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Bunions on the BBC

Discussion in 'General Issues and Discussion Forum' started by Simon Spooner, Apr 22, 2010.

  1. Members do not see these Ads. Sign Up.
    "bunion" surgery featured on the BBC's one show tonight, it'll be on the iplayer soon. Follow this link and find Thu,22 Apr 2010 http://www.bbc.co.uk/iplayer/search/?q=one show its at the end of the show!

    Personally, I'll miss Adrian Chiles when he leaves the one show tomorrow, he's one of the few people on tele with a proper accent that can be clearly understood. Boing Boing Baggies.:drinks
  2. Saw that. They did a keyhole technique.

    I took a photo of the x ray she was waxing lyrical about. I'm no surgeon but it looks a bit... ragged to me. And the end of one of the screws is sticking out quite a bit is it not?

    I get frustrated :eek: (not like me) with a lot of bunion surgery. Its lovely to have straight toes but I see loads and loads with nice transverse plane position and almost no sagittal plane range. 6 months later, no windlass -> no 1st met plantarflexion -> much reduced 1st met head weightbearing and overload pain 2-4 PMA. 3 years later 1st met fixed dorsiflexed, forefoot inverted etc. But so far as the surgeon is concerned the toe is straight so jobs a good 'un. :eek: And the pascom questionaire is only handed out at discharge, (if the patient is not satisfied they cannot be discharged of course) so there is no reference in the "success rate" to these surgeries.

    I know that is not ALL surgeons and far from all surgeries. I see the odd few with good range and mobility. But the emphasis on the "straight toe" in that program did vex me. Which is odd considering I'm such a mellow guy.

    Doubtless I'll be flooded with patients asking me why they can't have keyhole bunion surgery now.
  3. The length of the screw is interesting, if you are going to take it out, fair enough. If you plan to leave it in... well it ain't rocket science is it.
  4. Well they did'nt mention taking it out did they?!

    The lateral side of the 1st met head just behind the articular surface looks a bit moth eaten to me as well.

    And as a side note, what is going on between the 2nd and 3rd met?
  5. Tony Maher

    Tony Maher Welcome New Poster


    I would like to pick you up on your point regarding PASCOM and the PATSAT questionnaire. To some extent individual departments of Podiatric Surgery will always develop their own ways of working and auditing. However, the PATSAT should be completed at 6 months post intervention irrespective of discharge. In fact the documentation completed by the surgeon at 6 months, alongside the PATSAT allows for recording of complications, failure, recurrences and so forth.

    PASCOM in its latest incarnation is currently leading the way in developing negative performance indicators as a tool for bench marking outcomes in foot surgery.

    Contrary to your beliefs, surgeons are certainly interested in more than the post operative transverse plane angle of the 1st MTPj. Great care is taken to correct both sagittal and transverse plane position. In my experience the incidence of metatarsalgia is very low following routine HAV repairs. Tim Kilmartins latest paper reports an 8% incidence at 9yrs post op.

    Surgery for HAV is not without its failings but through the use of audit tools such as PASCOM and measures of HRQOL we are doing our level best to provide a high quality (as defined by Lord Darzi) evidence based intervention.

  6. Hey Tony, Long time no see :drinks.

    I agree that it should. The problem is, all too often, it isn't:eek:

    It is certainly the best audit tool of its type which I have encountered. And its inception is a huge step in the right direction. Nobody expects such a scheme to be perfect right out the gate.


    For me there is a big hole in it, and until it is filled I think it is far to open to abuse. For the data to come out of it to be reliable, useful or representative there must be a mechanism to prevent "bad" data points from being "lost". Otherwise there is nothing to prevent people cherry picking what is recorded and that renders the whole batch of data suspect.

    Perhaps there should be a mechanism whereby when an operation is carried out an entry is made to the system to indicate the fact. The outcome entry would then need to be made in a timely manner so that the number of feedbacks correlates to the number of surgeries. It could even be sent out independantly, triggered by a clock which starts when the cut is made. It would not prevent people from failing to enter surgeries which they suspected of having negative outcomes but it would certainly be a start.

    The problem, as always, with this sort of thing is that the clinicians who will use it conscientiously are unlikely to be producing the "negative performance" you mentioned. The ones who are may not be inclined to use the tool. Its like having a voluntery driving test to find bad drivers. Its great to show how good we can be, but as a tool to develop NEGATIVE performance indicators it is flawed IMO.

    I said range, not position ;). Position is something you see on the table. Range is what we see afterward. Sagittal plane position helps the windlass not at all. However, that rather pedantic point aside, and I'm certain you take great pains to try for the best possible range as well, I'm sure you're right. Nobody WANTS bad outcomes. Yet they happen, and are not always measured.

    I'm sure. But out of interest (and I'm not trying to trip you up here, I'm just interested) how long post op do you see patients?

    Indeed, and you and your colleagues involved in this are to be applauded for it. Its the sort of initiative that we could all learn from and I don't doubt it will continue to evolve. The Online incarnation of pascom presented at the SCP conference was very exciting and has huge potential.

    But in my irrelevant opinion, it still has a long way to go.

    Good to hear from you Tony. This came up a while back but nobody was around to fly the flag for pascom. :drinks. Still got a yearbook somewhere. Its nice to see what became of our cohort.

  7. Greg Quinn

    Greg Quinn Active Member

    Hi Robert,
    As a point of clarification the phalangeal screw appears to have been employed for fixation of an Akin's osteotomy. As with all such Internal Fixation placements the distal fragment should have some prominence of the screw beyond the cortex to help establish a 'lag effect' for compression of the osteotomy. This, according to original ASIF teachings, will promote stability and encourage primary bone union.

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