations, one woman was relating the details of her ongoing foot pain. One doctor in particular she was happy to be rid of.

“He said I would need…”

(Here she paused for dramatic effect.)

“…surgery.”

Sympathetic groans erupted from around the table, accompanied by sad shaking of heads. You would have thought she’d said “strychnine.”

Surgery, for many patients, is the worst clinical outcome they can imagine, something to be adamantly avoided even if the alternative is a life of pain and disability. And that’s probably not surprising. Surgery comes with risks; we’ve all heard the horror stories of patients who went to the hospital for routine surgery and never came home. Surgery comes with costs; for decades, we’ve been bombarded with health care reform rhetoric about how expensive and often unnecessary surgeries are among the factors contributing to this country’s current medical crisis.

Some patients’ perceptions of surgery may come from practitioners. For many practitioners who specialize in conservative care, surgery is a last resort, a sign of failure. Practitioners who feel this way may find it difficult to present surgery in a positive light, as the patient’s best hope for a pain-free, functional outcome.

But sometimes, that’s exactly what surgery is.

There may be no better example of this than the case of a patient whose diabetic neuropathy is complicated by an anatomical foot deformity that affects plantar pressure distribution during gait (see “Deformity and diabetes dictate surgical strategy.” )

That’s twice as many risk factors for foot ulceration than a patient who only has diabetic neuropathy. Even those with neuropathy alone have unacceptably high ulcer recurrence rates, and a deformity can make it nearly impossible to effectively offload those high pressure areas even if primary healing can be achieved. That’s one reason why some research suggests amputation rates in patients with Charcot arthropathy are strongly tied to ulceration rates (see “Charcot and limb loss,” July, page 17).

Many practitioners view amputation as a clinical failure; amputation rates are now routinely quoted as evidence of the relative effectiveness of diabetic foot care. But even an amputation isn’t a failure if it makes a patient more mobile and less vulnerable to ulceration. The case for deformity correction is even clearer.

Granted, not all patients are good candidates for surgery. Smoking habits, vascular patency, immune system health, and other variables must all be factored into the decision. Unnecessary surgery, or surgery that is unnecessarily risky, should be avoided. That doesn’t mean all surgery should be.

I have a good friend whose poor mother, a former avid runner, hobbled around on decimated knees for years before finally consenting to total joint arthroplasty in one knee. That’s pretty typical of the way patients feel about having surgery.

Now, amazed at the difference, my friend’s mother can’t wait to have the same procedure on her other knee. And that’s typical of what the right surgery can do for the right patient.

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