Advice for tough case

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I have a 51 y.o. female that presented to my office complaining of pain
in the right great toe. She stated she had bunion surgery about 2 years
ago, but it never healed and is still causing her considerable pain.

Upon x-rays and examination, she was diagnosed with post-op Hallux limitus with decreased joint space. The x-ray showed
a screw in the middle of the first metatarsal poking into the first MPJ, causing
her decreased motion and pain and a degenerated joint

She wants surgery to remove the screw and relieve the pain.

I was planning on putting in a hemi-implant, but I don't know what to do
with the screw. As I mentioned, it is right in the middle of the metatarsal,
I will not be able to get to the screw head. It is not dorsal, medial or lateral.
Any suggestions would be greatly appreciated. The surgery is coming up very
fast, so please hurry with advice. Thank you.

 

Re: tough case

Hi Footdoc,
Any chance you could put the x-rays up here?

Ryan

 

Re: tough case

Of course you can get to the screw head, you will just have to go into the bone to get to it. One option is to either extract the screw out through the distal metatarsal head or push the screw back through the original screw hole on the dorsal cortex, if the dorsal screw hole hasn't filled in yet. There are also trephine type tools that allow buried screws to be extracted. A last option is to just simply push the screw back into the metatarsal then do an arthrodesis with new hardware. There always lots of ways to "skin a cat", so to say. Please post x-rays if you want better advice.

 

As per Dr. Kirby's answer, there is always a solution. If a screw can be put in, it can also be removed. Sometimes it simply takes a little creativity. I wouldn't recommend placing the screw back in, since it will always have the potential to migrate once again, although if the joint is fused that's a mute point.

As Dr. Kirby mentioned, it is always possible to locate the area of the head of the screw via flouroscopy and use a trephine to access the head. Sometimes a small burr can also be utilized to create a cavity to access the head. You must also be prepared to improvise depending on the design of the screw head and the instrument you will need to back out the screw.

I tell my residents that this is exactly what makes surgery challenging and less of a "cook book". It's those little occurrences such as this that aren't always in the textbooks that challenges us to be creative and come up with a solution. But a solution DOES exist.

But as always, if you are not comfortable performing the surgery, do not compromise the care of the patient. Refer the patient to someone else, learn from this case and the NEXT time this occurs you will be comfortable performing it yourself.

 

It's probably easiest to back the screw out the way it was put in. Just burr down to the head, and back it out. A hemi implant would be nice, or maybe a modified Vallenti.

Make sure all the pain is coming from the obviously impinged joint. Sometimes there can be nerve entrapment in the previous scar, or a Joplin's neuroma etc., that can overlap the symptoms of the obvious problem.

Cheers

Frederick

 

FootDoc:
One more thing....don't hesitate to send a note over the the original surgeon, perhaps he needs a technique review. I would assume he over drilled and the screw advanced into he joint space.
In addition, the screw direction was poorly chosen.

What kind of screw is it? If it's headless you may be able to advance it out through the head, otherwise, as others have suggested, you can drill to the head and back it out, just use fluoroscopy to make your job easier.
Try to identify what make, size and type of screw it is preoperatively so you can have the proper instrumentation available.

Good luck

Steve

 

Although Dr. Arbes is in agreement with what I wrote in my post regarding the use of flouroscopy to make the job easier, and to be prepared in case you don't know the type of actual screw manufacturer, I'm not sure I agree with Dr. Arbes recommendation to contact the original surgeon.

To contact the original surgeon and state that "perhaps he needs a technique review" in my opinion is rather presumptuous. It is always easy to critique another surgeon's case or technique "after the fact" or several years down the line, but we often aren't provided with the entire story. To contact the original surgeon based on an "assumption" (as per Dr. Arbes quote) is not a wise idea. In my opinion, the word "assume" has no place in medicine.

Perhaps the patient didn't provide the present treating doctor with the ENTIRE story. Perhaps the patient wasn't entirely compliant following the surgery and there was migration of the screw or fixation? Is it possible that the screw was originally placed correctly and the head was NOT countersunk overly aggressive but that there was some bone resorption that resulted in the migration of the screw?? Could it be that the patient's bone stock was not ideal which resulted in some migration of the screw?

