An ambulance rushes a 29-year-old man to the SBH emergency department after a high-speed motorcycle accident. In addition to internal injuries, the patient is soon found to have suffered multiple fractures to his foot. Once he is stabilized, the surgeon begins a race against the clock to treat the patient’s compartment syndrome, as excessive pressure builds inside the enclosed muscle space that has compromised the flow of blood to his foot. This causes severe pain and the threat of amputation. The doctor performs a fasciotomy, cutting into the band of connective tissue that attaches, stabilizes, encloses and separates muscles in the patient’s foot to relieve pressure and restore circulation to the tissue and muscle. The patient’s foot is saved.
In the middle of the night, a middle-aged woman leaps from her seventh story window. This causes, among other injuries, an open fracture of her heel. The surgeon washes out the injury, pieces together the tiny bones as if working on a jigsaw puzzle, and fixates it using pins that will stabilize the foot and allow the wound to heal.
A young man staggers into the emergency department with a low velocity gunshot wound to his foot. X-rays indicate that the bullet had caused several simple fractures of the metatarsal bone before exiting from a small hole in the foot. The surgeon places an external fixation across the area of the fracture (which will later be resected with a bone graft placed within the fracture fragments). His biggest concern now is infection, whether the wound becomes contaminated from metal fragments, a sock, or dirt from the ground. This involves performing local wound debridement, irrigation and antibiotic ointment.
Podiatrists On Call
In each case, the emergency room surgeon is an SBH podiatrist. Podiatrists are on emergency call at the hospital 24/7, with a podiatric resident stationed in the ER at all times. The podiatry department receives 3,000 ER calls annually, with an average of three trauma calls weekly that are serious enough to require calling in an attending podiatrist to treat the injury. This may raise the eyebrows of those who associate podiatry more with ingrown toenails and bunions than with limb-saving surgery.
Podiatrists at SBH often work closely with emergency medicine physicians and orthopedic, trauma, vascular and plastic surgeons in treating trauma victims. “We become involved whenever it involves an extremity, after vitals and internal organs have been checked to see that the patient’s life is not in danger,” says Dr. Emilio Goez, Chief of Podiatry at SBH. “The foot is often the last thing to be taken care of, and yet it may be the only thing requiring surgery.”
The podiatry team includes Dr. Goez, Dr. Andrew Campbell, and Dr. Harold Goldstein, all with 25 or more years at SBH, and younger podiatrists, as well as 20 or so first to fourth year podiatry residents. In addition to trauma and sports injuries to the foot and ankle, ER cases often involve severe diabetic infections and other soft tissue injuries.
This includes Charcot foot, or Charcot Neuroarthropathy, which is a severe joint disease that attacks the bones, joints and soft tissue of the foot. As the bones of the foot lose calcium and begin to weaken, they can break and shift out of place. While it’s a condition commonly found among diabetics, it can also occur as a result of a skin infection, a spinal cord injury, Parkinson’s disease, a sexually transmitted disease, post foot surgery, or other causes. As with any diabetic infection, it can hit with a vengeance with little if any warning. The patient can become septic and may arrive in the ER unconscious and/or with signs that may more closely resemble a head injury than a foot condition.
Without proper diagnosis and treatment, the foot may soon lose its shape, toes may curl, and the ankle may become twisted and unsteady. As the condition deteriorates, the foot may need to be removed. Surgical stabilization during early-stage Charcot foot is a consideration for those with complications of a foot deformity and difficulties should such conservative treatments as prolonged immobilization, custom shoes and bracing, and activity modification fail. Surgical procedures include ostectomy, which involves removal of abnormal bone growth and bone and cartilage fragments; midfoot realignment arthrodesis (permanent fusion of the joints between the bones), where bony overgrowths are removed and the collapsed arch is repaired; or hindfoot and ankle realignment arthrodesis, where screws and plates are inserted to stabilize the bones and cartilage is removed.
“Emergency foot surgery has seen a huge amount of progress in recent years,” says Dr. Goez. “There are new technologies today, better materials and more treatment options for podiatrists, as well as for vascular surgeons and other doctors we work with in this environment of collaborative care. This means that only when the blood flow is not there, or the pain is so severe, are we likely today to consider amputation.”
FIXING FLAT FEET
Most children are born with flat feet (i.e. feet without arches), with the arch height of their feet gradually increasing over several years. Yet, when Eric celebrated his eighth birthday, he had feet that were flat in all positions – loaded (standing on the whole foot), unloaded (off the foot) and standing on his toes positions. This caused him increasing pain in the soles of his feet and ankles when walking or running.
“Surgery may be an option when flat feet are associated with pain or decreased function, and don’t respond to such conservative treatment as braces, stretching, physical therapy or shoe orthotics,” says Dr. Goez. “With pediatric patients we try to hold off on surgery until foot growth is complete (by around age 10).”
Children and adults with flat feet often over pronate, or roll their feet inwards too much, which can make them vulnerable to foot, ankle, knee, hip and back injuries over time. They may also complain, he says, about legs that feel tired (a response to their muscles working overtime).
During the patient evaluation, a full medical history is taken and a physical exam, clinical exam, radiographs and gait evaluation are performed (as well as a CAT-scan and/or MRI in certain cases). Once the type of flat foot deformity is determined, specific surgical procedures are selected to target the cause of the problem(s).
For patients like Eric, whose condition was not helped by conservative treatments, surgery was performed to lengthen his short Achilles tendon and combine it with a bone graft.
“The success rate for children like this is very high,” says Dr. Goez. “By restoring the arch, we can prevent opposite knee and back pain from occurring years later. We also do this type of surgery with adults with flat feet, but it takes longer for them to heal and the rate of success is not as high. Our goal with children is that they do so well we never see them again.”