My point is that we shouldn't always be quick to blame our colleagues and believe that we are the only one's capable of performing "perfect" surgery. There are many competent surgeons out there and unfortunately sometimes complications can occur, despite excellent technique.

Yes, some surgeons simply suck. But unless you have the ENTIRE story and facts or have the immediate post operative films, I wouldn't be quick to send the original surgeon a letter pointing out his/her errors.

 

Well.....Dave.... apparently you have a slight problem with my post.

Actually what I said is that you should not hesitate to contact the original surgeon , PERHAPS he needs a technique review. PERHAPS it's not the first time this has happens, and perhaps he needs to know if his technique is predisposing his patients to complications. Perhaps not. Maybe he puts in 200 screws a year that work perfectly and it was just one of those things.

Nowhere did I suggest that anyone tell him he needs a technique review, but information is always a good thing to have. What he does with that information is up to him. I would be grateful if someone gave me a headsup to a patient's problem that I was responsible for.

Dave, you apparently have some type of chip on your shoulder concerning my posts, lets not read into things and try to find fault where there isn't any.

A little objectivity goes a long way. IF you have some PERSONAL issue you can always sent a private message.

Steve

 

Steve,

I have no personal issue with you or your posts. I would certainly welcome anyone to let me know if a patient walked into his/her office and told me about a problem that I had caused.

However, my point in this particular case was that I don't believe it was really determined that the original surgeon had definitively erred. None of us had enough information to make that call and it is always easy to be critical after the fact, and even easier to be critical without ALL the facts.

Unfortunately, I have been an expert witness defending DPM's in cases where there was very little merit, simply because a patient brought up a lawsuit based on a comment that a subsequent treating DPM made about the care rendered by a previous DPM. So I guess I'm a little sensitive when I see or hear other DPM's critiquing DPM's without knowing the entire story.

Steve, once again I have no personal issues with you or your posts. I'm a pretty open guy and simply call it as I see it at the time. I'm an honest guy and respect everyone's differences, but I will voice my opinion if and when I disagree and I will voice my opinion when I agree.

If I truly have/had a problem with you, I would have sent you a PM by now and would not make it public. That's not my style. I'll leave that to the biomechanics guys!

Have a healthy, happy New Year.

David

 

Steve:

I'll have to agree with Dave on this one. It looks like you are suggesting that it might help to send a note to the surgeon to tell him that his surgical technique needs improvement. I don't know of any surgeons that appreciate this type of advice, unless it is from another surgeon they already know and highly respect. In addition, I would never put that type of advice in writing due to the possible legal issues that may arise later. A simple phone call is best and, of course, done with great care and humility.

Dave:

Isn't the whole purpose of an academic website expressly run for a medical profession, such as Podiatry Arena, to have open discussions so that opinions can be shared and topics can be debated? When you write: "If I truly have/had a problem with you, I would have sent you a PM by now and would not make it public. That's not my style. I'll leave that to the biomechanics guys!", it seems to imply that us "biomechanics guys" never talk to each other privately and always make everything public. I have many private discussions with individuals on this forum that are never made public.

Maybe the "surgery guys" of the podiatry profession, (not referring specifically to you and Steve) would improve the surgical side of the podiatry profession if there was much more public debate on surgical subjects and much more demand for evidence for all the surgeries being performed that otherwise have only anecdotal evidence to support them.

I'm very tired of hearing podiatric surgeons at podiatric surgical seminars discuss about how great their new surgical technique that they invented works with not a shred of non-anecdotal evidence to support it. Maybe if the "surgery guys" were a little more open and up front publicly as to why certain surgeries should never be performed, regardless of who their friends are on the surgical boards, surgery specialty societies, etc., then fewer people would be permanently crippled by unnecessary and ill-advised surgeries by these same surgeons??

Maybe this should be a good New Year's resolution for the Podiatric Surgeons of the USA?.....openly critique the use of surgery versus conservative care and the benefits of one surgical procedure over another. Maybe this type of healthy, open critique will create more demand that quality research evidence be produced by the podiatric surgeons that will, eventually, prevent fewer people from being harmed and more people being helped?

Happy 2009 everyone!!

 

Kevin,

Thanks for your input. Of course I hope you know I was only joking when I made that comment about the "biomechanics guys". Actually, your suggestion is exactly what I have attempted to bring to the surgical forum since I believe it's been missing.

And you are 100% correct regarding all the surgical "gurus". I despise going to podiatric seminars, because every time I go all I hear is that everyone is performing 200 procedures a week, with no complications and has just "pioneered" some amazing procedure. It's amazing that most DPM's don't have more rotator cuff injuries from patting themselves on the backs!

I have no problem respectfully disagreeing with Steve or anyone else on this forum. However, if I had a PERSONAL problem with Steve or anyone else I would not air that out on a public forum, but would use a PM to play out my personal issues.

Come on Kevin, I'm still having difficulty trying not to use the terminology "hypermobile first ray"!!

David

 

Dave:

You can probably see that you touched on one of my raw nerve areas by using the term "biomechanics guys". Sorry for the rant.

Many of us here on Podiatry Arena do privately e-mail or phone call each other when there are personal issues involved since we respect each other and don't want to offend each other. Then there are others, who you can probably figure out from the tone of my postings, who I don't feel they even deserve a private e-mail due to their poor ethical behavior and whose sole desire in life is to sell their product in an unscrupulous and unprofessional fashion here on an academic website. I feel my job is to expose them for who they really are and what their product really is. Because if I (or a few choice others on this forum) didn't expose their fraud, then who would publicly expose them for what they are??

By the way, Dave, regarding the term "hypermobile first ray", if you bought a truck that had leaf springs or coil springs on the rear axle that bottomed out with every bump you drove over, would you call those springs with too little stiffness "hypermobile leaf springs" or "hypermobile coil springs"?? If you can answer that question with a good mechanical analysis that describes why the load-deformation characteristics of a spring-like machine, like the suspension springs of a truck or the first ray of the foot, should be called "hypermobile", then I would have no problem with the term "hypermobile first ray".

Happy New Year!

 

Kevin,

As always, your points are well taken. I fully understand your "exposure" of those you believe are attempting to hawk a product, etc. On another website, myself along with another doctor (David Wedemeyer DC, Cped) and Jeremy Long, Cped, had a similar experience with a DPM "hawking" a silicone orthosis that we basically exposed as fraudulent in it's proposed theories.

I really have no problem having an intelligent disagreement with anyone, and will respect the opinion of the other party, but once there is a product involved or the sale of a product, then all objectivity is usually tossed aside. So, I could not agree with you more.

And in reality, prior to reading your thoughts regarding a hypermobile first ray, I hadn't given the terminology much thought and simply went along with the masses. But now I've "seen the light" and have been educated, and more importantly have basically been de-programmed!

Thanks. Now it's time to get on with the New Year's celebration.

David

 

Far be it for me to enter a discussion about anything surgical, I want to comment on this thread because it extends to inter-professional courtesy and what I have encountered personally in my practice over the years.

Steve I don't want to raise your ire or create any bad feelings between us, especially because we have not had any discussion previously and the posts that I have read of yours are clearly those of a practiced surgeon and intelligent.

I read this thread very carefully and I have to agree that you clearly questioned not only the technique of the surgeon in question here but the chosen path of the fixation screw. I may be a layperson when it comes to podiatry but even I can read.

Okay back to the "biomechanics guys" threads.

David should you ever visit "laid back California" I hope you come by the office. I am going to ask Kevin to attend and there will be a mandatory 36 hour lecture by Kevin on various biomechanical theories and there will be an oral exam by us "biomechanics guys" during which we will be able to consume yeast and hop based beverages and you will not (you're learning after all), we need you sharp) . :hammer:

Regards,

 

Hi David:
No problem, I'm a teddy bear.

"Steve I don't want to raise your ire or create any bad feelings between us, especially because we have not had any discussion previously and the posts that I have read of yours are clearly those of a practiced surgeon and intelligent. "

There is absolutely nothing wrong with letting the original surgeon know that there was a complication with one of his cases. This is done out of professional courtesy. If it is done with the good of the patient and the standard of care in mind then I doubt anyone would consider this anything but a positive gesture. Of course you can't account for everyones ego, but that is not the issue here.

The main issue is a complication PERHAPS stemming from a poor technique. Now I'm not, nor did I ever, suggest calling the original surgeon out on this, but merely informing him (or her) in a professional manner that there is complication that he may be interested in. Period.

I've been on the giving AND receiving end of these and both end up being a good and healthy exchange of information.

Steve

 

Steve,

No worries. I only meant to point out to you that the language that you phrased that response it sounded quite a bit different than what you are explaining now.

Sometimes the written word lacks the inflection and tone of verbal speech and perhaps all of us can benefit from being very humble and precise when addressing such an issue with our colleagues and especially patients.

To a patient you must admit that comments worded that way would probably raise doubts about their surgeon's choice of procedure and methods. I cannot tell you how many times a patient who wasn't experiencing a miracle in my office presented after seeing another provider who told them "I wouldn't have done it that way" or "that orthotic is posted wrong" and in reality there are often numerous methods to arrive at the same result.

Sometimes I see treatments or devices far from what I would recommend but they function appropriately and work and I can't imagine that it would be greatly different given the variety of surgical options available.

Regards,

 

Hi Dave:
"To a patient you must admit that comments worded that way would probably raise doubts about their surgeon's choice of procedure and methods"

I couldn't agree more. No one ever suggested painting the original surgeon in a bad light to the patient.

I did reread my post....sorry if it "sounded" aggressive, it didn't to me, but I can see how it may have been taken that way.

I NEVER (again) suggested anything more than contacting the original surgeon. Then I went on to state that his technique may be in need of improvement - perhaps I should have disassociated these two thoughts. I did not mean to tell the original surgeon this (even though he did apparently put a screw into the articular surface!!!!!)

I think that keeping avenues of correspondence open with other providers in your area is a very, very good thing.

Steve

 

Steve,

Although you stated again that "apparently" he put a screw into the articular surface, once again I KNOW that YOU know that it's certainly possible that the screw could have migrated due to bone resorption, etc.

Regardless, I believe that we now all understand that your original statement wasn't as "harsh" as it sounded and we can all appreciate that the original surgeon may have wanted to know that one of his patients had experienced a post operative complication.

Interestingly, over my many years of practice I've attempted to contact prior treating doctors for a plethora of reasons, but always for the benefit of the patient and NEVER to criticize the doctor. Those calls have been met with the spectrum of responses from gratitude to arrogance, despite the fact that I've always given the doctor the benefit of the doubt and have never even remotely questioned the doctor's judgment or skills. I just informed the doctor of the events and even told the doctor that I recommended the patient return to him/her for care.

Knowing these doctors from my years in practice, I can tell you that as an overall "survey", the doctors that responded with the most appreciation are overwhelmingly the higher quality surgeons, and the doctors that responded by getting upset, hanging up, etc., where usually the doctors that in my opinion had the lowest level of surgical skill.

So Steve, your points are well taken, and so are David's. Many years ago, I was taught a lesson that it's simply how something is stated and that's how it will be interpreted, and that's what I believe David was stating. It's all a matter of the wording!!! The example I've always given my office staff is the following, because depending where the emphasis is placed, each sentence basically has a completely different meaning!

MARY said Sue was lazy.

Mary SAID Sue was lazy.

Mary said SUE was lazy.

Mary said Sue WAS lazy.

Mary said Sue was LAZY.

I don't always put the "emphasis" where I should when I speak or write, and then I think of the simple examples above and realize that the interpretation can change dramatically.

Now if I can just get my office staff to follow those rules a LITTLE more often.......


David

 

OK.....
But just for the record before we get accused of beating a dead horse;

there only 4 things that I know of that can happen to a screw after it's put in (assuming nothing is not one of them) -
it can migrate forward, back out, it can break, it can bend.

Knowing this, if a screw is placed for osteotomy fixation for a bunionectomy and it's pointing at the articular surface one must assume that sooner or later they may get one that migrates forward and will end up in the joint.
Thus, this is a bad technique.

There are many many ways of fixating a distal metatarsal osteotomy, pointing a screw at the articular surface (apparently close) is not one I would recommend.

Steve

 

Steve,

You actually raise a very interesting point regarding screw placement, that is applicable to distal metatarsal osteotomies in general, and not just this case. I do agree with you 100% that poor technique can lead to a screw that is misplaced. However, there MAY be an explanation.

I will elaborate. During my training, and possibly your training, there was a "general rule" during fixation to attempt to fix unstable to stable. Therefore, you would direct the fixation from the capital fragment/metatarsal head (unstable) toward the metatarsal shaft (stable). This worked well if the surgeon utilized K-wires, screws, OrthoSorb, or whatever fixation the surgeon chose.

Classically, this method taught that the screw for an osteotomy such as an "Austin" or modified "Austin" was driven from dorsal-distal to plantar-proximal. This direction avoided the delicate proximal portion of the dorsal "wing" and also directed the distal aspect of the screw away from the joint and sesamoid apparatus.

And of course, it fixated "unstable to stable" bone.

However, there is/was a school of thought that this angle of fixation worked against the forces of gait, and that placing a screw from dorsal-proximal to plantar-distal allows the ground forces to help "compress" the fixation. But this directs the distal end of the screw toward the sesamoid apparatus or even toward the joint a little if the screw migrates.

I'm not sure which direction or method you utilize when you perform a distal osteotomy, but I'm confident you utilize whichever has worked best for you. I do know that at some recent lectures, they have started advocating the second method I mentioned (dorsal-proximal to plantar-distal) so the ground forces aren't fighting the fixation.

However, once again this direction has the distal end of the screw heading toward the sesamoids or possibly the joint if the screw is "off" a little.

Steve, as stated above, I am in 100% agreement with you on this, but if the original doctor utilized "method #2", it MAY be a possible explanation for the screw entering the joint. It's still not an excuse for poor technique, but it may at least explain the surgeon's thought process.

David

 

Steve:

Most of the foot surgeons I know of in California and the west coast, including myself and all the 10 podiatrists and three 3rd year podiatry residents that I help train at the Sacramento Kaiser Hospitals, when performing screw fixation for 1st metatarsal head osteotomies, angulate the screw tip toward the cartilage of the 1st MPJ from dorsal-proximal to plantar-distal. That is why screws have heads on them....to prevent screw migration toward the tip of the screw.

I have never had a problem with this technique and never seen a screw migrate toward the tip, if proper technique is used. Does that mean that, as you say, we are all using "a bad technique" since we point the screw toward the joint??

 

Hi Gentlemen:

Can of worms here.

I have no problem inserting a screw from Proximal to distal (although David is correct that this is not classic ORIF technique). However, if you are doing it this way then you should not direct it at the head but either plantarly or laterally.

Kevin, I would assume that the path of the screw is plantar to the articular surface when you insert these, it would be the natural line to take.

If all of the attendings and residents on the "West Coast" are using the same technique and are getting no complications then I would not argue against success.

Which brings us all back to the reason for this thread. A patient has a screw in the middle of her MTPJ. I would suggest that a screw NOT directed at the MTPJ cannot end up in a MTPJ.


KEVIN WROTE:
"That is why screws have heads on them....to prevent screw migration toward the tip of the screw......" Kevin, please, you know as well as I do that not all screws have heads, nor did screws not migrate when they all did. Overtapping, overdrilling, wrong drill size, poor bone stock, it all happens. Plus, it's very unlike you to use the "numbers" argument when trying to prove your point. I thought the "in your hands" was old fashion and out of date? Remember? You told me this once when I was using the "experience" card to prove a point rather than refining my facts.

So, my bottom line here is this: If inserting a screw towards an MTPJ never has any complications (on the West Coast) then how did this patient end up with this complication? Apparently she's from out of state.
(now you have to know that the last part is sarcasm, right? Don't write back asking me to explain that, a sense a humor goes a long way.)

Steve

 

Steve:

I'm doing two of these surgeries this week. I use a cannulated screw directed toward the distal plantar 1st metatarsal head at about a 45 degree angle to the dorsal metatarsal shaft with the screw entry hole about 10 mm proximal to the dorsal arm of the horizontal "L" type osteomy I use for these procedures. The tip of the screw generally ends up being about 2-3 mm from the distal surface of the articular cartilage of the first metatarsal head. This is fairly standard screw orientation with the podiatrists I know here in California for these types of osteotomies. I thought it was like this elsewhere in the States, but I can see now that I was wrong in this assumption.

By the way, Steve, my "screw head" comment was also a little sarcasm for you.....since I know by now you can handle it. Keep up the good comments.:drinks

 

Kevin,

WAY out here on the East Coast, I believe the osteotomy you are referring to is what we call a "distal "L" (aren't we creative?). Unlike an Austin, it's almost impossible to fixate the "distal L" with a screw placed from dorsal-distal to plantar-proximal, therefore must be placed the direction you describe.

The distal "L" procedure is a procedure I like to utilize when I need to address "PASA" since it allows me to remove a wedge if needed (Reverdin-Laird). However, I must admit that residents have informed me that they have seen cases where during insertion of a screw the head has actually "split" due to the direction of the screw. Naturally, this probably occurred due to the screw being too large for the size of the capital portion. Additionally, I have seen surgeons choose a screw a little too long and breach the intra-articular space. Naturally, this can be easily avoided by simply looking at the joint intra-operatively after fixation or taking an intra-operative x-ray or using flouroscopy to assure proper hardware placement.

Is the "distal L" your preferred distal osteotomy and do you prefer this vs. an Austin type osteotomy if you aren't planning on any "PASA" correction? I'm just curious to see what you "biomechanical guys" think (now you know I'm only kidding). Seriously though, I'd like to know what the general consensus is on that coast. Because the majority of distal osteotomies on the East Coast are definitely Austin types.

David

 

Dave:

Yes, the osteotomy I use is a "distal L" osteotomy, also called the Reverdin-Laird (for Patrick Laird, DPM) who was of my professors in biomechanics and surgery, now deceased, or the Reverdin-Green (for Donald Green, DPM) who I wrote my flatfoot chapter with. I don't do Austin cuts since I find them to be more technically difficult and don't allow as easy a correction of the proximal articular set angle (PASA). I use the same type of "distal L" cut for hallux limitus surgery (shortening osteotomy of the first metatarsal head with a cheilectomy) by removing a 2-4 mm section of bone via a second vertical cut proximal to the vertical arm and then fixating with a cannulated 3.0 - 4.0 mm titanium-alloy screw.

When doing screw fixation of this type, I open the joint to visualize the tip of the guide pin as I drill the pin into the joint. I then back up the tip of the pin about 2 mm into the metatarsal head. I countersink the dorsal pin entry site and when I measure, I go either the length measured or shorten the length by 1 mm (i.e. if I measure 16 mm, I will use a 16 mm long screw and if I measure 15 mm I will use a 14 mm long screw). I also use a second pin across the osteotomy to stabilize the capital fragment from rotation during screw insertion/fixation. This second pin is then removed once the screw is fully seated into place.

As I said earlier, I haven't had any problems with screw migration plantar-distally. However, I saw a patient from one of the podiatric surgeons locally who did this same procedure and had a screw back out that caused irritation which I needed to remove on one foot. At the same time, I performed the same procedure as he did on the patient's contralateral foot, but this time with a larger diameter screw that stayed properly seated without incident.

 

Kevin,

Thanks. It's funny how procedures often seem to "cycle" in practice. In my earlier days I favored the Reverdin-Laird procedure and then for some reason seemed to migrate to the ever popular Austin/modified Austin. And recently I have "re-discovered" the Reverdin-Laird and wondered why I had abandoned the procedure.

Now maybe I'll go to my closet and "re-discover" some bell-bottom pants from the early 70's!!


David

 

I will share with you a similar case I have had. I don't know about contacting the previous surgeon. I personally see no reason to do that. I had a patient with a failed bunionectomy, insisting it had "never healed correctly." She was angry at the original surgeon, and miserable for a number of reasons, including a painful hallux limitus. Additionally, she had diagnoses of chronic pain syndrome and fibromyalgia. There was x-ray evidence that migration of hardware resulted in a small portion of the screw extending into the joint space.
First, I referred her to a pain management clinic, and to a physiatrist. My expectation was that she was expecting complete pain relief after my surgery, and I felt that was probably an unreasonable expectation. Next, I met with her and carefully went over her history and all films, studies, making it clear to her that her expectations were too high. Instead of a hemi-implant, I simply performed a cheilectomy, and removed the screw. I made sure, before the case was scheduled, that she had arrangements/an appointment with an excellent pedorthist to be casted for orthotics. By spending an extra 20 minutes with her, adjusting her expectations, educating her, I made the whole experience better for the both of us. She has sent several patients to me since. Now, she is angry with an orthopedic surgeon who performed surgery on a contracted finger. She insists it "never healed correctly..."